Modeling good research practices--overview: a report of the ISPOR-SMDM Modeling Good Research Practices Task Force--1

Cost-effectiveness of finerenone therapy for patients with chronic kidney disease and type 2 diabetes in England & Wales: results of the FINE-CKD model

OBJECTIVE

Chronic kidney disease (CKD) is the leading cause of kidney failure, end-stage kidney disease (ESKD), and cardiovascular (CV) events in patients with type 2 diabetes (T2D). The FIDELIO-DKD trial demonstrated that finerenone lowered the risk of renal and CV events in patients with CKD and T2D, regardless of cardiovascular disease history. This study evaluated the cost-effectiveness of finerenone added to background treatment (finerenone + BT) versus background treatment (BT) alone in patients with CKD and T2D from the perspective of the National Health Service in England and Wales.

METHODS

A lifetime Markov model assessed the indicated usage of finerenone for the treatment of stage 3 or 4 CKD with albuminuria associated with T2D in adults, as per the relevant marketing authorization. The model structure considered kidney disease progression and CV risk, with health states encompassing patients' kidney disease stage and CV event profiles, using patient-level data from the FIDELIO-DKD trial. Model outcomes were life years, quality-adjusted life years (QALYs), per-patient costs, incremental costs, and incremental cost-effectiveness ratio (ICER). Sensitivity and scenario analysis were performed, including an analysis exploring the impact of real-world data which suggests more frequent sodium-glucose co-transporter-2 (SGLT2) inhibitor use in the United Kingdom since FIDELIO-DKD.

RESULTS

Patients receiving finerenone experienced kidney and CV benefits, including reduced rates of nonfatal CV events and CV deaths, translating to improvements in survival and quality-adjusted life years (QALYs) of 6.11 and 5.97 per patient for finerenone + BT versus BT, respectively. Total discounted per-patient costs were £48,940 for finerenone + BT and £47,716 for BT alone, resulting in an incremental cost-effectiveness ratio of £8,808 per QALY gained for finerenone + BT versus BT.

CONCLUSION

Sensitivity and scenario analyses, including more frequent SGLT2 inhibitor use consistent with real-world data, indicate a robust ICER that remains within the bounds of what is typically considered cost-effective.

Cost-effectiveness of wastewater and environmental monitoring of respiratory syncytial virus to guide universal infant immunoprophylaxis in Canada

AIMS

To compare the cost-effectiveness of wastewater and environmental monitoring (WEM) versus clinical surveillance (CS)-guided respiratory syncytial virus (RSV) prophylaxis programs in Canada.

MATERIALS AND METHODS

A cost-utility model was developed comprising two identical decision trees for RSV-WEM and RSV-CS. Within each tree, children could conservatively receive nirsevimab prophylaxis (71% coverage) or not at the start of the RSV season and subsequently experience an RSV-related hospitalization, medically-attended, non-hospitalized RSV-infection, or be uninfected/non-medically attended. All children could experience respiratory morbidity up to age 18 years, with higher rates following RSV-related hospitalization. All prophylaxis and RSV-related costs were identical for RSV-WEM and RSV-CS. No costs were assumed for RSV-CS; whereas a cost of CAD$12.31 per infant (infrastructure: CAD$4.07 plus sampling: CAD$8.24) was assumed if a new RSV-WEM system was initiated, with all infrastructure costs included in year 1. Predicated on data from the 2022-23 Ontario RSV season, RSV-WEM was assumed to provide a 15.1% benefit for earlier initiation of the prophylaxis program versus RSV-CS. Outcomes were modelled over an 18-year time horizon (1.5% discounting).

RESULTS

RSV-WEM dominated (lower costs and higher utilities) RSV-CS and remained unaltered in all scenario analyses. Scenarios included: amortization of RSV-WEM infrastructure costs over 5 years; using existing WEM infrastructure for RSV detection; 25% reduction in extra cases identified by RSV-WEM; 50%-90% prophylaxis coverage based on real-world data; and 25% increase in the cost of RSV-WEM.

CONCLUSIONS

The integration of RSV-WEM appears a highly cost-effective strategy (vs RSV-CS exclusively) to guide the earlier launch of RSV seasonal prophylaxis in Canada.

Comparing pulsed field ablation and thermal energy catheter ablation for paroxysmal atrial fibrillation: a cost-effectiveness analysis of the ADVENT trial

BACKGROUND

Pulsed field ablation (PFA) has emerged as an effective technology in the treatment of paroxysmal atrial fibrillation (AF).

OBJECTIVE

To evaluate the cost-effectiveness of PFA vs. thermal ablation from a US healthcare payer perspective using data from a randomized trial.

METHODS

A hybrid decision tree and Markov model was developed comparing patients receiving PFA to thermal ablation (either radiofrequency or cryoballoon ablation) from a US healthcare payer perspective at 5-, 10-, 20-, and 40-year time horizons. Direct medical costs (in 2024 US Dollars), quality-adjusted life years (QALYs), and the net monetary benefit were evaluated at a willingness-to-pay (WTP) threshold of $100,000/QALY. Univariate and probabilistic sensitivity analyses were performed to test model uncertainty. The budget impact for a standard US healthcare payer with 1 million beneficiaries was also assessed.

RESULTS

Over a 40-year time horizon, PFA resulted in an additional 0.044 QALYs at a lower cost of $2,871 compared to thermal ablation. PFA was cost-effective in 54.9% of simulations. Anticoagulation and ablation procedure costs had the largest impact on model uncertainty. The expected cost savings per member per month for a US healthcare payer adopting PFA were $0.00015, $0.0059, and $0.02343 in years 1, 4, and 6, respectively.

CONCLUSIONS

PFA was at least as cost-effective as conventional thermal ablation modalities for treatment of paroxysmal AF and potentially reduces US healthcare payer costs. Providers and payers should consider designating PFA among the preferred first-line therapies for eligible patients.

Cost-Effectiveness Analysis of Angiotensin Receptor Neprilysin Inhibitor Compared With Angiotensin-Converting Enzyme Inhibitor Among Patients With Heart Failure With Reduced Ejection Fraction in Malaysia

OBJECTIVES

This study compared the costs and effectiveness of angiotensin receptor neprilysin inhibitor (ARNI) with angiotensin-converting enzyme inhibitor (ACEI) for the heart failure with reduced ejection fraction population from the Malaysian Ministry of Health's perspective.

METHODS

A 3-state Markov model, with a monthly cycle, was constructed to estimate the lifetime healthcare costs, quality-adjusted life year (QALY), and incremental cost-effectiveness ratio (ICER) of ARNI and ACEI. The monthly baseline risks for all-cause mortality and heart failure (HF) hospitalization were estimated from the PARADIGM-HF trial and age-adjusted to the Malaysian population. The treatment effects were obtained from the PARADIGM-HF trial. All-cause mortality risks from hospitalization, utility values, and costs were derived from local studies. All costs were adjusted to 2023. The ICER was compared with Malaysian Ringgit (RM) 55 426 per QALY (one gross domestic product per capita).

RESULTS

Despite ARNI being more expensive compared with ACEI, it gained more QALYs, resulting in an ICER of RM46 498 per QALY. One-way sensitivity analyses found that the key model drivers were the relative treatment effects on cardiovascular mortality, duration of treatment effects, and time horizon. Probabilistic sensitivity analysis estimated that ARNI is 66% cost-effective at the cost-effectiveness threshold of RM55 426 per QALY. Subgroup analysis showed that ICER increased with age. Scenario analysis demonstrated that initiation of ARNI alongside sodium-glucose cotransporter-2 inhibitor (SGLT-2i) produces more favorable ICER and ARNI without SGLT-2i.

CONCLUSIONS

At the cost-effectiveness threshold of RM55 426 per QALY, ARNI is cost-effective compared with ACEI for the heart failure with reduced ejection fraction population. Expanding patient access to ARNI is likely to improve health outcomes cost-effectively.

Analysis of the economically justifiable price of mepolizumab in adults with asthma in Colombia

INTRODUCTION

Asthma imposes a critical economic burden on health systems, especially with the incorporation of new drugs. Recently, mepolizumab has been approved to prevent exacerbations in patients with eosinophilic asthma, however their high cost constitutes a barrier for their use, especially in middle- and low-income countries. This study aimed to estimate the economically justifiable price of mepolizumab for preventing exacerbations in patients with severe asthma in Colombia.

MATERIALS AND METHODS

A model was developed using the microsimulation to estimate the quality-adjusted costs and life years of two interventions: mepolizumab versus not applying standard treatment without mepolizumab. This analysis was made during a lifetime horizon and from a third-payer perspective. We analyzed the economically justifiable price using two recent willingness to pay (WTP) estimates in Colombia ($4,828 and $5,128) and $19,992, equivalent to up to three times the GDP per capita, as previously used in conjunction with the two estimates mentioned above.

RESULTS

At current costs of US$781 per dose of 100 mg of mepolizumab, this drug is not cost-effective using a WTP of U$4828, U$ 5128, and U$19 992 per QALY. Based on the thresholds of $4,828, $5,128, and $19,992 per QALY assessed in this study, the economically justifiable costs of mepolizumab were determined to be $147, $165, and $691 per dose, respectively.

CONCLUSION

The economically justifiable cost for mepolizumab in Colombia is between $147 and $691 per dose, depending on the WTP used. This result should encourage more studies in the region that optimize decision-making processes when incorporating this drug into the health plans of each country.

Under-reporting of Validation Efforts for Health Economic Models Persists Despite the Availability of Validation Tools: A Systematic Review

OBJECTIVE

In this study we aimed to identify possible changes over time in validation efforts and the way in which they are reported for model-based health economic (HE) evaluations, given the introduction of several new validation tools and methods in the past decade.

METHODS

A systematic review was conducted using PubMed and Embase on published HE models for early breast cancer (EBC) for the period 2016 to 2024. AdViSHE-consisting of four validation categories that cover the main HE model aspects-was utilized to systematically evaluate the reported evaluation efforts. The percentage of studies reporting validation per category was compared with the review by de Boer et al. that covers the years 2008 to 2015.

RESULTS

Of the 2199 records, 78 studies fulfilled the eligibility criteria. Reported validation efforts did not significantly improve compared with the previous period, except for the validation of input data by experts. Reporting on the validation of the conceptual model remained low with around 10% of the studies providing validation. Validation of the computerized model and validation against outcomes using alternative input data were the most underreported validation categories with < 4% of the studies. The validation of model outcomes, specifically cross validity and the comparison with empirical data, remained the most reported categories in this review also, with 52% and 36%, respectively. When validation efforts were reported, this was done in a non-systematic manner, and the tests and results were rarely detailed.

CONCLUSION

Overall reporting of validation efforts for model-based HE evaluations in the past decade did not significantly change compared with the previous decade.

The Lebanese health economic evaluation guideline

BACKGROUND

Economic evaluation guidelines (EEGs) serve as a valuable tool to assist appraisers in making consistent and transparent recommendations, standardize EE studies, enhance their quality, and minimize methodological uncertainties. As other LMICs, Lebanon aims for UHC where EEG is a necessity. This paper aims to report on the Lebanese health EEG (LEEG) and its reference case, including the intermediate results leading to the final decisions.‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬.

RESEARCH DESIGN AND METHODS

The LEEG followed a structured, systematic, and transparent process: (1) identifying the rationale and the guideline scope; (2) establishing the Guideline Development Group; (3) searching the evidence; (4) planning the development process; (5) selecting the panel for the deliberative process; (6) surveying Lebanese stakeholders; (7) deliberating on the results; (8) drafting the guideline; and (9) consulting with international experts.

RESULTS

The LEEG includes three general characteristics, 19 key features, a reference case, and an action plan.

CONCLUSIONS

The LEEG is the first national EEG for health interventions. It will help decision-makers, researchers, and healthcare providers improve the quality and assessment of EE in Lebanon to identify the most cost-effective health interventions. Implementing LEEG is crucial to promoting an equitable, efficient, and high-quality health system with a more consistent decision-making process.

Changing Time Representation in Microsimulation Models

BackgroundIn microsimulation models of diseases with an early, acute phase requiring short cycle lengths followed by a chronic phase, fixed short cycles may lead to computational inefficiency. Examples include epidemic or resource constraint models with early short cycles where long-term economic consequences are of interest for individuals surviving the epidemic or ultimately obtaining the resource. In this article, we demonstrate methods to improve efficiency in such scenarios. Furthermore, we show that care must be taken when applying these methods to epidemic or resource constraint models to avoid bias.MethodsTo demonstrate efficiency, we compared the model runtime among 3 versions of a microsimulation model: with short fixed cycles for all states (FCL), with dynamic cycle length (DCL) defined locally for each state, and with DCL features plus a discrete-event-like hybrid component. To demonstrate bias mitigation, we compared discounted lifetime costs for 3 versions of a resource constraint model: with a fixed horizon where simulation stops, with a fixed entry horizon beyond which new individuals could not enter the model, and with a fixed entry horizon plus a mechanism to maintain a constant level of competition for the resource after the horizon.ResultsThe 3 versions of the microsimulation model had average runtimes of 515 (95% credible interval [CI]: 477 to 545; FCL), 2.70 (95% CI: 1.48 to 2.92; DCL), and 1.45 (95% CI: 1.26 to 2.61; DCL-pseudo discrete event simulation) seconds, respectively. The first 2 resource constraint versions underestimated costs relative to the constant competition version: $20,055 (95% CI: $19,000 to $21,120), $27,030 (95% CI: $24,680 to $29,412), and $33,424 (95% CI: $27,510 to $44,484), respectively.LimitationsThe magnitude of improvements in efficiency and reduction in bias may be model specific.ConclusionChanging time representation in microsimulation may offer computational advantages.HighlightsShort cycle lengths may be required to model the acute phase of an illness but lead to computational inefficiency in a subsequent chronic phase in microsimulation models.A solution is to create state-specific cycle lengths so that cycle lengths change dynamically as the simulation progresses.Computational efficiency can be enhanced further by using a hybrid model containing discrete-event-simulation-like features.Hybrid models can efficiently handle events subsequent to exit from an epidemic or resource constraint model provided steps are taken to mitigate potential bias.

Evaluating the Health and Economic Impacts of Return-to-Work Interventions: A Modeling Study

OBJECTIVES

The rate of sickness absence in Norway is at its highest point since 2009, and policymakers need tools to make informed decisions on high-value interventions to address sick leave. Using trial-linked registry data, multi-state modeling, and decision-analytic modeling, we assessed the cost-effectiveness of 2 return-to-work (RTW) interventions for individuals with musculoskeletal and psychological disorders in Norway.

METHODS

Using data from 166 individuals in a randomized trial, we developed a decision-analytic model to compare 2 multidomain RTW interventions: outpatient acceptance and commitment therapy (O-ACT) and inpatient multimodal occupational rehabilitation (I-MORE). The probabilistic model was informed using trial-based input parameters, including transition probabilities, healthcare costs, production loss, and health-related quality of life to project long-term costs and quality-adjusted life-years (QALYs) over a 25-year time horizon for each intervention.

RESULTS

Modeled outcomes were consistent with the trial outcomes, showing that I-MORE led participants to RTW more quickly. However, assuming a healthcare perspective and a cost-effectiveness threshold of $50 000 per QALY, I-MORE was not considered cost-effective in 98% of our simulations (probabilistic incremental cost-effectiveness ratio, $356 447 per QALY gained) compared with O-ACT. In contrast, when accounting for production loss, I-MORE not only became cost-effective but also was projected to be more beneficial and less costly than O-ACT.

CONCLUSIONS

Under current Norwegian benchmarks for cost-effectiveness, I-MORE would not be considered cost-effective unless production loss was included. Our findings emphasize the key role of a broader societal perspective in economic evaluations, which, although it is being considered, is currently not recommended in Norwegian guidelines.

Public Health Impact of Introducing a Pentavalent Vaccine Against Invasive Meningococcal Disease in the United States

BACKGROUND

Invasive meningococcal disease (IMD) is primarily associated with five Neisseria meningitidis serogroups: A, B, C, W, or Y. In the United States (US), available vaccines protect against serogroups B (MenB), A, C, W, and Y (MenACWY), and A, B, C, W, and Y (MenABCWY). The Advisory Committee on Immunization Practices is re-evaluating the adolescent meningococcal vaccination schedule with varying recommendation formats. This analysis aimed to predict which schedule could avert the most IMD cases and have the most positive public health impact (PHI).

METHODS

An epidemiological model compared the 15-year PHI of vaccination schedules using MenB, MenACWY, and/or MenABCWY vaccines versus current US standard of care (SoC). Varying coverage rates reflected routine, shared clinical decision making, and risk-based recommendations. Sensitivity analyses assessed robustness of the results to different inputs/assumptions.

RESULTS

The most positive PHI compared with SoC was observed with one dose of MenACWY at 11 years of age and two doses of MenABCWY (6 months apart) at 16 years of age, assuming routine recommendation and coverage reflecting real-world uptake of MenACWY. This strategy resulted in 123 IMD cases averted (MenB: 59, MenACWY: 64), 17 deaths prevented, 574 life-years saved, and 757 quality-adjusted life-years gained versus SoC. Eliminating MenACWY vaccination at 11 years was found to result in an additional IMD burden.

CONCLUSION

A routinely recommended two-dose pentavalent vaccine, with doses administered 6 months apart at 16 years of age, alongside the routinely recommended MenACWY vaccine at 11 years of age, would improve the PHI and benefits of IMD vaccination to society.

Economic Model of Uridine Triacetate Versus Supportive Care for the Treatment of Patients with Life-Threatening Early-Onset Severe Toxicity

BACKGROUND

Early-onset severe toxicity following the administration of 5-fluorouracil (5-FU) or capecitabine occurs in approximately 10-30% of patients receiving fluoropyrimidine therapy in the USA and is fatal to at least 0.5% of patients treated. Supportive care measures used to manage symptoms of toxicity are associated with extended hospital length of stay, high cost of care, and poor survival. Uridine triacetate is indicated as an emergency treatment for patients who exhibit early-onset, severe or life-threatening toxicity, and has been shown to significantly improve clinical outcomes. Despite its life-saving capability to reverse early-onset severe toxicity, uridine triacetate may be underutilized.

PURPOSE

This study aims to evaluate the economic impact of uridine triacetate as a rescue therapy for adult patients from the US hospital payer perspective for early-onset severe toxicity, who are expected to die without treatment.

METHODS

A decision tree model was developed to compare inpatient survival, hospital length of stay, and inpatient healthcare resource utilization for patients treated with and without uridine triacetate. Costs associated with hospitalization, including supportive care measures and monitoring were evaluated, considering medications and procedures commonly used to manage various severe toxicities experienced (e.g., gastrointestinal, hematological, etc.). The model compared the hypothetical current practice, in which approximately half of patients expected to die from early-onset severe toxicity receive uridine triacetate in addition to supportive care, with the proposed future practice in which all eligible patients receive uridine triacetate during their hospital stay. Hypothetical practical scenarios for US institutions were also considered.

RESULTS

For each adult patient hospitalized for early-onset severe or life-threatening toxicity who would be expected to die without treatment, adoption of uridine triacetate as a rescue treatment was associated with clinical benefits, including increased inpatient survival (48.5%) and a 7.3-day reduction in total hospital length of stay per patient. Treatment of each additional patient with uridine triacetate was associated with an incremental cost of US$25,247 per patient. Seventy percent of the drug cost was offset by reduction in inpatient healthcare resources utilization. This cost offset is likely underestimated as it does not include additional savings from potential reimbursements associated with changes in hospital length of stay, readmissions and discounting. Hypothetical scenarios demonstrated that model outputs were most sensitive to changes in length of stay and hospitalization costs.

CONCLUSION

Optimal treatment with uridine triacetate for all hospitalized patients in the USA expected to die from early-onset severe toxicity has the potential to improve inpatient survival at a minimal inpatient budget increase. The majority of the drug cost is offset by a reduction in the length of hospital stay and associated costs.

Cost-effectiveness of nirmatrelvir/ritonavir in COVID-19 patient groups at high risk for progression to severe COVID-19 in the Netherlands

BACKGROUND

Nirmatrelvir/ritonavir is indicated for the treatment of COVID-19 in symptomatic adults with increased risk for severe illness, not requiring supplemental oxygen yet. From a Dutch societal perspective, a cost-utility assessment of nirmatrelvir/ritonavir versus best supportive care (BSC) was conducted in three patient groups: (a) immunocompromised patients, (b) patients aged at least 60 years with one comorbidity, (c) patients aged at least 70 years. Groups were selected considering their relevance as high-risk groups, as described in Dutch and international guidelines and recommendations.

METHODS

A one-year decision-tree, estimating costs and outcomes associated with a COVID-19 infection was coupled to a lifetime two-state Markov component simulating subsequent life-time survival and quality of life. Effectiveness estimates, informing the intervention preventing hospital admission or death, were based on real-world evidence by Lewnard and colleagues (2023) in a vaccinated population during a timeframe with predominance of the Omicron variant. Epidemiology relies on publicly available data, primarily sourced during the Omicron variant's era. In the decision tree, clinically relevant event-related disutilities per disease course were applied to adjusted age-dependent Dutch-specific utility levels. In the Markov component, a disutility was considered for post-ICU patients. Costs rely on Dutch pharmacoeconomic guidelines and public data sources. The incremental cost-effectiveness ratio (ICER) was analysed as the main outcome, with a positive ICER indicating the cost associated with each additional quality-adjusted life year (QALY) gained by adopting the intervention.

RESULTS

Nirmatrelvir/ritonavir was associated with an ICER of € 395 in the immunocompromised group (per patient: + 0.125 QALYs gained; + 0.130 life-years [LYs] gained; € 49 incremental cost), with an ICER of € 8700 in 60-plus patients with comorbidity (+ 0.054 QALYs; + 0.055 LYs; € 474 incremental cost), and with an ICER of € 13,021 among 70-plus patients (+ 0.053 QALYs; + 0.045 LYs; € 689 incremental cost). Results were most sensitive to the baseline hospitalization rates among high-risk individuals. Probabilistic sensitivity analyses indicate a high probability of being cost-effective (100, 94, 85% respectively), considering a willingness-to-pay threshold of € 20,000 per QALY.

CONCLUSIONS

From a Dutch societal perspective, over a lifetime horizon, nirmatrelvir/ritonavir is cost-effective versus BSC in the three groups analysed.

The Cancer Tracking System (CATSystem): Study protocol of a randomized control trial to evaluate a systems level intervention for cervical cancer screening, treatment, referral and follow up in Kenya

BACKGROUND

Cervical cancer (CC) is preventable, yet remains a significant public health threat, particularly in Sub-Saharan Africa. Despite considerable awareness, screening rates for CC in Kenya are low and loss to follow-up following treatment for premalignant cervical lesions remains high. This study investigates the efficacy of the Cancer Tracking System (CATSystem), a web-based intervention, to improve CC screening and treatment retention.

METHODS

A matched, cluster randomized controlled trial will be conducted in Kenyan government hospitals (n = 10) with five intervention and five standard-of-care (SOC) sites. The primary outcome is the proportion of women with a positive screen who receive appropriate treatment (onsite or referral). Secondary outcomes include CC screening uptake among all women and timeliness of treatment initiation. We will utilize mixed methods to assess intervention feasibility, acceptability, and cost-effectiveness.

DISCUSSION

The CATSystem has the potential to improve CC care in Kenya by leveraging existing technology to address known barriers in the screening and treatment cascade. This study will provide valuable evidence for potential scale-up of the intervention.

Generative Artificial Intelligence for Health Technology Assessment: Opportunities, Challenges, and Policy Considerations: An ISPOR Working Group Report

OBJECTIVES

To provide an introduction to the uses of generative artificial intelligence (AI) and foundation models, including large language models, in the field of health technology assessment (HTA).

METHODS

We reviewed applications of generative AI in 3 areas: systematic literature reviews, real-world evidence, and health economic modeling.

RESULTS

(1) Literature reviews: generative AI has the potential to assist in automating aspects of systematic literature reviews by proposing search terms, screening abstracts, extracting data, and generating code for meta-analyses; (2) real-world evidence: generative AI can facilitate automating processes and analyze large collections of real-world data, including unstructured clinical notes and imaging; (3) health economic modeling: generative AI can aid in the development of health economic models, from conceptualization to validation. Limitations in the use of foundation models and large language models include challenges surrounding their scientific rigor and reliability, the potential for bias, implications for equity, as well as nontrivial concerns regarding adherence to regulatory and ethical standards, particularly in terms of data privacy and security. Additionally, we survey the current policy landscape and provide suggestions for HTA agencies on responsibly integrating generative AI into their workflows, emphasizing the importance of human oversight and the fast-evolving nature of these tools.

CONCLUSIONS

Although generative AI technology holds promise with respect to HTA applications, it is still undergoing rapid developments and improvements. Continued careful evaluation of their applications to HTA is required. Both developers and users of research incorporating these tools, should familiarize themselves with their current capabilities and limitations.

Critical assessment of uncertainty in economic evaluations on influenza vaccines for the elderly population in Spain

BACKGROUND

Influenza is a seasonal infection with a huge impact on morbidity and mortality in older adults, for whom vaccination is recommended. New influenza vaccines for this population have been introduced in Spain in the past 5 years, and a number of cost-effectiveness analyses (CEA) have been published to aid healthcare decision-making. The objective of this study was to assess possible sources of uncertainty in the CEAs of influenza vaccines for the older adults in Spain.

METHODS

A systematic review was performed to identify Spanish CEAs published since 2016. Potential sources of structural, methodologic and parametric uncertainty in CEA results were systematically analysed using the TRansparent Uncertainty ASsessmenT (TRUST) Tool, quality assessment checklists, and the WHO guidance on economic evaluations of influenza vaccine strategies. The primary sources of efficacy/effectiveness were analysed in depth to ascertain whether they could support the conclusions of the respective CEAs.

RESULTS

Seven CEAs were included. Overall, they were designed and performed in accordance with the applicable guidelines; however, some critical sources of uncertainty were detected, mainly: (1) the choice and use of efficacy/effectiveness data (real-world single season studies, meta-analyses including studies with high risk of bias and/or high heterogeneity with biased interpretation); (2) use of fewer than 5 seasons to estimate influenza burden; (3) generalized use of influenza-like illness data to estimate effectiveness and burden, among others.

CONCLUSIONS

Seemingly well-designed studies may conceal important sources of uncertainty that affect the results. This must be taken into account when interpreting results to support decision-making.

Good Practices for Health Technology Assessment Guideline Development: A Report of the Health Technology Assessment International, HTAsiaLink, and ISPOR Special Task Force

OBJECTIVES

Health technology assessment (HTA) guidelines are intended to support the successful implementation of HTA by enhancing consistency and transparency in concepts, methods, processes, and use, thereby enhancing the legitimacy of the decision-making process. This report lays out good practices and practical recommendations for developing or updating HTA guidelines to ensure successful implementation.

METHODS

The task force was established in 2022 and comprised experts and academics from various geographical regions, each with substantial experience in developing HTA guidelines for national health policy making. Literature reviews and key informant interviews were conducted to inform these good practices. Stakeholder consultations, open peer reviews, and expert opinions validated the recommendations. A series of teleconferences among task force members was held to iteratively refine the report.

RESULTS

The recommendations cover six key aspects throughout the guideline development cycle: (1) setting objectives, scope, and principles of the guideline, (2) building a team for a quality guideline, (3) defining a stakeholder engagement plan, (4) developing content and utilizing available resources, (5) putting in place appropriate institutional arrangements, and (6) monitoring and evaluating guideline success.

CONCLUSION

This report presents a set of resources and context-appropriate practices for developing or updating HTA guidelines. Across all contexts, the recommendations emphasize transparency, building trust among stakeholders, and fostering a culture of ongoing learning and improvement. The report recommends timing development and revision of guidelines according to the HTA landscape and pace of HTA institutionalization. Because HTA is increasingly used to inform different kinds of decision making in a variety of country contexts, it will be important to continue to monitor lessons learned to ensure the recommendations remain relevant and effective.

Cost-utility analysis of ropeginterferon alfa-2b to manage low-risk patients with polycythemia vera as compared to phlebotomy only in the Austrian healthcare system

Treatment of polycythemia vera (PV) aims to maintain hematocrit on target to reduce risk of thrombotic complications, while preventing disease progression to myelofibrosis (MF) and acute myeloid leukemia (AML). This analysis evaluated cost-effectiveness of adding ropeginterferon alfa-2b (ropegIFNα) to phlebotomy in patients with low-risk PV (those younger than 60 years without prior thrombosis), compared to phlebotomy alone. We combined a 12-month decision tree with a semi-Markov cohort model comparing ropegIFNα to the standard treatment from the Austrian healthcare system perspective over 30 years. Outcomes were quality adjusted life years (QALYs), costs, and incremental cost-utility ratio (ICUR). Model inputs were obtained from the phase 2 Low-PV study, additional published literature and from Austrian-specific cost databases. One-way and probabilistic sensitivity analyses (SA) assessed the robustness of findings. RopegIFNα led to 1,43 higher QALYs and 50.960 EUR overall higher costs compared to phlebotomy alone, with an ICUR of 35.525 EUR/QALY. Thrombosis, MF, and AML costs decreased for the ropegIFNα group by 12%, 30% and 16% respectively, due to the delayed complications onset and disease progression. In the one-way SA, ropegIFNα costs and discount rates had the greatest impact on results. The probabilistic SA showed a 100% probability of cost-effectiveness at willingness-to-pay threshold aligned to the Austrian GDP per capita. RopegIFNα is a cost-effective treatment option for patients with low-risk PV. These findings suggest that early treatment with ropegIFNα could ensure optimal resource allocation by preventing costly thrombotic events and progression to MF whilst increasing patient quality of life.

Comparative Analysis of Traditional and Pharmacometric-Based Pharmacoeconomic Modeling in the Cost-Utility Evaluation of Sunitinib Therapy

BACKGROUND

Cost-utility analyses (CUAs) increasingly use models to predict long-term outcomes and translate trial data to real-world settings. Model structure uncertainty affects these predictions. This study compares pharmacometric against traditional pharmacoeconomic model evaluations for CUAs of sunitinib in gastrointestinal stromal tumors (GIST).

METHODS

A two-arm trial comparing sunitinib 37.5 mg daily with no treatment was simulated using a pharmacometric-based pharmacoeconomic model framework. Overall, four existing models [time-to-event (TTE) and Markov models] were re-estimated to the survival data and linked to logistic regression models describing the toxicity data [neutropenia, thrombocytopenia, hypertension, fatigue, and hand-foot syndrome (HFS)] to create traditional pharmacoeconomic model frameworks. All five frameworks were used to simulate clinical outcomes and sunitinib treatment costs, including a therapeutic drug monitoring (TDM) scenario.

RESULTS

The pharmacometric model framework predicted that sunitinib treatment costs an additional 142,756 euros per quality adjusted life year (QALY) compared with no treatment, with deviations - 21.2% (discrete Markov), - 15.1% (continuous Markov), + 7.2% (TTE Weibull), and + 39.6% (TTE exponential) from the traditional model frameworks. The pharmacometric framework captured the change in toxicity over treatment cycles (e.g., increased HFS incidence until cycle 4 with a decrease thereafter), a pattern not observed in the pharmacoeconomic frameworks (e.g., stable HFS incidence over all treatment cycles). Furthermore, the pharmacoeconomic frameworks excessively forecasted the percentage of patients encountering subtherapeutic concentrations of sunitinib over the course of time (pharmacoeconomic: 24.6% at cycle 2 to 98.7% at cycle 16, versus pharmacometric: 13.7% at cycle 2 to 34.1% at cycle 16).

CONCLUSIONS

Model structure significantly influences CUA predictions. The pharmacometric-based model framework more closely represented real-world toxicity trends and drug exposure changes. The relevance of these findings depends on the specific question a CUA seeks to address.

Cost-effectiveness of the Floodlight® MS app in Austria. Unlocking the mystery of costs and outcomes of a digital health application for patients with multiple sclerosis

Objective

Multiple sclerosis (MS) is a chronic inflammatory demyelinating disease affecting 2.9 million people worldwide, often leading to permanent disability. MS patients frequently use eHealth tools due to their relatively young age. The Floodlight® MS app is a scientifically designed smartphone application that helps patients monitor hand motor skills, walking ability and cognition between medical appointments. This study assesses the cost-effectiveness of using the Floodlight® MS app alongside standard-of-care (SoC) versus SoC alone in patients with relapsing-remitting MS (RRMS) from the perspective of the healthcare system.

Methods

A 10-year decision-analytic model was developed to assess the cost-effectiveness of incorporating the Floodlight® MS app alongside SoC. The analysis included treatment-naive individuals and those already on drug therapy, modelling the app's role in early detection of disease progression and relapses to improve quality-of-life.

Results

For treatment-naive patients, using the Floodlight® MS app resulted in a 2,660 € increase in total costs but yielded potential medical-cost savings of 786 € through health improvements. These patients experienced fewer relapses and slower disability progression, translating to a quality-of-life improvement of 4.5 months in perfect health and an incremental-cost-effectiveness-ratio (ICER) of 7,071 €. Pre-treated patients showed similar trends, with medical-cost savings of 718 €, an ICER of 7,864 €, and a quality-of-life improvement of 4.2 months. Higher effectiveness (+5%) led to an additional 8.3 months in perfect health and a reduction in overall costs.

Conclusion

The analysis demonstrates that the Floodlight® MS app is a cost-effective digital health application, encouraging broader discussions on maximizing the potential of software-as-medical-devices within the care pathway.

Cost-Effectiveness Analysis of Current Treatment Options for Eosinophilic Esophagitis

INTRODUCTION

The management strategies for eosinophilic esophagitis include proton pump inhibitors (PPIs), swallowed topical corticosteroids (tCSs), elimination diets, and the biologic agent dupilumab, although there remains little guidance on the selection of initial treatment. We performed cost-effectiveness analyses to compare these approaches of first-line therapy.

METHODS

A Markov model was constructed from a payer perspective to evaluate the cost-effectiveness of first-line therapies for eosinophilic esophagitis, including PPI, tCS, and 6-food elimination diet (SFED), with crossover in treatments for primary and secondary nonresponse. The primary outcome was incremental cost-effectiveness ratio at 2 and 5-year time horizons. Secondary analyses included modeling from a societal perspective that also accounted for patient-specific costs, as well as a separate simplified model comparing dupilumab with tCS and PPI.

RESULTS

In the base-case scenario (5-year time horizon), the average costs were SFED: $15,296.81, PPI: $16,153.77, and tCS: $20,975.33 as initial therapy, with SFED being the dominant strategy (more effective/less costly), while PPI offered the lowest cost on a 2-year time horizon. From a societal perspective, PPI was the dominant initial strategy on both 2 and 5-year time horizons. Among pharmacologic therapies, PPI was the most cost-effective first-line option. Dupilumab was not cost-effective relative to tCS, unless the quarterly cost is reduced from $7,311 to $2,038.50 per price threshold analysis under permissive modeling conditions.

DISCUSSION

SFED was the most effective/least costly first-line therapy from the payer perspective while PPI was more cost-effective from the societal perspective. PPI is also the most cost-effective pharmacologic strategy. Dupilumab requires substantial cost reductions to be considered cost-effective first-line pharmacotherapy.

Intended Conservative Management Versus Caesarean Hysterectomy for Known or Suspected Placenta Accreta Spectrum: A Cost-Effectiveness Analysis

OBJECTIVE

We examined the cost-effectiveness of conservative management (CM) compared to planned caesarean hysterectomy (CH) for placenta accreta spectrum (PAS).

DESIGN

A cost-effectiveness analysis in a theoretical cohort of patients.

SETTING

A decision analytic model.

POPULATION

A theoretical cohort of 1000 pregnant patients with PAS greater than 20 weeks gestation.

METHODS

In base case analysis, we assumed that between 20% and 40% of individuals would be eligible for CM. Model inputs were derived from the literature. Analysis was conducted from a healthcare system perspective with a 1 year analytic horizon. Outcomes included hysterectomy, surgical site infection (SSI), length of hospitalisation, intensive care unit (ICU) admission and death. An incremental cost-effectiveness ratio (ICER) of $50 000 per quality-adjusted life year (QALY) defined cost-effectiveness. Sensitivity analyses were performed.

MAIN OUTCOME MEASURES

The cost gained per life year and per QALY.

RESULTS

For base case estimates, CM was the cost-saving strategy with an ICER of $9330.51 USD. Compared to CH, CM resulted in 905 fewer hysterectomies, 80 fewer instances of SSI and five fewer deaths. CM resulted in 149 more admissions with length of stay > 5 days and 25 more ICU admissions. In probabilistic sensitivity analysis, CM was the cost-effective strategy in 71% of runs and the dominant strategy in 42% of runs.

CONCLUSIONS

CM was the cost-effective strategy for the management of PAS in greater than 70% of iterations of our model. Modelling demonstrated significant uncertainty in the comparative effectiveness of the two strategies, highlighting the need for prospective research evaluating the effectiveness of CM.

Investigation of the health economic analysis of informal care for people living with a chronic neurological disease: A systematic review and meta-analysis of the global evidence for multiple sclerosis

Multiple sclerosis (MS) is a chronic neurological disease that causes substantial health economic impacts, however, the cost of informal care for MS is often excluded from health economic analysis. As a result there is a paucity of information for decision-making. This review aims to summarise, synthesise and where appropriate meta-analyse the global evidence regarding the health economics of informal care for people with MS. The findings will provide consolidated evidence that policymakers and other stakeholders can use to inform decisions, including the development of health economics models. This review was conducted with a pre-determined study protocol (PROSPERO- CRD42023396457). Biomedical and economic databases were searched. Costs were converted to 2022 United States dollars (USD). Mean cost was calculated and pooled with a random-effects model. Subgroup analysis and meta-regression was conducted for stratified variables such as country income level and Expanded Disability Status Scale (EDSS). Of 6,306 identified studies, 61 were retained for narrative synthesis and 50 for meta-analysis. Studies were conducted in 25 countries. Cost information was collected from the person with MS, not the caregiver. 83.6% of studies used the opportunity cost method. Average monthly caregiving time was 60.1 h. Informal care costs accounted for 15% of total societal cost of MS. Pooled mean annual cost of informal care per person was USD $6,308 (95% CI $5,022-7,594). Informal care costs were USD $6,797 and $1,478 in high- and middle-income countries. Costs for mild, moderate, and severe disability of the person with MS were $1,123, $6,643, and $15,855, respectively. Informal care cost contributes considerably to MS-related costs. Despite study heterogeneity, cost of informal care increases with MS-related disability severity, time attributed to care and country income level. These results can be used to inform health economic models for reimbursement decisions for MS. Future studies regarding the health economic burden of informal care should gather the data from the informal carers themselves.

Estimating the economic impact of blister-packaging on medication adherence and health care costs for a Medicare Advantage health plan

BACKGROUND

Medication nonadherence is a persistent challenge in the United States, leading to increased health care resource utilization (HCRU) and health care costs and worsened health outcomes. Medicare Star Ratings is a program developed by the Centers for Medicare and Medicaid Services (CMS) to evaluate Medicare health plan quality and performance. Three of the Medicare Part D Star Ratings quality measures assess medication adherence, showing the importance CMS places on improving medication adherence in older adults. Although a variety of medication adherence-enhancing interventions are available to help promote adherence among patients, one intervention that has shown success historically is blister-packaging.

OBJECTIVE

To model the potential impact of blister-packaging chronic medications on HCRU and health care costs in the Medicare population.

METHODS

An economic model was developed to assess the potential impact of blister-packaging the 3 Medicare Star Ratings adherence measure medication classes: renin-angiotensin system antagonists (RASAs), statins, and noninsulin antidiabetics. The model perspective was that of a hypothetical Medicare Advantage health plan with a plan size of 100,000 members. A 12-month time horizon was used in the model. The dichotomous adherence threshold in the model was set at 80% or greater of the proportion of days covered (PDC). Literature-based references were used to inform both the impact of blister-packaging on the number of patients who become adherent as well as the impact of medication adherence on HCRU and health care costs for each of the medication classes. One-way sensitivity analyses and several scenario analyses were conducted to assess model uncertainty.

RESULTS

Owing to increased adherence from the blister-packaging intervention, the hypothetical health plan in the analysis saw 776 additional members adherent to RASAs, 1,651 additional members adherent to statins, and 414 additional members adherent to oral antidiabetics. Although medication expenditure increased for all 3 medication classes (RASAs: $274,963; statins: $730,083; oral antidiabetics: $100,529), medical costs decreased across all classes (RASAs: -$4,098,848; statins: -$5,549,699; oral antidiabetics: -$917,968). Total net health care costs decreased by $3,823,885 for RASAs (-$3.19 per member per month [PMPM]), $4,819,616 for statins (-$4.02 PMPM), and $817,438 for oral antidiabetics (-$0.68 PMPM). The entire Medicare Advantage population scenario analysis saw reductions in total health care costs of $1,081,394,737 for RASAs, $1,362,987,376 for statins, and $231,171,496 for oral antidiabetics.

CONCLUSIONS

Dispensing chronic medications with blister-packaging for Medicare Advantage health plan patients was modeled to reduce HCRU and health care costs. Future studies are needed to assess whether the impact of blister-packaging medications is tied to reductions in HCRU and health care costs in real-world settings.

Cost-effectiveness analysis of mHealth applications for depression in Germany using a Markov cohort simulation

Regulated mobile health applications are called digital health applications ("DiGA") in Germany. To qualify for reimbursement by statutory health insurance companies, DiGA have to prove positive care effects in scientific studies. Since the empirical exploration of DiGA cost-effectiveness remains largely uncharted, this study pioneers the methodology of cohort-based state-transition Markov models to evaluate DiGA for depression. As health states, we define mild, moderate, severe depression, remission and death. Comparing a future scenario where 50% of patients receive supplementary DiGA access with the current standard of care reveals a gain of 0.02 quality-adjusted life years (QALYs) per patient, which comes at additional direct costs of ~1536 EUR per patient over a five-year timeframe. Influencing factors determining DiGA cost-effectiveness are the DiGA cost structure and individual DiGA effectiveness. Under Germany's existing cost structure, DiGA for depression are yet to demonstrate the ability to generate overall savings in healthcare expenditures.

Estimation of the Eligible Population For Resmetirom Among Adults in the United States for Treatment of Non-Cirrhotic NASH with Moderate-to-Advanced Liver Fibrosis

INTRODUCTION

As of March 2024, resmetirom is the first and only therapy approved in the United States (US) for the treatment of adults with non-cirrhotic nonalcoholic steatohepatitis (NASH) with moderate-to-advanced liver fibrosis (MALF) consistent with stages F2/F3 fibrosis. Estimates of the diagnosed, treatment-eligible NASH population are poorly understood due to diagnostic variability. This study provides a contemporary estimate of the size of the US resmetirom treatment-eligible population.

METHODS

A dynamic population calculator was developed combining literature, screening guidelines, resmetirom study criteria, and analyses of the NHANES 2017-March 2020 cycle. It computes NASH prevalence, proportion non-cirrhotic NASH with MALF, Year 1 diagnosis, and new diagnoses in Years 2 and 3. NASH prevalence was estimated by applying the American Association of Clinical Endocrinology screening algorithm and recommended NIT cut-offs in the NHANES dataset. The proportion of non-cirrhotic NASH with MALF was informed by analyses of the Forian US integrated medical claims database using NASH and cirrhosis-specific ICD-10-CM codes and FIB-4 scores. NASH diagnosis rates were obtained from published estimates and NHANES responses. Treatment-eligible population growth was projected using published incidence data. Estimates were compared to a NASH budget-impact-analysis (BIA) from the Institute for Clinical and Economic Review (ICER).

RESULTS

In the base case, a NASH prevalence of 4.6% was modeled (range 1.3-14.2%). This value was multiplied by the proportion estimated to have non-cirrhotic MALF (i.e., 35%). Published analyses suggest a diagnosis rate of ~ 10% (range 3.3-14.3%) and ~ 16% year-over-year growth in the treatment-eligible population. Assuming a 1-million commercial-member population, the resmetirom treatment-eligible population was estimated as 1255-1699 in Years 1-3 following approval. Sensitivity analyses were conducted and comparison to the ICER BIA was influenced by different diagnosis rates.

CONCLUSION

Estimation of the treatment-eligible population for resmetirom depends importantly on NASH diagnosis rates, which are predicted to be < 15% in the 3 years after drug approval. Nonalcoholic steatohepatitis (NASH) is an advanced form of nonalcoholic fatty liver disease. Previously there were no treatments for NASH in the United States (US), but as of March 2024, the US Food and Drug Administration (FDA) approved resmetirom (REZDIFFRA™), a once-daily, oral therapy, in conjunction with diet and exercise, under accelerated approval for the treatment of adults (aged 18 years or older) with non-cirrhotic NASH with moderate-to-advanced liver fibrosis (MALF), consistent with stages F2-F3. It is not well understood how many diagnosed patients with NASH would be eligible for treatment with resmetirom; thus, this study aimed to estimate the size of the US resmetirom treatment-eligible population. To do so, we created a flexible population calculator that considers how many people have NASH, what proportion would be eligible for resmetirom treatment-i.e., have non-cirrhotic NASH with MALF-and of those how many people would be diagnosed. We used published literature, screening guidelines, resmetirom study criteria, and analyses of national surveys to inform our range of estimates. In the main analysis, we modeled a NASH prevalence of 4.6% (range 1.3-14.2%), which was then limited to the proportion estimated to have non-cirrhotic NASH with MALF (i.e., 35%) and diagnosed (i.e., 10%, range 3.3-14.3%). A year-over-year growth of approximately 16% in the treatment-eligible population was modeled in years following approval. Assuming a population of 1 million commercial insurance enrollees, the resmetirom treatment-eligible population was estimated to be 1255-1699 in Years 1-3 following approval. We assessed alternative scenarios and have compared our results to existing models.

Data-driven Huntington's disease progression modelling and estimation of societal cost in the UK

We develop a Huntington's disease (HD) progression model and integrate this with a novel economic model, accounting for the major factors of the HD's societal cost. Data from the Enroll-HD observational study were used to fit a continuous-time hidden Markov disease progression model, which identified five distinct states. The number of disease states was determined using a cross-validated maximum likelihood approach. A novel data augmentation method was used to correct the biased life expectancy of the progression model. Multiple sources of cost data were then mapped to Enroll-HD variables using expert experience. A simulation of a synthetic patient population was used to show the feasibility of the approach in estimating population costs and the impact of hypothetical intervention scenarios. Our results confirm that early cognitive decline, which is not captured by the total functional capacity score currently used by clinicians but flagged up in HD integrated staging system, can be quantified from participants' visits. Finally, the results of the UK cost modelling show that indirect costs of HD such as state benefits and lost gross domestic product contribution could be the driving factors for the societal cost, over and above health and social care costs.

National Recommendations for Pharmacoeconomic Evaluations Reporting for Reimbursement and Procurement of New Pharmaceutical Applications in Egypt

Introduction

To improve resource allocation within our healthcare system, the Egyptian Authority for Unified Procurement, Medical Supply and the Management of Medical Technology (UPA) and Universal Health Insurance Authority (UHIA) established a joint economic evaluation process to support UHIA reimbursement decisions and UPA procurement decisions. The main objective of this study is to describe the developed national pharmacoeconomic guidelines in Egypt, especially for reimbursement and procurement for new pharmaceuticals.

Methods

A focus group was formed as a national initiative activity by governmental authorities in Egypt. The aim of this focus group was to develop national pharmacoeconomic guidelines for the evaluation of innovative and high-budget pharmaceutical products. This group consisted of various stakeholders with experience in health economics, outcomes research, public health, and pharmacy practice. To develop our national pharmacoeconomic guidelines, three steps were taken. First, the focus group reviewed the European Network for Health Technology Assessment (EUnetHTA) methods for health economic evaluations for new pharmaceuticals as well as the Canadian Agency for Drugs and Technologies in Health (CADTH) guidelines and the Academy of Managed Care Pharmacy (AMCP) Format for Formulary Submissions. Second, the focus group used the EUnetHTA guideline as a reference and adapted it to our local context. The focus group added the value assessment component, using the CADTH and AMCP guidelines. Third, the focus group collected input and feedback from key stakeholders through a focus group by using the quasi-Delphi panel approach.

Results

The results of the focus group are a main structure of national pharmacoeconomic guidelines for the evaluation of innovative and high-budget pharmaceutical products, consisting of seven main topics.

Conclusion

Economic evaluation is a core element of Health Technology Assessment, (HTA); therefore, the UHIA and UPA were encouraged to produce unified joint pharmacoeconomic guidelines for innovative products as an initial step in their commitment to implement the use of HTA in decision-making. This standardization of guidelines not only ensures transparency but also guarantees an accurate and transparent process to support evidence-based decision-making. These guidelines are expected to help decision-makers improve their process and attain better health outcomes for Egyptian patients.

Cost savings associated with extended battery longevity in cardiac resynchronization therapy defibrillators

Background

Cardiac resynchronization therapy-defibrillators (CRT-D) are devices established as treatment for symptomatic heart failure patients at risk of sudden cardiac death. Battery depletion poses a significant clinical and economic burden; extended service life may reduce costs because of generator changes and associated complications.

Objective

This study estimated cost-savings associated with extended battery longevity in Medicare patients receiving CRT-D implantation.

Methods

A decision tree was used to explore 3 battery capacities: 1.0 ampere-hours (Ah), 1.6Ah, and 2.1Ah. Yearly risk of all-cause mortality, device-related complications, and end of battery life were estimated. Over 6 years, estimated costs included device implantation, replacement, follow-up appointments, and complications.

Results

The average total costs to Medicare over 6 years were $41,527, $48,515, and $56,647 per person (USD 2023) for the 2.1 Ah, 1.6 Ah, and 1.0 Ah, respectively. The total per-person replacement cost for the 1.0-Ah devices was more than 4 times that of the 2.1-Ah devices ($20,126 vs $5,006). When extrapolated to the total number of CRT-D implants over a 6-year period, the difference in costs between 2.1-Ah and 1.0-Ah battery capacity exceeded $500 million.

Conclusion

Extended longevity CRT-D batteries demonstrate significant cost savings to Medicare over 6 years. These data indicate long-term economic considerations should be included in device selection.

Enhancing Outcomes in Opioid Use Disorder Treatment: An Economic Evaluation of Improving Medication Adherence for Buprenorphine Through Blister-Packaging

Background

The opioid epidemic has severely impacted the US over the last 15 years. Buprenorphine is a partial opioid agonist indicated for the treatment of opioid use disorder (OUD) and is recognized as an effective treatment when taken as prescribed. However, adherence rates have been low in real-world settings. Blister-packaging has been shown to promote medication adherence across a variety of disease states, although it has never been studied in OUD.

Methods

An economic analysis was conducted to assess the impact of increased adherence of blister-packaged buprenorphine on health care resource utilization (HCRU) and health care costs for 10,000 patients initiating therapy for OUD. The model analyzed a commercially insured population within the US over a one-year time horizon. Medication adherence was defined in the model as proportion of days covered (PDC) of at least 80%. Literature-based references were used to inform both the impact of blister-packaging on the number of patients who became adherent as well as the impact of medication adherence on HCRU and health care costs. Model input uncertainty was assessed in one-way sensitivity analyses.

Results

With the implementation of blister-packaging buprenorphine, adherence rates increased from 37.1% of patients in the pre-intervention period to 45.3%, resulting in an additional 818 patients becoming adherent post-intervention. The increase in adherence led to a reduction of medical costs of $12,138,757 (-$1,214 per-patient (PP)). Specifically, inpatient costs decreased by $7,127,073 (-$713 PP) while outpatient costs decreased by $5,013,319 (-$501 PP). Pharmacy costs increased by $3,432,705 ($343 PP). Despite the increase in pharmacy costs, total health care costs saw a reduction of $8,559,684 (-$856 PP).

Conclusion

Blister-packaging buprenorphine for treatment of OUD has potential to improve medication adherence and health outcomes while reducing HCRU and health care costs. Future studies are necessary to assess the real-world application and impact of blister-packaging buprenorphine for OUD across various patient populations and health care settings.

Improving Adherence and Reducing Health Care Costs Through Blister-Packaging: An Economic Model for a Commercially Insured Health Plan

Purpose

To model the potential clinical and economic impact of blister-packaging medications for chronic conditions on medication adherence and healthcare costs in a commercially insured population.

Methods

A health economic model was developed to evaluate the potential impact of blister-packaging chronic medications for a commercially insured population. The chronic medication classes assessed were renin-angiotensin-system (RAS) antagonists, statins, non-insulin oral antidiabetics, and direct oral anticoagulants (DOACs). The model was designed to reflect the perspective of a hypothetical commercially insured health plan with 100,000 members, over a one-year time horizon. Literature-based or best available epidemiologic references were used to inform the number of patients utilizing each medication class, the impact of blister-packaging on the number of patients who become adherent, as well as the impact of medication adherence in a commercially insured population on healthcare costs for each medication class assessed. Impact on costs was measured in total net healthcare costs, as well as being stratified by medical costs and medication costs.

Results

Following the blister-packaging intervention, there were an additional 591 patients adherent to RAS antagonists, 1196 patients adherent to statins, 169 patients adherent to oral antidiabetics, and 25 patients adherent to DOACs. While pharmacy costs increased, these costs were more than offset by the reduction in medical costs. Overall, the increase in patients adherent to therapy due to blister-packaging led to a reduction in total healthcare costs of $879,312 for RAS antagonists (-$0.73 per-member per-month (PMPM)), $343,322 for statins (-$0.29 PMPM), $78,917 for oral antidiabetics (-$0.07 PMPM), and $120,793 for DOACs (-$0.10 PMPM).

Conclusion

Blister-packaging chronic medications in a commercially insured population has the potential to reduce healthcare costs. Future research is needed to confirm these findings in real-world settings and to fully understand the clinical and economic implications of blister-packaging chronic medications.

Models for malaria control optimization-a systematic review

BACKGROUND

Despite advances made in curbing the global malaria burden since the 2000s, progress has stalled, in part due to a plateauing of the financing available to implement needed interventions. In 2020, approximately 3.3 billion USD was invested globally for malaria interventions, falling short of the targeted 6.8 billion USD set by the GTS, increasing the financial gap between desirable and actual investment. Models for malaria control optimization are used to disentangle the most efficient interventions or packages of interventions for inherently constrained budgets. This systematic review aimed to identify and characterise models for malaria control optimization for resource allocation in limited resource settings and assess their strengths and limitations.

METHODS

Following the Prospective Register of Systematic Reviews and Preferred reporting Items for Systematic Reviews and Meta-Analysis guidelines, a comprehensive search across PubMed and Embase databases was performed of peer-reviewed literature published from inception until June 2024. The following keywords were used: optimization model; malaria; control interventions; elimination interventions. Editorials, commentaries, opinion papers, conference abstracts, media reports, letters, bulletins, pre-prints, grey literature, non-English language studies, systematic reviews and meta-analyses were excluded from the search.

RESULTS

The search yielded 2950 records, of which 15 met the inclusion criteria. The studies were carried out mainly in countries in Africa (53.3%), such as Ghana, Nigeria, Tanzania, Uganda, and countries in Asia (26.7%), such as Thailand and Myanmar. The most used interventions for analyses were insecticide-treated bed nets (93.3%), IRS (80.0%), Seasonal Malaria Chemoprevention (33.3%) and Case management (33.3%). The methods used for estimating health benefits were compartmental models (40.0%), individual-based models (40.0%), static models (13.0%) and linear regression model (7%). Data used in the analysis were validated country-specific data (60.0%) or non-country-specific data (40.0%) and were analysed at national only (40.0%), national and subnational levels (46.7%), or subnational only levels (13.3%).

CONCLUSION

This review identified available optimization models for malaria resource allocation. The findings highlighted the need for country-specific analysis for malaria control optimization, the use of country-specific epidemiological and cost data in performing modelling analyses, performing cost sensitivity analyses and defining the perspective for the analysis, with an emphasis on subnational tailoring for data collection and analysis for more accurate and good quality results. It is critical that the future modelling efforts account for fairness and target at risk malaria populations that are hard-to-reach to maximize impact.

TRIAL REGISTRATION

PROSPERO Registration number: CRD42023436966.

Incorporating Social Determinants of Health in Infectious Disease Models: A Systematic Review of Guidelines

BACKGROUND

Infectious disease (ID) models have been the backbone of policy decisions during the COVID-19 pandemic. However, models often overlook variation in disease risk, health burden, and policy impact across social groups. Nonetheless, social determinants are becoming increasingly recognized as fundamental to the success of control strategies overall and to the mitigation of disparities.

METHODS

To underscore the importance of considering social heterogeneity in epidemiological modeling, we systematically reviewed ID modeling guidelines to identify reasons and recommendations for incorporating social determinants of health into models in relation to the conceptualization, implementation, and interpretations of models.

RESULTS

After identifying 1,372 citations, we found 19 guidelines, of which 14 directly referenced at least 1 social determinant. Age (n = 11), sex and gender (n = 5), and socioeconomic status (n = 5) were the most commonly discussed social determinants. Specific recommendations were identified to consider social determinants to 1) improve the predictive accuracy of models, 2) understand heterogeneity of disease burden and policy impact, 3) contextualize decision making, 4) address inequalities, and 5) assess implementation challenges.

CONCLUSION

This study can support modelers and policy makers in taking into account social heterogeneity, to consider the distributional impact of infectious disease outbreaks across social groups as well as to tailor approaches to improve equitable access to prevention, diagnostics, and therapeutics.

HIGHLIGHTS

Infectious disease (ID) models often overlook the role of social determinants of health (SDH) in understanding variation in disease risk, health burden, and policy impact across social groups.In this study, we systematically review ID guidelines and identify key areas to consider SDH in relation to the conceptualization, implementation, and interpretations of models.We identify specific recommendations to consider SDH to improve model accuracy, understand heterogeneity, estimate policy impact, address inequalities, and assess implementation challenges.

'Managing values' in health economics modelling: Philosophical and practical considerations

Stakeholder involvement has been proposed as a key strategy for appropriately managing value-laden decisions or 'value judgments' in health economics modelling. Philosophers of science, however, conceive of stakeholder involvement in research in conflicting ways, and also propose alternative strategies for 'managing values' in science. Furthermore, all proposed strategies for managing values in science raise philosophical questions and practical challenges that are difficult to resolve. As a result, health economists who seek to appropriately inform value judgments in modelling must currently go without straightforward guidance. There is a need to further explore how health economists should manage value judgments in modelling, taking into account philosophical debates and contextual constraints. This paper discusses core proposals for managing values in science and identifies philosophical questions and practical challenges these proposals leave unresolved. It further considers how this could potentially inform processes to manage value judgments in health economics modelling, using examples from an ongoing modelling project called LEAP (Lifetime Exposures and Asthma Outcomes Projection). We conclude that all strategies to 'manage values' in health economics modelling have strengths and weaknesses, but are generally compatible with one another, suggesting that health economists may use a combination of strategies. Further research is needed to explore the effects of strategies to 'manage values' in health economics modelling.

The conceptualisation of cardiometabolic disease policy model in the UK

BACKGROUND

Decision models are increasingly used to inform policy-making processes, and there is a need to improve their credibility. The estimation of health and economic outcomes generated from decision models is influenced by the development process itself. This paper aims to present the conceptual model development process of cardiometabolic disease (CMD) policy models in the UK setting.

METHODS

This conceptual model followed the International Society of Pharmacoeconomics and Outcomes Research-Society of Medical Decision Making (ISPOR-SMDM) Modelling Good Research Practices Task Force-2.

RESULTS

First, for the conceptualisation of the problem, the CMD disease staging, progression and current clinical guidelines were summarised, followed by a systematic review of published policy models. We critically appraised policy models such as cardiovascular disease and type 2 diabetes. Key messages from the review emphasised the importance of understanding various determinants influencing model development, including risk factors, model structure, models' parameters, data utilisation, economic perspective, equality/equity consideration, transparency and validation process. Second, as a sequential process, is model conceptualisation, to determine which modelling types and their attributes best represent the defined problem. Expert opinions, including a clinician and experienced modellers, provided input on the state transition model to ensure the structure is clinically relevant. From this stage, the consideration and agreement to establish a disease state in a state transition model was discussed.

CONCLUSION

This conceptual model serves as a basis for representing the systematic process for structuring a CMD policy model to enhance its transparency and credibility.

How are maternal and fetal outcomes incorporated when measuring benefits of interventions in pregnancy? Findings from a systematic review of cost-utility analyses

OBJECTIVE

Medical interventions used in pregnancy can affect the length and quality of life of both the pregnant person and fetus. The aim of this systematic review was to identify and describe the theoretical frameworks that underpin outcome measurement in cost-utility analyses of pregnancy interventions.

METHODS

Searches were conducted in the Paediatric Economic Database Evaluation (PEDE) database (up to 2017), as well as Medline, Embase and EconLit (2017-2019). We included all cost-utility analyses of any intervention given during pregnancy, published in English. We conducted a narrative synthesis of: study design; outcome construction (life expectancy, quality adjustment, discount rate); and whether the Incremental Cost-Effectiveness Ratio (ICER) was constructed using maternal or fetal outcomes. Where both outcomes were included, methods for combining them were extracted.

RESULTS

We identified 127 cost-utility analyses in pregnancy, of which 89 reported QALYs and 38 DALYs. Outcomes were considered solely for the fetus in 59 studies (47%), solely for the pregnant person in 13 studies (10%), and for both in 49 studies (39%). The choice to include or exclude one or both sets of outcomes was not consistent within particular clinical areas. Where outcomes for both mother and baby were included, methods for combining these outcomes varied. Twenty-nine studies summed QALYs/DALYs for maternal and fetal outcomes, with no adjustment. The remaining 20 took a variety of approaches designed to weigh maternal and fetal outcomes differently. These include (1) treating fetal outcomes as a component of maternal quality of life, rather than (or in addition to) an independent individual health outcome; (2) treating the maternal-fetal dyad as a single entity and applying a single utility value to each combination of outcomes; and (3) assigning a shorter time horizon to fetal outcomes to reduce the weight of lifetime fetal outcomes. Each approach made different assumptions about the relative value of maternal and fetal health outcomes, demonstrating a lack of consistency and the need for guidance.

CONCLUSION

Methods for capturing QALY/DALY outcomes in cost-utility analysis in pregnancy vary widely. This lack of consistency indicates a need for new methods to support the valuation of maternal and fetal health outcomes.

Cost-effectiveness analysis of biologic sequential treatments for moderate-to-severe psoriasis: A Malaysian healthcare system perspective

OBJECTIVE

In Malaysia, there is now a dearth of recommendations pertaining to the priority of biologic treatments for the effective management of psoriasis, given the multitude of available therapeutic alternatives. Present analysis reports results of a cost-effectiveness model that determines the most optimal arrangement of biologic treatments, with a particular focus of adding biosimilars to the existing treatment pathway for psoriasis in Malaysia.

METHODS

A Markov model was developed to compare the cost effectiveness of various biologic sequential treatments in a hypothetical cohort of moderate to severe psoriasis patient in Malaysia over a lifetime horizon. The model simulated the progression of patients through three lines of active biologic therapy, before transitioning to best supportive care. Costs and effects were discounted annually at a rate of 3%.

RESULTS

First line secukinumab has produced lowest incremental cost effectiveness ratios (ICERs) when compared to first line systemic [ICERs value; US$152,474 (first set analysis) and US$110,572 (second set analysis)] and first line phototherapy [ICERs value; US$147,057 (first set analysis) and US$107,616 (second set analysis)]. However, these values were slightly higher than the Malaysian based threshold of three times gross domestic product per capita, US$104,337. A 40% reduction in the unit costs of reference biologics renders most of the evaluated treatment sequences cost-effective.

CONCLUSION

Adding biosimilar to the current treatment sequence could achieve cost savings ranging from 4.3% to 10.8% without significant loss of effectiveness. Given the significant impact of comorbidities and the resulting decline in quality of life among individuals with psoriasis, it may be justifiable to establish a threshold of up to US$184,000 per quality-adjusted life year (QALY) for the provision of therapies in the context of Malaysia.

Early economic evaluation of magnetic resonance imaging for prostate cancer detection in primary care

Objectives

To explore the potential impacts of incorporating prebiopsy magnetic resonance imaging into primary care as a triage test within the prostate cancer diagnostic pathway.

Subjects and methods

Decision analytic modelling with decision trees was utilised for this early economic evaluation. A conceptual model was developed reflecting the common primary care routes to diagnosis for prostate cancer: opportunistic, asymptomatic prostate-specific antigen (PSA) screening or symptomatic presentation. The use of multiparametric MRI (mpMRI) or biparametric MRI (bpMRI) as a primary care triage test following an elevated PSA result was evaluated. A health system perspective was adopted with a time horizon of 12 months. Health effects were expressed in terms of utilities drawn from the literature. The primary outcome was prostate cancer diagnosis. Evidence used to inform the model was drawn from published primary studies, systematic reviews, and secondary analyses of primary and secondary care datasets.

Results

Base case analysis showed that the PSA pathway was dominated by both mpMRI- and bpMRI-based pathways for patients undergoing opportunistic screening and symptomatic assessment. bpMRI pathways had greater improvement in cost and utility than mpMRI pathways in both clinical scenarios. Significantly more MRI scans would be performed using the modelled approach (66 626 scans vs. 37 456 scans per 100 000 patients per annum), with fewer subsequent urgent suspected cancer referrals for both mpMRI (38% reduction for screening and symptomatic patients) and bpMRI (72% reduction for screening; 71% for symptomatic) pathways, and a small increase in number of missed cancer diagnoses. Deterministic sensitivity analyses, varying each parameter to its upper and lower 95% confidence intervals, showed no significant change in the dominance of the MRI-based prostate cancer diagnostic pathways.

Conclusion

Using prostate MRI as a second-level triage test for suspected prostate cancer in primary care could reduce health service costs without a detrimental effect on patient utility.

A Targeted Review of Worldwide Indirect Treatment Comparison Guidelines and Best Practices

OBJECTIVES

Controls and governance over the methodology and reporting of indirect treatment comparisons (ITCs) have been introduced to minimize bias and ensure scientific credibility and transparency in healthcare decision making. The objective of this study was to highlight ITC techniques that are key to conducting objective and analytically sound analyses and to ascertain circumstantial suitability of ITCs as a source of comparative evidence for healthcare interventions.

METHODS

Ovid MEDLINE was searched from January 2010 through August 2023 to identify publicly available ITC-related documents (ie, guidelines and best practices) in the English language. This was supplemented with hand searches of websites of various international organizations, regulatory agencies, and reimbursement agencies of Europe, North America, and Asia-Pacific. The jurisdiction-specific ITC methodology and reporting recommendations were reviewed.

RESULTS

Sixty-eight guidelines from 10 authorities worldwide were included for synthesis. Many of the included guidelines were updated within the last 5 years and commonly cited the absence of direct comparative studies as primary justification for using ITCs. Most jurisdictions favored population-adjusted or anchored ITC techniques opposed to naive comparisons. Recommendations on the reporting and presentation of these ITCs varied across authorities; however, there was some overlap among the key elements.

CONCLUSIONS

Given the challenges of conducting head-to-head randomized controlled trials, comparative data from ITCs offer valuable insights into clinical-effectiveness. As such, multiple ITC guidelines have emerged worldwide. According to the most recent versions of the guidelines, the suitability and subsequent acceptability of the ITC technique used depends on the data sources, available evidence, and magnitude of benefit/uncertainty.

Cost-Effectiveness of Axicabtagene Ciloleucel for Adult Patients With Relapsed or Refractory Follicular Lymphoma in the United States

OBJECTIVES

The results of a recent single-arm trial (ZUMA-5) of axicabtagene ciloleucel (axi-cel) for relapsed/refractory (r/r) follicular lymphoma (FL) demonstrated high rates of durable response and tolerable toxicity among treated patients. To quantify the value of axi-cel compared with standard of care (SOC) to manage r/r FL patients who have had at least 2 prior lines of systemic therapy (3L+), a cost-effectiveness model was developed from a US third-party payer perspective.

METHODS

A 3-state partitioned-survival cost-effectiveness model was developed with a lifetime horizon. Patient-level analyses of the 36-month ZUMA-5 (axi-cel) and SCHOLAR-5 (SOC) studies were used to extrapolate progression-free and overall survivals. After 5 years of survival, an estimated 40% of the modeled population was assumed to experience long-term remission based on literature. Results include the incremental cost-effectiveness ratio (ICER) measured as incremental cost per quality-adjusted life year (QALY) gained. One-way sensitivity analysis, probabilistic sensitivity analysis, and scenario analyses were performed. All outcomes were discounted 3% per year.

RESULTS

Axi-cel led to an increase of 4.28 life-years, 3.64 QALYs, and a total cost increase of $321 192 relative to SOC, resulting in an ICER of $88 300 per QALY. Across all parameters varied in the one-way sensitivity analysis, the ICER varied between $133 030 and $67 277. In the probabilistic sensitivity analysis, axi-cel had a 99% probability of being cost-effective across 5000 iterations using a $150 000 willingness-to-pay threshold.

CONCLUSIONS

Given the robustness of the model results and sensitivity analyses, axi-cel is expected to be a cost-effective treatment in 3L+ r/r FL.

Economic Evaluations of Chimeric Antigen Receptor T-Cell Therapies for Hematologic and Solid Malignancies: A Systematic Review

OBJECTIVES

This study aimed to systematically review evidence on the cost-effectiveness of chimeric antigen receptor T-cell (CAR-T) therapies for patients with cancer.

METHODS

Electronic databases were searched in October 2022 and updated in September 2023. Systematic reviews, health technology assessments, and economic evaluations that compared costs and effects of CAR-T therapy in patients with cancer were included. Two reviewers independently screened studies, extracted data, synthesized results, and critically appraised studies using the Philips checklist. Cost data were presented in 2022 US dollars.

RESULTS

Our search yielded 1809 records, 47 of which were included. Most of included studies were cost-utility analysis, published between 2018 and 2023, and conducted in the United States. Tisagenlecleucel, axicabtagene ciloleucel, idecabtagene vicleucel, ciltacabtagene autoleucel, lisocabtagene maraleucel, brexucabtagene autoleucel, and relmacabtagene autoleucel were compared with various standard of care chemotherapies. The incremental cost-effectiveness ratio (ICER) for CAR-T therapies ranged from $9424 to $4 124 105 per quality-adjusted life-year (QALY) in adults and from $20 784 to $243 177 per QALY in pediatric patients. Incremental cost-effectiveness ratios were found to improve over longer time horizons or when an earlier cure point was assumed. Most studies failed to meet the Philips checklist due to a lack of head-to-head comparisons and uncertainty surrounding CAR-T costs and curative effects.

CONCLUSIONS

CAR-T therapies were more expensive and generated more QALYs than comparators, but their cost-effectiveness was uncertain and dependent on patient population, cancer type, and model assumptions. This highlights the need for more nuanced economic evaluations and continued research to better understand the value of CAR-T therapies in diverse patient populations.

Cost-effectiveness of applying high-sensitivity troponin I to a score for cardiovascular risk prediction in asymptomatic population

INTRODUCTION

Risk stratification scores such as the European Systematic COronary Risk Evaluation (SCORE) are used to guide individuals on cardiovascular disease (CVD) prevention. Adding high-sensitivity troponin I (hsTnI) to such risk scores has the potential to improve accuracy of CVD prediction. We investigated how applying hsTnI in addition to SCORE may impact management, outcome, and cost-effectiveness.

METHODS

Characteristics of 72,190 apparently healthy individuals from the Biomarker for Cardiovascular Risk Assessment in Europe (BiomarCaRE) project were included into a discrete-event simulation comparing two strategies for assessing CVD risk. The standard strategy reflecting current practice employed SCORE (SCORE); the alternative strategy involved adding hsTnI information for further stratifying SCORE risk categories (S-SCORE). Individuals were followed over ten years from baseline examination to CVD event, death or end of follow-up. The model tracked the occurrence of events and calculated direct costs of screening, prevention, and treatment from a European health system perspective. Cost-effectiveness was expressed as incremental cost-effectiveness ratio (ICER) in € per quality-adjusted life year (QALYs) gained during 10 years of follow-up. Outputs were validated against observed rates, and results were tested in deterministic and probabilistic sensitivity analyses.

RESULTS

S-SCORE yielded a change in management for 10.0% of individuals, and a reduction in CVD events (4.85% vs. 5.38%, p<0.001) and mortality (6.80% vs. 7.04%, p<0.001). S-SCORE led to 23 (95%CI: 20-26) additional event-free years and 7 (95%CI: 5-9) additional QALYs per 1,000 subjects screened, and resulted in a relative risk reduction for CVD of 9.9% (95%CI: 7.3-13.5%) with a number needed to screen to prevent one event of 183 (95%CI: 172 to 203). S-SCORE increased costs per subject by 187€ (95%CI: 177 € to 196 €), leading to an ICER of 27,440€/QALY gained. Sensitivity analysis was performed with eligibility for treatment being the most sensitive.

CONCLUSION

Adding a person's hsTnI value to SCORE can impact clinical decision making and eventually improves QALYs and is cost-effective compared to CVD prevention strategies using SCORE alone. Stratifying SCORE risk classes for hsTnI would likely offer cost-effective alternatives, particularly when targeting higher risk groups.

An Economic Analysis of SC24 in Canada: A Randomized Study of SBRT Compared With Conventional Palliative RT for Spinal Metastases

PURPOSE

The Canadian Cancer Trials Group (CCTG) Symptom Control 24 protocol (SC.24) was a multicenter randomized controlled phase 2/3 trial conducted in Canada and Australia. Patients with painful spinal metastases were randomized to either 24 Gy/2 stereotactic body radiation therapy (SBRT) or 20 Gy/5 conventional external beam radiation therapy (CRT). The study met its primary endpoint and demonstrated superior complete pain response rates at 3 months following SBRT (35%) versus CRT (14%). SBRT planning and delivery is resource intensive. Given its benefits in SC.24, we performed an economic analysis to determine the incremental cost-effectiveness of SBRT compared with CRT.

METHODS AND MATERIALS

The trial recruited 229 patients. Cost-effectiveness was assessed using a Markov model taking into account observed survival, treatments costs, retreatment, and quality of life over the lifetime of the patient. The EORTC-QLU-C10D was used to determine quality of life values. Transition probabilities for outcomes were from available patient data. Health system costs were from the Canadian health care perspective and were based on 2021 Canadian dollars (CAD). The incremental cost-effectiveness ratio (ICER) was expressed as the ratio of incremental cost to quality-adjusted life years (QALY). The impact of parameter uncertainty was investigated using deterministic and probabilistic sensitivity analyses.

RESULTS

The base case for SBRT compared with CRT had an ICER of $9,040CAD per QALY gained. Sensitivity analyses demonstrated that the ICER was most sensitive to variations in the utility assigned to "No local failure" ($5,457CAD to $241,051CAD per QALY), adopting low and high estimates of utility and the cost of the SBRT (ICERs ranging from $7345-$123,361CAD per QALY). It was more robust to variations in assumptions around survival and response rate.

CONCLUSIONS

SBRT is associated with higher upfront costs than CRT. The ICER shows that, within the Canadian health care system, SBRT with 2 fractions is likely to be more cost-effective than CRT.

Emulator-Based Bayesian Calibration of the CISNET Colorectal Cancer Models

PURPOSE

To calibrate Cancer Intervention and Surveillance Modeling Network (CISNET)'s SimCRC, MISCAN-Colon, and CRC-SPIN simulation models of the natural history colorectal cancer (CRC) with an emulator-based Bayesian algorithm and internally validate the model-predicted outcomes to calibration targets.

METHODS

We used Latin hypercube sampling to sample up to 50,000 parameter sets for each CISNET-CRC model and generated the corresponding outputs. We trained multilayer perceptron artificial neural networks (ANNs) as emulators using the input and output samples for each CISNET-CRC model. We selected ANN structures with corresponding hyperparameters (i.e., number of hidden layers, nodes, activation functions, epochs, and optimizer) that minimize the predicted mean square error on the validation sample. We implemented the ANN emulators in a probabilistic programming language and calibrated the input parameters with Hamiltonian Monte Carlo-based algorithms to obtain the joint posterior distributions of the CISNET-CRC models' parameters. We internally validated each calibrated emulator by comparing the model-predicted posterior outputs against the calibration targets.

RESULTS

The optimal ANN for SimCRC had 4 hidden layers and 360 hidden nodes, MISCAN-Colon had 4 hidden layers and 114 hidden nodes, and CRC-SPIN had 1 hidden layer and 140 hidden nodes. The total time for training and calibrating the emulators was 7.3, 4.0, and 0.66 h for SimCRC, MISCAN-Colon, and CRC-SPIN, respectively. The mean of the model-predicted outputs fell within the 95% confidence intervals of the calibration targets in 98 of 110 for SimCRC, 65 of 93 for MISCAN, and 31 of 41 targets for CRC-SPIN.

CONCLUSIONS

Using ANN emulators is a practical solution to reduce the computational burden and complexity for Bayesian calibration of individual-level simulation models used for policy analysis, such as the CISNET CRC models. In this work, we present a step-by-step guide to constructing emulators for calibrating 3 realistic CRC individual-level models using a Bayesian approach.

HIGHLIGHTS

We use artificial neural networks (ANNs) to build emulators that surrogate complex individual-based models to reduce the computational burden in the Bayesian calibration process.ANNs showed good performance in emulating the CISNET-CRC microsimulation models, despite having many input parameters and outputs.Using ANN emulators is a practical solution to reduce the computational burden and complexity for Bayesian calibration of individual-level simulation models used for policy analysis.This work aims to support health decision scientists who want to quantify the uncertainty of calibrated parameters of computationally intensive simulation models under a Bayesian framework.

Cost Effectiveness of Adding Fenfluramine to Standard of Care for Patients with Dravet Syndrome in Sweden

OBJECTIVE

This study evaluated, in a Swedish setting, the cost effectiveness of fenfluramine (FFA) as an add-on to standard of care (SoC) for reducing seizure frequency in Dravet syndrome, a severe developmental epileptic encephalopathy.

METHODS

Cost effectiveness of FFA+SoC compared with SoC only was evaluated using a patient-level simulation model with a lifetime horizon. Patient characteristics and treatment effects, including convulsive seizures, seizure-free days and mortality, were derived from FFA clinical trials. Resource use and costs included cost of drug acquisition, routine care and monitoring, as well as ongoing and emergency resources. Quality of life (QoL) estimates for patients and their caregivers were derived from clinical trial data. Robustness was evaluated by one-way sensitivity analysis, probabilistic sensitivity analysis and scenario analyses.

RESULTS

Lifetime cost of FFA+SoC was ~3 million SEK per patient compared with ~1.5 million SEK for SoC only. FFA+SoC generated 15% more QALYs than SoC only (21.2 vs 18.5 over a lifetime), resulting in an incremental cost-effectiveness ratio (ICER) of ~540,000 SEK. Moreover, FFA+SoC had a higher probability of being cost effective than SoC only from a willingness-to-pay threshold of 710,000 SEK. Results remained generally consistent across scenario analyses, with only few exceptions (exclusions of carer utility or FFA effect on sudden unexpected death in epilepsy).

CONCLUSION

Due to better seizure control, FFA is a clinically meaningful add-on therapy and was estimated to be a cost-effective addition to current SoC for patients with this rare disease in Sweden at a willingness-to-pay threshold of 1,000,000 SEK.

A structured process for the validation of a decision-analytic model: application to a cost-effectiveness model for risk-stratified national breast screening

BACKGROUND

Decision-makers require knowledge of the strengths and weaknesses of decision-analytic models used to evaluate healthcare interventions to be able to confidently use the results of such models to inform policy. A number of aspects of model validity have previously been described, but no systematic approach to assessing the validity of a model has been proposed. This study aimed to consolidate the different aspects of model validity into a step-by-step approach to assessing the strengths and weaknesses of a decision-analytic model.

METHODS

A pre-defined set of steps were used to conduct the validation process of an exemplar early decision-analytic-model-based cost-effectiveness analysis of a risk-stratified national breast cancer screening programme [UK healthcare perspective; lifetime horizon; costs (£; 2021)]. Internal validation was assessed in terms of descriptive validity, technical validity and face validity. External validation was assessed in terms of operational validation, convergent validity (or corroboration) and predictive validity.

RESULTS

The results outline the findings of each step of internal and external validation of the early decision-analytic-model and present the validated model (called 'MANC-RISK-SCREEN'). The positive aspects in terms of meeting internal validation requirements are shown together with the remaining limitations of MANC-RISK-SCREEN.

CONCLUSION

Following a transparent and structured validation process, MANC-RISK-SCREEN has been shown to have satisfactory internal and external validity for use in informing resource allocation decision-making. We suggest that MANC-RISK-SCREEN can be used to assess the cost-effectiveness of exemplars of risk-stratified national breast cancer screening programmes (NBSP) from the UK perspective.

IMPLICATIONS

A step-by-step process for conducting the validation of a decision-analytic model was developed for future use by health economists. Using this approach may help researchers to fully demonstrate the strengths and limitations of their model to decision-makers.

HPVsim: An agent-based model of HPV transmission and cervical disease

In 2020, the WHO launched its first global strategy to accelerate the elimination of cervical cancer, outlining an ambitious set of targets for countries to achieve over the next decade. At the same time, new tools, technologies, and strategies are in the pipeline that may improve screening performance, expand the reach of prophylactic vaccines, and prevent the acquisition, persistence and progression of oncogenic HPV. Detailed mechanistic modelling can help identify the combinations of current and future strategies to combat cervical cancer. Open-source modelling tools are needed to shift the capacity for such evaluations in-country. Here, we introduce the Human papillomavirus simulator (HPVsim), a new open-source software package for creating flexible agent-based models parameterised with country-specific vital dynamics, structured sexual networks, and co-transmitting HPV genotypes. HPVsim includes a novel methodology for modelling cervical disease progression, designed to be readily adaptable to new forms of screening. The software itself is implemented in Python, has built-in tools for simulating commonly-used interventions, includes a comprehensive set of tests and documentation, and runs quickly (seconds to minutes) on a laptop. Performance is greatly enhanced by HPVsim's multiscale modelling functionality. HPVsim is open source under the MIT License and available via both the Python Package Index (via pip install) and GitHub (hpvsim.org).

Cost-Effectiveness of 2 Models of Pessary Care for Pelvic Organ Prolapse: Findings From the TOPSY Randomized Controlled Trial

OBJECTIVES

Pelvic organ prolapse is the descent of one or more reproductive organs from their normal position, causing associated negative symptoms. One conservative treatment option is pessary management. This study aimed to to investigate the cost-effectiveness of pessary self-management (SM) when compared with clinic-based care (CBC). A decision analytic model was developed to extend the economic evaluation.

METHODS

A randomized controlled trial with health economic evaluation. The SM group received a 30-minute SM teaching session, information leaflet, 2-week follow-up call, and a local helpline number. The CBC group received routine outpatient pessary appointments, determined by usual practice. The primary outcome for the cost-effectiveness analysis was incremental cost per quality-adjusted life year (QALY), 18 months post-randomization. Uncertainty was handled using nonparametric bootstrap analysis. In addition, a simple decision analytic model was developed using the trial data to extend the analysis over a 5-year period.

RESULTS

There was no significant difference in the mean number of QALYs gained between SM and CBC (1.241 vs 1.221), but mean cost was lower for SM (£578 vs £728). The incremental net benefit estimated at a willingness to pay of £20 000 per QALY gained was £564, with an 80.8% probability of cost-effectiveness. The modeling results were consistent with the trial analysis: the incremental net benefit was estimated as £4221, and the probability of SM being cost-effective at 5 years was 69.7%.

CONCLUSIONS

Results suggest that pessary SM is likely to be cost-effective. The decision analytic model suggests that this result is likely to persist over longer durations.

Economic evaluation of the effect of needle and syringe programs on skin, soft tissue, and vascular infections in people who inject drugs: a microsimulation modelling approach

BACKGROUND

Needle and syringe programs (NSP) are effective harm-reduction strategies against HIV and hepatitis C. Although skin, soft tissue, and vascular infections (SSTVI) are the most common morbidities in people who inject drugs (PWID), the extent to which NSP are clinically and cost-effective in relation to SSTVI in PWID remains unclear. The objective of this study was to model the clinical- and cost-effectiveness of NSP with respect to treatment of SSTVI in PWID.

METHODS

We performed a model-based, economic evaluation comparing a scenario with NSP to a scenario without NSP. We developed a microsimulation model to generate two cohorts of 100,000 individuals corresponding to each NSP scenario and estimated quality-adjusted life-years (QALY) and cost (in 2022 Canadian dollars) over a 5-year time horizon (1.5% per annum for costs and outcomes). To assess the clinical effectiveness of NSP, we conducted survival analysis that accounted for the recurrent use of health care services for treating SSTVI and SSTVI mortality in the presence of competing risks.

RESULTS

The incremental cost-effectiveness ratio associated with NSP was $70,278 per QALY, with incremental cost and QALY gains corresponding to $1207 and 0.017 QALY, respectively. Under the scenario with NSP, there were 788 fewer SSTVI deaths per 100,000 PWID, corresponding to 24% lower relative hazard of mortality from SSTVI (hazard ratio [HR] = 0.76; 95% confidence interval [CI] = 0.72-0.80). Health service utilization over the 5-year period remained lower under the scenario with NSP (outpatient: 66,511 vs. 86,879; emergency department: 9920 vs. 12,922; inpatient: 4282 vs. 5596). Relatedly, having NSP was associated with a modest reduction in the relative hazard of recurrent outpatient visits (HR = 0.96; 95% CI = 0.95-0.97) for purulent SSTVI as well as outpatient (HR = 0.88; 95% CI = 0.87-0.88) and emergency department visits (HR = 0.98; 95% CI = 0.97-0.99) for non-purulent SSTVI.

CONCLUSIONS

Both the individuals and the healthcare system benefit from NSP through lower risk of SSTVI mortality and prevention of recurrent outpatient and emergency department visits to treat SSTVI. The microsimulation framework provides insights into clinical and economic implications of NSP, which can serve as valuable evidence that can aid decision-making in expansion of NSP services.