Abdominal aortic aneurysm screening: how many life years lost from underuse of the medicare screening benefit?

BACKGROUND

Since 2007, Medicare has provided one-time abdominal aortic aneurysm (AAA) screening for men with smoking history, and men and women with a family history of AAA as part of its Welcome to Medicare visit.

OBJECTIVE

We examined utilization of the new AAA screening benefit and estimated how increased utilization could influence population health as measured by life years gained. Additionally, we explored the impact of expanding screening to women with smoking history.

DESIGN

Analysis of Medicare claims and a simulation model to estimate the effects of screening, using published data for parameter estimates.

SETTING

AAA screening in the primary care setting.

PATIENTS

Newly-enrolled Medicare beneficiaries aged 65 years, with smoking history or family history of AAA.

MAIN MEASURES

Life expectancy, 10-year survival rates.

KEY RESULTS

Medicare data revealed low utilization of AAA screening, under 1% among those eligible. We estimate that screening could increase life expectancy per individual invited to screening for men with smoking history (0.11 years), with family history of AAA (0.17 years), and women with family history (0.08 years), and smoking history (0.09 years). Average gains of 131 life years per 1,000 persons screened for AAA compare favorably with the grade B United States Preventive Services Task Force (USPSTF) recommendation for breast cancer screening, which yields 95-128 life years per 1,000 women screened. These findings were robust over a range of scenarios.

LIMITATIONS

The simulation results reflect assumptions regarding AAA prevalence, treatment, and outcomes in specific populations based on published research and US survey data. Published data on women were limited.

CONCLUSIONS

The Welcome to Medicare and AAA screening benefits have been underutilized. Increasing utilization of AAA screening would yield substantial gains in life expectancy. Expanding screening to women with smoking history also has the potential for substantial health benefits.

A survey of individuals in US-based pharmaceutical industry HEOR departments: attitudes on policy topics

We surveyed US-based leaders in health economics and outcomes research (HEOR) departments in drug and device companies to examine their views on the state of the field. We created a questionnaire that was emailed to 123 US-based senior HEOR professionals at 54 companies. Of the 123 recipients, 74 (60%) completed the survey. Most respondents (92%) expected their company's HEOR use to increase, and 80% reported that their organization's senior management viewed HEOR work as critical. Approximately 62% agreed that Academy of Managed Care Pharmacy (AMCP) dossiers are useful to US health plans, and 55% stated that Food and Drug Administration Modernization Act (FDAMA) Section 114 is useful. Approximately 49% believed the US government should use cost-effectiveness analysis in coverage and reimbursement decisions, but only 31% expected this to occur within 3 years. The findings suggest strong support for the function at senior management levels and optimism about the field.

The value of specialty pharmaceuticals - a systematic review

OBJECTIVES

Novel specialty biopharmaceuticals hold promise for patients living with complex and chronic conditions. However, high research and development costs, special handling, and other necessary enhancements to patient support programs all contribute to frequently higher prices for these products. This study sought to assess the value of specialty pharmaceuticals through an examination of the clinical, functional, and economic benefits of these treatments for the top 3 disease areas by pharmaceutical spend: rheumatoid arthritis (RA), multiple sclerosis (MS), and breast cancer (BC).

STUDY DESIGN

Systematic literature review.

METHODS

A systematic review of market research and cost-effectiveness articles was conducted for each disease area to assess clinical, functional, and economic outcomes associated with specialty medicine treatments versus the previous standard of care.

RESULTS

All RA clinical (American College of Rheumatology) and functional (Health Assessment Questionnaire) outcome articles were classified as positive. The median cost-effectiveness ratio was $38,900 per quality-adjusted life year (QALY). All MS clinical outcome (relapse rate) articles were positive. The MS functional outcome (Expanded Disability Status Scale) findings were less conclusive. The median cost-effectiveness ratio was $248,000 per QALY. The majority of BC articles yielded statistically inconclusive results for survival. All functional outcome (Quality of Life Questionnaire- Core 30) articles were positive. The median cost-effectiveness ratio was $51,900 per QALY.

CONCLUSIONS

Novel specialty therapies hold promise for arresting disease progression and improving quality of life for the 3 conditions associated with the highest specialty pharmaceutical spend. These findings demonstrate a strong value proposition for specialty pharmaceuticals, and suggest even greater potential individual patient benefit with consideration of patient heterogeneity.

Does framing of cancer survival affect perceived value of care? A willingness-to-pay survey of US residents

AIMS

To investigate the relationship between the framing of survival gains and the perceived value of cancer care.

METHODS

Through a population-based survey of 2040 US adults, respondents were randomized to one of the two sets of hypothetical scenarios, each of which described the survival benefit for a new treatment as either an increase in median survival time (median survival), or an increase in the probability of survival for a given length of time (landmark survival). Each respondent was presented with two randomly selected scenarios with different prognosis and survival improvements, and asked about their willingness to pay (WTP) for the new treatments.

RESULTS

Predicted WTP increased with survival benefits and respondents' income, regardless of how survival benefits were described. Framing therapeutic benefits as improvements in landmark rather than median time survival increased the proportion of the population willing to pay for that gain by 11-35%, and the mean WTP amount by 42-72% in the scenarios we compared.

CONCLUSION

How survival benefits are described may influence the value people place on cancer care.

Medicare covers the majority of FDA-approved devices and Part B drugs, but restrictions and discrepancies remain

The Food and Drug Administration (FDA) and Medicare use different standards to determine, first, whether a new drug or medical device can be marketed to the public and, second, if the federal health insurance program will pay for use of the drug or device. This discrepancy creates hurdles and uncertainty for drug and device manufacturers. We analyzed discrepancies between FDA approval and Medicare national coverage determinations for sixty-nine devices and Part B drugs approved during 1999-2011. We found that Medicare covered FDA-approved drugs or devices 80 percent of the time. However, Medicare often added conditions beyond FDA approval, particularly for devices and most often restricting coverage to patients with the most severe disease. In some instances, Medicare was less restrictive than the FDA. Our findings highlight the importance for drug and device makers of anticipating Medicare's needs when conducting clinical studies to support their products. Our findings also provide important insights for the FDA's and Medicare's pilot parallel review program.

Oncologists' and family physicians' views on value for money of cancer and congestive heart failure care

BACKGROUND

Previous studies suggest that cancer-related interventions are valued by policy makers more favorably than interventions for other medical conditions, but the views of practicing physicians have not yet been assessed in Israel. Attitudes and judgments of practicing physicians may assist decision-makers in their deliberations on coverage of new technologies. We conducted a national survey in Israel among oncologists and family physicians to explore their views on access to care, coverage decisions and treatment recommendations for cancer and congestive heart failure (CHF) patients.

METHODS

We administered a web-based survey to 300 family physicians and 156 oncologists. The questionnaire included 24 statements and physicians were asked to indicate their level of agreement with each statement on a 5-point Likert scale, ranging from "strongly agree" to "strongly disagree". Where relevant, physicians were asked to express their views on interventions for cancer and CHF respectively.

RESULTS

Response rates were 39% for family physicians and 36% for oncologists. Participants expressed similar views on cancer and CHF care and no significant differences were found between the two medical specialties. More than 85% of physicians believe that inclusion of a treatment in the National List of Health Services (NLHS) strongly affects their patients' access to care. Approximately 80% suggest that more use of comparative-effectiveness and cost-effectiveness analysis is needed in coverage decisions. The vast majority of respondents (75%) suggest that assessment of value-for-money should be made by an independent (academic) institution or the national committee responsible for recommending coverage decisions, Seventy percent believe that treatments not included in the NLHS should be included in supplementary health insurance programs and only a small minority of respondents (<30%) believe that cancer-related interventions should receive higher priority than non-cancer interventions in coverage decisions.

CONCLUSIONS

Our findings suggest that both oncologists and family physicians value cancer and CHF interventions equally. We could not find evidence for a "cancer premium" as implied from previous surveys and analysis of coverage decisions in various countries.

Potentially avoidable hospitalizations among Medicare beneficiaries with Alzheimer's disease and related disorders

BACKGROUND

Individuals with Alzheimer's disease and related disorders (ADRD) have more frequent hospitalizations than individuals without ADRD, and some of these admissions may be preventable with proactive outpatient care.

METHODS

This study was a cross-sectional analysis of Medicare claims data from 195,024 fee-for-service ADRD beneficiaries aged ≥65 years and an equal number of matched non-ADRD controls drawn from the 5% random sample of Medicare beneficiaries in 2007-2008. We analyzed the proportion of patients with potentially avoidable hospitalizations (PAHs, as defined by the Medicare Ambulatory Care Indicators for the Elderly) and used logistic regression to examine patient characteristics associated with PAHs. We used paired t tests to compare Medicare expenditures by ADRD status, stratified by whether there were PAHs related to a particular condition.

RESULTS

Compared with matched non-ADRD subjects, Medicare beneficiaries with ADRD were significantly more likely to have PAHs for diabetes short-term complications (OR = 1.43; 95% CI 1.31-1.57), diabetes long-term complications (OR = 1.08; 95% CI = 1.02-1.14), and hypertension (OR = 1.22; 95% CI 1.08-1.38), but less likely to have PAHs for chronic obstructive pulmonary disease (COPD)/asthma (OR = 0.85; 95% CI 0.82-0.87) and heart failure (OR = 0.89; 95% CI 0.86-0.92). Risks of PAHs increased significantly with comorbidity burden. Among beneficiaries with a PAH, total Medicare expenditures were significantly higher for those subjects who also had ADRD.

CONCLUSION

Medicare beneficiaries with ADRD were at a higher risk of PAHs for certain uncontrolled comorbidities and incurred higher Medicare expenditures compared with matched controls without dementia. ADRD appears to make the management of some comorbidities more difficult and expensive. Ideally, ADRD programs should involve care management targeting high-risk patients with multiple chronic conditions.

Measuring Alzheimer disease progression with transition probabilities: estimates from NACC-UDS

OBJECTIVES

Estimate the probabilities, for Alzheimer's disease (AD) patients, of transitioning between stages of disease severity (mild, moderate, severe, dead) and care settings (community, institutional).

METHODS

Data were compiled by the National Alzheimer Coordinating Center. The main analyses were limited to 3,852 patients who were 50 years old, diagnosed with possible/probable AD and had at least two center visits. A multinomial logistic model accounting for patient and center level correlation was used to calculate transition probabilities between stages of the Clinical Dementia Rating (CDR). Separately we calculated the probabilities of being institutionalized based on CDR stage. Both analyses controlled for baseline age, time between visits, sex, marital status, whether white, whether Hispanic and number of years of education.

RESULTS

The annual probabilities of dying for patients in mild, moderate and severe health states were 5.5%, 21.5% and 48.0%, respectively, while the annual probabilities for institutionalization were 1.2%, 3.4% and 6.6%, respectively. The majority of mild and moderate patients remain in the same health state after one year, 77.4% and 50.1% respectively. Progressing patients are most likely to transition one stage, but 1.3% of mild patients become severe in one year. Some patients revert to lower severity stages, 7% from moderate to mild.

CONCLUSIONS

Transition probabilities to higher CDR stages and to institutionalization are lower than those published previously, but the probability of death is higher. These results are useful for understanding AD progression and can be used in simulation models to evaluate costs and compare new treatments or policies.

Willingness to pay for diagnostic technologies: a review of the contingent valuation literature

OBJECTIVES

To understand how people value information from diagnostic technologies, we reviewed and analyzed published willingness-to-pay (WTP) studies on the topic.

METHODS

We searched PubMed for English-language articles related to WTP for diagnostic laboratory tests published from 1985 through 2011. We characterized methodological differences across studies, examined individual- and technology-level factors associated with WTP, and summarized median WTP values across different diagnostic tests.

RESULTS

We identified 66 relevant WTP studies. Half focused on oncology, while others analyzed infectious diseases (n = 11, 16.1%) and obstetric or gynecological conditions (n = 8, 11.7%), among others. Most laboratory tests included in studies were biological samples/genetic testing (n = 44, 61.1%) or imaging tests (n = 23, 31.9%). Approximately one third of the analyses (n = 20, 30.3%) used discrete-choice questions to elicit WTP values. Higher income, education, disease severity, perceived disease risk, family history, and more accurate tests were in general associated with higher WTP values for diagnostic information. Of the 44 studies with median WTP values available, most reported a median WTP value below $100. The median WTP value for colon or colorectal cancer screening ranged from below $100 to over $1000.

CONCLUSIONS

The contingent valuation literature in diagnostics has grown rapidly, and suggests that many respondents place considerable value on diagnostic information. There exists, however, great variation in studies with respect to the type of technologies and diseases assessed, respondent characteristics, and study methodology. The perceived value of diagnostic technologies is also influenced by the study design and elicitation methods.

Which is more valuable, longer survival or better quality of life? Israeli oncologists' and family physicians' attitudes toward the relative value of new cancer and congestive heart failure interventions

OBJECTIVES

We determined how Israeli oncologists and family physicians value life-prolongation versus quality-of-life (QOL)-enhancing outcomes attributable to cancer and congestive heart failure interventions.

METHODS

We presented physicians with two scenarios involving a hypothetical patient with metastatic cancer expected to survive 12 months with current treatment. In a life-prolongation scenario, we suggested that a new treatment increases survival at an incremental cost of $50,000 over the standard of care. Participants were asked what minimum improvement in median survival the new therapy would need to provide for them to recommend it over the standard of care. In the QOL-enhancing scenario, we asked the maximum willingness to pay for an intervention that leads to the same survival as the standard treatment, but increases patient's QOL from 50 to 75 (on a 0-100 scale). We replicated these scenarios by substituting a patient with congestive heart failure instead of metastatic cancer. We derived the incremental cost-effectiveness ratio per quality-adjusted life-year (QALY) gained threshold implied by each response.

RESULTS

In the life-prolongation scenario, the cost-effectiveness thresholds implied by oncologists were $150,000/QALY and $100,000/QALY for cancer and CHF, respectively. Cost-effectiveness thresholds implied by family physicians were $50,000/QALY regardless of the disease type. Willingness to pay for the QOL-enhancing scenarios was $60,000/QALY and did not differ by physicians' specialty or disease.

CONCLUSIONS

Our findings suggest that family physicians value life-prolonging and QOL-enhancing interventions roughly equally, while oncologists value interventions that extend survival more highly than those that improve only QOL. These findings may have important implications for coverage and reimbursement decisions of new technologies.

Illustrating potential efficiency gains from using cost-effectiveness evidence to reallocate Medicare expenditures

OBJECTIVES

The Centers for Medicare & Medicaid Services does not explicitly use cost-effectiveness information in national coverage determinations. The objective of this study was to illustrate potential efficiency gains from reallocating Medicare expenditures by using cost-effectiveness information, and the consequences for health gains among Medicare beneficiaries.

METHODS

We included national coverage determinations from 1999 through 2007. Estimates of cost-effectiveness were identified through a literature review. For coverage decisions with an associated cost-effectiveness estimate, we estimated utilization and size of the "unserved" eligible population by using a Medicare claims database (2007) and diagnostic and reimbursement codes. Technology costs originated from the cost-effectiveness literature or were estimated by using reimbursement codes. We illustrated potential aggregate health gains from increasing utilization of dominant interventions (i.e., cost saving and health increasing) and from reallocating expenditures by decreasing investment in cost-ineffective interventions and increasing investment in relatively cost-effective interventions.

RESULTS

Complete information was available for 36 interventions. Increasing investment in dominant interventions alone led to an increase of 270,000 quality-adjusted life-years (QALYs) and savings of $12.9 billion. Reallocation of a broader array of interventions yielded an additional 1.8 million QALYs, approximately 0.17 QALYs per affected Medicare beneficiary. Compared with the distribution of resources prior to reallocation, following reallocation a greater proportion was directed to oncology, diagnostic imaging/tests, and the most prevalent diseases. A smaller proportion of resources went to cardiology, treatments (including drugs, surgeries, and medical devices, as opposed to nontreatments such as preventive services), and the least prevalent diseases.

CONCLUSIONS

Using cost-effectiveness information has the potential to increase the aggregate health of Medicare beneficiaries while maintaining existing spending levels.

The validity of dependence as a health outcome measure in Alzheimer's disease

BACKGROUND

Relating to Alzheimer's disease (AD), dependence has been defined as the increased need for assistance due to deterioration in cognition, physical functioning, and behavior. Our objective was to evaluate the association between dependence and measures of functional impairment.

METHODS

Data were compiled by the National Alzheimer's Coordinating Center. We used multinomial logistic regression to estimate the association between dependence and cognition, physical functioning, and behavior.

RESULTS

The independent association with dependence was positive. Dependence was most strongly associated with physical functioning. A secondary analysis suggested a strong association of dependence with multiple impairments, as measured by the interaction terms, in more severe patients.

CONCLUSIONS

We find that dependence is simultaneously associated with physical functioning, cognition, and behavior, which support the construct validity of dependence. Dependence might be a more simple measure to explain the multifaceted disease progression of AD and convey the increasing need for care.

Advancing Alzheimer's disease diagnosis, treatment, and care: recommendations from the Ware Invitational Summit

To address the pending public health crisis due to Alzheimer's disease (AD) and related neurodegenerative disorders, the Marian S. Ware Alzheimer Program at the University of Pennsylvania held a meeting entitled "State of the Science Conference on the Advancement of Alzheimer's Diagnosis, Treatment and Care," on June 21-22, 2012. The meeting comprised four workgroups focusing on Biomarkers; Clinical Care and Health Services Research; Drug Development; and Health Economics, Policy, and Ethics. The workgroups shared, discussed, and compiled an integrated set of priorities, recommendations, and action plans, which are presented in this article.

Early trends from the Study to Evaluate the Prospective Payment System Impact on Small Dialysis Organizations (STEPPS)

BACKGROUND

Launched in January 2011, the prospective payment system (PPS) for the US Medicare End-Stage Renal Disease Program bundled payment for services previously reimbursed independently. Small dialysis organizations may be particularly susceptible to the financial implications of the PPS. The ongoing Study to Evaluate the Prospective Payment System Impact on Small Dialysis Organizations (STEPPS) was designed to describe trends in care and outcomes over the period of PPS implementation. This report details early results between October 2010 and June 2011.

STUDY DESIGN

Prospective observational cohort study of patients from a sample of 51 small dialysis organizations.

SETTING & PARTICIPANTS

1,873 adult hemodialysis and peritoneal dialysis patients.

OUTCOMES

Secular trends in processes of care, anemia, metabolic bone disease management, and red blood cell transfusions.

MEASUREMENTS

Facility-level data are collected quarterly. Patient characteristics were collected at enrollment and scheduled intervals thereafter. Clinical outcomes are collected on an ongoing basis.

RESULTS

Over time, no significant changes were observed in patient to staff ratios. There was a temporal trend toward greater use of peritoneal dialysis (from 2.4% to 3.6%; P = 0.09). Use of cinacalcet, phosphate binders, and oral vitamin D increased; intravenous (IV) vitamin D use decreased (P for trend for all <0.001). Parathyroid hormone levels increased (from 273 to 324 pg/dL; P < 0.001). Erythropoiesis-stimulating agent doses decreased (P < 0.001 for IV epoetin alfa and IV darbepoetin alfa), particularly high doses. Mean hemoglobin levels decreased (P < 0.001), the percentage of patients with hemoglobin levels <10 g/dL increased (from 12.7% to 16.8%), and transfusion rates increased (from 14.3 to 19.6/100 person-years; P = 0.1). Changes in anemia management were more pronounced for African American patients.

LIMITATIONS

Limited data were available for the prebundle period. Secular trends may be subject to the ecologic fallacy and are not causal in nature.

CONCLUSIONS

In the period after PPS implementation, IV vitamin D use decreased, use of oral therapies for metabolic bone disease increased, erythropoiesis-stimulating agent use and hemoglobin levels decreased, and transfusion rates increased numerically.

A role for research: an observation on preventive services for women

BACKGROUND

The Patient Protection and Affordable Care Act of 2010 (ACA) added preventive services for women, recommended by the IOM, to healthcare coverage requirements beginning in August 2011.

PURPOSE

The current review provides evidence on the economic impact of services that will be covered under the ACA, focusing on IOM-recommended measures that address women's health.

METHODS

This review analyzed the cost-effectiveness literature related to these services using the Tufts Medical Center Cost-Effectiveness Analysis Registry (www.cearegistry.org), which catalogs detailed information on cost-effectiveness studies published in English in the peer-reviewed literature. In order to keep the review relevant to current clinical practice, the analysis was restricted to studies published in 2000-2010. The data search and analysis were performed in 2011.

RESULTS

Cost-effectiveness studies have evaluated a limited subset of the preventive measures available for women. Further, few cost-effectiveness studies have evaluated the recommended counseling and screening services for women. Of 16 relevant studies found, eight focused on HIV screening, with results varying substantially depending on the specific groups screened and the screening frequency.

CONCLUSIONS

The current review underscores the finding that there is a substantial gap in the health economic literature on preventive care, especially with respect to screening and counseling of women in the primary care setting. There is some evidence that better access to preventive services can be maintained at a reasonable cost to the healthcare system, and that certain services may even lower healthcare costs.

Imputing productivity gains from clinical trials

OBJECTIVE

To respond to employer and payer interest in the extent to which productivity gains offset therapy costs by identifying clinical trials that did not include such measures and using their clinical data to impute productivity impact.

METHODS

A PubMed search identified the sample of 25 clinical trials of musculoskeletal pain medications and antidepressants. Next, we applied regression coefficients, quantifying the empirical relationship between clinical measures to each trial's clinical outcomes data. This validated methodology provides estimates of Work Limitations Questionnaire Productivity Loss scores.

RESULTS

Based on imputation, musculoskeletal medications and antidepressants achieved median productivity gains of approximately 0.5% and 1.0%, respectively.

CONCLUSION

Accounting for productivity gains based on the Work Limitations Questionnaire could substantially influence cost-effectiveness results reported in the health economics literature.

In a survey, marked inconsistency in how oncologists judged value of high-cost cancer drugs in relation to gains in survival

Amid calls for physicians to become better stewards of the nation's health care resources, it is important to gain insight into how physicians think about the cost-effectiveness of new treatments. Expensive new cancer treatments that can extend life raise questions about whether physicians are prepared to make "value for money" trade-offs when treating patients. We asked oncologists in the United States and Canada how much benefit, in additional months of life expectancy, a new drug would need to provide to justify its cost and warrant its use in an individual patient. The majority of oncologists agreed that a new cancer treatment that might add a year to a patient's life would be worthwhile if the cost was less than $100,000. But when given a hypothetical case of an individual patient to review, the oncologists also endorsed a hypothetical drug whose cost might be as high as $250,000 per life-year gained. The results show that oncologists are not consistent in deciding how many months an expensive new therapy should extend a person's life before the cost of therapy is justified. Moreover, the benefit that oncologists demand from new treatments in terms of length of survival does not necessarily increase according to the price of the treatment. The findings suggest that policy makers should find ways to improve how physicians are educated on the use of cost-effectiveness information and to influence physician decision making through clinical guidelines that incorporate cost-effectiveness information.

Therapies for advanced cancers pose a special challenge for health technology assessment organizations in many countries

Health technology assessment organizations evaluate medical therapies and technologies to help inform coverage and reimbursement decisions for payers around the globe. Even as they establish strict review processes, these organizations--and the reimbursement authorities that use their assessments--have sometimes handled cancer interventions with special care. We found that some countries have created separate health technology assessment pathways for cancer treatment, while others have eased access to cancer treatments through end-of-life or disease-severity exceptions within health technology assessment policies. In the United States, although no separate evaluation pathways exist for cancer, cancer drugs receive special status by virtue of unique Medicare rules covering off-label indications. Worldwide, we demonstrate that health technology assessment organizations are struggling with cancer's "exceptionalism."

Medicare's enduring struggle to define "reasonable and necessary" care

Medicare legislation mandates that the program not pay for items and services that are not "reasonable and necessary" - terms that are open to interpretation and easily politicized. In today's fiscal environment, "reasonable and necessary" warrants a closer look.

Economic impact of childhood and adult attention-deficit/hyperactivity disorder in the United States

OBJECTIVE

Attention-deficit/hyperactivity disorder (ADHD) is one of the most prevalent mental disorders in children in the United States and often persists into adulthood with associated symptomatology and impairments. This article comprehensively reviews studies reporting ADHD-related incremental (excess) costs for children/adolescents and adults and presents estimates of annual national incremental costs of ADHD.

METHOD

A systematic search for primary United States-based studies published from January 1, 1990 through June 30, 2011 on costs of children/adolescents and adults with ADHD and their family members was conducted. Only studies in which mean annual incremental costs per individual with ADHD above non-ADHD controls were reported or could be derived were included. Per-person incremental costs were adjusted to 2010 U.S. dollars and converted to annual national incremental costs of ADHD based on 2010 U.S. Census population estimates, ADHD prevalence rates, number of household members, and employment rates by age group.

RESULTS

Nineteen studies met the inclusion criteria. Overall national annual incremental costs of ADHD ranged from $143 to $266 billion (B). Most of these costs were incurred by adults ($105 B-$194 B) compared with children/adolescents ($38 B-$72 B). For adults, the largest cost category was productivity and income losses ($87 B-$138 B). For children, the largest cost categories were health care ($21 B-$44 B) and education ($15 B-$25 B). Spillover costs borne by the family members of individuals with ADHD were also substantial ($33 B-$43 B).

CONCLUSION

Despite a wide range in the magnitude of the cost estimates, this study indicates that ADHD has a substantial economic impact in the United States. Implications of these findings and future directions for research are discussed.

Medicare's national coverage determinations in diagnostic radiology: examining evidence and setting limits

OBJECTIVE

To systematically review and summarize the Center for Medicare and Medicaid Services (CMS) national coverage determination (NCDs) pertaining diagnostic imaging technologies from 1999 through 2010.

METHODS

All NCDs pertaining to diagnostic imaging were identified from the Tufts Medical Center NCD database. The variables under study included the quality of the clinical evidence and the final coverage determination. The types of restrictions were categorized. We also categorized the final decisions as "positive coverage" or "no positive/no change in coverage" and assessed the correlation between positive coverage and other variables using Fisher exact test.

RESULTS

Twenty-two of 152 (15%) NCDs pertained to diagnostic imaging technologies. The supporting evidence was judge to be good, fair, and poor in 5, 6, and 11 cases, respectively. Eleven technologies (50%) were covered with conditions, four (18%) deferred the coverage decision to local level, and two (9%) were completely not covered. In five instances there was no change to the prior coverage status. Of the 11 decisions resulting in positive coverage, 8 (73%) restricted use to specific population subgroups, 5 (46%) applied restrictions related to treatment, 4 were covered with evidence development, and 2 were restricted to care in specific settings. A significantly higher rate of positive coverage decisions was achieved if the available evidence was good (100% 5/5) or fair (83% 5/6) compared to technologies with poor evidence (10% 1/10) (P < .01).

CONCLUSION

CMS has demonstrated a propensity to limit the use of advanced diagnostic imaging to scenarios in which appropriateness is supported by adequate evidence of clinical utility and improved outcomes with the quality of evidence being a significant factor on final decisions. Understanding the need for high-quality evidence and the types of limitations placed on coverage allows for appropriate planning for the incorporation of diagnostic imaging technologies into clinical practice.

FDA actions against health economic promotions, 2002-2011

OBJECTIVE

To investigate Food and Drug Administration (FDA) regulatory actions against drug companies' health economic promotions from 2002 through 2011 to understand how frequently and in what circumstances the agency has considered such promotions false or misleading.

METHODS

We reviewed all warning letters and notices of violation ("untitled letters") issued by the FDA's Division of Drug Marketing, Advertising and Communications (DDMAC) to pharmaceutical companies from January 2002 through December 2011. We analyzed letters containing a violation related to "health economic promotion," defined according to one of several categories (e.g., implied claims of cost savings due to work productivity or economic claims containing unsupported statements about effectiveness or safety). We also collected information on factors such as the indication and type of media involved and whether the letter referenced Section 114 of the Food and Drug Administration Modernization Act.

RESULTS

Of 291 DDMAC letters sent to pharmaceutical companies during the study period, 35 (12%) cited a health economic violation. The most common type of violation cited was an implied claim of cost savings due to work productivity or functioning (found in 20 letters) and economic claims containing unsubstantiated comparative claims of effectiveness, safety, or interchangeability (7 letters). The violations covered various indications, mostly commonly psychiatric disorders (6 letters) and pain (6 letters). No DDMAC letter pertained to Food and Drug Administration Modernization Act Section 114.

CONCLUSION

The FDA has cited inappropriate health economic promotions in roughly 12% of the letters issued by the DDMAC. The letters highlight drug companies' interest in promoting the value of their products and the FDA's concerns in certain cases about the lack of supporting evidence.

Principles for planning and conducting comparative effectiveness research

Aims: To develop principles for planning and conducting comparative effectiveness research (CER). Methods: Beginning with a modified existing list of health technology assessment principles, we developed a set of CER principles using literature review, engagement of multiple experts and broad stakeholder feedback. Results & conclusion: Thirteen principles and actions to fulfill their intent are proposed. Principles include clarity of objectives, transparency, engagement of stakeholders, consideration of relevant perspectives, use of relevant comparators, and evaluation of relevant outcomes and treatment heterogeneity. Should these principles be found appropriate and useful, CER studies should be audited for adherence to them and monitored for their impact on care management, patient relevant outcomes and clinical guidelines.

Risk-sharing arrangements that link payment for drugs to health outcomes are proving hard to implement

Risk-sharing agreements, under which payers and pharmaceutical manufacturers agree to link payment for drugs to health outcomes achieved, rather than the volume of products used, offer an appealing payment model for pharmaceuticals. Although such agreements have been widely touted, the experience to date mainly demonstrates how hard they are to implement. Barriers include high implementation costs, measurement challenges, and the absence of a suitable data infrastructure. Risk-sharing arrangements could gain traction in the United States as payers and product manufacturers acquire experience with the concept and as measurement techniques and information systems improve. For the foreseeable future, they are likely to remain the exception as drug companies pursue payment models unconnected to data collection or performance assessment.

Accuracy, risk and the intrinsic value of diagnostic imaging: a review of the cost-utility literature

RATIONALE AND OBJECTIVES

The aim of this study was to systematically review the reporting of the value of imaging unrelated to treatment consequences and test characteristics in all imaging-related published cost-utility analyses (CUAs) in the medical literature.

MATERIALS AND METHODS

All CUAs published between 1976 and 2008 evaluating diagnostic imaging technologies contained in the CEA Registry, a publicly available comprehensive database of health related CUAs, were screened. Publication characteristics, imaging modality, and the inclusion of test characteristics including accuracy, costs, risks, and the potential value unrelated to treatment consequences (eg, reassurance or anxiety) were assessed.

RESULTS

Ninety-six published CUAs evaluating 155 different imaging technologies were included in the final sample; 27 studies were published in imaging-specialized journals. Fifty-two studies (54%) evaluated the performance of a single imaging modality, while 44 studies (46%) compared two or more different imaging modalities. The most common areas of interest were cardiovascular (45%) and neuroradiology (17%). Forty-two technologies (27%) concerned ultrasound, while 34 (22%) concerned magnetic resonance. Seventy-nine (51%) technologies used ionizing radiation. Test accuracy was reported or calculated for 90% (n = 133 and n = 5, respectively) and assumed perfect (reference test or gold-standard test without alternative testing strategy to capture false-negatives and false-positives) for 8% (n = 12) of technologies. Only 22 studies (23%) assessing 40 imaging technologies (26%) considered inconclusive or indeterminate results. The risk of testing was reported for 32 imaging technologies (21%). Fifteen studies (16%) considered the value of diagnostic imaging unrelated to treatment. Four studies incorporated it as quality-of-life adjustments, while 10 studies mentioned it only in their discussions or as a limitation.

CONCLUSIONS

The intrinsic value of imaging (the value of imaging unrelated to treatment) has not been appropriately defined or incorporated in the existing cost-utility literature, which could be due to a lack of evidence on the issue. Thus, more research is needed on metrics for a more comprehensive evaluation of diagnostic imaging. Similarly, the incorporation of variations in imaging tests accuracy, inconclusive results and associated risks has lacked uniformity in the cost-utility literature. Acknowledgment of these characteristics in future cost-utility publications will enhance their value and provide results that more closely resemble routine clinical practice.

Willingness-to-pay for predictive tests with no immediate treatment implications: a survey of US residents

We assessed how much, if anything, people would pay for a laboratory test that predicted their future disease status. A questionnaire was administered via an internet-based survey to a random sample of adult US respondents. Each respondent answered questions about two different scenarios, each of which specified: one of four randomly selected diseases (Alzheimer's, arthritis, breast cancer, or prostate cancer); an ex ante risk of developing the disease (randomly designated 10 or 25%); and test accuracy (randomly designated perfect or 'not perfectly accurate'). Willingness-to-pay (WTP) was elicited with a double-bounded, dichotomous-choice approach. Of 1463 respondents who completed the survey, most (70-88%, depending on the scenario) were inclined to take the test. Inclination to take the test was lower for Alzheimer's and higher for prostate cancer compared with arthritis, and rose somewhat with disease prevalence and for the perfect versus imperfect test [Correction made here after initial online publication.]. Median WTP varied from $109 for the imperfect arthritis test to $263 for the perfect prostate cancer test. Respondents' preferences for predictive testing, even in the absence of direct treatment consequences, reflected health and non-health related factors, and suggests that conventional cost-effectiveness analyses may underestimate the value of testing.

The cost-effectiveness of biopharmaceuticals: a look at the evidence

Due to the increasing availability and costs of biopharmaceuticals, policymakers are questioning whether they provide good value relative to other health interventions and many are increasingly relying on cost-utility analyses (CUAs) to supplement decision-making. Analyzing data from the Tufts Medical Center Cost-Effectiveness Analysis Registry, this study critically reviewed the cost-utility literature for biopharmaceuticals and compared their value to other health interventions. Of 2,383 studies in the registry, biopharmaceutical CUAs comprised the sixth largest category of interventions at 11%. Characteristics of biopharmaceutical articles were similar to other CUAs; however, they displayed slightly better quality. The median cost-effectiveness ratio of biopharmaceuticals was less favorable (i.e., higher) than other interventions though many seem to provide value for money. A logistic regression showed that among biopharmaceuticals the cost-effectiveness of industry-sponsored studies and products that treat infectious diseases were significantly more likely to be favorable (less than the overall median), while cancer and neurological treatments were significantly less likely.

Cost-utility analyses of diagnostic laboratory tests: a systematic review

OBJECTIVE

To review and evaluate the literature of cost-utility analyses (CUAs) regarding diagnostic laboratory testing.

METHODS

We reviewed all articles related to diagnostic laboratory testing in the Tufts Medical Center Cost-Effectiveness Analysis Registry (www.cearegistry.org), which contains detailed information on over 2000 published CUAs through 2008. We analyzed the extent to which the studies adhered to recommended practices for conducting and reporting cost-effectiveness analyses. We also recorded whether the studies contained information on diagnostic test accuracy and costs, and whether any account was taken of potential benefits or harms of testing that are unrelated to subsequent treatment, such as the reassurance value of testing.

RESULTS

We identified 141 published CUAs pertaining to diagnostic laboratory testing published through 2008 which contained 433 separate incremental cost-effectiveness ratios. Prior to 2000, there were only 20 CUAs published, but the number averaged 13.4 annually thereafter. Most studies focused on hematology/oncology (n = 42, 30%) and obstetrics/gynecology (n = 36, 26%) applications. Approximately 63% (n = 89) of studies clearly reported information about the accuracy of the test, but only 10% (n = 14) mentioned test safety or possible risks. A small number (n = 10, 7%) mentioned or considered the potential value or harm of testing unrelated to treatment consequences. Over 55% of the reported incremental cost-effectiveness ratios (ICERs) were either dominant (more quality-adjusted life years for less cost), or below $50,000 per quality-adjusted life years gained (in 2008 US dollars).

CONCLUSION

The number of CUAs investigating laboratory diagnostic testing has increased substantially with applications to diverse clinical areas. The literature reveals many areas in which testing represents good value for money. The vast majority of studies have not considered preferences for test information unrelated to treatment consequences.

A review of the costs and cost effectiveness of interventions in chronic kidney disease: implications for policy

Given rising healthcare costs and a growing population of patients with chronic kidney disease (CKD), there is an urgent need to identify health interventions that provide good value for money. For this review, the English-language literature was searched for studies of interventions in CKD reporting an original incremental cost-utility (cost per QALY) or cost-effectiveness (cost per life-year) ratio. Published cost studies that did not report cost-effectiveness or cost-utility ratios were also reviewed. League tables were then created for both cost-utility and cost-effectiveness ratios to assess interventions in patients with stage 1-4 CKD, waitlist and transplant patients and those with end-stage renal disease (ESRD). In addition, the percentage of cost-saving or dominant interventions (those that save money and improve health) was compared across these three disease categories. A total of 84 studies were included, contributing 72 cost-utility ratios, 20 cost-effectiveness ratios and 42 other cost measures. Many of the interventions were dominant over the comparator, indicating better health outcomes and lower costs. For the three disease categories, the greatest number of dominant or cost-saving interventions was reported for stage 1-4 CKD patients, followed by waitlist and transplant recipients and those with ESRD (91%, 87% and 55% of studies reporting a dominant or cost-saving intervention, respectively). There is evidence of opportunities to lower costs in the treatment of patients with CKD, while either improving or maintaining the quality of care. In order to realize these cost savings, efforts will be required to promote and effectively implement changes in treatment practices.

US FDA Modernization Act, section 114: uses, opportunities and implications for comparative effectiveness research

BACKGROUND

Section 114 of the 1997 US FDA Modernization Act (FDAMA) is an important vehicle for pharmaceutical companies to promote the economic value of their drugs to formulary decision makers, but little is known about how the Section has been interpreted and used.

METHODS

We conducted a web-based survey of a convenience sample of 35 outcomes directors of major pharmaceutical and biotechnology companies. We asked them about their interpretation of, and experiences with, Section 114, as well as their views regarding the FDA's role in the matter, and whether the advent of comparative effectiveness research (CER) will affect the use of Section 114 promotions.

RESULTS

Of the 35 experts, 16 (46%) completed the survey. 81% stated they always or frequently consider using Section 114 when making promotional claims for drugs. 75% stated that the FDA should issue guidance on how to make such promotions to payers, especially what qualifies as "healthcare economic information" and "competent and reliable scientific evidence." Most expected to use Section 114 to a greater extent in the future, and agreed that the increased focus on CER would increase Section 114 use.

CONCLUSIONS

The survey suggests strong awareness about Section 114 among the outcomes directors and some use of the Section for promotional purposes. It also reflects a belief that CER will increase use of Section 114 promotions, and that guidance from the FDA is needed. More clarity - and, ideally, flexible interpretation - from the FDA is warranted, especially given the rise of CER.

Is the United States ready for QALYs?

Quality-adjusted life-years (QALYs) are used in cost-effectiveness analyses to aid coverage and reimbursement decisions worldwide. QALYs provide a flexible and convenient metric for measuring and comparing health outcomes across diverse diseases and treatments. But their use has stirred controversy about how accurately they reflect preferences for health care and whether their use is fair. We review the debate and the use of QALYs in other countries and discuss prospects for using them in the U.S. health care system. Strict adherence to a QALY approach is likely to prove unacceptable in the United States, but a more flexible use of QALYs could be beneficial.

Regression analysis on the variation in efficiency frontiers for prevention stage of HIV/AIDS

OBJECTIVES

To investigate how the cost effectiveness of preventing HIV/AIDS varies across possible efficiency frontiers (EFs) by taking into account potentially relevant external factors, such as prevention stage, and how the EFs can be characterized using regression analysis given uncertainty of the QALY-cost estimates.

METHODS

We reviewed cost-effectiveness estimates for the prevention and treatment of HIV/AIDS published from 2002-2007 and catalogued in the Tufts Medical Center Cost-Effectiveness Analysis (CEA) Registry. We constructed efficiency frontier (EF) curves by plotting QALYs against costs, using methods used by the Institute for Quality and Efficiency in Health Care (IQWiG) in Germany. We stratified the QALY-cost ratios by prevention stage, country of study, and payer perspective, and estimated EF equations using log and square-root models.

RESULTS

A total of 53 QALY-cost ratios were identified for HIV/AIDS in the Tufts CEA Registry. Plotted ratios stratified by prevention stage were visually grouped into a cluster consisting of primary/secondary prevention measures and a cluster consisting of tertiary measures. Correlation coefficients for each cluster were statistically significant. For each cluster, we derived two EF equations - one based on the log model, and one based on the square-root model.

DISCUSSION

Our findings indicate that stratification of HIV/AIDS interventions by prevention stage can yield distinct EFs, and that the correlation and regression analyses are useful for parametrically characterizing EF equations. Our study has certain limitations, such as the small number of included articles and the potential for study populations to be non-representative of countries of interest. Nonetheless, our approach could help develop a deeper appreciation of cost effectiveness beyond the deterministic approach developed by IQWiG.

How long and how well: oncologists' attitudes toward the relative value of life-prolonging v. quality of life-enhancing treatments

OBJECTIVE

To determine how oncologists value quality-enhancing v. life-prolonging outcomes attributable to chemotherapy.

METHODS

The authors surveyed a random sample of 1379 US medical oncologists (members of the American Society of Clinical Oncology), presenting them with 2 scenarios involving a hypothetical new chemotherapy drug. Given their responses, the authors derived the implicit cost-effectiveness ratios each physician attributed to quality-enhancing and life-prolonging chemotherapies.

RESULTS

The authors received responses from 58% of the oncologists surveyed. On average, the responses implied that oncologists were willing to prescribe treatments that cost $245,972 per quality-adjusted life-year (QALY; SD $243,663 per QALY) in life-prolonging situations v. only $119,082 per QALY (SD $197,048 per QALY) for treatments that improve quality of life but do not prolong survival (P < 0.001). This difference did not depend on age, gender, percentage of time in clinical work, or self-reported preparedness to use and interpret cost-effectiveness information (P > 0.05 for all specifications). Differences across these situations persisted even among those who considered themselves to be "well-prepared" to make cost-effectiveness decisions.

CONCLUSION

Cost-effectiveness thresholds for oncologists vary widely for life-prolonging chemotherapy compared to treatments that only enhance quality of life. This difference suggests that oncologists value length of survival more highly than quality of life when making chemotherapy decisions.