Traditional Cost-effectiveness Research Articles

Drug-Eluting Stents

“Does it make economic sense to completely abandon a therapy that works well for 85% to 90% of the population for a new therapy costing four times as much to treat a transient health condition with no impact on either death or myocardial infarction?” J.M. Brophy and L.J. Erickson1 Since Andreas Gruntzig performed the first percutaneous coronary intervention (PCI) in 1977,2 the cost-effectiveness of this procedure has engendered major controversy. Debates have erupted over the clinical value and cost-effectiveness of each new device or therapy that has become available. Controversies have arisen regarding the cost of atherectomy, bare metal stents (BMS), brachytherapy, distal protection devices, glycoprotein IIb/IIIa inhibitors, and intravascular ultrasound.3–6 Drug-eluting stents (DES) are the most recent devices to have their cost scrutinized.7–12 Response by Ryan and Cohen p 1754 Balloon angioplasty is associated with restenosis rates of 30% to 40%, whereas PCI with BMS is associated with rates of 20% to 30%,13,14 and PCI with DES is associated with rates in the single digits.15,16 My colleagues and I pooled the results of 11 DES trials involving >5000 patients using a hierarchical Bayesian random-effects model.17 We found that, compared with BMS, DES reduce angiographic restenosis from 29.3% to 8.9% (Table 1 and Figure 1). There was no difference between DES and BMS in terms of mortality (0.9% versus 0.9%, respectively) or myocardial infarction (2.7% versus 2.9%, respectively). There was a suggestion that restenosis was less with sirolimus-eluting stents (SES) compared with polymeric paclitaxel-eluting stents (PES) (6.2% for SES versus 36.9% for BMS; 7.1% for PES versus 23.5% for BMS), a finding that was subsequently identified in another meta-analysis.18 View this table: TABLE 1. Clinical Events and Restenosis Rates in Randomized Clinical Trials Investigating DESs Figure 1. Forest plot comparing rates of angiographic restenosis for …

Sexual and reproductive health: challenges for priority-setting in Ghana's health reforms.

Many countries are undertaking widespread structural change of their health sectors. There is mounting concern that priority-setting mechanisms used in planning the reforms are not suited to recognizing or taking account of the needs and priorities of sexual and reproductive health (SRH) services. The main aim of this research was to assess the sensitivity of the priority-setting tools and mechanisms used in the development of the health sector reforms in Ghana, to the needs and priorities of SRH services, and to consider how priority-setting mechanisms could be improved. We conclude that priority-setting tools in Ghana's reform process were rudimentary, and SRH donors and advocates were little involved. While it is tempting for a strong programme like Ghana's SRH programme to remain independent, we argue that closer involvement in system-wide reforms is a preferable long-term objective. Clearly, SRH priorities need safeguarding within a systems approach and we suggest a number of ways in which this can be achieved. Most importantly, the SRH community, in collaboration with the wider development community, needs to challenge current priority-setting mechanisms and the long-held view that traditional disease-ranking and cost-effectiveness measures are necessarily the best, most accurate way to measure health priorities. Traditional priority-setting tools do not adequately reflect the long-term benefits of preventive interventions such as family planning, and are therefore not an adequate reflection of holistic health sector planning needs. In response to this, there needs to be greater commitment from the international development and research communities to: (1) support collaboration between economists and reproductive health specialists to develop better measures for the effectiveness and impact of SRH services; and (2) in the interim, accept proxies for priority-setting which may include small-scale, qualitative research data combined with priorities identified by SRH specialists. To achieve this, the priority-setting processes need to become more inclusive and SRH specialists need to be proactive in their engagement with health sector decision-makers.

Resource allocation for control of infectious diseases in multiple independent populations: beyond cost-effectiveness analysis

Traditional cost-effectiveness analysis (CEA) assumes that program costs and benefits scale linearly with investment—an unrealistic assumption for epidemic control programs. This paper combines epidemic modeling with optimization techniques to determine the optimal allocation of a limited resource for epidemic control among multiple noninteracting populations. We show that the optimal resource allocation depends on many factors including the size of each population, the state of the epidemic in each population before resources are allocated (e.g. infection prevalence and incidence), the length of the time horizon, and prevention program characteristics. We establish conditions that characterize the optimal solution in certain cases.

Combining a budgetary-impact analysis and a cost-effectiveness analysis using decision-analytic modelling techniques.

Reimbursement of new drugs is usually based on the budgetary impact of a new drug but there is also increasing demand for cost-effectiveness data on new drugs. To present a modelling technique (methodology) for an appropriate assessment of the budgetary impact of a new drug, which can simultaneously be used for a traditional cost-effectiveness analysis. DESIGN AND PERSPECTIVE: To illustrate the methodology, a model was constructed for a new hypothetical drug in Parkinson's disease, which allowed us to determine the budgetary impact and the cost effectiveness of this new antiparkinsonian drug from a societal perspective. The methodology consisted of two steps: (i) a simple population model (Markov model) was constructed to validate the epidemiological data by proving the consistency between the prevalence and incidence of Parkinson's disease for the Dutch population; (ii) this model was extended to a more complex model (semi-Markov model) by incorporation of disease progression for Parkinson's disease and all relevant economic and clinical measures. These included all drug utilisation associated with Parkinson's disease, as well as other resource utilisation patterns associated with outpatient and inpatient care for the treatment of Parkinson's disease. The study showed that the difference in epidemiological data between a simple model and a complex model are substantial, which justifies the development of a complex model with a higher external validity. The complex model allowed an assessment of all potential candidates for the new drug and simultaneously allowed the assessment of the cost effectiveness of the new drug versus usual care. One model can be used for an appropriate assessment of the budgetary impact and the cost effectiveness of a new drug.

Measuring the performance of lot-sizing techniques in uncertain environments

Cost-effectiveness and computational time are the traditional criteria for evaluating lot-sizing techniques. However, in evolving environments, frequent revisions of demand forecasts may induce various degrees of instability in planned orders, depending on the selected lot-sizing technique. In poorly flexible production systems, the cost of implementing these alterations may overcome the benefits from using a cost-efficient technique. In this paper, we evaluate lot-sizing techniques on the basis of two criteria. The first is the traditional cost-effectiveness criterion. The second, that we call robustness, is designed to capture some of the characteristic features of decision-making in uncertain environments. Robustness is related to the stability of the set-up streams when demand fluctuates. We propose and discuss several alternative measures of robustness. The simulation results clearly show an inverse relationship between cost-effectiveness and instability. Therefore, managers should take into account these two “opposite” dimensions in their decision process, under quite unforeseeable environments.

CVA2 Cost-Effectiveness and Economic Efficiency: The Case of Statin Therapy in Secondary Prevention of Cornary Heart Disease

Health-care case management places pressure on decision makers to adopt treatment strategies that promote economic efficiency and hence profitability. Traditional costeffectiveness analysis (CEA), where the objective is to calculate cost-effectiveness ratios, can better inform decision making in markets where prices and efficacy vary widely. However, the threshold at which a given therapy becomes economically efficient relative to competing therapies is not evident from cost-effictiveness ratios alone. OBJECTIVE: To illustrate the use of spatial techniques for identifying efficient treatment options, using statin therapy in secondary prevention of coronary heart disease (CHD) as a case study. METHODS: We used a Markov model of CHD epidemiology and treatment to estimate cost-effectivness of 13 statin regimens versus no therapy in secondary prevention of CHD. Comparative efficacy was assessed using data from a recent trial (CURVES) that included these regimens. Patients were assumed to have a history of CHD with risk factors similar to those observed in the trial. CHD event risk was estimated using new subsequent-event risk equations from the Framingham Heart Study. Effectiveness was measured alternatively as gain in life expectancy and CHD events averted. RESULTS: At usual starting doses, atorvastatin therapy provided the largest life expectancy gain and CHD event avoidance at the lowest cost per life-year gained ($12,900 and $23,400 for men and women, respectively), followed by simvastatin ($17,700 and $31,700), lovastatin ($18,800 and $33,700), pravastatin ($22,600 and $40,200), and fluvastatin ($23,800 and $42,000). Any desired level of effectiveness can be obtained at lowest cost with atorvastatin. CONCLUSION: Economic efficiency is enhanced when atorvastatin is used to treat some or all patients requiring statin therapy in secondary prevention of CHD.

Is caries prevention cost-effective? Does anybody care?

The aim of this article is to review current issues concerning the cost-effectiveness of caries prevention. Several decades after considerable improvements in the oral disease situation were documented in Scandinavia, doubts are still expressed about whether preventive measures are cost-effective. An analytic model is suggested to explore the relationships between the dental profession, which provides the prevention, the research and development activities, which provide the material and data basis for prevention, and political/societal responses to the professional input. The four elements considered were the definition of prevention, the practical perception of effective prevention, the appropriateness of traditional cost-effectiveness analysis, and the time factor with regard to when a preventive effect should be evaluated. The main arguments of the discussion are that caries prevention is not uniformly defined by the profession, that dental research is casting doubt on the effectiveness of traditionally accepted preventive measures, that political pressures on health care are motivated by economic pressures, but that traditional cost-benefit/effectiveness analyses have not been able to help the decision-makers choose wisely. Often the time perspective for the real effects of prevention lies beyond the interests of decision-makers. Although caries prevention may be viewed as an investment in health by the profession, this contention may not be acceptable to a society with very short-term perspectives.

Treatment costs, equilibrium, and the allocation of patiens to therapy alternatives

This paper addresses the problem of increasing costs (or decreasing returns) in the treatment of patients within health care systems. We examine the implications of such a situation for (1) the allocation of patients to alternative drug therapies within a disease area; and (2) the proportions of patients being treated within the disease area to the total patient population as a function of the equilibrium conditions for maximized health care outcomes, given alternative assumptions about the existence of budget constraints on the resources allocated to the disease area. The reason for considering these issues (in this case, from a purely theoretical perspective) is that such a model and the assumptions that drive it stand in marked contrast to those underlying (implicitly if not explicitly) the traditional approach to cost-effectiveness modeling. In traditional cost-effectiveness analysis, the assumption is that costs and outcomes exhibit constant returns to scale and that the process of patient selection and the characteristics of the treating population and not be taken into account. However, our analysis demonstrates that once the assumption of constant returns is abandoned, any assessment of the net impact of therapeutic interventions can be made only within an equilibrium, or comparative static, framework that is subject to budget constraints and in which the cost functions that drive patterns of switching between therapies are specified. Under such conditions, the traditional, clinical-trial—based notion of cost-effectiveness loses all meaning

High blood pressure control in a high risk minority population: Charles F. Lovell, Virginia Department of Health, Richmond, Virginia; G. Kenneth Morgan, American Heart Association, Virginia Affiliate;

This commentary identifies and defines potentially useful expansions to traditional cost-effectiveness analysis as often used in health technology assessment. Since the seminal 1977 article by Weinstein and Stason, the recommended approach has been the use of the incremental cost-effectiveness ratio based on the metric of the cost per quality-adjusted life-year gained, allowing comparisons across different technologies. An expanded framework, incorporating a wider range of the elements of value, is proposed. In addition to the core value drivers of health gain and other health system cost savings (if any), we propose adding other less recognized elements related to the value of knowing and informational externalities. We describe each of five factors related to the value of knowing: 1) a reduction in uncertainty, reflecting the benefit of a companion diagnostic increasing the certainty of a patient׳s response to a medicine; 2) insurance value related to greater peace of mind due to protection against catastrophic health and financial loss; 3) the value of hope for a "cure," leading individuals to become risk seekers in some circumstances; 4) real option value due to life extension opening possibilities for individuals to benefit from future innovation; and 5) spillovers or externalities arising from benefits of scientific advances that cannot be entirely appropriated by those making the advances. Further thought and research are needed on how best to measure and integrate these elements into an incremental value framework and on coverage and pricing decisions.

Primary Care and the Practice of Medicine

The many facets of care are well explored in this easily read primer, which is edited by Dr Noble. Contributors, who write from experience, include family physicians, internists, educators, institutional directors, nurses, and planners. Four appropriate sections address first, the patient and primary physician, second, types of practice organization, third institutional interrelationships, and fourth, community resources. Chapter subdivisions are insightful and most provocative, especially since a fatiguing compendium is not attempted. Patient and physician expectations, needs, and outcome criteria are discussed, and the question of who has what responsibility is addressed. How the patient relates to family and community, is well-illustrated. The traditional practice, its structure, extended practices, and cost effectiveness are discussed. The questions of who is the primary physician in the hospital, and how physician-consultant relationships can be improved are answered. Traditional modes of continuing education are rightfully questioned, and positive suggestions are given toward improved practice