Third-party Healthcare Payer Research Articles

Epidemiology and comprehensive economic impact of atrial fibrillation and associated stroke in Slovakia.

Atrial fibrillation (AF) is the most common sustained cardiac arrhythmia. It is also a major risk factor for ischemic stroke. The main objective of our study was to identify direct and indirect costs of AF and AF-related stroke in Slovakia. We conducted a retrospective population-based study of AF and stroke related costs both from the third-party healthcare payers and societal perspective. The prevalence and incidence of AF and stroke were determined from central government run healthcare database. Further we estimated both indirect and direct costs of AF and stroke. All costs and healthcare resources were assessed from 2015 through 2019 and were expressed in the respective year. Over the 5-year study period, the prevalence of AF increased by 26% to a total of 149,198 AF cases in 2019, with an estimated total annual economic burden of €66,242,359. Direct medical costs accounted for 94% of the total cost of AF. The total cost of treating patients with stroke in 2019 was estimated at €89,505,669. As a result, the medical costs of stroke that develops as a complication of AF have been estimated to be €25,734,080 in 2019. Our study shows a substantial economic burden of AF and AF-related stroke in Slovakia. In view of the above, both screening for asymptomatic AF in high-risk populations and effective early management of AF with a focused on thromboprophylaxis rhythm control should be implemented.

Cost-effectiveness analysis of biologics for the treatment of chronic rhinosinusitis with nasal polyps in Canada

BackgroundDupilumab, omalizumab, and mepolizumab are the three biologics currently approved for use in CRSwNP in Canada. Despite evidence of efficacy, their cost-effectiveness, which is a key factor influencing prescribing patterns, has not yet been compared to each other.MethodsA cost-effectiveness model using quality-adjusted life years (QALYs) was constructed using a Decision Tree Markov analysis. A third-party healthcare payer perspective and a 10-year time horizon was used. A willingness-to-pay (WTP) threshold of 50,000 Canadian dollars (CAD) per QALY was used to determine cost-effectiveness. Dupilumab, omalizumab, and mepolizumab were each compared to each other.ResultsOmalizumab was the most cost-effective biologic using current estimates of cost and efficacy in CRSwNP. Using omalizumab as a baseline, dupilumab had an ICER of $235,305/QALY. Mepolizumab was dominated by omalizumab and dupilumab at the current drug prices and estimates of efficacy. Sensitivity analyses determined that when increasing the WTP threshold to $150,000/QALY, dupilumab became cost-effective compared to omalizumab in 22.5% of simulation scenarios. Additionally, altering dosing frequency had a significant effect on cost-effectiveness.ConclusionWhen comparing the relative cost-effectiveness of biologics in recalcitrant CRSwNP, omalizumab currently appears to be the most cost-effective option. Future reductions in drug prices, adjustments to currently approved dosing regimens, better patient selection, and improvements in sinus surgery outcomes will challenge the current cost-effectiveness models and necessitate reassessment as treatments for CRSwNP continue to evolve.

Orphan drugs' clinical uncertainty and prices: Addressing allocative and technical inefficiencies in orphan drug reimbursement.

Legislations incentivising orphan drug development and scientific advances have made orphan drugs pharma's high-end favourite for the past two decades. Currently, around 50% of new marketing authorizations are for orphan drugs. For third-party healthcare payers ("payers") the rise of orphan drugs presents new challenges, including a high degree of uncertainty around clinical benefits and harms, a moderate effect size (for many orphan drugs), and a high price tag. The association of high clinical uncertainty and moderate effect sizes is not surprising in small target populations but in combination with high prices creates the risk of allocative and technical inefficiencies for payers. We here discuss and illustrate these risks. A combination of policies is needed for mitigation of allocative inefficiency: while there may be a rationale for higher prices for orphan than non-orphan drugs, a focus of pricing and reimbursement negotiations should include considerations of product profitability and of the consequences of orphan drug costs on the distribution inequality of medication costs for individual insured persons, coupled to knowledge generation from reimbursement contracts covering high-price orphan drugs that would benefit the wider patient community. Performance-based managed entry agreements could help to de-risk the economic consequences of clinical uncertainty and to mitigate technical inefficiency.

Cost-effectiveness of a hybrid emergency room system for severe trauma: a health technology assessment from the perspective of the third-party payer in Japan

BackgroundHybrid emergency room (ER) systems, consisting of an angiography-computed tomography (CT) machine in a trauma resuscitation room, are reported to be effective for reducing death from exsanguination in trauma patients. We aimed to investigate the cost-effectiveness of a hybrid ER system in severe trauma patients without severe traumatic brain injury (TBI).MethodsWe conducted a cost-utility analysis comparing the hybrid ER system to the conventional ER system from the perspective of the third-party healthcare payer in Japan. A short-term decision tree and a long-term Markov model using a lifetime time horizon were constructed to estimate quality-adjusted life years (QALYs) and associated lifetime healthcare costs. Short-term mortality and healthcare costs were derived from medical records and claims data in a tertiary care hospital with a hybrid ER. Long-term mortality and utilities were extrapolated from the literature. The willingness-to-pay threshold was set at $47,619 per QALY gained and the discount rate was 2%. Deterministic and probabilistic sensitivity analyses were conducted.ResultsThe hybrid ER system was associated with a gain of 1.03 QALYs and an increment of $33,591 lifetime costs compared to the conventional ER system, resulting in an ICER of $32,522 per QALY gained. The ICER was lower than the willingness-to-pay threshold if the odds ratio of 28-day mortality was < 0.66. Probabilistic sensitivity analysis indicated that the hybrid ER system was cost-effective with a 79.3% probability.ConclusionThe present study suggested that the hybrid ER system is a likely cost-effective strategy for treating severe trauma patients without severe TBI.

Estimating costs and health outcomes of publicly funded tick-born encephalitis vaccination: A cost-effectiveness analysis

BackgroundThe number of notified cases of Tick-Borne Encephalitis (TBE) in Sweden has been increasing the past years despite the increased use of TBE-vaccine not subsidized by the healthcare system. Stockholm County is a high endemic area and an earlier study has shown that low-income households have lower vaccination coverage even when they are at high risk. This paper aims to determine the cost-effectiveness of a publicly funded TBE vaccination program in Stockholm. MethodsIn three different cohorts with individuals aged 3, 40 or 50 years, long-term costs and health outcomes of an out-of-pocket strategy (53% of the cohort is vaccinated on their own expenses) and a structured vaccination program (full cohort is vaccinated covered by the publicly funded health care system), were estimated using a Markov model. The Markov model predicts the costs and effects in term of Quality-adjusted Life Years (QALYs) over a lifetime horizon using a third-party healthcare payer perspective. The primary results are presented as an incremental cost effectiveness ratio (ICER) indicating the additional cost required to achieve one additional QALY with the structured vaccination program. ResultsThe results show that the structured vaccination program is associated with a gain in QALYs and increased costs compared with an out-of-pocket strategy. The calculated ICERs were 27 761, 99 527 and 160 827 SEK/QALY in cohorts of age 3, 40 and 50, respectively. The sensitivity analyses showed that the results are robust when varying different parameters. ConclusionGiven the setting of Stockholm county, this analysis shows a cost per QALY of a free vaccinations program, especially for children of 3 years old, below generally acceptable cost-effectiveness thresholds in Sweden.

Cost-Effectiveness Analysis of Paclitaxel-Coated Balloons for Endovascular Therapy of Femoropopliteal Arterial Obstructions

To explore the cost-effectiveness of using drug-eluting balloon (DEB) angioplasty for the treatment of femoropopliteal arterial lesions, which has been shown to significantly lower the rates of target lesion revascularization (TLR) compared with standard balloon angioplasty (BA). A simplified decision-analytic model based on TLR rates reported in the literature was applied to baseline and follow-up costs associated with in-hospital patient treatment during 1 year of follow-up. Costs were expressed in Swiss Francs (sFr) and calculated per 100 patients treated. Budgets were analyzed in the context of current SwissDRG reimbursement figures and calculated from two different perspectives: a general budget on total treatment costs (third-party healthcare payer) as well as a budget focusing on the physician/facility provider perspective. After 1 year, use of DEB was associated with substantially lower total inpatient treatment costs when compared with BA (sFr 861,916 vs. sFr 951,877) despite the need for a greater investment at baseline related to higher prices for DEBs. In the absence of dedicated reimbursement incentives, however, use of DEB was shown to be the financially less favorable treatment approach from the physician/facility provider perspective (12-month total earnings: sFr 179,238 vs. sFr 333,678). Use of DEBs may be cost-effective through prevention of TLR at 1 year of follow-up. The introduction of dedicated financial incentives aimed at improving DEB reimbursements may help lower total healthcare costs.

Cost-Effectiveness of Two Inexpensive Postfracture Osteoporosis Interventions: Results of a Randomized Trial

Most older patients are not treated for osteoporosis after fragility fracture. In a 3-armed randomized trial, we reported that 2 inexpensive mail-based interventions, one directed at physicians and the other at physicians plus patients, increased 1-year osteoporosis treatment starts by 4% and 6% (respectively) compared with usual care starts of 11%. The cost-effectiveness of these interventions is unknown. The incremental cost-effectiveness of interventions compared with usual care was assessed using Markov decision-analytic models. Costs were expressed in 2010 Canadian dollars and long-term effectiveness based on quality-adjusted life years (QALYs) gained derived from hypothetical model simulations. The perspective was third-party health care payer; the time horizon was lifetime; and the costs and benefits were discounted 3%. The physician intervention cost was $7.12 per patient, whereas the physician plus patient intervention cost was $8.45. Compared with usual care, the economic simulation demonstrated that for every 1000 patients getting the physician intervention, there were 2 fewer fractures, 2 more QALYs gained, and $22,000 saved. Compared with physician intervention, the simulation demonstrated that for every 1000 patients receiving physician plus patient intervention, there was 1 fewer fracture and 1 more QALY gained, with $18,000 saved. Both interventions dominated usual care and were cost saving or highly cost effective in 67% of 10 000 probabilistic simulations. Although the physician plus patient intervention cost was $1.33 more per patient than the physician intervention, it was still the most economically attractive option. Pragmatic mail-based interventions directed at patients with recent fractures and their physicians are a highly cost-effective means to improving osteoporosis management and both interventions dominated usual care.

Influence of gait training and prosthetic foot category on external work symmetry during unilateral transtibial amputee gait

Prosthetic foot prescription guidelines lack scientific evidence and are concurrent with an amputee's concurrent with an amputee's Medicare Functional Classification Level (K-Level) and categorization of prosthetic feet. To evaluate the influence of gait training and four categories of prosthetic feet (K1, K2, K3, and microprocessor ankle/foot) on Symmetry in External Work for K-Level-2 and K-Level-3 unilateral transtibial amputees. Randomized repeated-measures trial. Five K-Level-2 and five K-Level-3 subjects were tested in their existing prosthesis during Session 1 and again in Session 2, following 2 weeks of standardized gait training. In Sessions 3-6, subjects were tested using a study socket and one of four randomized test feet. There was an accommodation period of 10-14 days with each foot. Symmetry in External Work for positive and negative work was calculated at each session to determine symmetry of gait dynamics between limbs at self-selected walking speeds. K-Level-2 subjects had significantly higher negative work symmetry with the K3 foot, compared to K1/K2 feet. For both subject groups, gait training had a greater impact on positive work symmetry than test feet. Higher work symmetry is possible for K-Level-2 amputees who are trained to take advantage of K3 prosthetic feet designs. There exists a need for an objective determinant for categorizing and prescribing prosthetic feet.

Direct healthcare costs for 5 years post-fracture in Canada

High direct incremental healthcare costs post-fracture are seen in the first year, but total costs from a third-party healthcare payer perspective eventually fall below pre-fracture levels. We attribute this to higher mortality among fracture cases who are already the heaviest users of healthcare ("healthy survivor bias"). Economic analyses that do not account for the possibility of a long-term reduction in direct healthcare costs in the post-fracture population may systematically overestimate the total economic burden of fracture. High healthcare costs in the first 1-2 years after an osteoporotic fracture are well recognized, but long-term costs are uncertain. We evaluated incremental costs of non-traumatic fractures up to 5 years from a third-party healthcare payer perspective. A total of 16,198 incident fracture cases and 48,594 matched non-fracture controls were identified in the province of Manitoba, Canada (1997-2002). We calculated the difference in median direct healthcare costs for the year pre-fracture and 5 years post-fracture expressed in 2009 Canadian dollars with adjustment for expected age-related healthcare cost increases. Incremental median costs for a hip fracture were highest in the first year ($25,306 in women, $21,396 in men), remaining above pre-fracture baseline to 5 years in women but falling below pre-fracture costs by 5 years in men. In those who survived 5 years following a hip fracture, incremental costs remained above pre-fracture costs at 5 years ($12,670 in women, $7,933 in men). Incremental costs were consistently increased for 5 years after spine fracture in women. Total incremental healthcare costs for all incident fractures combined showed a large increase over pre-fracture costs in the first year ($137 million in women, $57 million in men), but fell below pre-fracture costs within 3-4 years. Elevated total healthcare costs were seen at year 5 in women after wrist, humerus and spine fractures, but these were somewhat offset by decreases in total healthcare costs for other fractures. High direct healthcare costs post-fracture are seen in the first year, but total costs eventually fall below pre-fracture levels. Among those who survive 5 years following a fracture, healthcare costs remain above pre-fracture levels.

Let's Get SEERious: More Accurate Staging With Consequent High Management Impact Is Not Just Stage Migration

issue in heath care resourcing. Although individuals with non–smallcell lung carcinoma (NSCLC), their physicians, and third-party health care payers deserve reassurance that the increasing use of positron emission tomography (PET) is beneficial, we have significant concerns regarding the methodology applied and, consequently, the validity of the resulting conclusions. Most importantly, we feel that all-cause survival is an inappropriate primary end point for judging the benefits of a diagnostic test. This parameter ignores the potential of a superior investigation to guide more efficient and appropriate use of therapeutic interventions and to induce changes in management that may influence quality of life or progressionfree survival in particular patient subgroups without necessarily affecting long-term survival. This is particularly relevant in a disease like NSCLC in which current therapeutic interventions have suboptimal efficacy and are associated with substantial cost and toxicity. Nevertheless, because it has been previously established that the dominant effect of applying PET to NSCLC staging is the detection of unrecognized metastases, 2,3 a logical assumption must be that palliative therapies would be more frequently applied with increasing use of PET. If PET inappropriately upstages patients and results in patients’ denial of potentially curative therapies, overall survival should logically deteriorate. The authors’ finding that all-cause survival did not change significantly with the increasing use of PET supports a conclusion that PET may reduce morbidity associated with futile therapies without negatively affecting overall patient outcomes. We believe that if any conclusion can be reached, their data thus support rather than repudiate the utility of PET in NSCLC. As there is currently no curative therapy available for stage 4 NSCLC, it is unreasonable to expect a large change in overall survival with the application of PET. The earliest study end point of 2-year overall survival used by the authors is, we contend, too long to reliably detect improvements in survival associated with better selection and delivery of palliative treatments in such patients. In our own recently published prospective trial of PET/computed tomography in NSCLC, the median survival of patients with stage 4 disease on PET was less than a year and almost all patients in this stage group died within 2 years. 4 Moreover, patients who died as an immediate complication of futile therapy would also not be detected because the study excluded patients who died within 2 months.

Cost-effectiveness of a multifaceted intervention to improve quality of osteoporosis care after wrist fracture

In a randomized trial, a multifaceted intervention tripled rates of osteoporosis treatment in older patients with wrist fracture. An economic analysis of the trial now demonstrates that the intervention tested "dominates" usual care: over a lifetime horizon, it reduces fracture, increases quality-adjusted life years, and saves the healthcare system money. In a randomized trial (N = 272), we reported a multifaceted quality improvement intervention directed at older patients and their physicians could triple rates of osteoporosis treatment within 6 months of a wrist fracture when compared with usual care (22% vs 7%). Alongside the trial, we conducted an economic evaluation. Using 1-year outcome data from our trial and micro-costing time-motion studies, we constructed a Markov decision-analytic model to determine cost-effectiveness of the intervention compared with usual care over the patients' remaining lifetime. We took the perspective of third-party healthcare payers. In the base case, costs and benefits were discounted at 3% and expressed in 2006 Canadian dollars. One-way deterministic and probabilistic sensitivity analyses were conducted. Median age of patients was 60 years, 77% were women, and 72% had low bone mineral density (BMD). The intervention cost $12 per patient. Compared with usual care, the intervention strategy was dominant: for every 100 patients receiving the intervention, three fractures (one hip fracture) would be prevented, 1.1 quality-adjusted life year gained, and $26,800 saved by the healthcare system over their remaining lifetime. The intervention dominated usual care across numerous one-way sensitivity analyses: with respect to cost, the most influential parameter was drug price; in terms of effectiveness, the most influential parameter was rate of BMD testing. The intervention was cost saving in 80% of probabilistic model simulations. For outpatients with wrist fractures, our multifaceted osteoporosis intervention was cost-effective. Healthcare systems implementing similar interventions should expect to save money, reduce fractures, and gain quality-adjusted life expectancy.

Long-term costs and clinical outcomes associated with metformin-glibenclamide combination tablets (Glucovance®) in patients with type 2 diabetes sub-optimally controlled by metformin: a modelling study in the French setting

Objectives Most patients eventually become hyperglycaemic on metformin monotherapy. We modelled clinical and economic consequences for such patients of switching to a single-tablet metformin-glibenclamide combination (Glucovance®) or glibenclamide, or increasing metformin dosage. Methods A validated computer simulation model of diabetes projected long-term clinical and cost outcomes for the French setting, using data from a 16-week randomised controlled trial. Results Compared with metformin, Glucovance® 500/2.5 mg or 500/5 mg was associated with increased quality-adjusted life expectancy (0.45 and 0.27 quality-adjusted life-years [QALYs] respectively; base case analysis), reduced direct medical costs (by 3,331 and 2,026) and fewer diabetes-related complications. Compared with glibenclamide, Glucovance® 500/5 mg increased quality-adjusted life expectancy by 0.28 QALYs and reduced direct medical costs by 1,793. Conclusions From a third-party healthcare payer perspective in France, Glucovance® represents a dominant treatment option versus metformin or glibenclamide for patients sub-optimally controlled on metformin monotherapy.

Therapy conversion to insulin detemir among patients with type 2 diabetes treated with oral agents: A modeling study of cost-effectiveness in the United States

The aim of this study was to gain a preliminary indication of the long-term clinical and economic implications of converting treatment for patients with type 2 diabetes to insulin detemir+/-oral hypoglycemic agents (OHAs) in a routine clinical practice setting in the United States. With the use of outcome data and patient characteristics reported from an ongoing prospective observational trial, a validated computer simulation model of diabetes was used to project the clinical and cost outcomes associated with therapy conversion to insulin detemir over a 35-y period from (1) OHA only, (2) neutral protamine Hagedorn insulin (NPH)+/-OHA, and (3) insulin glargine+/-OHA. Cost-effectiveness was assessed from a third-party healthcare payer perspective for the year 2005. Costs and clinical outcomes were discounted at a rate of 3%. Treatment with insulin detemir+/-OHA was associated with increases in quality-adjusted life expectancy of 0.309, 0.350, and 0.333 quality-adjusted life-years (QALYs) versus treatment with OHA alone, NPH+/-OHA, and insulin glargine+/-OHA, respectively. Increases in pharmacy costs were partially offset by reduced complications, rticularly renal complications and neuropathy. Projected incremental cost-effectiveness ratios were well within the range considered to represent good value in the United States, at $7412, $6269, and $3951 per QALY gained for treatment with Idet+/-OHA versus OHA alone, NPH+/-OHA, and Iglarg+/-OHA, respectively. On the basis of preliminary evidence of short-term improvements in glycemic control and reduced hypoglycemia, therapy conversion to insulin detemir+/-OHA from OHA alone, NPH+/-OHA, or insulin glargine+/-OHA was projected to increase quality-adjusted life expectancy and to represent a cost-effective treatment option in the United States.

Visual Function Assessment Questionnaires

With increased emphasis on functional outcomes in ophthalmology, third-party health care payers and research funding agencies have turned their attention to the development and use of visual function questionnaires. Since 1980, more than a dozen such self-report visual function questionnaires have been developed. All of these instruments include items that ask about specific daily activities; patients must respond with a rating that represents the level of difficulty that they experience with the activity described. This article reviews all of the known instruments, with special attention paid to their validity and reliability. Most validation studies have reported high response consistency across items and significant correlations of instrument scores with visual impairment measures. Only two studies have measured test–retest reliability. The developers of visual function questionnaires typically divide the items into several different subscales, suggesting that different variables are being measured. Although the items are very similar for the different instruments, there is little agreement among instruments on the definition of subscales. All instruments are scored as the average of the ordinal patient ratings across items for each subscale and/or for the total instrument. Measurement issues underlying the scoring of ordinal patient ratings are discussed. It is argued that unless the instruments can be converted to interval scales, the averaging of patient ratings does not yield true measurements. The three visual function questionnaires that were calibrated with a statistical item response model, which estimates interval scales, are reviewed. It is concluded that future research and development should devote additional attention to the measurement properties of functional assessment instruments.