Cost Effectiveness of Meningococcal Serogroup B Vaccination in College-Aged Young Adults

Accounting for Adverse Events Following Immunization in Economic Evaluation: Systematic Review of Economic Evaluations of Pediatric Vaccines Against Pneumococcus, Rotavirus, Human Papillomavirus, Meningococcus and Measles-Mumps-Rubella-Varicella

OBJECTIVES

Economic evaluations of vaccines should accurately represent all relevant economic and health consequences of vaccination, including losses due to adverse events following immunization (AEFI). We investigated to what extent economic evaluations of pediatric vaccines account for AEFI, which methods are used to do so and whether inclusion of AEFI is associated with study characteristics and the vaccine's safety profile.

METHODS

A systematic literature search (MEDLINE, EMBASE, Cochrane Systematic Reviews and Trials, Database of the Centre for Reviews and Dissemination of the University of York, EconPapers, Paediatric Economic Database Evaluation, Tufts New England Cost-Effectiveness Analysis Registry, Tufts New England Global Health CEA, International Network of Agencies for Health Technology Assessment Database) was performed for economic evaluations published between 2014 and 29 April 2021 (date of search) pertaining to the five groups of pediatric vaccines licensed in Europe and the United States since 1998: the human papillomavirus (HPV) vaccines, the meningococcal vaccines (MCV), the measles-mumps-rubella-varicella (MMRV) combination vaccines, the pneumococcal conjugate vaccines (PCV) and the rotavirus vaccines (RV). Rates of accounting for AEFI were calculated, stratified by study characteristics (e.g., region, publication year, journal impact factor, level of industry involvement) and triangulated with the vaccine's safety profile (Advisory Committee on Immunization Practices [ACIP] recommendations and information on safety-related product label changes). The studies accounting for AEFI were analyzed in terms of the methods used to account for both cost and effect implications of AEFI.

RESULTS

We identified 112 economic evaluations, of which 28 (25%) accounted for AEFI. This proportion was significantly higher for MMRV (80%, four out of five evaluations), MCV (61%, 11 out of 18 evaluations) and RV (60%, nine out of 15 evaluations) compared to HPV (6%, three out of 53 evaluations) and PCV (5%, one out of 21 evaluations). No other study characteristics were associated with a study's likelihood of accounting for AEFI. Vaccines for which AEFI were more frequently accounted for also had a higher frequency of label changes and a higher level of attention to AEFI in ACIP recommendations. Nine studies accounted for both the cost and health implications of AEFI, 18 studies considered only costs and one only health outcomes. While the cost impact was usually estimated based on routine billing data, the adverse health impact of AEFI was usually estimated based on assumptions.

DISCUSSION

Although (mild) AEFI were demonstrated for all five studied vaccines, only a quarter of reviewed studies accounted for these, mostly in an incomplete and inaccurate manner. We provide guidance on which methods to use to better quantify the impact of AEFI on both costs and health outcomes. Policymakers should be aware that the impact of AEFI on cost-effectiveness is likely to be underestimated in the majority of economic evaluations.

How Far Is Too Far? Cost-Effectiveness Analysis of Regionalized Rectal Cancer Surgery

BACKGROUND

Regionalized rectal cancer surgery may decrease postoperative and long-term cancer-related mortality. However, the regionalization of care may be an undue burden on patients.

OBJECTIVE

This study aimed to assess the cost-effectiveness of regionalized rectal cancer surgery.

DESIGN

Tree-based decision analysis.

PATIENTS

Patients with stage II/III rectal cancer anatomically suitable for low anterior resection were included.

SETTING

Rectal cancer surgery performed at a high-volume regional center rather than the closest hospital available.

MAIN OUTCOME MEASURES

Incremental costs ($) and effectiveness (quality-adjusted life year) reflected a societal perspective and were time-discounted at 3%. Costs and benefits were combined to produce the incremental cost-effectiveness ratio ($ per quality-adjusted life year). Multivariable probabilistic sensitivity analysis modeled uncertainty in probabilities, costs, and effectiveness.

RESULTS

Regionalized surgery economically dominated local surgery. Regionalized rectal cancer surgery was both less expensive on average ($50,406 versus $65,430 in present-day costs) and produced better long-term outcomes (10.36 versus 9.51 quality-adjusted life years). The total costs and inconvenience of traveling to a regional high-volume center would need to exceed $15,024 per patient to achieve economic breakeven alone or $112,476 per patient to satisfy conventional cost-effectiveness standards. These results were robust on sensitivity analysis and maintained in 94.6% of scenario testing.

LIMITATIONS

Decision analysis models are limited to policy level rather than individualized decision-making.

CONCLUSIONS

Regionalized rectal cancer surgery improves clinical outcomes and reduces total societal costs compared to local surgical care. Prescriptive measures and patient inducements may be needed to expand the role of regionalized surgery for rectal cancer. See Video Abstract at http://links.lww.com/DCR/C83 .

QU TAN LEJOS ES DEMASIADO LEJOS ANLISIS DE COSTOEFECTIVIDAD DE LA CIRUGA DE CNCER DE RECTO REGIONALIZADO

ANTECEDENTES:La cirugía de cáncer de recto regionalizado puede disminuir la mortalidad posoperatoria y a largo plazo relacionada con el cáncer. Sin embargo, la regionalización de la atención puede ser una carga indebida para los pacientes.OBJETIVO:Evaluar la rentabilidad de la cirugía oncológica de recto regionalizada.DISEÑO:Análisis de decisiones basado en árboles.PACIENTES:Pacientes con cáncer de recto en estadio II/III anatómicamente aptos para resección anterior baja.AJUSTE:Cirugía de cáncer rectal realizada en un centro regional de alto volumen en lugar del hospital más cercano disponible.PRINCIPALES MEDIDAS DE RESULTADO:Los costos incrementales ($) y la efectividad (años de vida ajustados por calidad) reflejaron una perspectiva social y se descontaron en el tiempo al 3%. Los costos y los beneficios se combinaron para producir la relación costo-efectividad incremental ($ por año de vida ajustado por calidad). El análisis de sensibilidad probabilístico multivariable modeló la incertidumbre en las probabilidades, los costos y la efectividad.RESULTADOS:La cirugía regionalizada predominó económicamente la cirugía local. La cirugía de cáncer de recto regionalizado fue menos costosa en promedio ($50 406 versus $65 430 en costos actuales) y produjo mejores resultados a largo plazo (10,36 versus 9,51 años de vida ajustados por calidad). Los costos totales y la inconveniencia de viajar a un centro regional de alto volumen necesitarían superar los $15,024 por paciente para alcanzar el punto de equilibrio económico o $112,476 por paciente para satisfacer los estándares convencionales de rentabilidad. Estos resultados fueron sólidos en el análisis de sensibilidad y se mantuvieron en el 94,6% de las pruebas de escenarios.LIMITACIONES:Los modelos de análisis de decisiones se limitan al nivel de políticas en lugar de la toma de decisiones individualizada.CONCLUSIONES:La cirugía de cáncer de recto regionalizada mejora los resultados clínicos y reduce los costos sociales totales en comparación con la atención quirúrgica local. Es posible que se necesiten medidas prescriptivas e incentivos para los pacientes a fin de ampliar el papel de la cirugía regionalizada para el cáncer de recto. Consulte Video Resumen en http://links.lww.com/DCR/C83 . (Traducción- Dr. Francisco M. Abarca-Rendon ).

Estimating the cost of university-based outbreaks of serogroup B meningococcal disease with different pre-matriculation vaccination policies in the United States

Objective: We developed an Excel-based cost calculator to assess the economic burden of university-based Neisseria meningitidis serogroup B (MenB) outbreaks. Participants: Hypothetical university with 6,354 students. Methods: Total societal costs of outbreak were estimated for three MenB pre-matriculation immunization policies-vaccination required, vaccination recommended, and no vaccine policy-under three different cost assumptions (low/mid-range/high cost). Results: Mid-range cost estimates of an outbreak under "no policy" were $2.60 and $2.70 million (of which 35% were incurred by the university) if targeting all undergraduates for mass vaccination with a two-/three-dose vaccine, respectively. The "required" and "recommended" policies lowered the burden to $2.17-$2.18 million and $2.34-$2.39 million, respectively. For a larger university with 40,000 students, costs were almost $9 million for a two-dose vaccine with "no policy" in place. Conclusions: The economic burden of a university MenB outbreak is substantial, but could be mitigated by a pre-matriculation MenB vaccination requirement or recommendation.

Clinical and Public Health Considerations for HPV Vaccination in Midadulthood: A Narrative Review

Human papillomavirus (HPV) is an important cause of anogenital and oropharyngeal cancers, anogenital warts, and recurrent respiratory papillomatosis. Beginning in 2019, US guidelines recommended shared clinical decision-making (SCDM) for HPV vaccination among midadults (27-45 years). We conducted a narrative review of existing literature on HPV vaccination in midadults. The available evidence demonstrates that HPV vaccination in midadults is safe, efficacious, and likely to benefit both HPV-naïve midadults and those with previous infections. However, gaps in knowledge related to HPV vaccination have been identified among clinicians and midadult patients. Universal midadult HPV vaccination in the United States could avert 20 934-37 856 cancer cases over 100 years, costing $141 000-$1 471 000 per quality-adjusted life-year gained. Wide variation in these estimates reflects uncertainties in sexual behavior, HPV natural history, and naturally acquired immunity. Greater awareness among clinicians and midadult patients and broad implementation of SCDM may accelerate progress toward eliminating HPV-associated cancers and other diseases.

The Optimal Length-of-Stay After Microvascular Breast Reconstruction: A Cost-Utility Analysis

BACKGROUND

Length-of-stay (LOS) can have a large impact on overall surgical costs. Several studies have demonstrated that a shortened LOS is safe and effective after microvascular breast reconstruction (MBR). The optimal LOS from a cost-utility perspective is not known.

METHODS

The authors used a decision tree model to evaluate the cost-utility, from the perspective of the hospital, of a variety of LOS strategies. Health state probabilities were estimated from an institutional chart review. Expected costs and quality-adjusted life-years (QALY) were assess using Monte Carlo simulation and sensitivity analyses.

RESULTS

Over a ten-year period, our overall flap loss and take-back rates were 1.6% and 4.9%, respectively. After rollback, a 3-day LOS was identified as the most cost-effective strategy, with an expected cost of $41,680.19 and an expected health utility of 25.68 QALYs. Monte Carlo sensitivity analysis confirmed that discharge on POD3 was the most cost-effective strategy in the majority of simulations when the willingness-to-pay threshold varied from $50,000-$130,000/QALY gained.

CONCLUSION

This cost-utility analysis suggests that a 3-day LOS is the most cost-effective strategy after MBR.

Cost-Effectiveness of Aspirin for Extended Venous Thromboembolism Prophylaxis After Major Surgery for Inflammatory Bowel Disease

BACKGROUND AND PURPOSE

Venous thromboembolism extended prophylaxis after inflammatory bowel disease surgery remains controversial. The purpose of this study was to evaluate if adopting an aspirin-based prophylaxis strategy may address current cost-effectiveness limitations.

METHODS

A decision analysis model was used to compare costs and outcomes of a reference case patient undergoing inflammatory bowel disease-associated colorectal surgery considered for post-discharge thromboembolism prophylaxis. Low-dose aspirin was compared to an enoxaparin regimen as well as no prophylaxis. Source estimates were obtained from aggregated existing literature. Secondary analysis included out-of-pocket costs. A 10,000-simulation Monte Carlo probabilistic sensitivity analysis accounted for uncertainty in model estimates.

RESULTS

An enoxaparin-based regimen compared to aspirin demonstrated an unfavorable incremental cost-effectiveness ratio of $908,268 per quality-adjusted life year. Sensitivity analysis supported this finding in > 75% of simulated cases; scenarios favoring enoxaparin included those with > 4% post-discharge event rates. Aspirin versus no prophylaxis demonstrated a favorable ratio of $106,601 per quality-adjusted life year. Findings were vulnerable to a post-discharge thromboembolism rate < 1%, aspirin-associated bleeding rate > 1%, median hospital costs of bleeding > 3 × , and decreased efficacy of aspirin (RR > 0.75). The average out-of-pocket cost of choosing an aspirin ePpx strategy increased by $54 per patient versus $708 per patient with enoxaparin.

CONCLUSIONS

Low-dose aspirin extended prophylaxis following inflammatory bowel disease surgery has a favorable cost-safety profile and may be an attractive alternative approach.

Do Cost Limitations of Extended Prophylaxis After Surgery Apply to Ulcerative Colitis Patients?

BACKGROUND

Colorectal surgery patients with ulcerative colitis are at increased risk of postoperative venous thromboembolism. Extended prophylaxis for thromboembolism prevention has been used in colorectal surgery patients, but it has been criticized for its lack of cost-effectiveness. However, the cost-effectiveness of extended prophylaxis for postoperative ulcerative colitis patients may be unique.

OBJECTIVE

This study aimed to assess the cost-effectiveness of extended prophylaxis in postoperative ulcerative colitis patients.

DESIGN

A decision analysis compared costs and benefits in postoperative ulcerative colitis patients with and without extended prophylaxis over a lifetime horizon.

SETTING

Assumptions for decision analysis were identified from available literature for a typical ulcerative colitis patient's risk of thrombosis, age at surgery, type of thrombosis, prophylaxis risk reduction, bleeding complications, and mortality.

MAIN OUTCOME MEASURES

Costs ($) and benefits (quality-adjusted life year) reflected a societal perspective and were time-discounted at 3%. Costs and benefits were combined to produce the main outcome measure, the incremental cost-effectiveness ratio ($ per quality-adjusted life year). Multivariable probabilistic sensitivity analysis modeled uncertainty in probabilities, costs, and disutilities.

RESULTS

Using reference parameters, the individual expected societal total cost of care was $957 without and $1775 with prophylaxis (not cost-effective; $257,280 per quality-adjusted life year). Preventing a single mortality with prophylaxis would cost $5 million (number needed to treat: 6134 individuals). Adjusting across a range of scenarios upheld these conclusions 77% of the time. With further sensitivity testing, venous thromboembolism cumulative risk (>1.5%) and ePpx regimen pricing (<$299) were the 2 parameters most sensitive to uncertainty.

LIMITATIONS

Recommendations of decision analysis methodology are limited to group decision-making, not an individual risk profile.

CONCLUSION

Routine ePpx in postoperative ulcerative colitis patients is not cost-effective. This finding is sensitive to higher-than-average rates of venous thromboembolism and low-cost prophylaxis opportunities. See Video Abstract at http://links.lww.com/DCR/B818.

SE APLICAN LAS LIMITACIONES DE COSTOS DE LA PROFILAXIS PROLONGADA DESPUS DE LA CIRUGA A LOS PACIENTES CON COLITIS ULCEROSA

ANTECEDENTES:Los pacientes de cirugía colorrectal con colitis ulcerosa tienen un mayor riesgo de tromboembolismo venoso posoperatorio. La profilaxis extendida para la prevención de la tromboembolia se ha utilizado en pacientes con cirugía colorrectal, aunque ha sido criticada por su falta de rentabilidad. Sin embargo, la rentabilidad de la profilaxis prolongada para los pacientes posoperados con colitis ulcerosa puede ser aceptable.OBJETIVO:Evaluar la rentabilidad de la profilaxis prolongada en pacientes posoperados con colitis ulcerosa.DISEÑO:Un análisis de decisiones comparó los costos y beneficios en pacientes posoperados con colitis ulcerosa con y sin profilaxis prolongada de por vida.AJUSTE:Los supuestos para el análisis de decisiones se identificaron a partir de la literatura disponible para el riesgo de trombosis de un paciente con colitis ulcerosa típica, la edad al momento de la cirugía, el tipo de trombosis, la reducción del riesgo con profilaxis, las complicaciones hemorrágicas y la mortalidad.PRINCIPALES MEDIDAS DE RESULTADO:Los costos ($) y los beneficios (año de vida ajustado por calidad) reflejaron una perspectiva social y se descontaron en el tiempo al 3%. Los costos y los beneficios se combinaron para producir la principal medida de resultado, la relación costo-efectividad incremental ($ por año de vida ajustado por calidad). El análisis de sensibilidad probabilística multivariable modeló la incertidumbre en probabilidades, costos y desutilidades.RESULTADOS:Utilizando parámetros de referencia, el costo total de atención social esperado individual fue de $957 sin profilaxis y $1775 con profilaxis (no rentable; $257,280 por año de vida ajustado por calidad). La prevención de una sola mortalidad con profilaxis costaría $5.0 millones (número necesario a tratar: 6.134 personas). El ajuste en una variedad de escenarios mantuvo estas conclusiones el 77% de las veces. Con más pruebas de sensibilidad, el riesgo acumulado de TEV (>1,5%) y el precio del régimen de ePpx (<$299) fueron los dos parámetros más sensibles a la incertidumbre.LIMITACIONES:Las recomendaciones de la metodología de análisis de decisiones se limitan a la toma de decisiones en grupo, no a un perfil de riesgo individual.CONCLUSIÓN:La profilaxis extendida de rutina en pacientes posoperados con colitis ulcerosa no es rentable. Este hallazgo es sensible a tasas de TEV superiores al promedio y oportunidades de profilaxis de bajo costo. Consulted Video Resumen en http://links.lww.com/DCR/B818. (Traducción-Dr. Felipe Bellolio).

Meningococcal disease and vaccination in college students

Neisseria meningitidis is a bacterial pathogen capable of causing rapidly progressing illness from nonspecific symptoms to end-organ failure or death in a matter of hours to days. Despite the availability of meningococcal vaccines, there remains a notable disease incidence peak among individuals aged 18-19 years, with college students at increased risk for disease relative to non-college students. Between 2007 and 2017, as many as one in five colleges in the United States experienced an outbreak of meningococcal disease at their own or a nearby institution. Evidence-based strategies to promote meningococcal vaccination among students can be adapted for the college setting, but barriers exist that limit widespread implementation of these strategies by colleges. In this article, we review meningococcal disease characteristics and epidemiology among US college students, vaccination indications and coverage levels among US college students, as well as college vaccination policies and practices that can impact students' vaccine uptake.

Canadian Association of Gastroenterology Clinical Practice Guideline for Immunizations in Patients With Inflammatory Bowel Disease (IBD)-Part 2: Inactivated Vaccines

Background and Aims

The effectiveness and safety of vaccinations can be altered by immunosuppressive therapies, and perhaps by inflammatory bowel disease (IBD) itself. These recommendations developed by the Canadian Association of Gastroenterology and endorsed by the American Gastroenterological Association, aim to provide guidance on immunizations in adult and pediatric patients with IBD. This publication focused on inactivated vaccines.

Methods

Systematic reviews evaluating the efficacy, effectiveness, and safety of vaccines in patients with IBD, other immune-mediated inflammatory diseases, and the general population were performed. Critical outcomes included mortality, vaccine-preventable diseases, and serious adverse events. Immunogenicity was considered a surrogate outcome for vaccine efficacy. Certainty of evidence and strength of recommendations were rated according to the GRADE (Grading of Recommendation Assessment, Development, and Evaluation) approach. Key questions were developed through an iterative online platform, and voted on by a multidisciplinary group. Recommendations were formulated using the Evidence-to-Decision framework. Strong recommendation means that most patients should receive the recommended course of action, whereas a conditional recommendation means that different choices will be appropriate for different patients.

Results

Consensus was reached on 15 of 20 questions. Recommendations address the following vaccines: Haemophilus influenzae type b, recombinant zoster, hepatitis B, influenza, pneumococcus, meningococcus, tetanus-diphtheria-pertussis, and human papillomavirus. Most of the recommendations for patients with IBD are congruent with the current Centers for Disease Control and Prevention and Canada’s National Advisory Committee on Immunization recommendations for the general population, with the following exceptions. In patients with IBD, the panel suggested Haemophilus influenzae type b vaccine for patients older than 5 years of age, recombinant zoster vaccine for adults younger than 50 year of age, and hepatitis B vaccine for adults without a risk factor. Consensus was not reached, and recommendations were not made for 5 statements, due largely to lack of evidence, including double-dose hepatitis B vaccine, timing of influenza immunization in patients on biologics, pneumococcal and meningococcal vaccines in adult patients without risk factors, and human papillomavirus vaccine in patients aged 27–45 years.

Conclusions

Patients with IBD may be at increased risk of some vaccine-preventable diseases. Therefore, maintaining appropriate vaccination status in these patients is critical to optimize patient outcomes. In general, IBD is not a contraindication to the use of inactivated vaccines, but immunosuppressive therapy may reduce vaccine responses.

Canadian Association of Gastroenterology Clinical Practice Guideline for Immunizations in Patients With Inflammatory Bowel Disease (IBD)-Part 2: Inactivated Vaccines

BACKGROUND AND AIMS

The effectiveness and safety of vaccinations can be altered by immunosuppressive therapies, and perhaps by inflammatory bowel disease (IBD) itself. These recommendations developed by the Canadian Association of Gastroenterology and endorsed by the American Gastroenterological Association, aim to provide guidance on immunizations in adult and pediatric patients with IBD. This publication focused on inactivated vaccines.

METHODS

Systematic reviews evaluating the efficacy, effectiveness, and safety of vaccines in patients with IBD, other immune-mediated inflammatory diseases, and the general population were performed. Critical outcomes included mortality, vaccine-preventable diseases, and serious adverse events. Immunogenicity was considered a surrogate outcome for vaccine efficacy. Certainty of evidence and strength of recommendations were rated according to the GRADE (Grading of Recommendation Assessment, Development, and Evaluation) approach. Key questions were developed through an iterative online platform, and voted on by a multidisciplinary group. Recommendations were formulated using the Evidence-to-Decision framework. Strong recommendation means that most patients should receive the recommended course of action, whereas a conditional recommendation means that different choices will be appropriate for different patients.

RESULTS

Consensus was reached on 15 of 20 questions. Recommendations address the following vaccines: Haemophilus influenzae type b, recombinant zoster, hepatitis B, influenza, pneumococcus, meningococcus, tetanus-diphtheria-pertussis, and human papillomavirus. Most of the recommendations for patients with IBD are congruent with the current Centers for Disease Control and Prevention and Canada's National Advisory Committee on Immunization recommendations for the general population, with the following exceptions. In patients with IBD, the panel suggested Haemophilus influenzae type b vaccine for patients older than 5 years of age, recombinant zoster vaccine for adults younger than 50 year of age, and hepatitis B vaccine for adults without a risk factor. Consensus was not reached, and recommendations were not made for 5 statements, due largely to lack of evidence, including double-dose hepatitis B vaccine, timing of influenza immunization in patients on biologics, pneumococcal and meningococcal vaccines in adult patients without risk factors, and human papillomavirus vaccine in patients aged 27-45 years.

CONCLUSIONS

Patients with IBD may be at increased risk of some vaccine-preventable diseases. Therefore, maintaining appropriate vaccination status in these patients is critical to optimize patient outcomes. In general, IBD is not a contraindication to the use of inactivated vaccines, but immunosuppressive therapy may reduce vaccine responses.

Evidence gaps in economic analyses of hearing healthcare: A systematic review

BACKGROUND

Hearing loss is a common and costly medical condition. This systematic review sought to identify evidence gaps in published model-based economic analyses addressing hearing loss to inform model development for an ongoing Lancet Commission.

METHODS

We searched the published literature through 14 June 2020 and our inclusion criteria included decision model-based cost-effectiveness analyses that addressed diagnosis, treatment, or prevention of hearing loss. Two investigators screened articles for inclusion at the title, abstract, and full-text levels. Data were abstracted and the studies were assessed for the qualities of model structure, data assumptions, and reporting using a previously published quality scale.

FINDINGS

Of 1437 articles identified by our search, 117 unique studies met the inclusion criteria. Most of these model-based analyses were set in high-income countries (n = 96, 82%). The evaluated interventions were hearing screening (n = 35, 30%), cochlear implantation (n = 34, 29%), hearing aid use (n = 28, 24%), vaccination (n = 22, 19%), and other interventions (n = 29, 25%); some studies included multiple interventions. Eighty-six studies reported the main outcome in quality-adjusted or disability-adjusted life-years, 24 of which derived their own utility values. The majority of the studies used decision tree (n = 72, 62%) or Markov (n = 41, 35%) models. Forty-one studies (35%) incorporated indirect economic effects. The median quality rating was 92/100 (IQR:72-100).

INTERPRETATION

The review identified a large body of literature exploring the economic efficiency of hearing healthcare interventions. However, gaps in evidence remain in evaluation of hearing healthcare in low- and middle-income countries, as well as in investigating interventions across the lifespan. Additionally, considerable uncertainty remains around productivity benefits of hearing healthcare interventions as well as utility values for hearing-assisted health states. Future economic evaluations could address these limitations.

FUNDING

NCATS 3UL1-TR002553-03S3.

Economic evaluation of meningococcal serogroup B (MenB) vaccines: A systematic review

BACKGROUND

Meningococcal serogroup B (MenB) has emerged as the leading cause of invasive meningococcal disease (IMD) in several countries following the release of effective vaccines against serogroups A, C, W, and Y. In 2013, however, the first multicomponent MenB vaccine (Bexsero®) was licensed in Europe.

AIM

To review the evidence on the cost-effectiveness of vaccination against MenB.

METHODS

Searches were performed in MEDLINE, EMBASE, Web of Science, NHS EED, Econlit, Tufts CEA registry, and HTA. Three reviewers independently screened and selected studies. Using a narrative synthesis, studies were categorized by vaccination strategies. The quality of included studies was assessed using the Comparative Health Economics Evaluation Reporting Standards (CHEERS) checklist.

RESULTS

13 studies were included. Ten studies were conducted in the European region and three in the Americas. None of the vaccination strategies were considered cost-effective. Including herd effects improved value for money for MenB vaccines. Routine infant vaccination was the most effective short-term strategy, however, adolescent strategies offered the best value for money. Without herd immunity, routine infant vaccination had the lowest incremental cost-effectiveness ratio estimates.

CONCLUSION

Routine MenB vaccination does not offer substantial value for money, mainly due to high vaccine costs and low disease incidence.

Use of Cost-Effectiveness Analyses for Decisions About Vaccination Programs for Meningococcal Disease in the United States, United Kingdom, The Netherlands, and Canada

INTRODUCTION

Meningococcal vaccines to protect against invasive meningococcal disease (IMD) vary in terms of vaccine technology and serogroup coverage (Polysaccharide MnACWY, conjugated C and ACWY, outer membrane vesicle-based or protein-based B vaccines), and the national recommendations for each of them vary in terms of target population and number of doses. We sought to understand factors associated with the evolution of meningococcal vaccination program recommendations in four countries with formal evaluation processes: the UK, US, the Netherlands, and Canada.

AREAS COVERED

A targeted review of published literature and internet sources for the four countries relating to meningococcal vaccination decision-making was conducted. The review focused on the impact of cost-effectiveness analyses on vaccine policy decisions and the extent to which variation in incidence of IMD and its potential catastrophic consequences influenced policy decisions.The evolution of meningococcal vaccine recommendations in the four countries was mainly driven by changes in vaccine availability and changes in serogroup incidence. Public pressure due to the catastrophic nature of IMD influenced recommendations. The role of cost-effectiveness analyses varied across the 4 countries.

EXPERT OPINION

The value of implementing meningococcal vaccination programs should be assessed using factors beyond those included in traditional cost-effectiveness analyses.

Serogroup B meningococcal vaccination practice patterns on college campuses

BACKGROUND

Most Neisseria meningitidis involved in invasive disease among American college students express serogroup B antigen. The Advisory Committee on Immunization Practices (ACIP) recommends healthcare providers (HCPs) share clinical decision making with patients to determine individual value of meningococcal serogroup B vaccination (MenB) rather than routinely recommend vaccination as with the meningococcal A,C,W,Y vaccine (MenACWY). This study examines the attitudes and practices of HCPs working in college student health centers (SHCs) regarding the recommendation and administration of MenB to students.

METHODS

The study was conducted as an online and phone survey of SHC HCPs from a sample of colleges across the United States between May 2017 and July 2018. Items compared college SHC policies and practices for MenB to those for MenACWY. It also assessed perceived barriers to and facilitators of MenB delivery to students.

RESULTS

Among the 147 respondents, almost 50% more reported their SHC stocked and administered MenACWY (54.1%) than MenB (37%) (p = .004). Almost five times as many colleges required their students receive MenACWY as MenB (53.5% vs. 10.5%, p < .001). A greater percentage requested students to submit records for MenACWY than MenB (77.3% vs. 46.9%, p < .001), and over three times as many tracked student-body coverage rates for MenACWY than MenB (55.6% vs. 15.8%, p < .001). Nearly three quarters of respondents estimated their college's student body MenB coverage rate to be ≤ 10% or were unable to provide any estimate. Factors perceived by over half of the participants as moderate to extreme barriers to administering MenB included high upfront costs for SHCs to purchase and stock MenB (68.7%), and high out-of-pocket costs for students to receive it (82.8%).

CONCLUSIONS

A minority of college SHCs require, offer or track Men B vaccination on their campuses. Financial concerns are common barriers to SHCs' stocking and administering MenB to students.

Epidemiological impact and cost-effectiveness of universal meningitis b vaccination among college students prior to college entry

OBJECTIVES

University students are at significantly higher risk of serogroup B meningococcal (MenB) infection, which can result in debilitating sequelae and excessive healthcare usage. This study aimed to elucidate the impact of universal pre-enrollment vaccination on MenB outbreak probability and the cost-effectiveness in outbreak-only scenarios.

METHODS

We developed an infectious disease transmission model to determine the number of outbreaks averted under universal vaccination and a Markov model to simulate the costs accrued and QALYs lost associated with infection. The analysis was done on a hypothetical population of 40,000 college students over a four-year time frame. We used the outputs of these two models to calculate the incremental cost-effectiveness ratio (ICER) of universal MenB vaccination from a societal perspective.

RESULTS

We find that the vaccination strategy was estimated to reduce MenB incidence by 63% and outbreak frequency rate by 90%. Under base case assumptions, the ICER of universal vaccination was $748,129 per QALY and in outbreak-only scenarios, it was cost-saving.

CONCLUSIONS

Universal vaccination is not cost-effective at the current low MenB incidence levels and vaccine price in the U.S., but it is cost-saving if outbreak is imminent.

Cost-Benefit Limitations of Extended, Outpatient Venous Thromboembolism Prophylaxis Following Surgery for Crohn's Disease

BACKGROUND

Patients with Crohn's disease are at increased risk of postoperative venous thromboembolism. Historically, extended outpatient prophylaxis has not met conventional measures of societal cost-benefit advantage. However, extended prophylaxis for patients with Crohn's disease may be more cost-effective because of the patients' high thrombotic risk and long life expectancy.

OBJECTIVE

This study aimed to assess the cost-effectiveness of extended prophylaxis in patients with Crohn's disease after abdominal surgery.

DESIGN

A decision tree model was used to assess the incremental cost-effectiveness and cost per case averted with extended-duration venous thromboembolism prophylaxis following abdominal surgery.

SETTING

The risk of a postdischarge thrombotic event, age at surgery, type of thrombotic event, prophylaxis risk reduction, bleeding complications, and mortality were estimated by using existing published sources.

PATIENTS

Studied were patients with Crohn's disease versus routine care.

INTERVENTION

We constructed a decision analysis to compare costs and outcomes in patients with Crohn's disease postoperatively with and without extended prophylaxis over a lifetime horizon.

MAIN OUTCOME MEASURES

Productivity costs ($) and benefits (quality-adjusted life-year) were used to reflect a societal perspective and were time discounted at 3%. Multivariable probabilistic sensitivity analysis accounted for uncertainty in probabilities, costs, and utility weights.

RESULTS

With the use of reference parameters, the individual expected societal total cost of care was $399.83 without and $1387.95 with prophylaxis. Preventing a single mortality with prophylaxis would cost $43.00 million (number needed to treat: 39,839 individuals). The incremental cost was $1.90 million per quality-adjusted life-year. Adjusting across a range of scenarios upheld these conclusions 88% of the time. With further sensitivity testing, subpopulations with postdischarge thrombosis rates greater than 4.9% favors postoperative extended-duration venous thromboembolism prophylaxis.

LIMITATIONS

Further investigation is needed to determine if specific high-risk individuals can be preemptively identified in the Crohn's surgical population for targeted prophylaxis.

CONCLUSION

Extended prophylaxis in patients with Crohn's disease postoperatively is not cost-effective when the cumulative incidence of posthospital thrombosis remains less than 4.9%. These findings are driven by the low absolute risk of thrombosis in this population and the considerable cost of universal treatment. See Video Abstract at http://links.lww.com/DCR/A998. LIMITACIONES DE COSTO-BENEFICIO DE LA PROFILAXIS AMBULATORIA PROLONGADA DEL TROMBOEMBOLISMO VENOSO DESPUÉS DE CIRUGÍA EN CASOS DE ENFERMEDAD DE CROHN:: Los pacientes con enfermedad de Crohn tienen un mayor riesgo de tromboembolismo venoso postoperatorio. Históricamente, la profilaxis ambulatoria prolongada no ha cumplido con las medidas convencionales de ventajas en costo-beneficio para la sociedad. Sin embargo, la profilaxis prolongada en los pacientes con Crohn puede ser más rentable debido al alto riesgo trombótico y a una larga esperanza de vida en estos pacientes.Evaluar la rentabilidad de la profilaxis prolongada en pacientes postoperados de un Crohn.Se utilizó un modelo de árbol de decisión para evaluar el incremento de rentabilidad y el costo por cada caso evitado con la profilaxis prolongada de tromboembolismo venoso después de cirugía abdominal.Se calcularon utilizando fuentes publicadas el riesgo de evento trombótico posterior al alta, la edad del paciente al momento de la cirugía, el tipo de evento trombótico, la reducción del riesgo de profilaxis, las complicaciones hemorrágicas y la mortalidad.Se estudiaron los pacientes de atención rutinaria versus aquellos portadores de Crohn.Construimos un arbol de análisis decisional para comparar costos y resultados de pacientes portadores de Crohn, con y sin profilaxis prolongada en el postoperatorio en un horizonte de por vida.Los costos de productividad ($) y los beneficios (año de vida ajustado por calidad) se utilizaron para reflejar la perspectiva social y se descontaron en el tiempo de un 3%. El análisis de sensibilidad probabilística multivariable dió cuenta de la incertidumbre en las probabilidades, costos y peso de utilidades.Usando parámetros de referencia, el costo total social esperado de la atención individual fue de $ 399.83 sin y $ 1,387.95 con profilaxis. La prevención del deceso de un paciente con profilaxis costaría $ 43.00 millones (valor requerido para tratar: 39,839 individuos). El costo incrementado fue de $ 1.90 millones por año de vida ajustado por la calidad. El ajuste a través de una gama de escenarios confirmó estas conclusiones el 88% del tiempo. Con pruebas de sensibilidad adicionales, las subpoblaciones con tasas de trombosis posteriores al alta fueron superiores al 4,9% y favorecían la profilaxis prolongada del tromboembolismo venoso en el postoperatorio.Se necesita más investigación para determinar si se puede identificar de manera preventiva los individuos específicos de alto riesgo en la población quirúrgica de Crohn en casos de profilaxis dirigida.La profilaxis prolongada en pacientes postoperados de un Crohn no es rentable cuando la incidencia acumulada de trombosis posthospitalaria sigue siendo inferior al 4,9%. Estos hallazgos son impulsados por el bajo riesgo absoluto de trombosis en esta población y el costo considerable del tratamiento universal. Vea el resumen del video en http://links.lww.com/DCR/A998.