Some reflections on cost-effectiveness analysis

Economic and Performance Evaluation of E-Health before and after the Pandemic Era: A Literature Review and Future Perspectives

E-Health represents one of the pillars of the modern healthcare system and a strategy involving the use of digital and telemedicine tools to provide assistance to an increasing number of patients, reducing, at the same time, healthcare costs. Measuring and understanding the economic value and performance of e-Health tools is, therefore, essential to understanding the outcome and best uses of such technologies. The aim of this paper is to determine the most frequently used methods for measuring the economic value and the performance of services in the framework of e-Health, considering different pathologies. An in-depth analysis of 20 recent articles, rigorously selected from more than 5000 contributions, underlines a great interest from the clinical community in economic and performance-related topics. Several diseases are the object of detailed clinical trials and protocols, leading to various economic outcomes, especially in the COVID-19 post-pandemic era. Many e-Health tools are mentioned in the studies, especially those that appear more frequently in people's lives outside of the clinical setting, such as apps and web portals, which allow for clinicians to keep in contact with their patients. While such e-Health tools and programs are increasingly studied from practical perspectives, such as in the case of Virtual Hospital frameworks, there is a lack of consensus regarding the recommended models to map and report their economic outcomes and performance. More investigations and guidelines by scientific societies are advised to understand the potential and path of such an evolving and promising phenomenon.

Encouraging Mammograms Using Behavioral Economics: A Randomized Controlled Trial in Chile

OBJECTIVES

This article illustrates the effect of a direct mail campaign that used insights from behavioral economics and psychology to increase the number of free mammograms in Chilean women aged 50 years or older.

METHODS

We hypothesized 4 barriers in obtaining a mammogram based on previous literature and focus group analysis. A behavioral economic approach providing incentives was used to help overcome these barriers. We accessed a unique data set, which comprised 12 000 women 50 years old or older, with private health insurance who have not had a mammogram for 24 or more months. We conducted a randomized controlled trial with 8 treatments, each involving a specific combination of messages.

RESULTS

The intervention overall led to a 167% increase in the use of free mammograms, a 1.13% to 3.03% average increase from the control to treatment groups, respectively. Regarding barriers, we found that all messages were effective, with a slightly larger and persistent effect for the less complex ones in terms of information. This finding illustrates the benefits of keeping the message simple.

CONCLUSIONS

Finally, these results suggest a successful public policy for increasing use of free mammography programs. Moreover, they are potentially transferable because the study considered decision-making heuristics that are not specific to one culture or social context.

An overview of the methodological aspects and policy implications of willingness-to-pay studies in oral health: a scoping review of existing literature

Background

Demands for dental services seem to be beyond the capacities of most healthcare systems these days. Patient preferences have been increasingly emphasized to be considered in the joint decision-making process. Willingness-to-pay (WTP) is a recommended method for measuring the utility of health services; increasingly being used in recent decades. Taking these points into consideration, this article aims to provide an overview of the methodological aspects and policy implications of WTP studies in the field of oral health.

Methods

The research was conducted in ISPOR, PubMed and Google Scholar databases. In addition, reference lists of included articles were checked to identify the relevant studies. All studies published were included that were in the English language and reported using WTP for oral health-related goods and services. A data-charting form was developed by a focus group discussion panel of seven experts to derive the main methodological aspects of WTP. Also, Core policy suggestions were categorized through thematic content analysis of the included papers.

Results

The search strategy yielded 389 studies of which 52 were included. WTP studies in oral health show an increasing trend in global publications. The UK and Canada have a greater share in published material than in any other country. The dominant field of these researches is in restorative and prosthetic dentistry, and a wide range of different methodological aspects was documented. Policy suggestions were categorized in three main themes: (A) setting new tariffs or subsidizing the item, (B) provision of the item due to population preferences, and (C) improving literacy regarding the item.

Conclusions

An urgent need for a common framework regarding the design of WTP studies in dentistry seems paramount. Some policy suggestions seem not to be applicable, perhaps due to insufficient familiarity of the researchers with the complexities of the public policymaking process.

Theoretical bounds on the value of improved health

Policies that improve health and longevity are often valued by combining expected gains in quality-adjusted life years (QALYs) with a constant willingness-to-pay (WTP) per QALY. This constant is derived by dividing value per statistical life (VSL) estimates by expected future QALYs. We explore the theoretical validity of this practice by studying the properties of WTP for improved health and longevity in a framework that makes minimal assumptions about the shape of an agent's utility function. We find that dividing VSL by expected QALYs results in an upper bound on the WTP for a marginal improvement in the quality of life, as measured by gains in health status or longevity. Calibration results suggest that analysts using this approach to monetize health benefits overestimate the value of a program or policy by a factor of two on average. We also derive a lower bound on the WTP for improved health and longevity that permits a novel empirical test for the descriptive validity of the QALY model. Our calibrations suggest that this lower bound is on average 20% smaller than the actual WTP.

Mitigating hypothetical bias in willingness to pay studies: post-estimation uncertainty and anchoring on irrelevant information

One possible source of hypothetical bias in willingness to pay (WTP) estimates is response uncertainty, referring to subject's uncertainty about the value of the good under assessment. It has been argued that uncertainty can be measured using the post-valuation 'certainty question' that asks: 'How certain are you about your stated WTP?' and marks the degree of certainty on a quantitative or a qualitative scale. Research has shown that the self-reported certainty evaluations can help mitigate hypothetical bias and obtain increasingly accurate WTP estimates. These study reports present a simple test of reliability of post-valuation certainty assessment and then looks at the empirical evidence for clues regarding the general usefulness of certainty adjustment in mitigating hypothetical bias in WTP studies. We find that the post-estimation uncertainty scores are malleable, i.e., significantly correlated with entirely irrelevant information. We conclude that more robust evidence could justify the routine inclusion of certainty evaluation in WTP studies although in the meantime the interpretation of certainty-adjusted WTP values should be approached cautiously.

Friction Cost Estimates of Productivity Costs in Cost-of-Illness Studies in Comparison with Human Capital Estimates: A Review

Cost-of-illness (COI) studies often include the 'indirect' cost of lost production resulting from disease, disability, and premature death, which is an important component of the economic burden of chronic conditions assessed from the societal perspective. In most COI studies, productivity costs are estimated primarily as the economic value of production forgone associated with loss of paid employment (foregone gross earnings); some studies include the imputed value of lost unpaid work as well. This approach is commonly but imprecisely referred to as the human capital approach (HCA). However, there is a lack of consensus among health economists as to how to quantify loss of economic productivity. Some experts argue that the HCA overstates productivity losses and propose use of the friction cost approach (FCA) that estimates societal productivity loss as the short-term costs incurred by employers in replacing a lost worker. This review sought to identify COI studies published during 1995-2017 that used the FCA, with or without comparison to the HCA, and to compare FCA and HCA estimates from those studies that used both approaches. We identified 80 full COI studies (of which 75% focused on chronic conditions), roughly 5-8% of all COI studies. The majority of those studies came from three countries, Canada, Germany, and the Netherlands, that have officially endorsed use of the FCA. The FCA results in smaller productivity loss estimates than the HCA, although the differential varied widely across studies. Lack of standardization of HCA and FCA methods makes productivity cost estimates difficult to compare across studies.

Measuring the end-of-life premium in cancer using individual ex ante willingness to pay

For the assessment of value of new therapies in healthcare, Health Technology Assessment (HTA) agencies often review the cost per quality-adjusted life-year (QALY) gained. Some HTA agencies accept a higher cost per QALY gained when treatment is aimed at prolonging survival for patients with a short expected remaining lifetime, a so-called end-of-life (EoL) premium. The objective of this study is to elicit the existence and size of an EoL premium in cancer. Data was collected from 509 individuals in the Swedish general population 20-80 years old using a web-based questionnaire. Preferences were elicited using subjective risk estimation and the contingent valuation (CV) method. A split-sample design was applied to test for order bias. The mean value of a QALY was MSEK4.8 (€528,000), and there was an EoL premium of 4-10% at 6 months of expected remaining lifetime. Using subjective risk resulted in more robust and valid estimates of the value of a QALY. Order of scenarios did not have a significant impact on the WTP and the result showed scale sensitivity. Our result provides some support for the use of an EoL premium based on individual preferences when expected remaining lifetime is short and below 24 months. Furthermore, we find support for a value of a QALY that is above the current threshold of several HTA agencies.

New findings from the time trade-off for income approach to elicit willingness to pay for a quality adjusted life year

In this paper we empirically investigate how to appropriately model utility of wealth and health. We use a recently proposed alternative approach to value willingness to pay (WTP) for health, making use of trade-offs between income and life years or quality of life, which we extend to allow for a more realistic multiplicative utility function over health and money. Moreover, we show how reference-dependency can be incorporated into this model and derive its predictions for WTP elicitation. We propose three experimental elicitation procedures and test these in a feasibility study, analysing the responses under different assumptions about the discount rate. Several interesting results are reported: first, the data are highly skewed, but if we trim the 5% lowest and highest values, we obtain plausible WTP estimates. Second, the results differ considerably between procedures, indicating that WTP estimates are sensitive to the assumed utility function. Third, respondents appear to be loss averse for both health and money, which is consistent with assumptions from prospect theory. Finally, our results also indicate that respondents are more willing to trade quality of life than life years.

Hidden costs: The ethics of cost-effectiveness analyses for health interventions in resource-limited settings

Cost-effectiveness analysis (CEA) is an increasingly appealing tool for evaluating and comparing health-related interventions in resource-limited settings. The goal is to inform decision-makers regarding the health benefits and associated costs of alternative interventions, helping guide allocation of limited resources by prioritising interventions that offer the most health for the least money. Although only one component of a more complex decision-making process, CEAs influence the distribution of health-care resources, directly influencing morbidity and mortality for the world's most vulnerable populations. However, CEA-associated measures are frequently setting-specific valuations, and CEA outcomes may violate ethical principles of equity and distributive justice. We examine the assumptions and analytical tools used in CEAs that may conflict with societal values. We then evaluate contextual features unique to resource-limited settings, including the source of health-state utilities and disability weights, implications of CEA thresholds in light of economic uncertainty, and the role of external donors. Finally, we explore opportunities to help align interpretation of CEA outcomes with values and budgetary constraints in resource-limited settings. The ethical implications of CEAs in resource-limited settings are vast. It is imperative that CEA outcome summary measures and implementation thresholds adequately reflect societal values and ethical priorities in resource-limited settings.

Determination of Cost-Effectiveness Threshold for Health Care Interventions in Malaysia

BACKGROUND

One major challenge in prioritizing health care using cost-effectiveness (CE) information is when alternatives are more expensive but more effective than existing technology. In such a situation, an external criterion in the form of a CE threshold that reflects the willingness to pay (WTP) per quality-adjusted life-year is necessary.

OBJECTIVES

To determine a CE threshold for health care interventions in Malaysia.

METHODS

A cross-sectional, contingent valuation study was conducted using a stratified multistage cluster random sampling technique in four states in Malaysia. One thousand thirteen respondents were interviewed in person for their socioeconomic background, quality of life, and WTP for a hypothetical scenario.

RESULTS

The CE thresholds established using the nonparametric Turnbull method ranged from MYR12,810 to MYR22,840 (~US $4,000-US $7,000), whereas those estimated with the parametric interval regression model were between MYR19,929 and MYR28,470 (~US $6,200-US $8,900). Key factors that affected the CE thresholds were education level, estimated monthly household income, and the description of health state scenarios.

CONCLUSIONS

These findings suggest that there is no single WTP value for a quality-adjusted life-year. The CE threshold estimated for Malaysia was found to be lower than the threshold value recommended by the World Health Organization.

Simultaneous Bilateral Versus Staged Bilateral Carpal Tunnel Release: A Cost-effectiveness Analysis

The purpose of this study was to determine if simultaneous bilateral carpal tunnel release (CTR) is a cost-effective strategy compared with bilateral staged CTR for the treatment of bilateral carpal tunnel syndrome.

METHODS

A decision analytic model was created to compare the cost effectiveness of three strategies (ie, bilateral simultaneous CTR, bilateral staged CTR, and no treatment). Direct medical costs were estimated from 2013 Medicare reimbursement rates and wholesale drug costs in US dollars. Indirect costs were derived from consecutive patients undergoing unilateral or simultaneous bilateral CTR at our institution and from national average wages for 2013. Health state utility values were derived from a general population of volunteers using the Short Form-6 dimensions (SF-6D) health questionnaire.

RESULTS

Both surgical strategies were cost effective compared with the no-treatment strategy. Bilateral simultaneous CTR had lower total costs and higher total effectiveness than bilateral staged CTR, and had an incremental cost-effectiveness ratio of $921 per quality-adjusted life year compared with the no-treatment strategy. The conclusions of the analysis remained unchanged though all sensitivity analyses, displaying robustness against parameter uncertainty.

CONCLUSIONS

Surgical management is cost effective for the treatment of bilateral carpal tunnel syndrome. Bilateral simultaneous CTR, however, has lower total costs and higher total effectiveness compared with bilateral staged CTR.

LEVEL OF EVIDENCE

Economic and Decision Analysis I.

Exploring a new method for deriving the monetary value of a QALY

Several studies have sought to determine the monetary value of health gains expressed as quality adjusted life years (QALYs) gained, predominantly using willingness to pay approaches. However, willingness to pay has a number of recognized problems, most notably its insensitivity to scope. This paper presents an alternative approach to estimate the monetary value of a QALY, which is based on the time trade-off method. Moreover, it presents the results of an online study conducted in the Netherlands exploring the feasibility of this novel approach. The results seem promising, but also highlight a number of methodological problems with this approach, most notably nontrading and the elicitation of negative values. Additional research is necessary to try to overcome these problems and to determine the potential of this new approach.

Systematic overview of cost-effectiveness thresholds in ten countries across four continents

AIM

To provide an overview of thresholds for incremental cost-effectiveness ratios (ICERs) representing willingness-to-pay (WTP) across multiple countries and insights into exemptions pertaining to the ICER (e.g., cancer). To compare ICER thresholds to individual country's estimated ability-to-pay.

MATERIALS & METHODS

We included AHRQ/USA, BIQG-GOEG/Austria, CADTH/Canada, DAHTA@DIMDI/Germany, DECIT-CGATS/Brazil, HAS/France, HITAP/Thailand, IQWiG/Germany, LBI-HTA/Austria, MSAC/Australia, NICE/England/Wales and SBU/Sweden. ICER thresholds were derived from systematic literature/website search/expert surveys. WTP was compared with ATP using Spearman's rank correlation.

RESULTS

Two general and explicitly acknowledged thresholds (England/Wales, Thailand), implicit thresholds in six countries and different ICER thresholds/decision-making rules in oncology were identified. Correlation between WTP and ability-to-pay was moderate.

DISCUSSION

Our overview supports country-specific discussions on WTP and on how to define value(s) within societies.

Methods for the estimation of the National Institute for Health and Care Excellence cost-effectiveness threshold

BACKGROUND

Cost-effectiveness analysis involves the comparison of the incremental cost-effectiveness ratio of a new technology, which is more costly than existing alternatives, with the cost-effectiveness threshold. This indicates whether or not the health expected to be gained from its use exceeds the health expected to be lost elsewhere as other health-care activities are displaced. The threshold therefore represents the additional cost that has to be imposed on the system to forgo 1 quality-adjusted life-year (QALY) of health through displacement. There are no empirical estimates of the cost-effectiveness threshold used by the National Institute for Health and Care Excellence.

OBJECTIVES

(1) To provide a conceptual framework to define the cost-effectiveness threshold and to provide the basis for its empirical estimation. (2) Using programme budgeting data for the English NHS, to estimate the relationship between changes in overall NHS expenditure and changes in mortality. (3) To extend this mortality measure of the health effects of a change in expenditure to life-years and to QALYs by estimating the quality-of-life (QoL) associated with effects on years of life and the additional direct impact on QoL itself. (4) To present the best estimate of the cost-effectiveness threshold for policy purposes.

METHODS

Earlier econometric analysis estimated the relationship between differences in primary care trust (PCT) spending, across programme budget categories (PBCs), and associated disease-specific mortality. This research is extended in several ways including estimating the impact of marginal increases or decreases in overall NHS expenditure on spending in each of the 23 PBCs. Further stages of work link the econometrics to broader health effects in terms of QALYs.

RESULTS

The most relevant 'central' threshold is estimated to be £12,936 per QALY (2008 expenditure, 2008-10 mortality). Uncertainty analysis indicates that the probability that the threshold is < £20,000 per QALY is 0.89 and the probability that it is < £30,000 per QALY is 0.97. Additional 'structural' uncertainty suggests, on balance, that the central or best estimate is, if anything, likely to be an overestimate. The health effects of changes in expenditure are greater when PCTs are under more financial pressure and are more likely to be disinvesting than investing. This indicates that the central estimate of the threshold is likely to be an overestimate for all technologies which impose net costs on the NHS and the appropriate threshold to apply should be lower for technologies which have a greater impact on NHS costs.

LIMITATIONS

The central estimate is based on identifying a preferred analysis at each stage based on the analysis that made the best use of available information, whether or not the assumptions required appeared more reasonable than the other alternatives available, and which provided a more complete picture of the likely health effects of a change in expenditure. However, the limitation of currently available data means that there is substantial uncertainty associated with the estimate of the overall threshold.

CONCLUSIONS

The methods go some way to providing an empirical estimate of the scale of opportunity costs the NHS faces when considering whether or not the health benefits associated with new technologies are greater than the health that is likely to be lost elsewhere in the NHS. Priorities for future research include estimating the threshold for subsequent waves of expenditure and outcome data, for example by utilising expenditure and outcomes available at the level of Clinical Commissioning Groups as well as additional data collected on QoL and updated estimates of incidence (by age and gender) and duration of disease. Nonetheless, the study also starts to make the other NHS patients, who ultimately bear the opportunity costs of such decisions, less abstract and more 'known' in social decisions.

FUNDING

The National Institute for Health Research-Medical Research Council Methodology Research Programme.

The Willingness to Pay for a Quality Adjusted Life Year: A Review of the Empirical Literature

There has been a rapid increase in the use of cost-effectiveness analysis, with quality adjusted life years (QALYs) as an outcome measure, in evaluating both medical technologies and public health interventions. Alongside, there is a growing literature on the monetary value of a QALY based on estimates of the willingness to pay (WTP). This paper conducts a review of the literature on the WTP for a QALY. In total, 24 studies containing 383 unique estimates of the WTP for a QALY are identified. Trimmed mean and median estimates amount to 74,159 and 24,226 Euros (2010 price level), respectively. In regression analyses, the results indicate that the WTP for a QALY is significantly higher if the QALY gain comes from life extension rather than quality of life improvements. The results also show that the WTP for a QALY is dependent on the size of the QALY gain valued. Copyright © 2014 John Wiley & Sons, Ltd.

Health-Related Quality of Life and Willingness to Pay per Quality-Adjusted Life-Year Threshold-A Study in Patients with Epilepsy in China

OBJECTIVES

To assess the health-related quality of life (HRQOL) and willingness to pay (WTP) per quality-adjusted life-year (QALY) amount of patients with epilepsy in China.

METHODS

Adults with epilepsy and a healthy control were recruited in two tertiary hospitals in China. Participants completed two indirect utility elicitation instruments (Quality of Well-being Scale-self administered version and EuroQol five-dimensional questionnaire) and a WTP questionnaire. Correlations between sociodemographic or epilepsy-specific variables (age of epilepsy onset, duration of epilepsy, seizure types, types of antiepileptic drug treatment, etc.) and HRQOL or WTP/QALY were assessed to identify the candidate predictor. Multiple linear regression models were adopted to investigate the predictive performances of identified candidate predictors. Data analyses were performed on SPSS 20.0 (SPSS, Inc., Chicago, IL).

RESULTS

For utilities of both the Quality of Well-being Scale-self administered version and the EuroQol five-dimensional questionnaire, patients with epilepsy had statistically lower values than did the control group (P < 0.0001). In terms of the WTP/month, the percentage of WTP accounting for the monthly income and the WTP/QALY values from the epilepsy group were substantially higher than those from the control group (P < 0.0001). [Formula: see text] The multiple linear regression model identified working status (P = 0.05), seizure types (P = 0.022), income (P = 0.006), and self-rating health state (P < 0.05) as predictors of HRQOL while income (P = 0.000) and self-rating health state (P < 0.05) statistically contributed to the variations in WTP/QALY value for the epilepsy group.

CONCLUSIONS

Patients with epilepsy had substantially lower HRQOL than did the healthy population.

A systematic review of studies eliciting willingness-to-pay per quality-adjusted life year: does it justify CE threshold?

BACKGROUND

A number of studies have been conducted to estimate willingness to pay (WTP) per quality-adjusted life years (QALY) in patients or general population for various diseases. However, there has not been any systematic review summarizing the relationship between WTP per QALY and cost-effectiveness (CE) threshold based on World Health Organization (WHO) recommendation.

OBJECTIVE

To systematically review willingness-to-pay per quality-adjusted-life-year (WTP per QALY) literature, to compare WTP per QALY with Cost-effectiveness (CE) threshold recommended by WHO, and to determine potential influencing factors.

METHODS

We searched MEDLINE, EMBASE, Psyinfo, Cumulative Index to Nursing and Allied Health Literature (CINAHL), Center of Research Dissemination (CRD), and EconLit from inception through 15 July 2014. To be included, studies have to estimate WTP per QALY in health-related issues using stated preference method. Two investigators independently reviewed each abstract, completed full-text reviews, and extracted information for included studies. We compared WTP per QALY to GDP per capita, analyzed, and summarized potential influencing factors.

RESULTS

Out of 3,914 articles founded, 14 studies were included. Most studies (92.85%) used contingent valuation method, while only one study used discrete choice experiments. Sample size varied from 104 to 21,896 persons. The ratio between WTP per QALY and GDP per capita varied widely from 0.05 to 5.40, depending on scenario outcomes (e.g., whether it extended/saved life or improved quality of life), severity of hypothetical scenarios, duration of scenario, and source of funding. The average ratio of WTP per QALY and GDP per capita for extending life or saving life (2.03) was significantly higher than the average for improving quality of life (0.59) with the mean difference of 1.43 (95% CI, 1.81 to 1.06).

CONCLUSION

This systematic review provides an overview summary of all studies estimating WTP per QALY studies. The variation of ratio of WTP per QALY and GDP per capita depended on several factors may prompt discussions on the CE threshold policy. Our research work provides a foundation for defining future direction of decision criteria for an evidence-informed decision making system.

Thresholds for the cost-effectiveness of interventions: alternative approaches

Many countries use the cost-effectiveness thresholds recommended by the World Health Organization's Choosing Interventions that are Cost-Effective project (WHO-CHOICE) when evaluating health interventions. This project sets the threshold for cost-effectiveness as the cost of the intervention per disability-adjusted life-year (DALY) averted less than three times the country's annual gross domestic product (GDP) per capita. Highly cost-effective interventions are defined as meeting a threshold per DALY averted of once the annual GDP per capita. We argue that reliance on these thresholds reduces the value of cost-effectiveness analyses and makes such analyses too blunt to be useful for most decision-making in the field of public health. Use of these thresholds has little theoretical justification, skirts the difficult but necessary ranking of the relative values of locally-applicable interventions and omits any consideration of what is truly affordable. The WHO-CHOICE thresholds set such a low bar for cost-effectiveness that very few interventions with evidence of efficacy can be ruled out. The thresholds have little value in assessing the trade-offs that decision-makers must confront. We present alternative approaches for applying cost-effectiveness criteria to choices in the allocation of health-care resources.

Implementing smart pump technology in a pediatric intensive care unit: a cost-effective approach

OBJECTIVE

To analyze the cost effectiveness of implementing smart infusion pump technology in a pediatric intensive care unit (PICU).

MATERIAL AND METHODS

An observational, prospective, intervention study with analytical components was carried out. A drug library was developed and integrated into the Carefusion Alaris Guardrails® infusion systems. A systematic analysis of all the data stored on the devices during use was performed by the data processing program Guardrails® CQI v4.1 Event Reporter. Intercepted errors were classified in terms of their potential severity and probability of causing an adverse effect (PAE) had they reached the patient. Knowing the estimated cost of a preventable adverse effect (AE), we analyzed costs saved and the profit/cost ratio resulting from the implementation process.

RESULTS

Compliance with the drug library was 92% and during the study period 92 infusion-related programming errors were intercepted, leading to a saving of 172,279 euros by preventing AEs. This means that 2.15 euros would be obtained for each euro invested in hiring a pharmacist to implement this technology.

DISCUSSION

The high percentage of use of safety software in our study compared to others allowed for the interception of 92 errors. The estimation of the potential impact of these errors is based on clinical judgment. The cost saved might be underestimated because the cost of an AE is usually higher in pediatrics, indirect and intangible costs were not considered and pharmacists involved do not spend the whole day on this task.

CONCLUSIONS

Smart pumps have shown to be profitable in a PICU because they have the ability to intercept potentially serious medication errors and reduce costs associated with such errors.

Patients value metastatic cancer therapy more highly than is typically shown through traditional estimates

There is a growing emphasis on promoting medical treatments that provide the most benefits relative to their costs. However, objective criteria for determining the value patients receive from treatment are lacking. This study used data on the treatment choices of terminally ill patients to estimate the value they associate with care. We found that patients place high valuations on metastatic cancer therapy--on average, twenty-three times higher than its cost--and that other traditional methods used to estimate the value of these treatments for patients significantly undervalues how patients view them. Our methods provide another framework for an evidence-based approach to assessing the value of treatments for terminal illness.

Willingness to pay for a QALY: past, present and future

This paper is focused on establishing why a willingness-to-pay per quality-adjusted life-year value is needed and how such a value can be used in healthcare decision-making. Studies that have estimated willingness-to-pay per quality-adjusted life-year values from stated preference data are reviewed and categorized into three groups. These studies are then compared within and between groups highlighting the limitations of existing studies and their suitability for use in policy-making. The future of such work will be discussed, noting key issues for consideration and debate.

Disentangling WTP per QALY data: different analytical approaches, different answers

A large random sample of the Danish general population was asked to value health improvements by way of both the time trade-off elicitation technique and willingness-to-pay (WTP) using contingent valuation methods. The data demonstrate a high degree of heterogeneity across respondents in their relative valuations on the two scales. This has implications for data analysis. We show that the estimates of WTP per QALY are highly sensitive to the analytical strategy. For both open-ended and dichotomous choice data we demonstrate that choice of aggregated approach (ratios of means) or disaggregated approach (means of ratios) affects estimates markedly as does the interpretation of the constant term (which allows for disproportionality across the two scales) in the regression analyses. We propose that future research should focus on why some respondents are unwilling to trade on the time trade-off scale, on how to interpret the constant value in the regression analyses, and on how best to capture the heterogeneity in preference structures when applying mixed multinomial logit.

Effectiveness and cost-effectiveness of first BCG vaccination against tuberculosis in school-age children without previous tuberculin test (BCG-REVAC trial): a cluster-randomised trial

BACKGROUND

Neonatal BCG vaccination is part of routine vaccination schedules in many developing countries; vaccination at school age has not been assessed in trials in low-income and middle-income countries. Catch-up BCG vaccination of school-age children who missed neonatal BCG vaccination could be indicated if it confers protection and is cost-effective. We did a cluster-randomised trial (BCG REVAC) to estimate the effectiveness (efficacy given in routine settings) of school-age vaccination.

METHODS

We assessed the effectiveness of BCG vaccination in school-age children (aged 7-14 years) with unknown tuberculin status who did not receive neonatal BCG vaccination (subpopulation of the BCG REVAC cluster-randomised trial), between July, 1997, and June, 2006, in Salvador, Brazil, and between January, 1999, and December, 2007, in Manaus, Brazil. 763 schools were randomly assigned into BCG vaccination group or a not-vaccinated control group. Neither allocation nor intervention was concealed. Incidence of tuberculosis was the primary outcome. Cases were identified via the Brazilian Tuberculosis Control Programme. Study staff were masked to vaccination status when identified cases were linked to the study population. We estimated cost-effectiveness in Salvador by comparison of the cost for vaccination to prevent one case of tuberculosis (censored at 9 years) with the average cost of treating one case of tuberculosis. Analysis of all included children was by intention to treat. For calculation of the incidence rate we used generalised estimating equations and correlated observations over time.

FINDINGS

We randomly assigned 20,622 children from 385 schools to the BCG vaccination group and 18,507 children from 365 schools to the control group. The crude incidence of tuberculosis was 54·9 (95% CI 45·3-66·7) per 100,000 person-years in the BCG vaccination group and 72·7 (62·8-86·8) per 100,000 person-years in the control group. The overall vaccine effectiveness of a first BCG vaccination at school age was 25% (3-43%). In Salvador, where vaccine effectiveness was 34% (8-53%), vaccination of 381 children would prevent one case of tuberculosis and was cheaper than treatment. The frequency of adverse events was very low with only one axillary lymphadenitis and one ulcer greater than 1 cm in 11,980 BCG vaccinations.

INTERPRETATION

Vaccination of school-age children without previous tuberculin testing can reduce the incidence of tuberculosis and could reduce the costs of tuberculosis control. Restriction of BCG vaccination to the first year of life is not in the best interests of the public nor of programmes for tuberculosis control.

FUNDING

UK Department for International Development, National Health Foundation.

Regression models for analyzing costs and their determinants in health care: an introductory review

OBJECTIVE

This article aims to describe the various approaches in multivariable modelling of healthcare costs data and to synthesize the respective criticisms as proposed in the literature.

METHODS

We present regression methods suitable for the analysis of healthcare costs and then apply them to an experimental setting in cardiovascular treatment (COSTAMI study) and an observational setting in diabetes hospital care.

RESULTS

We show how methods can produce different results depending on the degree of matching between the underlying assumptions of each method and the specific characteristics of the healthcare problem.

CONCLUSIONS

The matching of healthcare cost models to the analytic objectives and characteristics of the data available to a study requires caution. The study results and interpretation can be heavily dependent on the choice of model with a real risk of spurious results and conclusions.

Measurement of QALYS and the welfare implications of survivor consumption and leisure forgone

In previous work (Health Econ. 2004; 13: 417-427; Health Econ. 2006; 15: 319-322) has suggested that survivor consumption costs should be included in cost-utility analyses only if the corresponding utility gains are also included. Here, it is further argued that the welfare implications of survivor consumption are already known because unlike new medical treatments or interventions whose complex and uncertain outcomes and third-party purchasing make the welfare implications unclear, survivor consumption must have passed a private market welfare test. That is, the gains must have exceeded the costs in order for the survivor consumption to be purchased; therefore, survivor consumption is welfare increasing. The same would apply for survivor leisure forgone. Implications for cost-benefit analysis are clear, but are less so for cost-utility analysis. Moreover, as it is currently practiced, cost-utility analysis does not evaluate welfare because quality-adjusted life years (QALYs) do not meet all the criteria for representing utility. Therefore, rather than using QALYs to analyze welfare, cost-QALY analysis should be differentiated from cost-utility analysis. The former should continue to employ existing QALYs as a measure of health-focused effectiveness, but the latter should develop a new broader measure that meets the criteria for representing utility, and either this new measure or cost-benefit analysis should be used to evaluate welfare.

Welfare, QALYs, and costs - a comment

What costs and what effects should be included in cost-effectiveness analysis from a welfare theoretic perspective? There is a broad agreement to include health-care costs and to measure the effects as Quality-Adjusted Life-Years (QALYs). However, a hot topic has been how to handle survivor consumption and leisure foregone. It is well established that the costs for these aspects should be included only if their associated benefits are also included. The key question is, then, if these benefits are included in QALYs. In a recent paper by Nyman (Health Econ., in press) it was argued that these benefits are not generally included in the empirical assessment of QALYs and that these costs therefore should be excluded. Even if this recommendation is correct, the reasons for it can be questioned. It is here instead argued that this decision should be based on theoretical - and not empirical - considerations. Thus, these costs should be excluded because QALYs are unlikely to be consistent with a utility function also including consumption and leisure. If so, then it becomes more important to instruct individuals not to include these benefits in their QALY assessments than to consider to what extent they may or may not be implicitly included. It is also demonstrated that these results have bearings on non-medical costs for the case when survival is not affected.

Willingness to pay for a quality-adjusted life-year: the individual perspective

OBJECTIVE

The aim of this study was to elicit the individual willingness to pay (WTP) for a quality-adjusted life-year (QALY).

METHODS

In a Web-based questionnaire containing contingent valuation exercises, respondents valued health changes in five scenarios. In each scenario, the respondents first valued two health states on a visual analog scale (VAS) and expressed their WTP for avoiding a decline in health from the better health state to the worse, using a payment scale followed by a bounded open contingent valuation question.

ANALYSIS

WTP per QALY was calculated for QALY gains calculated using VAS valuations, as well as the Dutch EQ-5D tariffs, the two steps in the WTP estimations and each scenario. Heterogeneity in WTP per QALY ratios was examined from the perspective of: 1) household income; and 2) the level of certainty in WTP indicated by respondents. Theoretical validity was analyzed using clustered multivariate regressions.

RESULTS

A total of 1091 respondents, representative of the Dutch population, participated in the survey. Mean WTP per QALY was € 12,900 based on VAS valuations, and € 24,500 based on the Dutch EuroQoL tariffs. WTP per QALY was strongly associated with income, varying from € 5000 in the lowest to € 75,400 in the highest income group. Respondents indicating higher certainty exhibited marginally higher WTP. Regression analyses confirmed expected relations between WTP per QALY, income, and other personal characteristics.

CONCLUSION

  Individual WTP per QALY values elicited in this study are similar to those found in comparable studies. The use of individual valuations in social decision-making deserves attention, however.

Practical approach for using Medicare data to estimate costs for cost-effectiveness analysis

Many methods have been used to measure costs for cost-effectiveness analysis in healthcare. A central challenge in cost estimation is determining the direct cost of medical goods and services from a societal perspective. This review applies the methodology for calculating Medicare reimbursements for physician services, hospital services and medications as a means of estimating healthcare costs from a US societal perspective. This review provides the tools and information needed to calculate direct medical costs related to in- and outpatient services provided by physicians and hospitals, as well as drug costs using Medicare reimbursement data. The data used in calculating Medicare reimbursements was obtained from the Centers for Medicare and Medicaid Services website. Methods for estimating costs for a particular service in a specific location using Medicare and Medicaid Services are described and demonstrated. A method based on Medicare data that uses the unadjusted geographic practice cost index and standard hospital base rate to estimate healthcare costs that can be generalized to the US population is described and demonstrated. This review provides cost-effectiveness analysts with the tools needed to calculate healthcare service costs for economic research. It contains links to all websites needed for obtaining Medicare and Medicaid Services data and provides a step-by-step analysis of the methodology involved in calculating costs. A practical guide for applying the methodology used by Medicare and Medicaid Services to calculate direct medical costs in order to estimate US societal costs in cost-effectiveness analysis is provided.

On the welfare theoretic foundation of cost-effectiveness analysis-the case when survival is not affected

This paper develops a welfare theoretic foundation for cost-effectiveness analysis (CEA) when survival is not affected. With this foundation, all costs and their corresponding utility-terms should be included. A key question, though, is whether these utility-terms are consistent with quality-adjusted life year (QALY) (utility) theory or not. The results show that health care costs and changes in the utility of health should be included. However, as QALYs do not capture the utility of changes in consumption (as this utility must be independent of health, according to QALY theory), the corresponding changes in consumption costs should be excluded. Regarding the costs for changes in absence from work, these should only be included if the utility of changes in the amount of leisure is included. As no QALY theory has been developed that includes this utility, it is unclear how to handle these costs (even if there are arguments for excluding them). For changes in productivity at work, though, there are robust arguments for the inclusion of these costs. Overall, it seems difficult to provide a clear basis for CEA in economic welfare theory when also including non-medical goods such as consumption and leisure.

[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.

Modelling the monetary value of a QALY: a new approach based on UK data

Debate about the monetary value of a quality-adjusted life year (QALY) has existed in the health economics literature for some time. More recently, concern about such a value has arisen in UK health policy. This paper reports on an attempt to 'model' a willingness-to-pay-based value of a QALY from the existing value of preventing a statistical fatality (VPF) currently used in UK public sector decision making. Two methods of deriving the value of a QALY from the existing UK VPF are outlined: one conventional and one new. The advantages and disadvantages of each of the approaches are discussed as well as the implications of the results for policy and health economic evaluation methodology.

The estimated economic value of the welfare loss due to prostate cancer pain in a defined population

The aim of the study reported here was to estimate the economic value of the welfare loss due to prostate cancer pain by estimating the extent to which pain affects health-related quality of life among patients with prostate cancer. The material consisted of a point estimate of health status among men with prostate cancer in a well-defined population of 200000 males. Clinical data concerning the disease at diagnosis (extracted from patients' records and the Regional Prostate Cancer Registry), and health utility ratings (using EuroQol) were obtained from 1 156 males with prostate cancer. A descriptive model showed that optimal treatment that would reduce pain to zero during the whole episode of disease would add on average 0.85 quality-adjusted life years (QALY) to every man with prostate cancer. Based on an estimate of the willingness to pay for a QALY the economic value of this welfare loss due to prostate cancer pain is in the magnitude of Euro 86 600 000 per year (Euro 19 800000 per million men in Sweden).

Trying to estimate a monetary value for the QALY

In this paper we study the feasibility of estimating a monetary value for a QALY (MVQ). Using two different surveys of the Spanish population (total n = 892), we consider whether willingness to pay (WTP) is (approximately) proportional to the health gains measured in QALYs. We also explore whether subjects' responses are prone to any significant biases. We find that the estimated MVQ varies inversely with the magnitude of health gain. We also find two other (ir)regularities: the existence of ordering effects; and insensitivity of WTP to the duration of the period of payment. Taken together, these effects result in large variations in estimates of the MVQ. If we are ever to obtain consistent and stable estimates, we should try to understand better the sources of variability found in the course of this study.

An empiric estimate of the value of life: updating the renal dialysis cost-effectiveness standard

OBJECTIVES

Proposals to make decisions about coverage of new technology by comparing the technology's incremental cost-effectiveness with the traditional benchmark of dialysis imply that the incremental cost-effectiveness ratio of dialysis is seen a proxy for the value of a statistical year of life. The frequently used ratio for dialysis has, however, not been updated to reflect more recently available data on dialysis.

METHODS

We developed a computer simulation model for the end-stage renal disease population and compared cost, life expectancy, and quality adjusted life expectancy of current dialysis practice relative to three less costly alternatives and to no dialysis. We estimated incremental cost-effectiveness ratios for these alternatives relative to the next least costly alternative and no dialysis and analyzed the population distribution of the ratios. Model parameters and costs were estimated using data from the Medicare population and a large integrated health-care delivery system between 1996 and 2003. The sensitivity of results to model assumptions was tested using 38 scenarios of one-way sensitivity analysis, where parameters informing the cost, utility, mortality and morbidity, etc. components of the model were by perturbed +/-50%.

RESULTS

The incremental cost-effectiveness ratio of dialysis of current practice relative to the next least costly alternative is on average $129,090 per quality-adjusted life-year (QALY) ($61,294 per year), but its distribution within the population is wide; the interquartile range is $71,890 per QALY, while the 1st and 99th percentiles are $65,496 and $488,360 per QALY, respectively. Higher incremental cost-effectiveness ratios were associated with older age and more comorbid conditions. Sensitivity to model parameters was comparatively small, with most of the scenarios leading to a change of less than 10% in the ratio.

CONCLUSIONS

The value of a statistical year of life implied by dialysis practice currently averages $129,090 per QALY ($61,294 per year), but is distributed widely within the dialysis population. The spread suggests that coverage decisions using dialysis as the benchmark may need to incorporate percentile values (which are higher than the average) to be consistent with the Rawlsian principles of justice of preserving the rights and interests of society's most vulnerable patient groups.

The societal cost of alcohol consumption: an estimation of the economic and human cost including health effects in Sweden, 2002

This article estimates the societal cost of alcohol consumption in Sweden in 2002, as well as the effects on health and quality of life. The estimation includes direct costs, indirect costs and intangible costs. Relevant cost-of-illness methods are applied using the human capital method and prevalence-based estimates, as suggested in existing international guidelines, allowing cautious comparison with prior studies. The results show that the net cost (i.e. including protective effects of alcohol consumption) is 20.3 billion Swedish kronor (SEK) and the gross cost (counting only detrimental effects) is 29.4 billion (0.9 and 1.3% of GDP). Alcohol consumption is estimated to cause a net loss of 121,800 QALYs. The results are within the range found in prior studies, although at the low end. A large number of sensitivity analyses are performed, indicating a sensitivity range of 50%.

Valuing lives and life years: anomalies, implications, and an alternative

Many government interventions seek to reduce the risk of death. The value of preventing a fatality (VPF) is the monetary amount associated with each statistical death that an intervention can be expected to prevent. The VPF has been estimated using a preference-based approach, either by observing market behaviour (revealed preferences) or by asking hypothetical questions that seek to replicate the market (stated preferences). The VPF has been shown to differ across and within these methods. In theory, the VPF should vary according to factors such as baseline and background risk, but, in practice, the estimates vary more by theoretically irrelevant factors, such as the starting point in stated preference studies. This variation makes it difficult to choose one unique VPF. The theoretically irrelevant factors also affect the estimates of the monetary value of a statistical life year and the value of a quality-adjusted life year. In light of such problems, it may be fruitful to focus more research efforts on generating the VPF using an approach based on the subjective well-being associated with different states of the world.

What does the value of modern medicine say about the $50,000 per quality-adjusted life-year decision rule?

BACKGROUND

In the United States, $50,000 per Quality-Adjusted Life-Year (QALY) is a decision rule that is often used to guide interpretation of cost-effectiveness analyses. However, many investigators have questioned the scientific basis of this rule, and it has not been updated.

METHODS

We used 2 separate approaches to investigate whether the $50,000 per QALY rule is consistent with current resource allocation decisions. To infer a lower bound for the decision rule, we estimated the incremental cost-effectiveness of recent (2003) versus pre-"modern era" (1950) medical care in the United States. To infer an upper bound for the decision rule, we estimated the incremental cost-effectiveness of unsubsidized health insurance versus self-pay for nonelderly adults (ages 21-64) without health insurance. We discounted both costs and benefits, following recommendations of the Panel on Cost-Effectiveness in Health and Medicine.

RESULTS

Our base case analyses suggest that plausible lower and upper bounds for a cost-effectiveness decision rule are $183,000 per life-year and $264,000 per life-year, respectively. Our sensitivity analyses widen the plausible range (between $95,000 per life-year saved and $264,000 per life-year saved when we considered only health care's impact on quantity of life, and between $109,000 per QALY saved and $297,000 per QALY saved when we considered health care's impact on quality as well as quantity of life) but it remained substantially higher than $50,000 per QALY.

CONCLUSIONS

It is very unlikely that $50,000 per QALY is consistent with societal preferences in the United States.

Implant overdentures for edentulous elders: study of patient preference

BACKGROUND

Studies show that elders wearing implant overdentures have improved nutrition and quality of life. However, upfront costs of this therapy are high, and the income of elderly edentulous populations is low.

OBJECTIVES

This study was designed (i) to measure the preferences of edentulous patients for mandibular two-implant overdentures using Willingness-To-Pay (WTP) and Willingness-To-Accept (WTA), (ii) to assess the effect of long-term financing on WTP and (iii) to assess the desired role of health care plans in financing dental prostheses.

METHODS

Edentulous elders (68-79 years; n = 36) wearing maxillary dentures and either a mandibular conventional denture (CD, n = 13) or a two-implant overdenture with ball attachments (IOD, n = 23) participated in this study. All had received their prostheses 2 years previously, as part of a randomised clinical trial. A three-part questionnaire was completed during a 20-min interview with a trained researcher.

RESULTS

Forty-six per cent (6/13) of the CD wearers and 70% (16/23) of the IOD wearers were willing to pay three times more than the current cost of conventional dentures for implant prostheses. These percentages were increased to 77% (CD) and 96% (IOD) if participants could pay for implant overdentures in monthly instalments. Eighty-six per cent (31/36) of all participants in both groups (21/23 IOD; 10/13 CD) thought that the government should cover at least some of the cost of implant overdentures.

CONCLUSIONS

This study shows that, the majority of elderly edentate individuals who have not experienced mandibular two-implant overdenture therapy are willing to pay the cost, particularly when payment can be made in monthly instalments.

On future non-medical costs in economic evaluations

Economic evaluation in health care is still an evolving discipline. One of the current controversies in cost-effectiveness analysis regards the inclusion or exclusion of future non-medical costs (i.e. consumption net of production) due to increased survival. This paper examines the implications of a symmetry rule stating that there should be consistency between costs included in the numerator and utility aspects included in the denominator. While the observation that no quality-adjusted life year (QALY) instruments explicitly include consumption and leisure seems to give support to the notion that future non-medical costs should be excluded when QALYs are used as the outcome measure, a better understanding of what respondents actually consider when reporting QALY weights is required. However, the more fundamental question is whether QALYs can be interpreted as utilities. Or more precisely, what are the assumptions needed for a general utility model also including consumption and leisure to be consistent with QALYs? Once those assumptions are identified, they need to be experimentally tested to see whether they are at least approximately valid. Until we have answers to these areas for future research, it seems premature to include future non-medical costs.

The value of implementation and the value of information: combined and uneven development

AIM

In a budget-constrained health care system, the decision to invest in strategies to improve the implementation of cost-effective technologies must be made alongside decisions regarding investment in the technologies themselves and investment in further research. This article presents a single, unified framework that simultaneously addresses the problem of allocating funds between these separate but linked activities.

METHODS

The framework presents a simple 4-state world where both information and implementation can be either at the current level or "perfect.'' Through this framework, it is possible to determine the maximum return to further research and an upper bound on the value of adopting implementation strategies. The framework is illustrated through case studies of health care technologies selected from those previously considered by the UK National Institute for Health and Clinical Excellence (NICE).

RESULTS

Through the case studies, several key factors that influence the expected values of perfect information and perfect implementation are identified. These factors include the maximum acceptable cost-effectiveness ratio, the level of uncertainty surrounding the adoption decision, the expected net benefits associated with the technologies, the current level of implementation, and the size of the eligible population.

CONCLUSIONS

Previous methods for valuing implementation strategies have not distinguished the value of efficacy research and the value of strategies to change the level of implementation. This framework demonstrates that the value of information and the value of implementation can be examined separately but simultaneously in a single framework. This can usefully inform policy decisions about investment in health care services, further research, and adopting implementation strategies that are likely to differ between technologies.

Unrelated medical costs in life-years gained: should they be included in economic evaluations of healthcare interventions?

Which costs and benefits to consider in economic evaluations of healthcare interventions remains an area of much controversy. Unrelated medical costs in life-years gained is an important cost category that is normally ignored in economic evaluations, irrespective of the perspective chosen for the analysis. National guidelines for pharmacoeconomic research largely endorse this practice, either by explicitly requiring researchers to exclude these costs from the analysis or by leaving inclusion or exclusion up to the discretion of the analyst. However, the inclusion of unrelated medical costs in life-years gained appears to be gaining support in the literature.This article provides an overview of the discussions to date. The inclusion of unrelated medical costs in life-years gained seems warranted, in terms of both optimality and internal and external consistency. We use an example of a smoking-cessation intervention to highlight the consequences of different practices of accounting for costs and effects in economic evaluations. Only inclusion of all costs and effects of unrelated medical care in life-years gained can be considered both internally and externally consistent. Including or excluding unrelated future medical costs may have important distributional consequences, especially for interventions that substantially increase length of life. Regarding practical objections against inclusion of future costs, it is important to note that it is becoming increasingly possible to accurately estimate unrelated medical costs in life-years gained. We therefore conclude that the inclusion of unrelated medical costs should become the new standard.

Costs of rheumatoid arthritis: new estimates from the human capital method and comparison to the willingness-to-pay method

BACKGROUND

Individuals' valuation of changes in health states in monetary terms have been measured by examining changes in the direct and indirect costs of disease and by the willingness-to-pay (WTP) methodology.

METHODS

In 2002, a 2-part study was conducted in Quebec. In one part of the study, 121 rheumatoid arthritis (RA) patients from the McGill University Health Centre were mailed the Stanford Cost Assessment Questionnaire, which enabled the elicitation of direct costs and indirect costs, according to the friction cost and the human capital methods. The other part was a phone survey conducted in a representative sample of the general population and in the same sample of patients, aiming to elicit the societal WTP for a complete cure of RA in the context of 2 different scenarios: a public coverage or private insurance. These estimates were then compared.

RESULTS

Estimates of the cost of illness of RA ranged from 11,717 to 28,498 Canadian Dollars (CAD) depending on the method. These estimates are higher than those previously published in Canada from the 1990s, which is partly due to the recent and costly biological therapies and to a change in the measurement of productivity losses. These estimates are somewhat lower than the societal WTP elicited from the WTP survey, that is, 26,717 and 36,817 CAD per RA case, depending on the public or private health insurance context in which the cure would be available.

CONCLUSION

Given that neither method is ideal, data from both methods would provide an important sensitivity analysis when monetary estimates of health state changes are required.

Cost of breast cancer in Sweden in 2002

Breast cancer is the most common cancer among Swedish women and an important cause of illness and death. The aim of this study was to estimate the total cost of breast cancer in Sweden in 2002, using a top-down prevalence-based cost-of-illness approach. The total cost of breast cancer in Sweden in 2002 was estimated at 3.0 billion SEK (1 euro = 9.4 SEK). The direct costs were estimated at 895 million SEK and constituted 30% of the total cost. Indirect costs were estimated at 2.1 billion SEK and constituted 70% of the total cost. The main cost driver was production losses caused by premature mortality, amounting to 52% of the indirect costs. The reason that indirect costs were the dominant cost is because most newly detected breast cancers occur in patients aged below 65, thus causing significant production losses due to sick leave, early retirement, and premature mortality.

Potential for bone turnover markers to cost-effectively identify and select post-menopausal osteopenic women at high risk of fracture for bisphosphonate therapy

INTRODUCTION AND HYPOTHESIS

Over half of all fractures among post-menopausal women occur in those who do not have osteoporosis by bone density criteria. Measurement of bone turnover may cost-effectively identify a subset of women with T-score >-2.5 for whom anti-resorptive drug therapy is cost-effective.

METHODS

Using a Markov model, we estimated the cost per quality adjusted life year (QALY) for five years of oral bisphosphonate compared to no drug therapy for osteopenic post-menopausal women aged 60 to 80 years with a high (top quartile) or low (bottom 3 quartiles) level of a bone turnover marker.

RESULTS

For women with high bone turnover, the cost per QALY gained with alendronate compared to no drug therapy among women aged 70 years with T-scores of -2.0 or -1.5 were $58,000 and $80,000 (U.S. 2004 dollars), respectively. If bisphosphonates therapy also reduced the risk of non-vertebral fractures by 20% among osteopenic women with high bone turnover, then the costs per QALY gained were $34,000 and $50,000 for women age 70 with high bone turnover and T-scores of -2.0 and -1.5, respectively.

CONCLUSION

Measurement of bone turnover markers has the potential to identify a subset of post-menopausal women without osteoporosis by bone density criteria for whom bisphosphonate therapy to prevent fracture is cost-effective. The size of that subset highly depends on the assumed efficacy of bisphosphonates for fracture risk reduction among women with both a T-score >-2.5 and high bone turnover and the cost of bisphosphonate treatment.

Cost-effectiveness of genotypic antiretroviral resistance testing in HIV-infected patients with treatment failure

Background

Genotypic antiretroviral resistance testing (GRT) in HIV infection with drug resistant virus is recommended to optimize antiretroviral therapy, in particular in patients with virological failure. We estimated the clinical effect, cost and cost-effectiveness of using GRT as compared to expert opinion in patients with antiretroviral treatment failure.

Methods

We developed a mathematical model of HIV disease to describe disease progression in HIV-infected patients with treatment failure and compared the incremental impact of GRT versus expert opinion to guide antiretroviral therapy. The analysis was conducted from the health care (discount rate 4%) and societal (discount rate 2%) perspective. Outcome measures included life-expectancy, quality-adjusted life-expectancy, health care costs, productivity costs and cost-effectiveness in US Dollars per quality-adjusted life-year (QALY) gained. Clinical and economic data were extracted from the large Swiss HIV Cohort Study and clinical trials.

Results

Patients whose treatment was optimized with GRT versus expert opinion had an increase in discounted life-expectancy and quality-adjusted life-expectancy of three and two weeks, respectively. Health care costs with and without GRT were $US 421,000 and $US 419,000, leading to an incremental cost-effectiveness ratio of $US 35,000 per QALY gained. In the analysis from the societal perspective, GRT versus expert opinion led to an increase in discounted life-expectancy and quality-adjusted life-expectancy of three and four weeks, respectively. Health care costs with and without GRT were $US 551,000 and $US 549,000, respectively. When productivity changes were included in the analysis, GRT was cost-saving.

Conclusions

GRT for treatment optimization in HIV-infected patients with treatment failure is a cost-effective use of scarce health care resources and beneficial to the society at large.

Decision analysis in obstetrics and gynecology

Decision analysis is a type of study design that can help to explicitly compare different medical choices and provide additional perspective to information provided by observational and interventional studies. This review will detail the circumstances under which decision analysis is most appropriate to use and the conceptual approach to the development of a decision model.

TARGET AUDIENCE

Obstetricians & Gynecologists, Family Physicians.

LEARNING OBJECTIVES

After completion of this article, the reader should be able to summarize that decision analysis will: help to compare different medical choices; supply additional perspectives to information provided by observational and interventional studies; and allow comparison of medical strategies that involve health outcomes, cost, or combined cost-effectiveness measures.

Costs of treatment of Swiss patients with HIV on antiretroviral therapy in hospital-based and general practice-based care: a prospective cohort study

Some ambulant people with HIV are cared for primarily by their general practitioner and some in an outpatient clinic. Costs and patterns of care in these settings were studied in 65 such patients based in Zürich, from a limited societal perspective (excluding patient costs) based on medical resource use. Antiretroviral therapy (ART), other medications and patient variables were collected prospectively, and non-medication resources (professional time and investigations) and treatment history data were collected from medical records and by record linkage to the Swiss HIV Cohort Study database. Cost differences between the settings were estimated using multiple regression, controlling for differences in case-mix. ART comprised 80% of the total cost, non-medication costs 15% and non-ART medications 5%. Total costs were higher in the outpatient clinic (estimated additional cost after controlling for case-mix = 3489 Swiss Francs per year at 1999 prices, 95% confidence interval 742 to 6236, p=0.017). The difference was accounted for by higher ART costs in the outpatient clinic, not through a tendency to use more expensive drugs or higher doses but rather through the use of more drugs concurrently. Differences in ART prescribing patterns between the doctors in the outpatient clinic and the general practitioners were considerable and appear worthy of further investigation.