Cost-effectiveness analyses in gynecologic oncology: methodological quality and trends

Methodological reviews of economic evaluations in health care: what do they target?

INTRODUCTION AND OBJECTIVES

An increasing number of published studies of economic evaluations of health technologies have been reviewed and summarized with different purposes, among them to facilitate decision-making processes. These reviews have covered different aspects of economic evaluations, using a variety of methodological approaches. The aim of this study is to analyze the methodological characteristics of the reviews of economic evaluations in health care, published during the period 1990-2010, to identify their main features and the potential missing elements. This may help to develop a common procedure for elaborating these kinds of reviews.

METHODS

We performed systematic searches in electronic databases (Scopus, Medline and PubMed) of methodological reviews published in English, period 1990-2010. We selected the articles whose main purpose was to review and assess the methodology applied in the economic evaluation studies. We classified the data according to the study objectives, period of the review, number of reviewed studies, methodological and non-methodological items assessed, medical specialty, type of disease and technology, databases used for the review and their main conclusions. We performed a descriptive statistical analysis and checked how generalizability issues were considered in the reviews.

RESULTS

We identified 76 methodological reviews, 42 published in the period 1990-2001 and 34 during 2002-2010. The items assessed most frequently (by 70% of the reviews) were perspective, type of economic study, uncertainty and discounting. The reviews also described the type of intervention and disease, funding sources, country in which the evaluation took place, type of journal and author's characteristics. Regarding the intertemporal comparison, higher frequencies were found in the second period for two key methodological items: the source of effectiveness data and the models used in the studies. However, the generalizability issues that apparently are creating a growing interest in the economic evaluation literature did not receive as much attention in the reviews of the second period. The remaining items showed similar frequencies in both periods.

CONCLUSIONS

Increasingly more reviews of economic evaluation studies aim to analyze the application of methodological principles, and offer summaries of papers classified by either diseases or health technologies. These reviews are useful for finding literature trends, aims of studies and possible deficiencies in the implementation of methods of specific health interventions. As no significant methodological improvement was clearly detected in the two periods analyzed, it would be convenient to pay more attention to the methodological aspects of the reviews.

Pelvic floor consequences of cesarean delivery on maternal request in women with a single birth: a cost-effectiveness analysis

BACKGROUND

The potential benefit in preventing pelvic floor disorders (PFDs) is a frequently cited reason for requesting or performing cesarean delivery on maternal request (CDMR). However, for primigravid women without medical/obstetric indications, the lifetime cost-effectiveness of CDMR remains unknown, particularly with regard to lifelong pelvic floor consequences. Our objective was to assess the cost-effectiveness of CDMR in comparison to trial of labor (TOL) for primigravid women without medical/obstetric indications with a single childbirth over their lifetime, while explicitly accounting for the management of PFD throughout the lifetime.

METHODS

We used Monte Carlo simulation of a decision model containing 249 chance events and 101 parameters depicting lifelong maternal and neonatal outcomes in the following domains: actual mode of delivery, emergency hysterectomy, transient maternal morbidity and mortality, perinatal morbidity and mortality, and the lifelong management of PFDs. Parameter estimates were obtained from published literature. The analysis was conducted from a societal perspective. All costs and quality-adjusted life-years (QALYs) were discounted to the present value at childbirth.

RESULTS

The estimated mean cost and QALYs were $14,259 (95% confidence interval [CI] $8,964-$24,002) and 58.21 (95% CI 57.43-58.67) for CDMR and $13,283 (95% CI $7,861-$23,829) and 57.87 (95% CI 56.97-58.46) for TOL over the combined lifetime of the mother and the child. Parameters related to PFDs play an important role in determining cost and quality of life.

CONCLUSIONS

When a woman without medical/obstetric indications has only one childbirth in her lifetime, cost-effectiveness analysis does not reveal a clearly preferable mode of delivery.

Intraperitoneal cisplatin and paclitaxel versus intravenous carboplatin and paclitaxel chemotherapy for Stage III ovarian cancer: A cost-effectiveness analysis

OBJECTIVE

To evaluate the cost-effectiveness of intraperitoneal cisplatin and paclitaxel chemotherapy as front-line treatment for patients with Stage III epithelial ovarian cancer following optimal primary cytoreductive surgery.

METHODS

Based on Gynecologic Oncology Group protocols #172 and #158, a decision analysis model was created to compare two treatment strategies for patients with optimal residual disease Stage III ovarian cancer: (1) inpatient intravenous paclitaxel (24 h) and intraperitoneal cisplatin plus outpatient intraperitoneal paclitaxel chemotherapy (IP/IV), and (2) outpatient intravenous paclitaxel (3 h) and carboplatin chemotherapy (IV/IV). The cost-effectiveness of each strategy was evaluated from the perspective of society.

RESULTS

Cost-effectiveness analysis revealed that the strategy of IP/IV chemotherapy had an overall cost per patient of $39,861 and effectiveness of 5.16 QALYs compared to $18,822 and 4.59 QALYs for IV/IV chemotherapy. The IP/IV chemotherapy strategy was associated with an additional 0.56 QALYs at an incremental cost of $21,039. The incremental C/E ratio for IP/IV chemotherapy was $37,454/QALY. Inpatient treatment accounted for 43.2% of the cost of IP/IV chemotherapy. Sensitivity analysis testing confirmed the robustness of the model.

CONCLUSIONS

In this model, IP/IV chemotherapy was associated with a modest extension in quality-adjusted survival time but was also more costly than IV/IV chemotherapy. On balance, the IP/IV strategy can be considered a good healthcare value. However, these data also suggest that efforts to reduce the cost of IP/IV chemotherapy, such as through development of an ambulatory regimen with equivalent therapeutic efficacy but an improved toxicity profile, would improve the overall value of this adjuvant treatment program.

Centralization of care for patients with advanced-stage ovarian cancer: a cost-effectiveness analysis

BACKGROUND

The objective of this study was to evaluate the cost-effectiveness of centralized referral of patients with advanced-stage epithelial ovarian cancer who underwent primary cytoreductive surgery and adjuvant chemotherapy.

METHODS

A decision-analysis model was used to compare 2 referral strategies for patients with advanced-stage ovarian cancer: 1) referral to an expert center, with a rate of optimal primary cytoreduction of 75% and utilization of combined intraperitoneal and intravenous adjuvant chemotherapy, and 2) referral to a less experienced center, with a rate of optimal primary cytoreduction of 25% and adjuvant treatment that consisted predominantly of intravenous chemotherapy alone. The cost-effectiveness of each strategy was evaluated from the perspective of society.

RESULTS

A cost-effectiveness analysis revealed that the strategy of expert center referral had an overall cost per patient of $50,652 and had an effectiveness of 5.12 quality-adjusted life years (QALYs). The strategy of referral to a less experienced center carried an overall cost of $39,957 and had an effectiveness of 2.33 QALYs. The expert center strategy was associated with an additional 2.78 QALYs at an incremental cost of $10,695 but was more cost-effective, with a cost-effective ratio of $9893 per QALY compared with $17,149 per QALY for the less experienced center referral strategy. Sensitivity analyses and a Monte Carlo simulation confirmed the robustness of the model.

CONCLUSIONS

According to results from the decision-analysis model, centralized referral of patients with ovarian cancer to an expert center was a cost-effective healthcare strategy and represents a paradigm for quality cancer care, delivering superior patient outcomes at an economically affordable cost. Increased efforts to align current patterns of care with a universal strategy of centralized expert referral are warranted.

Methodologic quality of cost-effectiveness analyses of surgical procedures

OBJECTIVE

The purpose of this study was to evaluate the methodologic quality of economic analyses of surgical procedures and to compare quality across publications.

SUMMARY BACKGROUND DATA

With healthcare resources limited and technologies rapidly advancing across specialties, including surgery, there is increasing demand for evidence of cost-effectiveness.

METHODS

A MEDLINE search identified English-language articles published from 1995 to 2004 that included economic analyses of surgical procedures. Two of the authors reviewed 110 studies and scored each based on compliance with 10 methodologic criteria. Data analyses used Cohen's kappa statistic, regression models, Mann-Whitney U tests, and Kruskal-Wallis tests.

RESULTS

The 110 articles appeared in 79 different journals, including 57 articles in 37 surgical journals. Most journals (75%) had only 1 article eligible for inclusion. The average number of criteria met was 4.1, with 10 articles meeting all 10 methodologic standards. Compliance rates for the 5 methodologic criteria most frequently neglected ranged from 34% to 45% in nonsurgical journals and 9% to 14% in surgical journals (P < 0.001).

CONCLUSIONS

While methodologic guidelines for cost-effectiveness analyses have appeared in the medical literature, studies of cost-effectiveness in surgery often do not meet these criteria. As healthcare policy seeks to incorporate information from economic evaluations, it is increasingly important that surgical journals adhere to accepted guidelines and perform quality assurance on these studies. This may be aided by wider promulgation of the methodologic criteria in surgical journals or at surgical meetings.

Prevention of adhesion formation after radical hysterectomy using a sodium hyaluronate-carboxymethylcellulose (HA-CMC) barrier: a cost-effectiveness analysis

OBJECTIVE

To evaluate the cost-effectiveness of an adhesion prevention strategy compared to routine care, in which no adhesion prevention measures are taken, through a decision analysis model in the clinical setting of patients undergoing radical hysterectomy and pelvic lymphadenectomy for Stage IB cervical cancer.

METHODS

A decision analysis model compared two strategies to manage the risk of adhesion-related morbidity following radical hysterectomy for Stage IB cervical cancer: (1) routine care with no adhesion prevention measures, and (2) the intervention strategy with a HA-CMC anti-adhesion barrier. The cost-effectiveness of each strategy was evaluated from the perspective of society and that of a third party payer.

RESULTS

From the perspective of society, the HA-CMC strategy had an overall cost per patient of $1932 and effectiveness of 7.901 QALYs and dominated the routine care strategy, which had a cost per patient of $3043 and effectiveness of 7.805 QALYs. From the perspective of a third party payer, the HA-CMC strategy had an overall cost per patient of $1247 and effectiveness of 7.987 QALYs and dominated the routine care strategy, which had a cost per patient of $1629 and effectiveness of 7.970 QALYs. A series of one-way sensitivity analyses confirmed the robustness of the model.

CONCLUSIONS

Under a conservative set of clinical and economic assumptions, an adhesion prevention strategy utilizing a HA-CMC barrier in patients undergoing radical hysterectomy for Stage IB cervical cancer is cost-effective from both the perspective of society as a whole and that of a third party payer.