Measuring the Benefits of Healthcare: DALYs and QALYs - Does the Choice of Measure Matter? A Case Study of Two Preventive Interventions

Cost effectiveness analysis of expanding tuberculosis preventive therapy to household contacts aged 5-14 years in the Philippines

Background

Children aged 5-14 years who are household contacts (HHCs) of index people with active TB disease (PWTB) have limited coverage for TB preventive therapy (TPT) due to variable uptake of the national guideline recommendations in the Philippines. We conducted a cost-effectiveness analysis evaluating the expansion of TB infection (TBI) testing and treatment among pediatric (5-14 years) HHCs of index PWTB in the Philippines to assist the National TB program in choosing the most cost-effective testing and treatment strategy for TBI among HHCs of index PWTB.

Methods

Using a Markov state transition model, eligible HHCs age 5-14 years are screened for TBI with either the tuberculin skin test (TST) or interferon gamma release assay (IGRA). Those who test positive are then simulated to receive one of the following TPT strategies: 6 months of daily isoniazid (6H), 3 months of weekly isoniazid and rifapentine (3HP), 3 months of daily isoniazid plus rifampicin (3HR) and the current practice of no testing or treatment for TBI (NTT). The analysis assesses the projected cost and quality-adjusted life years (QALY) gained for every strategy from the perspective of the Philippines public healthcare system over a time horizon of 20 years. The total cost and gain in QALYs are presented as an incremental cost-effectiveness ratio (ICER) comparing cost per QALY gained for each strategy over NTT.

Results

Our model estimates that expanding TPT coverage to HHCs aged 5-14 years would be cost-effective with incremental cost-effectiveness ratios (ICERs) ranging from 1,024 $/QALY gained when using TST and 6H (Uncertainty range: 497---2,334) to 2,293 $/QALY gained when IGRA and 3HR are used (Uncertainty range: 1,140 - 5,203). These findings were robust to sensitivity analyses over a wide range of parameter values.

Conclusion

Expanding TPT coverage to HHCs aged 5-14 years is cost-effective when using TST and 6H closely followed by a strategy combining TST and 3HP.

A framework for quantifying the multisectoral burden of animal disease to support decision making

Animal diseases have wide-ranging impacts in multiple societal arenas, including agriculture, public health and the environment. These diseases cause significant economic losses for farmers, disrupt food security and present zoonotic risks to human populations. Additionally, they contribute to antimicrobial resistance and a range of environmental issues such as greenhouse gas emissions. The societal and ecological costs of livestock diseases are frequently underrepresented or unaddressed in policy decisions and resource allocations. Social cost-benefit analysis (SCBA) offers a comprehensive framework to evaluate the broad impacts of animal diseases across different sectors. This approach aligns with the One Health concept, which seeks to integrate and optimize the health of humans, animals and the environment. Traditional economic evaluations often focus narrowly on profit maximization within the livestock sector, neglecting wider externalities such as public health and environmental impacts. In contrast, SCBA takes a multi-sectoral whole-system view, considering multiple factors to guide public and private sector investments toward maximizing societal benefits. This paper discusses three separate sector specific (Animal health, Human health, Environmental health) methodologies for quantifying the burden of animal diseases. It then discusses how these estimates can be combined to generate multisectoral estimates of the impacts of animal diseases on human societies and the environment using monetary values. Finally this paper explores how this framework can support the evaluation of interventions from a One Health perspective though SCBA. This integrated assessment framework supports informed decision-making and resource allocation, ultimately contributing to improved public health outcomes, enhanced animal welfare, and greater environmental sustainability.

Cost-effectiveness analysis of the 13-valent pneumococcal conjugate vaccine administered to children under 5 years of age in the Republic of Moldova

Background

The Moldovan health authorities introduced the 13 valent pneumococcal conjugate vaccine into the national immunization schedule for children in 2013. This study aimed to evaluate the cost-effectiveness of the pneumococcal conjugate vaccine compared to a no-vaccination strategy in children under 5 Years of age in the Republic of Moldova.

Methods

We used UNIVAC (version 1.7), a static decision model, to evaluate the health and economic outcomes of vaccination in a single-cohort of children under five years. We modeled vaccine introduction over 10 birth cohorts starting in 2013. We assumed a 2+1 (two doses + booster) schedule and a vaccination price of US$ 16.34 per dose. We used locally-specific data for pneumonia incidence, mortality, treatment, and costs. Model outcomes included pneumonia cases, hospitalizations, deaths, disability-adjusted life years, and costs presented in USD. Cost-effectiveness was reported as Incremental Cost Effectiveness Ratio. The Incremental Cost Effectiveness Ratio was calculated to estimate the additional cost to save an additional life year.

Results

From the governmental health sector the Incremental Cost Effectiveness Ratio was $5939 and from society perspective, $7272, respectively. Withal cost per disability-adjusted life years (DALY) averted was US$ 6311. PCV-13 was projected to prevent 2310 hospitalizations due to pneumococcal disease, including 118 deaths. Vaccination could potentially reduce the highest treatment cost from the payer perspective at $ 4 081 412 for the 13 valent pneumococcal conjugate vaccine.

Conclusion

This study evidenced that cost per DALY averted is US$ 6311, which is between one and three times Gross Domestic Product (GDP) per capita, these findings extrapolate PCV-13 as a cost-effective intervention. Considering the scenario of Republic of Moldova the PCV program is a cost effective intervention and justifies the introduction of PCV into routine immunization schedule throughout the country in order to reduce morbidity and mortality among the under-five-year-old children.

Navigating Choices in Nephrology: The Role of Patient-Reported Outcomes and Preferences in Economic Evaluations and Decisions in Health Care

The increasing burden of chronic kidney disease (CKD) on the health care system highlights the need to prioritize services and manage the use of resources efficiently. Amid these financial constraints, key decision makers must weigh the impact of an intervention or program on health care expenditure when determining the allocation of limited resources. Patient-reported outcome measures (PROMs) are relevant in health economic decision-making within nephrology. Health-related quality of life, a patient-reported outcome, can provide data that inform economic evaluations of treatments for patients with CKD. PROMs help determine the value of different therapies by assessing their impact on patients' daily lives beyond clinical outcomes and can help policymakers make decisions about funding and reimbursement that consider the priorities and preferences of patients. Economic evaluations often employ cost-utility analyses, which use quality-adjusted life years as a key metric. Quality-adjusted life years combine both the quality and quantity of life lived, allowing for comparison of the effectiveness of different interventions in a standardized manner. By integrating utilities derived from PROMs, these analyses quantify the benefits of CKD treatments in terms of how patients feel and function. Furthermore, PROMs contribute to quality improvement initiatives by identifying areas where patient care can be enhanced, guiding the implementation of programs that improve health-related quality of life while maintaining cost-effectiveness. In value-based financing environments, the integration of PROMs ensures that patient-centered outcomes are prioritized, leading to more effective and equitable health care delivery. In this article, we discuss the role of PROMs in economic evaluations in CKD and provide an overview of approaches for using PROMs in economic evaluations to inform decision-making in nephrology.

Cost-effectiveness of cytomegalovirus vaccination for females in China: A decision-analytical Markov study

BACKGROUND

The global burden of disease caused by congenital cytomegalovirus (CMV) infection is high. Previous modeling studies have suggested that CMV vaccination may be cost-effective in developed countries. Congenital CMV infection is more likely driven by maternal non-primary infection in China. We aimed to measure the effectiveness and cost-effectiveness of population-level CMV vaccination in Chinese females.

METHODS

A decision tree Markov model was developed to simulate potential CMV vaccination strategies in a multi-cohort setting, with a population size of 1,000,000 each for the infant, adolescent (10-year-old) and young adult (20-year-old) cohorts. The hypothetical vaccines were assumed to have 50% efficacy, 20 years of protection, 70% coverage, at a price of US$120/dose for base-case analysis. Costs and disability-adjusted life years (DALYs) were discounted by 3% per year and the vaccination would be considered cost-effective if an incremental cost-effectiveness ratio (ICER) was lower than 2021 Chinese per capita GDP (US$12,500).

FINDINGS

For the pre-infection (PRI) vaccine efficacy type, the adolescent strategy was the most cost-effective, with an ICER of US$12,213 (12,134 to 12,291) pre DALY averted, compared with the next best strategy (young adult strategy). For pre- and post-infection (P&PI) efficacy type, the young adult strategy was the most cost-effective as it was cost-saving. In one-way analysis varying the PRI vaccine price, the infant strategy, adolescent strategy and the young adult strategy would be a dominant strategy over others if the vaccine cost ≤US$60, US$61-121 and US$122-251 per dose respectively. In contrast, the young adult strategy continued to be the preferred strategy until the P&PI vaccine price exceeded US$226/dose. Our main results were robust under a wide variety of sensitivity analyses and scenario analyses.

INTERPRETATION

CMV vaccination for females would be cost-effective and even cost-saving in China. Our findings had public health implications for control of CMV diseases.

The estimated disease burden of COVID-19 in Japan from 2020 to 2021

BACKGROUND

To date, it is not fully understood to what extent COVID-19 has burdened society in Japan. This study aimed to estimate the total disease burden due to COVID-19 in Japan during 2020-2021.

METHODS

We stratify disease burden estimates by age group and present it as absolute Quality Adjusted Life Years (QALYs) lost and QALYs lost per 100,000 persons. The total estimated value of QALYs lost consists of (1) QALYs lost brought by deaths due to COVID-19, (2) QALYs lost brought by inpatient cases, (3) QALYs lost brought by outpatient cases, and (4) QALYs lost brought by long-COVID.

RESULTS

The total QALYs lost due to COVID-19 was estimated as 286,782 for two years, 114.0 QALYs per 100,000 population per year. 71.3% of them were explained by the burden derived from deaths. Probabilistic sensitivity analysis showed that the burden of outpatient cases was the most sensitive factor.

CONCLUSIONS

The large part of disease burden due to COVID-19 in Japan from the beginning of 2020 to the end of 2021 was derived from Wave 3, 4, and 5 and the proportion of QALYs lost due to morbidity in the total burden increased gradually. The estimated disease burden was smaller than that in other high-income countries. It will be our future challenge to take other indirect factors into consideration.

Does the Choice of Health Metric, DALY or QALY, Influence Conclusions of Health Economic Evaluation? A Case Study of Rotavirus Vaccine in Burundi

BACKGROUND

Two metrics, quality-adjusted life-year (QALY) and disability-adjusted life-year (DALY), have been commonly used to measure health benefits associated with health interventions. This study aimed to explore the effect of the choice of health metric (DALY or QALY) on economic evaluation conclusion.

METHODS

A previous published model for a cost-utility analysis (CUA) of rotavirus vaccine was adapted to estimate the QALYs gained and DALYs averted from four rotavirus vaccines: Rotarix, RotaTeq, Rotavac, and Rotasiil. The study was conducted in both Burundi provider and societal perspectives over a five-year time horizon. Disability weights (DW) were derived from the Global Burden of Disease (GBD) study. Scenario analysis was performed to evaluate the impact of age weights and source of utility weight.

RESULTS

In base-case analysis, the QALYs gained ranged from 46 to 78% of the DALYs averted. The incremental cost-effectiveness ratios (ICER) per QALY gained were higher than ICER per DALY averted by 28 to 113%, leading to less favorable cost effectiveness. The QALYs gained from using 1-DW as utility weight were slightly higher than those using EQ-5D utility weight obtained from previous literature, yet less likely to alter CUA conclusions. When age-weighting was incorporated in the DALY calculation, the ICERs per DALY averted were reduced leading to more favorable cost effectiveness.

CONCLUSION

In case of rotavirus diarrhea, in which mortality burden is considered larger than morbidity due to short duration of disease, although the use of DALY consistently led to more favorable cost-effective result than the use of QALY such effects were considered small and less likely to affect the EE conclusion under current CET of 1 GDP per capita.

Estimating the range of incremental cost-effectiveness thresholds for healthcare based on willingness to pay and GDP per capita: A systematic review

Background

Decision-making in healthcare policy involves assessing both costs and benefits. In determining the cost-effectiveness (CE) threshold, willingness to pay (WTP) per quality-adjusted life year (QALY), GDP per capita, and other factors are important. However, the relationship between WTP/QALY or GDP per capita and the CE threshold is unclear. It is important to clarify the relationship between WTP/QALY and GDP to provide a clear basis for setting the CE threshold.

Objective

The purpose of this study was to compare WTP/QALY and GDP per capita, and to develop a new CE threshold range based on WTP using GDP per capita. The relationship between WTP/QALY and healthy life expectancy (HALE) was also investigated.

Methods

We searched MEDLINE, EMBASE and Web of Science from 1980/01/01 to 2020/12/31 using the following selection criteria (latest search: Dec 2021):1, studies that estimated WTP/QALY; 2, the general population was surveyed; 3, the article was in English. From the collected articles, we obtained average values of WTP/QALY for various countries and compared WTP/QALY with GDP per capita. The correlation between WTP/QALY and HALE was also examined.

Results

We identified 20 papers from 17 countries. Comparison of mean WTP/QALY values with GDP per capita showed that most WTP/QALY values were in the range of 0.5–1.5 times GDP per capita, though the median values were less than 0.5 times. Comparison of WTP/QALY with HALE showed a statistically significant positive correlation when Taiwan was excluded as an outlier.

Conclusions

Our results suggest a CE threshold range of 0.5–1.5 times GDP per capita is appropriate but lower than the WHO-recommended range of 1–3 times. The correlation between WTP/QALY and HALE suggests that investment in healthcare is reflected in an increased healthy life expectancy. Since WTP is based on consumer preferences, this range could be used to set a generally acceptable criterion.

Estimation of Health and Economic Benefits of a Small Automatic External Defibrillator for Rapid Treatment of Sudden Cardiac Arrest (SMART): A Cost-Effectiveness Analysis

Background

Sudden cardiac arrest (SCA) occurs in 0.4% of the general population and up to 6% or more of at-risk groups each year. Early CPR and defibrillation improves SCA outcomes but access to automatic external defibrillators (AEDs) remains limited.

Methods

Markov models were used to evaluate the cost-effectiveness of a portable SMART (SMall AED for Rapid Treatment of SCA) approach to early SCA management over a life-time horizon in at-risk and not at-risk populations. Simulated patients (n = 600,000) who had not received an implantable cardioverter defibrillator (ICD) were randomized to a SMART device with CPR prompts or non-SMART approaches. Annual SCA risk was varied from 0.2 to 3.5%. Analysis was performed in a US economy from both societal (SP) and healthcare (HP) perspectives to evaluate the number of SCA fatalities prevented by SMART, and SMART cost-effectiveness at a threshold of $100,000/Quality Adjusted Life Year (QALY).

Results

A SMART approach was cost-effective when annual SCA risk exceeded 1.51% (SP) and 1.62% (HP). The incremental cost-effectiveness ratios (ICER) were $95,251/QALY (SP) and $100,797/QALY (HP) at a 1.60% SCA annual risk. At a 3.5% annual SCA risk, SMART was highly cost-effective from both SP and HP [ICER: $53,925/QALY (SP), $59,672/QALY (HP)]. In microsimulation, SMART prevented 1,762 fatalities across risk strata (1.59% fatality relative risk reduction across groups). From a population perspective, SMART could prevent at least 109,839 SCA deaths in persons 45 years and older in the United States.

Conclusions and Relevance

A SMART approach to SCA prophylaxis prevents fatalities and is cost-effective in patients at elevated SCA risk. The availability of a smart-phone enabled pocket-sized AED with CPR prompts has the potential to greatly improve population health and economic outcomes.

The Cost-Effectiveness of Adjuvant Tamoxifen Treatment of Hormone Receptor-Positive Early Breast Cancer Among Premenopausal and Perimenopausal Ghanaian Women

OBJECTIVES

Most breast cancer cases in Ghana occur in premenopausal and perimenopausal (PPM) women. This study evaluated the cost-effectiveness of tamoxifen compared with no tamoxifen for the adjuvant treatment of hormone receptor-positive (HR+) early breast cancer (EBC) among PPM Ghanaian women.

METHODS

A Markov model was constructed to synthesize data on the effectiveness, costs, and health benefits of tamoxifen. Effectiveness and utility data were sourced from a literature review. Resource use and healthcare costs were estimated from Ghanaian sources. The evaluation was conducted in 2017 from the perspective of the health system over a 15-year time horizon. The financial impact of funding tamoxifen on Ghana's National Health Insurance Scheme (NHIS) was also estimated.

RESULTS

Adjuvant tamoxifen treatment for women with HR+ EBC was more effective and more costly than no-tamoxifen therapy. The incremental benefit and costs were estimated to be 1.38 quality-adjusted life-years gained and Ghana cedis (GHC) 2338 ($520), respectively. The incremental cost-effectiveness ratio was estimated to be GHC 1694 ($376). The model was sensitive to the cost of tamoxifen and utility values. The cost of tamoxifen for the treatment of HR+ EBC represents less than 0.01% GHC 96 960 ($21 547) of the current NHIS total claims expenditure.

CONCLUSIONS

Tamoxifen provides additional benefits to PPM Ghanaian women with HR+ EBC and is cost-effective compared with no tamoxifen. These results support the public funding of tamoxifen under the NHIS and provide Ghanaian policy makers with vital information for future budgetary planning.

Cost-effectiveness analysis of a community-based colorectal cancer screening program in Shanghai, China

OBJECTIVE

This study investigated the cost-effectiveness of a community-based colorectal cancer-screening program (C-CRCSP) in Shanghai, China, among the residents in the urban, suburban and rural areas.

METHODS

A Markov model was constructed to evaluate the cost-effectiveness of a 25-year annual C-CRCSP including 100 000 populations. Cost-effectiveness was determined by the incremental cost-effectiveness ratio (ICER); referring to either life-years gained, or quality-adjusted life-years (QALYs) gained. The threshold was gross domestic product per capita. Univariate and multivariate sensitivity analyses were performed to investigate the influence of compliance, prevalence, technological performance, medical cost and annual cost discount rate (3.5%) on ICER. A probabilistic sensitivity analysis evaluated the probability of the cost-effectiveness of C-CRCSP at different maximum acceptable ceiling ratios.

RESULTS

Compared with no screening, the C-CRCSP resulted in total gains of 7840 QALYs and 2210 life-years (LY), at a total cost of CNY 58.54 million; that is, the ICER were CNY 7460/QALYs and CNY 26650/LY. Stratifying by residency, the cumulative gains in QALYs and LY were estimated to be the lowest in the urban populations compared with the rural and suburban populations. The cost for the urban population was 3-fold and 6-fold that of the suburban and rural populations. The ICER for QALYs ranged from 2180 (rural) to 16 840 (urban).

CONCLUSION

The cost-effectiveness of a C-CRCSP in Shanghai was most favorable for the rural population, while the urban population benefits less in terms of QALYs. ICER could be enhanced by measures that increase compliance.

Cost-Effectiveness of Amphotericin B Deoxycholate Versus Itraconazole for Induction Therapy of Talaromycosis in Human Immunodeficiency Virus-Infected Adults in Vietnam

BACKGROUND

Talaromycosis (penicilliosis) is an invasive fungal infection and a major cause of human immunodeficiency virus (HIV)-related deaths in Southeast Asia. Guidelines recommend induction therapy with amphotericin B deoxycholate; however, treatment with itraconazole has fewer toxic effects, is easier to administer, and is less expensive. Our recent randomized controlled trial in Vietnam found that amphotericin B was superior to itraconazole with respect to 6-month mortality. We undertook an economic evaluation alongside this trial to determine whether the more effective treatment is cost-effective.

METHODS

Resource use, direct and indirect costs, and health and quality-of-life outcomes (measured using quality-adjusted life-years [QALYs]) were evaluated for 405 trial participants from 2012 to 2016. Both a Vietnamese health service and a broader societal costing perspective were considered. Mean costs and QALYs were combined to calculate the within-trial cost-effectiveness of amphotericin vs itraconazole from both perspectives.

RESULTS

From a Vietnamese health service perspective, amphotericin increases costs but improves health outcomes compared to itraconazole, at a cost of $3013/QALY gained. The probability that amphotericin is cost-effective at a conventional (World Health Organization CHOICE) threshold of value for money is 46%. From a societal perspective, amphotericin is cost-reducing and improves outcomes compared to itraconazole, and is likely to be a cost-effective strategy at any value for money threshold greater than $0.

CONCLUSIONS

Our analysis indicates that induction therapy with amphotericin is a cost-effective treatment strategy for HIV-infected adults diagnosed with talaromycosis in Vietnam. These results provide the evidence base for health care providers and policy makers to improve access to and use of amphotericin.

La Charge Globale de Morbidité (Global Burden of Diseases): c'est Quoi? Pourquoi? Comment?

Cette série…

Le Réseau Maghrébin PRP2S et la Rédaction de la revue «La Tunisie Médicale» ont l'honneur de continuer d'une manière régulière, à partir du numéro de mars 2021, et pour la deuxième année successive, la série des fiches techniques en épidémiologie, en bio statistique et en rédaction médicale scientifique. Cette série a eu un grand succès au cours de sa première année d'édition en 2020, comme indique le nombre de téléchargements dépassant significativement celui des articles originaux et illustrant un besoin très manifeste des jeunes chercheurs, au renforcement de leurs capacités en méthodologie de recherche scientifique en sciences de santé, selon une pédagogie centrée sur l'acquisition des compétences pratiques de recherche biomédicale. En effet, nos fiches méthodologiques décrivent, d'une manière standardisée, les modes d'usage des concepts, des outils et des méthodes, utilisés d'une part lors du continuum de la recherche biomédicale scientifique, dès la phase conceptuelle jusqu'à la phase rédactionnelle et d'autre part lors des différentes phases de la rédaction médicale scientifique, depuis l'étape de la recherche documentaire jusqu'à l'étape de la communication médicale scientifique. Cette série est rédigée par les experts du Réseau Maghrébin PRP2S, en méthodologie de recherche, exerçant dans les universités du Grand Maghreb et les facultés soeurs au Nord de la Méditerranée. Chaque fiche répond à trois questions essentielles (Quoi ? Pourquoi ? Comment) du concept étudié, en se basant sur un article publié dans la revue «La Tunisie Médicale».

Economic evaluation of a novel community-based diabetes care model in rural Mexico: a cost and cost-effectiveness study

OBJECTIVES

Diabetes is the leading cause of disability-adjusted life years in Mexico, and cost-effective care models are needed to address the epidemic. We sought to evaluate the cost and cost-effectiveness of a novel community-based model of diabetes care in rural Mexico, compared with usual care.

DESIGN

We performed time-driven activity-based costing to estimate annualised costs associated with typical diabetes care in Chiapas, Mexico, as well as a novel diabetes care model known as Compañeros En Salud Programa de Enfermedades Crónicas (CESPEC). We conducted Markov chain analysis to estimate the cost-effectiveness of CESPEC compared with usual care from a societal perspective. We used patient outcomes from CESPEC in 2016, as well as secondary data from existing literature.

SETTING

Rural primary care clinics in Chiapas, Mexico.

PARTICIPANTS

Adults with diabetes.

INTERVENTIONS

CESPEC is a novel, comprehensive, diabetes care model that integrates community health workers, provider education, supply chain management and active case finding.

OUTCOME MEASURE

The primary outcome was the incremental cost-effectiveness of CESPEC compared with care as usual, per quality-adjusted life year (QALY) gained, expressed in 2016 US dollars.

RESULTS

The economic cost of the CESPEC diabetes model was US$144 per patient per year, compared with US$125 for diabetes care as usual. However, CESPEC care was associated with 0.13 additional years of health-adjusted life expectancy compared with usual care and 0.02 additional years in the first 5 years of treatment. This translated to an incremental cost-effectiveness ratio (ICER) of US$2981 per QALY gained over a patient's lifetime and an ICER of US$10 444 over the first 5 years. Findings were robust to multiple sensitivity analyses.

CONCLUSIONS

CESPEC is a cost-effective, community-based model of diabetes care for patients in rural Mexico. Given the high prevalence and significant morbidity associated with diabetes in Mexico and other countries in Central America, this model should be considered for broader scale up and evaluation.

COVID/HIV Co-Infection: A Syndemic Perspective on What to Ask and How to Answer

The present commentary explored the intersecting nature of the COVID-19 and HIV pandemics to identify a shared research agenda using a syndemic approach. The research agenda posits the following questions. Questions around HIV infection, transmission, and diagnosis include: (i) molecular, genetic, clinical, and environmental assessments of COVID-19 in people living with HIV, (ii) alternative options for facility-based HIV testing services such as self- and home-based HIV testing, and (iii) COVID-19 related sexual violence and mental health on HIV transmission and early diagnosis. These and related questions could be assessed using Biopsychosocial and socio-ecological models. Questions around HIV treatment include: (i) the effect of COVID-19 on HIV treatment services, (ii) alternative options for facility-based treatment provision such as community-based antiretroviral therapy groups, and (iii) equitable distribution of treatment and vaccines for COVID-19, if successful. Bickman's logic model and the social determinants of health framework could guide these issues. The impact of stigma, the role of leveraging lessons on sustained intra-behavioral change, the role of medical mistrust and conspiracy beliefs, and the role of digital health on integrated management of HIV care and spectrum of care of COVID-19 need assessment using several frameworks including Goffman's stigma framework, Luhmann's Trust theory, and Gidden's theory of structuration. In conclusion, the potential research agenda of this commentary encompasses a variety of research fields and disciplinary areas-clinicians, laboratory scientists, public health practitioners, health economists, and psychologists-, and suggests several theoretical frameworks to guide examination of complex issues comprehensively.

Using QALYs versus DALYs to measure cost-effectiveness: How much does it matter?

OBJECTIVES

Quality-adjusted life-years (QALYs) and disability-adjusted life-years (DALYs) are commonly used in cost-effectiveness analysis (CEA) to measure health benefits. We sought to quantify and explain differences between QALY- and DALY-based cost-effectiveness ratios, and explore whether using one versus the other would materially affect conclusions about an intervention's cost-effectiveness.

METHODS

We identified CEAs using both QALYs and DALYs from the Tufts Medical Center CEA Registry and Global Health CEA Registry, with a supplemental search to ensure comprehensive literature coverage. We calculated absolute and relative differences between the QALY- and DALY-based ratios, and compared ratios to common benchmarks (e.g., 1× gross domestic product per capita). We converted reported costs into US dollars.

RESULTS

Among eleven published CEAs reporting both QALYs and DALYs, seven focused on pharmaceuticals and infectious disease, and five were conducted in high-income countries. Four studies concluded that the intervention was "dominant" (cost-saving). Among the QALY- and DALY-based ratios reported from the remaining seven studies, absolute differences ranged from approximately $2 to $15,000 per unit of benefit, and relative differences from 6-120 percent, but most differences were modest in comparison with the ratio value itself. The values assigned to utility and disability weights explained most observed differences. In comparison with cost-effectiveness thresholds, conclusions were consistent regardless of the ratio type in ten of eleven cases.

CONCLUSIONS

Our results suggest that although QALY- and DALY-based ratios for the same intervention can differ, differences tend to be modest and do not materially affect comparisons to common cost-effectiveness thresholds.

A Financial Theory Perspective of the Metrics Employed to Measure Value in the “Value in Healthcare” Methodologies

<b><i>Background:</i></b> Value in healthcare is becoming an important paradigm in the drafting of health policies, the management of healthcare institutions, the financing of healthcare provision, and the choice of technologies in healthcare delivery. Several different metrics have been proposed and are currently used by academics and practitioners in this field. <b><i>Summary:</i></b> There are many challenges, both ethical and methodological, in the attempt to measure value in healthcare. One arises from the close relationship between health and life. Although it is generally regarded that human life should not be subject to monetary valuation, several human activities, namely work, are currently valued. This allows for the valuation of health as it impacts on these human activities. Other challenges are measuring health benefits and costs. Several metrics have been proposed in the literature and are used in practice. The purpose of this paper is to appraise, from the perspective of modern financial theory, several metrics used for determining value in healthcare. <b><i>Key Messages:</i></b> Most metrics used to determine value in healthcare do not reflect the concept of value used in modern financial theory. They rely mostly on accounting concepts such as costs, not in a prospective cash-flow perspective. Some adjustments need to be made to bring them into step with the financial theory of value.

The Inequitable Global Burden of Lip and Oral Cancers: Widening Disparities Across Countries

PURPOSE

In light of continued innovation in cancer immunotherapy regimens and surgical management, no studies currently exist assessing the effect of these advances on global disparities in lip and oral cavity cancer disease burden. The purpose of this study is to characterize longitudinal trends in disease burden caused by lip and oral cavity cancers globally.

MATERIALS AND METHODS

This retrospective, longitudinal cohort study extracted data on lip and oral cavity cancer disease burden from The Global Health Data Exchange for 1990-2017. The primary predictor variable was country human development index (HDI). The primary outcome variable was disease burden, measured by age-standardized disability-adjusted life years (DALYs) per 100,000 population, listed for each individual country. Additional variables assessed include country-level data on alcohol consumption and tobacco smoking. Concentration indices were also calculated. Mann-Whitney U and Kruskal-Wallis one-way analysis of variance tests with Bonferroni correction were utilized with a significance threshold of 0.008.

RESULTS

A total of 185 countries met inclusion criteria. Global age-standardized DALYs increased from 44.5 ± 35.7 to 51.1 ± 41.1 from 1990 to 2017. High HDI and medium HDI countries showed a +37.6% and +22.4% median increase in DALYs, respectively, which is significantly greater than very-high HDI (+3.8%) and low HDI countries (-0.5%) (P < .001). The concentration index for lip and oral cavity cancer became increasingly negative from -0.064 to -0.077 from 1990 to 2015. In 2017, disease burden was concentrated in South Asia and Eastern Europe.

CONCLUSIONS

High and medium HDI countries experienced a disproportionate growth in lip and oral cavity cancer disease burden. These findings may have resulted from increased life expectancy among these countries. Global and public health policy initiatives should focus on understanding the mechanisms driving these disparities with the goal of reducing disease burden globally.

Estimating a cost-effectiveness threshold for health care decision-making in South Africa

Cost-effectiveness thresholds are important decision rules that determine whether health interventions represent good value for money. In low- and middle-income countries, the World Health Organization (WHO) one to three times per capita gross domestic product (GDP) per disability-adjusted life years (DALYs) averted has been the most widely used threshold for informing resource allocation decisions. However, in 2016, the WHO withdrew recommendations for using this threshold, creating a significant vacuum in South Africa and many countries that rely on results of cost-effectiveness analyses for making resource allocation decisions. This study estimates a cost-effectiveness threshold that reflects the health opportunity cost of health spending in South Africa using a three-step approach. First, marginal returns to health spending was estimated as health spending elasticity for crude death rates using a fixed effect estimation approach. Second, the opportunity cost of health spending was estimated as DALYs averted. Finally, a cost per DALY averted threshold was estimated as the inverse of the marginal product of health spending. We show that 1% of total health spending in 2015 (equivalent to approximately ZAR 1.54 billion/USD 120.7 million) averted 1050 deaths, 34 180 years of life lost, 5880 years lived with disability and 40 055 DALYs. The cost-effectiveness threshold was estimated at approximately ZAR 38 500 (USD 3015) per DALY averted, ∼53% of South Africa's per capita GDP in 2015 (ZAR 72 700/USD 5700) and lower than the previously recommended one to three times per capita GDP. As South Africa moves towards implementing universal health coverage reforms through National Health Insurance by 2025, the adoption of a threshold that reflects health opportunity costs will be crucial for ensuring efficiency in the allocation of scarce resources. This study provides useful insight into the magnitude of the health opportunity cost of health spending in South Africa and highlights the need for further research.

Human Health and Economic Costs of Air Pollution in Utah: An Expert Assessment

Air pollution causes more damage to health and economy than previously understood, contributing to approximately one in six deaths globally. However, pollution reduction policies remain controversial even when proven effective and cost negative, partially because of misunderstanding and growing mistrust in science. We used an expert assessment to bridge these research–policy divides in the State of Utah, USA, combining quantitative estimates from 23 local researchers and specialists on the human health and economic costs of air pollution. Experts estimated that air pollution in Utah causes 2480 to 8000 premature deaths annually (90% confidence interval) and decreases the median life expectancy by 1.1 to 3.6 years. Economic costs of air pollution in Utah totaled $0.75 to $3.3 billion annually, up to 1.7% of the state’s gross domestic product. Though these results were generally in line with available estimates from downscaled national studies, they were met with surprise in the state legislature, where there had been an almost complete absence of quantitative health and economic cost estimates. We discuss the legislative and personal responses of Utah policy makers to these results and present a framework for increasing the assimilation of data into decision making via regional expert assessment. In conclusion, combining quantitative assessments from local experts is a responsive and cost-effective tool to increase trust and information uptake during time-sensitive policy windows.

Ranking Preventive Interventions from Different Policy Domains: What Are the Most Cost-Effective Ways to Improve Public Health?

It is widely acknowledged that in order to promote public health and prevent diseases, a wide range of scientific disciplines and sectors beyond the health sector need to be involved. Evidence-based interventions, beyond preventive health interventions targeting disease risk factors and interventions from other sectors, should be developed and implemented. Investing in these preventive health policies is challenging as budgets have to compete with other governmental expenditures. The current study aimed to identify, compare and rank cost-effective preventive interventions targeting metabolic, environmental, occupational and behavioral risk factors. To identify these interventions, a literature search was performed including original full economic evaluations of Western country interventions that had not yet been implemented in the Netherlands. Several workshops were held with experts from different disciplines. In total, 51 different interventions (including 13 cost saving interventions) were identified and ranked based on their incremental cost-effectiveness ratio (ICER) and potential averted disability-adjusted life years (DALYs), resulting in two rankings of the most cost-effective interventions and one ranking of the 13 cost saving interventions. This approach, resulting in an intersectoral ranking, can assist policy makers in implementing cost-effective preventive action that considers not only the health sector, but also other sectors.

An Empirical Study on the Benefits Equity of the Medical Security Policy: the China Health and Nutrition Survey (CHNS)

Background: One of the fundamental objectives of the basic medical security system is to provide institutional guarantees for the appropriate medical needs of different groups. Among them, achieving fairness of benefits is the first principle of the system. This study aims to explore the benefit equity of preventive health care for different groups and the specific path to promote fairness. Methods: Based on the 2015 CHNS survey data, through the theory construction of benefit fairness in the basic medical insurance and using the two-stage IV-Heckman model, the paper analyzes the benefit fairness of the basic medical insurance in urban and rural China. Results: This study indicates that (1) the results of empirical and theoretical models are not consistent with the sample of the insured population. (2) As private medical insurance and medical assistance are restricted in the model, the reimbursement ratio of medical insurance in other income groups is all higher than the highest one. However, the coefficient is getting larger, with the lowest income group having the largest coefficient. After controlling for variables of disease and severity, the results suggest that the main impact path is hospitalization costs. (3) Taking the highest income group as a reference, the compensation proportion of preventive health care in other groups is higher, respectively, than the reference group, while the groups below middle income have a significant relationship with compensation for preventive health care. Conclusions: Supplementary private medical insurance and medical assistance have important protection functions for low- and middle-income populations. However, owing to the actual income threshold, the two groups cannot benefit from the medical security system. This result is still valid in the field of preventive health care. The increase of preventive health care expenditure reduces the cost of individual hospitalization, but the high-income group has emerged with more preventive health care expenditures, creating new unfairness.

Engaging patient partners in state-of-the-art allergy care: Finding balance when discussing risk

OBJECTIVE

To review risk communication in the context of shared decision making.

DATA SOURCES

Articles describing risk communication, shared decision making, and cost-effective healthcare delivery.

STUDY SELECTIONS

A narrative review detailing approaches to improve risk communication and shared decision making to optimize patient-centered cost-effective practice.

RESULTS

Risk communication must occur on a foundation of mutual trust and can be improved by keeping risk in perspective of everyday hazards, such as using pictograms when possible, providing numeric likelihoods of risks and benefits, and discussing absolute risks. Variability in patient-perceived quality of life for allergic and nonallergic health states may affect the health and economic outcomes of many allergy therapies. Shared decision making improves patient knowledge and risk perception, engagement, and adherence. Patient decision aids can be time-consuming to develop and validate, but their use is associated with a more accurate understanding of patient-oriented outcomes.

CONCLUSION

Communicating risk is complex, and validated patient decision aids using visual aids, presenting essential information, using knowledge checks, and incorporating values clarification can reduce decisional conflict and improve decisional self-efficacy.

Reflecting the Health Opportunity Costs of Funding Decisions Within Value Frameworks: Initial Estimates and the Need for Further Research

PURPOSE

Evaluating whether a new health technology provides good value for money requires an assessment of its opportunity cost. If the opportunity cost of the new health technology exceeds the benefits, however measured, a net loss is produced. Value frameworks using economic evaluation methods have been developed to guide the assessment of the value of new technologies within health care in response to rising spending. However, few explicitly consider health opportunity costs and fewer still base health opportunity costs on empirical estimates. This may partly be due to the dearth of estimates available, with only a handful of countries having estimates based on within-country data. To fill this gap, this study provides estimates of cost per disability-adjusted life year (DALY) averted for 33 high-income countries and the remaining Organization for Economic Cooperation and Development (OECD) and BRIICS countries (Brazil, Russia, India, Indonesia, China and South Africa).

METHODS

Cost per DALY averted for each country was based on estimated elasticities of the health effects of changes in expenditure on health outcomes from applying an existing published econometric model that uses cross-country data to an expanded dataset and other existing elasticities drawn from selected UK within-country studies to country-level data on health expenditure, demographic characteristics, and burden of ill health. To provide a comprehensive picture of the state of research around empirical estimates of health opportunity costs for these countries, results from this study are reported against previously published estimates of cost per quality-adjusted life year (QALY) gained for the same countries.

FINDINGS

All but one of the ranges estimated fall below 3× the gross domestic product (GDP) per capita, the upper end of the widely applied range of 1-3× GDP per capita. The range of estimates based on applying an existing published econometric model that uses cross-country data to an expanded dataset are higher than when cost per DALY averted is calculated from other existing elasticities of the health effects of changes in expenditure drawn from selected UK within-country studies. They also tend to be higher than published estimates of cost per QALY gained.

IMPLICATIONS

This study provides placeholder cost per DALY averted estimates that reflect health opportunity costs for 33 high-income countries and the remaining OECD and BRIICS countries. These estimates can be used to estimate the health opportunity costs of government health care expenditure until country-specific health opportunity cost are estimated using within-country data.

Projecting burden of hypertension and its management in Turkey, 2015-2030

BACKGROUND

In Turkey, hypertension was responsible for 13% of total deaths in 2015. We apply existing research finding regarding the impact of a population-wide reduction in sodium consumption on the decrease of the hypertension prevalence rate among 15+ years population and the gender-age specific reduction in total death rates among 30+ years population, and compare hypertension burden, averted deaths, costs and benefits between two scenarios.

METHODS

The first scenario (i.e. status quo) assumes constant hypertension prevalence rate and the death rates between 2015 and 2030. Based on the Framingham Heart Study and INTERSALT Study findings on the impact of salt-reduction strategies on hypertension prevalence rate, the second scenario (Scenario II) assumes a 17% reduction in the prevalence of hypertension in Turkey in 2030, from its 2015 prevalence level. We project hypertension attributable disability adjusted life years (DALYs) in 2030, monetize DALYs using GDP (and income) per capita, and compare the projected economic benefits of DALYs averted and the additional costs associated with the increases in hypertension treatment through antihypertensive medications and physician consultations.

RESULTS

The estimated benefits of reducing the economic burden of hypertension deaths outweigh the cost of providing hypertension treatment. A decrease in hypertension prevalence by 17%, attributable to population-wide reduction in salt consumption, is projected to avert 24.3 thousand deaths in 2030. We projected that, compared to status quo, 392 thousand DALYs will be averted in Scenario II in 2030. The economic benefits of reduction in potential hypertension deaths are estimated to be 6.7 to 8.6 folds higher than the additional cost of hypertension treatment.

CONCLUSION

Population-wide hypertension prevention and management is a win-win situation for public health and the Turkish health care system as the economic benefits of reducing deaths and disabilities associated with hypertension outweigh the costs significantly.

Long-term cost-effectiveness of a Patient Empowerment Programme for type 2 diabetes mellitus in primary care

AIM

To evaluate the long-term cost-effectiveness of a Patient Empowerment Programme (PEP) for type 2 diabetes mellitus (DM) in primary care.

MATERIALS AND METHODS

PEP participants were subjects with type 2 DM who enrolled into PEP in addition to enrolment in the Risk Assessment and Management Programme for DM (RAMP-DM) at primary care level. The comparison group was subjects who only enrolled into RAMP-DM without participating in PEP (non-PEP). A cost-effectiveness analysis was conducted using a patient-level simulation model (with fixed-time increments) from a societal perspective. We incorporated the empirical data from a matched cohort of PEP and non-PEP groups to simulate lifetime costs and outcomes for subjects with DM with or without PEP. Incremental cost-effectiveness ratios (ICER) in terms of cost per quality adjusted life year (QALY) gained were calculated. Probabilistic sensitivity analysis was conducted with results presented as a cost-effectiveness acceptability curve.

RESULTS

With an assumption that the PEP effect would last for 5 years as shown by the empirical data, the incremental cost per subject was US $197 and the incremental QALYs gained were 0.06 per subject, which resulted in an ICER of US $3290 per QALY gained compared with no PEP across the lifetime. Probabilistic sensitivity analysis showed 66% likelihood that PEP is cost-effective compared with non-PEP when willingness-to-pay for a QALY is ≥US $46 153 (based on per capita GDP 2017).

CONCLUSIONS

Based on this carefully measured cost of PEP and its potentially large benefits, PEP could be highly cost-effective from a societal perspective as an adjunct intervention for patients with DM.

Economic Analysis of Vaccination Programs: An ISPOR Good Practices for Outcomes Research Task Force Report

This report provides recommendations for budget holders and decision makers in high-, middle, and low-income countries requiring economic analyses of new vaccination programs to allocate scarce resources given budget constraints. ISPOR's Economic Evaluation of Vaccines Designed to Prevent Infectious Disease: Good Practices Task Force wrote guidelines for three analytic methods and solicited comments on them from external reviewers. Cost-effectiveness analyses use decision-analytic models to estimate cumulative changes in resource use, costs, and changes in quality- or disability-adjusted life-years attributable to changes in disease outcomes. Constrained optimization modeling uses a mathematical objective function to be optimized (e.g. disease cases avoided) for a target population for a set of interventions including vaccination programs within established constraints. Fiscal health modeling estimates changes in net present value of government revenues and expenditures attributable to changes in disease outcomes. The task force recommends that those designing economic analyses for new vaccination programs take into account the decision maker's policy objectives and country-specific decision context when estimating: uptake rate in the target population; vaccination program's impact on disease cases in the population over time using a dynamic transmission epidemiologic model; vaccination program implementation and operating costs; and the changes in costs and health outcomes of the target disease(s). The three approaches to economic analysis are complementary and can be used alone or together to estimate a vaccination program's economic value for national, regional, or subregional decision makers in high-, middle-, and low-income countries.

Global Patterns of QALY and DALY Use in Surgical Cost-Utility Analyses: A Systematic Review

BACKGROUND

Surgical interventions are being increasingly recognized as cost-effective global priorities, the utility of which are frequently measured using either quality-adjusted (QALY) or disability-adjusted (DALY) life years. The objectives of this study were to: (1) identify surgical cost-effectiveness studies that utilized a formulation of the QALY or DALY as a summary measure, (2) report on global patterns of QALY and DALY use in surgery and the income characteristics of the countries and/or regions involved, and (3) assess for possible associations between national/regional-income levels and the relative prominence of either measure.

STUDY DESIGN

PRISMA-guided systematic review of surgical cost-effectiveness studies indexed in PubMed or EMBASE prior to December 15, 2014, that used the DALY and/or QALY as a summary measure. National locations were used to classify publications based on the 2014 World Bank income stratification scheme into: low-, lower-middle-, upper-middle-, or high-income countries. Differences in QALY/DALY use were considered by income level as well as for differences in geographic location and year using descriptive statistics (two-sided Chi-squared tests, Fischer's exact tests in cell counts <5).

RESULTS

A total of 540 publications from 128 countries met inclusion criteria, representing 825 "national studies" (regional publications included data from multiple countries). Data for 69.0% (569/825) were reported using QALYs (2.1% low-, 1.2% lower-middle-, 4.4% upper-middle-, and 92.3% high-income countries), compared to 31.0% (256/825) reported using DALYs (46.9% low-, 31.6% lower-middle-, 16.8% upper-middle-, and 4.7% high-income countries) (p<0.001). Studies from the US and the UK dominated the total number of QALY studies (49.9%) and were themselves almost exclusively QALY-based. DALY use, in contrast, was the most common in Africa and Asia. While prominent published use of QALYs (1990s) in surgical cost-effectiveness studies began approximately 10 years earlier than DALYs (2000s), the use of both measures continues to increase.

CONCLUSION

As global prioritization of surgical interventions gains prominence, it will be important to consider the comparative implications of summary measure use. The results of this study demonstrate significant income- and geographic-based differences in the preferential utilization of the QALY and DALY for surgical cost-effectiveness studies. Such regional variation holds important implications for efforts to interpret and utilize global health policy research. PROSPERO registration number: CRD42015015991.