Relative Cost-effectiveness Research Articles

Prioritisation of critical factors affecting the adoption of social media using best-worst method: Evidence from SMEs in Egypt

This study aims to identify, analyse, and rank the critical factors affecting social media usage in Egyptian SMEs. This study proposed Technology-Organisation-Environment-Individual (TOEI) framework that integrates the individual dimension into the TOE framework to identify the key factors that drive SMEs in Egypt to use social media in their businesses. The identified factors were collected through a comprehensive review of literature, as well as participants’ opinions. The Best-Worst Method (BWM) was employed to evaluate and prioritise the factors according to their relative importance using data collected from twenty participants. The research findings indicate that relative advantage, cost-effectiveness, customer pressure, competitive pressure, complexity, owner attitude, owner support, owner innovativeness, interactivity, and observability are the highest ranked factors driving the usage of social media among SMEs in Egypt. This research has important implications for practitioners and researchers interested in investigating SMEs’ adoption of social media and how to promote the usage of social media among SMEs in developing countries. The findings of this study also help Egyptian SMEs’ owners recognise the major aspects that influence their decisions to use social media.

Cost-Effectiveness Analysis of Motixafortide Versus Plerixafor in Stem Cell Mobilization for Autologous Transplantation in Patients with Multiple Myeloma

Introduction: The Phase 3 GENESIS trial (NCT03246529) compared the efficacy and safety of motixafortide and granulocyte-colony stimulating factor (M+G) to placebo + G (PBO+G) for the mobilization of hematopoietic stem cells (HSCs) prior to autologous stem cell transplantation (ASCT) in patients with multiple myeloma (MM). Compared with PBO+G, M+G significantly increased the proportion of patients who were able to successfully mobilize ≥6x106 CD34+ cells/kg for ASCT within 2 apheresis days (92.5% vs. 26.2%; p<0.0001). In a cost-effectiveness model (CEM) based on the GENESIS trial, M+G yielded additional quality-adjusted life years (QALYs) and cost savings relative to G alone from a United States (US) healthcare payer perspective (Lamotte et al. (2022) Value Health 25(7): S346). Plerixafor + G (P+G) is also used for HSC mobilization prior to ASCT in patients with MM. To date, M+G and P+G have not been directly compared in head-to-head trials; therefore, the relative efficacy and cost effectiveness of these therapies is currently unknown. Methods: The Bucher method was used to assess the relative efficacy of M+G in the GENESIS trial and P+G in the Phase 3 AMD-3102 trial (NCT00103662), with the PBO+G arms of both trials used as a common comparator. Risk ratios (RRs) were derived for binary trial endpoints (i.e., proportion with mobilization of ≥6x106 CD34+ cells/kg within 1-4 apheresis days, successful engraftment, use of rescue therapy, proportion who underwent ASCT, incidence of serious adverse events [SAEs]) and mean differences were derived for continuous trial endpoints (i.e., number of study drug doses received, frequency and amount of G doses, and number of apheresis sessions). The RRs were then used to update the CEM to compare the cost effectiveness of M+G and P+G from a US healthcare payer perspective over a lifetime horizon; model assumptions and sources for unit costs and quality of life scores were unchanged from the previously published CEM. Results: The mean age at baseline was 59-60 years in GENESIS and 58 years in AMD-3102; heterogeneity was observed for the mean time since diagnosis (6-7 vs. 11-12 months), prior radiotherapy (10%-11% vs. 27%-31%), and the ethnic and sex distribution of the PBO+G arms (White: 95% vs. 83%; males: 57% vs. 70%). Notably, prior lenalidomide use was markedly lower in AMD-3102 (<10%) than in GENESIS (70%), which likely contributed to the higher mobilization rates in the AMD-3102 PBO+G arm than in the GENESIS PBO+G arm. In the Bucher analysis, healthcare resource utilization (HRU) outcomes significantly favored M+G during primary mobilization, including less frequent administration of G (mean difference [MD]: -0.97; 95% CI -1.43, -0.50; p=0.0001), lower G doses (MD: -920 mcg; 95% CI -1,368, -471; p=0.0001), and fewer apheresis sessions (MD: -0.98; 95% CI -1.34, -0.63; p<0.0001) (Table 1). The proportion of patients with successful mobilization of ≥6x106 CD34+ cells/kg within 1 apheresis day was significantly greater with M+G (88.8%) than with P+G (54.2%; RR 2.97; 95% CI 1.08, 8.17; p=0.0341). Similar results were observed between groups for other outcomes, including ASCT rates (RR 1.06; 95% CI 0.93, 1.21; p=0.4124), engraftment durability by 100 days (RR 0.98; 95% CI 0.87, 1.11; p=0.7894), and SAE rate (RR 2.36; 95% CI 0.26, 21.05; p=0.4521); analyses were limited to publicly available data for P+G, and were not feasible for the use of rescue therapy because of insufficient sample size. In the cost-effectiveness analysis, M+G was dominant to P+G over a lifetime horizon, resulting in additional QALYs (+0.0358) and lower total costs (-$17,378 USD; Table 2) as per base case deterministic results. The key cost drivers were the probability of successful transplantation, long-term maintenance costs, and the time to engraftment in poor mobilizers. In a probabilistic sensitivity analysis, M+G was dominant in 66% of simulations and 92% cost effective at a WTP threshold of $50,000 per QALY. Conclusions: The results of this analysis show that the use of M+G was associated with significantly lower HRU relative to P+G for the mobilization of HSCs prior to ASCT in patients with MM, as well as significantly greater successful mobilization of ≥6x106 CD34+ cells/kg within 1 apheresis day. Cost-effectiveness analysis results showed that M+G was dominant to P+G, yielding additional QALYs and net cost savings over a lifetime horizon from a US healthcare payer perspective. Figure 1View largeDownload PPTFigure 1View largeDownload PPT Close modal

Cost-Effectiveness of Emicizumab for Prophylaxis in People with Severe Hemophilia A without Inhibitors

Background: With the entry of gene therapy into the hemophilia A treatment landscape, healthcare decision makers are re-evaluating the relative value of different prophylaxis options for people with hemophilia A (PwHA) without inhibitors. While there are multiple elements of value to consider when conducting a clinical and economic assessment of treatments for PwHA, this study aims to answer questions about the relative cost-effectiveness of prophylactic therapies. Methods: A Markov model was used to estimate the cost-effectiveness of emicizumab compared to: valoctogene roxaparvovec gene therapy, standard half-life factor VIII (FVIII) , and extended half-life FVIII replacement products. Health states in the model included: life with no arthropathy, life with arthropathy, life after joint replacement surgery, and death. Parameter estimates, including annualized bleed rates and durability of treatment (Table 1), were estimated from clinical trial and real-world data. Costs included the wholesale acquisition cost of drugs, treatment of bleeds, and management of hemophilia-related joint disease, which were estimated from published literature. The cost of gene therapy was assumed to be a one-time cost of $2.5 million (in 2022 US Dollars) per treated patient. Utilities were derived from patient-reported outcomes in published real-world data. Incremental cost-effectiveness (ICER) was estimated in cost per quality-adjusted life-year (QALY) gained, from a payer perspective over a 2-year, 5-year, and a lifetime horizon. Results: Compared to gene therapy, emicizumab was estimated to be less costly (-$1.395 million) with similar effectiveness (0.00 QALY incremental difference) over a 2-year horizon, less costly and more effective over a 5-year horizon (-$125,215; 0.02 QALY), and more costly but cost-effective over a lifetime horizon ($8,945; 0.95 QALY; ICER $9,406/QALY). Compared to standard half-life FVIII prophylaxis and extended half-life FVIII prophylaxis, emicizumab was dominant (less costly and more effective) over each model time horizon. Conclusions: Emicizumab remains a highly cost-effective prophylaxis strategy compared with FVIII prophylaxis in adult PwHA. Uncertainties around the effectiveness and durability of gene therapy make assessment of 2 and 5-year cost-effectiveness challenging, but over a lifetime emicizumab appears to be cost-effective compared with gene therapy for PwHA. Given the uncertainties related to new therapies, additional sensitivity analyses are needed to estimate the value of therapies under different scenarios and to consider other elements of value that are important to PwHA. Figure 1View largeDownload PPTFigure 1View largeDownload PPT Close modal

Relative cost-effectiveness of long-acting injectable cabotegravir versus oral pre-exposure prophylaxis in South Africa based on the HPTN 083 and HPTN 084 trials: a modelled economic evaluation and threshold analysis

Long-acting injectable cabotegravir, a drug taken every 2 months, has been shown to be more effective at preventing HIV infection than daily oral tenofovir disoproxil fumarate and emtricitabine, but its cost-effectiveness in a high-prevalence setting is not known. We aimed to estimate the incremental cost-effectiveness of long-acting injectable cabotegravir compared with tenofovir disoproxil fumarate and emtricitabine in South Africa, using methods standard to government planning, and to determine the threshold price at which long-acting injectable cabotegravir is as cost-effective as tenofovir disoproxil fumarate and emtricitabine. In this modelled economic evaluation and threshold analysis, we updated a deterministic model of the South African HIV epidemic with data from the HPTN 083 and HPTN 084 trials to evaluate the effect of tenofovir disoproxil fumarate and emtricitabine and long-acting injectable cabotegravir provision to heterosexual adolescents and young women and men aged 15-24 years, female sex workers, and men who have sex with men. We estimated the average intervention cost, in 2021 US$, using ingredients-based costing, and modelled the cost-effectiveness of two coverage scenarios (medium or high, assuming higher uptake of long-acting injectable cabotegravir than tenofovir disoproxil fumarate and emtricitabine throughout) and, for long-acting injectable cabotegravir, two duration subscenarios (minimum: same pre-exposure prophylaxis duration as for tenofovir disoproxil fumarate and emtricitabine; maximum: longer duration than tenofovir disoproxil fumarate and emtricitabine) over 2022-41. Across long-acting injectable cabotegravir scenarios, 15-28% more new HIV infections were averted compared with the baseline scenario (current tenofovir disoproxil fumarate and emtricitabine roll-out). In scenarios with increased coverage with oral tenofovir disoproxil fumarate and emtricitabine, 4-8% more new HIV infections were averted compared with the baseline scenario. If long-acting injectable cabotegravir drug costs were equal to those of tenofovir disoproxil fumarate and emtricitabine for the same 2-month period, the incremental cost of long-acting injectable cabotegravir to the HIV programme was higher than that of tenofovir disoproxil fumarate and emtricitabine (5-10% vs 2-4%) due to higher assumed uptake of long-acting injectable cabotegravir. The cost per infection averted was $6053-6610 (tenofovir disoproxil fumarate and emtricitabine) and $4471-6785 (long-acting injectable cabotegravir). The cost per long-acting cabotegravir injection needed to be less than twice that of a 2-month supply of tenofovir disoproxil fumarate and emtricitabine to remain as cost-effective, with threshold prices ranging between $9·03 per injection (high coverage; maximum duration) and $14·47 per injection (medium coverage; minimum duration). Long-acting injectable cabotegravir could potentially substantially change HIV prevention. However, for its implementation to be financially feasible across low-income and middle-income countries with high HIV incidence, long-acting injectable cabotegravir must be reasonably priced. United States Agency for International Development, The Bill & Melinda Gates Foundation.

Cost-effectiveness of management strategies for patients with recurrent ovarian cancer and inoperable malignant bowel obstruction

ObjectivesPatients with recurrent platinum-resistant ovarian cancer often present with inoperable malignant bowel obstruction (MBO) from a large burden of abdominal disease. Interventions such as total parenteral nutrition (TPN) and chemotherapy may be used in this setting. We aim to describe the relative cost-effectiveness of these interventions to inform clinical decision making. MethodsFour strategies for management of platinum-resistant recurrent ovarian cancer with inoperable MBO were compared from a societal perspective using a Monte Carlo simulation: (1) hospice, (2) TPN, (3) chemotherapy, and (4) TPN + chemotherapy. Survival, hospitalization rates, end-of-life (EOL) setting, and MBO-related utilities were obtained from literature review: hospice (survival 38 days, 6% hospitalization), chemotherapy (42 days, 29%), TPN (55 days, 25%), TPN + chemotherapy (74 days, 47%). Outcomes were the average cost per strategy and incremental cost-effectiveness ratios (ICERs) in US dollars per quality-adjusted life year (QALY) gained. ResultsIn the base case scenario, TPN + chemotherapy was the most costly strategy (mean; 95% CI) ($49,741; $49,329–$50,162) and provided the highest QALYs (0.089; 0.089–0.090). The lowest cost strategy was hospice ($14,591; $14,527–$14,654). The TPN alone and chemotherapy alone strategies were dominated by a combination of hospice and TPN + chemotherapy. The ICER of TPN + chemotherapy was $918,538/QALY compared to hospice. With a societal willingness to pay threshold of $150,000/QALY, hospice was the strategy of choice in 71.6% of cases, chemotherapy alone in 28.4%, and TPN-containing strategies in 0%. ConclusionsTPN with or without chemotherapy is not cost-effective in management of inoperable malignant bowel obstruction and platinum-resistant ovarian cancer.

A symptomatic approach to tuberculosis screening for high-risk groups in Malaysia: Cost-effectiveness and budget impact analysis

BackgroundOne of the crucial areas of eliminating TB is the early detection of cases through the screening programme. This study's focal point is to measure the relative cost-effectiveness and budget impact of the symptomatic approach compared to the existing approach of TB screening (consisted of both symptomatic and asymptomatic screening) among high-risk groups in Malaysia. MethodThe Cost-Effectiveness Analysis (CEA) was measured using a decision tree model and the outcome is presented in terms of cost per TB case detected and the ICER. Analysis was conducted using secondary data collected from the Disease Control Division, Sabah and Sarawak State Health Departments. The robustness of the model is determined by Deterministic and Probabilistic Sensitivity Analysis. Subsequently, Budget impact over 5 years period, from 2018 to 2022 was estimated for both approaches. ResultsThe symptomatic approach was more cost-effective than the existing approach with ICER of MYR 424.71. The cost of conducting Sputum for Acid Fast Bacilli (SAFB) was found as the key driver for ICER. Budget Impact Analysis showed that switching from the existing approach towards the symptomatic approach would result in a cost-saving of MYR 65.5 million over 5 years. However, this would lead to 4473 TB cases being undetected over the same duration. ConclusionThis study suggests that the policymakers have to weigh the trade-off between cost-saving and TB case detection. This cost-saving can be channelled to new TB intervention programme with a higher chance of TB case detection. Nevertheless, any decision made must be in concordance to the objectives of the country’s TB programme.

Recruitment of general practitioners in China: a scoping review of strategies and challenges.

BackgroundChina is rapidly expanding its general practitioner (GP) workforce as part of recent healthcare reform, with an extra 400,000 GPs by 2030. This scoping review identifies the published strategies for GP recruitment that are being implemented and the challenges encountered.MethodsWe searched six English and three Chinese databases from 2015 to April 2022, following Arksey and O’Malley’s framework and the PRISMA ScR reporting guidelines.ResultsA total of 40 Chinese-language and 5 English-language records were included. We identified multiple policies, pathways and programmes focused on expanding GP recruitment. Twenty-two evaluations of these initiatives show varying degrees of effectiveness. Selecting general practice as a career is affected by many factors, including individual’s background, remuneration and benefits, career prospects, working environment, self-fulfilment, and current national developments and reorganisations of primary care. The challenge most frequently reported was the adequate provision of qualified GP in rural regions. The targeting of students from rural areas and provision of free education in return for an obligatory six-years’ working in their hometown upon graduation appears to be effective. Extracted records mostly studied views of trainees in a defined locality, and we identified a paucity of studies which explored the perspectives of organisations and institutions, similarly there were areas of China not contributing to the literature and there were no records taking a national perspective.ConclusionsLong-term monitoring is required to assess policy changes and to systematically evaluate the effectiveness of the interventions nationally. The monitoring of the challenges influencing GP recruitment can be used to inform the design of future initiatives.Development of a minimum agreed standardised set of outcomes used to measure and report evaluations will help assess the relative contributions and cost effectiveness of different approaches being used to boost GP numbers. We provide suggestions for improving the benefits and rewards for GPs and how to promote recruitment to the more rural or less attractive areas.Supplementary InformationThe online version contains supplementary material available at 10.1186/s12875-022-01854-0.

Value-Based Analysis of Therapies in Refractory Metastatic Colorectal Cancer in US

BackgroundRecent phase 2 trials have provided data supporting regorafenib dose optimization (ReDO) and trifluridine/tipiracil (TAS-102) with bevacizumab (TAS-BEV) as treatment options in refractory metastatic colorectal cancer (mCRC). Historically, regorafenib standard dose (RSD) and TAS-102 have been utilized as third-line options in mCRC. Given the incorporation of ReDO and TAS-BEV as treatment options, we sought to evaluate relative cost-effectiveness of ReDO vs. RSD, TAS-102, and TAS-BEV for mCRC from a payer perspective. MethodsA Markov model was constructed to estimate total costs and quality-adjusted life-years (QALYs) for ReDO, RSD, TAS-102, and TAS-BEV. Clinical parameters were obtained from phase 2 and 3 trials for comparators. Health state utility values were from the RSD phase 3 clinical trial. Incremental cost-effectiveness ratios (ICERs) were utilized to compare treatments. Model robustness was checked with one-way and probabilistic sensitivity analyses. ResultsIn the base case, ReDO was dominant over TAS-BEV (ie provided a higher QALY at a lower cost). ReDO produced an ICER of $104,308 per QALY relative to RSD and $37,966 relative to TAS-102. In one-way sensitivity analyses, monthly drug cost of TAS-BEV was the most influential parameter determining relative cost-effectiveness between TAS-BEV and ReDO. When TAS-102 and RSD were independently compared to ReDO, the most influential parameters were related to duration of OS and PFS and costs of managing AEs. ConclusionsThe optimum dosing strategy for regorafenib has improved its benefit-to-toxicity ratio and relative cost-effectiveness compared to RSD, TAS-102, and TAS-BEV.

The cost-effectiveness of brigatinib in adult patients with ALK inhibitor-naive ALK-positive non-small cell lung cancer from a US perspective.

BACKGROUND: The discovery of specific oncogenic drivers in non-small cell lung cancer (NSCLC) has led to the development of highly targeted anaplastic lymphoma kinase tyrosine kinase inhibitors (ALKis). Brigatinib is a next-generation ALKi associated with prolonged progression-free survival in patients with ALKi-naive ALK+ NSCLC. OBJECTIVE: To estimate the cost-effectiveness of brigatinib compared with crizotinib and alectinib in patients with ALKi-naive ALK+ NSCLC, from a US payer perspective. METHODS: A lifetime area under the curve-partitioned survival model with 4 health states was used to evaluate the relative cost-effectiveness of brigatinib in the ALKi-naive ALK+ NSCLC setting. Brigatinib was compared with crizotinib within a cost-effectiveness framework and compared with alectinib in a cost-comparison framework, where all efficacy outcomes were assumed equal. The efficacy of brigatinib and crizotinib was informed by the ALTA-1L trial, and an indirect treatment comparison was performed to inform the efficacy of brigatinib vs alectinib owing to a lack of head-to-head data. Costs were derived from public sources. The main outcomes of the model were total costs, quality-adjusted life-years (QALYs), life-years, and incremental cost-effectiveness ratios. Univariate and probabilistic sensitivity analyses, in addition to multiple scenario analyses, were conducted to assess the robustness of the model outcomes. RESULTS: The improved outcomes observed in ALTA-1L translated into QALY gains (+0.97) in the comparison of brigatinib vs crizotinib. The superior efficacy profile was associated with increased time on treatment with brigatinib, which drove the increase in costs vs crizotinib (+$210,519). The resulting base-case incremental cost-effectiveness ratio was $217,607/QALY gained. Compared with alectinib, brigatinib was associated with a cost difference of -$8,546. Sensitivity analysis suggested that extrapolation of overall survival, the assumptions relating to time on treatment, and subsequent therapy costs were the most influential determinants of results. Probabilistic sensitivity analysis suggested brigatinib had the highest probability of being cost-effective beyond willingness-to-pay thresholds of $236,000 per QALY vs crizotinib and alectinib. CONCLUSIONS: At list prices and under base-case assumptions in the current analysis, brigatinib was associated with cost-savings vs alectinib, and QALY gains but at higher costs vs crizotinib. Additional research into the real-world efficacy of ALKis is warranted to further understand the comparative cost-effectiveness of these therapies. DISCLOSURES: Ms Cranmer and Ms Kearns are employees of Takeda UK Ltd. Dr Young is a former employee of Takeda Pharmaceuticals America, Inc. Dr Humphries is an employee of Takeda Pharmaceuticals U.S.A., Inc. Mr Trueman is an employee of Source Health Economics, the consultancy company that provided health economic and writing services. This work was funded by ARIAD Pharmaceuticals, Inc., a wholly owned subsidiary of Takeda Pharmaceutical Company Limited. Work by Source Health Economics was funded by ARIAD Pharmaceuticals, Inc. Professional medical writing assistance was provided by Phillipa White, of Source Health Economics, and funded by ARIAD Pharmaceuticals, Inc.

211. Assessing the economic benefit of robotic and navigational assistance in surgical treatment of L4-L5 spondylolisthesis: is higher upfront equipment cost worth the operative and safety benefits?

<h3>BACKGROUND CONTEXT</h3> The use of robotic or navigational guidance has seen tremendous growth in recent years in minimally invasive spine surgery (MISS) due to its ability to reduce operative time, increase patient safety, and aid in surgical accessibility, especially in high incidence pathologies. However, there remain considerable gaps in the literature in regards to the cost-effectiveness of robotic or navigational guidance in the surgical treatment of L4-L5 spondylolisthesis. <h3>PURPOSE</h3> To assess differences in patient outcomes and relative cost effectiveness in L4-L5 spondylolisthesis patients treated using robotic or navigational guidance in MISS procedures. <h3>STUDY DESIGN/SETTING</h3> Retrospective review of prospective MISS database. <h3>PATIENT SAMPLE</h3> A total of 524 MISS patients. <h3>OUTCOME MEASURES</h3> HRQLs, complications, surgical factors. <h3>METHODS</h3> MISS patients with preoperative diagnoses of L4-L5 spondylolisthesis and baseline (BL) and 2-year (2Y) postoperative radiographic/HRQL data were included. Patients were split between those operated on using robotic or navigational guidance (Robotic+) or not (Robotic-). Means comparison analysis assessed differences in radiographic and clinical outcomes at BL, 1Y and 2Y postoperatively. Costs were calculated using the PearlDiver database through estimates from Medicare payscales for services within a 30-day window, including estimates regarding costs of postoperative complications, outpatient healthcare encounters, revisions and medical related readmissions. Quality-adjusted life years (QALYs) was calculated using NDI mapped to SF6D using validated methodology and utilized a 3% discount rate to account for residual decline to life expectancy (78.7 years). <h3>RESULTS</h3> Eighty-eight patients (54.40±12.49 years, 40% female, 30.93±6.52 kg/m², mean CCI: 2.23±1.55) with L4-5 spondylolisthesis were included. At baseline, patients were comparable in age, gender, BMI and CCI (all p>.05). Similarly, patients did not differ significantly in baseline regional nor global radiographic deformity (all p>.05). Perioperatively, Robotic+ patients were significantly less likely to undergo corpectomy (p=.006), and also demonstrated significantly lower EBL (p=.013) and operative time (p=.009). Economic analysis revealed broad cost savings for Robotic+ patients. Specifically, Robotic+ patients demonstrated increased utility gained per QALYs at 1Y (p=.028), as well as Life Expectancy QALYs (p=.002). Furthermore, Robotic+ patients were significantly more likely to demonstrate increased QALYs gained by 2Y (p=.029). Conversely, overall cost per QALY by 2Y was significantly higher for Robotic- patients, which resulted in an approximately 6.5x greater cost per QALY for such patients (76,848 vs 11,839 USD). Overall, Robotic+ patients demonstrated significantly higher cost-effectiveness by 2Y (p<.001). <h3>CONCLUSIONS</h3> Corrective procedures for the treatment of L4-L5 spondylolisthesis and other common spinal pathologies has seen significant growth in the uptake of novel technologies such as robotic or navigational assistance. Though robotic and navigational assistance systems have a significantly higher upfront cost compared to existing techniques, our findings demonstrate reductions in intraoperative invasiveness and OR time pay great dividends in demonstrating the 2Y cost-effectiveness of such novel technologies in minimally-invasive adult spinal deformity surgery. <h3>FDA DEVICE/DRUG STATUS</h3> This abstract does not discuss or include any applicable devices or drugs.

Cost-effectiveness of alternative minimum recall intervals between whole blood donations.

The INTERVAL trial showed shorter inter-donation intervals could safely increase the frequency of whole-blood donation. We extended the INTERVAL trial to consider the relative cost-effectiveness of reduced inter-donation intervals. Our within-trial cost-effectiveness analysis (CEA) used data from 44,863 whole-blood donors randomly assigned to 12, 10 or 8 week (males), and 16, 14 or 12 week inter-donation intervals (females). The CEA analysed the number of whole-blood donations, deferrals including low- haemoglobin deferrals, and donors' health-related quality of life (QoL) to report costs and cost-effectiveness over two years. The mean number of blood donation visits over two years was higher for the reduced interval strategies, for males (7.76, 6.60 and 5.68 average donations in the 8-, 10- and 12- week arms) and for females (5.10, 4.60 and 4.01 donations in the 12-, 14- and 16- week arms). For males, the average rate of deferral for low haemoglobin per session attended, was 5.71% (8- week arm), 3.73% (10- week), and 2.55% (12- week), and for females the rates were: 7.92% (12-week), 6.63% (14- week), and 5.05% (16- week). Donors' QoL was similar across strategies, although self-reported symptoms were increased with shorter donation intervals. The shorter interval strategies increased average cost, with incremental cost-effectiveness ratios of £9.51 (95% CI 9.33 to 9.69) per additional whole-blood donation for the 8- versus 12- week interval for males, and £10.17 (95% CI 9.80 to 10.54) for the 12- versus 16- week interval arm for females. Over two years, reducing the minimum donation interval could provide additional units of whole-blood at a small additional cost, including for those donor subgroups whose blood type is in relatively high demand. However, the significance of self-reported symptoms needs to be investigated further before these policies are expanded.

An integrated approach to prioritize restoration for carnivore conservation in shared landscapes

Global land use change has resulted in the loss and fragmentation of habitats and amplified the pace of species extinction. With carnivores being disproportionately at risk of range contraction, restoration is an important strategy to counter the impacts of habitat loss and fragmentation. While protection of public lands has been the cornerstone of conservation, private lands can play an important supplementary role. India harbors 23 % of the global carnivore species, threatened by a rapidly growing economy and high human densities. Using a social-ecological systems approach, we prioritized private agricultural lands for agroforestry in the buffer area of Pench Tiger Reserve. We applied systematic conservation planning tools and combined data on (1) habitat use of four carnivores (tiger, leopard, dhole, and sloth bear), (2) landowner willingness to modify land use through enrolment in an incentive-based program, and (3) monetary cost of program implementation, to identify priority areas for agroforestry based on their relative cost-effectiveness. Our integrated approach generated a configuration of priority areas that was markedly different than if we selected areas using ecological data only. Over an 8-year period, restoration of ~4900, ~8300 and ~12,000 acres through agroforestry was estimated to have a cumulative cost of USD 56 million, USD 95 million, and USD 140 million, respectively. Partnering with and incentivizing private landowners can expand the effective size of small and fragmented protected areas. Our approach can be applied to other shared landscapes, dominated by private ownership, to identify areas that deliver a compromise between ecological suitability, social acceptability, and economic viability.

Compact high-flux X-ray source based on irradiation of solid targets by gigahertz and megahertz bursts of femtosecond laser pulses

In this study, we demonstrate the significant increase in the hard X-ray yield (more than 1011 photons/s in 4π solid angle in 6 - 40 keV range) that can be achieved in an ambient air environment when solid targets are irradiated by sequences of high average power (90 W) bursts of femtosecond laser pulses, generated in GHz burst laser amplifier operated at high repetition rate (100 kHz). The combination of the prepulse and ∼ 10 times greater driving pulse not only enhances X-ray generation efficiency (∼ 10−6) by more than two orders of magnitude compared to the single pulse regime but also protects a target allowing continuous operation for 3 hours with only 30% predictable and gradual drop of X-ray yield. In addition, we show that X-ray yield enhancement becomes around 6 times more pronounced at higher repetition rates (100 kHz compared to &lt; 5 kHz). The simplicity and relative cost-effectiveness of the presented X-ray source makes it an attractive solution for future applications in ultrafast X-ray imaging and spectroscopy.

Pay or Nudge Employees Into Change? An Experiment on the Effect of Nudging for Organizational Change

Organizational change often fails due to employees’ resistance to change resulting in unforeseen expenses, delays, or other disruptions in organizations. In our experiment, we compare behavioral interventions—a pro-change default rule and a pro-change recommendation—with a costly pay raise to foster supportive behavior. We support the effectiveness of a default nudge in enhancing change-related success. Our results indicate that a recommendation nudge has no significant effect in change-related scenarios. In addition, we find that a pay raise has a positive effect that is likely to be triggered by positive reciprocity. If this pay raise fails to materialize, we report supporting evidence for negative reciprocity. We compare the effect sizes for these nudges and the pay raise and provide insights for the relative cost-effectiveness of such nudges compared to a pay raise for organizational change. We conclude with managerial implications.

Cost-effectiveness of management strategies for patients with recurrent ovarian cancer and inoperable malignant bowel obstruction (078)

Objectives: Patients with recurrent platinum-resistant ovarian cancer often present with inoperable malignant bowel obstruction from large burden abdominal disease. End-of-life interventions such as total parenteral nutrition (TPN) and chemotherapy may modestly improve survival but may also result in a worsened quality of life (QOL) and high cost. We aimed to describe the relative cost-effectiveness of these interventions to inform clinical decision-making. Methods: Four strategies, including home hospice, TPN alone, chemotherapy alone, and TPN+chemotherapy, for management of platinum-resistant recurrent ovarian cancer with inoperable malignant bowel obstruction and gastrostomy tube, were compared using a simple decision model. Chemotherapy regimens modeled included standard monotherapies (liposomal doxorubicin, pacli-taxel, gemcitabine, or topotecan). An alternative scenario assumed a higher cost novel therapy (pembrolizumab). Costs and rates of blood transfusion ($451,15%) and granulocyte colony-stimulating factor ($3079, 9.6%) were incorporated into standard chemotherapy costs. Median survival and rates of hospitalization were obtained from the detailed literature review: hospice (survival 38 days, 6% hospitalization), chemotherapy (42 days, 24%), TPN (55 days, 24%), and TPN+chemotherapy (74 days, 43%). End-of-life QOL-related utilities (0.08 for end-stage with bowel obstruction; 0.07 for additional hospitalization) were incorporated. Outcomes included the average cost of strategy and incremental cost-effectiveness ratios (ICERs) in US dollars per quality-adjusted life-year (QALY) gained. Multiple one-way sensitivity analyses performed on utilities, costs, probability of hospitalization, and expected survival time (Figure 1). Results: TPN+chemotherapy was the most costly strategy ($33,099) in the base case scenario and was associated with the highest QALYs (0.016). The lowest cost strategy was standard chemotherapy alone (cost $7,078, QALYs 0.009), which dominated home hospice ($8,666, QALYs 0.008) due to lower cost and slightly higher QALYs. The TPN alone strategy (cost $21,025, QALYs 0.012) was dominated by a combination of other strategies. The ICER of TPN+chemotherapy was $3.8 million/QALY compared to chemotherapy alone. In the novel therapy scenario, hospice was the least costly strategy, novel therapy alone was dominated, and TPN+novel therapy had an ICER of $11 million/QALY compared to the next less costly strategy. The model’s results were stable to multiple one-way sensitivity analyses. Objectives: Patients with recurrent platinum-resistant ovarian cancer often present with inoperable malignant bowel obstruction from large burden abdominal disease. End-of-life interventions such as total parenteral nutrition (TPN) and chemotherapy may modestly improve survival but may also result in a worsened quality of life (QOL) and high cost. We aimed to describe the relative cost-effectiveness of these interventions to inform clinical decision-making. Methods: Four strategies, including home hospice, TPN alone, chemotherapy alone, and TPN+chemotherapy, for management of platinum-resistant recurrent ovarian cancer with inoperable malignant bowel obstruction and gastrostomy tube, were compared using a simple decision model. Chemotherapy regimens modeled included standard monotherapies (liposomal doxorubicin, pacli-taxel, gemcitabine, or topotecan). An alternative scenario assumed a higher cost novel therapy (pembrolizumab). Costs and rates of blood transfusion ($451,15%) and granulocyte colony-stimulating factor ($3079, 9.6%) were incorporated into standard chemotherapy costs. Median survival and rates of hospitalization were obtained from the detailed literature review: hospice (survival 38 days, 6% hospitalization), chemotherapy (42 days, 24%), TPN (55 days, 24%), and TPN+chemotherapy (74 days, 43%). End-of-life QOL-related utilities (0.08 for end-stage with bowel obstruction; 0.07 for additional hospitalization) were incorporated. Outcomes included the average cost of strategy and incremental cost-effectiveness ratios (ICERs) in US dollars per quality-adjusted life-year (QALY) gained. Multiple one-way sensitivity analyses performed on utilities, costs, probability of hospitalization, and expected survival time (Figure 1). Results: TPN+chemotherapy was the most costly strategy ($33,099) in the base case scenario and was associated with the highest QALYs (0.016). The lowest cost strategy was standard chemotherapy alone (cost $7,078, QALYs 0.009), which dominated home hospice ($8,666, QALYs 0.008) due to lower cost and slightly higher QALYs. The TPN alone strategy (cost $21,025, QALYs 0.012) was dominated by a combination of other strategies. The ICER of TPN+chemotherapy was $3.8 million/QALY compared to chemotherapy alone. In the novel therapy scenario, hospice was the least costly strategy, novel therapy alone was dominated, and TPN+novel therapy had an ICER of $11 million/QALY compared to the next less costly strategy. The model’s results were stable to multiple one-way sensitivity analyses.

An Economic Evaluation of a Proactive Consultation-Liaison Psychiatry Pilot as Compared to Usual Psychiatric Consultation on Demand for Hospital Medicine.

A growing literature demonstrates the value of the proactive consultation-liaison psychiatry model for health care systems through reductions in hospital length of stay. Few studies include financial outcomes. We evaluated the return on investment of a 1-year proactive consultation-liaison psychiatry pilot in a hospital medicine unit. We used a pre-post method with an active comparison of three hospital medicine units with regular psychiatric consultation on demand. We staffed the pilot unit with one full-time psychiatrist who focused on early case finding, close communication with unit staff, frequent follow-up visits, and proactive discharge planning. We assessed the 1-year change in mean length of stay for all patients receiving psychiatric consultation, from which we estimated the direct contribution margin from bed-backfills and the program's return on investment. On the pilot unit, the percent of discharges that received psychiatric consultation increased from 7.34% to 13.79%, and the length of stay for patients who consulted declined by a mean of 1.82 days (P < 0.05), as compared to an increase of 0.15 days (P > 0.05) on the usual-care units. The pilot unit reduction in length of stay saved 451.71 days in total, allowing for 73.81 bed-backfills, a direct contribution margin of $419,343 (95% confidence interval, $50,754 to $787,933), a net direct contribution margin of $298,245 (-$70,344 to $666,835), and an return on investment of 132% (-31% to 295%). This study strengthens existing evidence for the relative cost-effectiveness of proactive consultation-liaison psychiatry for hospital medicine compared with usual psychiatric consultation on demand.

Priority setting in early childhood development: an analytical framework for economic evaluation of interventions

BackgroundEarly childhood development (ECD) sets the foundation for healthy and successful lives with important ramifications for education, labour market outcomes and other domains of well-being. Even though a large number...

Con: freeze-all for all? One size does not fit all.

IVF has traditionally involved transfer of fresh embryos. However, a 'freeze-all' strategy where all embryos are cryopreserved for transfer in subsequent, unstimulated cycles has emerged as an alternative approach. This is thought to eliminate the negative effects of controlled ovarian stimulation on the endometrium and reduce the risk of ovarian hyperstimulation syndrome (OHSS). There are a growing number of studies evaluating live birth rates after use of a freeze-all versus fresh embryo transfer (ET) strategy. However, results to date are inconsistent. Certainly, the benefits of a freeze-all strategy appear to be less clear cut in ovulatory women with infertility, while those with a good ovarian response (more than 10 or 15 oocytes retrieved) may be suitable candidates. Variable responses to a freeze-all strategy compared with fresh ET have also been reported depending on whether cleavage stage embryos or blastocysts were transferred. In terms of safety, the risk of OHSS appears to be lower with a freeze-all strategy. For other safety endpoints, some appear to be better when a freeze-all approach is used (e.g. rates of pregnancy loss/miscarriage, preterm delivery, low birthweight and small for gestational age) while other complications are more common (e.g. hypertensive disorders of pregnancy/pre-eclampsia, large for gestational age and high birthweight). Preliminary longer-term data suggest that a freeze-all strategy does not have a negative impact on childhood development. Other factors to consider include time to pregnancy (longer after freeze-all) and the relative cost-effectiveness of the two approaches. Available data are too inconsistent to allow a freeze-all approach to be recommended for all patients. Instead, a personalized, balanced approach should be taken based on individual patient characteristics (especially steroid hormone levels on the day of trigger) and incorporating patient preference. While a freeze-all strategy might be the right choice for some patients, freeze-all is definitely not good for all.

Extreme Heat and COVID-19: A Dual Burden for Farmworkers.

Currently, there is an extensive literature examining heat impacts on labor productivity and health, as well as a recent surge in research around COVID-19. However, to our knowledge, no research to date examines the dual burden of COVID-19 and extreme heat on labor productivity and laborers' health and livelihoods. To close this research gap and shed light on a critical health and livelihood issue affecting a vulnerable population, we urge researchers to study the two topics in tandem. Because farmworkers have a high incidence of COVID-19 infections and a low rate of inoculation, they will be among those who suffer most from this dual burden. In this article, we discuss impacts from extreme heat and COVID-19 on farm laborers. We provide examples from the literature and a conceptual framework showing the bi-directional nature of heat impacts on COVID-19 and vice versa. We conclude with questions for further research and with specific policy recommendations to alleviate this dual burden. If implemented, these policies would enhance the wellbeing of farmworkers through improved unemployment benefits, updated regulations, and consistent implementation of outdoor labor regulations. Additionally, policies for farmworker-related health needs and cultural aspects of policy implementation and farmworker outreach are needed. These and related policies could potentially reduce the dual burden of COVID-19 and extreme heat impacts while future research explores their relative cost-effectiveness.

Protocol for a systematic review of economic evaluations conducted on gender-transformative interventions aimed at preventing unintended pregnancy and promoting sexual health in adolescents

IntroductionIn the context of family planning and reproductive health, a gender-transformative approach involves helping communities understand and challenge the social norms that perpetuate inequalities between men and women, and improving...