Estimating treatment cost functions for progressive diseases: a multiproduct approach with an application to breast cancer

A Cost Decision Model Supporting Treatment Strategy Selection in BRCA1/2 Mutation Carriers in Breast Cancer

In this paper, a cost decision-making model that compares the healthcare costs for diverse treatment strategies is built for BRCA-mutated women with breast cancer. Moreover, this model calculates the cancer treatment costs that could potentially be prevented, if the treatment strategy with the lowest total cost, along the entire lifetime of the patient, is chosen for high-risk women with breast cancer. The benchmark of the healthcare costs for diverse treatment strategies is selected in the presence of uncertainty, i.e., considering, throughout the lifetime of the patient, the risks and complications that may arise in each strategy and, therefore, the costs associated with the management of such events. Our results reveal a clear economic advantage of adopting the cost decision-making model for benchmarking the healthcare costs for various treatment strategies for BRCA-mutated women with breast cancer. The cost savings were higher when all breast cancer patients underwent counseling and genetic testing before deciding on any diagnostic-therapeutic path, with a probability of obtaining savings of over 75%.

Is Age-targeted full-field digital mammography screening cost-effective in emerging countries? A micro simulation model

OBJECTIVE

The present paper estimates the cost-effectiveness of population-based breast cancer (BC) screening strategies in Brazil for women under 50 years from the perspective of the Brazilian public health system.

METHODS

A Markov model, simulating the natural history of female BC sufferers in Brazil, was developed. This model compares the lifetime effects, costs, and cost-effectiveness of seven BC screening strategies in women between 40 to 49 years: (A) usual care; (B) annual screen-film mammography (SFM); (C) SFM every 2 years; (D) annual full-field digital mammography (FFDM); (E) FFDM every 2 years; and (F and G) age-targeted options, with FFDM annually until 49 years and SFM annually (or biannually) from 50 to 69 years.

RESULTS

Adopting SFM every 2 years (Strategy C) was found to be slightly more costly but also more effective in terms of quality-adjusted life years (QALYs), yielding an incremental cost-effectiveness ratio (ICER) of R$ 1,509 per QALY gained. Annual SFM (Strategy B) was the next best option at an additional R$ 13,131 per QALY gained. FFDM annual screening (Strategy E) was dominated by Strategy F, the age-targeted option. For younger women, the age-based strategy had an ICER of R$ 30,520 per QALY gained. In the sensitivity analysis, the ICERs ranged from R$ 15,300 to R$ 257,899 in different regions of the country, depending on BC incidence, population age distribution, and mammography coverage.

CONCLUSIONS

SFM every 2 years for all women starting between the ages of 40 and 49 would be a cost-effective strategy. Taking into account regional specificities, age-targeted FFDM is one option to improve the outcomes of BC patients in an emerging country.

Analytic considerations in economic evaluations of multinational cardiovascular clinical trials

OBJECTIVES

The growing number of economic evaluations that use data collected in multinational clinical trials raises numerous questions regarding their execution and interpretation. Although recommendations for conducting economic evaluations have been widely disseminated, relatively little guidance has been given for conducting economic evaluations alongside clinical trials, particularly multinational trials.

METHODS

Building on a literature review that was conducted in preparation for an expert workshop, we evaluated a subset of methodological issues related to conducting economic evaluations alongside multinational clinical trials.

RESULTS

We found wide variation in the types of costs included as part of the analyses and in the methods used to assign costs to hospitalization events. Furthermore, we found that the extrapolation of costs and survival outcomes beyond the trial period is an inconsistent practice and is often not dependent on whether a survival benefit was observed in the trial or on the epidemiology or practice patterns in the country to which the findings are directed.

CONCLUSIONS

Although the limited sample size precluded a quantitative analysis of trial characteristics and their associations with the methodologies employed, our findings highlight the need for more guidance to analysts regarding the execution of economic evaluations using data from multinational clinical trials. As the research community grapples with the complexities of methodological and logistical issues involved in multinational economic evaluations, the development of a standardized format to report the basic methodological characteristics of such studies would help to improve transparency and comparability for other analysts and decision-makers.

The direct cost of managing patients with chronic hepatitis B infection in Australia

GOALS

To estimate the average annual cost of managing a patient with chronic hepatitis B (CHB) disease in Australia.

BACKGROUND

Little is known about the prevalence or economic burden of hepatitis B viral (HBV) infection in Australia, despite it being recognized as a significant cause of morbidity and mortality.

STUDY

A retrospective analysis of 149 patients with CHB disease in six disease states (noncirrhotic CHB, compensated and decompensated cirrhosis, hepatocellular carcinoma, liver transplantation in year 1, and liver transplantation in subsequent posttransplantation years) was conducted. The cost of palliative care for 53 patients with chronic hepatitis and hepatocellular carcinoma was also estimated, based on data from a palliative care unit.

RESULTS

The average annual costs (year-2001 AUS$) for each disease state per patient were: noncirrhotic CHB, 1233 dollars (95% CI 939 dollars-1544 dollars); compensated cirrhosis, 1394 dollars (95% CI 975 dollars-1797 dollars); decompensated cirrhosis, 11,961 dollars (95% CI 6993 dollars-18,503 dollars); liver transplantation in year 1, 144,392 dollars (SD, 115,374 dollars); liver transplantation in year 2+, 23,160 dollars (SD, 19,289 dollars); and hepatocellular carcinoma, 11,753 dollars (95% CI 7385 dollars-17,159 dollars). Within the noncirrhotic CHB group, the cost of managing active disease was 1778 dollars (95% CI 1212 dollars-2374 dollars) compared with 758 dollars (95% CI 519 dollars-1045 dollars) for inactive disease. The average cost of palliative care for patients with chronic hepatitis and hepatocellular carcinoma was 6307 dollars (95% CI 4848 dollars-8187 dollars). Multivariate statistical analysis indicated that age, sex, marital status, country of birth, and duration of follow-up were not statistically significant in explaining variation in costs.

CONCLUSIONS

The cost of managing patients with CHB disease varies significantly between the noncirrhotic CHB/compensated cirrhosis states and the other four disease states. Within the noncirrhotic CHB state, there is also a significant difference between the cost of managing active and inactive disease. These results will be useful in future cost-effectiveness analyses of prevention and treatment options.

Relevance of outlier cases in case mix systems and evaluation of trimming methods

OBJECTIVES

To determine the most appropriate outlier trimming method when the main source of information for case mix classification is length of stay (LOS) because cost information is unavailable.

METHODS

Discharges (35,262) from two public hospitals were analysed. LOS and cost outliers were calculated using different trimming methods. The agreement between cost and LOS trimming was analysed.

RESULTS

The trimming method using the geometric mean with two standard deviations (GM2) showed the highest level of agreement between cost and LOS and revealed the greatest proportion of extreme costs. Nearly 5% of cases were outliers, containing 16% of total LOS. This was the best approximation to 18% of extreme cost because when GM2 was applied to LOS, 88% of outlier cost was revealed.

CONCLUSIONS

The methods were analysed because they are the most frequently used but the same methodology could be employed to compare other outlier determination methods. Outliers should be calculated because they ought to be valued differently from inlier cases.

Analysis of the eligibility of published economic evaluations for transfer to a given health care system. Methodological approach and application to the French health care system

CONTEXT

Economic evaluations are costly and cannot always be carried out locally. Therefore, decision-makers may wish to use studies already performed in other settings.

OBJECTIVE

To define a method for assessing the eligibility of published economic evaluations for transfer to a given health care system and apply it to the french health care system in the clinical situation of adjuvant therapy for women with breast cancer.

METHODS

(1) Literature search in six databases from 1982 to 1996; (2) critical appraisal of articles based on four inclusion criteria; and (3) assessment of the eligibility of the studies for transfer based on five indicators.

RESULTS

We identified 26 published economic evaluations concerning adjuvant therapy in women with breast cancer. Six (23%) met all four criteria used to select studies, but none of these studies were eligible for transfer to the french health care system. The main reason was that cost data was not reported in a transparent way.

CONCLUSIONS

To improve the transferability of economic evaluations, we recommend that requirements for data provision in publications be standardized and international collaboration strengthened.

Economic evaluation of breast cancer screening: A review

PURPOSE

The authors provide a review of the economic evaluation literature of breast cancer screening and identify important trends and gaps in the literature.

OVERVIEW

Healthcare resources are limited and economic evaluation plays a critical role in resource allocation, healthcare policy, and clinical decisions. Many economic evaluations of medical practice, however, are unreliable and do not use appropriate analytic techniques. Three important trends were observed. First, two economic evaluation methods are dominant. Second, a wide range of cost estimates exists across studies. Third, a lack of standardization exists across studies with regard to basic economic evaluation principles. These findings should be considered when conducting future research, analyzing economic evaluations of breast cancer screening, and developing clinical guidelines.

CLINICAL IMPLICATIONS

Concerns about cost containment in healthcare make it necessary for physicians and clinical administrators to take an active role in resource allocation decisions at the clinical level. For instance, the recent debate on the proper age to begin annual mammography screening involves both resource allocation and clinical issues. Thus, it is important for physicians and clinical administrators to be familiar with the economic evaluation literature of breast cancer screening, economic evaluation methodology, and the associated shortcomings of published estimates.

The costs of treating breast cancer in the United Kingdom: implications for screening

Total treatment costs by stage at diagnosis are estimated for a sample of breast cancer patients. At 4 years, stage 4 cancers emerge as being more expensive to treat than those at earlier stages, although this difference fails to achieve significance when expected lifetime costs are considered. The inclusion of treatment cost estimates in a screening model indicates that screening may increase expected treatment costs by a marginal amount, although the model also suggests that the cost-effectiveness ratio of breast cancer screening might be better than had originally been thought.