Two-way Sensitivity Analysis Research Articles

Cost-effectiveness analysis of first-line pembrolizumab treatment for PD-L1 positive, non-small cell lung cancer in China

Purpose: Pembrolizumab was recently approved in several countries as a first-line treatment for patients with PD-L1 positive, non-small cell lung cancer (NSCLC). However, it is expensive. This study aimed to assess the cost-effectiveness of pembrolizumab in treating advanced NSCLC patients with PD-L1 positive cancer in China.Methods: A Markov model was developed to compare the cost-effectiveness of pembrolizumab with chemotherapy for patients with PD-L1 expression on at least 50% of NSCLC tumor cells. Model inputs for transition probabilities and toxicity were derived from published clinical trial data, while health utilities were estimated from a literature review. Costs for drugs were updated to standard fee data from West China Hospital in 2017. Health outcomes were measured in quality-adjusted life years (QALYs), and cost-effectiveness was measured as the incremental cost-effectiveness ratio (ICER). Sensitivity analyses were conducted to test the robustness of the model.Results: Pembrolizumab gained 0.45 QALYs at an incremental cost of $46,362 compared to chemotherapy for an ICER of $103,128 per QALY gained. In most scenarios, the ICER exceeded three times the Chinese Gross Domestic Product per capita. Two-way sensitivity analysis showed that, when the utility of the progression-free status increased to the maximal value of 0.845 and the 1 mg dose price decreased to $10.50, the ICER reduced to $25,216/QALY.Conclusions: Pembrolizumab is not likely to be cost-effective in the treatment of PD-L1 positive, NSCLC for Chinese patients. Less aggressive pricing may increase accessibility for patients in China.

Cost Effectiveness Analysis of Antipsychotic Medications in the Management of Schizophrenia in Benin City

Background: Studies on cost effectiveness analysis (CEA) of typical versus atypical antipsychotics in the management of schizophrenia are still lacking in Nigeria thus the objectives of this study are to determine which of the class of antipsychotics is more cost-effective as well as the impact of socio-demographic factors on the response rate to antipsychotics. Method: The effectiveness was measured by Brief Psychiatric rating scale (BPRS) and costs were in Nigerian naira (NGN). The impact of different socio-demographics on the mean BPRScore ± Standard deviation (SD) reduction was determined. The study was conducted from patient’s perspective with decision tree analysis model using two-way sensitivity analysis. The model was used to explore incremental cost effectiveness ratios (ICER) of oral antipsychotic medications Haloperidol /Trifluoperazine versus Olanzepine /Risperidone over a 24-week study period. Results: Cost effectiveness analysis with 1st scenario sensitivity test of medications, trifluoperazine 17.81±2.51mg is more cost effective than olanzapine 10mg, while haloperidol 10mg is more cost effective than risperidone 3.5± 0.51mg. In the second scenario of sensitivity analysis, olanzapine is more cost effective than trifluoperazine only when the savings of making one person free from schizophrenia in a month is worth more than NGN537 while risperidone is more cost effective than haloperidol only when the savings of making one person free from schizophrenia in a month is worth more than NGN2524.1. The effect on response rate to antipsychotics gave p=0.0251, P=0.009, P<0.0001 for educational status, income, stable relationship respectively. Conclusion: Atypical antipsychotic medications are not more cost effective compared to the typical antipsychotics. Higher educational level, income and stable relationship positively affected the outcome of effectiveness of antipsychotics.

748: Tranexamic acid in the treatment of post-partum hemorrhage in the united states: a cost-effectiveness analysis

The WOMAN trial demonstrated that tranexamic acid (TXA) reduces hemorrhage-related mortality and laparotomies, especially when given in the first 3 hours after birth. The World Health Organization has thus recommended early use of TXA in the treatment of post-partum hemorrhage (PPH). We aim to demonstrate the cost -effectiveness of routine TXA administration in the treatment of PPH in the US. We constructed a decision tree comparing 3 strategies in women with PPH from a health care institution perspective: no TXA, TXA given at any time, and TXA given within 3 hours of delivery. We incorporated probabilities and costs based on available data in the model of a population of women with PPH in the US. We assumed the risk reduction of TXA for death and laparotomy would be similar to the WOMAN trial. Primary outcomes included incremental cost, PPH-related deaths avoided, and laparotomies avoided under each strategy. As we anticipated that the risk reduction with TXA in the US may be lower than in the WOMAN trial, we performed one-way and two- way sensitivity analyses to explore the parameter uncertainty across a wide range of data-supported estimates. Probabilistic sensitivity analyses with Monte Carlo simulation were performed. TXA strategies were dominant (more effective and cost-saving) compared to no routine TXA for patients with PPH in the US (Table). One-way threshold analyses showed that TXA is cost-saving as long as any of the following criteria are met: the risk reduction of death with TXA is at least 5%, the risk reduction of laparotomy with TXA is at least 7%, or the cost of TXA is no greater than $194. A two-way sensitivity analysis of the risk of PPH-related death and the risk reduction of death due to TXA confirmed that TXA is cost-saving across a wide range of plausible estimates (Figure). Probabilistic sensitivity analysis with 10,000 Monte Carlo simulations demonstrated that the TXA strategies are cost- saving in >99.9% of simulations, and that TXA within 3 hours is the cost-saving approach 86.4% of the time. The annual cost savings expected from routine use of TXA for treatment of PPH in the US is $18.8 million (Table). In the US, a policy of routine TXA treatment during PPH is effective, safe, and cost-saving, despite the upfront cost of routine TXA use. This conclusion is true across a wide range of probability and cost assumptions.View Large Image Figure ViewerDownload Hi-res image Download (PPT)

Economic and environmental models for cold products with time varying demand

In response to the rising public concerns on environmental issues and the recently imposed governmental legislations and directives in this regard, companies nowadays ought to constantly adopt sustainable practices in their day-to-day operations. To that end, this paper seeks to optimize the replenishment strategy for a firm (e.g. retailer), who is facing a discrete time-varying demand for a temperature-sensitive (cold) product, while taking into account carbon emissions resulting from transportation and storage activities. In essence, the problem tackled herein is a variant of the classical dynamic lot-sizing problem (DLSP) for cold products with limited shelf life. To better resemble reality, we assume a stepwise cost function that is proportional to the number of fixed-capacity refrigerated trucks and cold stores used. We present three mathematical models, with the first being a cost minimization model, the second a carbon footprint minimization model, and the third a hybrid model that utilizes the carbon tax policy to jointly optimize both economic and environmental measures. We identify several structural properties of the optimal solution to the three models leading to the development of an exact solution algorithm based on the dynamic programming approach. The results of the computational experiments suggest that accounting for environmental aspects induces a change in the cost minimizing lot-sizing policy, resulting in a minor increase in the operational cost where the savings in the CO2 related costs outweigh this minor increase. The two-way sensitivity analysis, conducted under randomized values of the demand, truck sizes, and cold stores capacities, indicates that higher savings in cost and carbon reductions are realized for increasing values of the carbon tax rate. Furthermore, on average, more cost savings and lower carbon emissions are also achieved when the values of the shelf life, truck size, and cold store capacity are increased.

Low-dose Bacillus Calmette-Guerin versus full-dose for intermediate and high-risk of non-muscle invasive bladder cancer: a Markov model

BackgroundTo compare the efficacy of low dose (27 mg) Bacillus Calmette-Guérin (BCG) and a full dose (81 mg) BCG immunotherapy for patients with intermediate and high-risk non-muscle invasive bladder cancer (NMIBC) after a typical transurethral bladder resection.MethodsWe constructed a Markov model for a 20-year simulation of the disease to compare the overall survival of patients with intermediate and high-risk of NMIBC between the full-dose therapy (FD group) and the low-dose therapy (LD group). Base case analysis, one-way and two-way sensitivity analysis and a second-order Monte Carlo analysis were performed based on data from 15 published articles.ResultsThe expected overall survivals were 9.56 (9.55–9.57) years for FD group and 9.63 (9.61–9.64) years for LD group(P < 0.001). The estimated mortality in the FD group at 5, 10, and 20 years were 34.23%, 57.51% and 83.14%, respectively. The corresponding values in the LD group were 34.11%, 57.17%, 82.16%, respectively. Age-specific mortality and metastatic rate after undergoing radical cystectomy (RC) were the most two sensitive parameters in both groups. The rate of disease recurrence with disease worsening is the determining factor when choosing the optimal dose of BCG treatment.ConclusionsA low-dose BCG treatment may act slightly better than a full-dose BCG treatment for patients with intermediate and high-risk of NMIBC. This finding will require further high-quality studies to validate.

Cost-Utility Analysis of Biologic and Biosynthetic Mesh in Ventral Hernia Repair: When Are They Worth It?

Biologic and biosynthetic meshes typically cost more than synthetic meshes for use in ventral hernia repair (VHR), with unknown comparative effectiveness. Cost-utility analysis was performed from a limited societal perspective assessing direct medical costs and outcomes for open, elective, retromuscular VHR. Short-term and 5-year major complications and costs were modeled using best available evidence from published studies, Healthcare Cost and Utilization Project data, and Americas Hernia Society Quality Collaborative data. Costs were analyzed in 2017 US dollars, and utilities were assessed using quality adjusted life years (QALYs). Sensitivity analyses were performed to determine threshold probabilities of long-term complications favoring particular mesh types. Synthetic mesh was the preferred strategy, with a cost of $15,620 and QALYs of 18.85, assuming a baseline 5.6% rate of long-term complications for all meshes. One-way sensitivity analysis demonstrated that biosynthetic and biologic mesh became the better choice as long-term complication rates for synthetic mesh increased to 15.5% and 26.2%, respectively. Two-way sensitivity analysis demonstrated that biologic and biosynthetic meshes became favorable as the cost of biologic mesh decreased and long-term synthetic mesh complication rates increased. Biologic and biosynthetic meshes also became more cost-effective when their relative long-term complication rates decreased and long-term synthetic mesh complication rates increased. Using modeling techniques, synthetic mesh is the best option for retromuscular VHR given currently available evidence. We established long-term complication thresholds, possibly justifying the higher up-front costs for biologic or biosynthetic meshes. This emphasizes the critical need to obtain long-term complication surveillance data to help individualize mesh choice in VHR.

Cost-Effectiveness of Short Course Radiation Therapy Versus Long-Course Chemoradiation for Locally Advanced Rectal Adenocarcinoma

Although long-course chemoradiation (LCRT; 50.4 Gy in 28 fractions with concurrent 5-fluorocuracil based chemotherapy) followed by delayed total mesorectal excision and adjuvant chemotherapy remains the standard of care in the United States for locally advanced rectal adenocarcinoma, many countries follow a protocol of short course radiation therapy (SCRT; 25 Gy in 5 fractions) followed by surgery one week later and subsequent adjuvant chemotherapy. The purpose of this study was to analyze the cost-effectiveness of SCRT versus LCRT for patients with locally advanced rectal cancer. We developed a cost-effectiveness model simulating 10-year outcomes for 65-year-old patients with locally advanced rectal cancer treated with either SCRT or LCRT, both followed by surgery and adjuvant chemotherapy. For the base case analysis, we assumed 3D-conformal radiation treatment. We used utilities and costs based on the literature and Medicare Fee schedules to determine incremental cost-effectiveness ratios of SCRT versus LCRT. We defined cost effectiveness at an incremental cost-effectiveness ratio (ICER) of $100,000/quality-adjusted life-year (QALY) or less. We assumed that SCRT would not result in tumor shrinkage adequate enough to change rates of sphincter preservation, while LCRT would result in higher rates of low anterior resection (LAR). To model preference-sensitive care, we conducted a two-way sensitivity analysis in which we simultaneously varied the utilities of the no evidence of disease states with LAR (NED-LAR) and abdominoperineal resection (APR; NED-APR). To model the current practice of many radiation oncologists, we repeated the analysis assuming 3D-conformal treatment for LCRT but intensity modulated radiation therapy (IMRT) for SCRT. In the base case analysis, SCRT was the cost-effective strategy as compared to LCRT (ICER of $259,545/QALY). SCRT remained the cost-effective strategy as compared to LCRT when assuming 3D-conformal treatment for LCRT but IMRT for SCRT (ICER of $236,832/QALY). On one-way sensitivity analysis, LCRT became the cost-effective approach when the utility of NED-APR was below 0.47. Two-way sensitivity analysis revealed that the cost-effective approach for a given patient depended on the utilities for the NED-LAR and NED-APR states. SCRT was the cost-effective strategy as compared to LCRT for patients locally advanced rectal cancer. However, the cost effectiveness of SCRT versus LCRT was sensitive to the utilities associated with the NED-LAR and NED-APR health states, highlighting the importance of patient preference-sensitive care.

Wednesday, September 26, 2018 1:00 PM – 2:00 PM Spinal Trauma: 54. Nonsurgical management versus cement augmentation versus transpedicular instrumented stabilization for the treatment of osteoporotic compression fractures: a cost-effectiveness analysis

BACKGROUND CONTEXT Historically, despite the mainstay of osteoporotic vertebral compression fracture (OVCF) treatment being nonsurgical management (NSM), patients often had persistent symptoms with objective sequalae that continued to significantly impair their quality of life and activities of daily living. Cement augmentation (CA) subsequently emerged as a safe, and cost-effective alternative. However, morbidity and mortality, despite this treatment, remains high. Transpedicular instrumented stabilization (TPIS) has traditionally been advised against due to an unacceptably high failure rate in this elderly cohort; however, the efficacy of surgery has not been revisited following advances in surgical optimization and surgical techniques. PURPOSE We sought to perform a cost-effective analysis via a Markov model for the treatment of OVCF fracture with either NSM, CA, or TPIS. STUDY DESIGN/SETTING A Markov state-transition decision model was constructed to estimate the cumulative economic benefit of managing OVCF with NSM versus CA versus TPIS. PATIENT SAMPLE In the model, a hypothetical 70-year-old patient who sustained an OVCF was analyzed. OUTCOME MEASURES A cost-effectiveness analysis was performed that yielded: cost-effectiveness (cost per quality adjusted life years [QALY]), incremental cost-effectiveness ratio, net monetary benefit of each treatment compared to others, and a one-way and two-way sensitivity analysis. METHODS A Markov analysis was performed. Variables included in the model are: QALY, success rates, complication and mortality rates and costs. These variables were derived from recent peer-reviewed articles, mostly randomized controlled trials. RESULTS Assuming patients entered the cycle at age 70, NSM corresponded with a 5.02 QALY gain over the remainder of the patient's life, CA corresponded with an 8.04 QALY gain, and TPIS corresponded with a 0.31 QALY loss. CA was the most cost-effective treatment, followed by NSM. TPIS was not cost-effective. Additional cost per unit of effectiveness gained when comparing CA to NSM was $11,166.76. CONCLUSIONS In our study, TPIS was both less effective and more expensive compared to the cheapest treatment, hence it was dominated, and by definition, not cost-effective. However, CA may be a cost-effective alternative for the treatment of OVCF compared to NSM. The additional cost per unit of effectiveness gained from CA, compared to NSM, was five times lower than the WTP standard of $50,000. FDA DEVICE/DRUG STATUS This abstract does not discuss or include any applicable devices or drugs.

Cost-Effectiveness of Robot-assisted Radical Cystectomy Using a Propensity-matched Cohort

BackgroundHealth-related quality of life is important for patients undergoing radical cystectomy (RC). ObjectiveTo determine the cost-effectiveness of robotic-assisted RC (RARC) compared to open cystectomy (OC) for bladder cancer and factors that contribute to cost-effectiveness. Design, setting, and participantsA decision analytic model was used to compare health-related quality of life and medical costs for RARCs with intracorporeal urinary diversion and OCs performed between 2007 and 2015. Outcome measurements and statistical analysisPropensity matching was performed among 1322 cases to yield a final cohort of 100 RARC and 96 ORC cases. Probabilities were obtained from the clinical study data, while quality-adjusted life years (QALYs) and health utility values were derived from the literature. A complication, readmission, or transfusion was included in the 90-d time horizon model. Results and limitationsThere were no differences between the groups in patient demographics, pathologic staging, or length of stay. Multivariable analysis revealed that the RARC group had fewer transfusions and complications compared to the OC group. The incremental cost-effectiveness ratio was $2969. RARC cost $2969 less per QALY when compared to OC. While RARC was $17000 more expensive, it also associated with an increase of 0.32 QALYs. One-way sensitivity analysis identified RARC as the preferred strategy if a complication can be prevented 74% of the time. RARC is preferred as long as it is 70% effective in preventing a transfusion. Two-way sensitivity analysis showed that as long as RARC can prevent complications and transfusions, it is the preferred cost-effective treatment when compared to OC. The study is limited by the omission of a societal perspective and the lack of health utility values for RC. ConclusionsRARC is cost-effective compared to OC when the rates of complications and transfusions are significantly lower. Patient summaryBladder removal via a robotic approach is more expensive, but it improves health-related quality of life. Robotic surgery is cost-effective compared to an open approach for bladder removal if there are low rates of complications and blood transfusion.

PMD68 - The Cost-Effectiveness of a Public Health Nurse Program to Screen for Amblyopia in Ontario

To examine the cost-effectiveness of screening for amblyopia risk factors by a public health nurse compared to screening by a physician at Well Baby Visits for children aged 4 years in Ontario. This study was conducted from the perspective of the Ontario Ministry of Health and Long-Term Care. A combined decision tree and Markov model was constructed to simulate a cohort of 4-year-old children over a lifetime horizon. The model structure, costs, health utilities and probabilities were informed by the literature and clinical experts. Future costs and health utilities were discounted to the present at a rate of 1.5%. Deterministic one-way and two-way sensitivity analysis were conducted to assess the robustness of the results. The public health nurse screening strategy was less costly ($861 less) and more effective (0.03 QALYs more) than the paediatrician Well Baby Visit screening strategy. The public health nurse screening strategy dominated the Well Baby Visit screening strategy in most of the sensitivity analyses. The results were sensitive to the health utility of amblyopia patients aged 10-64 years and the sensitivity of public health nurse screening. At a sensitivity of at least 0.42 the public health nurse screening strategy was no longer dominant and resulted in an ICER of $27,169 per QALY gained. If the health utility of having amblyopia at age 10-64 years increased to 0.94, then the intervention was no longer dominant and results in an ICER of $68,030 per QALY gained. Based on our model, screening for amblyopia by a public health nurse at age 4 years is cost-effective. Further research needs to be conducted on the costs of amblyopia as well as the health-related quality of life of vision impairment.

Distal pancreatectomy without intraperitoneal drainage: a cost-effective alternative to routine drainage

Background: The use of drains after distal pancreatectomy (DP) remains controversial. Several studies, including a randomized multicenter clinical trial (RCT), have demonstrated that the absence of intraperitoneal drainage does not increase postoperative complications. In this context, we performed a cost-utility analysis comparing distal pancreatectomy without peritoneal drainage to routine peritoneal drainage. Methods: Decision model analysis of the cost and effectiveness of DP without drainage vs with routine drainage was performed. The primary outcome was quality-adjusted life years (QALY) gained. The incremental cost-effectiveness of DP without drainage was determined from the perspective of a third-party payer. Probabilities and utilities were obtained from literature and costs from Medicare database and Agency for Health Research and Quality. Results: The base case analysis, utilizing RCT data, revealed that both strategies produced 0.8 QALYs. However, DP with drainage cost more, being dominated by DP without drainage. One-way sensitive analysis, showed the decision model was most sensitive to the inpatient costs for patients without complications, followed by inpatient costs for patients with complications. Two-way sensitivity analysis showed that DP without drainage was favored with the increase in the inpatient costs for patients with complications and when inpatient costs for patients without complications was lower than US$ 68,417. Monte Carlo simulation confirmed the base-case results. DP without drainage, when compared to with drainage, produced 0.83 QALYs vs 0.8, and it was US$ 2,105.96 cheaper. Therefore, DP with drainage remained dominated. Conclusion: In this study, distal pancreatectomy without intraperitoneal drainage was more cost-effective than routine drainage.Table 1Costs, Utilities and Cost-Effectiveness Ratios Comparing Distal Pancreatectomy without peritoneal drainage and with peritoneal drainage.Base-case analysisUtilities & costsDP without drainageDP with drainageQALYs0.800.80Incremental QALYs–0Perioperative costs (US$)64,125.6364,155.84Incremental costs (US$)–30.22Cost-effectiveness ratio79,718.5780,114.69ICER–−8510.50Cost-effective?YesDominatedAfter sensitivity analysis with Monte Carlo simulation methodQALYs0.830.80Incremental QALYs–−0.02Perioperative cost (US$)72,654.6474,760.60Incremental costs (US$)–2,105.96Cost-effectiveness ratio87,878.7993,137.57ICER–−87,494.92Cost-effective?YesDominatedICER–incremental cost-effectiveness ratio Open table in a new tab ICER–incremental cost-effectiveness ratio

Cost and outcome of a community-based paediatric hearing screening programme in rural India with application of tele-audiology for follow-up diagnostic hearing assessment

Objective: This study evaluated the cost and outcome of a community-based hearing screening programme in which village health workers (VHWs) screened children in their homes using a two-step DPOAE screening protocol. Children referred in a second screening underwent tele diagnostic ABR testing in a mobile tele-van using satellite connectivity or at local centre using broadband internet at the rural location. Design: Economic analysis was carried out to estimate cost incurred and outcome achieved for hearing screening, follow-up diagnostic assessment and identification of hearing loss. Two-way sensitivity analysis determined the most beneficial cost-outcome. Study sample: 1335 children under 5 years of age underwent screening by VHWs. Results: Nineteen of the 22 children referred completed the tele diagnostic evaluation. Five children were identified with hearing loss. The cost-outcomes were better when using broadband internet for tele-diagnostics. The use of least expensive human resources and equipment yielded the lowest cost per child screened (Rs.1526; $23; €21). When follow-up expenses were thus maximised, the cost per child was reduced considerably for diagnostic hearing assessment (Rs.102,065; $1532; €1368) and for the cost per child identified (Rs.388,237; $5826; €5204). Conclusion: Settings with constrained resources can benefit from a community-based programme integrated with tele diagnostics.

A cost-utility analysis of small bite sutures versus large bite sutures in the closure of midline laparotomies in the United Kingdom National Health Service.

PurposeThis study aimed to perform an economic evaluation of small bite sutures versus large bite sutures in the closure of midline laparotomies in the United Kingdom National Health Service (NHS).MethodsA cost-utility analysis was conducted using data from a systematic literature review. Large bite sutures placed 10 mm from the wound edge were compared to small bite sutures 3–6 mm from the wound edge. The analysis used a 3-year time horizon in order to take into account complications including incisional hernias and surgical site infections (SSIs). Cost and benefit data were considered from the perspective of the NHS. A two-way sensitivity analysis was conducted to assess the impact of a variation in the clinical effectiveness of small bite sutures.ResultsThe incremental cost-effectiveness ratio was calculated to be −£482.61 per quality-adjusted life year (QALY) using the proposed small bite suture technique, indicating a cost saving to the NHS. Sensitivity analysis demonstrated that small bites are a cost-neutral technique provided that the cost of using small bites is less than £98 per patient. Small bites cost less than £20,000/QALY when they reduce either the rate of SSIs by more than 15% or the rate of hernias by more than 3.4%.ConclusionThis study proposes that small bite sutures should become the mainstay suturing technique in the closure of midline laparotomies, replacing large bite sutures, which dominate current practice. The financial savings accompanied by the decrease in SSI rates and herniation warrant the use of this new technique. The sensitivity analysis demonstrates that findings hold true for a wide range of levels of clinical effectiveness for small bites.

Cost-effectiveness of short course radiation therapy versus long-course chemoradiation for locally advanced rectal adenocarcinoma.

749 Background: Long-course chemoradiation (LCRT; 50.4 Gy in 28 fractions with concurrent chemotherapy) followed by surgery and adjuvant chemotherapy is the standard of care in the United States for locally advanced rectal cancer. However, many countries follow a protocol of short course radiation therapy (SCRT; 25 Gy in 5 fractions). The purpose of this study was to analyze the cost-effectiveness of SCRT versus LCRT. Methods: We developed a cost-effectiveness model simulating 10-year outcomes for 65-year-old patients treated with either SCRT or LCRT. For the base case analysis, we assumed 3D-conformal radiation treatment. We used probabilities, utilities and costs based on the literature and Medicare Fee schedules to determine the incremental cost-effectiveness ratio (ICER) of SCRT versus LCRT. We defined cost effectiveness at an ICER of $100,000/quality-adjusted life-year (QALY) or less. We assumed that SCRT would not result in tumor downstaging adequate enough to change rates of sphincter preservation, while LCRT resulted in higher rates of low anterior resection (LAR). To model preference-sensitive care, we conducted a two-way sensitivity analysis in which we simultaneously varied the utilities of the no evidence of disease states with LAR (NED-LAR) and abdominoperineal resection (APR; NED-APR). To model current practice, we repeated the analysis assuming 3D-conformal treatment for LCRT but intensity modulated radiation therapy (IMRT) for SCRT. Results: With an ICER of $351,731/QALY, SCRT was cost-effective as compared to LCRT. SCRT remained the cost-effective strategy with 3D-conformal treatment for LCRT but IMRT for SCRT (ICER of $314,022/QALY). On one-way sensitivity analysis, LCRT became the cost-effective approach when the utility of NED-APR was below 0.61. Two-way sensitivity analysis revealed that the cost-effective approach for a given patient depended on the utilities for the NED-LAR and NED-APR states. Conclusions: SCRT was the cost-effective strategy as compared to LCRT. However, the cost effectiveness of SCRT versus LCRT was sensitive to the utilities of NED-LAR and NED-APR, highlighting the importance of patient preference-sensitive care.

Markov decision analysis of neoadjuvant treatment pathway versus surgery first pathway for resectable pancreatic cancer.

456 Background: Surgery first (SF) versus neoadjuvant approach (NAT) to management of potentially resectable pancreatic ductal adenocarcinoma (PDAC) is controversial. This study is unique in utilizing institutional data to offer Markov decision-analysis of overall treatment pathways for resectable PDAC. Methods: An advanced Markov decision analysis model was constructed and populated with data from a retrospective institutional database. Patients presenting with resectable PDAC from 2008-2012 were included in the SF arm. Those presenting with resectable PDAC from 2012-2016 and treated within NAT pathway populated the NAT arm. Model uncertainties were tested with one and two-way deterministic sensitivity analysis and probabilistic Monte Carlo sensitivity analysis set to 1000 cycles with variables altered between highest and lowest observed values. Results: NAT pathway gave an additional 0.58 QALMs (22.43 vs. 21.85 QALMs). Monte Carlo analysis reported indifference between treatment strategies. One-way deterministic sensitivity analysis showed that probability of resection in the SF pathway must be greater than 0.82, or below 0.72 in NAT pathway, and probability of receiving adjuvant therapy above 0.6 to alter pathway superiority. Two-way deterministic sensitivity analysis demonstrated treatment superiority depended on resection rate in each pathway and receiving adjuvant therapy in SF pathway. Markov cohort analysis demonstrated superiority of neoadjuvant pathway (Table). Conclusions: Optimal treatment pathway remains debatable on an intention-to-treat Markov decision analysis. Markov cohort analysis of treatment received demonstrated benefit with NAT pathway. [Table: see text]

Cost Effectiveness Analysis of Fecal Transplant Delivery Methods for Recurrent Clostridium difficile Infections in Outpatients

Background Clostridium difficile infection (CDI) accounts for more than $1 billion annually in US health care costs. Recurrent CDI (RCDI, recurrence within 8 weeks of initial treatment) contributes substantially to this cost. The objective of the study was to compare the cost effectiveness of FMT delivered via colonoscopy vs. blind nasogastric tube (NGT) in outpatients. We hypothesized that FMT by NGT would be cost-effective given its low risk and simplicity.MethodsA decision-analytic simulation model compared the cost effectiveness of FMT by colonoscopy vs. NGT from a third-party payer perspective. Our base case cure rates were derived from a cohort receiving outpatient RCDI treatment at our institution. Cure was defined as resolution of symptoms for ≥ 90 days. Procedural cost and consultation was defined by average reimbursement to a large southeastern medical center in 2016 USD based on current procedural terminology (CPT) codes, and cost of disease states were derived from published literature. Health utilities were defined by quality of life year (QALY) based on published literature. Incremental Cost Effectiveness ratio (ICER) was defined as the cost per additional QALY gained. We assumed a 90 day time horizon. One-way sensitivity analysis was performed on all variables using ranges defined by published literature. We used TreeAge Software (Williamstown, MA).ResultsIn the base case, FMT by colonoscopy was dominant (more effective and less costly) than NGT, with cost of $1,568/QALY vs. $1,910/QALY respectively. Cure rates of FMT by colonoscopy vs. NGT (100% vs. 87%) had the largest impact on ICER based on one-way sensitivity analysis. Therefore, a subsequent two-way sensitivity analysis was conducted to compare cure rates of both delivery methods and found that NGT delivery is cost effective as cure rates approach colonoscopy delivery cure rates within 5 percentage points.ConclusionContrary to our hypothesis, our decision model supports FMT by colonoscopy as the preferred delivery method in outpatients with RCDI relative to NGT delivery. Additional costs of colonoscopy delivery are off-set by the improved cure rate leading to lower overall costs. As cure rates from NGT delivery are optimized, NGT may become the preferred method for FMT delivery.Disclosures All authors: No reported disclosures.

Cost-effectiveness of magnetic resonance imaging versus ultrasound for the detection of symptomatic full-thickness supraspinatus tendon tears

The purpose of this study was to determine the value of magnetic resonance imaging (MRI) and ultrasound-based imaging strategies in the evaluation of a hypothetical population with a symptomatic full-thickness supraspinatus tendon (FTST) tear using formal cost-effectiveness analysis. A decision analytic model from the health care system perspective for 60-year-old patients with symptoms secondary to a suspected FTST tear was used to evaluate the incremental cost-effectiveness of 3 imaging strategies during a 2-year time horizon: MRI, ultrasound, and ultrasound followed by MRI. Comprehensive literature search and expert opinion provided data on cost, probability, and quality of life estimates. The primary effectiveness outcome was quality-adjusted life-years (QALYs) through 2 years, with a willingness-to-pay threshold set to $100,000/QALY gained (2016 U.S. dollars). Costs and health benefits were discounted at 3%. Ultrasound was the least costly strategy ($1385). MRI was the most effective (1.332 QALYs). Ultrasound was the most cost-effective strategy but was not dominant. The incremental cost-effectiveness ratio for MRI was $22,756/QALY gained, below the willingness-to-pay threshold. Two-way sensitivity analysis demonstrated that MRI was favored over the other imaging strategies over a wide range of reasonable costs. In probabilistic sensitivity analysis, MRI was the preferred imaging strategy in 78% of the simulations. MRI and ultrasound represent cost-effective imaging options for evaluation of the patient thought to have a symptomatic FTST tear. The results indicate that MRI is the preferred strategy based on cost-effectiveness criteria, although the decision between MRI and ultrasound for an imaging center is likely to be dependent on additional factors, such as available resources and workflow.

The impact of urban speed reduction programmes on health system cost and utilities

BackgroundVehicle speed changes impact the probability of injuring a pedestrian in ways that differ from the way that it impacts the probability of a collision or of death. Therefore, return...

A cost-effectiveness analysis of the diagnostic strategies for differentiating focal nodular hyperplasia from hepatocellular adenoma.

We evaluated the cost-effectiveness of a gadoxetic acid-enhanced MRI (EOB-MRI) strategy compared with conventional MRI strategy and biopsy to differentiate focal nodular hyperplasia (FNH) from hepatocellular adenoma (HCA). A decision tree model was constructed to compare the cost-effectiveness of EOB-MRI, conventional MRI with extracellular contrast agents, and biopsy as the initial diagnostic modality in patients with incidentally detected focal liver lesions suspected of being FNH or HCA. We analysed the cost and effectiveness, i.e. probability of successful diagnosis of each strategy. Costs were based on utilisation rates and Medicare reimbursements in the USA and South Korea. In the base case analysis of our decision tree model, the effectiveness of the three strategies was similar. The cost of the EOB-MRI strategy ($1283 in USA, $813 in South Korea) was lowest compared with the biopsy strategy ($1725 in USA, $847 in South Korea) and the conventional MRI strategy ($1750 in USA, $962 in South Korea). One-way, two-way and probabilistic sensitivity analysis showed unchanged results over an acceptable range. EOB-MRI strategy is the most cost-effective strategy for differentiating FNH from HCA in patients with incidentally detected focal liver lesions in a non-cirrhotic liver. • The effectiveness of the three strategies was similar. • The cost of the EOB-MRI strategy was lowest. • EOB-MRI strategy is the most cost-effective for differentiating FNH from HCA.

Alignment Accuracy and Cost-Savings Threshold of Patient-Specific Instrumentation In Total Ankle Replacements

Category: Ankle Arthritis Introduction/Purpose: Traditional intraoperative referencing for total ankle replacements (TAR) involves multiple steps and fluoroscopic guidance to determine mechanical alignment. Recent adoption of patient-specific instrumentation (PSI) allows for referencing to be determined preoperatively, resulting in less steps and potentially decreased operative time. We hypothesize that usage of PSI will result in decreased operating room time that offsets the additional cost of PSI as compared to standard referencing (SR). Additionally, we aim to demonstrate similar postoperative radiographic alignment between PSI and SR. Methods: Between 2014 and 2015, 87 patients undergoing TAR were enrolled in a prospectively collected TAR database. Patients were divided into cohorts based on PSI versus SR and operative times were reviewed. Radiographic alignment parameters were retrospectively measured at 6 weeks postoperatively. Time-driven activity-based costing (TDABC) was utilized to derive direct costs. Cost versus operative time-savings were examined via two-way sensitivity analysis to determine cost-saving thresholds for PSI applicable to a range of institution types. Cost-saving thresholds defined the price of PSI below which PSI is cost-saving. Results: A total of 35 PSI and 52 SR cases were evaluated with no significant differences identified in patient characteristics. Operative time from incision to completion of casting in cases without adjunct procedures was 127 minutes with PSI and 161 minutes with SR (p &lt; 0.05). PSI demonstrated similar postoperative accuracy to SR in coronal tibial-plafond alignment (1.1° vs. 0.3° varus, p=0.06) and tibial component sagittal alignment (0.7° vs. 0.9° plantarflexion, p=0.14). TDABC methodology estimated a PSI cost-savings threshold range at our institution of $863 - $1,026 below which PSI pricing will provide net cost-savings. Two-way sensitivity analysis generated a globally applicable cost-savings threshold model based on institution-specific costs and surgeon-specific time-savings. Conclusion: This study demonstrates equivalent post-operative TAR alignment with PSI and SR referencing systems but with a significant decrease in operative time with PSI. Based on TDABC and associated sensitivity analysis, a cost-savings threshold of $863 - $1,026 is identified for PSI pricing at our institution below which PSI is less costly than SR. Similar internal cost accounting may benefit healthcare systems for identifying cost drivers and obtaining leverage during price negotiations.