The burden of health-care costs on society continues to grow. U.S. health-care expenditures reached $4.9 trillion in 2023, accounting for 17.6% of the U.S. gross domestic product1. In a world of limited resources, alternative treatment options need to be evaluated for their cost-effectiveness in addition to their comparative safety and effectiveness. The article by Suter et al. provides a useful cost-effectiveness analysis of the 2 alternative treatments for displaced, closed humeral shaft fractures, with practical implications for shared decision-making at the individual patient level. The practicing traumatologist must consider 2 reasonable options when treating displaced, closed humeral shaft fractures: (1) nonoperative treatment with functional bracing and (2) open reduction with internal fixation (ORIF). Nonoperative management of closed humeral shaft fractures was the established norm during the 20th century, especially after functional bracing was introduced by Sarmiento in 19772. ORIF, developed to decrease the period of immobilization and to quicken the return to function, has since become the predominant treatment modality in the U.S., with utilization increasing from 47.2% of humeral shaft fractures in 2002 to 60.3% of humeral shaft fractures in 20113. A recently published analysis found that patients who were on Medicare or Medicaid or who were self-paying were significantly less likely to undergo operative treatment for humeral shaft fractures4. Outside the U.S., functional bracing remains recommended as the first treatment of choice. Clearly, economic resource limitations continue to drive ongoing disparities in the treatment of displaced, closed humeral fractures. The prespecified economic analysis by Suter et al. compares ORIF and functional bracing in the Finnish health-care system with use of prospectively collected economic and outcome data from a pragmatic randomized clinical trial (RCT) for which 1-, 2-, and 5-year clinical results have already been published5–7. These published reports found significantly improved DASH (Disabilities of the Arm, Shoulder and Hand) and Constant-Murley shoulder function scores for the surgery group compared with the bracing group at 6 weeks and 3 months of follow-up but no significant differences at 1 year (the primary outcome measure) or at 2 and 5 years, suggesting that the ultimate trajectory of recovery was similar regardless of the allocated treatment group. In their comparison of societal versus health-care perspectives, Suter et al. identified patient-specific factors that influenced the cost-effectiveness of these 2 treatment alternatives. The base-case analysis, prespecified as the societal perspective, found that ORIF was more effective than functional bracing and yielded a cost-saving incremental net monetary benefit (INMB) of €9,423. Surgery was also clinically favored for health-related quality of life measured using the 15D utility instrument. This result was considered a cost-effectiveness win-win for society, with all bootstrapped estimates overwhelmingly found in the lower right (win-win) quadrant of the standard cost-effectiveness plane. This societal cost-saving was primarily driven by the inclusion of the indirect cost of time away from work for employed patients. Conversely, when the analysis considered only direct health-care costs, ORIF became markedly more expensive than functional bracing, with an INMB of +€4,087. Despite the solid evidence of the cost-effectiveness of ORIF from the societal perspective and the finding that 32% of patients who were randomized to functional bracing still required surgery, policy-makers might still tend to favor functional bracing because of health-care resource limitations. Simply put, humeral fracture is just 1 of many “buckets” of societal costs related to injury or degenerative conditions. Policy-makers must allocate available funds among buckets corresponding to multiple disease states and treatments. Randomized health economic trials are the gold-standard tool for guiding the allocation of funds among disease and/or treatment-specific health-care buckets at the societal level. Suter et al. also provide pragmatic evidence to inform treatment decisions for individual patients. This report should be of interest to both practicing clinicians and health economists. Cost-effectiveness was primarily calculated as an INMB in simple € terms that are easy for clinicians to understand. The incremental cost-effectiveness ratio (ICER) favored by health economists was included in the Appendix to facilitate comparison across multiple disease states and treatments. The societal cost-effectiveness of ORIF also has relevant implications for shared decision-making at the individual patient level, establishing a useful framework for patient-physician discussions. This analysis highlights the importance of taking multiple clinical and socioeconomic factors into consideration when making patient-specific decisions. Moreover, it suggests the need for patient-specific flexibility in health-care policy, rather than the typically rigid reliance on treatment guidelines imposed by payers who are forced to deal with group-level effects and resource limitations.

Health, economic, and equity impact of a COVID-19 mobile vaccine clinic program in US: a cost-effectiveness analysis.

Feasibility of Home Hemodialysis for Colombia, Cost-Effectiveness Perspective.

Cost-effectiveness of community-based interventions for reducing opioid overdose and non-overdose deaths: simulation modeling of HEALing Communities Study.

Psoriatic disease, including psoriasis and psoriatic arthritis, is associated with increased risk of comorbidities (cardiovascular disease, mental health disorders, type 2 diabetes mellitus and obesity), placing substantial burden on patients and health systems. We aimed to quantify the lifetime economic burden of these four comorbidities in populations with moderate-to-severe psoriasis and psoriatic arthritis. We subsequently estimated the potential comorbidity-related gross cost offsets from timely systemic therapy across three diverse country settings (Denmark, the USA and Vietnam). We conducted a literature review to identify data on prevalence, comorbidity risk, treatment-associated risk reduction and cost inputs, followed by development of a static cohort-based economic model from a societal perspective. The model compared untreated/undertreated moderate-to-severe psoriasis/psoriatic arthritis; and systemic treatment scenarios (conventional systemic disease-modifying antirheumatic drugs [csDMARDs]; biologic DMARDs [bDMARDs]; and targeted synthetic DMARDs [tsDMARDs]) over a lifetime horizon in Denmark, the USA and Vietnam, reporting total comorbidity cost offsets across direct (healthcare) and indirect (societal) costs. Systemic treatment reduced lifetime comorbidity-related direct and societal costs across settings. In the USA, patients with moderate-to-severe psoriasis incurred annual direct costs of approximately 4.6 billion USD (indirect 0.6 billion USD), and untreated lifetime burden of about 153.0 billion USD. Treating all patients with bDMARDs yielded an estimated cost offset of 62.9 billion USD in the direct costs and an offset of 8.1 billion USD in the societal costs compared with a fully undertreated population. Equivalent analyses in Denmark and Vietnam reflected similar effects on comorbidity-related costs. The model shows that early systemic therapy yields substantial effect on the direct and societal costs via reduced comorbidity incidence. Timely and efficacious systemic treatment of psoriatic disease can significantly reduce lifetime economic burden of comorbidities across diverse healthcare settings. These findings underscore the value of early, proactive management of psoriatic disease and highlight the need for further cost-effectiveness research, including treatment uptake and real-world comorbidity prevention.

Economic Evaluation and Budget Impact Analysis of Secukinumab as a Second-Line Treatment Among Patients With Psoriatic Arthritis Who Were Tumor Necrosis Factor Inadequate Responders in Thailand.

Cost-Utility and Budget Impact Analysis of Pharmacogenetic-Guided Antiplatelet Therapy for Acute Coronary Syndrome in Thailand.

Cost-Utility Analysis of Adjuvant Osimertinib in Resected Epidermal-Growth-Factor-Receptor-Mutated Early-Stage Non-Small Cell Lung Cancer.

Economic burden of leukemia diagnosis and treatment in South Africa: A retrospective cost of illness analysis.

The aim of this study was to evaluate the cost-effectiveness of a problem-solving intervention with workplace involvement (PSI-WPI) compared with care as usual (CAU) among employees on sick leave due to common mental disorders in Swedish primary healthcare centers. Employees aged 18 to 59 years on sick leave for common mental disorders (n = 197) were included in a controlled cluster-randomized trial by coordinators (n = 19) recruited at primary care centers in Region Västra Götaland, Sweden. The study was conducted between February 2018 and August 2021, with 18 months of follow-up per participant. The economic evaluation included a cost-effectiveness analysis comparing changes in sick leave with direct costs from a healthcare perspective, calculated from register data, and intervention costs; a cost-utility analysis based on EQ-5D questionnaires and a societal perspective included indirect costs calculated from registered sick leave. Sensitivity analyses explored robustness to alternative missingness assumptions. The PSI-WPI resulted in more sickness absence (average 40 extra days; 95% confidence interval, 3-77 days) compared with CAU and higher healthcare costs (SEK 21 650, SEK 4962-48 262) over 18 months. At 12 months, the cost of care was SEK 23 734 (SEK 537-46 931) higher in the PSI-WPI group. The difference in quality-adjusted life-years between the groups was negligible. The sensitivity analysis indicated robust results, and diagnoses not targeted by the study were important cost drivers. The PSI-WPI was not cost-effective for employees on sick leave due to common mental disorders compared with CAU only.

Anxiety disorders are common in children and adolescents, but constrained resources limit access to cognitive-behavioral therapy (CBT). Stepped and stratified care models offer different ways to organize care. Stepped care starts with lower-resource CBT and escalates when needed, whereas stratified care matches CBT format to patient complexity from the outset. Economic evidence comparing these models remains scarce. We conducted a pilot economic evaluation alongside an RCT of 51 youths with anxiety disorders to examine the feasibility of health-economic evaluation and generate preliminary cost-effectiveness estimates. Participants were randomized to stepped care (guided internet-delivered CBT [iCBT] with escalation to in-person CBT if needed, n = 25) or stratified care (baseline allocation to guided iCBT or in-person CBT with escalation to in-person CBT if needed, n = 26). Health outcomes and costs from the healthcare and societal perspectives were collected over 6 months, with the base case analysis estimating the change in utility scores. Incremental cost-effectiveness ratios (ICERs) were estimated using non-parametric bootstrapping. Stratified care yielded greater, though not statistically significant, health gains than stepped care and was dominant from the societal perspective. From the healthcare perspective, the AUC-derived quality-adjusted life years (QALY) sensitivity analysis yielded an ICER of USD 6,878 per QALY gained, although estimates remained uncertain given the small pilot sample. Subgroup analyses by age, sex, and treatment response generally supported these patterns while highlighting heterogeneity. These findings support the feasibility of conducting economic evaluations of care models in routine youth mental health care, but larger trials are needed to provide more precise cost-effectiveness estimates and inform service-delivery policy.

In 2021, globally, cardiometabolic diseases (CMDs) accounted for 35% of the 1.73 billion disability-adjusted life years (DALYs) attributed to non-communicable diseases. The Healthy Life Trajectories Initiative (HeLTI), a four-country randomised controlled trial based on the developmental origins of health and disease(DOHaD) concept, evaluates whether integrated longitudinal public health interventions started prepregnancy reduce the risk of childhood adiposity and, consequently, the development of CMDs in the offspring. This paper presents the protocol for the economic evaluation of the interventions in the Indian arm of HeLTI. The aim is to facilitate the translation of effective and affordable preventive strategies that mitigate the health, social and economic burden of CMDs. A within-trial economic evaluation will be conducted from provider, health system and societal perspectives. Costs will be identified using the activity-based costing method mapped onto a theory-of-change framework that attributes interventions to health outcomes. Costs will include both direct and indirect costs as well as capital and recurring costs. Cost data will be collected using project accounts, time-use tools, surveys and key informant interviews. The incremental cost-effectiveness ratio (ICER) will be estimated for the fat mass index, a measure of adiposity, the primary health outcome, at the fifth year of offspring. Cost-utility and cost-consequence results will be presented for health-related quality of life (HRQoL) and other secondary health outcomes, respectively, in mothers and offsprings. Sensitivity of the results to assumptions will be analysed and uncertainty intervals will be presented. Equity impact of the outcomes will be assessed using the social determinants of health framework. The study has been approved by the ethics committees of the lead local institutions, CSI Holdsworth Memorial Hospital (Ref CSIHMH/ERU2019/1) and Swami Vivekananda Youth Movement (Ref IRB 004/2020-21). Findings will be disseminated through scholarly articles, policy briefs, opinion pieces, conferences, interactive sessions with stakeholders and the HeLTI website. ISRCTN20161479.

Cost-Effectiveness of Vaccine for the Prevention of Herpes Zoster in Kidney Transplant Recipients in Thailand.

The Higher or Lower Hemoglobin Transfusion Thresholds for Preterm Infants randomized trial compared higher versus lower hemoglobin transfusion thresholds in extremely low birth weight infants. This publication compares the economic implications of the two strategies. We undertook a prospectively-planned economic evaluation, using patient level data from the parent clinical trial. We report costs in 2020 United States dollars, from health sector and modified societal perspectives, with a time horizon through the end of clinical follow-up. We derived costs from hospital finance systems, Medicaid fee schedules, and family questionnaires, and efficacy from trial data. Of the 1824 patients enrolled in the trial in 19 centers, data were available for 1305 for analysis from a health sector perspective, and 752 for analysis from a societal perspective. The mean cost from the health sector perspective was USD 331,186 per patient in the higher hemoglobin transfusion threshold group and USD 351,579 in the lower hemoglobin transfusion threshold group; the difference was not statistically significant after adjustment for study site and birth weight stratum (p=0.085). The mean costs from the societal perspective were also not statistically significant (p=0.094). The incremental cost-effectiveness ratios for adoption of a lower tranfusion threshold from health sector and societal perspectives were USD 6,797,666 and USD 5,596,666 per additional survivor without NDI, respectively. There was substantial uncertainty in these cost-effectiveness estimates. Similarly to prior results for clinical efficacy, choosing between a lower or higher hemoglobin transfusion threshold for extremely preterm infants has no significant economic advantage.

Varicella vaccination is not currently included in Portugal's childhood national immunization program. We modeled the clinical and economic impact of a two-dose universal varicella vaccination (UVV) program in Portugal. A dynamic transmission model was adapted to Portugal to assess the impact of UVV over a 50-year time horizon. Two two-dose UVV strategies (first dose at 12 months, second dose at 5 years) were compared to no vaccination. Clinical outcomes included varicella and herpes zoster incidence rates, cases, deaths, quality-adjusted life years (QALYs) lost, and varicella-related health care resource use. Costs were assessed from the payer perspective (direct costs of treatment) and societal perspective (direct costs plus indirect costs of lost workdays). Both UVV strategies reduced total varicella cases by 79.4-85.3%, outpatient visits by 78.9-84.8%, and varicella hospitalizations by 69.3-71.3% compared to no varicella vaccination. Herpes zoster cases were reduced by 2.4-2.9%. These strategies resulted in the gain of 5977-6094 QALYs and cost savings of €12.0 million (M)-15.9M from the payer perspective and €84.2M-93.9M from the societal perspective. A two-dose UVV program is estimated to substantially reduce the burden of varicella disease in Portugal and to be cost-saving from both the payer and societal perspectives.

Despite growing awareness of organ donation, the persistent shortage of transplantable organs remains a challenge. Machine perfusion (MP) is a preservation technique that increases organ availability. As these technologies evolve, robust economic evaluations offer an opportunity to guide timely and consistent decision-making in transplantation. Therefore, the aim was to investigate existing economic evaluations of MP to determine to what extent they capture all relevant outcomes and mechanisms. Using JBI and PRISMA guidelines, a 3-step approach was used to identify (1) all MP-related outcomes reported in studies, (2) evaluate how these outcomes were incorporated into economic evaluations, and (3) examine the mechanisms used in economic models. Of 902 references, 43 studies were included. We found that (1) the beneficial outcomes of MP extended beyond complications, including reduced waitlist mortality, lower posttransplant costs, and improved logistics; (2) the incorporation of these outcomes varied within and among organ types, no study applied a societal perspective, and models differed in cycle length, time horizon, and health states; and (3) waitlist and complication effects were inconsistently modeled. More exhaustive and transparent use of mechanisms in economic evaluations in transplant care is needed to reach optimal decisions in policy, clinical practice, and research investments.

Which infertility treatment pathway is most cost-effective for women with polycystic ovary syndrome (PCOS)-related infertility in centres with expertise in oocyte in vitro maturation (IVM)? Cost-effectiveness analysis of treatment pathways for PCOS-related infertility using a Markov decision-analytic model. Real-life data from 517 anovulatory PCOS patients treated between January 2018 and January 2023 at a Belgian tertiary infertility clinic informed model parameters and defined the treatment-as-usual (TAU) strategy. Five pathways including incremental cycles of letrozole, low-dose gonadotropins, assisted reproductive technology (ART) after conventional ovarian stimulation (COS) or IVM were modelled and compared to TAU. Patients transitioned between treatment cycles, resulting in ongoing pregnancy or drop-out over a 24-month horizon. Costs were assessed from healthcare and societal perspectives, including direct and indirect costs. Incremental cost-effectiveness ratios (ICERs) were calculated, with sensitivity analyses performed. Ongoing pregnancy rates (OPR) after the first, fourth, and sixth letrozole cycles were 16.1%, 41.6%, and 45.7%, with minimal gain beyond 4cycles. Deterministic analysis identified two cost-effective pathways: (a) 4cycles of letrozole followed by 2cycles of low-dose gonadotropins and COS, and (b) 4cycles of letrozole followed by 2cycles of low-dose gonadotropins, 1cycle of IVM, and COS, with ICERs of -€8174 and -€10,805 from the healthcare perspective, and -€11,494 and -€14,083 from the societal perspective, respectively. Incorporating IVM as second-line would require a 25.7% relative OPR increase from IVM, to become the most cost-effective pathway. Probabilistic sensitivity analyses confirmed robustness. This model highlights the role of IVM as a valuable component of PCOS infertility treatment in centres of expertise, with potential for greater impact as culture systems advance.

Quantifying the Economic Value of AI-Assisted Diabetic Retinopathy Screening: A Meta-Analysis Using the Incremental Net Benefit Framework.

To determine drug-specific FRAX® thresholds for cost-effective initiation of osteoporosis treatment (alendronate, zoledronate, denosumab, teriparatide) in Chinese postmenopausal women using real-world data. A validated Markov microsimulation model was used to simulate lifetime costs and quality-adjusted life years (QALYs) of no treatment versus alendronate, zoledronate, denosumab, and teriparatide treatment. Baseline patient characteristics and risk factor distribution were sampled from the largest national osteoporosis survey in mainland China. The analysis was conducted from the societal perspective, applying a willingness-to-pay threshold of USD 13,000 per QALY gained (equivalent to one times China's GDP per capita). Denosumab was cost-effective at a 10-year major osteoporotic fracture probability of 7% and zoledronate at 12%; neither alendronate nor teriparatide became cost-effective. For denosumab, the cost-effective threshold of 10-year major osteoporotic fracture probability increased with age from 51 to 65years and then declined in older women, ranging from 5 to 12%. For zoledronate treatment, the cost-effective thresholds of a 10-year major osteoporotic fracture probability were 8% at 51-55years, 12% at 71-75years, and 8.5% at 76-80years. For Chinese postmenopausal women, denosumab was the most cost-effective treatment, while zoledronate also reached favorable thresholds in selected age groups. Implementing drug-specific FRAX®-guided thresholds may optimize treatment decisions for osteoporosis and support efficient healthcare resource use.

IntroductionIn many low- and middle-income countries, there is widespread use of point-of-care tests (POCTs) to diagnose a variety of infectious diseases, even in hospitals due to weak laboratory capacity. Often, POCT use is unregulated and expensive while the use of substandard tests is common. A cost-effectiveness analysis was conducted to investigate which POCTs for non-malarial febrile illness (NMFI) represent the best use of resources in Lao PDR in outpatient settings, assuming best-in-class POCTs are used.MethodsA decision-tree cost-effectiveness analysis was conducted to simulate use of POCTs of interest for outpatients presenting with NMFI, compared to clinical assessment alone. The analyses were performed from both healthcare provider’s perspective and a limited societal perspective, which included cost estimates of the contribution of antibiotic consumption by class to future AMR costs. Deterministic and probabilistic analyses were performed.ResultsIn probabilistic and deterministic analyses, dengue and rickettsia POCTs were consistently cost-effective and the most cost-effective of the four POCTs evaluated. Deterministic analyses estimated that typhoid and leptospirosis POCTs were cost-effective compared with clinical assessment alone. However, in probabilistic analyses, clinical assessment was more likely to be cost-effective than typhoid or leptospirosis POCTs at the estimated cost-effectiveness threshold in the Lao PDR.ConclusionsThis evaluation was able to make use of comprehensive primary data from fever studies in Lao PDR, giving an understanding of the aetiology and prescribing behaviour of physicians for undifferentiated NMFI. However, sensitivity analyses showed that there was substantial uncertainty about which strategy would be most cost-effective and if substandard POCTs were analysed then it is more likely that clinical assessment alone would be the most cost-effective strategy. This research shows that there is good reason to be cautious about the overuse of POCTs for NMFI and whether they represent good value for money in low-income contexts compared with clinical assessment alone.