Incremental cost-effectiveness ratio and net monetary benefit: Current use in pharmacoeconomics and future perspectives

Cost-effectiveness of the recombinant zoster vaccine (RZV) against herpes zoster: An updated critical review

The objective of this study was to critically review the cost-effectiveness (CE) of the recombinant zoster vaccine (RZV) against herpes zoster (HZ). A literature review was conducted in PubMed, Embase, and Cochrane between January 1, 2017, and February 28, 2022, and on select public healthcare agency websites to identify and collect data from CE studies comparing RZV to zoster vaccine live (ZVL) or to no vaccination. Study characteristics, inputs, and outputs were collected. The overall CE of RZV was assessed. RZV vaccination against HZ is cost-effective in 15 out of 18 studies included in the present review. Varying incremental cost-effectiveness ratios (ICERs) observed may be associated with different assumptions on the duration of protection of RZV, as well as different combinations of structural and disease-related study (model) inputs driving the estimation of ICERs.

Managing Tenders in the Procurement of Advanced Medical Devices: An Original Model Based on the Net Monetary Benefit Combined With Three Clinical Endpoints

In medical devices, recent studies have proposed original approaches for standardizing competitive tenders with the aim of promoting reproducibility, avoiding discretional decisions, and applying value-based principles. In the framework of tenders' standardization, the net monetary benefit (NMB) method has attracted much interest, but its mathematical complexity has prevented a wide application. In the present work, we developed a procurement model that simplifies clinical information management for high-technology devices purchased for our public hospitals. Our objective was to promote the application of NMB in competitive tenders, particularly at the final stage of the procurement process, where the tender scores are determined. Software to facilitate this task in everyday practice has been developed. This software is made available through the present technical report. We surveyed the most relevant literature about NMB to select the main models commonly used in the studies published thus far. Standard equations of cost-effectiveness were identified. A simplified computation model based on three clinical endpoints was developed to estimate the NMB with less mathematical complexity. This model is proposed as an alternative to the standard approach based on a full economic analysis. The model developed herein has been implemented in a web-based software freely available on the Internet. This software is accompanied by a detailed description of the equations by which the NMB is estimated. A detailed application example is reported; a real tender carried out in 2021 has been re-examined for this purpose. In this re-analysis, the new software has been used to calculate the NMB of three devices. To our knowledge, this is the first experience in which an institution of the Italian healthcare system has evaluated the NMB as a tool for determining tender scores. The model is designed to offer performance similar to a full economic analysis. Our preliminary results are encouraging and suggest a wider application of this method. This approach has important implications regarding cost-effectiveness and cost containment because a value-based procurement is known to maximize effectiveness without determining an increase in costs.

Cost effectiveness of virtual reality game compared to clinic based McKenzie extension therapy for chronic non-specific low back pain

BACKGROUND

Low-back pain (LBP) is a major public health problem globally and its direct and indirect healthcare costs are growing rapidly. Virtual reality involving the use of video games or non-game applications are alternatives to conventional face-to-face physical therapy for LBP. The purpose of this study was to assess the cost-effectiveness of Back Extension-Virtual Reality Game (BE-VRG) compared to Clinic-based McKenzie therapy (CBMT) for chronic non-specific LBP in Nigeria.

METHODS

Patients with chronic non-specific LBP were randomised into either BE-VRG or CBMT group. Patients' level of disability was assessed using Oswestry Disability Index (ODI) at week 4 and week 8. ODI was mapped to SF-6D to generate quality adjusted life years (QALYs) used for cost-effectiveness analysis. Resource use and costs were assessed based on rehabilitation services from a healthcare perspective. Cost-effectiveness analysis which included direct healthcare costs was conducted. Incremental cost per QALY was also calculated.

RESULTS

Forty-six patients (BE-VRG, n = 22; CBMT, n = 24) with the mean (±SD) age of 32.6 ± (11.5) years for BE-VRG and 48.8 ± (10.2) years for CBMT intervention completed in this study. The mean direct health costs per patient were USD100.67 and USD106.3 for BE-VRG and CBMT, respectively. The mean quality adjusted life years at week 4 and week 8 were (BE-VRG, 0.0574 ± (0.002); CBMT, 0.0548 ± (0.002)); and (BE-VRG; 0.116 ± (0.002); CBMT; 0.114 ± (0.004)), respectively. Incremental cost-effectiveness ratio showed that BE-VRG arm was less costly and more effective than CBMT.

CONCLUSION

The findings of this study suggest that BE-VRG was cost saving for chronic non-specific LBP compared to CBMT. This evidence could guide policy makers, payers and clinicians in evaluating BE-VRG as a treatment option for people with chronic non-specific LBP.

Fexapotide triflutate vs oral pharmacotherapy as initial therapy for moderate-to-severe benign prostate hyperplasia patients: a cost-effectiveness analysis

BACKGROUND

To assess the price range in which fexapotide triflutate (FT), a novel injectable, is cost-effective relative to current oral pharmacotherapy (5 α-reductase inhibitor, α-blocker, 5 α-reductase inhibitor and α-blocker combination therapy) as initial therapy followed by surgery for moderate-to-severe benign prostate hyperplasia patients with lower urinary tract symptoms (BPH-LUTS).

METHODS

We developed a microsimulation decision-analytic model to track the progression of BPH-LUTS and associated costs and quality-adjusted life years in the target population. The cost-effectiveness analysis was performed from Medicare's perspective with a time horizon of 4 years using 2019 US dollars for all costs. The microsimulation model considered treatment patterns associated with nonadherence to oral medication and progression to surgery. Model parameters were estimated from large randomized controlled trials, literature and expert opinion. For each initial treatment option, simulations were performed with 1000 iterations, with 1000 patients per iteration.

RESULTS

Three upfront oral pharmacotherapy options are close in cost-effectiveness, with combination therapy being the most cost-effective option. Relative to upfront oral pharmacotherapy options, FT slightly increases quality-adjusted life years (QALY) per patient (1.870 (95% CI, 1.868 to 1.872) vs. 1.957 (95% CI, 1.955 to 1.959) QALYs). Under the willingness-to-pay (WTP) threshold of $150,000 per QALY, at price per injection of $14,000, FT is about as cost-effective as upfront oral pharmacotherapy options with net monetary benefit (NMB) $279,168.54. Under the WTP threshold of $50,000 per QALY, at price per injection of $5,000, FT is about as cost-effective as upfront oral pharmacotherapy options with NMB $92,135.18. In an alternative 10-year time horizon scenario, FT price per injection at $11,000 and $4,500 makes FT as cost-effective as oral pharmacotherapies. One-way sensitivity analysis showed this result is most sensitive to upfront therapy prices, FT efficacy and initial IPSS. At price per injections of $5,000, $10,000 and $15,000, the probability that FT is either cost-effective or dominant compared to upfront oral pharmacotherapy options using a WTP threshold of $150,000 per QALY is 100%, 93% and 40%, respectively.

CONCLUSIONS

Compared to upfront oral pharmacotherapy options, FT would be cost-effective at a price per injection below $14,000, assuming a WTP threshold of $150,000 per QALY.

Optimizing diabetes screening frequencies for at-risk groups

There is strong evidence that diabetes is underdiagnosed in the US: the Centers for Disease Control and Prevention (CDC) estimates that approximately 25% of diabetic patients are unaware of their condition. To encourage timely diagnosis of at-risk patients, we develop screening guidelines stratified by body mass index (BMI), age, and prior test history by using a Partially Observed Markov Decision Process (POMDP) framework to provide more personalized screening frequency recommendations. We identify structural results that prove the existence of threshold solutions in our problem and allow us to determine the relative timing and frequency of screening given different risk profiles. We then use nationally representative empirical data to identify a policy that provides the optimal action (screen or wait) every six months from age 45 to 90. We find that the current screening guidelines are suboptimal, and the recommended diabetes screening policy should be stratified by age and by finer BMI thresholds than in the status quo. We identify age ranges and BMI categories for which relatively less or more screening is needed compared to the existing guidelines to help physicians target patients most at risk. Compared to the status quo, we estimate that an optimal screening policy would generate higher net monetary benefits by $3,200-$3,570 and save $120-$1,290 in health expenditures per individual in the US above age 45.

Prehospital continuous positive airway pressure for acute respiratory failure: the ACUTE feasibility RCT

BACKGROUND

Acute respiratory failure is a life-threatening emergency. Standard prehospital management involves controlled oxygen therapy. Continuous positive airway pressure is a potentially beneficial alternative treatment; however, it is uncertain whether or not this treatment could improve outcomes in NHS ambulance services.

OBJECTIVES

To assess the feasibility of a large-scale pragmatic trial and to update an existing economic model to determine cost-effectiveness and the value of further research.

DESIGN

(1) An open-label, individual patient randomised controlled external pilot trial. (2) Cost-effectiveness and value-of-information analyses, updating an existing economic model. (3) Ancillary substudies, comprising an acute respiratory failure incidence study, an acute respiratory failure diagnostic agreement study, clinicians perceptions of a continuous positive airway pressure mixed-methods study and an investigation of allocation concealment.

SETTING

Four West Midlands Ambulance Service hubs, recruiting between August 2017 and July 2018.

PARTICIPANTS

Adults with respiratory distress and peripheral oxygen saturations below the British Thoracic Society's target levels were included. Patients with limited potential to benefit from, or with contraindications to, continuous positive airway pressure were excluded.

INTERVENTIONS

Prehospital continuous positive airway pressure (O-Two system, O-Two Medical Technologies Inc., Brampton, ON, Canada) was compared with standard oxygen therapy, titrated to the British Thoracic Society's peripheral oxygen saturation targets. Interventions were provided in identical sealed boxes.

MAIN OUTCOME MEASURES

Feasibility objectives estimated the incidence of eligible patients, the proportion recruited and allocated to treatment appropriately, adherence to allocated treatment, and retention and data completeness. The primary clinical end point was 30-day mortality.

RESULTS

Seventy-seven patients were enrolled (target 120 patients), including seven patients with a diagnosis for which continuous positive airway pressure could be ineffective or harmful. Continuous positive airway pressure was fully delivered to 74% of participants (target 75%). There were no major protocol violations/non-compliances. Full data were available for all key outcomes (target ≥ 90%). Thirty-day mortality was 27.3%. Of the 21 deceased participants, 14 (68%) either did not have a respiratory condition or had ceiling-of-treatment decision implemented that excluded hospital non-invasive ventilation and critical care. The base-case economic evaluation indicated that standard oxygen therapy was probably cost-effective (incremental cost-effectiveness ratio £5685 per quality-adjusted life-year), but there was considerable uncertainty (population expected value of perfect information of £16.5M). Expected value of partial perfect information analyses indicated that effectiveness of prehospital continuous positive airway pressure was the only important variable. The incidence rate of acute respiratory failure was 17.4 (95% confidence interval 16.3 to 18.5) per 100,000 persons per year. There was moderate agreement between the primary prehospital and final hospital diagnoses (Gwet's AC1 coefficient 0.56, 95% confidence interval 0.43 to 0.69). Lack of hospital awareness of the Ambulance continuous positive airway pressure (CPAP): Use, Treatment Effect and economics (ACUTE) trial, limited time to complete trial training and a desire to provide continuous positive airway pressure treatment were highlighted as key challenges by participating clinicians.

LIMITATIONS

During week 10 of recruitment, the continuous positive airway pressure arm equipment boxes developed a 'rattle'. After repackaging and redistribution, no further concerns were noted. A total of 41.4% of ambulance service clinicians not participating in the ACUTE trial indicated a difference between the control and the intervention arm trial boxes (115/278); of these clinician 70.4% correctly identified box contents.

CONCLUSIONS

Recruitment rate was below target and feasibility was not demonstrated. The economic evaluation results suggested that a definitive trial could represent value for money. However, limited compliance with continuous positive airway pressure and difficulty in identifying patients who could benefit from continuous positive airway pressure indicate that prehospital continuous positive airway pressure is unlikely to materially reduce mortality.

FUTURE WORK

A definitive clinical effectiveness trial of continuous positive airway pressure in the NHS is not recommended.

TRIAL REGISTRATION

Current Controlled Trials ISRCTN12048261.

FUNDING

This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 25, No. 7. See the NIHR Journals Library website for further project information.

Cost-Effectiveness Assessment of Monitoring Abiraterone Levels in Metastatic Castration-Resistant Prostate Cancer Patients

OBJECTIVES

Abiraterone acetate is registered for the treatment of metastatic castration-sensitive and resistant prostate cancer (mCRPC). Treatment outcome is associated with plasma trough concentrations (C_min) of abiraterone. Patients with a plasma C_min below the target of 8.4 ng/mL may benefit from treatment optimization by dose increase or concomitant intake with food. This study aims to investigate the cost-effectiveness of monitoring abiraterone C_min in patients with mCRPC.

METHODS

A Markov model was built with health states progression-free survival, progressed disease, and death. The benefits of monitoring abiraterone C_min followed by a dose increase or food intervention were modeled via a difference in the percentage of patients achieving adequate C_min taking a healthcare payer perspective. Deterministic and probabilistic sensitivity analyses were performed to assess uncertainties and their impac to the incremental cost-effectiveness ratio (ICER).

RESULTS

Monitoring abiraterone followed by a dose increase resulted in 0.149 incremental quality-adjusted life-years (QALYs) with €22 145 incremental costs and an ICER of €177 821/QALY. The food intervention assumed equal effects and estimated incremental costs of €7599, resulting in an ICER of €61 019/QALY. The likelihoods of therapeutic drug monitoring (TDM) with a dose increase or food intervention being cost-effective were 8.04%and 81.9%, respectively.

CONCLUSIONS

Monitoring abiraterone followed by a dose increase is not cost-effective in patients with mCRPC from a healthcare payer perspective. Monitoring in combination with a food intervention is likely to be cost-effective. This cost-effectiveness assessment may assist decision making in future integration of abiraterone TDM followed by a food intervention into standard abiraterone acetate treatment practices of mCRPC patients.

Choice across 10 pharmacologic combination strategies for type 2 diabetes: a cost-effectiveness analysis

BACKGROUND

Clinical guidelines recommend a stepped-escalation treatment strategy for type 2 diabetes (T2DM). Across multiple treatment strategies varying in efficacy and costs, no clinical or economic studies directly compared them. This study aims to estimate and compare the cost-effectiveness of 10 commonly used pharmacologic combination strategies for T2DM.

METHODS

Based on Chinese guideline and practice, 10 three-stepwise add-on strategies were identified, which start with metformin, then switch to metformin plus one oral drug (i.e., sulfonylurea, thiazolidinedione, α-glucosidase inhibitor, glinide, or DPP-4 inhibitor) as second line, and finally switch to metformin plus one injection (i.e., insulin or GLP-1 receptor agonist) as third line. A cohort of 10,000 Chinese patients with newly diagnosed T2DM was established. From a healthcare system perspective, the Cardiff model was used to estimate the cost-effectiveness of the strategies, with clinical data sourced from a systematic review and indirect treatment comparison of 324 trials, costs from claims data of 1164 T2DM patients, and utilities from an EQ-5D study. Outcome measures include costs, quality-adjusted life-years (QALYs), incremental cost-effectiveness ratios (ICERs), and net monetary benefits (NMBs).

RESULTS

Over 40-year simulation, the costs accumulated for a patient ranged from $7661 with strategy 1 to $14,273 with strategy 10, while the QALY gains ranged from 13.965 with strategy 1 to 14.117 with strategy 8. Strategy 7 was dominant over seven strategies (strategies 2~6, 9~10) with higher QALYs but lower costs. Additionally, at a willingness-to-pay threshold of $30,787/QALY (i.e., 3 times GDP/capita for China), strategy 7 was cost-effective compared with strategy 1 (ICER of strategy 7 vs. 1, $3371/QALY) and strategy 8 (ICER of strategy 8 vs. 7, $132,790/QALY). Ranking the strategies by ICERs and NMBs, strategy 7 provided the best value for money when compared to all other strategies, followed by strategies 5, 9, 8, 1, 3, 6, 10, 2, and 4. Scenario analyses showed that patients insist on pharmacologic treatments increased their QALYs (0.456~0.653) at an acceptable range of cost increase (ICERs, $1450/QALY~$12,360/QALY) or even at cost saving compared with those not receive treatments.

CONCLUSIONS

This study provides evidence-based references for diabetes management. Our findings can be used to design the essential drug formulary, infer clinical practice, and help the decision-maker design reimbursement policy.

Cost-effectiveness analyses demonstrate that observation is superior to sentinel lymph node biopsy for postmenopausal women with HR + breast cancer and negative axillary ultrasound

PURPOSE

To evaluate the cost-effectiveness of axillary observation versus sentinel lymph node biopsy (SLNB) after negative axillary ultrasound (AUS). In patients with clinical T1-T2 N0 breast cancer and negative AUS, SLNB is the current standard of care for axillary staging. However, SLNB is costly, invasive, decreasing in importance for medical decision-making, and is not considered therapeutic. Observation alone is currently being evaluated in randomized clinical trials, and is thought to be non-inferior to SLNB for patients with negative AUS.

METHODS

We performed cost-effectiveness analyses of observation versus SLNB after negative AUS in postmenopausal women with clinical T1-T2 N0, HR⁺/HER2^- breast cancer. Costs at the 2016 price level were evaluated from a third-party commercial payer perspective using the MarketScan® Database. We compared cost, quality-adjusted life years (QALYs), and net monetary benefit (NMB). Multiple sensitivity analyses varying baseline probabilities, costs, utilities, and willingness-to-pay thresholds were performed.

RESULTS

Observation was superior to SLNB for patients with N0 and N1 disease, and for the entire patient population (NMB in US$: $655,659 for observation versus $641,778 for SLNB for the entire patient population). In the N0 and N1 groups, observation incurred lower cost and was associated with greater QALYs. SLNB was superior for patients with > 3 positive lymph nodes, representing approximately 5% of the population. Sensitivity analyses consistently demonstrated that observation is the optimal strategy for AUS-negative patients.

CONCLUSION

Considering both cost and effectiveness, observation is superior to SLNB in postmenopausal women with cT1-T2 N0, HR⁺/HER2^- breast cancer and negative AUS.

Willingness-to-Pay and Benefit-Cost Analysis of IPL for Rosacea Treatment: A Cross-Sectional Study in China

BACKGROUND

Intense pulsed light (IPL), as a therapeutic approach for rosacea, had advantage in removing erythema and telangiectasia and was gradually accepted by rosacea patients, but there have been few studies on economic evaluation of this therapy.

PURPOSE

This study aimed to detect willingness-to-pay (WTP) of IPL treatment for rosacea and to conduct a benefit-cost analysis (BCA) among the Chinese population, so as to provide an economic reference for doctors to make treatment decisions.

MATERIALS AND METHODS

An observational, cross-sectional study assessed respondent's demographic characteristics and willingness-to-pay (WTP) of IPL and rosacea patients' clinical data and Dermatology Life Quality Index (DLQI). WTP was obtained by contingent valuation (CV) method. In brief, contrast figures of three cases treated with IPL (Case1, Case2, and Case3 represented the increasing severity of rosacea) were showed and WTP was inquired. The costs were obtained according the market and compared with WTP (benefits) to get a benefit-cost ratio (BCR). Predictors of cost-effective WTP were identified using the multivariable logistic regression model.

RESULTS

A total of 303 rosacea patients and 202 controls were included in the study. The average cost of a single IPL treatment for rosacea was USD 208.04 in Changsha, China. The mean WTP for Case 1, Case 2, and Case 3 was USD 201.57, 214.64, and 221.74, respectively. WTP was statistically lower for Case 1 than that for Case 2 or Case 3 (P<0.05). The BCRs were 0.85, 1.03, and 1.06 for Case 1, Case 2, and Case 3, respectively. WTP is significantly associated with household monthly income, previous treatment cost, and DLQI after adjustments for demographic characteristics (P<0.05).

CONCLUSION

IPL is an acceptable treatment for rosacea with moderate to severe erythema. For patients with relatively high income or severely impaired quality of life, IPL is an economically feasible therapy and deserves to be recommended.

Pay less and spend more-the real value in healthcare procurement

Healthcare performances have been for long evaluated according to outcomes and costs. What still needs to be defined is which outcomes are the most relevant to the patient, and which costs any supplier is capable to reduce, or increase, to the funder. If technical efficiencies during healthcare production and delivery may continue to evolve, the opportunities for further savings are likely to decrease. Major improvement could be achieved from better definition of outcomes that really matters to patients and stakeholders, that is measuring the real value. Many purchasers are shifting from a traditional approach based on single-unit cost-saving to a more holistic approach, encompassing long-lasting performance evaluation, including the highest possible number of stakeholders and wider sets of indicators. Value-based procurement (VBP) has been defined as achieving "outcomes that matter to people at the lowest possible cost". Although this approach may appear complicated in practice, it was already proven successful in different countries, medical and surgical applications, and has also been endorsed by some important international institutions. The scope of this review is to introduce VBP from a theoretical and an empirical level, referring to relevant practices and challenges which emerged in the current institutional, clinical and academic debate. VBP seems to be a promising solution to improve healthcare efficiency and fairness, provided a clear conception of what is value and a permanent collaboration between clinicians and scientists. When different dimensions of value (i.e., personal, technical, allocative and societal) are supported by well-designed study to identify the respective outcomes, it becomes easier to find better solutions in support of healthcare quality and sustainability.

Handling the procurement of prostheses for total hip replacement: description of an original value based approach and application to a real-life dataset reported in the UK

OBJECTIVES

In most European countries, innovative medical devices are not managed according to cost-utility methods, the reason being that national agencies do not generally evaluate these products. The objective of our study was to investigate the cost-utility profile of prostheses for hip replacement and to calculate a value-based score to be used in the process of procurement and tendering for these devices.

METHODS

The first phase of our study was aimed at retrieving the studies reporting the values of QALYs, direct cost, and net monetary benefit (NMB) from patients undergoing total hip arthroplasty (THA) with different brands of hip prosthesis. The second phase was aimed at calculating, on the basis of the results of cost-utility analysis, a tender score for each device (defined according to standard tendering equations and adapted to a 0-100 scale). This allowed us to determine the ranking of each device in the simulated tender.

RESULTS

We identified a single study as the source of information for our analysis. Nine device brands (cemented, cementless, or hybrid) were evaluated. The cemented prosthesis Exeter V40/Elite Plus Ogee, the cementless device Taperloc/Exceed, and the hybrid device Exeter V40/Trident had the highest NMB (£152 877, £156 356, and £156 210, respectively) and the best value-based tender score.

CONCLUSIONS

The incorporation of value-based criteria in the procurement process can contribute to optimising the value for money for THA devices. According to the approach described herein, the acquisition of these devices does not necessarily converge on the product with the lowest cost; in fact, more costly devices should be preferred when their increased cost is offset by the monetary value of the increased clinical benefit.

Value-based procurement of prostheses for total knee replacement

Cost-effectiveness evaluations concerning devices for total knee arthroplasty (TKA) have little impact on real-life management of these devices. This study explored how pharmacoeconomic models can inform the procurement of TKA devices to improve their value for money. Our study included three phases: i) literature search for data of outcome, cost, and device type in TKA; ii) development of a Markov model predicting costs, QALYs, and net monetary benefit (NMB); iii) simulation of tenders aimed at value-based device procurement. Phases 1 and 2 were managed by selecting a single study as the source of data for our analysis. In Phase 3, each TKA device was associated with its values of NMB, and the tender scores were estimated. Finally, the ranking of each device in the simulated tender was determined. We identified a study published in 2016 as our source of data. Five devices were evaluated. For these devices, QALYs were 7.3952, 7.2939, 7.4952, 7.1919, 7.2930; NMB: £142,005, £140,653, £144,184, £138,040, £140,261; tender scores: 64.53, 42.53, 100, 0, 36.15, respectively. We showed that incorporating the principles of cost-effectiveness into the tendering process is feasible for TKA devices. This can maximize the value for money for these devices.