A systematic review of discounting in national health economic evaluation guidelines: healthcare value implications

The Lebanese health economic evaluation guideline

BACKGROUND

Economic evaluation guidelines (EEGs) serve as a valuable tool to assist appraisers in making consistent and transparent recommendations, standardize EE studies, enhance their quality, and minimize methodological uncertainties. As other LMICs, Lebanon aims for UHC where EEG is a necessity. This paper aims to report on the Lebanese health EEG (LEEG) and its reference case, including the intermediate results leading to the final decisions.‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬.

RESEARCH DESIGN AND METHODS

The LEEG followed a structured, systematic, and transparent process: (1) identifying the rationale and the guideline scope; (2) establishing the Guideline Development Group; (3) searching the evidence; (4) planning the development process; (5) selecting the panel for the deliberative process; (6) surveying Lebanese stakeholders; (7) deliberating on the results; (8) drafting the guideline; and (9) consulting with international experts.

RESULTS

The LEEG includes three general characteristics, 19 key features, a reference case, and an action plan.

CONCLUSIONS

The LEEG is the first national EEG for health interventions. It will help decision-makers, researchers, and healthcare providers improve the quality and assessment of EE in Lebanon to identify the most cost-effective health interventions. Implementing LEEG is crucial to promoting an equitable, efficient, and high-quality health system with a more consistent decision-making process.

Whether temporal discounting is domain-specific between health outcomes and money: a systematic review and meta-analysis

BACKGROUND

Temporal discounting, the preference for immediate over delayed rewards, affects decision-making in domains like health and finance. Understanding the differences in how people discount health outcomes compared to monetary rewards is crucial to shaping health policy and technology assessments.

AIM

This systematic review and meta-analysis aimed to compare temporal discounting parameters between health outcomes and monetary rewards and evaluate their overall relationship.

METHOD

Studies were retrieved from PubMed, Embase, Web of Science, and the Cochrane Library up to December 2023. Standardized mean differences (SMD) assessed discounting differences between statistical indicators, and correlation coefficients were transformed into Fisher's Z scores. Subgroup analyses based on population, tradability, magnitude, sign, and experimental process explored potential heterogeneity.

RESULTS

A total of 32 studies were included: 29 studies (47 pairs of health and money) for the comparative meta-analysis and 19 studies (32 pairs) for the correlation meta-analysis. No significant differences were found between health and money discounting, although the individuals were more patient with the health outcomes and more impulsive with the money. In the sign effect subgroup, health discounting for delayed losses was lower than for monetary losses (SMD: - 0.293; 95% CI: - 0.458, - 0.129). The pooled correlation coefficient (r) for all studies was 0.333 (95% CI: 0.283-0.383), indicating a moderate association. In subgroup analysis, when the indicator was the discount rate, the pooled r value for 16 studies was 0.278 (95% CI: 0.231, 0.325).

CONCLUSION

Although no significant statistical differences were found between health and money discounting, a moderate correlation was observed, supporting consistent discount rate settings for health technology assessments.

Cost-effectiveness of plasmapheresis and hemoperfusion in COVID-19 survivors: A six-month follow-up analysis after hospital discharge

INTRODUCTION

To evaluate the short- and long-term clinical and financial outcomes of apheresis in COVID-19 survivors after hospital discharge.

METHODS

Intensive care unit-discharged patients were followed for 6 months. Vital signs, laboratory markers, quality of life, and direct medical costs were analyzed to calculate incremental cost-effectiveness ratios (ICER) and to plot cost-effectiveness planes and acceptability curves.

RESULTS

A total of 68 patients (45 control, 18 plasmapheresis, and 5 hemoperfusion) were included. ICERs for plasmapheresis and hemoperfusion patients at discharge were $867.58 and $198.89 per quality-adjusted life years (QALY) gained, respectively. Respiration and blood pressure improved significantly at discharge. The improvements in oxygenation markers for plasmapheresis and hemoperfusion groups were lower than controls (8.56 ± 10.31 and 11.75 ± 16.88 vs. 11.37 ± 7.28 percent for SpO2, 11.15 ± 21.15 and 11.05 ± 24.95 vs. 16.03 ± 5.61 mm Hg for PaO2, respectively) However, the respiratory rate improvements corresponded to ICERs of $1034.77 and $269.94 for plasmapheresis and hemoperfusion, respectively. The ICERs for increasing mean arterial pressure were $24.83 and $30.94 per mm Hg, and plasmapheresis was more cost-effective than hemoperfusion in increasing serum calcium levels ($1649.35 per mg/dL). At 1-month post-discharge, both treatments showed worse outcomes compared to controls. At 6 months, the plasmapheresis ICER ($1884.95) exceeded the willingness-to-pay threshold. The ICER for plasmapheresis at 6 months was $112.83 per rehospitalization day avoided, while hemoperfusion remained less effective than controls.

CONCLUSION

While plasmapheresis and hemoperfusion improved some clinical outcomes, their high costs and limited long-term cost-effectiveness suggest that these interventions may not be economically justified for treating COVID-19 patients. Careful evaluation is needed when considering their use in clinical practice.

Good Practices for Health Technology Assessment Guideline Development: A Report of the Health Technology Assessment International, HTAsiaLink, and ISPOR Special Task Force

OBJECTIVES

Health technology assessment (HTA) guidelines are intended to support the successful implementation of HTA by enhancing consistency and transparency in concepts, methods, processes, and use, thereby enhancing the legitimacy of the decision-making process. This report lays out good practices and practical recommendations for developing or updating HTA guidelines to ensure successful implementation.

METHODS

The task force was established in 2022 and comprised experts and academics from various geographical regions, each with substantial experience in developing HTA guidelines for national health policy making. Literature reviews and key informant interviews were conducted to inform these good practices. Stakeholder consultations, open peer reviews, and expert opinions validated the recommendations. A series of teleconferences among task force members was held to iteratively refine the report.

RESULTS

The recommendations cover six key aspects throughout the guideline development cycle: (1) setting objectives, scope, and principles of the guideline, (2) building a team for a quality guideline, (3) defining a stakeholder engagement plan, (4) developing content and utilizing available resources, (5) putting in place appropriate institutional arrangements, and (6) monitoring and evaluating guideline success.

CONCLUSION

This report presents a set of resources and context-appropriate practices for developing or updating HTA guidelines. Across all contexts, the recommendations emphasize transparency, building trust among stakeholders, and fostering a culture of ongoing learning and improvement. The report recommends timing development and revision of guidelines according to the HTA landscape and pace of HTA institutionalization. Because HTA is increasingly used to inform different kinds of decision making in a variety of country contexts, it will be important to continue to monitor lessons learned to ensure the recommendations remain relevant and effective.

Impact of perioperative diagnostic tools on clinical outcomes and cost-effectiveness in parathyroid surgery: a decision model-based analysis

OBJECTIVES

Preoperative and intraoperative diagnostic tools influence the surgical management of primary hyperparathyroidism (PHPT), whereby their performance of classification varies considerably for the two common causes of PHPT: solitary adenomas and multiglandular disease. A consensus on the use of such diagnostic tools for optimal perioperative management of all PHPT patients has not been reached.

DESIGN

A decision tree model was constructed to estimate and compare the clinical outcomes and the cost-effectiveness of preoperative imaging modalities and intraoperative parathyroid hormone (ioPTH) monitoring criteria in a 21-year time horizon with a 3% discount rate. The robustness of the model was assessed by conducting a one-way sensitivity analysis and probabilistic uncertainty analysis.

SETTING

The US healthcare system.

POPULATION

A hypothetical population consisting of 5000 patients with sporadic, symptomatic or asymptomatic PHPT.

INTERVENTIONS

Preoperative and intraoperative diagnostic modalities for parathyroidectomy.

MAIN OUTCOME MEASURES

Costs, quality-adjusted life-years (QALYs), net monetary benefits (NMBs) and clinical outcomes.

RESULTS

In the base-case analysis, four-dimensional (4D) CT was the least expensive strategy with US$10 276 and 15.333 QALYs. Ultrasound and 99mTc-Sestamibi single-photon-emission CT/CT were both dominated strategies while 18F-fluorocholine positron emission tomography was cost-effective with an NMB of US$416 considering a willingness to pay a threshold of US$95 958. The application of ioPTH monitoring with the Vienna criterion decreased the rate of reoperations from 10.50 to 0.58 per 1000 patients compared to not using ioPTH monitoring. Due to an increased rate of bilateral neck explorations from 257.45 to 347.45 per 1000 patients, it was not cost-effective.

CONCLUSIONS

4D-CT is the most cost-effective modality for the preoperative localisation of solitary parathyroid adenomas and multiglandular disease. The use of ioPTH monitoring is not cost-effective, but to minimise clinical complications, the Miami criterion should be applied for suspected solitary adenomas and the Vienna criterion for multiglandular disease.

Estimated reduction in obesity prevalence and costs of a 20% and 30% ad valorem excise tax to sugar-sweetened beverages in Brazil: A modeling study

BACKGROUND

The consumption of sugar-sweetened beverages (SSBs) is associated with obesity, metabolic diseases, and incremental healthcare costs. Given their health consequences, the World Health Organization (WHO) recommended that countries implement taxes on SSB. Over the last 10 years, obesity prevalence has almost doubled in Brazil, yet, in 2016, the Brazilian government cut the existing federal SSB taxes to their current 4%. Since 2022, a bill to impose a 20% tax on SSB has been under discussion in the Brazilian Senate. To simulate the potential impact of increasing taxes on SSB in Brazil, we aimed to estimate the price-elasticity of SSB and the potential impact of a new 20% or 30% excise SSB tax on consumption, obesity prevalence, and cost savings.

METHODS AND FINDINGS

Using household purchases data from the Brazilian Household Budget Survey (POF) from 2017/2018, we estimated constant elasticity regressions. We used a log-log specification by income level for all beverage categories: (1) sugar-sweetened beverages; (2) alcoholic beverages; (3) unsweetened beverages; and (4) low-calorie or artificially sweetened beverages. We estimated the adult nationwide baseline intake for each beverage category using 24-h dietary recall data collected in 2017/2018. Taking group one as the taxed beverages, we applied the price and cross-price elasticities to the baseline intake data, we obtained changes in caloric intake. The caloric reduction was introduced into an individual dynamic model to estimate changes in weight and obesity prevalence. No benefits on cost savings were modeled during the first 3 years of intervention to account for the time lag in obesity cases to reduce costs. We multiplied the reduction in obesity cases during 7 years by the obesity costs per capita to predict the costs savings attributable to the sweetened beverage tax. SSB price elasticities were higher among the lowest tertile of income (-1.24) than in the highest income tertile (-1.13), and cross-price elasticities suggest SSB were weakly substituted by milk, water, and 100% fruit juices. We estimated a caloric change of -17.3 kcal/day/person under a 20% excise tax and -25.9 kcal/day/person under a 30% tax. Ten years after implementation, a 20% tax is expected to reduce obesity prevalence by 6.7%; 9.1% for a 30% tax. These reductions translate into a -2.8 million and -3.8 million obesity cases for a 20% and 30% tax, respectively, and a reduction of $US 13.3 billion and $US 17.9 billion in obesity costs over 10 years for a 20% and 30% tax, respectively. Study limitations include using a quantile distribution method to adjust self-reported baseline weight and height, which could be insufficient to correct for reporting bias; also, weight, height, and physical activity were assumed to be steady over time.

CONCLUSIONS

Adding a 20% to 30% excise tax on top of Brazil's current federal tax could help to reduce the consumption of ultra-processed beverages, empty calories, and body weight while avoiding large health-related costs. Given the recent cuts to SSB taxes in Brazil, a program to revise and implement excise taxes could prove beneficial for the Brazilian population.

Cost-effectiveness of treating advanced melanoma with tumor-infiltrating lymphocytes based on an international randomized phase 3 clinical trial

INTRODUCTION

In a multicenter, open-label randomized phase 3 clinical trial conducted in the Netherlands and Denmark, treatment with ex vivo-expanded tumor-infiltrating lymphocytes (TIL-NKI/CCIT) from autologous melanoma tumor compared with ipilimumab improved progression-free survival in patients with unresectable stage IIIC-IV melanoma after failure of first-line or second-line treatment. Based on this trial, we conducted a cost-utility analysis.

METHODS

A Markov decision model was constructed to estimate expected costs (expressed in 2021€) and outcomes (quality-adjusted life years (QALYs)) of TIL-NKI/CCIT versus ipilimumab in the Netherlands. The Danish setting was assessed in a scenario analysis. A modified societal perspective was applied over a lifetime horizon. TIL-NKI/CCIT production costs were estimated via activity-based costing. Through sensitivity analyses, uncertainties and their impact on the incremental cost-effectiveness ratio (ICER) were assessed.

RESULTS

Mean total undiscounted lifetime benefits were 4.47 life years (LYs) and 3.52 QALYs for TIL-NKI/CCIT and 3.33 LYs and 2.46 QALYs for ipilimumab. Total lifetime undiscounted costs in the Netherlands were €347,168 for TIL-NKI/CCIT (including €67,547 for production costs) compared with €433,634 for ipilimumab. Undiscounted lifetime cost in the Danish scenario were €337,309 and €436,135, respectively. This resulted in a dominant situation for TIL-NKI/CCIT compared with ipilimumab in both countries, meaning incremental QALYs were gained at lower costs. Survival probabilities, and utility in progressive disease affected the ICER most.

CONCLUSION

Based on the data of a randomized phase 3 trial, treatment with TIL-NKI/CCIT in patients with unresectable stage IIIC-IV melanoma is cost-effective and cost-saving, both in the current Dutch and Danish setting. These findings led to inclusion of TIL-NKI/CCIT as insured care and treatment guidelines. Publicly funded development of the TIL-NKI/CCIT cell therapy shows realistic promise to further explore development of effective personalized treatment while warranting economic sustainability of healthcare systems.

Examining how well economic evaluations capture the value of mental health

Health economics evidence informs health-care decision making, but the field has historically paid insufficient attention to mental health. Economic evaluations in health should define an appropriate scope for benefits and costs and how to value them. This Health Policy provides an overview of these processes and considers to what extent they capture the value of mental health. We suggest that although current practices are both transparent and justifiable, they have distinct limitations from the perspective of mental health. Most social value judgements, such as the exclusion of interindividual outcomes and intersectoral costs, diminish the value of improving mental health, and this reduction in value might be disproportionate compared with other types of health. Economic analyses might have disadvantaged interventions that improve mental health compared with physical health, but research is required to test the size of such differential effects and any subsequent effect on decision-making systems such as health technology assessment systems. Collaboration between health economics and the mental health sciences is crucial for achieving mental-physical health parity in evaluative frameworks and, ultimately, improving population mental health.

Fifteen Lessons from Fifteen Years of the Health Intervention and Technology Assessment Program in Thailand

The Health Intervention and Technology Assessment Program (HITAP) was established in 2007. This article highlights 15 lessons from over 15 years of experience, noting five achievements about what HITAP has done well, five areas that it is currently working on, and five aims for work in the future. HITAP built capacity for HTA and linked research to policy and practice in Thailand. With collaborators from academic and policy spheres, HITAP has mobilized regional and global support, and developed global public goods to enhance the field of HTA. HITAP's semi-autonomous structure has facilitated these changes, though they have not been without their challenges. HITAP aims to continue its work on HTA for public health interventions and disinvestments, effectively engaging with stakeholders and strategically managing its human resources. Moving forward, HITAP will develop and update global public goods on HTA, work on emerging topics such as early HTA, address issues in digital health, real-world evidence and equity, support HTA development globally, particularly in low-income settings, and seek to engage more effectively with the public. HITAP seeks to learn from its experience and invest in the areas identified so that it can grow sustainably. Its journey may be relevant to other countries and institutions that are interested in developing HTA programs.

Cost associated with diverting ostomy after rectal cancer surgery: a transnational analysis

BACKGROUND

Diverting ileostomy and colostomy after total mesorectal excision reduces the risk of complications related to anastomotic leakages but is associated with a reduction in health-related quality of life and long-term economic consequences that are unknown. Our objective was to estimate the lifetime costs of stoma placement after rectal cancer resection in the U.S., England, and Germany.

METHODS

Input parameters were derived from quasi-systematic literature searches. Decision-analytic models with survival from colorectal cancer-adjusted life tables and country-specific stoma reversal proportions were created for the three countries to calculate lifetime costs. Main cost items were stoma maintenance costs and reimbursement for reversal procedures. Discounting was applied according to respective national guidelines. Sensitivity analysis was conducted to explore the impact of parameter uncertainty onto the results.

RESULTS

The cohort starting ages and median survival were 63 and 11.5 years for the U.S., 69 years and 8.5 years for England, and 71 and 6.5 years for Germany. Lifetime discounted stoma-related costs were $26,311, £9512, and €10,021, respectively. All three models were most sensitive to the proportion of ostomy reversal, age at baseline, and discount rate applied.

CONCLUSION

Conservative model-based projections suggest that stoma care leads to significant long-term costs. Efforts to reduce the number of patients who need to undergo a diverting ostomy could result in meaningful cost savings.