Estimating Cost-Effectiveness Thresholds Under a Managed Healthcare System: Experiences from Colombia

Cost-Effectiveness Analysis of Pharmacological Treatment With Insulin and Insulin Analogs for Type 1 and Type 2 Diabetes Mellitus in Colombia

OBJECTIVES

This study aimed to estimate the cost-effectiveness relationship of insulins and insulin analogs in diabetes mellitus type 1 (DM1) and 2 (DM2), from the perspective of the Colombian health system.

METHODS

A short-term decision tree model (SM) was built, the outcome of which was severe/nocturnal hypoglycemia, and a long-term Markov model for quality-adjusted life-years. The probabilities were calculated through a literature review of effectiveness and safety. The costs are estimated from official databases. Deterministic and probabilistic sensitivity analyses were performed.

RESULTS

For DM1, in prandial insulins, and for both models, the cost-effective interventions (CEIs) are aspartate and lispro. In basal insulins, the CEIs are NPH and glargine U-100 in both models. In the comparison of detemir and NPH, detemir generates lower nocturnal hypoglycemia and higher quality-adjusted life-years; however, in the long-term Markov model, the incremental cost-effectiveness ratio exceeds the threshold. For DM2, in the prandial insulin, and for both models, aspartate is a CEI and the glargine U-300 is also a CEI in the SM. In basal insulin, the CEIs are glargine U-100 and detemir (for nocturnal hypoglycemia) in both models and glargine U-300 is also a CEI in the SM. Finally, in the group of combinations, iGlarLixi is dominant over IDegLira.

CONCLUSIONS

The results favor the use of analog insulins over human insulins, the former reducing the possibility of acute events and chronic complications to a greater extent.

Cost-effectiveness analysis of nephroprotection programs for patients with type 2 diabetes mellitus in insurers in Colombia

BACKGROUND

This research aimed to determine the cost-effectiveness of nephroprotection programs compared to no intervention in adults with type 2 diabetes mellitus (T2DM) in the Colombian national health system.

METHODS

A Markov analysis with 3 disease states (controlled, uncontrolled and death) was modeled using a 1-year cycle and a 10-year time horizon based on T2DM and chronic kidney disease (CKD) data in Colombia from 2020 to 2023 from the perspective of the health insurance system. Effectiveness was considered as the control of CKD progression, with a decrease of estimated glomerular filtration rate (eGFR using CKD-EPI) of less than 5 ml/min/1.73 m2, and glycated hemoglobin (HBA1c) of less than or equal to 7%. Costs are expressed in 2023 $USD. Univariate and multivariate probabilistic sensitivity analyses were conducted using 1,000 Monte Carlo simulations.

RESULTS

Compared to no intervention, nephroprotection programs were found to be cost-effective, with a dominant incremental cost-effectiveness ratio (ICER). Furthermore, the sensitivity analysis results showed that having a nephroprotection program is a cost-effective strategy in 89.2% and dominant in 56.7% of the simulations.

CONCLUSIONS

Nephroprotection programs result in better T2DM control and slower CKD progression, while also being lower in costs incurred during the year.

Exploratory analysis of the economically justifiable price of tezepelumab for asthma severe in Colombia

INTRODUCTION

Asthma severe imposes important economic burden on health systems, especially with the incorporation of new drugs. Recently, tezepelumab has been approved to prevent exacerbations in patients. This study explores the economically justifiable price of tezepelumab for preventing exacerbations in patients with severe asthma.

MATERIALS AND METHODS

A static model was developed using the decision tree microsimulation to estimate the quality-adjusted life years of two interventions: a single intramuscular dose of tezepelumab versus not applying tezepelumab. This analysis was made during a time horizon of 50 year and from a third-payer perspective.

RESULTS

Based on thresholds of U$4828, U$ 5128, and U$19 992 per QALY evaluated in this study, we established economically justifiable drug acquisition prices of U$ 795, U$ 835, and U$ 3384 per dose of Tezepelumab. Tezepelumab not was cost-effective using a WTP of U$4828 and U$ 5128. It only was cost effective at WTP of U$19 992 per QALY.

CONCLUSION

The economically justifiable cost for tezepelumab in Colombia is between U$795 to U$3384 per dose, depending on the WTP used to decide its implementation. 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.

Cost-Effectiveness and Budget Impact Analysis of the Use of Faricimab in Diabetic Macular Edema and Neovascular Age-Related Macular Degeneration in Colombia

Background: Retinal diseases are major contributors to disability, significantly affecting patients' quality of life. Diabetic macular edema (DME) and neovascular age-related macular degeneration (nAMD) represent a significant disease and economic burden in Colombia. Assessing the economic evaluation of available treatments is essential for the efficient allocation of healthcare resources. Objective: To estimate the cost-effectiveness and budget impact of using faricimab for the treatment of patients with DME and nAMD within the Colombian health system. Methods: This study used a 25-year Markov cohort model to estimate the cost-effectiveness of faricimab vs aflibercept, ranibizumab, and brolucizumab. We used the methodological guidelines of the local health technology assessment agency for conducting the cost-effectiveness and budget impact analysis. Transition probabilities and injection frequencies were derived from the literature. Drug prices were retrieved from public local databases. Quality-adjusted life years (QALYs) were assessed. The potential patient population for the budget impact analysis was estimated based on disease prevalence and expert consultations. Results: Faricimab treat-and-extend (T&E) was dominant vs aflibercept T&E (+0.22 QALYs), ranibizumab T&E (+0.55 QALYs), and brolucizumab for 8 to 12 weeks (+0.06 QALYs) in DME, generating cost savings (in US dollars) of 3849 , 1375, and 2824 , r e s p e c t i v e l y . I n n A M D , f a r i c i m a b a l s o s h o w e d d o m i n a n c e v s a f l i b e r c e p t a s n e e d e d ( + 0.12 Q A L Y s ) , r a n i b i z u m a b a s n e e d e d ( + 0.05 Q A L Y s ) , a n d b r o l u c i z u m a b 8 t o 12 w e e k s ( + 0.12 Q A L Y s ) w i t h s a v i n g s i n ( U S ) 7223, 5792 , a n d 6798, respectively. Assuming an annual market share increase for faricimab of 15% for DME and 13% for nAMD, the Colombian Health System could save 144 m i l l i o n o v e r 3 y e a r s . O f t h e s e s a v i n g s , 122.7 million are attributed to drug costs and 21.3 m i l l i o n t o a d m i n i s t r a t i o n c o s t s ( U S 1 = Col$4325). Conclusion: Considering a willingness to pay threshold of $5988 per additional QALY, faricimab is a cost-effective alternative for both DME and nAMD for the Colombian healthcare system, showing dominance over other anti-vascular endothelial growth factor agents. Faricimab provides better health outcomes at lower costs vs other treatments.

Economic Evaluation of 9 Intersectoral Strategies to Improve Youth Mental Health and Alleviate Financial Burden in Colombia Using System Dynamics Modeling

OBJECTIVES

Limited evidence exists for strategic actions in improving mental health at the youth population-level, particularly in low- and middle-income countries. This study investigates the health and economic impacts of intersectoral mental health programs to inform the optimal suite of interventions for young people in Bogotá, Colombia, where many are at risk of mental disorders and lack access to appropriate health services.

METHODS

This study evaluated 9 interventions compared with business as usual over a projected 10-year time horizon using a system dynamics model developed through a participatory process involving diverse local stakeholders. Sensitivity analyses were performed to account for uncertainties from a healthcare payer perspective.

RESULTS

Anti-bullying, community-based rehabilitation, and online mental health programs were dominant. General practitioner mental health training and gatekeeper suicide prevention training could significantly improve mental health outcomes at an incremental cost-effectiveness ratio below the threshold of US dollars $4890/quality-adjusted life-years. Nevertheless, simultaneously implementing all 9 strategies could produce a synergistic effect, yielding the greatest benefit relative to business as usual with an incremental net monetary benefit of $465 million and an incremental cost-effectiveness ratio of $586 per quality-adjusted life-years gained.

CONCLUSIONS

Combined intersectoral mental health strategies were synergistic and resulted in optimal health outcomes relative to business as usual. The system dynamics approach offers additional attributes to economic evaluation in mental health settings by considering capacity constraints, unintended consequences, and interactions between multiple interventions. It is a valuable approach for decision-makers to effectively and efficiently prioritize and allocate scarce resources in complex public health systems.

Estimating the Incremental Cost Per QALY Produced by the Spanish NHS: A Fixed-Effect Econometric Approach

BACKGROUND

Knowing the health opportunity costs of funding decisions is crucial to assess whether the health gains associated with new interventions are larger than the health losses imposed by the displacement of resources. Empirical estimates based on the effect of health spending on health outcomes have been proposed in several countries, including Spain, as a proxy to capture these opportunity costs. However, there is a need to regularly update existing health opportunity cost estimates and to explore the role of omitted variable bias in these estimations.

OBJECTIVE

The aim of this paper is to provide an updated and refined estimate of the causal impact of health spending on health in Spain that can be translated into an estimate of the incremental cost per quality-adjusted life-year produced by the Spanish national health system.

METHODS

We applied fixed-effect models using data for 17 Spanish regions from 2002 until 2022 to estimate the impact of public health spending on health outcomes and explored the extent of omitted variable bias. Changes in these estimates over time were assessed and alternative specifications were tested.

RESULTS

Based on fixed-effect models with control variables, the estimated spending elasticity was 0.061, which translated into an incremental cost per quality-adjusted life-year of approximately €34,000. The bias-corrected elasticity was 0.075, with a corresponding incremental cost per quality-adjusted life-year of €27,000. We found that the estimated impact of spending on health decreases when recent years of data are added, and that the extent of omitted variable bias appears to increase, particularly when adding the COVID-19 pandemic period.

CONCLUSIONS

This study provides an updated estimation of the incremental cost per quality-adjusted life-year produced by the Spanish national health system. The estimates provided can be easily updatable as new data become accessible, and the methods applied might be transferable to other settings with similar available data.

Efficient use of mepolizumab in children: An analysis of the economically justifiable price in Colombia

INTRODUCTION

Asthma imposes a crucial 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. This study explores the economically justifiable price of mepolizumab for preventing exacerbations in children with severe asthma.

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 time horizon of 50 years and from a third-payer perspective.

RESULTS

Mepolizumab was cost-effective using a WTP of U$ 19,992 per QALY, but not at a WTP of U$ 4828, U$ 5128 per QALY. The economically justifiable cost for mepolizumab in Colombia is between $33 and $350 per dose, for WTP of U$ 4828, and U$ 5128 respectively. At the current price of Mepolizumab, U$ 780 per dose, only using a WTP higher than U$ 10,300 per QALY mepolizumab will be the best alternative to no mepolizumab.

CONCLUSION

Our study shows that the economically justifiable cost for mepolizumab in Colombia is between $33 and $350 per dose, for WTP of 4828 and 5180 respectively. 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.

Cost-effectiveness of high-dose vitamin D supplementation to reduce the occurrence of repeat episodes of pneumonia in children

INTRODUCTION

Despite the growing evidence on efficacy, little is known regarding the efficiency of Vitamin D supplementation (VDS) to reduce the incidence of repeat episodes of pneumonia in children. This study aimed to determine the cost-utility of VDS to reduce the incidence rate of repeat episodes of pneumonia in children.

METHODS

A decision tree model was used to estimate the cost and quality-adjusted life-years (QALYs) of VDS in a patient aged 2 to 60 months with a clinical diagnosis of community-acquired pneumonia requiring in-hospital management. Multiple sensitivity analyses were conducted to evaluate the robustness of the model. Cost-effectiveness was evaluated at a willingness-to-pay (WTP) value of US$5180.

RESULTS

The QALYs per person were 0,93 with VDS and 0,92 without VDS. The total costs per person were US$ 1148 for VDS and US$ 1284 without VDS. This position of absolute dominance of VDS makes it unnecessary to estimate the incremental cost-effectiveness ratio. The ICER was sensitive to changes in the relative risk of Vitamin D supplementation.

CONCLUSION

In conclusion, our study shows that VDS is a cost-effective to reduce the incidence rate of repeat episodes of pneumonia in children, from a societal perspective. However, the sensitivity of ICER to relative risk makes it necessary to take the results of this economic evaluation with caution.

Use of Cost-Effectiveness Thresholds in Healthcare Public Policy: Progress and Challenges

The article offers a comparative analysis of the influence of cost-effectiveness thresholds in the decision-making processes in financing policies, coverage, and price regulation of health technologies in nine countries. We investigated whether countries used cost-effectiveness thresholds for public health policy decision making and found that few countries have adopted the cost-effectiveness threshold as an official criterion for financing, reimbursement, or pricing. However, in countries where it is applied, such as Thailand, the results have been very favorable in terms of minimizing health technology prices and ensuring the financial sustainability of the health system. Although the cost-effectiveness threshold has opportunities for improvement, particularly in certain institutional contexts and with adequate participation of the different strategic actors in the formulation of public policy, its potential use and added value are significant in various aspects.

Study on the concentration, distribution, and persistence of health spending for the contributory scheme in Colombia

Colombia is among the countries with the most robust financial protection against personal health spending in the world, with out-of-pocket spending ranking lowest across OECD countries. We investigate the evolution, distribution, and persistence of health spending by age group, sex, health care setting, health condition and geographic region for over 19 million users of Colombia's health system between 2013 and 2021 (contributory scheme). We use average patient-level expenditure data from the Health-Promoting Entities of the Ministry of Health and Social Protection. We applied multivariate statistical techniques such as multiple correspondence analysis, factor maps and correlations. For both sexes, average health expenditure increases gradually with age until 60 years, accelerating thereafter abruptly. Health conditions with the highest percentage of expenditure were those related to neoplasms, blood diseases, circulatory system, pregnancy, puerperium and perinatal period. We found that home-based care in Amazonía-Orinoquía is almost non-existent, and that outpatient care represents a high proportion in all age groups (over 65%) compared to the other regions. There is a strong persistence of expenditure from one year to the next (i.e. they can provide relevant information for prediction), especially in areas with a larger supply of health services such as Bogotá-Cundinamarca. To the authors' knowledge, this is the most comprehensive and detailed micro-analysis of health spending that has been developed for a Latin American country to date.

An assessment of economy- and transport-oriented health performance

BACKGROUND

Good health can prolong one's lifespan and is a fundamental human right. Thus, human health is being influenced by prejudiced from sociological, environmental, economic, and geographic aspects. The economy and transportation system pose a serious challenge to the assessment of the health performance of economies.

OBJECTIVE

This study aims to assess the health performance of Organization for Economic Cooperation and Development (OECD) economies by using economic and transport-related indicators and examining the role of health expenditure and governance in improving efficiency.

METHODS

This study measures the economy- and transport-oriented health efficiency of 35 OECD economies for the period of 2000-2022. In the first stage, this study employs a slacks-based measure and the data envelopment analysis-window analysis approach to conduct individual (economy and transportation) and joint assessments to measure health efficiency. In the second stage, this study uses the tobit regression method to investigate the effects of influencing factors, namely, government general health and pharmaceutical expenditures, the medical infrastructure, and governance, on health efficiency.

RESULTS

Empirical results reveal that a 1-unit change in the health expenditure during the research period improves economy-oriented health efficiency by 71% and transport-oriented health efficiency by 58%. The econometric analysis demonstrates that all the coefficients of economy- and transport-oriented health efficiency are significant and positive. Notably, a 1-unit change in the medical infrastructure increases economy- and transport-oriented health efficiency by 50.8%, and a 1% increase in pharmaceutical expenditure increases the health, economy, and transport efficiency scores by 16.3%, 33%, and 58.6%, respectively.

CONCLUSIONS

The findings suggest that some of the economies were efficient with regard to their health-oriented outputs, that is, quality of life and mortality and morbidity rates, and most of the economies demonstrated excellent economic performance. The findings of the transport-oriented health efficiency assessment reveal that the economies were unable to perform well in the last year of the research period owing to the nationwide lockdowns. Nonetheless, they demonstrated efficiency in the first half of the research period. The joint assessment of economy- and transport-oriented health efficiency indicates that economic and transport input resources can adversely affect the GDP and life expectancy simultaneously, and the medical infrastructure, pharmaceutical expenditure, and number of medical graduates serve as constructive stimuli for health efficiency improvement.

Genotype-driven asthma prescribing of inhaled corticosteroids and long-acting β2-agonist: A cost-effectiveness analysis

INTRODUCTION

Predicting response to inhaled corticosteroids (ICSs) + long-acting β2-agonist (LABA) by previously detecting the presence of Arg16Gly ADRB2 genotype is a strategy that could reduce and optimize the management of asthmatic patients. There is a need for economic evaluations to facilitate the implementation of such tests. This research aims to evaluate the cost-effectiveness of Arg16Gly ADRB2 screening in children with asthma in Colombia.

METHODS

From the perspective of a third-party payer, we conducted a cost-effectiveness analysis to determine the cost and quality-adjusted life-years (QALYs) of genotype-driven asthma prescribing based on the Arg16Gly ADRB2 genotype versus current treatment based on no genetic testing. Using four state-transition models, we estimate cost and QALYs employing micro-simulation modeling with a time horizon of 10 years and a cycle length of 1 week. Cost-effectiveness was assessed at a willingness-to-pay (WTP) value of US$5180.

RESULTS

The mean incremental cost of strategy genetic testing versus no genetic testing is US$ -6809. The mean incremental benefit of strategy genetic testing is 16 QALYs. The incremental net monetary benefit of strategic genetic testing versus no genetic testing is US$ 88,893. Genetic testing is the strategy with the highest expected net benefit. The outcomes derived from our primary analysis remained robust when subjected to variations in all underlying assumptions and parameter values.

CONCLUSION

Genetic testing of Arg16Gly ADRB2 is a cost-effective strategy to address asthma management in asthmatic children requiring ICS+LABA. This result should encourage the generation of more evidence and the incorporation of such evidence into clinical practice guidelines for pediatric asthma.

Cost-utility analysis of prenatal supplementation with long-chain n-3 fatty acids to reduce the incidence of wheezing and asthma in neonates

INTRODUCTION

Recent evidence indicates that Maternal Supplementation with Long-Chain n-3 Fatty Acids During Pregnancy Substantially Mitigates Offspring's Asthma. Adding information regarding its cost-utility will undoubtedly allow its adoption, or not, in clinical practice guidelines. This research aimed to determine the cost-utility of LCPUFA supplementation in the third trimester of pregnancy to reduce the risk of wheezing and asthma in infants in Colombia.

METHODS

A Markov model was formulated to estimate the cost and quality-adjusted life-years (QALYs) attributed to individuals with severe asthma in Colombia, with a time horizon of five years and a cycle length of two weeks. Probabilistic sensitivity analysis and a value of information (VOI) analysis were conducted to evaluate the uncertainties in the case base. Cost-utility was assessed at a willingness-to-pay (WTP) value of US$5180. All costs were adjusted to 2021 with a 5% annual discounting rate for cost and QALYs.

RESULTS

The mean incremental cost of LCPUFA supplementation versus no supplementation was US-43.65. The mean incremental benefit of LCPUFA supplementation versus no supplementation was 0.074 QALY. The incremental cost-utility ratio was estimated at US$590.68 per QALY. The outcomes derived from our primary analysis remained robust when subjected to variations in all underlying assumptions and parameter values.

CONCLUSION

Supplementation strategy supplementation with long-chain n-3 fatty acids during pregnancy is cost-effective in reducing the risk of developing asthma during childhood in Colombia.

Cost-utility analysis of a palliative care program in Colombia

BACKGROUND

The economic assessment of health care models in palliative care promotes their global development. The purpose of the study is to assess the cost-effectiveness of a palliative care program (named Contigo) with that of conventional care from the perspective of a health benefit plan administrator company, Sanitas, in Colombia.

METHODS

The incremental cost-utility ratio (ICUR) and the incremental net monetary benefit (INMB) were estimated using micro-costing in a retrospective, analytical cross-sectional study on the care of terminally ill patients enrolled in a palliative care program. A 6-month time horizon prior to death was used. The EQ-5D-3 L questionnaire (EQ-5D-3 L) and the McGill Quality of Life Questionnaire (MQOL) were used to measure the quality of life.

RESULTS

The study included 43 patients managed within the program and 16 patients who received conventional medical management. The program was less expensive than the conventional practice (difference of 1,924.35 US dollars (USD), P = 0.18). When compared to the last 15 days, there is a higher perception of quality of life, which yielded 0.25 in the EQ-5D-3 L (p < 0.01) and 1.55 in the MQOL (P < 0.01). The ICUR was negative and the INMB was positive.

CONCLUSION

Because the Contigo program reduces costs while improving quality of life, it is considered to be net cost-saving and a model with value in health care. Greater availability of palliative care programs, such as Contigo, in Colombia can help reduce existing gaps in access to universal palliative care health coverage, resulting in more cost-effective care.

Cost-Effectiveness Analysis of Pharmacological Treatment for Adult Kidney Transplant Recipients in Colombia

OBJECTIVES

To evaluate cost-effective pharmacological treatment in adult kidney transplant recipients from the perspective of the Colombian health system.

METHODS

A decision tree model for the induction phase and a Markov model for the maintenance phase were built. A review of the clinical literature was conducted to extract probabilities, and the life-years were used as the outcome. Costs were calculated using the administrative databases. The evaluating treatment schemes are organized by groups of evidence with direct comparisons.

RESULTS

In the induction phase, anti-thymocyte immunoglobulin+ methylprednisolone is dominant, more effective, and less expensive, compared with basiliximab+methylprednisolone. In the maintenance phase, azathioprine (AZA) is dominant in contrast to mycophenolate mofetil (MFM) both with cyclosporine (CIC)+ corticosteroids (CE); CIC is dominant relative to sirolimus (SIR) and tacrolimus (TAC) (both with MFM+CE or AZA+CE), and TAC is dominant compared with SIR (in addition with MFM+CE or mycophenolate sodium [MFS]+CE); MFM is dominant in relation to MFS and everolimus, and SIR is more effective MFM but it does not exceed the threshold (in sum with TAC+CE); MFS and MFM are dominant relative to everolimus, and SIR is more effective than MFM, but it does not exceed the threshold (in addiction with CIC+CE); MFM is dominant in relation to TAC (in sum with SIR+CE), and CIC+AZA+CE is dominant in relation to TAC+MFM+CE.

CONCLUSIONS

The base-case results for all evidence groups are consistent with the different sensitivity analyses.

Exploratory analysis of the economically justifiable price of nirsevimab for healthy late-preterm and term infants in Colombia

INTRODUCTION

Respiratory syncytial virus infection is the leading cause of lower respiratory infection globally. Recently, nirsevimab has been approved to prevent respiratory syncytial virus (RSV) infection. This study explores the economically justifiable price of nirsevimab for preventing RSV infection in Colombia's children under 1 year of age.

MATERIALS AND METHODS

A static model was developed using the decision tree microsimulation to estimate the quality-adjusted costs and life years of two interventions: a single intramuscular dose of nirsevimab versus not applying nirsevimab. This analysis was made during a time horizon of 1 year and from a societal perspective.

RESULTS

The annual savings in Colombia associated with this cost per dose ranged from U$ 2.5 to 4.1 million. Based on thresholds of U$ 4828, U$ 5128, and U$ 19 992 per QALY evaluated in this study, we established economically justifiable drug acquisition prices of U$ 21.88, U$ 25.04, and U$ 44.02 per dose of nirsevimab.

CONCLUSION

the economically justifiable cost for nirsevimab in Colombia is between U$ 21 to U$ 44 per dose, depending on the willingness to pay used to decide its implementation. 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.

Cost effectiveness of omalizumab for severe asthma in Colombia

BACKGROUND

Omalizumab is a humanized monoclonal antibody that specifically binds to free human immunoglobulin E. The introduction of this drug raises concerns about economic impact in scenarios with constrained. This study aimed to estimate the cost utility of omalizumab in adults with severe asthma uncontrolled in Colombia.

METHODS

We used a Markov state-transition model to estimate the cost and QALYs associated with omalizumab compared to standard of care; from a third payer perspective over a lifetime horizon. This model used local costs while utilities were derived from international literature. Cost and transition probabilities were obtained from a mixture of Colombian-specific and internationally published data.

RESULTS

The mean incremental cost of omalizumab versus standard of care is US$3 481. The mean incremental benefit of omalizumab versus standard of care 0.094 QALY. The incremental expected cost per unit of benefit is estimated at US$36846 per QALY. There is only a probability of 0.032 that Omalizumab is more cost-effective than standard of care at a threshold of US$5180 per QALY.

CONCLUSION

Omalizumab is not cost-effective in adults with severe asthma uncontrolled in Colombia. If the cost of Omalizumab is reduced by 83%, this treatment would be cost-effective in our country. Our study provides evidence that should be used by decision-makers to improve clinical practice guidelines and should be replicated to validate their results in other middle-income countries.

Cost-effectiveness analysis of dupilumab versus omalizumab, mepolizumab, and benralizumab added to the standard of care in adults with severe asthma in Colombia

BACKGROUND

Cost-effectiveness studies evaluate health technologies and help choose treatments. The current study compared dupilumab to omalizumab, mepolizumab, and benralizumab in Colombian adults with severe uncontrolled type 2 asthma.

METHODS

Over a 5-year period, a Markov model was utilized to assess the costs of biological treatments and management of exacerbations, comparing various doses of exacerbations, comparing various doses of dupilumab, omalizumab, mepolizumab, and benralizumab as add-on treatments. It included a 5% annual discount rate per local HTA, and set willingness-to-pay at three times GDP per capita per quality-adjusted life year (QALY) in Colombia.

RESULTS

Dupilumab (200 mg) exhibited greater QALYs and reduced overall costs compared to mepolizumab (100 mg), benralizumab (30 mg), and omalizumab (450 mg and 600 mg), with the incremental cost-effectiveness ratio (ICER) per QALYgained being -$5.429, -$6.269, -$196.567 and -$991.007, respectively. Dupilumab had greater QALYs and costs versus omalizumab 300 mg (ICERof $200.653 per QALY, above the willingness-to-pay threshold of 3 × GDP per capita). Sensitivity analyses were consistent with base case results.

CONCLUSIONS

Dupilumab 200 mg was strongly dominant versus omalizumab 450 mg and 600 mg, mepolizumab 100 mg, and benralizumab 30 mg; however, cost-effectiveness was not demonstrated versus omalizumab 300 mg. These results could assist healthcare professionals in choosing an appropriate biologic for treating severe type 2 asthma.

Systematic review of the impact of health care expenditure on health outcome measures: implications for cost-effectiveness thresholds

OBJECTIVE

Empirical estimates of the impact of healthcare expenditure on health outcome measures may inform the cost-effectiveness threshold (CET) for guiding funding decisions. This study aims to systematically review studies that estimated this, summarize and compare the estimates by country income level.

METHODS

We searched PubMed, Scopus, York Research database, and [anonymized] for Reviews and Dissemination database from inception to 1 August 2023. For inclusion, a study had to be an original article, estimating the impact of healthcare expenditure on health outcome measures at a country level, and presented estimates, in terms of cost per quality-adjusted life year (QALY) or disability-adjusted life year (DALY).

RESULTS

We included 18 studies with 385 estimates. The median (range) estimates were PPP$ 11,224 (PPP$ 223 - PPP$ 288,816) per QALY gained and PPP$ 5,963 (PPP$ 71 - PPP$ 165,629) per DALY averted. As ratios of Gross Domestic Product per capita (GDPPC), these estimates were 0.376 (0.041-182.840) and 0.318 (0.004-37.315) times of GDPPC, respectively.

CONCLUSIONS

The commonly used CET of GDPPC seems to be too high for all countries, but especially low-to-middle-income countries where the potential health losses from misallocation of the same money are greater.

REGISTRATION

The review protocol was published and registered in PROSPERO (CRD42020147276).

Cost-utility of tiotropium in patients with severe asthma

Add-on therapy with tiotropium was cost-effective when added to usual care in patients who remain uncontrolled despite treatment with medium or high-dose ICS/LABA in a middle-income country.

BACKGROUND

A significant proportion of asthma patients remain uncontrolled despite inhaled corticosteroids and long-acting beta-agonists. Some add-on therapies, such as tiotropium bromide, have been recommended for this subgroup of patients. This study aimed to assess the cost-effectiveness of tiotropium as an add-on therapy to inhaled corticosteroids and long-acting b2 agonists for patients with severe asthma.

METHODS

A probabilistic Markov model was created to estimate the cost and quality-adjusted life-years (QALYs) of patients with severe asthma in Colombia. Total costs and QALYs of two interventions include standard therapy with inhaled corticosteroids and long-acting bronchodilators versus add-on therapy with tiotropium. Multiple sensitivity analyses were conducted. Cost-effectiveness was evaluated at a willingness-to-pay value of $5180.

RESULTS

The expected incremental cost per QALY (ICER) is estimated at US$-2637.59. There is a probability of 0.77 that tiotropium + ICS + LABA is more cost-effective than ICS + LABA at a threshold of US$5180 per QALY. The strategy with the highest expected net benefit is Tiotropium, with an expected net benefit of US$800. Our base-case results were robust to parameter variations in the deterministic sensitivity analyses.

CONCLUSION

Add-on therapy with tiotropium was cost-effective when added to usual care in patients who remain uncontrolled despite treatment with medium or high-dose inhaled corticosteroids and long-acting bronchodilators. Our study provides evidence that should be used by decision-makers to improve clinical practice guidelines and should be replicated to validate their results in other middle-income countries.

Cost-Effectiveness of Tacrolimus Compared With Cyclosporine for Immunosuppression Therapy in Patients Who Underwent Heart Transplant in Colombia

OBJECTIVES

To evaluate the cost-effectiveness of pharmacological treatment in maintenance therapy for adult heart transplant recipients from the Colombian health system perspective.

METHODS

We constructed a decision tree model with a 1-year time horizon. A review of the clinical literature was performed to extract probabilities of health events and acute rejections avoided were used as the health outcome. Costs were calculated from the base-case approximation and were obtained from administrative databases in Colombia (Sistema de Información de Precios de Medicamentos 2020 and Suficiencia 2012-2019), and the prices were adjusted to US dollar 2021.

RESULTS

Two evaluation results were presented. The first evaluates the tacrolimus + azathioprine + corticosteroid (TAC) scheme compared with cyclosporine + azathioprine + corticosteroid (CAC), in which the incremental cost-effectiveness ratio indicates that 1 additional rejection avoided has a cost of US dollar $5461.09 which, compared with the cost-effectiveness threshold in the base case, indicates that the TAC scheme is not a cost-effective (CE) strategy with respect to the CAC scheme. The second result shows the comparison of tacrolimus + mycophenolate mofetil + corticosteroid (TMC) with cyclosporine + mycophenolate mofetil + corticosteroid (CMC) in which TMC was found to be a dominant alternative to CMC.

CONCLUSIONS

The tacrolimus-based immunosuppression scheme is not CE in its TAC scheme, versus CAC, and is dominant in its TMC scheme, versus CMC, sensitivity analyses show that tacrolimus could become a CE alternative in any scheme used against higher cost-effectiveness threshold.

Economic evaluation of self-help group interventions for health in LMICs: a scoping review

This scoping review aims to identify and critically appraise published economic evaluations of self-help group (SHG) interventions in low- and middle-income countries (LMICs) that seek to improve health and potentially also non-health outcomes. Through a systematic search of MEDLINE ALL (Ovid), EMBASE Ovid, PsychINFO, EconLit (Ovid) and Global Index Medicus, we identified studies published between 2014 and 2020 that were based in LMICs, included at least a health outcome, estimated intervention costs and reported the methods used. We critically analysed whether the methods employed can meaningfully inform decisions by ministries of health and other sectors, including donors, regarding whether to fund such interventions, and prioritized the aspects of evaluations that support decision-making and cross-sectoral decision-making especially. Nine studies met our inclusion criteria. Randomized controlled trials were the most commonly used vehicle to collect data and to establish a causal effect across studies. While all studies clearly stated one or more perspectives justifying the costs and effects that are reported, few papers clearly laid out the decision context or the decision maker(s) informed by the study. The latter is required to inform which costs, effects and opportunity costs are relevant to the decision and should be included in the analysis. Costs were typically reported from the provider or health-care sector perspective although other perspectives were also employed. Four papers reported outcomes in terms of a generic measure of health. Contrary to expectation, no studies reported outcomes beyond health. Our findings suggest limitations in the extent to which published studies are able to inform decision makers around the value of implementing SHG interventions in their particular context. Funders can make better informed decisions when evidence is presented using a cross-sectoral framework.

Corticosteroids for the treatment of respiratory infection by Mycoplasma pneumoniae in children: A cost-utility analysis

INTRODUCTION

Increasing evidence has demonstrated the effectiveness and safety of corticosteroids in community-acquired pneumonia in children. More economic evaluations incorporating the new evidence and in the pediatric population are needed to know the efficiency of this treatment. This study aimed to evaluate the cost utility of the use of corticosteroids as adjuvant treatment for children with Mycoplasma pneumonia.

METHODS

A decision tree model was used to estimate the cost and quality adjusted life years (QALY) associated with cost-effectiveness as an adjunct treatment for children with Mycoplasma pneumonia with persistent signs after standard treatment with macrolide drugs for ≥1 week. Multiple sensitivity analyses were conducted.

RESULTS

The QALYs per person estimated in the model for those treatments were 0.92 with corticosteroids plus antibiotics and 0.91 with antibiotics. The total costs per person were US$965 for corticosteroids plus antibiotics and US$1271 for antibiotics. This position of absolute dominance of corticosteroids plus antibiotics over antibiotics makes it unnecessary to estimate the incremental cost-effectiveness ratio.

CONCLUSION

Corticosteroids are cost-effective as an adjunct treatment for children with Mycoplasma pneumoniae pneumonia with persistent signs after standard treatment with macrolide drugs for ≥1 week. Our evidence should motivate the evaluation of this treatment in other countries.

Effect of Sterilization on the Dimensional and Mechanical Behavior of Polylactic Acid Pieces Produced by Fused Deposition Modeling

To successfully implement additive manufacturing (AM) techniques for custom medical device (MD) production with low-cost resources, it is imperative to understand the effect of common and affordable sterilization processes, such as formaldehyde or steam sterilization, on pieces manufactured by AM. In this way, the performance of low-risk MDs, such as biomodels and surgical guides, could be assessed for complying with safety, precision, and MD delivery requirements. In this context, the aim of the present work was to evaluate the effect of formaldehyde and steam sterilization on the dimensional and mechanical stability of standard polylactic acid (PLA) test pieces produced by fused deposition modeling (FDM). To achieve this, PLA samples were sterilized according to the sterilization protocol of a public hospital in the city of Bucaramanga, Colombia. Significant changes regarding mechanical and dimensional properties were found as a function of manufacturing parameters. This research attempts to contribute to the development of affordable approaches for the fabrication of functional and customized medical devices through AM technologies, an issue of particular interest for low- and middle-income countries.

Cost-utility of ambrisentan and bosentan for pediatric pulmonary arterial hypertension

INTRODUCTION

Despite the increasing evidence supporting the efficacy of ambrisentan and bosentan in improving functional classes among pediatric patients with pulmonary arterial hypertension (PAH), there is a lack of information regarding their cost implications. Therefore, the objective of this study is to assess the cost-utility of bosentan compared to ambrisentan for the treatment of pediatric patients with PAH in Colombia.

METHODS

We employed a Markov model to estimate the costs and quality-adjusted life-years (QALYs) associated with the use of ambrisentan or bosentan in pediatric patients diagnosed with pulmonary arterial hypertension (PAH). To ensure the reliability of our findings, we conducted sensitivity analyses to assess the robustness of the model. In our cost-effectiveness analysis, we evaluated the outcomes at a willingness-to-pay (WTP) threshold of US$5,180.

RESULTS

The expected annual cost per patient receiving ambrisentan was estimated to be $16,055 (95% CI 15,937 -16,172), while for bosentan it was $14,503 (95% CI 14,489 -14,615). The QALYs per person estimated for ambrisentan were 0.39 (95% CI 0.381-0.382), whereas for bosentan it was 0.40 (95% CI 0.401-0.403).

CONCLUSION

Our economic evaluation shows that ambrisentan is not cost-effective regarding bosentan to in treating pulmonary arterial hypertension in C.

High cost drugs in Latin America: access and barriers

INTRODUCTION

Latin America comprises a large set of culturally diverse middle-income countries sharing an inequality gap and a rapidly ageing population. A better informed growing middle class adds to the pressure on fragmented health systems that strive to attain universal coverage. Cost containment becomes crucial for sustainability.

AREAS COVERED

Using "high cost" as free term, together with individual country names, a search was performed in Pubmed and Scopus databases for relevant documents centered on pharmaceutical products. References of selected articles were also reviewed.

EXPERT OPINION

In the region as elsewhere improving health information systems has been the starting point. Official health technology assessment agencies have been established in several countries, supporting decisions on best available evidence. A few centralized procurement and price regulation schemes using international reference pricing have been successful. Fast-track approval of generics and biosimilars, or establishing a separate funding source for high cost technologies are other options that, with varying degrees of success, have been. Since Latin America is characterized by its social, geographical and political diversity, each health system needs to recognize its individual priorities, learn from successful experiences elsewhere, and adapt possible alternative interventions to the different local contexts.

Cost-Utility Analysis Comparing Ocrelizumab vs Rituximab in the Treatment of Relapsing-Remitting Multiple Sclerosis: The Colombian Perspective

OBJECTIVES

This study aimed to determine the cost-utility of ocrelizumab versus rituximab in patients with RRMS, from the perspective of the Colombian healthcare system.

METHODOLOGY

Cost-utility study based on a Markov model, with a 50-year horizon and payer perspective. The currency was the US dollar for the year 2019, with a cost-effectiveness threshold of $5180 defined for Colombian health system. The model used annual cycles according to the health status determined by the disability scale. Direct costs were considered, and the incremental cost-effectiveness ratio per 1 quality-adjusted life-year (QALY) gained was used as the outcome measure. A discount rate of 5% was applied to costs and outcomes. Multiple one-way deterministic sensitivity analyses and 10 000 Monte Carlo simulation were conducted.

RESULTS

For the treatment of patients with RRMS, ocrelizumab versus rituximab had an incremental cost-effectiveness ratio of $73 652 for each QALY gained. After 50 years, 1 subject treated with ocrelizumab earns 4.8 QALYs >1 subject treated with rituximab, but at a higher cost of $521 759 versus $168 752, respectively. Ocrelizumab becomes a cost-effective therapy if its price is discounted > 86% or if there is a high willingness to pay.

CONCLUSIONS

Ocrelizumab was not a cost-effective drug as compared with rituximab in treating patients with RRMS in Colombia.

Phosphodiesterase 5 Inhibitor for Pediatric Pulmonary Arterial Hypertension: A Cost-Utility Analysis

OBJECTIVES

Despite the growing evidence of efficacy, scarce information exists regarding the cost of tadalafil to improve the functional classes of pediatric patients with pulmonary arterial hypertension. This study aims to determine the cost-utility of tadalafil compared sildenafil to treat pediatric patients with pulmonary arterial hypertension in Colombia.

METHODS

A Markov model was developed to compare expected costs, outcomes, and quality-adjusted life-years of sildenafil and tadalafil in pediatric patients with pulmonary arterial hypertension. The model was analyzed probabilistically, and a value of information analysis was conducted to inform the value of conducting further research to reduce current uncertainties in the evidence base. Cost-effectiveness was evaluated at a willingness-to-pay value of US $5180.

RESULTS

The mean incremental cost of tadalafil versus sildenafil is US $15 270. The 95% credible interval for the incremental cost ranges from US $28 033.65 to US $5940.86. The mean incremental benefit of tadalafil versus sildenafil is 1.00 quality-adjusted life-years (QALY). The 95% credible interval for the incremental benefit ranges from 1.88 to 0.31 QALY. The expected incremental cost per QALY is estimated at US $15 286. There is a probability less than 1% that tadalafil is more cost-effective than sildenafil at a threshold of US $5180 per QALY. Form the value of information analysis, the theoretical upper bound on the value of further research was US $9.298 for Colombia.

CONCLUSION

Our economic evaluation shows that tadalafil is not cost-effective regarding sildenafil to treat pediatric patients with pulmonary arterial hypertension in Colombia. Our study provides evidence that should be used by decision-makers to improve clinical practice guidelines.

Cost-utility and budget impact analysis of CPAP therapy compared to no treatment in the management of moderate to severe obstructive sleep apnea in Colombia from a third-party payer perspective

OBJECTIVES

To conduct cost-utility and budget impact analysis of providing Continuous Positive Airway Pressure (CPAP) therapy versus no treatment for moderate to severe obstructive sleep apnea (OSA) in Colombia from a third-party payer perspective.

METHODS

We used a Markov model to assess the cost-utility and budget impact analysis of CPAP in patients over 40 years old with moderate to severe OSA. Data on effectiveness and utility values were obtained from published literature. A discount rate of 5% was applied for outcomes and costs. ICER was calculated and compared against the threshold estimated for Colombia, which is 86% of the GDP per capita.

RESULTS

Over a lifetime horizon, the base case analysis showed the incremental cost per quality-adjusted life-years (QALYs) gained with CPAP therapy was COP$3,503,804 (USD$1,011 in 2020 prices). The budget impact analysis showed that the adoption of CPAP therapy in the target population would lead to a cumulative net budget impact of COP$411,722 million (USD$118,784,412 in, 2020 prices) over five years of time horizon.

CONCLUSIONS

CPAP was cost-effective compared to no-treatment in OSA. According to the budget impact analysis, adopting this technology would require a budget allocation that is partially offset by reduced number of strokes and traffic accident events.

Comparison of three alternatives for the management of moderate asthma in children aged 6-11 years: a cost-utility analysis

BACKGROUND

Recent asthma guidelines for children 6-11 years with persistent asthma advocate three alternatives: SMART (budesonide/formoterol 80/4.5 mcg qd plus additional doses as needed), fixed combination of budesonide/formoterol, and fixed-dose budesonide. Concerns have arisen as to which of the proposed alternatives has the best possible cost-effectiveness profile. This study aimed to assess the health and economic consequences of SMART, fixed combination, and fixed-dose budesonide therapy in children 6-11 years old with persistent asthma.

METHODS

A probabilistic Markov model was created to estimate the cost and quality-adjusted life-years (QALYs) of patients with persistent asthma. Total costs and QALYs of SMART, fixed combination, and fixed-dose budesonide therapy were calculated over a time horizon of 6 years. Multiple sensitivity analyses were conducted.

RESULTS

The mean QALY per patient was 0.57 and 0.56 QALYs per patient per year of SMART and fixed combination and 0,52 with fixed-dose budesonide. The total mean of discounted costs per patient per cycle were US$111 for SMART, US$133 for fixed combination, and US$67 for fixed-dose budesonide. The net monetary benefit of SMART was US$12,549, US$12278 for fixed combination, and US$11,380 for fixed-dose budesonide.

CONCLUSION

Our study showed that SMART was more cost-effective than fixed combination and fixed-dose budesonide. These findings complement and support the GINA 2021 and National Asthma Education and Prevention Program asthma guideline recommendations for use of inhaled corticosteroids-formoterol in children 6-11 years old with persistent asthma.

Cost-Utility of Continuous Positive Airway Pressure for Respiratory Distress in Preterm Infants in a Middle-Income Country

OBJECTIVES

Despite the increased popularity of continuous positive airway pressure (CPAP) for preterm infants with respiratory distress, there is still uncertainty about whether the additional costs of this device justify the clinical benefits provided. This study aims to evaluate the cost-utility of CPAP in spontaneously breathing preterm infants with respiratory distress.

METHODS

Using a decision tree model, we estimated the cost and quality-adjusted life-years (QALYs) associated with CPAP and supplemental oxygen alone by headbox or low-flow nasal cannula (SO). The model was analyzed probabilistically, and a value of information analysis was conducted to inform the value of conducting further research to reduce current uncertainties in the evidence base. Cost-effectiveness was evaluated at a willingness-to-pay value of US$5180.

RESULTS

The mean incremental cost of CPAP versus SO was US$600. The mean incremental benefit of CPAP versus SO was 0.04 QALY. The expected incremental cost per QALY was estimated at US$13 172. The mean incremental net monetary benefit was US$-324 with a 95% credible interval of US$-536 to US$-201. The overall expected value of perfect information per person affected by the decision was estimated to be US$2346.

CONCLUSIONS

Compared with SO, the use of CPAP in spontaneously breathing preterm infants with respiratory distress is not cost-effective in Colombia. Evidence should continue to be generated with real-life effectiveness data and economic evaluations in other countries to confirm our findings.

Adherence to guidelines on the use of amoxicillin for treatment of ambulatory pneumonia in children younger than 5 years, Colombia, 2017-2019

Objectives

To determine the level of adherence to clinical guidelines in prescribing amoxicillin to children younger than 5 years with pneumonia in outpatient settings in Colombia from 2017 to 2019, and assess the factors associated with adherence.

Methods

This was a cross-sectional study of secondary data from the Colombian Integrated Social Protection Information System database. Adherence was defined as prescription of oral amoxicillin for bacterial and unspecified pneumonia and non-prescription for viral pneumonia. Variables examined included: age (< 1 year, 1-4 years) of child; sex; cause of pneumonia (bacterial, viral, unspecified); region (Andean, Amazonian, Pacific, Caribbean, Insular, Orinoquian); and payment mechanism (without prior authorization, capitation, direct payment, pay per case, pay for event).

Results

Of 215 925 cases of community-acquired pneumonia reported during 2017-2019, 64.8% were from the Andean region, 73.9% were bacterial pneumonia and 1.8% were viral pneumonia. Adherence to guidelines was observed in 5.8% of cases: this was highest for children diagnosed with viral (86.0%) compared with bacterial (2.0%) pneumonia. For children diagnosed with bacterial pneumonia, 9.4% were prescribed any antibiotic. A greater proportion of children covered by capitated payments (22.3%) were given treatment consistent with the guidelines compared with payment for event (1.3%).

Conclusion

In this first study from Colombia, adherence to guidelines for outpatient treatment of children with bacterial pneumonia was low and was better for viral pneumonia. Further qualitative studies are needed to explore the reasons for this lack of adherence and why bacterial pneumonia was the most commonly reported etiology.

Informing a cost-effectiveness threshold for Saudi Arabia

BACKGROUND

Saudi Arabia's Vision 2030 aims to reform health care across the Kingdom, with health technology assessment being adopted as one tool promising to improve the efficiency with which resources are used. An understanding of the opportunity costs of reimbursement decisions is key to fulfilling this promise and can be used to inform a cost-effectiveness threshold. This paper is the first to provide a range of estimates of this using existing evidence extrapolated to the context of Saudi Arabia.

METHODS AND MATERIALS

We use four approaches to estimate the marginal cost per unit of health produced by the healthcare system; drawing from existing evidence provided by a cross-country analysis, two alternative estimates from the UK context, and based on extrapolating a UK estimate using evidence on the income elasticity of the value of health. Consequences of estimation error are explored.

RESULTS

Based on the four approaches, we find a range of SAR 42,046 per QALY gained (48% of GDP per capita) to SAR 215,120 per QALY gained (246% of GDP per capita). Calculated potential central estimates from the average of estimated health gains based on each source gives a range of SAR 50,000-75,000. The results are in line with estimates from the emerging literature from across the world.

CONCLUSION

A cost-effectiveness threshold reflecting health opportunity costs can aid decision-making. Applying a cost-effectiveness threshold based on the range SAR 50,000 to 75,000 per QALY gained would ensure that resource allocation decisions in healthcare can in be informed in a way that accounts for health opportunity costs.

LIMITATIONS

A limitation is that it is not based on a within-country study for Saudi Arabia, which represents a promising line of future work.

OM-85 BV in pediatric recurrent respiratory tract infections: a cost-utility analysis

BACKGROUND

Despite the growing evidence on efficacy, little is known regarding the cost-utility of Vaxom/Imocur (OM-85 BV) supplementation to decrease the probability of recurrent respiratory tract infections in OM-85 BV to reduce the incidence of recurrent respiratory tract infections in children.

METHODS

A decision tree model was used to estimate the cost and quality-adjusted life-years (QALYs) of OM-85 BV in a patient aged 1-6 with a history of recurrent respiratory tract infections. Multiple sensitivity analyses were conducted to evaluate the robustness of the model. Cost-effectiveness was evaluated using the willingness-to-pay defined for Colombia of US$5180 per QALY. The time horizon defined was six months. Costs were estimated from a societal perspective.

RESULTS

The expected annual cost per patient with OM-85 BV was US$843 and with placebo was US$1167. The QALYs per person estimated with OM-85 BV was 0.91 and with placebo was 0.89.

CONCLUSION

In conclusion, our study shows that OM-85 BV is a cost-effective strategy to reduce the incidence of recurrent respiratory tract infections in children. Our study provides evidence that should be used by decision-makers to improve clinical practice guidelines.

Systematic review and cost-utility of high flow nasal cannula versus continuous positive airway pressure in children with acute severe or moderate bronchiolitis in Colombia

BACKGROUND

Nasal Continuous Positive Airway Pressure (CPAP) and High-Flow Nasal Cannula (HFNC) have emerged as alternatives to orotracheal intubation and conventional invasive ventilation in patients with moderate to severe bronchiolitis. This study aims to evaluate the evidence and the cost-utility of HFNC compared to CPAP in infants with moderate-severe bronchiolitis in Colombia.

METHODS

The search includes electronic databases such as Pubmed, ScienceDirect, and Embase. Through inclusion and exclusion criteria, screen randomized controlled trials. A decision tree model was used to estimate the cost-utility of CPAP compared with HFNC in infants with moderate-severe bronchiolitis. Sensitivity analysis of transition probabilities, utilities, and cost was carried out.

RESULTS

Incorporate five studies that meet the criteria. The risk of intubation rate in the patients with CPAP is lower than HFNC (relative risk 0.62; 95% confidence interval 0.46-0.84; I2  = 0%) The base-case analysis showed that compared with HFNC, CPAP was associated with lower costs and higher quality-adjusted life years (QALYs). The expected annual cost per patient with CPAP was US$17,574 and with HFNC was US$29,421. The QALYs per person estimated with CPAP were 0.92 and with HFNC was 0.91. This position of absolute dominance of CPAP (CPAP has lower costs and higher QALYs than HFNI) makes it unnecessary to estimate the incremental cost-utility ratio.

CONCLUSIONS

CPAP is cost-effective, over the HFNC, in infants with severe-moderate bronchiolitis in Colombia. Our study provides evidence that should be used by decision-makers to improve clinical practice guidelines and should be replicated to validate their results in other countries.

Vitamin A supplementation for the prevention of chronic lung disease in premature infants: A cost-utility analysis

INTRODUCTION

Despite the growing evidence on efficacy, little is known regarding the efficiency of Vitamin A supplementation to decrease the probability of chronic lung disease (CLD) in preterm infants. This study aims to determine the cost-utility of Vitamin A to prevent CLD in preterm infants in Colombia.

METHODS

A decision tree model was used to estimate the cost and quality-adjusted life-years (QALYs) of Vitamin A supplementation in preterm infants. Multiple sensitivity analyses were conducted to evaluate the robustness of the model. Cost-effectiveness was evaluated at a willingness-to-pay value of US$5180.

RESULTS

Vitamin A was associated with lower costs and higher QALYs. The expected annual cost per patient with Vitamin A was US$1579 (95% CI US$1555-US$1585) and without Vitamin A was US$1913 (95% CI US$1891-US$1934). The QALYs per person estimated with Vitamin A was 0.66 (95% CI 0.66-0.67) and without Vitamin A was 0.61 (95% CI 0.60-0.61). This position of absolute dominance (Vitamin A has lower costs and higher QALYs than without Vitamin A) is unnecessary to estimate the incremental cost-effectiveness ratio.

CONCLUSION

Our economic evaluation shows that Vitamin A is cost-effective to reduce the incidence rate of CLD in premature infants in Colombia. Our study provides evidence that should be used by decision-makers to improve clinical practice guidelines.

Dupilumab in children with moderate-to-severe asthma: A cost utility analysis

INTRODUCTION

Dupilumab is an effective and safe medicine for the management of severe asthma. Due to its high cost, concerns are generated regarding its cost-effectiveness. This study aimed to estimate the cost-utility of dupilumab plus standard of care (SoC) versus SoC alone in children between 6 and 11 years old with severe asthma and eosinophilic phenotype.

METHODS

A Markov-type model was developed to estimate costs and health outcomes of a simulated cohort of pediatric patients with persistent asthma treated over a 6-year period. To determine the robustness of the model deterministic and probabilistic sensitivity analyses were conducted.

RESULTS

The quality-adjusted life-years (QALYs) per patient estimated were 0.85 with dupilumab and 0.84 with SoC. The total mean of discounted costs per patient per cycle were US$ 379 for dupilumab and US$ 19 for SoC. The incremental cost-effectiveness ratio estimated was $24 660 US$ per QALY CONCLUSION: Dupilumab is not cost-effective in Colombia in children between 6 and 11 years old with severe asthma and eosinophilic phenotype. Our evidence should motivate regulatory agencies to improve negotiations for new drugs with better information and evidence.

Cost-Effectiveness Analysis of Pertuzumab Plus Trastuzumab and Docetaxel Compared With Trastuzumab and Docetaxel in the Adjuvant Treatment of Human Epidermal Growth Factor Receptor 2-Positive Metastatic Breast Cancer in Colombia

OBJECTIVES

The addition of pertuzumab to the scheme of docetaxel plus trastuzumab (TH) in patients with metastatic breast cancer with overexpression of human epidermal growth factor receptor 2 increases survival. Nevertheless, this addition could represent a high cost for the health system of a middle-income country such as Colombia. Therefore, it is necessary to evaluate the efficiency of the pertuzumab plus TH (PTH) scheme in comparison with TH.

METHODS

A partitioned survival model-based cost-utility analysis was performed. Progression-free survival and overall survival curves for each scheme were obtained from the CLEOPATRA study. The time horizon was 30 years with a discount rate of 5% for costs and quality-adjusted life-years. Total direct costs were calculated using national tariffs. Utilities were obtained from external sources. Model uncertainty was evaluated by deterministic and probabilistic sensitivity analysis. A willingness to pay value of 5180 US dollars was used.

RESULTS

The discounted total average costs of TH and PTH were $24 109 and $60 846, respectively. These regimens' average life-years were 5.78 and 8.38, and their quality-adjusted life-years were 3.28 and 4.51, respectively. The incremental cost-effectiveness ratio was $29 867. One-way sensitivity analysis showed that the cost of pertuzumab was the variable that explained the uncertainty in the model. The probability that PTH is cost-effective in the probabilistic sensitivity analysis is 0.0724.

CONCLUSIONS

The addition of pertuzumab to the TH regimen in patients with human epidermal growth factor receptor 2-positive metastatic breast cancer has a low probability of being cost-effective from the payer's perspective in the Colombian health system.

Cost utility of Vitamin D supplementation in adults with mild to moderate asthma

IntroductionUncontrolled asthma significantly impairs health-related quality of life and work productivity. Some add-on therapies, such as vitamin D supplements, safely reduce the rate of asthma exacerbation. The purpose of this study was to assess the cost-utility of vitamin D supplementation in adults with mild to moderate persistent asthma in Colombia.MethodsA Markov model was created to estimate the cost and quality-adjusted life-years (QALYs) of patients with severe asthma in Colombia. Total costs and QALYs of two therapy strategies, vitamin D supplementation plus ICS versus ICS alone, were calculated over a one-year time horizon. Deterministic and probability sensitivity analyses were conducted, and cost-effectiveness was evaluated at a willingness-to-pay value of $5,180 per QALY gained.ResultsThe base-case analysis showed that compared with no supplementation, vitamin D supplementation was associated with higher costs and higher QALYs. The expected annual cost per patient with vitamin D supplementation was US$1338 and without this supplementation it was US$1095. The QALYs per person estimated with vitamin D supplementation was 0,80, and without this supplementation it was 0,63. The estimated incremental cost-effectiveness ratio (ICER) was US$1583 per QALY.ConclusionAdd-on vitamin D supplement was cost-effective when added to the usual care in patients with mild to moderate persistent asthma. Our study provides evidence that should be used by decision-makers to improve clinical practice guidelines.

Fractional exhaled nitric oxide and eosinophil count in induced sputum to guide the management of children with asthma: a cost-utility analysis

Introduction

Previous evidence has shown that fractional exhaled nitric oxide (FeNO) and eosinophil count in induced sputum (EO) are cost-effective relative to standard of care in guiding the management of children with persistent asthma. There is some doubt as if there are differences between these two biomarkers in terms of costs and benefits. Clarifying this doubt would allow prioritization of the design of clinical practice guidelines. The study aimed to compare in terms of costs and benefits these biomarkers in patients with asthma between 4 and 18 years of age.

Methods

A Markov model was used to estimate the cost-utility of asthma management using FeNO and EO in patients between 4 and 18 years of age. Transition probabilities, cost and utilities were estimated from previously published local studies, while relative risks were obtained from the systematic review of published randomized clinical trials. The analysis was carried out from a societal perspective.

Results

The expected annual cost per patient with EO was US $1376 (CI 95% US $1376–US $1377) and for FeNO was US $1934 (CI 95% US $1333–US $1334), with a difference of US $42.3 between these strategies. The Quality-adjusted life years (QALYs) per person estimated with EO was 0.95 (CI 95% 0.951–0.952) and for FeNO was 0.94 (CI 95% 0.930–0.940), with a difference of 0.01 between these strategies. The NMB with EO was US $4902 (CI 95% 4900–4904) and for FeNO was US $4841 (CI 95% 4839–4843). The incremental cost-effectiveness ratio of EO was $3566 per QALY gained regarding FeNO.

Conclusion

Our study demonstrates that induced sputum-guided management is a strategy cost-effective over FeNO and standard asthma management in Colombia. This evidence should encourage the adoption of any of these techniques to objectively guide the management of children with asthma in routine clinical practice in low-resource settings.

Cost-effectiveness of procalcitonin for detection of serious bacterial infections in children presenting with fever without source

INTRODUCTION

Procalcitonin (PCT) offers better specificity than C-reactive protein (CRP) to detect SBI. However, their cost limited their use and routine application. The objective of this work is to determine the cost-effectiveness of PCT against CPR or Rochester scale in infants between 1 and 3 months from the perspective of the third payer in Colombia.

METHODS

A Monte Carlo simulation was performed with a hypothetical cohort of 10,000 patients with fever without focus (FWS) between 1 to 3 months, to estimate the number of cases correctly diagnosed for each test and the associated costs with each test.

RESULTS

The test with the highest number of correctly diagnosed cases was PCT 79%, followed by C-reactive protein 75%, and the Rochester scale 68%. The test with the lowest cost per patient was PCT $645 (95% CI US$646-US$645) followed by C-reactive protein U$ 653 (95% CI US$655-$645) and Rochester scale US$804 (95% CI US$807-US$804). This position of dominance of PCT eliminated the need to calculate an incremental cost effectiveness ratio.

CONCLUSIONS

PCT is the most cost-effective strategy for the detection of IBS in infants with FWS. These results should be interpreted within the clinical context of the patient and not as a single method for therapeutic decision-making.

Cost Utility of Intermittent Inhaled Corticosteroids in Preschoolers with Viral-Triggered Wheeze

Background: Evidence has demonstrated that adding intermittent inhaled corticosteroids (ICS) to treatment with short-acting b2-agonists (SABAs) in children 5 years of age and younger who experience intermittent viral-induced wheezing (VIW) reduces the risk of severe exacerbations. However, there is concern about whether the extra benefit offered by this drug outweighs the additional cost. This study aimed to evaluate the cost-effectiveness of intermittent ICS in children 5 years of age and younger who experience intermittent VIW. Methods: We constructed a probabilistic Markov model to estimate the cost and quality-adjusted life-years (QALYs) of intermittent ICS compared with SABA reliever therapy in preschoolers with viral-triggered wheezing in Colombia. Multiple sensitivity analyses were conducted. Cost-effectiveness was evaluated at a willingness-to-pay value of $5,180. Results: In an analysis of the Markov cohort model, we estimated a gain of 0.2 QALYs per patient per year on intermittent ICS compared with SABA and a reduction of cost per patient of USD $37 per year. This position of dominance negated the need to calculate an incremental cost-effectiveness ratio. Deterministic and probabilistic sensitivity analyses, our base case results were robust to variations of all assumptions and parameters. Conclusion: Adding intermittent ICS to treatment with SABAs in children 5 years of age and younger who experience intermittent VIW was found to be cost effective. These results could improve the use of health care resources, especially in settings with limited economic resources.