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

Bridging trial and decision: a checklist to frame health technology assessments for resource allocation decisions

OBJECTIVE

Health technology assessments (HTAs) intend to inform real-world decisions. They often draw on data from explanatory trials and hence are not always applicable to the decision problem. HTAs may therefore not meet the needs of decision makers. Our objective was to develop and apply a checklist to: 1) systematically frame HTAs in a way that they are applicable to the decision problem; and 2) assess if a decision problem can be informed by an available HTA.

METHODS

We reviewed published literature to identify factors that should be considered when framing HTAs for resource allocation decisions. The checklist was finalized in collaboration with clinicians and policy makers. We applied the checklist to the economic evaluation of trastuzumab in early breast cancer. We defined a reference case and for each study, retrieved through a systematic review, we examined if each factor was explicitly considered.

RESULTS

A checklist was developed with 11 factors (e.g., clinical practice, consequences, and patient use). In the case of trastuzumab, most factors were considered by the 11 retrieved economic evaluations. Two factors, being the inclusion of all relevant comparators and professional use, were considered by none of the studies.

CONCLUSIONS

We developed a comprehensive checklist with 11 factors to frame HTAs and to assess the applicability of HTAs to resource allocation decisions. Economic evaluations on trastuzumab considered some of these factors, but overlooked others. The proposed checklist assists in systematically considering all factors in developing the conceptual model of an HTA, to make HTAs better reflect the decision problem.

Relative weight-related costs of healthcare use by children--results from the two German birth cohorts, GINI-plus and LISA-plus

Obesity among children and adolescents is a growing public health burden. According to a national reference among German children and adolescents aged 3-17 years, 15% are overweight (including obese) and 6.3% are obese. This study aims to assess the economic burden associated with overweight and obesity in children based on a cross-sectional survey from two birth cohort studies: the GINI-plus - German Infant Nutritional Intervention plus Non-Intervention study (3287 respondents aged 9 to <12 years) and the LISA-plus study - Influence of life-style factors on the development of the immune system and allergies in East and West Germany (1762 respondents aged 9 to <12 years). Using a bottom-up approach, we analyse direct costs induced by the utilisation of healthcare services and indirect costs emerging from parents' productivity losses. To investigate the impact of Body Mass Index (BMI) on costs, we perform various descriptive analyses and estimate a two-part regression model. Average annual total direct medical costs of healthcare use are estimated to be €418 (95% CI [346-511]) per child, split between physician (22%), therapist (29%), hospital (41%) and inpatient rehabilitation costs (8%). Bivariate analysis shows considerable differences between BMI groups: €469 (severely underweight), €468 (underweight), €402 (normal weight), €468 (overweight) and €680 (obese). Indirect costs make up €101 per year on average and tend to be higher for obese children, although this was not statistically significant. Drawing on these results, differences in healthcare costs between BMI groups are already apparent in children.

Transferability of health technology assessments and economic evaluations: a systematic review of approaches for assessment and application

Background:

Health technology assessments (HTA) generally, and economic evaluations (EE) more specifically, have become an integral part of health care decision making around the world. However, these assessments are time consuming and expensive to conduct. Evaluation resources are scarce and therefore priorities need to be set for these assessments and the ability to use information from one country or region in another (geographic transferability) is an increasingly important consideration.

Objectives:

To review the existing approaches, systems, and tools for assessing the geographic transferability potential or guiding the conduct of transferring HTAs and EEs.

Methods:

A systematic literature review was conducted of several databases, supplemented with web searching, hand searching of journals, and bibliographic searching of identified articles. Systems, tools, checklists, and flow charts to assess, evaluate, or guide the conduct of transferability of HTAs and EEs were identified.

Results:

Of 282 references identified, 27 articles were reviewed in full text and of these, seven proposed unique systems, tools, checklists, or flow charts specifically for geographic transferability. All of the seven articles identified a checklist of transferability factors to consider, and most articles identified a subset of ‘critical’ factors for assessing transferability potential. Most of these critical factors related to study quality, transparency of methods, the level of reporting of methods and results, and the applicability of the treatment comparators to the target country. Some authors proposed a sequenced flow chart type approach, while others proposed an assessment of critical criteria first, followed by an assessment of other noncritical factors. Finally some authors proposed a quantitative score or index to measure transferability potential.

Conclusion:

Despite a number of publications on the topic, the proposed approaches and the factors used for assessing geographic transferability potential have varied substantially across the papers reviewed. Most promising is the identification of an extensive checklist of critical and noncritical factors in determining transferability potential, which may form the basis for consensus of a future tool. Due to the complexities of identifying appropriate weights for each of the noncritical factors, it is still uncertain whether the assessment and calculation of an overall transferability score or index will be practical or useful for transferability considerations in the future.

Economic evaluation of home blood pressure telemonitoring: a randomized controlled trial

AIMS

The purpose of the present study was to compare the costs of home blood pressure (BP) telemonitoring (HBPM) with the costs of conventional office BP monitoring. In a randomized controlled trial, 105 hypertensive patients performed HBPM and 118 patients received usual care with conventional office BP monitoring during 6 months. Costs were quantified from the healthcare perspective. Non-parametric simulations were performed to quantify the uncertainty around the mean estimates and cost-effectiveness acceptability curves were made.

MAJOR FINDINGS

Systolic and diastolic daytime and night-time ambulatory BP (ABP) were reduced in both groups. The uncertainty around the incremental cost effectiveness ratio point estimates was considerable for both systolic and diastolic ABP. For systolic ABP, the difference in cost effectiveness ratio between the two groups was 256 Danish kroner (DKK)/mmHg [95% uncertainty interval, UI -860 to 4544]. For diastolic ABP, the difference in cost effectiveness ratio between the two groups was 655 DKK/mmHg [95% UI -674 to 69315]. Medication and consultation costs were lowest in the intervention group, but were offset by the cost of the telemonitoring equipment.

CONCLUSIONS

Cost-effectiveness analysis showed that telemonitoring of home BP was more costly compared with usual monitoring of office BP. The cost-effectiveness result is surrounded with considerable uncertainty.

Economic evaluation of deep anterior lamellar keratoplasty versus penetrating keratoplasty in The Netherlands

PURPOSE

To evaluate the cost effectiveness of deep anterior lamellar keratoplasty (DALK) versus penetrating keratoplasty (PK) in The Netherlands.

DESIGN

Cost-effectiveness analysis alongside a randomized, multicenter clinical trial.

METHODS

Fifty-three patients with corneal stromal pathologic features not affecting the endothelium were included with 28 patients in the DALK group and 25 in the PK group. Quality of life was measured before surgery and 3, 6, and 12 months after surgery. The main outcome measures were incremental cost-effectiveness ratios per clinically improved patient on the 25-item National Eye Institute Visual Functioning Questionnaire and per patient with endothelial cell loss of maximally 20% within the first year.

RESULTS

Mean total bootstrapped costs per patient were €7607 (US$10,498) in the DALK group and €6552 (US$9042) in the PK group. The incremental cost-effectiveness ratios were €9977 (US$13,768) per clinically improved patient on the 25-item National Eye Institute Visual Functioning Questionnaire and €6900 (US$9522) per patient with cell loss of maximally 20%. In patients without perforation of the Descemet membrane, the incremental cost-effectiveness ratio was €5250 (US$7245) per patient.

CONCLUSIONS

This study shows that DALK is more costly and more effective as compared with PK. Results on the 25-item National Eye Institute Visual Functioning Questionnaire were in favor of DALK, and endothelial cell loss in DALK patients remained stable after 6 months, whereas cell loss in PK patients continued. Furthermore, DALK procedures performed without perforation of the Descemet membrane were more effective. However, because it is unknown what society is willing to pay for an additional improved patient, cost effectiveness of DALK within a limited follow-up period of 12 months is unclear. Cost effectiveness of DALK may improve over time because of lower graft failure.

What do international pharmacoeconomic guidelines say about economic data transferability?

OBJECTIVES

The objectives of this article were to assess the positions of the various national pharmacoeconomic guidelines on the transferability (or lack of transferability) of clinical and economic data and to review the methods suggested in the guidelines for addressing issues of transferability.

METHODS

A review of existing national pharmacoeconomic guidelines was conducted to assess recommendations on the transferability of clinical and economic data, whether there are important differences between countries, and whether common methodologies have been suggested to address key transferability issues. Pharmacoeconomic guidelines were initially identified through the ISPOR Web site. In addition, those national guidelines not included in the ISPOR Web site, but known to us, were also considered.

RESULTS

Across 27 sets of guidelines, baseline risk and unit costs were uniformly considered to be of low transferability, while treatment effect was classified as highly transferable. Results were more variable for resource use and utilities, which were considered to have low transferability in 63% and 45% of cases, respectively. There were some differences between older and more recent guidelines in the treatment of transferability issues.

CONCLUSIONS

A growing number of jurisdictions are using guidelines for the economic evaluation of pharmaceuticals. The recommendations in existing guidelines regarding the transferability of clinical and economic data are quite diverse. There is a case for standardization in dealing with transferability issues. One important step would be to update guidelines more frequently.

A systematic review of PET and PET/CT in oncology: a way to personalize cancer treatment in a cost-effective manner?

BACKGROUND

A number of diagnostic tests are required for the detection and management of cancer. Most imaging modalities such as computerized tomography (CT) are anatomical. However, positron emission tomography (PET) is a functional diagnostic imaging technique using compounds labelled with positron-emitting radioisotopes to measure cell metabolism. It has been a useful tool in studying soft tissues such as the brain, cardiovascular system, and cancer. The aim of this systematic review is to critically summarize the health economic evidence of oncologic PET in the literature.

METHODS

Eight electronic databases were searched from 2005 until February 2010 to identify economic evaluation studies not included in previous Health Technology Assessment (HTA) reports. Only full health economic evaluations in English, French, or German were considered for inclusion. Economic evaluations were appraised using published quality criteria for assessing the quality of decision-analytic models. Given the variety of methods used in the health economic evaluations, the economic evidence has been summarized in qualitative form.

RESULTS

From this new search, 14 publications were identified that met the inclusion criteria. All publications were decision-analytic models and evaluated PET using Fluorodeoxyglucose F18 (FDG-PET). Eight publications were cost-effectiveness analyses; six were cost-utility analyses. The studies were from Australia, Belgium, Canada, France, Italy, Taiwan, Japan, the Netherlands, the United Kingdom, and the United States. In the base case analyses of these studies, cost-effectiveness results ranged from dominated to dominant. The methodology of the economic evaluations was of varying quality. Cost-effectiveness was primarily influenced by the cost of PET, the specificity of PET, and the risk of malignancy.

CONCLUSIONS

Owing to improved care and less exposure to ineffective treatments, personalized medicine using PET may be cost-effective. However, the strongest evidence for the cost-effectiveness of PET is still in the staging of non-small cell lung cancer. Management decisions relating to the assessment of treatment response or radiotherapy treatment planning require further research to show the impact of PET on patient management and its cost-effectiveness. Because of the potential for increased patient throughput and the possible greater accuracy, the cost-effectiveness of PET/CT may be superior to that of PET. Only four studies of the cost-effectiveness of PET/CT were found in this review, and this is clearly an area for future research.

Economic evaluation of lifestyle interventions for preventing diabetes and cardiovascular diseases

Lifestyle interventions (i.e., diet and/or physical activity) are effective in delaying or preventing the onset of diabetes and cardiovascular disease. However, policymakers must know the cost-effectiveness of such interventions before implementing them at the large-scale population level. This review discusses various issues (e.g., characteristics, modeling, and long-term effectiveness) in the economic evaluation of lifestyle interventions for the primary and secondary prevention of diabetes and cardiovascular disease. The diverse nature of lifestyle interventions, i.e., type of intervention, means of provision, target groups, setting, and methodology, are the main obstacles to comparing evaluation results. However, most lifestyle interventions are among the intervention options usually regarded as cost-effective. Diabetes prevention programs, such as interventions starting with targeted or universal screening, childhood obesity prevention, and community-based interventions, have reported favorable cost-effectiveness ratios.

International comparison of cost of falls in older adults living in the community: a systematic review

SUMMARY

Our objective was to determine international estimates of the economic burden of falls in older people living in the community. Our systematic review emphasized the need for a consensus on methodology for cost of falls studies to enable more accurate comparisons and subgroup-specific estimates among different countries.

INTRODUCTION

The purpose of this study was to determine international estimates of the economic burden of falls in older people living in the community.

METHODS

This is a systematic review of peer-reviewed journal articles reporting estimates for the cost of falls in people aged > or =60 years living in the community. We searched for papers published between 1945 and December 2008 in MEDLINE, PUBMED, EMBASE, CINAHL, Cochrane Collaboration, and NHS EED databases that identified cost of falls in older adults. We extracted the cost of falls in the reported currency and converted them to US dollars at 2008 prices, cost items measured, perspective, time horizon, and sensitivity analysis. We assessed the quality of the studies using a selection of questions from Drummond's checklist.

RESULTS

Seventeen studies met our inclusion criteria. Studies varied with respect to viewpoint of the analysis, definition of falls, identification of important and relevant cost items, and time horizon. Only two studies reported a sensitivity analysis and only four studies identified the viewpoint of their economic analysis. In the USA, non-fatal and fatal falls cost US $23.3 billion (2008 prices) annually and US $1.6 billion in the UK.

CONCLUSIONS

The economic cost of falls is likely greater than policy makers appreciate. The mean cost of falls was dependent on the denominator used and ranged from US $3,476 per faller to US $10,749 per injurious fall and US $26,483 per fall requiring hospitalization. A consensus on methodology for cost of falls studies would enable more accurate comparisons and subgroup-specific estimates among different countries.

A methodological framework of preparing economic evidence for selection of medicines in the Chinese setting

Medicines are becoming a major component of health expenditure in China. Selection of effective and cost-effective medicines represents an important effort to improve medicines use. A guideline on cost-effectiveness studies has been available in China. This guideline, however, fails to be a practical tool to prepare and critically appraise economic evidence. This article discusses, in the Chinese context, the approach to integrating economic component into the medicines selection, and elaborates the methods of producing economic evidence, including conducing economic reviews and primary economic studies.

Transferability of model-based economic evaluations: the case of trastuzumab for the adjuvant treatment of HER2-positive early breast cancer in the Netherlands

INTRODUCTION

Geographic transferability of model-based cost-effectiveness results may facilitate and shorten the reimbursement process of new pharmaceuticals. This study provides a real world example of transferring a cost-effectiveness study of trastuzumab for the adjuvant treatment of HER2-positive early breast cancer from the United Kingdom to The Netherlands.

METHODS

Three successive steps were taken. Step 1: Collect available information with regard to the original model, and assess transferability using existing checklists. Step 2: Adapt transferability-limiting factors. Step 3: Obtain a country-specific estimate of cost-effectiveness.

RESULTS

The structure of the UK model was transferable, although some of the model inputs needed adaptation. From a health-care perspective, the Dutch estimate amounted to euro5828/quality-adjusted life-year gained. From a societal perspective, the incremental cost-effectiveness ratio was dominant.

CONCLUSION

Transferability of a model-based UK-study in three steps proved to be an efficient method to provide an early indication of the cost-effectiveness of trastuzumab and has led to the provisional reimbursement of the treatment.

Recent economic findings on childhood obesity: cost-of-illness and cost-effectiveness of interventions

PURPOSE OF REVIEW

The rising prevalence of obesity amongst children and adolescents is a growing public health burden. This study reviews recent studies, first, examining the economic consequences of childhood obesity, and, second, evaluating the cost-effectiveness of programs to prevent and to manage childhood obesity.

RECENT FINDINGS

Evidence of the impact of childhood obesity on healthcare costs for children is ambiguous. Although one study did not find increasing costs with increasing body mass index (BMI), in some other studies this effect was visible--partly only in subgroups. The evaluation studies show that in order to reach acceptable cost-effectiveness values, interventions cannot focus solely on physical activity, but must include nutrition as an intervention target. Moreover, there is some evidence supporting the expectation that childhood obesity prevention may be successful in combining health gains with net cost savings.

SUMMARY

There is a need to estimate the costs of childhood obesity as an essential part of identifying cost-effective treatment and prevention measures. Given the diversity and shortcomings of the methodological approaches chosen in the existing evaluation studies, there is an urgent need both for more standardized economic evaluations of those measures and more methodological research.

Economic evaluation and transferability of physical activity programmes in primary prevention: a systematic review

This systematic review aims to assess the characteristics of, and the clinical and economic evidence provided by, economic evaluations of primary preventive physical exercise interventions, and to analyse their transferability to Germany using recommended checklists. Fifteen economic evaluations from seven different countries met eligibility criteria, with seven of the fifteen providing high economic evidence in the special country context. Most of the identified studies conclude that the investigated intervention provide good value for money compared with alternatives. However, this review shows a high variability of the costing methods between the studies, which limits comparability, generalisability and transferability of the results.

Systematic reviews of economic evaluations: utility or futility?

Systematic reviews of studies of effectiveness are the centrepiece of evidence-based medicine and policy making. Increasingly, systematic reviews of economic evaluations are also an expected input into much evidence-based policy making, with some health economists even calling for 'an economics approach to systematic review'. This paper questions the value of conducting systematic reviews of economic evaluations to inform decision making in health care. It argues that the value of systematic reviews of economic evaluations is usually undermined by three things. Firstly, compared with effectiveness studies, there is a much wider range of factors that limit the generalisability of cost-effectiveness results, over time and between health systems and service settings, including the context-dependency of resource use and opportunity costs, and different decision contexts and budget constraints. Secondly, because economic evaluations are more explicitly intended to be decision-informing, the requirements for generalisability take primacy, and considerations of internal validity become more secondary. Thirdly, since one of the two main forms of economic evaluation - decision analytic modelling - is itself a well-developed method of evidence synthesis, in most cases the need for a comprehensive systematic review of previous economic evaluations of a particular health technology or policy choice is unwarranted. I conclude that apparent 'meta-analytic expectations' for clear and widely applicable cost-effectiveness conclusions from systematic reviews of economic evaluations are optimistic and generally futile. For more useful insights and knowledge from previous economic studies in evidence-based policy making, a more limited range of reasons for conducting systematic reviews of health economic studies is proposed.

The multinational nature of cost-effectiveness analyses alongside multinational clinical trials

OBJECTIVES

Applied and methodological evidence to the conduct of economic evaluations alongside multinational clinical trials have appeared in the literature over the last decade. Nevertheless, little is known about the number and identity of countries participating in these studies. A structured review was carried out to assess the reporting of the multinational nature of these studies.

METHODS

A structured review was conducted by using online databases from January 1996 to December 2007. Articles were included if they reported cost-effectiveness analysis alongside a multinational randomized trial with individual patient-level data on resource use and outcome in more than one country. Key data extracted included country information, sample size, unit cost collection, methods to calculate costs and effects, and the reporting of incremental cost-effectiveness ratios.

RESULTS

Sixty-five studies out of a total of 591 articles identified in the original search fulfilled the inclusion criteria and were included in the review. Information about countries participating in the trial was not reported in 16 (26%) of the 65 studies. The overall sample size from all the randomized controlled trials identified was estimated to be 172,401 patients. Country-specific sample size was reported for 74,852 (43%) of the patients, but the country contribution was unknown for 97,549 (57%) of the participants.

CONCLUSION

The reporting of the multinational nature of these studies is currently inadequate. Therefore, future guidelines of transferability of economic evaluations across settings should emphasize the importance of reporting the number and identity of countries and their contribution to the overall sample size in cost-effectiveness analyses alongside multinational clinical trials.

[A proposed guideline for economic evaluation of health technologies]

Over the last few years, economic evaluation of health technologies has become a major tool used by European health policy decision-makers to create strategies for prioritizing the allocation of health resources and the approval of new technologies. Spain was a pioneer in proposing the standardization of methodology applicable to economic evaluation studies. However, because health policy decision-makers refused to support the initiative, the methodology was never put into practice. In the medium term, evidence of the economic value of new health technologies financed by the national health system will probably be increasingly required. At that time, stakeholders and decision-makers will have to agree upon a clear and concise set of rules on the technical and methodological issues that must be followed by economic evaluations of health technologies. Consequently, we have provided guidelines and recommendations for producing first-rate economic evaluations. The recommendations appear under seventeen headings or sections. In each case, the recommended requirements to be satisfied by an economic evaluation of health technologies are provided and each recommendation is followed by a commentary, providing a justification and comparing and contrasting the proposal with other available alternatives.

Systematic review of economic evaluations of human cell-derived wound care products for the treatment of venous leg and diabetic foot ulcers

Background

Tissue engineering is an emerging field. Novel bioengineered skin substitutes and genetically derived growth factors offer innovative approaches to reduce the burden of diabetic foot and venous leg ulcers for both patients and health care systems. However, they frequently are very costly. Based on a systematic review of the literature, this study assesses the cost-effectiveness of these growth factors and tissue-engineered artificial skin for treating chronic wounds.

Methods

On the basis of an extensive explorative search, an appropriate algorithm for a systematic database search was developed. The following databases were searched: BIOSIS Previews, CRD databases, Cochrane Library, EconLit, Embase, Medline, and Web of Science. Only completed and published trial- or model-based studies which contained a full economic evaluation of growth factors and bioengineered skin substitutes for the treatment of chronic wounds were included. Two reviewers independently undertook the assessment of study quality. The relevant studies were assessed by a modified version of the Consensus on Health Economic Criteria (CHEC) list and a published checklist for evaluating model-based economic evaluations.

Results

Eleven health economic evaluations were included. Three biotechnology products were identified for which topical growth factors or bioengineered skin substitutes for the treatment of chronic leg ulceration were economically assessed: (1) Apligraf^®, a bilayered living human skin equivalent indicated for the treatment of diabetic foot and venous leg ulcers (five studies); (2) Dermagraft^®, a human fibroblast-derived dermal substitute, which is indicated only for use in the treatment of full-thickness diabetic foot ulcers (one study); (3) REGRANEX^® Gel, a human platelet-derived growth factor for the treatment of deep neuropathic diabetic foot ulcers (five studies). The studies considered in this review were of varying and partly low methodological quality. They calculated that due to shorter treatment periods, fewer complications and fewer inpatient episodes the initial cost of the novel biotechnology products may be offset, making the treatment cost-effective or even cost-saving. The results of most studies were sensitive to initial costs of the products and the evidence of effectiveness.

Conclusion

The study results suggest that some growth factors and tissue-engineered artificial skin products feature favourable cost-effectiveness ratios in selected patient groups with chronic wounds. Despite the limitations of the studies considered, it is evident that health care providers and coverage decision makers should take not only the high cost of the biotechnology product but the total cost of care into account when deciding about the appropriate allocation of their financial resources. However, not only the cost-effectiveness but first of all the effectiveness of these novel biotechnology products deserve further research.

Challenges of translating genetic tests into clinical and public health practice

Research in genetics and genomics has led to an expanding list of molecular genetic tests, which are increasingly entering health care systems. However, the evidence surrounding the benefits and harms of these tests is frequently weak. Here we present the main challenges to the successful translation of new research findings about genotype-phenotype associations into clinical practice. We discuss the means to achieve an accelerated translation research agenda that is conducted in a reasonable, fair and efficient manner.

The transferability of economic evaluations:testing the model of Welte

OBJECTIVE

One of the existing methods to assess the transferability of economic evaluations is the model of Welte, which is a decision-chart method that includes general and specific knockout criteria and a transferability checklist. This study aims to test Welte's model with the help of a case study.

METHODS

In this study, foreign studies were transferred to The Netherlands and then compared with a Dutch reference study. In the case study, the cost-effectiveness of physiotherapy was compared with a multidisciplinary treatment. With the help of a systematic search, several foreign studies could be identified. Based on these foreign studies, two different predictions were produced for The Netherlands. In the “all studies prediction,” all foreign studies were used. In the “Welte's model prediction,” only the foreign studies were used, which passed the general and specific knockout criteria. Both predictions were compared with the Dutch reference case.

RESULTS

A total of 14 non-Dutch studies were identified. Seven studies did not pass the general knockout criteria and one study did not pass the specific knockout criteria. As a result, 14 studies were included in the “all studies prediction” and 6 studies in the “Welte's model prediction.” The predictions yielded different results and the “Welte's model prediction” proved better on costs than the “all studies prediction.”

DISCUSSION

The application of Welte's model does influence cost and effects estimates when transferring economic data between countries. However, more cases should be subjected to the Welte transferability model before a final conclusion can be drawn.

Cost-effectiveness analysis of human papillomavirus-vaccination programs to prevent cervical cancer in Austria

OBJECTIVE

The study predicts long-term cervical cancer related population health and economic effects of introducing the HPV-vaccination for 12-year-old girls (and boys) in addition to current screening compared with screening only.

METHOD

Health effects are predicted by a dynamic transmission model. Model results are used to calculate incremental cost-effectiveness ratios (ICER) in euro per life year gained (LYG) for a time-horizon between 2008 and 2060 from a public payer and a societal perspective.

RESULTS

Vaccination of girls results a discounted ICER of euro 64,000/LYG and euro 50,000/LYG from a payer's and societal perspectives respectively. The additional vaccination of boys increases the ICER to euro 311,000 and euro 299,000/LYG respectively. Results were most sensitive to vaccination price, discount rate and time-horizon.

CONCLUSION

HPV-vaccination for girls should be cost-effective when adopting a longer time-horizon and a societal perspective. Applying a shorter time frame and a payer's perspective or vaccinating boys may not be cost-effective without reducing the vaccine price.

Transferability indices for health economic evaluations: methods and applications

In this paper, we have elaborated an index in two phases to measure the degree of transferability of the results of the economic evaluation of health technologies. In the first phase, we have considered the objective factors (critical and non-critical) to derive a general transferability index, which can be used to measure this internal property of the studies of economic evaluation applied to health technologies. In the second phase, with a more specific index, we have measured the degree of applicability of the results of a given study to a different setting. Both indices have been combined (arithmetic and geometric mean) to obtain a global transferability index. We have applied the global index to a sample of 27 Spanish studies on infectious diseases. We have obtained an average value for the index of 0.54, quite far from the maximum theoretical value of 1. We also found that 11 studies lacked some critical factor and were directly deemed as not transferable.

Transferability of economic evaluations across jurisdictions: ISPOR Good Research Practices Task Force report

ABSTRACT A growing number of jurisdictions now request economic data in support of their decision-making procedures for the pricing and/or reimbursement of health technologies. Because more jurisdictions request economic data, the burden on study sponsors and researchers increases. There are many reasons why the cost-effectiveness of health technologies might vary from place to place. Therefore, this report of an ISPOR Good Practices Task Force reviews what national guidelines for economic evaluation say about transferability, discusses which elements of data could potentially vary from place to place, and recommends good research practices for dealing with aspects of transferability, including strategies based on the analysis of individual patient data and based on decision-analytic modeling.

Guidelines for completing the EURONHEED transferability information checklists

The structure and methods to complete and derive a quality score from the European Network of Health Economic Evaluation Databases (EURONHEED) transferability information checklists for published economic evaluations were reported and discussed in a previous paper (Boulenger et al. in Eur J Health Econ 6, 334-346, 2005). Within the same paper, the use of the checklists was illustrated through their application to a sample of economic evaluations conducted in France and UK. The transferability information subchecklist, consisting of 16 items from the original 42-point checklist, and methods used to derive it, were validated among 16 health economists across Europe participating in the EURONHEED project. Recent correspondence with other researchers, however, indicates that the checklists are now being utilised in empirical work and the methodology of assessing transferability and generalisability. This supplementary paper provides full details of the guidelines that have been developed and recently updated by the authors, such that the overall and subchecklists can be more widely and consistently completed and utilised. We also briefly discuss associated issues such as weighting of items in the checklists and give further clarifications regarding what we consider the most appropriate applications of the checklists to be.

Barriers to generalizability of health economic evaluations in Latin America and the Caribbean region

Use and acceptance of health economic evaluations (HEEs) has been much greater in developed than in developing nations. Nevertheless, while developing countries lag behind in the development of HEE methods, they could benefit from the progress made in other countries and concentrate on ways in which existing methods can be used or would need to be modified to fulfill their specific needs. HEEs, as context-specific tools, are not easily generalizable from setting to setting. Existing studies regarding generalizability and transferability of HEEs have primarily been conducted in developed countries. Therefore, a legitimate question for policy makers in Latin America and the Caribbean region (LAC) is to what extent HEEs conducted in industrialized economies and in LAC are generalizable to LAC (trans-regional) and to other LAC countries (intra-regional), respectively. We conducted a systematic review, searching the NHS Economic Evaluation Database (NHS EED), Office of Health Economics Health Economic Evaluation Database (HEED), LILACS (Latin America health bibliographic database) and NEVALAT (Latin American Network on HEE) to identify HEEs published between 1980 and 2004. We included individual patient- and model-based HEEs (cost-effectiveness, cost-utility, cost-benefit and cost-consequences analyses) that involved at least one LAC country. Data were extracted by three independent reviewers using a checklist validated by regional and international experts. From 521 studies retrieved, 72 were full HEEs (39% randomized controlled trials [RCTs], 32% models, 17% non-randomized studies and 12% mixed trial-modeling approach). Over one-third of identified studies did not specifically report the type of HEE. Cost-effectiveness and cost-consequence analyses accounted for almost 80% of the studies. The three Latin American countries with the highest participation in HEE studies were Brazil, Argentina and Mexico. While we found relatively good standards of reporting the study's question, population, interventions, comparators and conclusions, the overall reporting was poor, and evidence of unfamiliarity with international guidelines was evident (i.e. absence of incremental analysis, of discounting long-term costs and effects). Analysis or description of place-to-place variability was infrequent. Of the 49 trial-based analyses, 43% were single centre, 33% multinational and 18% multicentre national. Main reporting problems included issues related to sample representativeness, data collection and data analysis. Of the 32 model-based studies (most commonly using epidemiological models), main problems included the inadequacy of search strategy, range selection for sensitivity analysis and theoretical justifications. There are a number of issues associated with the reporting and methodology used in multinational and local HEE studies relevant for LAC that preclude the assessment of their generalizability and potential transferability. Although the quality of reporting and methodology used in model-based HEEs was somewhat higher than those from trial-based HEEs, economic evaluation methodology was usually weak and less developed than the analysis of clinical data. Improving these aspects in LAC HEE studies is paramount to maximizing their potential benefits such as increasing the generalizability/transferability of their results.

Transferability of economic evaluations of medical technologies: a new technology for orthopedic surgery

Transferring results of economic evaluations across countries or jurisdictions can potentially save scarce evaluation resources while helping to make market access and reimbursement decisions in a timely fashion. This article points out why transferring results of economic evaluations is particularly important in the field of medical technologies. It then provides an overview of factors that are previously identified in the literature as affecting transferability of economic evaluations, as well as methods for transferring results in a scientifically sound way. As the current literature almost exclusively relates to transferability of pharmacoeconomic evaluations, this article highlights those factors and methodologies that are of particular relevance to transferring medical technology assessments. Considering the state-of-the-art literature and a worked, real life, example of transferring an economic evaluation of a product used in orthopedic surgery, we provide recommendations for future work in this important area of medical technology assessment.

Economic evaluation of cystic fibrosis screening: A review of the literature

OBJECTIVES

To critically examine the economic evidence regarding cystic fibrosis (CF) carrier screening and to understand issues relating to the transferability of international findings to any national context for policy decisions.

METHODS

A systematic literature search identified 14 studies (out of 29 economic studies on CF) focusing on preconception or prenatal screening between 1990 and 2006. These studies were then assessed against international benchmarks on conducting and reporting of economic evaluations, costing methodology used and focusing on the transferability of the evidence to national contexts.

RESULTS

The primary outcome measures varied considerably between studies and there was considerable ambiguity and variation on how costs were estimated. The Incremental Cost Effectiveness Ratio (ICER) and net savings, for preconception and prenatal screening were inconsistent and varied significantly, even after adjusting for timing and exchange rates. Differences in screening participation rates, reproductive choices, test sensitivity, cost of test and lifetime cost of care make up a large part of the ICER variations.

CONCLUSION

The heterogeneity in study design, model inputs and reporting of economic evaluations of CF carrier screening makes comparability and transferability across countries and even within countries difficult. This reinforces the need to assess any technology within the relevant context, and to not simply generalize from reported studies. In turn, this adds to the complex task of making efficient resource allocation decisions in the area of CF carrier screening. Our evaluation adds weight to the calls for revisiting the way economic studies are conducted and reported.

EuroGentest: DNA-based testing for heritable disorders in Europe

OBJECTIVES

Regarding the recent attention to develop policies regarding the provision of clinical genetic testing services, access to, acceptance, utilisation and regulation of genetic services was investigated in selected European countries as well as one non-European country.

METHODS

Data were collected on the basis of relevant international reports and sources accessible via the internet, from self- designed, internationally administered surveys and with the help of a panel of experts from European countries participating in several workshops as well as from National European Societies of Human Genetics.

RESULTS

A selection of divergent health care systems was reviewed and compared (e.g. Finland, Germany, Portugal, Sweden, UK, France, Italy, Spain, Czech Republic, Lithuania and Serbia/Montenegro). For the evaluation of clinical validity and utility of genetic testing, background information was provided focussing on DNA-based testing for heritable disorders with a strong genetic component (usually due to the action of a single gene).

CONCLUSIONS

There is great heterogeneity in genetic testing services among the countries surveyed. It is premature to mandate that genetic testing provided by clinical services meets professional standards regarding clinical validity and utility, because there is to date no consensus within the scientific community and among health care providers to what extent clinical validity and utility can and need to be assessed. Points to consider in the process of developing such standards are proposed.

Modeling the Cost Effectiveness of Secondary Febrile Neutropenia Prophylaxis During Standard-Dose Chemotherapy

Purpose

Current guidelines (ie, by the American Society of Clinical Oncology and the European Organisation for Research and Treatment of Cancer) do not recommend secondary infection prophylaxis, whereas, in contrast, caregivers prefer secondary prophylaxis to chemotherapy dose reduction after an episode of febrile neutropenia (FN). Because granulocyte colony-stimulating factor (G-CSF) is expensive, this study investigates the economic consequences of secondary prophylactic use of different prophylactic strategies (antibiotics, antibiotics plus G-CSF, and a combined sequential approach) in a population at risk of FN, using a Markov model.

Methods

The input for the model is mainly based on the clinical outcome and patient-based cost data set (adopting the health care payer's perspective for the Netherlands) derived from a randomized study on primary prophylaxis in small-cell lung cancer (SCLC) patients; establishing mean cost of an episode FN of €3,290 and prophylaxis of €79 (antibiotics) ± €1,616 (G-CSF) per cycle. The economic analysis was analyzed probabilistically using first- and second-order Monte Carlo simulation. The incremental cost-effectiveness ratio (ICER) was defined as cost per FN-free cycle.

Results

Secondary prophylaxis with antibiotics was the least expensive strategy (mean, €4,496/patient). The strategy antibiotics plus G-CSF was most expensive (mean, € 8,998/patient). Comparison of these two strategies resulted in an unacceptably high ICER (€343,110 per FN-free cycle) in the Dutch context. In scenarios using higher FN-related costs (as found in the United States), the strategies are less distinct in their monetary effects, but still favor antibiotics.

Conclusion

This model-based economic analysis demonstrates that in the Netherlands and most likely also in the United States, if secondary prophylaxis is preferred, the strategy with antibiotics is recommended.

Economic evaluation of enoxaparin for anticoagulation in early cardioversion of persisting nonvalvular atrial fibrillation: a statutory health insurance perspective from Germany

OBJECTIVE

To estimate, from the perspective of Statutory Health Insurance (SHI, third-party payer) in Germany, the economic consequences of using the subcutaneous low-molecular-weight heparin (LMWH) enoxaparin instead of intravenous unfractionated heparin followed by oral phenprocoumon (UFH/PPC) for anticoagulation in patients undergoing transesophageal echocardiography (TEE)-guided early electrical cardioversion (ECV) of persisting nonvalvular atrial fibrillation (AF) without intracardiac clot.

DESIGN AND SETTING

The incremental cost for the enoxaparin-based regimen versus the UFH/PPC-based regimen was chosen as the target variable. A decision-analytic model considering the in- and outpatient sectors was used to quantify the target variable. Resource use during in- and outpatient treatment was taken from the Anticoagulation in Cardioversion using Enoxaparin (ACE) trial and from expert interviews with cardiologists in Germany in order to reflect the day-to-day conditions of clinical practice. Costs were given by SHI expenses for inpatient treatment and for medical services, drugs, disposables, and laboratory tests during outpatient treatment. These costs were determined by multiplying utilized resource items by the price or tariff of each item based on German healthcare regulations for the reference period of 2003/2004. According to the ACE trial, the evaluation encompassed 28 (26-30) treatment days with two consecutive phases. Phase I with 5 (3-12) days comprised diagnostics, start of anticoagulation, and ECV. Phase II with the remaining days consisted of continued anticoagulation and patient monitoring. The dosage of enoxaparin was 1 mg/kg bodyweight twice daily in treatment phase I followed by 40 mg twice daily with a bodyweight <65 kg or 60 mg twice daily with a BW > or =65 kg in treatment phase II. The daily dosages of UFH by continuous infusion and overlapping PPC were adjusted to an International Normalized Ratio of 2.0-3.0 in treatment phase I followed by 2.25mg PPC once daily in treatment phase II. Patients with any comorbidity and complication level (CCL) and those with low comorbidity and complications expected to occur in rare cases only (low-risk patients) were analyzed separately. In each base-case analysis, exclusively point estimates of all respective model parameters were applied.

MAIN OUTCOME MEASURES AND RESULTS

There were savings of 339 euro and 579 euro per patient receiving the enoxaparin-based regimen versus the UFH/PPC-based regimen in the case of patients with any CCL and of low-risk patients, respectively (1 euro approximate, equals $US1.25; first quarter 2004 values). In comprehensive sensitivity analyzes, the robustness of the model and its results was shown. First, the impact of the model parameters on the target variable for each patient group was quantified in a deterministic model. Secondly, the dependency of the target variable on random variables was described for each patient group using Monte Carlo simulation. Irrespective of the patient group, the cost weight and the base rate of hospitals for inpatient ECV in phase I turned out to have the greatest impact on the savings obtained by the enoxaparin-based regimen. In the case of patients with any CCL, this impact was about 1.4-fold of that of the probability of enoxaparin patients undergoing outpatient ECV in phase I. In the case of low-risk patients, the impact of the cost weight and the base rate of hospitals for inpatient ECV in phase I was about 4.1-fold of that of the price of enoxaparin 60 mg prefilled syringes in the outpatient sector. In 79% and 93% of 10,000 simulated comparisons each versus the UFH/PPC-based regimen, there were savings obtained by the enoxaparin-based regimen in patients with any CCL and in low-risk patients, respectively.

CONCLUSIONS

Results of this evaluation showed that an enoxaparin-based regimen for TEE-guided ECV of AF in patients without intracardiac clot offers SHI in Germany a considerable saving potential when used instead of an UFH/PPC-based regimen.

Methods for determining cost-benefit ratios for pharmaceuticals in Germany

The aim of this methodological paper is to summarize evidence on how to implement cost-benefit assessment according to the new German legislative framework (Competition Enhancement Act). Given the complexity of existing health policy frameworks within industrialised countries in adapting health economics in their respective regulatory scheme, no clear international scientific consensus on which health economic methods should be chosen for assessment can be determined. Nevertheless, a broad consensus on the internal properties of methods itself can be found. Based on these common international standards in methodology, this work provides a minimum catalogue of methods and criteria that meet legal and local German requirements with regard to specific factors of its health care system. Aside from categorising clearly defined standards (e.g., study forms, cost and benefit categories) the suggested catalogue specifies some intensively debated areas in Germany (e.g., the QALY, modelling, the perspective used in the assessment). After the proposition of certain methods the paper leads to a first recommendation of a detailed assessment-process itself specific for the German way in implementing cost-benefit ratios within regulatory decision making in Germany.

Enhanced decision support for policy makers using a web interface to health-economic models—Illustrated with a cost-effectiveness analysis of nation-wide infant vaccination with the 7-valent pneumococcal conjugate vaccine in the Netherlands

We have developed a web-based user-interface (web interface) to enhance the usefulness of health-economic evaluations to support decision making (http://pcv.healtheconomics.nl). It allows the user to interact with a health-economic model to evaluate predefined and customized scenarios and perform sensitivity analysis. To explore its usefulness, it was applied to an evaluation of cost-effectiveness of nation-wide infant vaccination with the 7-valent pneumococcal conjugate vaccine (PCV7), that was used to support a policy decision on the inclusion of PCV7 in the national vaccination program (NVP) of the Netherlands. We used a decision-tree analytic model to project the impact of infant vaccination with four doses of PCV7 on an annual cohort of infants born in the Netherlands. The base-case analysis includes the beneficial effects on unvaccinated individuals (herd protection). Additional scenarios varying the number of doses, discount rate for effects and the number of serotypes in the vaccine were evaluated and can be analysed on the web. Our model projects a base-case incremental cost-effectiveness ratio (iCER) of euro14,000 (95% uncertainty interval (UI): 9,800-20,200) per quality adjusted life year (QALY) or euro15,600 (95% UI: 11,100-23,900) per life year gained (LYG).

Transferability of economic evaluations: approaches and factors to consider when using results from one geographic area for another

BACKGROUND

Geographic transferability of economic evaluation data from one country to another has the potential to make a more efficient use of national and international evaluation resources. However, inappropriate transferability of economic data can provide misleading results and lead to an inefficient use of scarce health care resources.

OBJECTIVES

The objective of this study was to review, summarize and categorize the literature on: (i) factors affecting the geographic transferability of economic evaluation data; and (ii) approaches which have either been proposed or used for transferability.

METHODS

A systematic literature review on transferability was conducted. Electronic databases, hand searching and bibliographic searching techniques were utilized. Inclusion criteria for the review included conceptual or empirical papers with mention of factors affecting, or approaches for, transferability of economic evaluation data across geographic locations. Exclusion criteria included papers published prior to 1966, non-English language papers, pure science studies and animal studies. Three databases were involved in the primary search: Ovid MEDLINE, EMBASE, and CINAHL. In addition to the primary search, the Heath Economic Evaluation Database (OHE HEED), the NHS EED database and the EconLit databases were searched. Transferability factors were classified into major and minor categories, a classification of alternative transferability approaches was developed, and the number of empirical studies was catalogued according to this classification.

RESULTS

There is a substantial amount of literature on factors potentially affecting transferability. Based on these papers we identified 77 factors and subsequently developed a classification system which grouped these factors into five broad categories based on characteristics of the patient, the disease, the provider, the health care system and methodological conventions. Another 40 studies were identified which attempted to transfer economic evaluation data from one country to another and these were classified according to the sources for clinical efficacy, resource utilization and unit cost data.

CONCLUSIONS

There is strong evidence indicating that transferability of economic evaluation data is a difficult and complex task. Approaches which have been used for transferability suggest that, at a minimum, there is a need for country-specific substitution of practice pattern data as well as unit cost data. A limitation of this review relates to the lack of empirical studies which prevents stronger conclusions regarding which transferability factors are most important to consider and under which circumstances.

Economic evaluations of cholesterol-lowering drugs: a critical and systematic review

The wide availability of economic evaluations and their increasing importance for decision making emphasises the need for economic evaluations that are methodologically sound. The aim of this review was to provide users of economic evaluations of cholesterol-lowering drugs with an insight into the quality of these evaluations. By focusing on the most relevant studies, the gap between research and policy making may be narrowed. A systematic review was conducted. All Dutch and English publications on economic evaluations of cholesterol-lowering drugs were identified by searching PubMed, the Centre for Reviews and Dissemination database (CRD), the NHS Economic Evaluation Database (NHS EED), the Health Technology Assessment database (HTA) and the Database of Abstracts of Reviews of Effects (DARE). A search strategy was set up to identify the articles to be included. The quality of these articles was assessed using Drummond's checklists. The scoring was performed by at least two reviewers. When necessary, disagreement between these reviewers was decided upon in a consensus meeting. We calculated an average quality score for the included articles. The search identified 1390 articles, of which 23 were included. Most studies measured the costs per life-year gained. The overall score per study was disappointing and varied between 2.7 and 7.7, with an average of 5.5. Most studies scored high on the measurement of costs and consequences, whereas the establishment of effectiveness left room for improvement. Only two studies included a well performed incremental analysis. This study noted an increase of quality of economic evaluations over time, suggesting the value of cost-effectiveness studies for policy decisions increases over time. In general, piggy-back evaluations tended to score higher on quality and may therefore be more valuable in decision making.

Cost effectiveness of an adherence-improving programme in hypertensive patients

BACKGROUND

Non-adherence to antihypertensive drugs is high, and the economic consequences of non-adherence may be substantial. The Medication Events Monitoring System (MEMS), which is a method to improve adherence, has been shown to be a useful tool for the management of adherence problems.

OBJECTIVE

To assess the cost effectiveness of the MEMS compared with usual care in a population of hypertensive patients with poor adherence. The MEMS programme consisted of provision of containers fitted with electronic caps together with adherence training if indicated.

METHODS

In a randomised controlled trial, 164 hypertensive patients in the experimental strategy and 89 patients in the usual care strategy were followed for 5 months. Patients who had a systolic blood pressure (SBP) > or = 160 mm Hg and/or diastolic BP (DBP) > or = 95 mm Hg despite the use of antihypertensive drugs were eligible. Patients were recruited by a GP, and treatment took place in general practice. In the experimental strategy, electronic monitoring of the intake of antihypertensive drugs was introduced without change of medication. Unsatisfactory adherence was defined as < 85% of days with the number of doses taken as prescribed. In the usual care strategy, antihypertensive treatment was intensified by the addition or change of antihypertensive drugs, if necessary, without provision of an electronic monitor. Outcome parameters included the proportion of patients with normalised blood pressure (NBP) at 5 months and QALYs. Costs were quantified from the healthcare and societal perspective. Non-parametric bootstrap simulations were performed to quantify the uncertainty around the mean estimates and cost-effectiveness acceptability curves were presented. In addition, a number of univariate sensitivity analyses were performed on deterministic variables.

RESULTS

At 5 months, 3.1% (95% UI [uncertainty interval] -9.7%, +15.8%) more patients had NBP, and 0.003 (95% UI -0.005, +0.010) more QALYs were generated in the experimental strategy. A statistically significant lower percentage of patients had a dose escalation in the experimental strategy. Irrespective of the ceiling ratio for cost effectiveness, the cost-effectiveness probability was between 75% and 80% for the analysis from the healthcare perspective using proportion of patients with NBP as the outcome parameter. For the analysis from the societal perspective using QALYs as the outcome parameter, this probability was between 45% and 51%.

CONCLUSION

For a time horizon of 5 months, a difference in both cost and effect could not be detected between an adherence-improving programme compared with usual care for hypertensive patients. The probability that the adherence-improving programme is cost effective is at best moderate. Moreover, the cost-effectiveness result is surrounded with considerable uncertainty and large-scale implementation warrants additional research into the economic consequences of this intervention. Patients may benefit from the use of a MEMS monitor in situations where BP targets are not reached because of suspected non-adherence and both patient and GP are reluctant to increase the dose or number of antihypertensive drugs.

Cost effectiveness of preventive interventions in type 2 diabetes mellitus: a systematic literature review

A systematic review of the literature was conducted to give an overview of economic evaluations of preventive interventions in type 2 diabetes mellitus. The interventions were sorted by type of preventive intervention (primary, secondary or tertiary) and by category (e.g. education, medication for hypertension). Several databases were searched for studies published between January 1990 and May 2004 on the three types of preventive intervention. For each study selected, inclusion of specific components from a standardised list of items, including quality, was recorded in a database. Summary tables were generated based on the database.A number of conclusions were drawn from this review. The most important was that strict blood pressure control was a more cost-effective intervention than less strict control, as shown by six studies reporting cost savings to very low costs per life-year gained. Primary and secondary prevention of type 2 diabetes were also highly cost effective, but these results were based on very few studies. Medications to reduce weight and hyperglycaemia together were cost effective compared with conventional interventions. Finally, the separate results regarding medications to reduce weight, hyperglycaemia and hypercholesterolaemia varied enormously, thus no conclusion could be drawn and further economic analysis is required.

Hospitalisation costs of cystic fibrosis

OBJECTIVE

To calculate per-case hospital costs for patients with cystic fibrosis under routine conditions from a healthcare provider's perspective; identify the impact of different cost categories; investigate whether cases with cystic fibrosis can be grouped into homogenous cost groups according to defined severity levels; and determine the value of specific factors as predictors of hospital cost variations.

METHODS

All data were collected from cases (n = 131) admitted to an inpatient cystic fibrosis unit under routine conditions during a period of 6 months in 2004. All costs were calculated for the year 2004 and divided into categories with high and low impact on variation in hospitalisation costs between patients. Staff costs for patient care, laboratory costs and drug costs were defined as categories with high impact, thus the individual resource utilisation for each case was measured. Cost categories that were classified as having a low impact were measured as overhead costs. Cases were classified according to two different severity models; within each model, patients were classified according to three severity levels. The diagnosis-related model classifies patients with pulmonary hypertension and global respiratory insufficiency as having severe disease, patients with Pseudomonas aeruginosa as having moderate disease, and patients with no colonisation of the lungs as having mild disease. The lung-function-related model differentiates patients as having mild, moderate and severe disease when patients have forced expiratory volumes in 1 second (FEV(1)) that are > or =70%, between > or =40% and <70%, and <40%, respectively. Analysis of variance tests were performed to investigate the differences of mean costs between the groups. Ordinary least squares regression analysis was used to determine predictors for cost variation.

RESULTS

The mean total costs per case were 7326 euro. Almost one-third of the total mean costs were attributable to drug costs (28% of total costs), while shares of staff costs for patient care and laboratory costs (both 9% of total costs) were relatively small. Most of the difference in costs between severity levels was attributable to the variation in overhead costs and drug costs. For both severity models differences in mean total costs of mild and severe cases were statistically significant (p < 0.01 and p < 0.05, respectively) when compared with the mean costs of non-mild and non-severe cases. However, in moderate cases, significant differences compared with cases that were not of moderate severity were only seen for certain cost categories. In the multiple regression model the variables 'diagnosis-related severity' and 'FEV(1)' explained 31% of the variance of 'Ln (total costs per case)' between severity levels (p < or = 0.01).

CONCLUSION

This study shows that to a large extent hospitalisation costs for patients with cystic fibrosis vary according to the severity of their disease; drug costs play a major role in these differences. In the light of this variation it seems plausible to create separate reimbursement rates for two or three severity groups. Diagnoses as well as FEV(1) seem suitable criteria for such a classification.

Can economic evaluations be made more transferable?

Several commentators have identified the lack of generalisability and transferability of economic evaluation results. The aims of this study were: (a) to develop a checklist to assess the level of generalisability and transferability of economic evaluations; (b) to assess the generalisability and transferability of economic evaluations between the UK and France using the checklist; (c) to identify reasons for any lack of transferability and generalisability; (d) to assess how the transferability and generalisability of economic evaluations can be improved; and (e) to outline ways in which databases of economic evaluations and journals can assist in this area. The checklist was developed using previous work and the templates of the NHS EED and CODECS databases. A sub-checklist of essential items was then derived. Validation of the two checklists was undertaken with Health Economists participating in the EURONHEED project. Economic evaluations involving the UK and France were then located and assessed using the checklist. A summary score for each study was calculated based on the percentage of correctly reported (applicable) points, and the results in the empirical analysis compared to identify differences. The extended checklist includes 42 items, and the sub-checklist 16 items. Twenty-five economic evaluations met the inclusion criteria for the empirical analysis. In the extended checklist the mean score was 66.9+/-13.6%. The results for the sub-checklist were very similar. The analysis revealed that costing, assessments of generalisability by the author(s), assessment of data variability, discounting, study population, and the reporting of effectiveness are areas that need more attention. Differences in cost-effectiveness results are often accounted for by price or organisational differences. The developed checklists are useful in assessing the generalisability and transferability of economic evaluations. In order to improve the generalisability and transferability of economic evaluations authors need to be more explicit and detailed in describing and reporting their studies. If they are to provide added value to their users, international databases of economic evaluations should systematically assess the generalisability and transferability of studies. Further research is in progress on producing a weighted version of the checklist.

Costs and effects of chlamydial screening: dynamic versus static modeling

OBJECTIVE

The objective of this study was to assess the impact of modeling type on the economic evaluation of screening programs for asymptomatic Chlamydia trachomatis infections.

STUDY

We compared a stochastic network simulation model (dynamic model) with a decision analysis model (static model) for estimating the cost-effectiveness of an opportunistic screening program. The influence of the model type on the required data, the computed results, and the sensitivity of model parameters were investigated.

RESULTS

When compared with static modeling, dynamic modeling yielded different cost-effectiveness ratios and identified other optimal screening strategies as it considers changes in the force of infection caused by screening. However, it is more complex, data- and time-demanding, and more sensitive to some parameters affecting the force of infection than static modeling.

CONCLUSIONS

Dynamic models should be applied for the economic evaluation of prevention measures that have the potential to lower the force of infection such as large-scale chlamydial screening programs.