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Nshimyumukiza L, Beaumont JA, Rousseau F, Reinharz D. Introducing cell-free DNA noninvasive testing in a Down syndrome public health screening program: a budget impact analysis. Cost Eff Resour Alloc 2020; 18:49. [PMID: 33292318 PMCID: PMC7640422 DOI: 10.1186/s12962-020-00245-5] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2017] [Accepted: 10/28/2020] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Non-invasive prenatal testing (NIPT) using cell-free fetal DNA in maternal plasma is a high accurate test for prenatal screening for Down syndrome. Although it has been reported to be cost effective as a contingent test, evidence about its budget impact is lacking. OBJECTIVE To evaluate, using computer simulations, the budget impact of implementing NIPT as a contingent test in the Quebec Program of screening for Trisomy 21. METHODS A semi-Markov analytic model built to simulate the budget impact of implementing NIPT into the current Quebec Trisomy 21 public Prenatal Screening, Serum Integrated prenatal screening (SIPS). Comparisons were made for a virtual population similar to that of expected Quebec pregnant women in 2015 in terms of size and age. Data input parameters were retrieved from a thorough literature search and in government databases, especially data from Quebec Program of screening for Trisomy 21. The 2015-2016 fiscal year budget impact was estimated from the Quebec healthcare system perspective and was expressed as the difference in the overall costs between the two alternatives (SIPS minus SPS + NIPT). RESULTS Our study found that, at a baseline cost for NIPT of CAD$ 795, NIPT as a second-tier test offered to high-risk women identified by current screening program (SIPS + NIPT) may be affordable for Quebec health care system. Compared to the current screening program, it would be implemented at a neutral cost, considering a modest annual savings of $ 80,432 (95% CI $ 79, $ 874-$ 81,462). Results were sensitive to the NIPT costs and the uptake-rate of invasive diagnostic tests. CONCLUSION Introducing NIPT as a contingent test in the Quebec Trisomy 21 screening program is an affordable strategy compared to the current practice. Further research is needed to confirm if our results can be reproduced in other healthcare jurisdictions.
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Affiliation(s)
- L. Nshimyumukiza
- Département de médecine sociale et préventive, Faculté de Médecine, Université Laval, Pavillon Ferdinand Vandry, Local 2432, 1050 Avenue de La Médecine, Quebec, QC G7V0A6 Canada
| | - J. A. Beaumont
- Département d’informatique et de Génie Logiciel, Faculté de Sciences et de Génie, Université Laval, Quebec, QC Canada
| | - F. Rousseau
- Centre de Recherche du Centre Hospitalier Universitaire de Québec, Québec, QC Canada
- Département de Biologie Moléculaire, Biochimie Médicale et Pathologie, Faculté de Médecine, Université Laval, Quebec, QC Canada
| | - D. Reinharz
- Département de médecine sociale et préventive, Faculté de Médecine, Université Laval, Pavillon Ferdinand Vandry, Local 2432, 1050 Avenue de La Médecine, Quebec, QC G7V0A6 Canada
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Nshimyumukiza L, Lieffers JRL, Ekwaru JP, Ohinmaa A, Veugelers PJ. Temporal changes in diet quality and the associated economic burden in Canada. PLoS One 2018; 13:e0206877. [PMID: 30408076 PMCID: PMC6224068 DOI: 10.1371/journal.pone.0206877] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2018] [Accepted: 10/22/2018] [Indexed: 11/25/2022] Open
Abstract
A high-quality diet is associated with a reduced of risk of chronic disease and all-cause mortality. In this study, we assessed changes in diet quality and the associated economic burden in the Canadian population between 2004 and 2015. We used a prevalence-based cost-of-illness approach. We first calculated the diet quality using the Healthy Eating Index-Canada-2010 (HEI-C-2010) and 24-hour recall data from the Canadian Community Health Surveys (CCHS) on nutrition (CCHS 2004 cycle 2.2 and the CCHS-NU 2015). We then retrieved relative risks of HEI-2010 quintiles for chronic diseases from meta-analyses. Based on the proportions of the population following diets of varying qualities and these relative risks, we computed the population-attributable fractions and attributable costs (direct health care and indirect costs) by survey year (2004 and 2015) as well as by age and sex group. Costs were estimated in 2017 Canadian dollars for comparison purposes. We observed that on average the diet quality of Canadians improved between 2004 and 2015: the proportion of the Canadian population that did not eat a diet of high quality decreased from 83% to 76%. This improvement in diet quality translated in a decrease in economic burden of $133 million, down from $13.21 billion in 2004 to $13.08 billion in 2015. The economic burden decreased by $219 million among males but increased by $86 million among females. It also decreased among people under the age of 65 years ($333 million) but increased among those over 65 years ($ 200 million). Our findings suggest that, despite some temporal improvements, the diet of the majority of Canadians is of poor quality resulting in a high attributable economic burden. Policy and decision makers are encouraged to expand nutrition programs and policies and to specifically target the elderly in order to prevent chronic diseases and reduce health care costs.
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Affiliation(s)
- Léon Nshimyumukiza
- Population Health Intervention Research Unit, School of Public Health, University of Alberta, Edmonton, Alberta, Canada
- Department of Family and Emergency Medicine, Faculty of Medicine, Université Laval, Quebec, Quebec, Canada
| | - Jessica R. L. Lieffers
- College of Pharmacy and Nutrition, University of Saskatchewan, Saskatoon, Saskatchewan, Canada
| | - John Paul Ekwaru
- Population Health Intervention Research Unit, School of Public Health, University of Alberta, Edmonton, Alberta, Canada
| | - Arto Ohinmaa
- Population Health Intervention Research Unit, School of Public Health, University of Alberta, Edmonton, Alberta, Canada
| | - Paul J. Veugelers
- Population Health Intervention Research Unit, School of Public Health, University of Alberta, Edmonton, Alberta, Canada
- * E-mail:
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Nshimyumukiza L, Menon S, Hina H, Rousseau F, Reinharz D. Cell-free DNA noninvasive prenatal screening for aneuploidy versus conventional screening: A systematic review of economic evaluations. Clin Genet 2018; 94:3-21. [PMID: 29030960 DOI: 10.1111/cge.13155] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2017] [Revised: 04/24/2017] [Accepted: 04/26/2017] [Indexed: 12/28/2022]
Abstract
Although noninvasive prenatal testing (NIPT) for aneuploidies using cell-free fetal DNA in maternal blood has been reported to have a high accuracy, only little evidence about its cost-effectiveness is available. We systematically reviewed and assessed quality of economic evaluation studies published between January 1, 2009 and January 1, 2016 where NIPT was compared to the current screening practices consisting of biochemical markers with or without nuchal translucency (NT) and/or maternal age. We included 16 studies and we found that, at current level of NIPT prices, contingent NIPT provide the best value for money, especially for publicly funded screening programs. NIPT as first-line test was found not cost-effective in the majority of studies. The NIPT unit cost, the risk cut-offs for current screening practice, the screening uptake rates (first- and second-line screening) as well as the costs and uptake rates of invasive diagnostic screening were the most common uncertain variables. The overall quality of included studies was fair. Considering a possible drop in prices and an ongoing NIPT expansion to include other chromosomes abnormalities other than T21, T18, T13 and sex chromosomes aneuploidies, future research are needed to examine the potential cost-effectiveness of implementing NIPT as first-line test.
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Affiliation(s)
- L Nshimyumukiza
- Département de Médecine Sociale et Préventive, Faculté de Médecine, Université Laval, Quebec, Canada
| | - S Menon
- International Centre for Reproductive Health, Ghent University, Ghent, Belgium
| | - H Hina
- Faculté des Sciences Infirmières, Université Laval, Quebec, Canada
| | - F Rousseau
- Centre de Recherche du Centre Hospitalier Universitaire de Québec, Quebec, Canada.,Département de Biologie Moléculaire, Biochimie Médicale et Pathologie, Faculté de Médecine, Université Laval, Quebec, Canada
| | - D Reinharz
- Département de Médecine Sociale et Préventive, Faculté de Médecine, Université Laval, Quebec, Canada
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Nshimyumukiza L, Beaumont JA, Duplantie J, Langlois S, Little J, Audibert F, McCabe C, Gekas J, Giguère Y, Gagné C, Reinharz D, Rousseau F. Cell-Free DNA-Based Non-invasive Prenatal Screening for Common Aneuploidies in a Canadian Province: A Cost-Effectiveness Analysis. J Obstet Gynaecol Can 2017; 40:48-60. [PMID: 28784564 DOI: 10.1016/j.jogc.2017.05.015] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2017] [Revised: 05/10/2017] [Accepted: 05/11/2017] [Indexed: 11/17/2022]
Abstract
OBJECTIVE Yearly, 450 000 pregnant Canadians are eligible for voluntary prenatal screening for trisomy 21. Different screening strategies select approximately 4% of women for invasive fetal chromosome testing. Non-invasive prenatal testing (NIPT) using maternal blood cell-free DNA could reduce those invasive procedures but is expensive. This study evaluated the cost-effectiveness of NIPT strategies compared with conventional strategies. METHODS This study used a decision analytic model to estimate the cost-effectiveness of 13 prenatal screening strategies for fetal aneuploidies: six frequently used strategies, universal NIPT, and six strategies incorporating NIPT as a second-tier test. The study considered a virtual cohort of pregnant women of similar size and age as women in Quebec. Model data were obtained from published sources and government databases. The study predicted the number of chromosomal anomalies detected (trisomies 21, 13, and 18), invasive procedures and euploid fetal losses, direct costs, and incremental cost-effectiveness ratios. RESULTS Of the 13 strategies compared, eight identified fewer cases at a higher cost than at least one of the remaining five strategies. Integrated serum screening with conditional NIPT had the lowest cost, and the cost per case detected was $63 139, with a 90% reduction of invasive procedures. The number of cases identified was improved with four other screening strategies, but with increasing of incremental costs per case (from $61 623 to $1 553 615). Results remained robust, except when NIPT costs and risk cut-offs varied. CONCLUSION NIPT as a second-tier test for high-risk women is likely to be cost-effective as compared with screening algorithms not involving NIPT.
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Affiliation(s)
- Léon Nshimyumukiza
- Department of Social and Preventive Medicine, Faculty of Medicine, Université Laval, Québec City, QC.
| | - Jean-Alexandre Beaumont
- Department of Software Engineering, Faculty of Sciences and Engineering, Université Laval, Québec City, QC
| | - Julie Duplantie
- Department of Social and Preventive Medicine, Faculty of Medicine, Université Laval, Québec City, QC
| | - Sylvie Langlois
- Department of Medical Genetics, University of British Columbia, Vancouver, BC
| | - Julian Little
- School of Epidemiology, Public Health and Preventive Medicine, University of Ottawa, Ottawa, ON
| | - François Audibert
- Department of Obstetrics and Gynaecology, Faculty of Medicine, Université de Montréal, Montréal, QC
| | - Christopher McCabe
- Department of Emergency Medicine, University of Alberta Hospital, Edmonton, AB
| | - Jean Gekas
- Research Centre, Centre hospitalier universitaire de Québec, Québec City, QC
| | - Yves Giguère
- Research Centre, Centre hospitalier universitaire de Québec, Québec City, QC; Department of Molecular Biology, Medical Biochemistry, and Pathology, Faculty of Medicine, Université Laval, Québec City, QC
| | - Christian Gagné
- Department of Computer Engineering, Faculty of Sciences and Engineering, Université Laval, Québec City, QC
| | - Daniel Reinharz
- Department of Social and Preventive Medicine, Faculty of Medicine, Université Laval, Québec City, QC
| | - François Rousseau
- Research Centre, Centre hospitalier universitaire de Québec, Québec City, QC; Department of Molecular Biology, Medical Biochemistry, and Pathology, Faculty of Medicine, Université Laval, Québec City, QC
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Nshimyumukiza L, Douville X, Fournier D, Duplantie J, Daher RK, Charlebois I, Longtin J, Papenburg J, Guay M, Boissinot M, Bergeron MG, Boudreau D, Gagné C, Rousseau F, Reinharz D. Cost-effectiveness analysis of antiviral treatment in the management of seasonal influenza A: point-of-care rapid test versus clinical judgment. Influenza Other Respir Viruses 2016; 10:113-21. [PMID: 26574910 PMCID: PMC4746566 DOI: 10.1111/irv.12359] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/23/2015] [Indexed: 11/27/2022] Open
Abstract
Background A point‐of‐care rapid test (POCRT) may help early and targeted use of antiviral drugs for the management of influenza A infection. Objective (i) To determine whether antiviral treatment based on a POCRT for influenza A is cost‐effective and, (ii) to determine the thresholds of key test parameters (sensitivity, specificity and cost) at which a POCRT based‐strategy appears to be cost effective. Methods An hybrid « susceptible, infected, recovered (SIR) » compartmental transmission and Markov decision analytic model was used to simulate the cost‐effectiveness of antiviral treatment based on a POCRT for influenza A in the social perspective. Data input parameters used were retrieved from peer‐review published studies and government databases. The outcome considered was the incremental cost per life‐year saved for one seasonal influenza season. Results In the base‐case analysis, the antiviral treatment based on POCRT saves 2 lives/100 000 person‐years and costs $7600 less than the empirical antiviral treatment based on clinical judgment alone, which demonstrates that the POCRT‐based strategy is dominant. In one and two way‐sensitivity analyses, results were sensitive to the POCRT accuracy and cost, to the vaccination coverage as well as to the prevalence of influenza A. In probabilistic sensitivity analyses, the POCRT strategy is cost‐effective in 66% of cases, for a commonly accepted threshold of $50 000 per life‐year saved. Conclusion The influenza antiviral treatment based on POCRT could be cost‐effective in specific conditions of performance, price and disease prevalence.
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Affiliation(s)
- Léon Nshimyumukiza
- Faculté de Médecine, Département de médecine sociale et préventive, Université Laval, Québec, QC, Canada
| | - Xavier Douville
- Faculté des sciences et génie, Département de génie électrique, Université Laval, Québec, QC, Canada
| | - Diane Fournier
- Faculté des sciences et génie, Département de génie électrique, Université Laval, Québec, QC, Canada
| | - Julie Duplantie
- Faculté de Médecine, Département de médecine sociale et préventive, Université Laval, Québec, QC, Canada
| | - Rana K Daher
- Centre de recherche en infectiologie (CRI), CHU de Québec (CHUQ), Québec, QC, Canada
| | - Isabelle Charlebois
- Centre de recherche en infectiologie (CRI), CHU de Québec (CHUQ), Québec, QC, Canada
| | - Jean Longtin
- Centre de recherche en infectiologie (CRI), CHU de Québec (CHUQ), Québec, QC, Canada.,Faculté de médecine, Département de microbiologie-infectiologie et d'immunologie, Université Laval, Québec, QC, Canada
| | - Jesse Papenburg
- Faculté de Médecine, Département de pédiatrie, Université McGill, Montréal, QC, Canada
| | - Maryse Guay
- Faculté de médecine, Département des sciences de la santé communautaire, Université de Sherbrooke, Longueuil, QC, Canada
| | - Maurice Boissinot
- Faculté de sciences et de génie, Département de physique, génie physique et d'optique, Université Laval, Québec, QC, Canada
| | - Michel G Bergeron
- Centre de recherche en infectiologie (CRI), CHU de Québec (CHUQ), Québec, QC, Canada.,Faculté de médecine, Département de microbiologie-infectiologie et d'immunologie, Université Laval, Québec, QC, Canada
| | - Denis Boudreau
- Faculté de sciences et de génie, Département de chimie, Université Laval, Québec, QC, Canada
| | - Christian Gagné
- Faculté des sciences et génie, Département de génie électrique, Université Laval, Québec, QC, Canada
| | - François Rousseau
- Faculté de médecine, Département de biologie moléculaire, biochimie médicale et pathologie, Université Laval, Québec, QC, Canada.,Unité de recherche en génétique humaine et moléculaire, Axe Santé des populations et pratiques optimales en santé, Centre de recherche du CHU de Québec (CHUQ), Québec, QC, Canada
| | - Daniel Reinharz
- Faculté de Médecine, Département de médecine sociale et préventive, Université Laval, Québec, QC, Canada
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Nshimyumukiza L, Bois A, Daigneault P, Lands L, Laberge AM, Fournier D, Duplantie J, Giguère Y, Gekas J, Gagné C, Rousseau F, Reinharz D. Cost effectiveness of newborn screening for cystic fibrosis: A simulation study. J Cyst Fibros 2014; 13:267-74. [DOI: 10.1016/j.jcf.2013.10.012] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2013] [Revised: 10/21/2013] [Accepted: 10/22/2013] [Indexed: 10/26/2022]
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Duplantie J, Gonzales OM, Bois A, Nshimyumukiza L, Gekas J, Bujold E, Morin V, Vallée M, Giguère Y, Gagné C, Rousseau F, Reinharz D. Cost-Effectiveness of the Management of Rh-Negative Pregnant Women. Journal of Obstetrics and Gynaecology Canada 2013; 35:730-740. [DOI: 10.1016/s1701-2163(15)30864-1] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
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Nshimyumukiza L, Duplantie J, Gagnon M, Douville X, Fournier D, Lindsay C, Parent M, Milot A, Giguère Y, Gagné C, Rousseau F, Reinharz D. Dabigatran versus warfarin under standard or pharmacogenetic-guided management for the prevention of stroke and systemic thromboembolism in patients with atrial fibrillation: a cost/utility analysis using an analytic decision model. Thromb J 2013; 11:14. [PMID: 23866305 PMCID: PMC3765702 DOI: 10.1186/1477-9560-11-14] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2013] [Accepted: 07/16/2013] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Atrial fibrillation (AF) is the most common form of heart arrhythmia and a leading cause of stroke and systemic embolism. Chronic anticoagulation is recommended for preventing those complications. Our study aimed to compare the cost/utility (CU) of three main anticoagulation options: 1) standard warfarin dosing (SD-W) 2) warfarin dosage under the guidance of CYP2C9 and VKORC1 genotyping (GT-W) and 3) dabigatran 150 mg twice a day. METHODS A Markov state transition model was built to simulate the expected C/U of dabigatran, SD-W and GT-W anticoagulation therapy for the prevention of stroke and systemic thromboembolism in patients with atrial fibrillation over a period of 5 years under the perspective of the public health care system. Model inputs were derived from extensive literature search and government's data bases. Outcomes considered were the number of total major events (thromboembolic and hemorrhagic events), total costs in Canadian dollars (1CAD$ = 1$US), total quality-adjusted life years (QALYs), costs/QALYs and incremental costs/QALYs gained (ICUR). RESULTS Raw base case results show that SD-W has the lowest C/U ratio. However, the dabigatran option might be considered as an alternative, as its cost per additional QALY gained compared to SD-W is CAD $ 4 765, i.e. less than 50 000, the ICUR threshold generally accepted to adopt an intervention. At the same threshold, GT-W doesn't appear to be an alternative to SD-W. Our results were robust to one-way and multi-way sensitivity analyses. CONCLUSION SD-W has the lowest C/U ratio among the 3 options. However, dabigatran might be considered as an alternative. GT-W is not C/U and should not currently be recommended for the routine anticoagulotherapy management of AF patients.
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Affiliation(s)
- Léon Nshimyumukiza
- Département de médecine sociale et préventive, Faculté de Médecine, Université Laval, 1050, avenue de la Médecine, Québec, QC G1V 0A6, Canada.
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Nshimyumukiza L, Durand A, Gagnon M, Douville X, Morin S, Lindsay C, Duplantie J, Gagné C, Jean S, Giguère Y, Dodin S, Rousseau F, Reinharz D. An economic evaluation: Simulation of the cost-effectiveness and cost-utility of universal prevention strategies against osteoporosis-related fractures. J Bone Miner Res 2013; 28:383-94. [PMID: 22991210 PMCID: PMC3580046 DOI: 10.1002/jbmr.1758] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/14/2012] [Revised: 08/30/2012] [Accepted: 09/04/2012] [Indexed: 12/30/2022]
Abstract
A patient-level Markov decision model was used to simulate a virtual cohort of 500,000 women 40 years old and over, in relation to osteoporosis-related hip, clinical vertebral, and wrist bone fractures events. Sixteen different screening options of three main scenario groups were compared: (1) the status quo (no specific national prevention program); (2) a universal primary prevention program; and (3) a universal screening and treatment program based on the 10-year absolute risk of fracture. The outcomes measured were total directs costs from the perspective of the public health care system, number of fractures, and quality-adjusted life-years (QALYs). Results show that an option consisting of a program promoting physical activity and treatment if a fracture occurs is the most cost-effective (CE) (cost/fracture averted) alternative and also the only cost saving one, especially for women 40 to 64 years old. In women who are 65 years and over, bone mineral density (BMD)-based screening and treatment based on the 10-year absolute fracture risk calculated using a Canadian Association of Radiologists and Osteoporosis Canada (CAROC) tool is the best next alternative. In terms of cost-utility (CU), results were similar. For women less than 65 years old, a program promoting physical activity emerged as cost-saving but BMD-based screening with pharmacological treatment also emerged as an interesting alternative. In conclusion, a program promoting physical activity is the most CE and CU option for women 40 to 64 years old. BMD screening and pharmacological treatment might be considered a reasonable alternative for women 65 years old and over because at a healthcare capacity of $50,000 Canadian dollars ($CAD) for each additional fracture averted or for one QALY gained its probabilities of cost-effectiveness compared to the program promoting physical activity are 63% and 75%, respectively, which could be considered socially acceptable. Consideration of the indirect costs could change these findings.
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Affiliation(s)
- Léon Nshimyumukiza
- Département de médecine sociale et préventive, Faculté de Médecine, Université Laval, Québec, Québec, Canada
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Durand A, Gagne C, Nshimyumukiza L, Gagnon M, Rousseau F, Giguere Y, Reinharz D. Population-Based Simulation for Public Health: Generic Software Infrastructure and Its Application to Osteoporosis. ACTA ACUST UNITED AC 2012. [DOI: 10.1109/tsmca.2012.2210210] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
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