A decision chart for assessing and improving the transferability of economic evaluation results between countries

Excess costs of comorbidities in chronic obstructive pulmonary disease: a systematic review

BACKGROUND

Chronic obstructive pulmonary disease (COPD) is a leading cause of morbidity and mortality worldwide. Comorbidities are often reported in patients with COPD and may influence the cost of care. Yet, the extent by which comorbidities affect costs remains to be determined.

OBJECTIVES

To review, quantify and evaluate excess costs of comorbidities in COPD.

METHODS

Using a systematic review approach, Pubmed and Embase were searched for studies analyzing excess costs of comorbidities in COPD. Resulting studies were evaluated according to study characteristics, comorbidity measurement and cost indicators. Mark-up factors were calculated for respective excess costs. Furthermore, a checklist of quality criteria was applied.

RESULTS

Twelve studies were included. Nine evaluated comorbidity specific costs; three examined index-based results. Pneumonia, cardiovascular disease and diabetes were associated with the highest excess costs. The mark-up factors for respective excess costs ranged between 1.5 and 2.5 in the majority of cases. On average the factors constituted a doubling of respective costs in the comorbid case. The main cost driver, among all studies, was inpatient cost. Indirect costs were not accounted for by the majority of studies. Study heterogeneity was high.

CONCLUSIONS

The reviewed studies clearly show that comorbidities are associated with significant excess costs in COPD. The inclusion of comorbid costs and effects in future health economic evaluations of preventive or therapeutic COPD interventions seems highly advisable.

Rational centre selection for RCTs with a parallel economic evaluation--the next step towards increased generalisability?

The paper discusses the impact of centre selection on the generalisability of randomised controlled trial (RCT)-based economic evaluations and suggests a future research agenda. The first section briefly reviews the current methods for addressing generalisability. We argue that these methods make no verifiable assumptions about how representative the recruiting centres are to the population of centres in the jurisdiction. The second section uses data from a multicentre RCT to illustrate that cost-effectiveness estimates can be influenced by the sample of recruiting centres. Finally, we propose two concepts that may advance generalisability research. First, we distinguish between the 'research space' and the 'policy space' and argue that policy makers are interested in the latter, while current methods describe the former. Second, we propose a centre-specific generalisability index used at RCT design stage to address generalisability. We conclude that future research should focus on generalisability at RCT design stage rather than on post hoc analyses.

The diagnostic pathway in complex paediatric neurology: a cost analysis

BACKGROUND

The diagnostic trajectory of complex paediatric neurology may be long, burdensome, and expensive while its diagnostic yield is frequently modest. Improvement in this trajectory is desirable and might be achieved by innovations such as whole exome sequencing. In order to explore the consequences of implementing them, it is important to map the current pathway. To that end, this study assessed the healthcare resource use and associated costs in this diagnostic trajectory in the Netherlands.

METHODS

Fifty patients presenting with complex paediatric neurological disorders of a suspected genetic origin were included between September 2011 and March 2012. Data on their healthcare resource utilization were collected from the hospital medical charts. Unit prices were obtained from the Dutch Healthcare Authority, the Dutch Healthcare Insurance Board, and the financial administration of the hospital. Bootstrap simulations were performed to determine mean quantities and costs.

RESULTS

The mean duration of the diagnostic trajectory was 40 months. A diagnosis was established in 6% of the patients. On average, patients made 16 physician visits, underwent four imaging and two neurophysiologic tests, and had eight genetic and 16 other tests. Mean bootstrapped costs per patient amounted to €12,475, of which 43% was for genetic tests (€5,321) and 25% for hospital visits (€3,112).

CONCLUSION

Currently, the diagnostic trajectories of paediatric patients who have complex neurological disease with a strong suspected genetic component are lengthy, resource-intensive, and low-yield. The data from this study provide a backdrop against which the introduction of novel techniques such as whole exome sequencing should be evaluated.

Cost-Effectiveness Analysis Comparing Chemotherapy Regimens in the Treatment of AIDS-Related Kaposi’s Sarcoma in Brazil

BACKGROUND

Economic analyses of agents used in the treatment of AIDS and opportunistic diseases are particularly important in developing countries.

PURPOSE

To analyze the cost-effectiveness of AIDS-related Kaposi's sarcoma (AIDS-KS) chemotherapy regimens in Brazil.

METHOD

A decision-analysis model was developed, and effectiveness data were derived from randomized phase III trials evaluating pegylated liposomal doxorubicin (PLD), liposomal daunorubicin (DNX), and the ABV regimen (doxorubicin, bleomycin, and vincristine). Resource data on direct medical costs were obtained from local sources.

RESULTS

The cost-effectiveness estimates (defined as average costs per patient who responds completely or partially) favored PLD (US $10,272/responder) in comparison to DNX (US $16,263/responder). Regarding cost-effectiveness, the ABV regimen that is widely used in developing countries had better results when compared to both PLD (US $1,268 vs. US $10,271) and DNX (US $1,268 vs. US $16,260). The incremental cost per additional responder of using PLD instead of ABV was US $20,990. Sensitivity analyses suggest that these results hold over a wide range of assumptions.

CONCLUSION

ABV seems to be the most reasonable treatment option for AIDS-KS patients in resource-limited countries like Brazil.

EQUIPT: protocol of a comparative effectiveness research study evaluating cross-context transferability of economic evidence on tobacco control

INTRODUCTION

Tobacco smoking claims 700,000 lives every year in Europe and the cost of tobacco smoking in the EU is estimated between €98 and €130 billion annually; direct medical care costs and indirect costs such as workday losses each represent half of this amount. Policymakers all across Europe are in need of bespoke information on the economic and wider returns of investing in evidence-based tobacco control, including smoking cessation agendas. EQUIPT is designed to test the transferability of one such economic evidence base-the English Tobacco Return on Investment (ROI) tool-to other EU member states.

METHODS AND ANALYSIS

EQUIPT is a multicentre, interdisciplinary comparative effectiveness research study in public health. The Tobacco ROI tool already developed in England by the National Institute for Health and Care Excellence (NICE) will be adapted to meet the needs of European decision-makers, following transferability criteria. Stakeholders' needs and intention to use ROI tools in sample countries (Germany, Hungary, Spain and the Netherlands) will be analysed through interviews and surveys and complemented by secondary analysis of the contextual and other factors. Informed by this contextual analysis, the next phase will develop country-specific ROI tools in sample countries using a mix of economic modelling and Visual Basic programming. The results from the country-specific ROI models will then be compared to derive policy proposals that are transferable to other EU states, from which a centralised web tool will be developed. This will then be made available to stakeholders to cater for different decision-making contexts across Europe.

ETHICS AND DISSEMINATION

The Brunel University Ethics Committee and relevant authorities in each of the participating countries approved the protocol. EQUIPT has a dedicated work package on dissemination, focusing on stakeholders' communication needs. Results will be disseminated via peer-reviewed publications, e-learning resources and policy briefs.

Transferability of health cost evaluation across locations in oncology: cluster and principal component analysis as an explorative tool

Background

The transferability of economic evaluation in health care is of increasing interest in today’s globalized environment. Here, we propose a methodology for assessing the variability of data elements in cost evaluations in oncology. This method was tested in the context of the European Network of Excellence “Connective Tissues Cancers Network”.

Methods

Using a database that was previously aimed at exploring sarcoma management practices in Rhône-Alpes (France) and Veneto (Italy), we developed a model to assess the transferability of health cost evaluation across different locations. A nested data structure with 60 final factors of variability (e.g., unit cost of chest radiograph) within 16 variability areas (e.g., unit cost of imaging) within 12 objects (e.g., diagnoses) was produced in Italy and France, separately. Distances between objects were measured by Euclidean distance, Mahalanobis distance, and city-block metric. A hierarchical structure using cluster analysis (CA) was constructed. The objects were also represented by their projections and area of variability through correlation studies using principal component analysis (PCA). Finally, a hierarchical clustering based on principal components was performed.

Results

CA suggested four clusters of objects: chemotherapy in France; follow-up with relapse in Italy; diagnosis, surgery, radiotherapy, chemotherapy, and follow-up without relapse in Italy; and diagnosis, surgery, and follow-up with or without relapse in France. The variability between clusters was high, suggesting a lower transferability of results. Also, PCA showed a high variability (i.e. lower transferability) for diagnosis between both countries with regard to the quantities and unit costs of biopsies.

Conclusion

CA and PCA were found to be useful for assessing the variability of cost evaluations across countries. In future studies, regression methods could be applied after these methods to elucidate the determinants of the differences found in these analyses.

Electronic supplementary material

The online version of this article (doi:10.1186/s12913-014-0537-x) contains supplementary material, which is available to authorized users.

Methodological reviews of economic evaluations in health care: what do they target?

INTRODUCTION AND OBJECTIVES

An increasing number of published studies of economic evaluations of health technologies have been reviewed and summarized with different purposes, among them to facilitate decision-making processes. These reviews have covered different aspects of economic evaluations, using a variety of methodological approaches. The aim of this study is to analyze the methodological characteristics of the reviews of economic evaluations in health care, published during the period 1990-2010, to identify their main features and the potential missing elements. This may help to develop a common procedure for elaborating these kinds of reviews.

METHODS

We performed systematic searches in electronic databases (Scopus, Medline and PubMed) of methodological reviews published in English, period 1990-2010. We selected the articles whose main purpose was to review and assess the methodology applied in the economic evaluation studies. We classified the data according to the study objectives, period of the review, number of reviewed studies, methodological and non-methodological items assessed, medical specialty, type of disease and technology, databases used for the review and their main conclusions. We performed a descriptive statistical analysis and checked how generalizability issues were considered in the reviews.

RESULTS

We identified 76 methodological reviews, 42 published in the period 1990-2001 and 34 during 2002-2010. The items assessed most frequently (by 70% of the reviews) were perspective, type of economic study, uncertainty and discounting. The reviews also described the type of intervention and disease, funding sources, country in which the evaluation took place, type of journal and author's characteristics. Regarding the intertemporal comparison, higher frequencies were found in the second period for two key methodological items: the source of effectiveness data and the models used in the studies. However, the generalizability issues that apparently are creating a growing interest in the economic evaluation literature did not receive as much attention in the reviews of the second period. The remaining items showed similar frequencies in both periods.

CONCLUSIONS

Increasingly more reviews of economic evaluation studies aim to analyze the application of methodological principles, and offer summaries of papers classified by either diseases or health technologies. These reviews are useful for finding literature trends, aims of studies and possible deficiencies in the implementation of methods of specific health interventions. As no significant methodological improvement was clearly detected in the two periods analyzed, it would be convenient to pay more attention to the methodological aspects of the reviews.

Potential transferability of economic evaluations of programs encouraging physical activity in children and adolescents across different countries--a systematic review of the literature

Physical inactivity is an increasing problem. Owing to limited financial resources, one method of getting information on the cost-effectiveness of different types of prevention programs is to examine existing programs and their results. The aim of this paper is to give an overview of the transferability of cost-effectiveness results of physical activity programs for children and adolescents to other contexts. Based on a systematic review of the literature, the transferability of the studies found was assessed using a sub-checklist of the European Network of Health Economic Evaluation Databases (EURONHEED). Thirteen studies of different physical activity interventions were found and analyzed. The results for transferability ranged from “low” to “very high”. A number of different factors influence a program’s cost-effectiveness (i.e., discount rate, time horizon, etc.). Therefore, transparency with regard to these factors is one fundamental element in the transferability of the results. A major point of criticism is that transferability is often limited because of lack of transparency. This paper is the first to provide both an overview and an assessment of transferability of economic evaluations of existing programs encouraging physical activity in children and adolescents. This allows decision makers to gain an impression on whether the findings are transferable to their decision contexts, which may lead to time and cost savings.

Pharmacogenetic-guided selection of warfarin versus novel oral anticoagulants for stroke prevention in patients with atrial fibrillation: a cost-effectiveness analysis

OBJECTIVES

To compare clinical and economic outcomes of two anticoagulation therapy strategies, (i) pharmacogenetic-guided selection (PG-AC) of warfarin versus novel oral anticoagulants (NOACs), and (ii) usual anticoagulation care (usual AC) in patients with atrial fibrillation (AF), from the perspective of US healthcare payers.

METHODS

A Markov model was used to simulate long-term outcomes in a hypothetical cohort of 65-year-old patients with newly diagnosed AF: (i) all usual AC patients received warfarin therapy, and (ii) all PG-AC patients were genotyped. Patients with normal warfarin sensitivity genotypes would receive warfarin. Patients with high or low warfarin sensitivity genotypes would receive NOAC. Model inputs were derived from clinical trials published in the literature. The outcome measure was incremental cost per quality-adjusted life-year (QALY) gained (ICER).

RESULTS

PG-AC gained higher QALYs with higher cost (9.912 QALYs and USD94 396) when compared with usual AC (9.721 QALYs and USD93 853) in base-case analysis. The ICER of PG-AC was 2843 USD/QALY. The ICER of PG-AC would exceed 50 000 USD/QALY if the monthly cost of NOAC was more than USD285 or the risk of stroke with NOAC versus warfarin was more than 0.93. In 10 000 Monte Carlo simulations, PG-AC was cost-effective 96.4% of the time and usual AC was cost-effective 3.6% of the time. PG-AC was more costly than usual AC with a mean cost difference of USD1927 (95% confidence interval 1.877-1.977, P<0.001), and gained higher QALYs by 0.209 (95% confidence interval 0.208-0.210, P<0.001).

CONCLUSION

Compared with warfarin therapy with time in therapeutic range of 60%, using genotype to triage AF patients to warfarin or NOAC appears to be highly cost-effective.

Comparative cost-effectiveness analysis of oral triptan therapy for migraine in four European countries

AIM

To assess the differences in the cost-effectiveness of oral triptan therapy for migraines among European countries.

METHODS

A cost-effectiveness analysis of triptan therapy for migraine was conducted from a health-care payer perspective in four European countries (France, Italy, Spain and the UK). The study included those orally administered triptans available in all of these countries (almotriptan, brand-name sumatriptan, generic sumatriptan, zolmitriptan), and it was performed using a decision-tree model that incorporated costs of the drugs and probabilities associated with the possible events and outcomes. Average cost-effectiveness ratios were calculated in two different scenarios.

RESULTS

The average cost-effectiveness ratio showed wide variations across the different countries, these differences being up to 131 % (almotriptan), 77 % (brand-name sumatriptan), 153 % (generic sumatriptan) and 77 % (zolmitriptan). Generic sumatriptan was the most cost-effective drug analysed in the studied countries.

CONCLUSIONS

Caution must be taken when trying to transfer conclusions of pharmacoeconomics studies on migraines even in neighbouring countries. This cross-country variability is a concern for decision-makers and also for the elaboration of international recommendations and clinical practice guidelines.

How to select the right cost-effectiveness model? : A systematic review and stepwise approach for selecting a transferable health economic evaluation model for rheumatoid arthritis

OBJECTIVE

In the current study, we propose an approach for selection of a model that is transferable to a specific decision-making context (in this case, the Netherlands), using the case of rheumatoid arthritis (RA). The objectives of this study were (a) to perform a systematic literature review to identify existing health economic evaluation models for economic evaluation of disease-modifying antirheumatic drugs (DMARDs) in RA; and (b) to test the appropriateness of a stepwise model-selection process.

METHODS

First, we searched Medline and Embase to identify relevant studies in the English language, published between 1 January 2002 and 31 August 2012. From the included studies, all unique models were identified. Second, we applied a multi-step approach to model selection. Models that did not meet all minimal methodological and structural requirements based on the Outcome Measures in Rheumatology (OMERACT) criteria were excluded. Next, models were assessed on the basis of their fit when transferred to the Dutch health care setting. The criteria for model fit were transferability factors, as published by Welte et al., after exclusion of those that were deemed transferable by simple adaptation. Finally, the remaining models underwent a general quality check using the Philips checklist. Models showing good fit and high quality were considered to be transferable to the Dutch health care setting, using simple adaptation.

RESULTS

The systematic literature search identified 498 articles, which included 33 unique health economic evaluation models. Only six models passed the minimal methodological and structural requirements. Two of these models had an imperfect transferability fit to the Dutch health care setting, according to the Welte method. The remaining four models were, according to the Philips method, of good quality and were expected to be transferable by a simple adaptation.

CONCLUSION

This study introduces a stepwise approach for selecting health economic evaluation models that are transferable by a simple adaptation. The approach seems feasible and can be applied in various therapeutic areas, provided that the minimal methodological and structural requirements are defined accordingly. Availability of health economic evaluation models coupled with structured model selection could improve the efficiency, quality and comparability of health economic research.

The cost-utility of open prostatectomy compared with active surveillance in early localised prostate cancer

BACKGROUND

There is an on-going debate about whether to perform surgery on early stage localised prostate cancer and risk the common long term side effects such as urinary incontinence and erectile dysfunction. Alternatively these patients could be closely monitored and treated only in case of disease progression (active surveillance). The aim of this paper is to develop a decision-analytic model comparing the cost-utility of active surveillance (AS) and radical prostatectomy (PE) for a cohort of 65 year old men with newly diagnosed low risk prostate cancer.

METHODS

A Markov model comparing PE and AS over a lifetime horizon was programmed in TreeAge from a German societal perspective. Comparative disease specific mortality was obtained from the Scandinavian Prostate Cancer Group trial. Direct costs were identified via national treatment guidelines and expert interviews covering in-patient, out-patient, medication, aids and remedies as well as out of pocket payments. Utility values were used as factor weights for age specific quality of life values of the German population. Uncertainty was assessed deterministically and probabilistically.

RESULTS

With quality adjustment, AS was the dominant strategy compared with initial treatment. In the base case, it was associated with an additional 0.04 quality adjusted life years (7.60 QALYs vs. 7.56 QALYs) and a cost reduction of €6,883 per patient (2011 prices). Considering only life-years gained, PE was more effective with an incremental cost-effectiveness ratio of €96,420/life year gained. Sensitivity analysis showed that the probability of developing metastases under AS and utility weights under AS are a major sources of uncertainty. A Monte Carlo simulation revealed that AS was more likely to be cost-effective even under very high willingness to pay thresholds.

CONCLUSION

AS is likely to be a cost-saving treatment strategy for some patients with early stage localised prostate cancer. However, cost-effectiveness is dependent on patients' valuation of health states. Better predictability of tumour progression and modified reimbursement practice would support widespread use of AS in the context of the German health care system. More research is necessary in order to reliably quantify the health benefits compared with initial treatment and account for patient preferences.

Methods for Systematic Reviews of Health Economic Evaluations

Introduction. The quality of systematic reviews of health economic evaluations (SR-HE) is often limited because of methodological shortcomings. One reason for this poor quality is that there are no established standards for the preparation of SR-HE. The objective of this study is to compare existing methods and suggest best practices for the preparation of SR-HE. Methods. To identify the relevant methodological literature on SR-HE, a systematic literature search was performed in Embase, Medline, the National Health System Economic Evaluation Database, the Health Technology Assessment Database, and the Cochrane methodology register, and webpages of international health technology assessment agencies were searched. The study selection was performed independently by 2 reviewers. Data were extracted by one reviewer and verified by a second reviewer. On the basis of the overlaps in the recommendations for the methods of SR-HE in the included papers, suggestions for best practices for the preparation of SR-HE were developed. Results. Nineteen relevant publications were identified. The recommendations within them often differed. However, for most process steps there was some overlap between recommendations for the methods of preparation. The overlaps were taken as basis on which to develop suggestions for the following process steps of preparation: defining the research question, developing eligibility criteria, conducting a literature search, selecting studies, assessing the methodological study quality, assessing transferability, and synthesizing data. Discussion. The differences in the proposed recommendations are not always explainable by the focus on certain evaluation types, target audiences, or integration in the decision process. Currently, there seem to be no standard methods for the preparation of SR-HE. The suggestions presented here can contribute to the harmonization of methods for the preparation of SR-HE.

Cost-effectiveness of magnetic resonance (MR) imaging and MR-guided targeted biopsy versus systematic transrectal ultrasound-guided biopsy in diagnosing prostate cancer: a modelling study from a health care perspective

BACKGROUND

The current diagnostic strategy using transrectal ultrasound-guided biopsy (TRUSGB) raises concerns regarding overdiagnosis and overtreatment of prostate cancer (PCa). Interest in integrating multiparametric magnetic resonance imaging (MRI) and magnetic resonance-guided biopsy (MRGB) into the diagnostic pathway to reduce overdiagnosis and improve grading is gaining ground, but it remains uncertain whether this image-based strategy is cost-effective.

OBJECTIVE

To determine the cost-effectiveness of multiparametric MRI and MRGB compared with TRUSGB.

DESIGN, SETTING, AND PARTICIPANTS

A combined decision tree and Markov model for men with elevated prostate-specific antigen (>4 ng/ml) was developed. Input data were derived from systematic literature searches, meta-analyses, and expert opinion.

OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS

Quality-adjusted life years (QALYs) and health care costs of both strategies were modelled over 10 yr after initial suspicion of PCa. Probabilistic and threshold analyses were performed to assess uncertainty.

RESULTS AND LIMITATIONS

Despite uncertainty around the presented cost-effectiveness estimates, our results suggest that the MRI strategy is cost-effective compared with the standard of care. Expected costs per patient were € 2423 for the MRI strategy and € 2392 for the TRUSGB strategy. Corresponding QALYs were higher for the MRI strategy (7.00 versus 6.90), resulting in an incremental cost-effectiveness ratio of € 323 per QALY. Threshold analysis revealed that MRI is cost-effective when sensitivity of MRGB is ≥ 20%. The probability that the MRI strategy is cost-effective is around 80% at willingness to pay thresholds higher than € 2000 per QALY.

CONCLUSIONS

Total costs of the MRI strategy are almost equal with the standard of care, while reduction of overdiagnosis and overtreatment with the MRI strategy leads to an improvement in quality of life.

PATIENT SUMMARY

We compared costs and quality of life (QoL) of the standard "blind" diagnostic technique with an image-based technique for men with suspicion of prostate cancer. Our results suggest that costs were comparable, with higher QoL for the image-based technique.

Economic analysis of the costs associated with prematurity from a literature review

OBJECTIVES

To analyse published cost-of-illness studies that had assessed the cost of prematurity according to gestational age at birth.

METHODS

A review of the literature was carried out in March 2011 using the following databases: Medline, ScienceDirect, The Cochrane Library, Econlit and Business Source Premier, and a French Public-Health database. Key-word sequences related to 'prematurity' and 'costs' were considered. Studies that assessed costs according to the gestational age (GA) at the premature birth (<37 weeks of gestation) in industrialized countries and during the last two decades were included. Variations in the reported costs were analysed using a check-list, which allowed the studies to be described according to several methodological and contextual criteria.

RESULTS

A total of 18 studies published since 1990 were included. According to these studies, costs were assessed for different follow-up periods (short, medium or long-term), and for different degrees of prematurity (extreme, early, moderate and late). Results showed that whatever the follow-up period, costs correlated inversely with GA. They also showed considerable variability in costs within the same GA group. Differences between studies could be explained by the choices made, concerning i/the study populations, ii/contextual information, iii/and various economic criteria. Despite these variations, a global trend of costs was estimated in the short-term period using mean costs from four American studies that presented similar methodologies. Costs stand at over US$ 100,000 for extreme prematurity, between US$ 40,000 and US$ 100,000 for early prematurity, between US$ 10,000 and US$ 30,000 for moderate prematurity and below US$ 4500 for late prematurity.

CONCLUSION

This review underlined not only the clear inverse relationship between costs and GA at birth, but also the difficulty to transfer the results to the French context. It suggests that studies specific to the French health system need to be carried out.

Epidemiology and cost of herpes zoster and postherpetic neuralgia in Germany

After acquiring a varicella virus infection, the virus can reactivate and cause herpes zoster (HZ)--a painful skin rash. A complication of HZ is long-term persistence of pain after the rash has resolved (so-called postherpetic neuralgia, PHN). We aimed to describe the epidemiology of HZ/PHN and to estimate HZ/PHN-related costs in the German statutory health insurance (SHI) system (~85% of the total population). Treatment data of one large SHI was utilized, containing data on approximately 240,000 insured and their utilisation of services in 2004-2009. Identification of HZ- and PHN-cases was performed based on 'International Statistical Classification of Diseases' and specific medications using a control-group design. Incidences per 1,000 person-years (PY) and cost-of-illness for 1 year following HZ-onset considering the payer and societal perspective were calculated. All amounts were inflated to 2010 Euros. Population-figures were standardised and extrapolated to the total SHI-population in Germany in 2010. A mean annual incidence of 5.79 HZ-cases per 1,000 PY was observed, translating into an estimated 403,625 HZ-cases per year in the total SHI-population. Approximately 5% of HZ-cases developed PHN. One HZ-case caused on average euro 210 and euro 376 of costs from the payer and societal perspective, respectively. The development of PHN generated additional costs of euro 1,123 (euro 1,645 societal perspective). Total annual HZ/PHN-related costs were estimated at euro 182 million (euro 105 million) to society (payer). HZ and PHN place a considerable burden on the German SHI-system. Since HZ-vaccines will soon be available, a health-economic evaluation of these vaccines should be conducted.

Manual therapy, exercise therapy, or both, in addition to usual care, for osteoarthritis of the hip or knee. 2: economic evaluation alongside a randomized controlled trial

OBJECTIVE

To evaluate the cost effectiveness of manual physiotherapy, exercise physiotherapy, and a combination of these therapies for patients with osteoarthritis of the hip or knee.

METHODS

206 Adults who met the American College of Rheumatology criteria for hip or knee osteoarthritis were included in an economic evaluation from the perspectives of the New Zealand health system and society alongside a randomized controlled trial. Resource use was collected using the Osteoarthritis Costs and Consequences Questionnaire. Quality-adjusted life years (QALYs) were calculated using the Short Form 6D. Willingness-to-pay threshold values were based on one to three times New Zealand's gross domestic product (GDP) per capita of NZ$ 29,149 (in 2009).

RESULTS

All three treatment programmes resulted in incremental QALY gains relative to usual care. From the perspective of the New Zealand health system, exercise therapy was the only treatment to result in an incremental cost utility ratio under one time GDP per capita at NZ$ 26,400 (-$34,081 to $103,899). From the societal perspective manual therapy was cost saving relative to usual care for most scenarios studied. Exercise therapy resulted in incremental cost utility ratios regarded as cost effective but was not cost saving. For most scenarios combined therapy was not as cost effective as the two therapies alone.

CONCLUSIONS

In this study, exercise therapy and manual therapy were more cost effective than usual care at policy relevant values of willingness-to-pay from both the perspective of the health system and society. Trial registration number Australian New Zealand Clinical Trials Registry ACTRN12608000130369.

Health economic evaluation of vaccination strategies for the prevention of herpes zoster and postherpetic neuralgia in Germany

BACKGROUND

Herpes zoster (HZ) is a self-limiting painful skin rash affecting mostly individuals from 50 years of age. The main complication is postherpetic neuralgia (PHN), a long-lasting pain after rash has resolved. A HZ-vaccine has recently been licensed in Europe for individuals older than 50 years. To support an informed decision-making for a potential vaccination recommendation, we conducted a health economic evaluation to identify the most cost-effective vaccination strategy.

METHODS

We developed a static Markov-cohort model, which compared a vaccine-scenario with no vaccination. The cohort entering the model was 50 years of age, vaccinated at age 60, and stayed over life-time in the model. Transition probabilities were based on HZ/PHN-epidemiology and demographic data from Germany, as well as vaccine efficacy (VE) data from clinical trials. Costs for vaccination and HZ/PHN-treatment (in Euros; 2010), as well as outcomes were discounted equally with 3% p.a. We accounted results from both, payer and societal perspective. We calculated benefit-cost-ratio (BCR), number-needed-to-vaccinate (NNV), and incremental cost-effectiveness ratios (ICERs) for costs per HZ-case avoided, per PHN-case avoided, and per quality-adjusted life-year (QALY) gained. Different target age-groups were compared to identify the most cost-effective vaccination strategy. Base-case-analysis as well as structural, descriptive-, and probabilistic-sensitivity-analyses (DSA, PSA) were performed.

RESULTS

When vaccinating 20% of a cohort of 1 million 50 year old individuals at the age of 60 years, approximately 20,000 HZ-cases will be avoided over life-time. The NNV to avoid one HZ (PHN)-case was 10 (144). However, with a BCR of 0.34 this vaccination-strategy did not save costs. The base-case-analysis yielded an ICER of 1,419 (20,809) Euros per avoided HZ (PHN)-case and 28,146 Euros per QALY gained. Vaccination at the age of 60 was identified in most (sensitivity) analyses to be the most cost-effective vaccination strategy. In DSA, vaccine price and VE were shown to be the most critical input-data.

CONCLUSIONS

According to our evaluation, HZ-vaccination is expected to avoid HZ/PHN-cases and gain QALYs to higher costs. However, the vaccine price had the highest impact on the ICERs. Among different scenarios, targeting individuals aged 60 years seems to represent the most cost-effective vaccination-strategy.

Cost-effectiveness of CTA, MRA and DSA in patients with non-traumatic subarachnoid haemorrhage

Objectives

Intra-arterial digital subtraction angiography (DSA), magnetic resonance angiography (MRA) and computed tomographic angiography (CTA) are imaging modalities used for diagnostic work-up of non-traumatic subarachnoid haemorrhage. The aim of our study was to compare the cost-effectiveness of MRA, DSA and CTA in the first year after the bleed.

Methods

A decision model was used to calculate costs and benefits (in quality-adjusted life-years [QALYs]) that accrued to cohorts of 1,000 patients. Costs and characteristics of diagnostic tests, therapy, patients’ quality of life and associated costs were respected. The diagnostic strategy with highest QALYs and lowest costs was considered most cost-effective.

Results

DSA was the most effective diagnostic option, yielding on average 0.6039 QALYs (95 % CI, 0.5761–0.6327) per patient, followed by CTA 0.5983 QALYs (95 % CI, 0.5704–0.6278) and MRA 0.5947 QALYs (95 % CI, 0.5674–0.6237). Cost was lowest for DSA (39,808 €; 95 % CI, 37,182–42,663), followed by CTA (40,748 €; 95 % CI, 37,937–43,831) and MRA (41,814 €; 95 % CI, 38,730–45,146). A strategy of CTA followed by DSA if CTA was negative or coiling deemed not feasible, was as effective as DSA alone at average costs of 39,767€ (95 % CI, 36,903–42,402).

Conclusion

A combined strategy of CTA and DSA was found to be the most cost-effective diagnostic approach.

Main Messages

• We defined a standard model for cost-effectiveness analysis in diagnostic imaging.

• Comparing total 1-year health costs and benefits, CTA is superior to MRA.

• A strategy of combining CTA and DSA was found to be the most cost-effective diagnostic approach.

Cost-effectiveness of additional catheter-directed thrombolysis for deep vein thrombosis

BACKGROUND

Additional treatment with catheter-directed thrombolysis (CDT) has recently been shown to reduce post-thrombotic syndrome (PTS).

OBJECTIVES

To estimate the cost effectiveness of additional CDT compared with standard treatment alone.

METHODS

Using a Markov decision model, we compared the two treatment strategies in patients with a high proximal deep vein thrombosis (DVT) and a low risk of bleeding. The model captured the development of PTS, recurrent venous thromboembolism and treatment-related adverse events within a lifetime horizon and the perspective of a third-party payer. Uncertainty was assessed with one-way and probabilistic sensitivity analyzes. Model inputs from the CaVenT study included PTS development, major bleeding from CDT and utilities for post DVT states including PTS. The remaining clinical inputs were obtained from the literature. Costs obtained from the CaVenT study, hospital accounts and the literature are expressed in US dollars ($); effects in quality adjusted life years (QALY).

RESULTS

In base case analyzes, additional CDT accumulated 32.31 QALYs compared with 31.68 QALYs after standard treatment alone. Direct medical costs were $64,709 for additional CDT and $51,866 for standard treatment. The incremental cost-effectiveness ratio (ICER) was $20,429/QALY gained. One-way sensitivity analysis showed model sensitivity to the clinical efficacy of both strategies, but the ICER remained < $55,000/QALY over the full range of all parameters. The probability that CDT is cost effective was 82% at a willingness to pay threshold of $50,000/QALY gained.

CONCLUSIONS

Additional CDT is likely to be a cost-effective alternative to the standard treatment for patients with a high proximal DVT and a low risk of bleeding.

Real-effectiveness medicine--pursuing the best effectiveness in the ordinary care of patients

Clinical know-how and skills as well as up-to-date scientific evidence are cornerstones for providing effective treatment for patients. However, in order to improve the effectiveness of treatment in ordinary practice, also appropriate documentation of care at the health care units and benchmarking based on this documentation are needed. This article presents the new concept of real-effectiveness medicine (REM) which pursues the best effectiveness of patient care in the real-world setting. In order to reach the goal, four layers of information are utilized: 1) good medical know-how and skills combined with the patient view, 2) up-to-date scientific evidence, 3) continuous documentation of performance in ordinary settings, and 4) benchmarking between providers. The new framework is suggested for clinicians, organizations, policy-makers, and researchers.

Are community-living and institutionalized dementia patients cared for differently? Evidence on service utilization and costs of care from German insurance claims data

Background

Dementia patients are often cared for in institutional arrangements, which are associated with substantial spending on professional long-term care services. Nevertheless, there is little evidence on the exact cost differences between community-based and institutional dementia care, especially when it comes to the distinct health care services. Adopting the perspective of the German social security system, which combines Statutory Health Insurance and Compulsory Long-Term Care Insurance (payer perspective), our study aimed to compare community-living and institutionalized dementia patients regarding their health care service utilization profiles and to contrast the respective expenditures.

Methods

We analysed 2006 claims data for 2,934 institutionalized and 5,484 community-living individuals stratified by so-called care levels, which reflect different needs for support in activities of daily living. Concordant general linear models adjusting for clinical and demographic differences were run for each stratum separately to estimate mean per capita utilization and expenditures in both settings. Subsequently, spending for the community-living and the institutionalized population as a whole was compared within an extended overall model.

Results

Regarding both settings, health and long-term care expenditures rose the higher the care level. Thus, long-term care spending was always increased in nursing homes, but health care spending was comparable. However, the underlying service utilization profiles differed, with nursing home residents receiving more frequent visits from medical specialists but fewer in-hospital services and anti-dementia drug prescriptions. Altogether, institutional care required additional yearly per capita expenses of ca. €200 on health and ca. €11,200 on long-term care.

Conclusion

Community-based dementia care is cost saving from the payer perspective due to substantially lower long-term care expenditures. Health care spending is comparable but community-living and institutionalized individuals present characteristic service utilization patterns. This apparently reflects the existence of setting-specific care strategies. However, the bare economic figures do not indicate whether these different concepts affect the quality of care provision and disregard patient preferences and caregiver-related aspects. Hence, additional research combining primary and secondary data seems to be required to foster both, sound allocation of scarce resources and the development of patient-centred dementia care in each setting.

Adapting a global cost-effectiveness model to local country requirements: posaconazole case study

BACKGROUND

Many countries have various requirements for local economic analyses to assess the value of a new health technology and/or to secure reimbursement. This study presents a case study of an economic model developed to assess the cost-effectiveness of posaconazole vs standard azole therapy (fluconazole/itraconazole) to prevent invasive fungal infections (IFIs), which was adapted by at least 11 countries.

METHODS

Modeling techniques were used to assess the cost-effectiveness of posaconazole vs fluconazole/itraconazole as IFI prophylaxis in patients with acute myelogenous leukemia or myelodysplastic syndromes and chemotherapy-induced neutropenia. For the core model, the probabilities of experiencing an IFI, IFI-related death, and death from other causes were estimated from clinical trial data. Long-term mortality, drug costs, and IFI treatment costs were obtained from secondary sources. Locally changed parameters were probabilities of long-term death and survival, currency, drug costs, health utility, IFI treatment costs, and discount rate.

RESULTS

Locally adapted cost-effective modeling studies indicate that prophylaxis with posaconazole, compared with fluconazole/itraconazole, prolongs survival, and, in most countries, is cost-saving. In all countries, the model predicted that prophylaxis with posaconazole would be associated with an increase in life-years, with increases ranging from 0.016-0.1 life-year saved. In all countries, use of the model led to posaconazole being approved by the appropriate reimbursement authority.

LIMITATIONS

The study did not have power to detect differences between posaconazole and fluconazole or itraconazole separately. The risk of death after 100 days was assumed to be equal for those who did and did not develop an IFI, and equal probabilities of IFI-related and other death during the trial period were used for both groups.

CONCLUSIONS

A core economic model was successfully adapted locally by several countries. The model showed that posaconazole was cost-saving or cost-effective vs fluconazole/itraconazole and led to positive reimbursement listings.

Cost effectiveness of therapeutic interventions in ankylosing spondylitis: a critical and systematic review

OBJECTIVES

This report reviews the cost effectiveness of different therapeutic interventions used in the treatment of ankylosing spondylitis (AS).

METHODS

We performed a systematic search of the databases MEDLINE via PubMed, EMBASE and the Cochrane Library and used hand-searching to identify articles on cost effectiveness of therapies for adult patients with AS published up to November 2010.

RESULTS

Of 135 articles, 13 studies were analysed. Two articles were on physical therapies, one article was on NSAIDs and ten articles were on tumour necrosis factor (TNF) inhibitors (infliximab = 6, etanercept = 2, infliximab and etanercept = 1 and adalimumab = 1). Of the latter, no article directly compared TNF inhibitors. Articles showed substantial heterogeneity in methodological approaches and thus results, which prevented us from any extensive comparison, data pooling or meta-analysis. The incremental cost-effectiveness ratio (ICER) for spa-exercise treatment was &U20AC;7465 (95% CI 3294, 14 686) per QALY. The ICERs for infliximab, etanercept and adalimumab were &U20AC;5307-237 010, &U20AC;29 815-123 761 and &U20AC;7344-33 303 per QALY, respectively.

CONCLUSIONS

Modelling treatment strategies in chronic relapsing diseases such as AS presents specific challenges, as reflected in the variation in the cost-effectiveness results reported. Although quite variable, the cost-effectiveness ratios for AS therapies remain within an acceptable range.

Specific guidelines for assessing and improving the methodological quality of economic evaluations of newborn screening

BACKGROUND

Economic evaluation of newborn screening poses specific methodological challenges. Amongst others, these challenges refer to the use of quality adjusted life years (QALYs) in newborns, and which costs and outcomes need to be considered in a full evaluation of newborn screening programmes. Because of the increasing scale and scope of such programmes, a better understanding of the methods of high-quality economic evaluations may be crucial for both producers/authors and consumers/reviewers of newborn screening-related economic evaluations. The aim of this study was therefore to develop specific guidelines designed to assess and improve the methodological quality of economic evaluations in newborn screening.

METHODS

To develop the guidelines, existing guidelines for assessing the quality of economic evaluations were identified through a literature search, and were reviewed and consolidated using a deductive iterative approach. In a subsequent test phase, these guidelines were applied to various economic evaluations which acted as case studies.

RESULTS

The guidelines for assessing and improving the methodological quality of economic evaluations in newborn screening are organized into 11 categories: "bibliographic details", "study question and design", "modelling", "health outcomes", "costs", "discounting", "presentation of results", "sensitivity analyses", "discussion", "conclusions", and "commentary".

CONCLUSIONS

The application of the guidelines highlights important issues regarding newborn screening-related economic evaluations, and underscores the need for such issues to be afforded greater consideration in future economic evaluations. The variety in methodological quality detected by this study reveals the need for specific guidelines on the appropriate methods for conducting sound economic evaluations in newborn screening.

Lost productivity in four European countries among patients with rheumatic disorders: are absenteeism and presenteeism transferable?

BACKGROUND

When national pharmacoeconomic guidelines are compared, different recommendations are identified on how to identify, measure and value lost productivity, leading to difficulties when comparing lost productivity estimates across countries. From a transferability point of view, the question arises of whether differences between countries regarding lost productivity are the result of using different calculation methods (methodological differences) or of other between-country differences. When lost productivity data differ significantly across countries, the transferability of lost productivity data across countries is hindered.

OBJECTIVE

The objective of this study was to investigate whether country of residence has a significant influence on the quantity of lost productivity among patients with rheumatic disorders. Confounding factors that might differ between countries were corrected for, while the methodology used to identify and measure lost productivity was kept the same.

METHODS

This question was investigated by means of an online questionnaire filled out by 200 respondents with a rheumatic disorder per country in four European countries, namely the Netherlands, the UK, Germany and France. In addition to those regarding lost productivity, the questionnaire contained questions about patient characteristics, disability insurance, disease characteristics, quality of life and job characteristics as these variables are expected to influence lost productivity in terms of absenteeism and presenteeism. The data were analysed by regression analyses, in which different components - being absent in last 3 months, number of days absent and presenteeism - of lost productivity were the main outcome measures and other variables, such as gender, impact of disease, shift work, job control, partial disability and overall general health, were corrected for.

RESULTS

The results showed that country sometimes has a significant influence on lost productivity and that other variables such as, for example, age, disease severity, number of contract hours, decision latitude, experienced health (as reported on the visual analogue scale) and partial disability, also influence lost productivity. A significant influence of country of residence was found on the variables 'being absent in the last three months', 'number of days absent' and 'quality of work on the last working day'. However, country did not influence 'quantity of work on the last working day' and 'overall presenteeism on the last working day'.

CONCLUSION

It can be concluded that country has a significant influence on lost productivity among patients with rheumatic disorders, when corrected for other variables that have an influence on absenteeism and presenteeism. Transferring lost productivity data across countries without adaptation is hindered by the significant differences between countries in this patient group. As a result, transferring lost productivity data, being either monetary values or volumes of productivity losses, between countries can give wrong estimations of the cost effectiveness of treatments.

The use of pharmacoeconomic evidence to support formulary decision making in Saudi Arabia: Methodological recommendations

In pharmacoeconomics the costs and consequences of alternative medications are compared. Many countries have begun to use pharmacoeconomic evidence to support decisions on licensing, pricing, reimbursement, or addition to the formulary. In Saudi Arabia, it is not mandatory to submit cost effectiveness evidence to support licensing or addition to the formulary decisions however, data will be considered if submitted. Previous evidence suggests that the use of pharmacoeconomic evidence by Saudi Pharmacy and Therapeutic (P&T) committee members in formulary decisions making process is limited mainly because of lack of expertise and lack of resources. This paper intended to provide Saudi P&T decision makers with a clear set of best practice methodological recommendations to help in increasing the utilisation of pharmacoeconomic evidence in the formulary decisions making process.

Deriving input parameters for cost-effectiveness modeling: taxonomy of data types and approaches to their statistical synthesis

BACKGROUND

The evidence base informing economic evaluation models is rarely derived from a single source. Researchers are typically expected to identify and combine available data to inform the estimation of model parameters for a particular decision problem. The absence of clear guidelines on what data can be used and how to effectively synthesize this evidence base under different scenarios inevitably leads to different approaches being used by different modelers.

OBJECTIVES

The aim of this article is to produce a taxonomy that can help modelers identify the most appropriate methods to use when synthesizing the available data for a given model parameter.

METHODS

This article developed a taxonomy based on possible scenarios faced by the analyst when dealing with the available evidence. While mainly focusing on clinical effectiveness parameters, this article also discusses strategies relevant to other key input parameters in any economic model (i.e., disease natural history, resource use/costs, and preferences).

RESULTS

The taxonomy categorizes the evidence base for health economic modeling according to whether 1) single or multiple data sources are available, 2) individual or aggregate data are available (or both), or 3) individual or multiple decision model parameters are to be estimated from the data. References to examples of the key methodological developments for each entry in the taxonomy together with citations to where such methods have been used in practice are provided throughout.

CONCLUSIONS

The use of the taxonomy developed in this article hopes to improve the quality of the synthesis of evidence informing decision models by bringing to the attention of health economics modelers recent methodological developments in this field.

TRANSFERABILITY OF HEALTH TECHNOLOGY ASSESSMENT REPORTS IN LATIN AMERICA: AN EXPLORATORY SURVEY OF RESEARCHERS AND DECISION MAKERS

Introduction: HTA agencies, especially in developing countries, are under resourced and unable to conduct the desired amount of assessments. Adapting HTA reports (HTAs) from other jurisdictions is an alternative for saving resources.

Objectives: To explore HTA transferability experiences in Latin-America and Caribbean (LAC): are decision makers (DMs) using HTAs from other jurisdictions? Are researchers adapting HTAs when developing local reports? How useful is the information found in HTAs from other jurisdictions?

Methods: Web-based survey sent to 13031 HTA researchers and DMs.

Results: We received 671 responses from 19 countries. DMs reported using HTAs from other jurisdictions to guide decisions in the majority of the situations: 52.6 percent HTAs from outside LAC (e.g., Europe), 23.1 percent from other LAC countries, and only 24.3 percent HTAs from their own countries. 63 percent of researchers reported using HTAs from other jurisdictions. Usefulness scored significantly higher for HTAs from other jurisdictions as compared to local HTAs (7.1 versus 6.0 in a 1–10 scale; p < .01). Both DMs and researchers considered the information regarding safety and effectiveness more applicable than the information on social aspects, or economic evaluation. Barriers that limit transferability had significantly different scores for HTAs from other LAC countries as compared to those from regions outside LAC (i.e., poor methodological quality 6.7 versus 5.3, different epidemiological context 6.0 versus 7.4; all p < .01).

Conclusions: HTAs from outside the region are commonly used. However, DMs and researchers agreed that HTAs from LAC had the greatest potential for transferability, provided that barriers such as poor methodological quality could be overcome.

Transferability of National Institute for Health and Clinical Excellence recommendations for pharmaceutical therapies in oncology to Central-Eastern European countries

The health burden of malignancies is greater in Central-Eastern Europe than in Western Europe. Furthermore, these countries have more limited healthcare resources, and therefore transparent decision criteria for innovative cancer therapies, including the assessment of cost-effectiveness, are an absolute necessity. Transferability of good-quality technology assessment reports, especially those prepared by National Institute for Health and Clinical Excellence (NICE) in the UK, could be highly beneficial to prevent duplication of efforts and save resources for local technology assessment. Our objective was to summarise key factors influencing the transferability of NICE recommendations in oncology for policy makers and oncologists in Central-Eastern Europe without personal experience in health technology assessment. In general, NICE recommendations are not transferable without adjustment of the analyses to local data. Even if the recommendation is positive, the conclusion can still be negative in lower-income countries, mainly due to relative price differences and the significance of the local budget impact. Technologies with negative NICE recommendations can still be cost-effective in Central-Eastern Europe due to the worse health status and therefore the greater potential health gain of the targeted population. The appropriateness of reimbursement decisions must be improved in Central-Eastern Europe, but copying NICE recommendations without local adjustment may do more harm than good.

An economic perspective on childhood obesity: recent findings on cost of illness and cost effectiveness of interventions

OBJECTIVE

This review aims to put an economic perspective on childhood and adolescent obesity by providing an overview on the latest literature on obesity-related costs and the cost effectiveness of interventions to prevent or manage the problem.

METHODS

The review is based on a comprehensive PubMed/Medline search performed in October 2011.

RESULTS

Findings on the economic burden of childhood obesity are inconclusive. Considering the different cost components and age groups, most but not all studies found excess health care costs for obese compared with normal-weight peers. The main limitations relate to short study periods and the strong focus on health care costs, neglecting other components of the economic burden of childhood obesity. The results of the economic evaluations of childhood and adolescent obesity programs support the expectation that preventive and management interventions with acceptable cost effectiveness do exist. Some interventions may even be cost saving. However, owing to the differences in various methodologic aspects, it is difficult to compare preventive and treatment approaches in their cost effectiveness or to determine the most cost-effective timing of preventive interventions during infancy and adolescence.

CONCLUSION

To design effective public policies against the obesity epidemic, a better understanding and a more precise assessment of the health care costs and the broader economic burden are necessary but, critically, depend on the collection of additional longitudinal data. The economic evaluation of childhood obesity interventions poses various methodologic challenges, which should be addressed in future research to fully use the potential of economic evaluation as an aid to decision making.

Conceptual framework for standard economic evaluation of physical activity programs in primary prevention

Economic evaluations of primary prevention physical activity programs have gained importance because of scarce resources in health-care-systems. A concept for economic evaluation should be based on the efficacy of physical activity, the standard methods of economic evaluation and the aims of public health. Previous publications have examined only parts of these components and have not developed a comprehensive conceptual framework; it is the objective of this article to develop such a framework. The derived method should aid decision makers and staff members of intervention programs in reviewing and conducting an economic evaluation. A literature search of articles was done using six electronic databases. Referenced works for standard methods and more comprehensive approaches for evaluation of preventive programs were studied. The newly developed conceptual framework for economic evaluation includes: (1) the type of physical activity program; (2) features of a selected study population; (3) the outcome dimension comprising exercise efficacy, reach, recruitment, response rate, maintenance, compliance and adverse health effects plus the social impact; and (4) the cost dimension consisting of program development costs, program implementation costs including the implementation, recruitment, program, participants' time costs and savings resulting from the health effects of the intervention. Cost-effectiveness also depends on the methodology, such as the chosen perspective, data collection, valuation methods and discounting. If an intervention is not considered cost-effective, it is necessary to check each dimension to find possible failures in order to learn for future interventions. A more detailed economic evaluation is of utmost importance for improved comparability and transferability.

The impact of BMI on direct costs in children and adolescents: empirical findings for the German Healthcare System based on the KiGGS-study

BACKGROUND

Childhood obesity is a growing public health burden. Among German children and adolescents, 15% are overweight (including obese) and 6.3% are obese according to a national reference. This is the first German study to assess aspects of the economic burden associated with overweight and obesity in children and adolescents based on a representative cross-sectional survey.

METHODS

Based on the German Interview and Examination Survey for Children and Adolescents (KiGGS), direct costs induced by utilisation of healthcare services (physician and therapist visits, hospital stays) were assessed using a bottom-up approach. To investigate the impact of body mass index (BMI) on costs, univariate analyses were performed and multivariate generalised mixed models were estimated.

RESULTS

Average annual total costs were estimated to be €442 (95% CI [402-486]). Bivariate analysis showed considerable differences between BMI groups in physician costs, but not for hospital or therapist costs. High socioeconomic status, residence in west Germany and underweight had a significant negative impact on total costs in multivariate analysis. The effect of overweight on total costs is positive but not significant; neither is the effect of obesity. However, overweight and obese children exhibit significantly higher physician costs and a higher probability of being high utilisers of healthcare services.

DISCUSSION

The economic implications of overweight and obesity are, to some extent, already visible in childhood. The results suggest that obese children should be classified as priority group for prevention. Despite limitations, this study provides important information concerning the relevance of childhood obesity as a health problem.

Contributions from the systematic review of economic evaluations: the case of childhood hepatitis A vaccination in Brazil

The aim of this study was to present the contributions of the systematic review of economic evaluations to the development of a national study on childhood hepatitis A vaccination. A literature review was performed in EMBASE, MEDLINE, WOPEC, HealthSTAR, SciELO and LILACS from 1995 to 2010. Most of the studies (8 of 10) showed favorable cost-effectiveness results. Sensitivity analysis indicated that the most important parameters for the results were cost of the vaccine, hepatitis A incidence, and medical costs of the disease. Variability was observed in methodological characteristics and estimates of key variables among the 10 studies reviewed. It is not possible to generalize results or transfer epidemiological estimates of resource utilization and costs associated with hepatitis A to the local context. Systematic review of economic evaluation studies of hepatitis A vaccine demonstrated the need for a national analysis and provided input for the development of a new decision-making model for Brazil.

Cost-effectiveness of nonpharmacologic, nonsurgical interventions for hip and/or knee osteoarthritis: systematic review

OBJECTIVE

To investigate the cost-effectiveness of nonpharmacological, nonsurgical interventions for the treatment of hip and/or knee osteoarthritis.

METHODS

We identified economic evaluations or cost studies associated with randomized or quasi-randomized controlled trials that assessed nonpharmacologic, nonsurgical interventions for the treatment of hip and/or knee osteoarthritis. Medline, Embase, PubMed, National Health Service Economic Evaluation Database, CENTRAL, EconLit, and OpenSIGLE were searched up to October 1, 2010. Study characteristics extracted include study population, health outcomes, and economic analysis elements. Economic analyses were assessed by using the Quality of Health Economic Studies instrument, and the methodological quality of the randomized controlled trials was graded by using an internal validity checklist. All costs were converted to 2008 US dollars.

RESULTS

Ten economic evaluations and one randomized controlled trial reporting health-care costs met our inclusion criteria. Interventions included exercise programs, acupuncture, rehabilitation programs, and lifestyle interventions. Six of the 11 studies exhibited high risks of bias for the cost and/or effect components of their cost-effectiveness estimate. Six studies used comparators of unknown cost-effectiveness. Four studies reported cost-effectiveness estimates lower than $50,000 per quality-adjusted life-year. All studies evaluating exercise interventions found the programs to be cost saving.

CONCLUSIONS

There is only limited evidence for the cost-effectiveness of conservative treatments for the management of hip and/or knee osteoarthritis. More high-quality economic evaluations of conservative interventions are needed to further inform practice.

Reviewing the cost-effectiveness of endocrine early breast cancer therapies: influence of differences in modeling methods on outcomes

OBJECTIVES

The purpose of this systematic review is primarily to identify published cost-effectiveness analyses and cost-utility analyses of endocrine therapies for the treatment of early breast cancer. A secondary objective is to identify whether differences in seven modeling characteristics are related to differences in outcome of these cost-effectiveness and cost-utility analyses.

METHODS

A systematic literature review was conducted to identify peer-reviewed full economic evaluations of endocrine treatments of early breast cancer published in the English language between 2000 and December 2010. Information from these publications was abstracted regarding outcome, quality, and modeling methods.

RESULTS

We identified 20 economic evaluations comprising 5 different endocrine therapeutic strategies, which are all assessed more then once. The incremental cost-effectiveness ratios (ICERs) of the reported outcomes varied widely for identical therapies. For anastrazole compared to tamoxifen, incremental life-years gained even ranged from 0.16 to 0.550 with an ICER ranging from €3,958 to €75,331. Incremental quality-adjusted life-years (QALYs) gained ranged from 0.092 to 0.378 with a cost per QALY gained varying from €3,696 to €120,265. These large differences in outcome were related to different modeling methods, with differences in time horizon and use of a carryover effect as most prominent causes.

CONCLUSION

Despite similar comparators and logical differences due to transferability issues, the outcomes of the included studies varied widely. To increase comparability and transparency of pharmacoeconomic evaluations, standardization of modeling methods for different therapeutic groups/diseases and the availability of a detailed and complete description of the model used in the evaluation is advocated. Recommendations for standardization in modeling treatment strategies in early breast cancer are presented.

Costing of physical activity programmes in primary prevention: a review of the literature

This literature review aims to analyse the costing methodology in economic analyses of primary preventive physical activity programmes. It demonstrates the usability of a recently published theoretical framework in practice, and may serve as a guide for future economic evaluation studies and for decision making.A comprehensive literature search was conducted to identify all relevant studies published before December 2009. All studies were analysed regarding their key economic findings and their costing methodology.In summary, 18 international economic analyses of primary preventive physical activity programmes were identified. Many of these studies conclude that the investigated intervention provides good value for money compared with alternatives (no intervention, usual care or different programme) or is even cost-saving. Although most studies did provide a description of the cost of the intervention programme, methodological details were often not displayed, and savings resulting from the health effects of the intervention were not always included sufficiently.This review shows the different costing methodologies used in the current health economic literature and compares them with a theoretical framework. The high variability regarding the costs assessment and the lack of transparency concerning the methods limits the comparability of the results, which points out the need for a handy minimal dataset of cost assessment.

Health economic evaluations comparing insulin glargine with NPH insulin in patients with type 1 diabetes: a systematic review

BACKGROUND

Compared to conventional human basal insulin (neutral protamine Hagedorn; NPH) the long-acting analogue insulin glargine (GLA) is associated with a number of advantages regarding metabolic control, hypoglycaemic events and convenience. However, the unit costs of GLA exceed those of NPH. This study aims to systematically review the economic evidence comparing GLA with NPH in basal-bolus treatment (intensified conventional therapy; ICT) of type 1 diabetes in order to facilitate informed decision making in clinical practice and health policy.

METHODS

A systematic literature search was performed for the period of January 1st 2000 to December 1st 2009 via Embase, Medline, the Cochrane Library, the databases GMS (German Medical Science) and DAHTA (Deutsche Agentur für Health Technology Assessment), and the abstract books of relevant international scientific congresses. Retrieved studies were reviewed based on predefined inclusion criteria, methodological and quality aspects. In order to allow comparison between studies, currencies were converted using purchasing power parities (PPP).

RESULTS

A total of 7 health economic evaluations from 4 different countries fulfilled the predefined criteria: 6 modelling studies, all of them cost-utility analyses, and one claims data analysis with a cost-minimisation design. One cost-utility analysis showed dominance of GLA over NPH. The other 5 cost-utility analyses resulted in additional costs per quality adjusted life year (QALY) gained for GLA, ranging from € 3,859 to € 57,002 (incremental cost effectiveness ratio; ICER). The cost-minimisation analysis revealed lower annual diabetes-specific costs in favour of NPH from the perspective of the German Statutory Health Insurance (SHI).

CONCLUSIONS

The incremental cost-utility-ratios (ICER) show favourable values for GLA with considerable variation. If a willingness-to-pay threshold of £ 30,000 (National Institute of Clinical Excellence, UK) is adopted, GLA is cost-effective in 4 of 6 cost utility analyses (CUA) included. Thus insulin glargine (GLA) seems to offer good value for money. Comparability between studies is limited because of methodological and country specific aspects. The results of this review underline that evaluation of insulin therapy should use evidence on efficacy of therapy from information synthesis. The concept of relating utility decrements to fear of hypoglycaemia is a plausible approach but needs further investigation. Also future evaluations of basal-bolus insulin therapy should include costs of consumables such as needles for insulin injection as well as test strips and lancets for blood glucose self monitoring.

Targeted versus universal prevention. a resource allocation model to prioritize cardiovascular prevention

BACKGROUND

Diabetes mellitus brings an increased risk for cardiovascular complications and patients profit from prevention. This prevention also suits the general population. The question arises what is a better strategy: target the general population or diabetes patients.

METHODS

A mathematical programming model was developed to calculate optimal allocations for the Dutch population of the following interventions: smoking cessation support, diet and exercise to reduce overweight, statins, and medication to reduce blood pressure. Outcomes were total lifetime health care costs and QALYs. Budget sizes were varied and the division of resources between the general population and diabetes patients was assessed.

RESULTS

Full implementation of all interventions resulted in a gain of 560,000 QALY at a cost of €640 per capita, about €12,900 per QALY on average. The large majority of these QALY gains could be obtained at incremental costs below €20,000 per QALY. Low or high budgets (below €9 or above €100 per capita) were predominantly spent in the general population. Moderate budgets were mostly spent in diabetes patients.

CONCLUSIONS

Major health gains can be realized efficiently by offering prevention to both the general and the diabetic population. However, a priori setting a specific distribution of resources is suboptimal. Resource allocation models allow accounting for capacity constraints and program size in addition to efficiency.