Transferability of economic evaluation results

Conceptual framework for standard economic evaluation of physical activity programs in primary prevention

Economic evaluations of primary prevention physical activity programs have gained importance because of scarce resources in health-care-systems. A concept for economic evaluation should be based on the efficacy of physical activity, the standard methods of economic evaluation and the aims of public health. Previous publications have examined only parts of these components and have not developed a comprehensive conceptual framework; it is the objective of this article to develop such a framework. The derived method should aid decision makers and staff members of intervention programs in reviewing and conducting an economic evaluation. A literature search of articles was done using six electronic databases. Referenced works for standard methods and more comprehensive approaches for evaluation of preventive programs were studied. The newly developed conceptual framework for economic evaluation includes: (1) the type of physical activity program; (2) features of a selected study population; (3) the outcome dimension comprising exercise efficacy, reach, recruitment, response rate, maintenance, compliance and adverse health effects plus the social impact; and (4) the cost dimension consisting of program development costs, program implementation costs including the implementation, recruitment, program, participants' time costs and savings resulting from the health effects of the intervention. Cost-effectiveness also depends on the methodology, such as the chosen perspective, data collection, valuation methods and discounting. If an intervention is not considered cost-effective, it is necessary to check each dimension to find possible failures in order to learn for future interventions. A more detailed economic evaluation is of utmost importance for improved comparability and transferability.

Methodological issues in cost-effectiveness studies: a brief overview

This article discussed two methodological issues around cost-effectiveness studies, including validity and transferability of results. In an economic analysis study, methods to costing, health utility measurement, and economic modeling represent three important sources that may threaten the validity. Variations in health systems and clinical practice, and differential resource use and unit prices across regions and countries may have potentially large influence on transferability. The limitations of piggybacked design may also have implications for transferability. Caution is warranted in the design, conduct, and interpretation of cost-effectiveness studies regarding their validity and transferability.

Cost-effectiveness of Treatment for Acute Childhood Idiopathic Thrombocytopenic Purpura (ITP) – a Systematic Review

The cost-effectiveness of treatment for acute paediatric idiopathic thrombocytopenic purpura (ITP) was assessed to provide evidence for health-care decision making and rational drug use. A systematic review of studies published between 1980 and 7 September 2007 on the clinical effects and economic profiles of treating ITP was undertaken. The quality of the studies was critically appraised and checklists were developed to assess methodological quality and transferability to the Chinese setting. Out of 174 studies, five (one Chinese; four USA) satisfied all the predefined criteria for inclusion and form the basis of this report. Methodological quality of most of the foreign studies was high, but transferability to other countries was low. Use of steroids provided additional life years and was cost-effective compared with intravenous immunoglobulin G and anti-D immunoglobulin. In comparison, the quality of the Chinese studies was low and long-term research rare. It was difficult to compare cost-effectiveness in different health-care settings and no life-time economic evaluations were available.

Economic evaluation of enoxaparin for anticoagulation in early cardioversion of persisting nonvalvular atrial fibrillation: a statutory health insurance perspective from Germany

OBJECTIVE

To estimate, from the perspective of Statutory Health Insurance (SHI, third-party payer) in Germany, the economic consequences of using the subcutaneous low-molecular-weight heparin (LMWH) enoxaparin instead of intravenous unfractionated heparin followed by oral phenprocoumon (UFH/PPC) for anticoagulation in patients undergoing transesophageal echocardiography (TEE)-guided early electrical cardioversion (ECV) of persisting nonvalvular atrial fibrillation (AF) without intracardiac clot.

DESIGN AND SETTING

The incremental cost for the enoxaparin-based regimen versus the UFH/PPC-based regimen was chosen as the target variable. A decision-analytic model considering the in- and outpatient sectors was used to quantify the target variable. Resource use during in- and outpatient treatment was taken from the Anticoagulation in Cardioversion using Enoxaparin (ACE) trial and from expert interviews with cardiologists in Germany in order to reflect the day-to-day conditions of clinical practice. Costs were given by SHI expenses for inpatient treatment and for medical services, drugs, disposables, and laboratory tests during outpatient treatment. These costs were determined by multiplying utilized resource items by the price or tariff of each item based on German healthcare regulations for the reference period of 2003/2004. According to the ACE trial, the evaluation encompassed 28 (26-30) treatment days with two consecutive phases. Phase I with 5 (3-12) days comprised diagnostics, start of anticoagulation, and ECV. Phase II with the remaining days consisted of continued anticoagulation and patient monitoring. The dosage of enoxaparin was 1 mg/kg bodyweight twice daily in treatment phase I followed by 40 mg twice daily with a bodyweight <65 kg or 60 mg twice daily with a BW > or =65 kg in treatment phase II. The daily dosages of UFH by continuous infusion and overlapping PPC were adjusted to an International Normalized Ratio of 2.0-3.0 in treatment phase I followed by 2.25mg PPC once daily in treatment phase II. Patients with any comorbidity and complication level (CCL) and those with low comorbidity and complications expected to occur in rare cases only (low-risk patients) were analyzed separately. In each base-case analysis, exclusively point estimates of all respective model parameters were applied.

MAIN OUTCOME MEASURES AND RESULTS

There were savings of 339 euro and 579 euro per patient receiving the enoxaparin-based regimen versus the UFH/PPC-based regimen in the case of patients with any CCL and of low-risk patients, respectively (1 euro approximate, equals $US1.25; first quarter 2004 values). In comprehensive sensitivity analyzes, the robustness of the model and its results was shown. First, the impact of the model parameters on the target variable for each patient group was quantified in a deterministic model. Secondly, the dependency of the target variable on random variables was described for each patient group using Monte Carlo simulation. Irrespective of the patient group, the cost weight and the base rate of hospitals for inpatient ECV in phase I turned out to have the greatest impact on the savings obtained by the enoxaparin-based regimen. In the case of patients with any CCL, this impact was about 1.4-fold of that of the probability of enoxaparin patients undergoing outpatient ECV in phase I. In the case of low-risk patients, the impact of the cost weight and the base rate of hospitals for inpatient ECV in phase I was about 4.1-fold of that of the price of enoxaparin 60 mg prefilled syringes in the outpatient sector. In 79% and 93% of 10,000 simulated comparisons each versus the UFH/PPC-based regimen, there were savings obtained by the enoxaparin-based regimen in patients with any CCL and in low-risk patients, respectively.

CONCLUSIONS

Results of this evaluation showed that an enoxaparin-based regimen for TEE-guided ECV of AF in patients without intracardiac clot offers SHI in Germany a considerable saving potential when used instead of an UFH/PPC-based regimen.

Comparative cost-effectiveness of antiviral therapies in patients with chronic hepatitis B: a systematic review of economic evidence

BACKGROUND AND AIM

Economic efficiency of the alternative antiviral therapies for chronic hepatitis B has not been systematically investigated and their quality remains unknown. The aim of the present study was to systematically overview economic evidence of antiviral therapies for chronic hepatitis B.

METHODS

We searched six databases and eight major journals supplemented with screening references of eligible studies. Full economic evaluations comparing alternative antiviral therapies in patients with chronic hepatitis B virus infection were included. Two investigators assessed the study quality and transferability, independently. Data were analyzed qualitatively with adjustment when appropriate.

RESULTS

Fourteen studies (six modeling vs eight trials and database analyses) were included. Quality was high in five studies, moderate in one US and five Chinese studies, and low in three Chinese studies. The major problems of quality are costing methods and analysis and the presentation of results. In Australia and Poland, lamivudine-preferred strategies dominated interferon (IFN)-alpha and its related strategy from the health-care sector perspective. In the US, adefovir salvage produced US$8446 per additional quality-adjusted life years (QALY) compared with IFN-alpha. In Spain, the cost of adefovir was US$34,840 for additional virological response. In Taiwan, the use of pegylated IFN-alpha (pegIFN-alpha) produced US$11,711.4 per additional QALY, compared with lamivudine. In China, the incremental cost-effectiveness ratios of combination therapy lamivudine ranged from US$2860 to US$22,160 per additional loss of hepatitis B e antigen (HBeAg), and IFN-alpha versus lamivudine ranged from US$2490 to US$8890 per additional loss of HBeAg.

CONCLUSION

The cost-effectiveness frontiers of treatment alternatives vary and are influenced by the comparators and socioeconomic conditions of countries. Lamivudine-containing therapy is cost-effective when newer antiviral agents (e.g. adefovir/pegIFN-alpha) were not available. Economic methods should be further improved in studies, particularly in China.