Incorporating future costs in medical cost-effectiveness analysis: implications for the cost-effectiveness of the treatment of hypertension

Optimal age to stop prostate cancer screening and early detection

BACKGROUND

Prostate Cancer screening should be discontinued at older ages because competing mortality risks eventually dominate the risk of Prostate Cancer and harms exceed benefits. We explored the Prostate Cancer screening stopping age from the patient, healthcare system, and social perspectives in Iran.

METHODS

We applied Bellman Equations to formulate the net benefits biopsy and "do nothing". Using difference between the net benefits of two alternatives, we calculated the stopping age. The cancer states were without cancer, undetected cancer, detected cancer, metastatic cancer, and death. To move between states, we applied Markov property. Transition probabilities, rewards, and costs were inferred from the medical literature. The base-case scenario estimated the stopping age from the patient, healthcare system, and social perspectives. A one-way sensitivity used to find the most influential parameters on the stopping age.

RESULTS

Our results suggested that Prostate Cancer screening stopping ages from the patient, healthcare system, and social were 70, 68, and 68 respectively. The univariate sensitivity analysis showed that the stopping ages were sensitive to the disutility of treatment, discount factor, the disutility of metastasis, the annual probability of death from other causes, and the annual probability of developing metastasis from the hidden cancer state.

CONCLUSIONS

Men should not be screened for Prostate Cancer beyond 70 years old, as this results in the net benefit of "do nothing" above the biopsy. Nevertheless, this finding needs to be further studied with more detailed cancer progression models (considering re-biopsy, comorbidities, and more complicated states transition) and using local utility and willingness to pay value information.

Incorporating future unrelated medical costs in cost-effectiveness analysis in China

The occurrence of future unrelated medical costs is a direct consequence of life-prolonging interventions, but most pharmacoeconomic guidelines recommend the exclusion of these costs. The Chinese guidelines were updated in 2020, taking an exclusion approach for the future unrelated medical cost. We notice the research surrounding this issue continues in other countries and leads to an inclusion recommendation in some guidelines. Meanwhile, this issue has not been discussed in China, reflecting an urgent need for extensive research on its impact. We reviewed the theoretical and practical studies surrounding the inclusion of future unrelated medical costs, summarised the landscape of guidelines in other jurisdictions. We found that the inclusion would increase the internal and external consistency of economic evaluation and the comparability of results between different jurisdictions. However, more research is needed surrounding this issue. We proposed a future research agenda to inform the update of Chinese guidelines. We recommend research on individual-level healthcare reimbursement data and end-of-life costs from hospital administrative data to generate the age-specific, sex-specific and condition-specific costs. We also recommend establishing a formal process to evaluate the ethical and economic impact of including future unrelated medical costs and adjust the threshold accordingly in the guidelines.

Catalog of Age- and Medical Condition-Specific Healthcare Costs in the United States to Inform Future Costs Calculations in Cost-Effectiveness Analysis

OBJECTIVES

This study aims to develop a catalog of annual age- and medical condition-specific healthcare costs per capita among those who are living at a certain age (survivors) and the costs attributable to death itself for those who die at that age (decedents) in the United States. These estimates can be used to inform future cost calculations in cost-effectiveness analysis (CEA).

METHODS

We discussed a theoretical framework to incorporate futures costs in CEA. We used the nationally representative Medical Expenditure Panel Survey data to estimate costs among survivors and death costs. For survivors, we obtained cost estimates nonparametrically using kernel-based regression and locally weighted scatterplot smoothing. We estimated costs attributable to death using inverse probability weights comparing decedents with appropriately weighted survivors at a given age after controlling for more than 270 clinical condition classifications, demographics, and interactions. Cost estimates were expressed in 2019 US dollar and also separately by sex and specific clinical conditions.

RESULTS

Average healthcare costs per capita among survivors, expectedly, rose over age from $2062 (95% confidence interval [CI] $1553-$2478) during the first year of life to $14 307 (95% CI $13 706-$14 956) at 85 years or older. Average costs of death were $44 569 (95% CI $14 304-$67 369) during the first year of life and declined by -$321 (95% CI -$620 to -$22) per 1 year older.

CONCLUSIONS

The US catalog of healthcare costs among survivors and decedents can facilitate calculations of future costs in CEA as recommended by the Second Panel on Cost-Effectiveness in Health and Medicine.

Perspective and Costing in Cost-Effectiveness Analysis, 1974-2018

OBJECTIVE

Our objective was to examine perspective and costing approaches used in cost-effectiveness analyses (CEAs) and the distribution of reported incremental cost-effectiveness ratios (ICERs).

METHODS

We analyzed the Tufts Medical Center's CEA and Global Health CEA registries, containing 6907 cost-per-quality-adjusted-life-year (QALY) and 698 cost-per-disability-adjusted-life-year (DALY) studies published through 2018. We examined how often published CEAs included non-health consequences and their impact on ICERs. We also reviewed 45 country-specific guidelines to examine recommended analytic perspectives.

RESULTS

Study authors often mis-specified or did not clearly state the perspective used. After re-classification by registry reviewers, a healthcare sector or payer perspective was most prevalent (74%). CEAs rarely included unrelated medical costs and impacts on non-healthcare sectors. The most common non-health consequence included was productivity loss in the cost-per-QALY studies (12%) and patient transportation in the cost-per-DALY studies (21%). Of 19,946 cost-per-QALY ratios, the median ICER was $US26,000/QALY (interquartile range [IQR] 2900-110,000), and 18% were cost saving and QALY increasing. Of 5572 cost-per-DALY ratios, the median ICER was $US430/DALY (IQR 67-3400), and 8% were cost saving and DALY averting. Based on 16 cost-per-QALY studies (2017-2018) reporting 68 ICERs from both the healthcare sector and societal perspectives, the median ICER from a societal perspective ($US22,710/QALY [IQR 11,991-49,603]) was more favorable than from a healthcare sector perspective ($US30,402/QALY [IQR 10,486-77,179]). Most governmental guidelines (67%) recommended either a healthcare sector or a payer perspective.

CONCLUSION

Researchers should justify and be transparent about their choice of perspective and costing approaches. The use of the impact inventory and reporting of disaggregate outcomes can reduce inconsistencies and confusion.

Future Costs in Cost-Effectiveness Analyses: Past, Present, Future

There has been considerable debate on the extent to which future costs should be included in cost-effectiveness analyses of health technologies. In this article, we summarize the theoretical debates and empirical research in this area and highlight the conclusions that can be drawn for current practice. For future related and future unrelated medical costs, the literature suggests that inclusion is required to obtain optimal outcomes from available resources. This conclusion does not depend on the perspective adopted by the decision maker. Future non-medical costs are only relevant when adopting a societal perspective; these should be included if the benefits of non-medical consumption and production are also included in the evaluation. Whether this is the case currently remains unclear, given that benefits are typically quantified in quality-adjusted life-years and only limited research has been performed on the extent to which these (implicitly) capture benefits beyond health. Empirical research has shown that the impact of including future costs can be large, and that estimation of such costs is feasible. In practice, however, future unrelated medical costs and future unrelated non-medical consumption costs are typically excluded from economic evaluations. This is explicitly prescribed in some pharmacoeconomic guidelines. Further research is warranted on the development and improvement of methods for the estimation of future costs. Standardization of methods is needed to enhance the practical applicability of inclusion for the analyst and the comparability of the outcomes of different studies. For future non-medical costs, further research is also needed on the extent to which benefits related to this spending are captured in the measurement and valuation of health benefits, and how to broaden the scope of the evaluation if they are not sufficiently captured.

Future Costs, Fixed Healthcare Budgets, and the Decision Rules of Cost-Effectiveness Analysis

Life-saving medical technologies result in additional demand for health care due to increased life expectancy. However, most economic evaluations do not include all medical costs that may result from this additional demand in health care and include only future costs of related illnesses. Although there has been much debate regarding the question to which extent future costs should be included from a societal perspective, the appropriate role of future medical costs in the widely adopted but more narrow healthcare perspective has been neglected. Using a theoretical model, we demonstrate that optimal decision rules for cost-effectiveness analyses assuming fixed healthcare budgets dictate that future costs of both related and unrelated medical care should be included. Practical relevance of including the costs of future unrelated medical care is illustrated using the example of transcatheter aortic valve implantation. Our findings suggest that guidelines should prescribe inclusion of these costs.

Incorporation of future costs in health economic analysis publications: current situation and recommendations for the future

Future costs are not usually included in economic evaluations. The aim of this study was to assess the extent of published economic analyses that incorporate future costs. A systematic review was conducted of economic analyses published from 2008 to 2013 in three general health economics journals: PharmacoEconomics, Value in Health and the European Journal of Health Economics. A total of 192 articles met the inclusion criteria, 94 of them (49.0%) incorporated future related medical costs, 9 (4.2%) also included future unrelated medical costs and none of them included future nonmedical costs. The percentage of articles including future costs increased from 2008 (30.8%) to 2013 (70.8%), and no differences were detected between the three journals. All relevant costs for the perspective considered should be included in economic evaluations, including related or unrelated, direct or indirect future costs. It is also advisable that pharmacoEconomic guidelines are adapted in this sense.

Ethical objections against including life-extension costs in cost-effectiveness analysis: a consistent approach

One of the major ethical concerns regarding cost-effectiveness analysis in health care has been the inclusion of life-extension costs ("it is cheaper to let people die"). For this reason, many analysts have opted to rule out life-extension costs from the analysis. However, surprisingly little has been written in the health economics literature regarding this ethical concern and the resulting practice. The purpose of this work was to present a framework and potential solution for ethical objections against life-extension costs. This work found three levels of ethical concern: (i) with respect to all life-extension costs (disease-related and -unrelated); (ii) with respect to disease-unrelated costs only; and (iii) regarding disease-unrelated costs plus disease-related costs not influenced by the intervention. Excluding all life-extension costs for ethical reasons would require-for reasons of consistency-a simultaneous exclusion of savings from reducing morbidity. At the other extreme, excluding only disease-unrelated life-extension costs for ethical reasons would require-again for reasons of consistency-the exclusion of health gains due to treatment of unrelated diseases. Therefore, addressing ethical concerns regarding the inclusion of life-extension costs necessitates fundamental changes in the calculation of cost effectiveness.

Predicting productivity based on EQ-5D: an explorative study

BACKGROUND

Productivity costs are often ignored in economic evaluations. In order to facilitate productivity cost inclusion, it has been suggested to estimate productivity costs indirectly using quality of life data.

OBJECTIVE

This study aimed to derive and validate an algorithm for predicting productivity losses on the basis of quality-of-life data using the EQ-5D-3L.

METHODS

A large representative sample of the Dutch general public (n = 1,100) was asked in a web-based questionnaire to state their expected level of productivity in terms of absenteeism and presenteeism for multiple EQ-5D health states. Based on these data, two generalized estimating equations (GEE) models were constructed: (1) a model predicting levels of absenteeism and (2) a model predicting presenteeism. The models were validated by comparing model predictions with conventionally measured productivity within a group of low back pain patients.

RESULTS

Predicted absenteeism levels based on EQ-5D health state closely resembled conventionally measured absenteeism levels. Productivity losses related to presenteeism seemed somewhat overestimated by our prediction model. Measured and predicted productivity were moderately but highly significantly correlated.

CONCLUSIONS

Overall, it appears possible to make reasonable productivity predictions based on EQ-5D data. Further exploration and validation of prediction algorithms remains necessary, however, especially for presenteeism.

Is testosterone replacement therapy in males with hypogonadism cost-effective? An analysis in Sweden

INTRODUCTION

Testosterone replacement therapy (TRT) has been recommended for the treatment of primary and secondary hypogonadism. However, long-term implications of TRT have not been investigated extensively.

AIM

The aim of this analysis was to evaluate health outcomes and costs associated with life-long TRT in patients suffering from Klinefelter syndrome and late-onset hypogonadism (LOH).

METHODS

A Markov model was developed to assess cost-effectiveness of testosterone undecanoate (TU) depot injection treatment compared with no treatment. Health outcomes and associated costs were modeled in monthly cycles per patient individually along a lifetime horizon. Modeled health outcomes included development of type 2 diabetes, depression, cardiovascular and cerebrovascular complications, and fractures. Analysis was performed for the Swedish health-care setting from health-care payer's and societal perspective. One-way sensitivity analyses evaluated the robustness of results.

MAIN OUTCOME MEASURES

The main outcome measures were quality-adjusted life-years (QALYs) and total cost in TU depot injection treatment and no treatment cohorts. In addition, outcomes were also expressed as incremental cost per QALY gained for TU depot injection therapy compared with no treatment (incremental cost-effectiveness ratio [ICER]).

RESULTS

TU depot injection compared to no-treatment yielded a gain of 1.67 QALYs at an incremental cost of 28,176 EUR (37,192 USD) in the Klinefelter population. The ICER was 16,884 EUR (22,287 USD) per QALY gained. Outcomes in LOH population estimated benefits of TRT at 19,719 EUR (26,029 USD) per QALY gained. Results showed to be considerably robust when tested in sensitivity analyses. Variation of relative risk to develop type 2 diabetes had the highest impact on long-term outcomes in both patient groups.

CONCLUSION

This analysis suggests that lifelong TU depot injection therapy of patients with hypogonadism is a cost-effective treatment in Sweden. Hence, it can support clinicians in decision making when considering appropriate treatment strategies for patients with testosterone deficiency.

Cost-utility analysis of eprosartan compared to enalapril in primary prevention and nitrendipine in secondary prevention in Europe--the HEALTH model

OBJECTIVE

To investigate the cost-utility of eprosartan versus enalapril (primary prevention) and versus nitrendipine (secondary prevention) on the basis of head-to-head evidence from randomized controlled trials.

METHODS

The HEALTH model (Health Economic Assessment of Life with Teveten for Hypertension) is an object-oriented probabilistic Monte Carlo simulation model. It combines a Framingham-based risk calculation with a systolic blood pressure approach to estimate the relative risk reduction of cardiovascular and cerebrovascular events based on recent meta-analyses. In secondary prevention, an additional risk reduction is modeled for eprosartan according to the results of the MOSES study ("Morbidity and Mortality after Stroke--Eprosartan Compared to Nitrendipine for Secondary Prevention"). Costs and utilities were derived from published estimates considering European country-specific health-care payer perspectives.

RESULTS

Comparing eprosartan to enalapril in a primary prevention setting the mean costs per quality adjusted life year (QALY) gained were highest in Germany (Euro 24,036) followed by Belgium (Euro 17,863), the UK (Euro 16,364), Norway (Euro 13,834), Sweden (Euro 11,691) and Spain (Euro 7918). In a secondary prevention setting (eprosartan vs. nitrendipine) the highest costs per QALY gained have been observed in Germany (Euro 9136) followed by the UK (Euro 6008), Norway (Euro 1695), Sweden (Euro 907), Spain (Euro -2054) and Belgium (Euro -5767).

CONCLUSIONS

Considering a Euro 30,000 willingness-to-pay threshold per QALY gained, eprosartan is cost-effective as compared to enalapril in primary prevention (patients >or=50 years old and a systolic blood pressure >or=160 mm Hg) and cost-effective as compared to nitrendipine in secondary prevention (all investigated patients).

Cost-effectiveness of HER2 testing and trastuzumab therapy for metastatic breast cancer

BACKGROUND

Trastuzumab is a monoclonal antibody that together with chemotherapy significantly improves time to progression and overall survival for metastatic breast cancer patients with tumours overexpressing HER2. The aim of this study was to analyse the cost-effectiveness of HER2 testing and trastuzumab in combination with chemotherapy compared with chemotherapy alone from a societal perspective in a Swedish setting.

MATERIAL AND METHODS

We used a Markov state transition model to simulate HER2 testing and subsequent treatment in a hypothetical cohort of 65 year old metastatic breast cancer patients. Outcomes included life-time costs, quality adjusted life years (QALY), and cost per QALY gained. Five different testing and treatment strategies were evaluated.

RESULTS

We estimated the cost per QALY gained to be about 485,000 SEK for the strategy of IHC testing for all patients, with FISH confirmation of 2+ and 3+, and trastuzumab and chemotherapy treatment for FISH positive patients. For the strategy of FISH testing for all patients, with trastuzumab and chemotherapy for FISH positive patients, we estimated the cost per QALY gained to about 561,000 SEK. The remaining testing and treatment strategies were dominated. Results were sensitive to changes in utilities, the risk of breast cancer related death, and test characteristics.

CONCLUSION

Our analysis indicate that FISH testing for all patients with trastuzumab and chemotherapy treatment for FISH positive patients is a cost-effective treatment option from a societal perspective.

Aging diseases--do they prevent preventive health care from saving costs?

The potential of preventive health-care services to save costs is intensely debated. On the one hand, a longer life span increases the probability that new and costly diseases occur. On the other hand, a higher life expectancy postpones the expensive last year of life (LYOL), which becomes cheaper with age. Using US expenditure data on survivors and decedents the paper shows that prevention in the general population causes expenditures for additional diseases that are larger than the savings from postponing the LYOL. This result may also hold for prevention in diseased individuals.

The lifetime cost effectiveness of amlodipine-based therapy plus atorvastatin compared with atenolol plus atorvastatin, amlodipine-based therapy alone and atenolol-based therapy alone: results from ASCOT1

BACKGROUND

ASCOT (Anglo-Scandinavian Cardiac Outcomes Trial) showed in hypertensive patients that blood pressure-lowering treatment with an amlodipine-based regimen reduces events compared with an atenolol-based regimen and that atorvastatin was more effective than placebo.

OBJECTIVE

To assess the cost effectiveness of four alternative treatment strategies in patients with hypertension and three or more cardiovascular risk factors in the UK (from the UK NHS perspective) or Sweden (from the societal perspective): amlodipine-based plus atorvastatin, atenolol-based plus atorvastatin, amlodipine-based alone and atenolol-based alone.

METHODS

Based on the trial data, a Markov model was constructed where the risk of myocardial infarction, revascularization procedures and stroke and the long-term costs, quality of life and mortality associated with these events were estimated. Transition probabilities and costs (euro, 2007 values) were based on the patient-level trial data. Outcomes were reported as life-years gained and QALYs. In the latter case, utility reduction from events was based on a substudy in ASCOT patients. Treatment was applied for the duration of the lipid-lowering arm of the trial (3 years) and patients were then followed to the end of their life.

RESULTS

Amlodipine-based therapy plus atorvastatin was the most expensive but also most effective treatment. Compared with amlodipine-based therapy alone, the cost to gain one QALY was euro 11,965 in the UK and euro 8,591 in Sweden. The incremental cost effectiveness of amlodipine-based therapy compared with atenolol-based therapy was euro 9,548 and euro 3,965 per QALY gained in the UK and Sweden, respectively. Atenolol-based therapy plus atorvastatin was eliminated through extended dominance. Applying the threshold values used by the National Institute for Health and Clinical Excellence (NICE) and the Swedish National Board of Health and Welfare, a combination of amlodipine-based therapy and atorvastatin appears to be cost effective in patients with hypertension and three or more additional risk factors.

Future costs in cost effectiveness analysis

This paper resolves several controversies in CEA. Generalizing [Garber, A.M., Phelps, C.E., 1997. Economic foundations of cost-effectiveness analysis. Journal of Health Economics 16 (1), 1-31], the paper shows accounting for unrelated future costs distorts decision making. After replicating [Meltzer, D., 1997. Accounting for future costs in medical cost-effectiveness analysis. Journal of Health Economics 16 (1), 33-64] quite different conclusion that unrelated future costs should be included in CEA, the paper shows that Meltzer's findings result from modeling the budget constraint as an annuity, which is problematic. The paper also shows that related costs should be included in CEA. This holds for a variety of models, including a health maximization model. CEA should treat costs in the manner recommended by Garber and Phelps.

The cost-effectiveness of the treatment of high risk women with osteoporosis, hypertension and hyperlipidaemia in Sweden

This paper assessed the cost-effectiveness of the treatment of high risk women with osteoporosis, hypertension and hyperlipidaemia in Sweden, using one model and a societal perspective. Cost-effective scenarios were found in all these chronic disorders. These findings are of relevance for decisions on the efficient allocation of health care resources.

INTRODUCTION

There is a need to assess the cost-effectiveness (CE) of treatment of osteoporosis from a societal perspective and to relate this to the CE of interventions in other disease areas. This is of relevance for decisions on the efficient allocation of health care resources within and between disease areas. The purpose of the paper was to estimate the CE of the treatment and prevention of osteoporosis and to put that into the perspective of treating hypertension and hyperlipidaemia. The CE was assessed for different high risk female populations aged 50-80 years.

METHODS

The estimation of CE was based on a model populated with data for Sweden.

RESULTS

Compared to no intervention, a 5-year treatment of osteoporosis, hypertension, and hyperlipidaemia, is cost effective for most of the assessed high risk female populations. The cost per gained quality adjusted life year (QALY) for the treatment of a 70-year-old woman never exceeded SEK 330,000 (US$ 44,000), which is generally judged as an acceptable cost for a gained QALY.

CONCLUSIONS

The study demonstrates that it is possible to produce reliable estimates of the CE of treatments in different disease areas within the context of a single model.

On future non-medical costs in economic evaluations

Economic evaluation in health care is still an evolving discipline. One of the current controversies in cost-effectiveness analysis regards the inclusion or exclusion of future non-medical costs (i.e. consumption net of production) due to increased survival. This paper examines the implications of a symmetry rule stating that there should be consistency between costs included in the numerator and utility aspects included in the denominator. While the observation that no quality-adjusted life year (QALY) instruments explicitly include consumption and leisure seems to give support to the notion that future non-medical costs should be excluded when QALYs are used as the outcome measure, a better understanding of what respondents actually consider when reporting QALY weights is required. However, the more fundamental question is whether QALYs can be interpreted as utilities. Or more precisely, what are the assumptions needed for a general utility model also including consumption and leisure to be consistent with QALYs? Once those assumptions are identified, they need to be experimentally tested to see whether they are at least approximately valid. Until we have answers to these areas for future research, it seems premature to include future non-medical costs.

Estimating 'costs' for cost-effectiveness analysis

Since 1999, the National Institute for Health and Clinical Excellence (NICE) Technology Appraisal Programme has been charged with producing guidance for the NHS in England and Wales on the appropriate use of new and existing healthcare programmes. Guidance is based on an assessment of a number of factors, including cost effectiveness. The identification, measurement and valuation of costs are important components of any cost-effectiveness analysis. However, working through these steps raises a number of important methodological questions. For example, how should 'future' resource use be estimated, and is there a need to consider all 'future' costs? Given that NICE produces national guidance, should national unit cost data be used to value resources or should local variations in negotiated prices be taken into account? This paper was initially prepared as a briefing paper as part of the process of updating NICE's 2004 Guide to the Methods of Technology Appraisal for a workshop on 'costs'. It outlines the issues that were raised in the original briefing paper and the subsequent questions that were discussed at the workshop.

The economics of primary prevention of cardiovascular disease - a systematic review of economic evaluations

BACKGROUND

In the quest for public and private resources, prevention continues to face a difficult challenge in obtaining tangible public and political support. This may be partly because the economic evidence in favour of prevention is often said to be largely missing. The overall aim of this paper is to examine whether economic evidence in favour of prevention does exist, and if so, what its main characteristics, weaknesses and strengths are. We concentrate on the evidence regarding primary prevention that targets cardiovascular disease event or risk reduction.

METHODS

We conducted a systematic literature review of journal articles published during the period 1995-2005, based on a comprehensive key-word based search in generic and specialized electronic databases, accompanied by manual searches of expert databases. The search strategy consisted of combinations of freetext and keywords related to economic evaluation, cardiovascular diseases, and primary preventive interventions of risk assessment or modification.

RESULTS

A total of 195 studies fulfilled all of the relevant inclusion criteria. Overall, a significant amount of relevant economic evidence in favour of prevention does exist, despite important remaining gaps. The majority of studies were cost-effectiveness-analyses, expressing benefits as "life years gained", were conducted in a US or UK setting, assessed clinical prevention, mainly drugs targeted at lowering lipid levels, and referred to subjects aged 35-64 years old with at least one risk factor.

CONCLUSION

First, this review has demonstrated the obvious lack of economic evaluations of broader health promotion interventions, when compared to clinical prevention. Second, the clear role for government to engage more actively in the economic evaluation of prevention has become very obvious, namely, to fill the gap left by private industry in terms of the evaluation of broader public health interventions and regarding clinical prevention, in light of the documented relationship between study funding and reporting of favourable results. Third, the value of greater adherence to established guidelines on economic evaluation cannot be emphasised enough. Finally, there appear to be certain methodological features in the practice of economic evaluations that might bias the choice between prevention and cure in favour of the latter.

Cost-effectiveness of genotypic antiretroviral resistance testing in HIV-infected patients with treatment failure

Background

Genotypic antiretroviral resistance testing (GRT) in HIV infection with drug resistant virus is recommended to optimize antiretroviral therapy, in particular in patients with virological failure. We estimated the clinical effect, cost and cost-effectiveness of using GRT as compared to expert opinion in patients with antiretroviral treatment failure.

Methods

We developed a mathematical model of HIV disease to describe disease progression in HIV-infected patients with treatment failure and compared the incremental impact of GRT versus expert opinion to guide antiretroviral therapy. The analysis was conducted from the health care (discount rate 4%) and societal (discount rate 2%) perspective. Outcome measures included life-expectancy, quality-adjusted life-expectancy, health care costs, productivity costs and cost-effectiveness in US Dollars per quality-adjusted life-year (QALY) gained. Clinical and economic data were extracted from the large Swiss HIV Cohort Study and clinical trials.

Results

Patients whose treatment was optimized with GRT versus expert opinion had an increase in discounted life-expectancy and quality-adjusted life-expectancy of three and two weeks, respectively. Health care costs with and without GRT were $US 421,000 and $US 419,000, leading to an incremental cost-effectiveness ratio of $US 35,000 per QALY gained. In the analysis from the societal perspective, GRT versus expert opinion led to an increase in discounted life-expectancy and quality-adjusted life-expectancy of three and four weeks, respectively. Health care costs with and without GRT were $US 551,000 and $US 549,000, respectively. When productivity changes were included in the analysis, GRT was cost-saving.

Conclusions

GRT for treatment optimization in HIV-infected patients with treatment failure is a cost-effective use of scarce health care resources and beneficial to the society at large.

Analytic considerations in economic evaluations of multinational cardiovascular clinical trials

OBJECTIVES

The growing number of economic evaluations that use data collected in multinational clinical trials raises numerous questions regarding their execution and interpretation. Although recommendations for conducting economic evaluations have been widely disseminated, relatively little guidance has been given for conducting economic evaluations alongside clinical trials, particularly multinational trials.

METHODS

Building on a literature review that was conducted in preparation for an expert workshop, we evaluated a subset of methodological issues related to conducting economic evaluations alongside multinational clinical trials.

RESULTS

We found wide variation in the types of costs included as part of the analyses and in the methods used to assign costs to hospitalization events. Furthermore, we found that the extrapolation of costs and survival outcomes beyond the trial period is an inconsistent practice and is often not dependent on whether a survival benefit was observed in the trial or on the epidemiology or practice patterns in the country to which the findings are directed.

CONCLUSIONS

Although the limited sample size precluded a quantitative analysis of trial characteristics and their associations with the methodologies employed, our findings highlight the need for more guidance to analysts regarding the execution of economic evaluations using data from multinational clinical trials. As the research community grapples with the complexities of methodological and logistical issues involved in multinational economic evaluations, the development of a standardized format to report the basic methodological characteristics of such studies would help to improve transparency and comparability for other analysts and decision-makers.

Economic evaluation of weight loss interventions in overweight and obese women

OBJECTIVE

To conduct a clinical and economic evaluation of outpatient weight loss strategies in overweight and obese adult U.S. women.

RESEARCH METHODS AND PROCEDURES

This study was a lifetime cost-use analysis from a societal perspective, using a first-order Monte Carlo simulation. Strategies included routine primary care and varying combinations of diet, exercise, behavior modification, and/or pharmacotherapy. Primary data were collected to assess program costs and obesity-related quality of life. Other data were obtained from clinical trials, population-based surveys, and other published literature. This was a simulated cohort of healthy 35-year-old overweight and obese women in the United States.

RESULTS

For overweight and obese women, a three-component intervention of diet, exercise, and behavior modification cost 12,600 US dollars per quality-adjusted life year gained compared with routine care. All other strategies were either less effective and more costly or less effective and less cost-effective compared with the next best alternative. Results were most influenced by obesity-related effects on quality of life and the probabilities of weight loss maintenance.

DISCUSSION

A multidisciplinary weight loss program consisting of diet, exercise, and behavior modification provides good value for money, but more research is required to confirm the impacts of such programs on quality of life and the likelihood of long-term weight loss maintenance.

The state of cost-effectiveness analysis in American managed care

In 1996, the US Panel on Cost-Effectiveness in Health and Medicine published detailed recommendations for the conduct and use of cost-effectiveness analyses (CEA) of medical technologies. These recommendations were expected to promote the use of CEA to inform the resource allocation decisions of a diverse audience including, among others, American managed care organizations. Yet, nearly 10 years later, the limited explicit use of CEA in the USA remains a prominent discussion topic, with few signs of resolution. Its limited use within managed care is especially striking given the industry's stated interest in efficient healthcare and historically unstable finances in the face of continually rising healthcare costs.

The cost-effectiveness of dual oral antiplatelet therapy following percutaneous coronary intervention: a Swedish analysis of the CREDO trial

The CREDO trial demonstrated the clinical efficacy of 12-month antiplatelet therapy with clopidogrel compared to standard 28-day treatment with a 27% relative reduction in the combined risk of death, myocardial infarction, or stroke in patients undergoing percutaneous coronary intervention (PCI) and being treated with aspirin. This study evaluated the long-term cost-effectiveness of 12-month vs. 28-day therapy with clopidogrel in Sweden. A Markov model was developed which assumed a hypothetical cohort of patients in a post-PCI state to have certain risks of suffering one of the endpoints of the CREDO trial: stroke, myocardial infarction, or death. The model predicted a mean survival of 12.098 years in the 12-month arm vs. 12.026 in the 28-day arm, an incremental gain of 0.072 life-years. The gain in survival came at a predicted incremental cost of Euro 217, resulting in an incremental cost-effectiveness ratio of Euro 3,022. Thus the predicted cost-effectiveness ratio of long-term treatment with clopidogrel in patients undergoing PCI is well below the threshold values currently considered cost-effective.

Comparing cost/utility of giving an aromatase inhibitor as monotherapy for 5 years versus sequential administration following 2-3 or 5 years of tamoxifen as adjuvant treatment for postmenopausal breast cancer

BACKGROUND

Several studies have shown aromatase inhibitors administered as monotherapy or sequentially to tamoxifen to improve relapse-free survival in postmenopausal women with early breast cancer. Any difference in cost/utility between the strategies may be of importance to therapy selection.

METHODS

Cost/utility was compared between the different regimens based on the theoretical assumption that costs, benefits and side-effects were similar for each drug and independent of whether it was administered as monotherapy or sequentially.

RESULTS

Tamoxifen for 2-3 years followed by an aromatase inhibitor for 3 or 2 years provided the lowest cost/quality-adjusted life years (QALY) estimates, while administration of an aromatase inhibitor subsequent to 5 years on tamoxifen provided the highest values. The difference between strategies increased with patient age. Cost/QALY estimates were sensitive to an increase in hip fracture risk and to cost reductions due to relapse prevention. Adding oral bisphosphonates increased costs moderately.

CONCLUSIONS

While tamoxifen for 2-3 years followed by an aromatase inhibitor provided the lowest cost/QALY estimates, a further improvement of relapse-free survival of 1% if the aromatase inhibitor is given up front provides an acceptable cost/QALY. In contrast, additional benefits achieved by administering an aromatase inhibitor subsequent to 5 years of tamoxifen provided unacceptable costs.

The importance of age in allocating health care resources: does intervention-type matter?

BACKGROUND

Recent proposals to reform cost-effectiveness analysis (CEA) by weighting health benefits [(Quality-adjusted life-years) QALYs] by recipients' age are based on studies examining age-related preferences in life-saving contexts. We investigated whether the perceived importance of age in resource allocation decisions differs among intervention-types.

METHODS

160 individuals were recruited from a cafeteria of a university medical centre and asked to choose between hypothetical health care programmes. Scenario A described two programmes treating life-threatening conditions and Scenario B two programmes providing palliative care. Programmes were identical except in average patient age (35 versus 65). Respondents also directly rated the importance of age for allocating resources for six types of interventions.

RESULTS

Responses for the life-saving scenario favoured younger age groups while those for the palliative care scenario showed no age preference. The difference between scenarios was statistically significant. When directly rating the importance of age in allocating treatment resources, people placed greatest importance on age in treating infertility and life-saving, and least importance in treating depression.

DISCUSSION

The importance people place on age as a resource allocation criterion depends on the clinical context. As QALYs serve as a common measure of health benefits for all intervention types, age weighting of QALYs is premature.

Does prevention save costs? Considering deferral of the expensive last year of life

Published cost-effectiveness analyses may overstate the cost-effectiveness ratio of preventive care if they do not explicitly model the costs of the last year of life, which is postponed by prevention. To determine the degree of overestimation, the authors built a statistical model using Medicare expenditure data on survivors and decedents. The model shows that the cost-effectiveness ratio of prevention may decrease by up to US$ 11,000 per quality-adjusted life year saved when expenditure data on the last year life are used. The model is able to explain more than half of the median cost increase of published cost-effectiveness analyses on clinical preventive services.

The cost-effectiveness of candesartan-based antihypertensive treatment for the prevention of nonfatal stroke: results from the Study on COgnition and Prognosis in the Elderly

Patients who survive a first stroke are often left with permanent disabilities, and have significant needs for rehabilitation and long-term care. Antihypertensive treatment reduces the risk of cardiovascular events such as stroke. The purpose of this study was to investigate the cost-effectiveness of candesartan-based antihypertensive treatment for the prevention of nonfatal stroke. The cost-effectiveness analysis was based on data from Study on COgnition and Prognosis in the Elderly (SCOPE), where patients were randomly assigned to receive the angiotensin receptor blocker candesartan or placebo, with open-label active antihypertensive treatment added as needed. The analysis was carried out using a Markov model, which combined clinical and resource utilization data from SCOPE with Swedish retail prices for drugs and unit costs for in-patient stays, and outpatient visits. The cost per patient was 1949 EUR in the candesartan group and 1578 EUR in the control group. The largest share of the cost was attributed to antihypertensive treatment in the candesartan group and to the long-term cost of stroke in the control group. Candesartan-based antihypertensive treatment was associated with 0.0289 additional quality-adjusted life-years (QALYs) per patient and an incremental cost per QALY gained of approximately 13,000 EUR. Sensitivity analyses showed that these results were fairly stable. In conclusion, the cost per QALY gained with candesartan-based antihypertensive treatment lies within the range of society's willingness to pay for health gains. The results indicate that candesartan-based antihypertensive treatment is cost-effective for the prevention of nonfatal stroke.

Intervention thresholds for osteoporosis in the UK

The aim of this study was to determine the threshold of fracture probability at which interventions became cost-effective in women based on data from the UK. We modelled the effects of an intervention costing pound 350 per year given for 5 years that decreased the risk of all osteoporotic fractures by 35% followed by a waning of effect (offset time) for a further 5 years. Sensitivity analyses included a range of treatment duration (3-10 years), intervention costs (pound 300-400/year) and offset times (0-15 years). Data on costs and risks were from the UK. Costs included direct costs, but excluded indirect costs due to morbidity. A threshold for cost-effectiveness of pound 30,000/QALY gained was used. With the base case ( pound 350 per year; 35% efficacy) treatment in women was cost-effective with a 10-year hip fracture probability that ranged from 1.1% at the age of 50 years to 9.0% at the age of 85 years. Intervention thresholds were sensitive to the assumed costs and offset time. The exclusion of osteoporotic fractures other than hip fracture significantly increased the cost-effectiveness ratio because of the substantial morbidity from such other fractures, particularly at younger ages. Cost-effective scenarios were found for women at the threshold for osteoporosis from the age of 60 years. Treatment of established osteoporosis was cost-effective irrespective of age. We conclude that the inclusion of all osteoporotic fractures has a marked effect on intervention thresholds, that these vary with age and that available treatments can be targeted cost-effectively to individuals from the UK at moderately increased fracture risk.

Intervention thresholds for osteoporosis in men and women: a study based on data from Sweden

The aim of this study was to determine the threshold of fracture probability at which interventions became cost-effective in men and women, based on data from Sweden. We modeled the effects of a treatment costing $500 per year given for 5 years that decreased the risk of all osteoporotic fractures by 35% followed by a waning of effect for a further 5 years. Sensitivity analyses included a range of effectiveness (10-50%) and a range of intervention costs ($200-500/year). Data on costs and risks were from Sweden. Costs included direct costs, but excluded indirect costs due to morbidity. A threshold for cost-effectiveness of approximately $45,000/QALY gained was used. Cost of added years was included in a sensitivity analysis. With the base case ($500 per year; 35% efficacy) treatment in women was cost-effective with a 10-year hip fracture probability that ranged from 1.2% at the age of 50 years to 7.4% at the age of 80 years. Similar results were observed in men except that the threshold for cost-effectiveness was higher at younger ages than in women (2.0 vs 1.2%, respectively, at the age of 50 years). Intervention thresholds were sensitive to the assumed effectiveness and intervention cost. The exclusion of osteoporotic fractures other than hip fracture significantly increased the cost-effectiveness ratio because of the substantial morbidity from such other fractures, particularly at younger ages. We conclude that the inclusion of all osteoporotic fractures has a marked effect on intervention thresholds, that these vary with age, and that available treatments can be targeted cost-effectively to individuals at moderately increased fracture risk.

Use of cost-effectiveness analysis in health-care resource allocation decision-making: how are cost-effectiveness thresholds expected to emerge?

BACKGROUND

An increasing number of health-care systems, both public and private, such as managed-care organizations, are adopting results from cost-effectiveness (CE) analysis as one of the measures to inform decisions on allocation of health-care resources. It is expected that thresholds for CE ratios may be established for the acceptance of reimbursement or formulary listing.

OBJECTIVE

This paper provides an overview of the development of and debate on CE thresholds, reviews threshold figures (i.e., cost per unit of health gain) currently proposed for or applied to resource-allocation decisions, and explores how thresholds may emerge.

DISCUSSION

At the time of this review, there is no evidence from the literature that any health-care system has yet implemented explicit CE ratio thresholds. The fact that some government agencies have utilized results from CE analysis in pricing/reimbursement decisions allows for retrospective analysis of the consistency of these decisions. As CE analysis becomes more widely utilized in assisting health-care decision-making, this may cause decision-makers to become increasingly consistent.

CONCLUSIONS

When CE analysis is conducted, well-established methodology should be used and transparency should be ensured. CE thresholds are expected to emerge in many countries, driven by the need for transparent and consistent decision-making. Future thresholds will likely be higher in most high-income countries than currently cited rules of thumb.

Illustrating the impact of including future costs in economic evaluations: an application to end-stage renal disease care

There are strong theoretical arguments for including future costs for related and unrelated medical care and non-medical expenditures within economic evaluations. Nevertheless, there is limited data on how inclusion of such costs affects the cost effectiveness of medical interventions in practice. For a low-cost intervention that improves survival in end-stage renal disease (ESRD) patients, we sought to determine how the inclusion of future costs for related medical care (i.e. dialysis and transplantation) and for unrelated medical care and non-medical expenditure would affect the magnitude of the cost per QALY ratio. We performed a cost-utility analysis comparing hemodialysis using a synthetic dialyser (the current treatment of choice in Canada) with the historical gold-standard treatment (use of a cellulose dialyser). We contrasted the results of the analysis including and excluding various measures of future costs. While the inclusion of future costs for unrelated medical care and non-medical expenditures had a significant impact on the cost per QALY ratio, the size of the cost per QALY ratio was most sensitive to inclusion of future costs for related medical care. Our analysis shows that even relatively inexpensive interventions that extend survival of dialysis patients may not be cost-effective since, by extending survival, the extra outpatient dialysis costs that are incurred are large. Inclusion of such costs (which, in and of itself, is methodologically correct) in economic evaluations in this area may mitigate against the acceptance of interventions that are relatively inexpensive themselves but which improve patient survival.

Health care economic analyses and value-based medicine

Health care economic analyses are becoming increasingly important in the evaluation of health care interventions, including many within ophthalmology. Encompassed with the realm of health care economic studies are cost-benefit analysis, cost-effectiveness analysis, cost-minimization analysis, and cost-utility analysis. Cost-utility analysis is the most sophisticated form of economic analysis and typically incorporates utility values. Utility values measure the preference for a health state and range from 0.0 (death) to 1.0 (perfect health). When the change in utility measures conferred by a health care intervention is multiplied by the duration of the benefit, the number of quality-adjusted life-years (QALYs) gained from the intervention is ascertained. This methodology incorporates both the improvement in quality of life and/or length of life, or the value, occurring as a result of the intervention. This improvement in value can then be amalgamated with discounted costs to yield expenditures per quality-adjusted life-year ($/QALY) gained. $/QALY gained is a measure that allows a comparison of the patient-perceived value of virtually all health care interventions for the dollars expended. A review of the literature on health care economic analyses, with particular emphasis on cost-utility analysis, is included in the present review. It is anticipated that cost-utility analysis will play a major role in health care within the coming decade.

Do HEDIS measures reflect cost-effective practices?

PURPOSE

Whether the Health Plan Employer Data and Information Set (HEDIS) performance measures for managed care plans encourage a cost-effective use of society's resources has not been quantified. Our study objectives were to examine the cost-effectiveness evidence for the clinical practices underlying HEDIS 2000 measures and to develop a list of practices not reflected in HEDIS that have evidence of cost effectiveness.

DATA SOURCES

Two databases of economic evaluations (Harvard School of Public Health Cost-Utility Registry and the Health Economics Evaluation Database) and two published lists of cost-effectiveness ratios in health and medicine.

STUDY SELECTION

For each of the 15 "effectiveness of care" measures in HEDIS 2000, we searched the data through 1998 for cost-effectiveness ratios of similar interventions and target populations. We also searched for important interventions with evidence of cost-effectiveness (<$20,000 per life-year [LY] or quality-adjusted life year [QALY] gained), which are not included in HEDIS. All ratios were standardized to 1998 dollars. The data were collected and analyzed during fall 2000 to summer 2001.

DATA EXTRACTION

Cost-effectiveness ratios reporting outcomes in terms of cost/LY or cost/QALY gained were included if they matched the intervention and population covered by the HEDIS measure.

DATA SYNTHESIS

Evidence was available for 11 of the 15 HEDIS measures. Cost-effectiveness ranges from cost saving to $660,000/LY gained. There are numerous non-HEDIS interventions with some evidence of cost effectiveness, particularly interventions to promote healthy behaviors.

CONCLUSIONS

HEDIS measures generally reflect cost-effective practices; however, in a number of cases, practices may not be cost effective for certain subgroups. Data quality and availability as well as study perspective remain key challenges in judging cost effectiveness. Opportunities exist to refine existing measures and to develop additional measures, which may promote a more efficient use of societal resources, although more research is needed on whether these measures would also satisfy other desirable attributes of HEDIS.

Intervention thresholds for osteoporosis

The aim of this study was to determine the threshold of fracture probability at which interventions become cost-effective. We modeled the effects of a treatment costing $500/year, given for 5 years, that decreased the risk of all osteoporotic fractures by 35%, followed by a waning of effect for 5 years. Sensitivity analyses included a range of effectiveness (10%-50%) and a range of intervention costs (200-500 dollars/year). Data on costs and risks were from Sweden. Costs included direct costs and costs in added years of life, but excluded indirect costs due to morbidity. A threshold for cost-effectiveness of 60,000 dollars per quality-adjusted life-year (QALY) gained was used. Costs of added years were excluded in a sensitivity analysis for which a threshold value of 30,000 dollars per QALY was used. In the base case, intervention was cost-effective when treatment was targeted to women at average risk at age of >or=65 years. Irrespective of the efficacy modeled (10%-50%) or of cost of intervention (200-500 dollars/year) segments of the population at average risk could be targeted cost-effectively: The lower the intervention cost and the higher the effectiveness, the lower the age at which intervention was cost-effective. With the base case (500 dollars/year; 35% efficacy) treatment in women was cost-effective with a 10 year hip fracture probability that ranged from 1.4% at the age of 50 years to 4.4% at the age of 65 years. The exclusion of osteoporotic fractures other than hip fracture would increase the threshold to a 9%-11% 10 year probability because of the substantial morbidity from fractures other than hip fracture, particularly at younger ages. We conclude that the inclusion of all osteoporotic fractures has a marked effect on intervention thresholds, that these vary with age, and that available treatments can be cost-effectively targeted to individuals at moderately increased risk.

Comparing cost-effectiveness analyses of anti-hypertensive drug therapy for decision making: mission impossible?

The purpose of this literature review was to compare the methodology used in the most recently published cost-effectiveness studies of antihypertensive treatments, and to identify methodological strengths and weaknesses that indicate the study's potential as a useful, decision-making tool. Based on the results of a search of several databases, spanning the years 1995 to 2000, 10 cost-effectiveness studies were identified. Although the majority of the studies reported their cost-effectiveness ratio in "costs per year of life gained," the studies also considered a varying range of components including additional end points. The methodology used to measure effectiveness, the cost variables included, and the characteristics of the patient population varied significantly across studies. Due to this lack of conformity, it would be difficult, if not impossible, to compare the results and draw conclusions about the relative cost-effectiveness of different types of antihypertensive drug therapies. This lack of uniform comparison across studies is likely to draw criticism from both the clinical and health-care decision-making communities. Future studies within this field should be thorough and useful for decision making. It is suggested that short-term outcomes should include systolic and diastolic blood pressure measurements and long-term outcomes should include end points such as myocardial infarction, stroke, congestive heart failure and renal events. Other positive outcomes such as a more favorable side-effect profile, should be used to enhance the primary outcomes. Additionally, when subpopulations are considered in submodels, studies should address the issue of generalizability. Cost calculations should be transparent and related to the perspective of the study. Modeling the cost-effectiveness of a drug may be an acceptable method provided that data sources and assumptions are valid and transparent.

The cost-effectiveness of ramipril in the treatment of patients at high risk of cardiovascular events: a Swedish sub-study to the HOPE study

OBJECTIVE

To evaluate if long-term treatment with ramipril is cost-effective in patients at high risk of cardiovascular events.

DESIGN

Randomized double-blind and placebo controlled. Information was gathered prospectively for a number of direct medical, direct nonmedical and indirect costs.

SETTING AND SUBJECT

This is a sub-study to the Heart Outcomes Prevention Evaluation (HOPE) study performed in Swedish patients. All Swedish centres (19; n= 554) were invited to take part and 18 centres agreed to do so (n=537). The patients were managed in a specialist setting with a mean follow-up period of 4.5 years. Main outcome measures. The number of life-years saved was derived from the global HOPE study (n=9297) and subsequently the estimated life expectancy of those who completed the clinical study alive was added to the calculation. Direct medical costs related to cardiovascular disease only were considered in the primary analysis, whilst all kinds of costs and costs for all kinds of diseases were included in subsequent analyses. The cost of added years of life, according to the future cost method, was included in sensitivity analyses.

RESULTS

The cost per life-year gained was SEK 16 600 (Euro 1940) when direct medical costs for cardiovascular reasons only were considered and SEK 45 400 (Euro 5300) when direct medical costs for all diseases were considered. The corresponding costs when direct nonmedical and indirect cost were added to the estimate were SEK 16 100 (Euro 1880) and SEK 54 600 (Euro 6380), respectively. When the future cost method was applied, the cost per life-year gained was SEK 208 300 (Euro 24 300).

CONCLUSION

Ramipril is highly cost-effective in the treatment of patients at high risk of cardiovascular events.

Economics of drug treatment: for which patients is it costeffective to lower cholesterol?

Today's society places a great emphasis on value for money, so medical interventions must not only be shown to be effective but also be proved to be costeffective. Drug treatment is no exception. In health economics, costeffectiveness is calculated differently depending on the indication and the perspective. For cholesterol-lowering drugs (as an example) there is a difference between primary and secondary intervention. In primary prevention, the cut off value for absolute risk when treatment is costeffective varies with age and sex, but in secondary prevention, although treatment is costeffective for all groups of patients, costeffectiveness varies with age, sex, cholesterol concentration, and other risk factors. There are three complementary approaches to economic assessment of secondary prevention-analysis of the whole population, subgroup analysis, and modelling.

Modelling the future costs of breast screening

The aim of this paper was to estimate the future breast cancer and non-breast cancer costs associated with breast screening. The Nottingham prognostic index (NPI) was used to stratify patients into different prognostic groups and to predict the impact of breast screening on future costs. A Markov model was used to estimate breast cancer and non-breast costs for each prognostic group. Breast cancer costs were found to increase as the severity of prognosis increases. The opposite pattern was found for non-breast cancer costs. The total future costs (breast cancer and non-breast cancer costs) for each prognostic group was between pound10000 and pound11000. As a percentage of the costs of screening, the savings in future breast cancer costs were 20.9%. Inclusion of non-breast cancer costs cancelled out any potential savings in future breast cancer cost resulting from a better prognosis and resulted in an increase of 5.7% in future costs. Whether to include the latter type of cost remains a methodological issue of debate in economic evaluation.

An off-the-shelf help list: a comprehensive catalog of preference scores from published cost-utility analyses

PURPOSE

The Panel on Cost-Effectiveness in Health and Medicine recommends an organized collection of preference measure values for health states that can be used in costutility analyses (CUAs). The authors sought to construct a catalog of preference scores from published CUAs, organize the catalog by clinical categories, and identify methods of preference score assessment.

METHOD

The authors systematically searched Medline and other databases to identify original CUAs published through 1997. Information was abstracted on the health state descriptions, corresponding preference scores, method of preference score elicitation, and the source of the estimate.

RESULTS

Two hundred twenty-eight CUAs were appraised. The authors found 949 health states and corresponding preference scores. Most frequently, health states pertained to the circulatory system (21.7%), health states were valued by experts (35.8%), and values were derived through community-based preference scores (23.5%).

CONCLUSION

A catalog of preference scores for health states can be constructed. The catalog (http://www.hsph.harvard.edu/organizations/hcra/cuadatabase/ intro.html) may provide a useful reference tool for producers and consumers of CUAs but also underscores the methodologic variation and inconsistencies present in the field.

Health-related quality of life after stroke a comprehensive review

BACKGROUND AND PURPOSE

We performed a comprehensive review of all quality-of-life (QOL) estimates for stroke appearing in the peer-reviewed literature between 1985 and 2000. We examine variation in QOL weights and the rigor of methods used to assess QOL and discuss the implications for cost-utility assessment and resource allocation decisions.

METHODS

Through a systematic search, we identified 67 articles that met our inclusion criteria. A team of trained researchers read each article and followed detailed guidelines to extract QOL weights and other parameters. This effort yielded 161 QOL estimates for stroke-related health states. All estimates were measured on a 0 to 1 scale, with 0 representing the worst outcome and 1 representing the best.

RESULTS

QOL estimates range from -0.02 to 0.71 (n=67) for major stroke, from 0.12 to 0.81 (n=14) for moderate stroke, from 0.45 to 0.92 (n=38) for minor stroke, and from 0.29 to 0.903 (n=42) for general stroke. Although QOL should decrease with severity, there were many instances in which the QOL for major stroke as reported by one study exceeded the QOL for moderate stroke as reported by another. The same reversal was found for moderate and minor stroke, and it occurred even when both authors used similar assessment methods and subject populations. Authors of cost-utility and decision analyses rarely base their choice of QOL weights on their own primary data (19%). When obtaining weights from secondary sources, some authors (23%) chose QOL weights for a severity of stroke that did not match the severity for which they sought data.

CONCLUSIONS

QOL estimates for stroke vary greatly and are not always estimated in sound fashion. This impedes the comparability and quality of the cost-effectiveness studies that use these QOL weights and hampers good resource allocation decisions.

Cost effectiveness of bisoprolol in the treatment of chronic congestive heart failure in Sweden: analysis using data from the Cardiac Insufficiency Bisoprolol Study II trial

OBJECTIVE

To investigate the cost effectiveness of adding the beta-blocker bisoprolol to standard treatment in patients with congestive heart failure (CHF).

DESIGN AND SETTING

A cost-effectiveness study was based on the Cardiac Insufficiency Bisoprolol Study II (CIBIS-II), a randomised clinical trial investigating the efficacy of adding bisoprolol to standard therapy of CHF. The cost-effectiveness analysis was carried out from a societal perspective.

METHODS

Health effects were measured in terms of years of life gained. On the cost side, treatment costs for pharmaceuticals and hospitalisations were included. Data on healthcare resource consumption from CIBIS-II were used and were combined with average Swedish retail prices for medicines, and average costs for hospitalisations based on hospital admissions, in the base case. The costs of added years of life, i.e. consumption net of production during life-years gained were also included.

RESULTS

If costs of added years of life were not included, then bisoprolol therapy increased life expectancy at an incremental cost of Swedish kronor (SEK) 13 094 (1999 values) per year of life gained. If costs of added years of life were included, then the incremental cost-effectiveness ratio of bisoprolol therapy was SEK 168 858 per year of life gained.

CONCLUSIONS

For patients with CHF with the characteristics of those in CIBIS-II, the cost effectiveness of bisoprolol therapy compares favourably with that of other cardiovascular therapies.

Effect of future costs on cost-effectiveness of medical interventions among young adults: the example of intensive therapy for type 1 diabetes mellitus

OBJECTIVES

Recent research based on a lifetime utility maximization model has suggested that cost-effectiveness analyses should account for all future costs, including medical costs for related and unrelated illnesses and nonmedical costs. This work has also shown that analyses that omit future costs are biased to favor interventions among the elderly that extend life over interventions that improve quality of life. However, the effect of including future costs on the cost-effectiveness of interventions among the young has not been studied. This article examines the effect of including future costs on the cost-effectiveness of intensive therapy for type 1 diabetes mellitus among young adults.

METHODS

By modifying a cost-effectiveness model based on the Diabetes Control and Complications Trial to include future costs, the effect of including future costs on the cost-effectiveness of intensive therapy for type 1 diabetes mellitus among young adults was examined. Future costs added to the model included future costs for medical expenditures for illnesses unrelated to diabetes and future nonmedical expenditures net of earnings.

RESULTS

Intensive therapy among young adults led to approximately equal increases in the expected number of years lived before age 65, when people generally produce more than they consume, and after age 65, when the opposite tends to hold. Because the discounted value of savings due to lower mortality before age 65 exceeded the discounted value of later increases in costs due to lower mortality after age 65, accounting for future costs decreased the cost-effectiveness ratio from $22,576 to $9,626 per quality-adjusted life-year.

CONCLUSIONS

The inclusion of future costs can significantly improve the cost-effectiveness of interventions that decrease mortality among young adults. The common practice of excluding future costs may bias cost-effectiveness analyses against such interventions.