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Quality-adjusted Life Year (quality-adjusted + life_year)
Selected AbstractsQuality-adjusted life years: how useful in medico economic studiesFUNDAMENTAL & CLINICAL PHARMACOLOGY, Issue 6 2005Carmen A. Brauer Abstract Cost-effectiveness analysis has evolved as a practical response to the need to allocate limited resources for health care. It can be used to compare interventions whose effects on health are different if the measure of effectiveness captures all the important health dimensions of the effects of the interventions. Using the quality-adjusted life year (QALY) as the unit of effectiveness attempts to approach this ideal and is currently the approach recommended by many consensus groups. Conventional QALYs represent time spend in a series of "quality-weighted" health states, where the quality weights reflect the desirability of living in the state. Many challenges arise when preferences are incorporated into an economic analysis. The purpose of this paper is to highlight some of the issues surrounding the use of QALYs and to encourage researchers to present their methodology in a clear and transparent way. [source] Insulin therapy in type 2 diabetes patients failing oral agents: cost-effectiveness of biphasic insulin aspart 70/30 vs. insulin glargine in the US,DIABETES OBESITY & METABOLISM, Issue 1 2007J. A. Ray Objectives:, To project the long-term clinical and economic outcomes of treatment with biphasic insulin aspart 30 (BIAsp 70/30, 30% soluble and 70% protaminated insulin aspart) vs. insulin glargine in insulin-naļve type 2 diabetes patients failing to achieve glycemic control with oral antidiabetic agents alone (OADs). Methods:, Baseline patient characteristics and treatment effect data from the recent ,INITIATE' clinical trial served as input to a peer-reviewed, validated Markov/Monte-Carlo simulation model. INITIATE demonstrated improvements in HbA1c favouring BIAsp 70/30 vs. glargine (,0.43%; p < 0.005) and greater efficacy in reaching glycaemic targets among patients poorly controlled on OAD therapy. Effects on life expectancy (LE), quality-adjusted life expectancy (QALE), cumulative incidence of diabetes-related complications and direct medical costs (2004 USD) were projected over 35 years. Clinical outcomes and costs were discounted at a rate of 3.0% per annum. Sensitivity analyses were performed. Results:, Improvements in glycaemic control were projected to lead to gains in LE (0.19 ± 0.24 years) and QALE (0.19 ± 0.17 years) favouring BIAsp 70/30 vs. glargine. Treatment with BIAsp 70/30 was also associated with reductions in the cumulative incidences of diabetes-related complications, notably in renal and retinal conditions. The incremental cost-effectiveness ratio was $46 533 per quality-adjusted life year gained with BIAsp 70/30 vs. glargine (for patients with baseline HbA1c , 8.5%, it was $34 916). Total lifetime costs were compared to efficacy rates in both arms as a ratio, which revealed that the lifetime cost per patient treated successfully to target HbA1c levels of <7.0% and , 6.5% were $80 523 and $93 242 lower with BIAsp 70/30 than with glargine, respectively. Conclusions:, Long-term treatment with BIAsp 70/30 was projected to be cost-effective for patients with type 2 diabetes insufficiently controlled on OADs alone compared to glargine. Treatment with BIAsp 70/30 was estimated to represent an appropriate investment of healthcare dollars in the management of type 2 diabetes. [source] Cost-effectiveness of extended buprenorphine,naloxone treatment for opioid-dependent youth: data from a randomized trialADDICTION, Issue 9 2010Daniel Polsky ABSTRACT Aims The objective is to estimate cost, net social cost and cost-effectiveness in a clinical trial of extended buprenorphine,naloxone (BUP) treatment versus brief detoxification treatment in opioid-dependent youth. Design Economic evaluation of a clinical trial conducted at six community out-patient treatment programs from July 2003 to December 2006, who were randomized to 12 weeks of BUP or a 14-day taper (DETOX). BUP patients were prescribed up to 24 mg per day for 9 weeks and then tapered to zero at the end of week 12. DETOX patients were prescribed up to 14 mg per day and then tapered to zero on day 14. All were offered twice-weekly drug counseling. Participants 152 patients aged 15,21 years. Measurements Data were collected prospectively during the 12-week treatment and at follow-up interviews at months 6, 9 and 12. Findings The 12-week out-patient study treatment cost was $1514 (P < 0.001) higher for BUP relative to DETOX. One-year total direct medical cost was only $83 higher for BUP (P = 0.97). The cost-effectiveness ratio of BUP relative to DETOX was $1376 in terms of 1-year direct medical cost per quality-adjusted life year (QALY) and $25 049 in terms of out-patient treatment program cost per QALY. The acceptability curve suggests that the cost-effectiveness ratio of BUP relative to DETOX has an 86% chance of being accepted as cost-effective for a threshold of $100 000 per QALY. Conclusions Extended BUP treatment relative to brief detoxification is cost effective in the US health-care system for the outpatient treatment of opioid-dependent youth. [source] Quality-adjusted life years: how useful in medico economic studiesFUNDAMENTAL & CLINICAL PHARMACOLOGY, Issue 6 2005Carmen A. Brauer Abstract Cost-effectiveness analysis has evolved as a practical response to the need to allocate limited resources for health care. It can be used to compare interventions whose effects on health are different if the measure of effectiveness captures all the important health dimensions of the effects of the interventions. Using the quality-adjusted life year (QALY) as the unit of effectiveness attempts to approach this ideal and is currently the approach recommended by many consensus groups. Conventional QALYs represent time spend in a series of "quality-weighted" health states, where the quality weights reflect the desirability of living in the state. Many challenges arise when preferences are incorporated into an economic analysis. The purpose of this paper is to highlight some of the issues surrounding the use of QALYs and to encourage researchers to present their methodology in a clear and transparent way. [source] On future non-medical costs in economic evaluationsHEALTH ECONOMICS, Issue 5 2008Bengt Liljas Abstract Economic evaluation in health care is still an evolving discipline. One of the current controversies in cost-effectiveness analysis regards the inclusion or exclusion of future non-medical costs (i.e. consumption net of production) due to increased survival. This paper examines the implications of a symmetry rule stating that there should be consistency between costs included in the numerator and utility aspects included in the denominator. While the observation that no quality-adjusted life year (QALY) instruments explicitly include consumption and leisure seems to give support to the notion that future non-medical costs should be excluded when QALYs are used as the outcome measure, a better understanding of what respondents actually consider when reporting QALY weights is required. However, the more fundamental question is whether QALYs can be interpreted as utilities. Or more precisely, what are the assumptions needed for a general utility model also including consumption and leisure to be consistent with QALYs? Once those assumptions are identified, they need to be experimentally tested to see whether they are at least approximately valid. Until we have answers to these areas for future research, it seems premature to include future non-medical costs. Copyright © 2007 John Wiley & Sons, Ltd. [source] Glucosamine sulphate in the treatment of knee osteoarthritis: cost-effectiveness comparison with paracetamolINTERNATIONAL JOURNAL OF CLINICAL PRACTICE, Issue 6 2010S. Scholtissen Summary Introduction:, The aim of this study was to explore the cost-effectiveness of glucosamine sulphate (GS) compared with paracetamol and placebo (PBO) in the treatment of knee osteoarthritis. For this purpose, a 6-month time horizon and a health care perspective was used. Material and methods:, The cost and effectiveness data were derived from Western Ontario and McMaster Universities Osteoarthritis Index data of the Glucosamine Unum In Die (once-a-day) Efficacy trial study by Herrero-Beaumont et al. Clinical effectiveness was converted into utility scores to allow for the computation of cost per quality-adjusted life year (QALY) For the three treatment arms Incremental Cost-Effectiveness Ratio were calculated and statistical uncertainty was explored using a bootstrap simulation. Results:, In terms of mean utility score at baseline, 3 and 6 months, no statistically significant difference was observed between the three groups. When considering the mean utility score changes from baseline to 3 and 6 months, no difference was observed in the first case but there was a statistically significant difference from baseline to 6 months with a p-value of 0.047. When comparing GS with paracetamol, the mean baseline incremental cost-effectiveness ratio (ICER) was dominant and the mean ICER after bootstrapping was ,1376 ,/QALY indicating dominance (with 79% probability). When comparing GS with PBO, the mean baseline and after bootstrapping ICER were 3617.47 and 4285 ,/QALY, respectively. Conclusion:, The results of the present cost-effectiveness analysis suggested that GS is a highly cost-effective therapy alternative compared with paracetamol and PBO to treat patients diagnosed with primary knee OA. [source] Cost-effectiveness of psoriasis therapy with etanercept in GermanyJOURNAL DER DEUTSCHEN DERMATOLOGISCHEN GESELLSCHAFT, Issue 9 2007Tatjana Heinen-Kammerer Summary Background: We estimated the cost-effectiveness of intermittent therapy with etanercept in patients with moderate-to-severe plaque-type psoriasis in comparison to non-systemic therapy in Germany. Patients and Methods: We performed a cost-utility analysis using the endpoint costs per quality-adjusted life year gained (costs/QALY). For this purpose, we adapted a UK-based Markov model by means of resource use data that we derived from a German cost study. Efficacy data, information on frequency of adverse events and changes in quality of life were derived from three pooled clinical trials. We extrapolated the further course of the disease and its treatment over a 10 year course. Results: For patients with an initial Psoriasis Area and Severity Index (PASI) > 10 and a Dermatology Life Quality Index (DLQI) > 10 the incremental cost-effectiveness ratio (ICER) for etanercept compared to non-systemic therapy was 45,491 ,/QALY. For patients with PASI and DLQI > 15 costs/QALY were 32,058 , and among patients with severe plaque psoriasis (DLQI and PASI > 20) 18,154 , . Conclusions: According to internationally accepted levels of cost-effectiveness thresholds, the intermittent treatment of (moderate to) severe plaque-type psoriasis with etanercept is a cost-effective measure within the German healthcare system. [source] Comparison of the metabolic and economic consequences of long-term treatment of schizophrenia using ziprasidone, olanzapine, quetiapine and risperidone in Canada: a cost-effectiveness analysisJOURNAL OF EVALUATION IN CLINICAL PRACTICE, Issue 4 2010Roger S. McIntyre MD FRCPC Abstract Rationale, aims and objectives, Second-generation antipsychotic agents have varying propensities to cause weight gain, elevated lipid levels and associated long-term complications. This study evaluates the cost-effectiveness of four second-generation antipsychotic agents used in Canada for the treatment of schizophrenia (ziprasidone, olanzapine, quetiapine, risperidone) with a focus on their long-term metabolic consequences. Method, Using data from the Clinical Antipsychotic Trials of Intervention Effectiveness Study, a semi-Markov model was developed to predict the incidence and associated costs of type 2 diabetes, cardiovascular complications (e.g. angina, myocardial infarction, stroke, cardiovascular disease death), and acute psychiatric hospitalizations in patients with chronic schizophrenia treated over 5 years. Incremental costs per quality-adjusted life year (QALY) gained were calculated from the perspective of the Canadian provincial ministries of health. Scenario and probabilistic sensitivity analyses were performed. Results, The total average cost of treatment with ziprasidone was $25 301 versus $28 563 with olanzapine, $26 233 with quetiapine and $21 831 with risperidone. Ziprasidone had the lowest predicted number of type 2 diabetes cases and cardiovascular disease events, and the highest QALY gains. Patients receiving quetiapine had the highest predicted number of hospitalizations. Ziprasidone was less costly and resulted in more QALYs compared with olanzapine and quetiapine. Compared with risperidone, ziprasidone was more costly and had higher QALYs, with an incremental cost per QALY gained of $218 060. Conclusion, Compared with olanzapine and quetiapine, ziprasidone produced savings to the health care system. Although ziprasidone generated incremental expenditures versus risperidone, it resulted in more QALYs. Based on this analysis, ziprasidone treatment possesses cost and therapeutic advantages compared with olanzapine and quetiapine. [source] Feasibility and cost-effectiveness of using magnification chromoendoscopy and pepsinogen serum levels for the follow-up of patients with atrophic chronic gastritis and intestinal metaplasiaJOURNAL OF GASTROENTEROLOGY AND HEPATOLOGY, Issue 10 2007Mįrio Dinis-Ribeiro Abstract Background:, The follow-up of patients with atrophic chronic gastritis or intestinal metaplasia may lead to early diagnosis of gastric cancer. However, to-date no cost-effective model has been proposed. Improved endoscopic examination using magnification chromoendoscopy together with non-invasive functional assessment with pepsinogen serum levels are accurate in the diagnosis of intestinal metaplasia (extension) and minute dysplastic lesions. The aim of this study was to assess the feasibility and cost-effectiveness of a follow-up model for patients with atrophic chronic gastritis and intestinal metaplasia based on gastric mucosal status using magnification chromoendoscopy and pepsinogen. Methods:, A cohort of patients with lesions as severe as atrophic chronic gastritis were followed-up according to a standardized protocol using magnification chromoendoscopy with methylene blue and measurement of serum pepsinogen I and II levels. A single node decision tree and Markov chain modeling were used to define cost-effectiveness of this follow-up model versus its absence. Transition rates were considered time-independent and calculated using primary data following cohort data analysis. Costs, quality of life and survival were estimated based on published data and extensive sensitivity analysis was performed. Results:, A total of 100 patients were successfully followed-up over 3 years. Seven cases of dysplasia were diagnosed during follow-up, all among patients with incomplete intestinal metaplasia at baseline, six of whom had extensive (pepsinogen I to II ratio <3) incomplete intestinal metaplasia. For those individuals with atrophic chronic gastritis or complete intestinal metaplasia, a yearly measurement of pepsinogen levels or an endoscopic examination on a 3-yearly basis would cost ,455 per quality-adjusted life year (QALY) gain. Endoscopic examination and pepsinogen serum level measurement on a yearly basis would cost ,1868 per QALY for patients with extensive intestinal metaplasia. Conclusions:, The follow-up of patients with atrophic chronic gastritis or intestinal metaplasia is both feasible and cost-effective if improved accurate endoscopic examination of gastric mucosa together with non-invasive assessment of gastric mucosal status are used to identify individuals at high-risk for development of gastric cancer. [source] Cost-Effectiveness of Screening for Unhealthy Alcohol Use with %Carbohydrate Deficient Transferrin: Results From a Literature-Based Decision Analytic Computer ModelALCOHOLISM, Issue 8 2009Alok Kapoor Background:, The %carbohydrate deficient transferrin (%CDT) test offers objective evidence of unhealthy alcohol use but its cost-effectiveness in primary care conditions is unknown. Methods:, Using a decision tree and Markov model, we performed a literature-based cost-effectiveness analysis of 4 strategies for detecting unhealthy alcohol use in adult primary care patients: (i) Questionnaire Only, using a validated 3-item alcohol questionnaire; (ii) %CDT Only; (iii) Questionnaire followed by %CDT (Questionnaire-%CDT) if the questionnaire is negative; and (iv) No Screening. For those patients screening positive, clinicians performed more detailed assessment to characterize unhealthy use and determine therapy. We estimated costs using Medicare reimbursement and the Medical Expenditure Panel Survey. We determined sensitivity, specificity, prevalence of disease, and mortality from the medical literature. In the base case, we calculated the incremental cost-effectiveness ratio (ICER) in 2006 dollars per quality-adjusted life year ($/QALY) for a 50-year-old cohort. Results:, In the base case, the ICER for the Questionnaire-%CDT strategy was $15,500/QALY compared with the Questionnaire Only strategy. Other strategies were dominated. When the prevalence of unhealthy alcohol use exceeded 15% and screening age was <60 years, the Questionnaire-%CDT strategy costs less than $50,000/QALY compared to the Questionnaire Only strategy. Conclusions:, Adding %CDT to questionnaire-based screening for unhealthy alcohol use was cost-effective in our literature-based decision analytic model set in typical primary care conditions. Screening with %CDT should be considered for adults up to the age of 60 when the prevalence of unhealthy alcohol use is 15% or more and screening questionnaires are negative. [source] The impact of prognosis without treatment on doctors' and patients' resource allocation decisions and its relevance to new drug recommendation processesBRITISH JOURNAL OF CLINICAL PHARMACOLOGY, Issue 2 2008D. Ross Camidge What is already known about this subject ,,The dominant health economic units upon which new treatment funding decisions are made are the incremental cost per life year gained (LYG) or the cost per quality-adjusted life year (QALY) gained. ,,Neither of these units modifies the amount of health gained, by the amount of health patients would have had if they had not been given the treatment under consideration, which may unfairly undervalue the treatments for poor prognosis conditions. ,,How certain patients make decisions about their own treatment has previously been explored, but not how they, or doctors, would allocate hypothetical resource within a healthcare system given information on disease-treatment scenarios' prognoses with and without treatment. What this study adds ,,Information on prognosis without treatment is used within the resource allocation strategies of many doctors and most patients. ,,Individuals use this information in a variety of different ways and a single dominant strategy for quantitative modification of health units is not apparent. ,,Information on prognosis without treatment, or prognosis with standard treatment, is available from the control arm of randomized controlled clinical trials and should be used qualitatively to facilitate decision-making around the second inflexion point on cost per QALY/LYG acceptability curves. Aims Health economic assessments increasingly contribute to funding decisions on new treatments. Treatments for many poor prognosis conditions perform badly in such assessments because of high costs and modest effects on survival. We aimed to determine whether underlying shortness of prognosis should also be considered as a modifier in such assessments. Methods Two hundred and eighty-three doctors and 201 oncology patients were asked to allocate treatment resource between hypothetical patients with unspecified life-shortening diseases. The prognoses with and without treatment were varied such that consistent use of one of four potential allocation strategies could be deduced: life years gained (LYGs) , which did not incorporate prognosis without treatment information; percentage increase in life years (PILY); life expectancy with treatment (LEWT) or immediate risk of death (IRD). Results Random choices were rare; 47% and 64% of doctors and patients, respectively, used prognosis without treatment in their strategies; while 50% and 32%, respectively, used pure LYG-based strategies. Ranking orders were LYG > PILY > IRD > LEWT (doctors) and LEWT > LYG > IRD > PILY (patients). When LYG information alone could not be used, 76% of doctors prioritized shorter prognoses, compared with 45% of patients. Conclusions Information on prognosis without treatment is used within the resource allocation strategies of many doctors and most patients, and should be considered as a qualitative modifier during the health economic assessments of new treatments for life-shortening diseases. A single dominant strategy incorporating this information for any quantitative modification of health units is not apparent. [source] Cost-effectiveness and quality-of-life analysis of physician-staffed helicopter emergency medical services,BRITISH JOURNAL OF SURGERY (NOW INCLUDES EUROPEAN JOURNAL OF SURGERY), Issue 11 2009A. N. Ringburg Background: The long-term health outcomes and costs of helicopter emergency medical services (HEMS) assistance remain uncertain. The aim of this study was to investigate the cost-effectiveness of HEMS assistance compared with emergency medical services (EMS). Methods: A prospective cohort study was performed at a level I trauma centre. Quality-of-life measurements were obtained at 2 years after trauma, using the EuroQol,Five Dimensions (EQ-5D) as generic measure to determine health status. Health outcomes and costs were combined into costs per quality-adjusted life year (QALY). Results: The study population receiving HEMS assistance was more severely injured than that receiving EMS assistance only. Over the 4-year study interval, HEMS assistance saved a total of 29 additional lives. No statistically significant differences in quality of life were found between assistance with HEMS or with EMS. Two years after trauma the mean EQ-5D utility score was 0·70 versus 0·71 respectively. The incremental cost,effectiveness ratio for HEMS versus EMS was ,28 327 per QALY. The sensitivity analysis showed a cost-effectiveness ratio between ,16 000 and ,62 000. Conclusion: In the Netherlands, the costs of HEMS assistance per QALY remain below the acceptance threshold. HEMS should therefore be considered as cost effective. Copyright © 2009 British Journal of Surgery Society Ltd. Published by John Wiley & Sons, Ltd. [source] Economic evaluation of erythropoiesis-stimulating agents for anemia related to cancerCANCER, Issue 13 2010Scott Klarenbach MD Abstract BACKGROUND: Erythropoiesis-stimulating agents (ESA) administered to cancer patients with anemia reduce the need for blood transfusions and improve quality-of-life (QOL). Concerns about toxicity have led to more restrictive recommendations for ESA use; however, the incremental costs and benefits of such a strategy are unknown. METHODS: The authors created a decision model to examine the costs and consequences of ESA use in patients with anemia and cancer from the perspective of the Canadian public healthcare system. Model inputs were informed by a recent systematic review. Extensive sensitivity analyses and scenario analysis rigorously assessed QOL benefits and more conservative ESA administration practices (initial hemoglobin [Hb] <10 g/dL, target Hb ,12 g/dL, and chemotherapy induced anemia only). RESULTS: Compared with supportive transfusions only, conventional ESA treatment was associated with an incremental cost per quality-adjusted life year (QALY) gained of $267,000 during a 15-week time frame. During a 1.3-year time horizon, ESA was associated with higher costs and worse clinical outcomes. In scenarios where multiple assumptions regarding QOL all favored ESA, the lowest incremental cost per QALY gained was $126,000. Analyses simulating the use of ESA in accordance with recently issued guidelines resulted in incremental cost per QALY gained of >$100,000 or ESA being dominated (greater costs with lower benefit) in the majority of the scenarios, although greater variability in the cost-utility ratio was present. CONCLUSIONS: Use of ESA for anemia related to cancer is associated with incremental cost-effectiveness ratios that are not economically attractive, even when used in a conservative fashion recommended by current guidelines. Cancer 2010. © 2010 American Cancer Society. [source] Cost effectiveness of pharmacogenetic testing for uridine diphosphate glucuronosyltransferase 1A1 before irinotecan administration for metastatic colorectal cancer,CANCER, Issue 17 2009Heather Taffet Gold PhD Abstract BACKGROUND: The objective of this study was to examine the cost effectiveness of using a pharmacogenetic test for uridine diphosphate glycosyltransferase 1A1*28 (UGT1A1*28) variant homozygosity before administering irinotecan to patients with metastatic colorectal cancer. METHODS: A decision-analytic model from the Medicare payer perspective followed hypothetical patients who were treated with combined 5-fluorouracil, leucovorin, and irinotecan. Under usual care, patients received a full dose of irinotecan. With genetic testing, irinotecan dosage was reduced 25% in homozygotes with the UGT1A1*28 variant allele. Test performance, chemotherapy toxicity, and quality-of-life weights were derived from clinical literature and product labels, and costs were derived from 2007 Medicare fee schedules. Chemotherapy efficacy after dose reduction, adverse event risk, and other parameters were varied in 1-way and probabilistic sensitivity analyses. The authors also calculated the value of investing in further studies of chemotherapy efficacy after homozygote dose reductions. RESULTS: Pretreatment genetic testing costs less ($272 savings per patient tested) and yields slightly improved quality-adjusted life expectancy (0.1 quality-adjusted day per patient tested; approximately 2 quality-adjusted hours). Results depended on treatment efficacy but not adverse event risk assumptions. The results indicated that testing would avoid 84 cases of severe neutropenia, including 4.4 deaths. At a threshold of $100,000 per quality-adjusted life year, the therapeutic efficacy of irinotecan in homozygotes after dose reduction had to be ,98.4% of full-dose efficacy for genetic testing to remain preferred. Future studies to determine whether this efficacy level can be achieved have an economic value of $22 million. CONCLUSIONS: The current results indicated that pharmacogenetic testing for UGT1A1*28 variant homozygosity may be cost effective, but only if irinotecan dose reduction in homozygotes does not reduce efficacy. Future studies to evaluate reduced-dose efficacy in homozygotes should be considered. Cancer 2009. © 2009 American Cancer Society. [source] Two schedules of second-line irinotecan for metastatic colon carcinomaCANCER, Issue 11 2004Economic evaluation of a randomized trial Abstract BACKGROUND In a recently reported, randomized trial, it was found that a regimen of irinotecan once every 3 weeks for patients with advanced colorectal carcinoma was associated with a lower incidence of severe diarrhea compared with weekly treatment, and both regimens had similar efficacy. METHODS Resource utilization was captured prospectively for all 291 patients who were included in the trial. Utilities were estimated by transformation of the global quality-of-life (QOL) item on the Eastern Organization for Research and Treatment of Cancer QLQ-C30 instrument. RESULTS Patients in the every-3-week arm incurred an average incremental cost of $1362, because they received higher average weekly doses and because the every-3-week regimen resulted in less toxicity, allowing delivery of 97% of the planned doses compared with delivery of only 75% of the planned doses in the weekly arm. This lower toxicity also resulted in offsetting savings from decreased hospitalization and less requirement for supportive medications. Non-chemotherapy-related treatment administration costs also were lower, because the every-3-week regimen could be delivered with half the number of infusions. Utility declined less in the every-3-week arm, resulting in a saving of 6.3 quality-adjusted days. The base-case cost:utility ratio was $78,627 per quality-adjusted life year for patients on the every-3-week schedule. However, that ratio was very sensitive to the cost of irinotecan. CONCLUSIONS The schedule of irinotecan once every 3 weeks schedule was more costly but achieved lower toxicity, resulting in modestly improved utility. The cost-per-utility ratio was comparable to other commonly accepted contemporary treatments. Cancer 2004. © 2004 American Cancer Society. [source] Valuing avoided morbidity using meta-regression analysis: what can health status measures and QALYs tell us about WTP?HEALTH ECONOMICS, Issue 8 2006George Van Houtven Abstract Many economists argue that willingness-to-pay (WTP) measures are most appropriate for assessing the welfare effects of health changes. Nevertheless, the health evaluation literature is still dominated by studies estimating nonmonetary health status measures (HSMs), which are often used to assess changes in quality-adjusted life years (QALYs). Using meta-regression analysis, this paper combines results from both WTP and HSM studies applied to acute morbidity, and it tests whether a systematic relationship exists between HSM and WTP estimates. We analyze over 230 WTP estimates from 17 different studies and find evidence that QALY-based estimates of illness severity , as measured by the Quality of Well-Being (QWB) Scale , are significant factors in explaining variation in WTP, as are changes in the duration of illness and the average income and age of the study populations. In addition, we test and reject the assumption of a constant WTP per QALY gain. We also demonstrate how the estimated meta-regression equations can serve as benefit transfer functions for policy analysis. By specifying the change in duration and severity of the acute illness and the characteristics of the affected population, we apply the regression functions to predict average WTP per case avoided. Copyright © 2006 John Wiley & Sons, Ltd. [source] QALY maximisation and people's preferences: a methodological review of the literatureHEALTH ECONOMICS, Issue 2 2005Paul Dolan Abstract In cost-utility analysis, the numbers of quality-adjusted life years (QALYs) gained are aggregated according to the sum-ranking (or QALY maximisation) rule. This requires that the social value from health improvements is a simple product of gains in quality of life, length of life and the number of persons treated. The results from a systematic review of the literature suggest that QALY maximisation is descriptively flawed. Rather than being linear in quality and length of life, it would seem that social value diminishes in marginal increments of both. And rather than being neutral to the characteristics of people other than their propensity to generate QALYs, the social value of a health improvement seems to be higher if the person has worse lifetime health prospects and higher if that person has dependents. In addition, there is a desire to reduce inequalities in health. However, there are some uncertainties surrounding the results, particularly in relation to what might be affecting the responses, and there is the need for more studies of the general public that attempt to highlight the relative importance of various key factors. Copyright © 2004 John Wiley & Sons, Ltd. [source] The benefits of switching smoking cessation drugs to over-the-counter statusHEALTH ECONOMICS, Issue 5 2002Theodore E. Keeler This paper provides an analysis of the benefits to society from the conversion of nicotine replacement drugs (nicotine patches and gum) in 1996 from sale by prescription only in the United States to over-the-counter (OTC) sales. To estimate these benefits, we first estimate statistical demand functions for nicotine patches and gum. Second, we calculate the effects of OTC conversion on sales of each type of nicotine replacement drug. Third, we survey the literature on the effects of nicotine replacement drugs on total quits of cigarette smoking. Fourth, we survey the literature on the effects of quits achieved on expected lifespan, and on the estimated monetary value of longer lives from smoking cessation. Finally, we use all this evidence to calculate the value of the social benefits of the OTC conversion to the US. As a result of the OTC conversion, consumption of nicotine replacement drugs has increased substantially, by 78,92% for nicotine patches and 180% for nicotine gum. We estimate that the resulting increase in smoking cessation generated annual net social benefits of the order of magnitude of $1.8,2 billion, based on conservative estimates both of the number of quits achieved and the value of added quality-adjusted life years from the reduced smoking. Copyright © 2002 John Wiley & Sons, Ltd. [source] The health and economic effects of HPV DNA screening in The Netherlands,INTERNATIONAL JOURNAL OF CANCER, Issue 9 2010Johannes Berkhof Abstract We studied the health and economic effects of human papillomavirus (HPV) DNA testing in cervical screening using a simulation model. The key data source was a Dutch longitudinal screening trial. We compared cytological testing with repeat cytology (for borderline/mildly abnormal smears) to HPV testing with cytology triage (for HPV-positive smears), combination testing (combined HPV and cytology) and cytological testing with HPV triage (for borderline/mildly abnormal smears). We varied the screening interval from 5 to 10 years. The main outcome measures were the number of cervical cancer cases, the number of quality-adjusted life years (QALYs), and the incremental cost-effectiveness ratio (ICER). The base-case estimates were accompanied with ranges across 118 calibrated parameter settings (calibration criteria: cervical intraepithelial neoplasia 2/3, cancer and mortality rates). In comparison to 5-yearly cytology, 5-yearly HPV testing with cytology triage gave a reduction in the number of cancer cases of 23% (range, 9,27%). The reduction was 26% (range, 10,29%) for combination testing and 3% (range, ,1 to 8%) for cytology with HPV triage. For strategies with primary HPV testing, the model also estimated a reduction in cancer cases when the screening interval was extended to 7.5 years. Five-yearly cytology with HPV triage and 5 to 7.5-yearly HPV testing with cytology triage were cost effective for the base-case settings and the majority of calibrated parameter settings (ICER below Dutch willingness-to-pay threshold of ,20,000/QALY). Our model indicates that HPV testing with cytology triage is likely to be cost effective. An extension of the screening interval may be considered to control costs. [source] Biphasic insulin aspart 70/30 vs. insulin glargine in insulin naļve type 2 diabetes patients: modelling the long-term health economic implications in a Swedish settingINTERNATIONAL JOURNAL OF CLINICAL PRACTICE, Issue 6 2008G. Goodall Summary Objectives:, To evaluate the long-term clinical and economic outcomes of biphasic insulin aspart 70/30 (BIAsp 70/30) treatment vs. insulin glargine in insulin naļve, type 2 diabetes patients failing oral antidiabetic drugs in a Swedish setting. Methods:, A published and validated computer simulation model (the CORE Diabetes Model) was used to project life expectancy, quality-adjusted life expectancy (QALE) and costs over patient lifetimes. Cohort characteristics [54.5% male, mean age 52.4 years, 9 years mean diabetes duration, mean glycosylated haemoglobin (HbA1c) 9.77%] and treatment effects were based on results from the Initiate Insulin by Aggressive Titration and Education (INITIATE) clinical trial. Direct medical costs were accounted in 2006 Swedish Kronor (SEK) and economic and clinical benefits were discounted at 3% per annum. Results:, Biphasic insulin aspart 70/30 treatment when compared with insulin glargine treatment was associated with improvements in discounted life expectancy of 0.21 years (13.10 vs. 12.89 years) and QALE of 0.21 quality-adjusted life years (QALYs) (9.16 vs. 8.96 QALYs). Reductions in the incidence of diabetes-related complications in the BIAsp 70/30 treatment arm led to reduced total costs of SEK 10,367 when compared with insulin glargine (SEK 396,475 vs. SEK 406,842) over patient lifetimes. BIAsp 70/30 treatment was projected to be dominant (cost and lifesaving) when compared with insulin glargine in the base case analysis. Conclusions:, Biphasic insulin aspart 70/30 treatment was associated with improved clinical outcomes and reduced costs compared with insulin glargine treatment over patient lifetimes. These results were driven by improved HbA1c levels associated with BIAsp 70/30 compared with insulin glargine and the accompanying reduction in diabetes-related complications despite increases in body mass index. [source] Review Article: Economic evaluation of prostate cancer screening with prostate-specific antigenINTERNATIONAL JOURNAL OF UROLOGY, Issue 4 2008Tomoaki Imamura Abstract: Economic issues cannot be ignored in conducting prostate cancer screening using prostate-specific antigen (PSA). Through an electronic search, we reviewed five descriptive cost studies and nine cost-effectiveness/cost-utility analyses concerning PSA screening. Most of the existing evidence was based on mathematical model analysis and the results are enormously disparate. The cost per quality-adjusted life years (QALY) gained was estimated to be $US 63.37 to $68.32, and $8400 to $23 100, respectively, or was dominated by no screening. Economic studies evaluating PSA screening are still far from sufficient. Urologists, epidemiologists and health economists must jointly conduct further studies on not only mortality but also quality of life assessment and economic evaluation, using randomized clinical trials, for a strict evaluation of the actual efficacy of PSA screening. At present, patients should be thoroughly informed of the limitations of PSA screening and, in consultation with urological specialists, make the personal decision of whether to receive it. [source] Cost-Effectiveness of Preventive Occupational Therapy for Independent-Living Older AdultsJOURNAL OF AMERICAN GERIATRICS SOCIETY, Issue 8 2002Joel Hay PhD OBJECTIVES: To evaluate the cost-effectiveness of a 9-month preventive occupational therapy (OT) program in the Well-Elderly Study: a randomized trial in independent-living older adults that found significant health, function, and quality of life benefits attributable to preventive OT. DESIGN: A randomized trial. SETTING: Two government-subsidized apartment complexes. PARTICIPANTS: One hundred sixty-three culturally diverse volunteers aged 60 and older. INTERVENTION: An OT group, a social activity group (active control), and a nontreatment group (passive control). MEASUREMENTS: Use of healthcare services was determined by telephone interview during and after the treatment phase. A conversion algorithm was applied to the RAND 36-item Short Form Health Survey to derive a preference-based health-related quality of life index, quality-adjusted life years (QALYs), and the incremental cost-effectiveness ratio for preventive OT relative to the combined control group. RESULTS: Costs for the 9-month OT program averaged $548 per subject. Postintervention healthcare costs were lower for the OT group ($967) than for the active control group ($1,726), the passive control group ($3,334), or a combination of the control groups ($2,593). The quality of life index showed a 4.5% QALY differential (OT vs combined control), P < .001. The cost per QALY estimates for the OT group was $10,666 (95% confidence interval = $6,747,$25,430). For the passive and active control groups, the corresponding costs per QALY were $13,784 and $7,820, respectively. CONCLUSION: In this study, preventive OT demonstrated cost-effectiveness in conjunction with a trend toward decreased medical expenditures. [source] Economic analysis for clinical practice , the case of 31 national consensus guidelines in the NetherlandsJOURNAL OF EVALUATION IN CLINICAL PRACTICE, Issue 1 2007Louis W. Niessen MD Abstract Rationale, aims and objective, Evidence on the cost-effectiveness of health interventions in the development of practice guidelines has become of interest in many countries. Challenges are the quality of economic data, the use of cost-effectiveness criteria, and the consensus process. Our paper aims to assess the quality and use of economic information in the formulation of consensus guidelines in a Dutch pilot programme and to recommend improvements. Methods, ,Retrospective qualitative review of economic evaluations and formulated recommendations, using a checklist based on international standards. Results, The national programme to support the development of guidelines with economic analysis in multidisciplinary consensus groups run from 1998 to 2002. It has included 31 medical guidelines, addressing 23 conditions across seven International Classification of Diseases (ICD)-disease groups. Experts in health technology assessment have participated in the guidelines groups. Economic information in all guidelines varies by all criteria in the level of evidence used. Information on quality-adjusted life years gained is limited as is statistical analysis in most studies. Highest cost-effectiveness ratios reported are between ,20 000 and ,30 000. However, there is no uniformity in the definitions of acceptable cost-effectiveness ratios. Conclusions, Economic recommendations can be included in guidelines. Interaction between clinicians and health economists promotes a balance between medical and economic arguments. Among panellists there appears to be agreement on the level of the cost-effectiveness ratios that is acceptable. It is recommended that economic analysis is used to strengthen the evidence-base of guidelines. An evidence-grading system should include the quality of economic evaluation. Roles of policymakers and providers need to be defined. [source] Cost-effectiveness of the surveillance program of hepatocellular carcinoma depends on the medical circumstancesJOURNAL OF GASTROENTEROLOGY AND HEPATOLOGY, Issue 3 2008Kazuhiro Nouso Abstract Background and Aim:, The clinical features of hepatocellular carcinoma (HCC) and the medical environment are diverse in different geographic areas. The aim of this study is to evaluate the cost-effectiveness of the surveillance of HCC in different medical circumstances. Methods:, The Markov model focused on variables that differ from country to country and may change in the future, especially in regards to the proportion of small HCC detected incidentally. The target population was 45-year-old patients with Child-Pugh class A cirrhosis, and the intervention was surveillance with ultrasonography every 6 months. Results:, The additional cost of the surveillance was $US15 100, the gain in quality-adjusted life years (QALYs) was 0.50 years, and the incremental cost-effectiveness ratio (ICER) was $US29 900/QALY in a base-case analysis (annual incidence of HCC = 4%). If 40% of small HCC were detected incidentally without surveillance, the gain in QALY decreased to 0.15 and the ICER increased to $US47 900/QALY. The increase in the annual incidence of HCC to 8% resulted in the increase of QALYs to 0.81, and the decrease of the ICER to $US25 400/QALY. The adoption of liver transplantation increased the gain in QALYs and the ICER to 0.84 and $US59 900/QALY, respectively. Conclusions:, The gain in QALYs and the ICER due to the surveillance of HCC varies between different patient subgroups and it critically depends on the rate of small HCC detected incidentally without surveillance, as well as the annual incidence of HCC and the adoption of liver transplantation. [source] Cost-effectiveness of the oral adsorbent AST-120 versus placebo for chronic kidney diseaseNEPHROLOGY, Issue 5 2008TOMOHIKO TAKAHASHI SUMMARY: Aim: This study was designed to evaluate the cost-effectiveness of AST-120, an oral adsorbent that attenuates the progression of chronic kidney disease. Methods: We developed a Markov model with six health states, including four levels of serum creatinine, haemodialysis and death, using data from a randomized clinical trial conducted in Japan. Direct costs relevant to chronic kidney disease were calculated from a Japanese reimbursement perspective. Projected quality-adjusted life years (QALY) and costs were compared between the AST-120 and placebo groups. The target population was nondiabetic patients with serum creatinine levels from 5.0 to 8.0 mg/dL (442,707 µmol/L) at baseline. Probabilistic sensitivity analysis was performed to evaluate the stability of the results. Results: At 3 years, mean total costs per patient were estimated at „6.67 million (US$56 982) in the AST-120 group and „9.38 million (US$80 196) in the placebo group. Mean total costs were „2.72 million (US$23 205) lower among patients receiving AST-120. QALY per patient were 0.295 (approximately 3.5 months) greater for patients receiving AST-120 than for those receiving placebo over 3 years. The finding that treatment with AST-120 dominated placebo (i.e. was less costly and resulted in more QALY) was upheld in sensitivity analyses. Conclusion: The use of AST-120 in patients with advanced chronic kidney disease may help to slow the rate of growth in expenditures for kidney disease. [source] Determinants of the optimal first-line therapy for follicular lymphoma: A decision analysis,AMERICAN JOURNAL OF HEMATOLOGY, Issue 4 2010Rebecca L. Olin Combination immunochemotherapy is the most common approach for initial therapy of patients with advanced-stage follicular lymphoma, but no consensus exists as to the optimal selection or sequence of available regimens. We undertook this decision analysis to systematically evaluate the parameters affecting the choice of early therapy in patients with this disease. We designed a Markov model incorporating the three most commonly utilized regimens (RCVP, RCHOP, and RFlu) in combinations of first- and second-line therapies, with the endpoint of number of quality-adjusted life years (QALYs) until disease progression. Data sources included Phase II and Phase III trials and literature estimates of long-term toxicities and health state utilities. Meta-analytic methods were used to derive the values and ranges of regimen-related parameters. Based on our model, the strategy associated with the greatest number of expected quality-adjusted life years was treatment with RCHOP in first-line therapy followed by treatment with RFlu in second-line therapy (9.00 QALYs). Strategies containing RCVP either in first- or second-line therapy resulted in the lowest number of QALYs (range 6.24,7.71). Sensitivity analysis used to determine the relative contribution of each model parameter identified PFS after first-line therapy and not short-term QOL as the most important factor in prolonging overall quality-adjusted life years. Our results suggest that regimens associated with a longer PFS provide a greater number of total QALYs, despite their short-term toxicities. For patients without contraindications to any of these regimens, use of a more active regimen may maximize overall quality of life. Am. J. Hematol. 2010. © 2010 Wiley-Liss, Inc. [source] Management of patients with acoustic neuromas: A Markov decision analysis,THE LARYNGOSCOPE, Issue 4 2010Daniel Morrison MD Abstract Objectives/Hypothesis: The management of patients with small (<1.5 cm) acoustic neuromas is controversial. Immediate treatment via microsurgical resection or radiosurgery is often advocated. A period of observation is sometimes advised followed by microsurgery or radiosurgery for tumors that demonstrate growth during the observation period. The purpose of this study is to calculate quality-adjusted life expectancy for the most commonly applied management strategies in hypothetical cohorts of patients of various ages. Study Design: Markov decision analysis; societal perspective. Methods: Assumptions used in creating this model and event probabilities were obtained from a thorough literature review. Key parameters were identified and defined by the best available evidence. The main outcome measure is the benefit derived from each management strategy in quality-adjusted life years (QALYs). Sensitivity analysis was used to define benchmark performance information for these parameters. Results: The benefit of a period of observation followed by radiosurgery, if needed, for significant tumor growth is greater then all other strategies for all age groups and both sexes. When compared to observation followed by microsurgery, the additional benefit is small. QALY totals for the two immediate treatment groups were significantly lower than that for the observation groups. Conclusions: For patients of all ages, a period of observation during which tumor growth and hearing thresholds are closely monitored is the superior strategy. For tumors that grow substantially or when hearing deteriorates, definitive management via radiosurgery is recommended. Laryngoscope, 2010 [source] Sixty-four,slice Computed Tomography of the Coronary Arteries: Cost,Effectiveness Analysis of Patients Presenting to the Emergency Department with Low-risk Chest PainACADEMIC EMERGENCY MEDICINE, Issue 7 2008Rahul K. Khare MD Abstract Objectives:, The aim was to use a computer model to estimate the cost,effectiveness of 64-slice multidetector computed tomography (MDCT) of the coronary arteries in the emergency department (ED) compared to an observation unit (OU) stay plus stress electrocardiogram (ECG) or stress echocardiography for the evaluation of low-risk chest pain patients presenting to the ED. Methods:, A decision analytic model was developed to compare health outcomes and costs that result from three different risk stratification strategies for low-risk chest pain patients in the ED: stress ECG testing after OU care, stress echocardiography after OU care, and MDCT with no OU care. Three patient populations were modeled with the prevalence of symptomatic coronary artery disease (CAD) being very low risk, 2%; low risk, 6% (base case); and moderate risk, 10%. Outcomes were measured as quality-adjusted life years (QALYs). Incremental cost,effectiveness ratios (ICERs), the ratio of change in costs of one test over another to the change in QALY, were calculated for comparisons between each strategy. Sensitivity analyses were conducted to test the robustness of the results to assumptions regarding the characteristics of the risk stratification strategies, costs, utility weights, and likelihood of events. Results:, In the base case, the mean (±standard deviation [SD]) costs and QALYs for each risk stratification strategy were MDCT arm $2,684 (±$1,773 to $4,418) and 24.69 (±24.54 to 24.76) QALYs, stress echocardiography arm $3,265 (±$2,383 to $4,836) and 24.63 (±24.28 to 24.74) QALYs, and stress ECG arm $3,461 (±$2,533 to $4,996) and 24.59 (±24.21 to 24.75) QALYs. The MDCT dominated (less costly and more effective) both OU plus stress echocardiography and OU plus stress ECG. This resulted in an ICER where the MDCT arm dominated the stress echocardiography arm (95% confidence interval [CI] = dominant to $29,738) and where MDCT dominated the ECG arm (95% CI = dominant to $7,332). The MDCT risk stratification arm also dominated stress echocardiography and stress ECG in the 2 and 10% prevalence scenarios, which demonstrated the same ICER trends as the 6% prevalence CAD base case. The thresholds where the MDCT arm remained a cost-saving strategy compared to the other risk stratification strategies were cost of MDCT, <$2,097; cost of OU care, >$1,092; prevalence of CAD, <70%; MDCT specificity, >65%; and a MDCT indeterminate rate, <30%. Conclusions:, In this computer-based model analysis, the MDCT risk stratification strategy is less costly and more effective than both OU-based stress echocardiography and stress ECG risk stratification strategies in chest pain patients presenting to the ED with low to moderate prevalence of CAD. [source] Cost-effectiveness analysis of immediate radical cystectomy versus intravesical Bacillus Calmette-Guerin therapy for high-risk, high-grade (T1G3) bladder cancer,CANCER, Issue 23 2009Girish S. Kulkarni MD Abstract BACKGROUND: Although both radical cystectomy and intravesical immunotherapy are initial treatment options for high-risk, T1, grade 3 (T1G3) bladder cancer, controversy regarding the optimal strategy persists. Because bladder cancer is the most expensive malignancy to treat per patient, decisions regarding the optimal treatment strategy should consider costs. METHODS: A Markov Monte-Carlo cost-effectiveness model was created to simulate the outcomes of a cohort of patients with incident, high-risk, T1G3 bladder cancer. Treatment options included immediate cystectomy and conservative therapy with intravesical Bacillus Calmette-Guerin (BCG). The base case was a man aged 60 years. Parameter uncertainty was assessed with probabilistic sensitivity analyses. Scenario analyses were used to explore the 2 strategies among patients stratified by age and comorbidity. RESULTS: The quality-adjusted survival with immediate cystectomy and BCG therapy was 9.46 quality-adjusted life years (QALYs) and 9.39 QALYs, respectively. The corresponding mean per-patient discounted lifetime costs (in 2005 Canadian dollars) were $37,600 and $42,400, respectively. At a willingness-to-pay threshold of $50,000 per QALY, the probability that immediate cystectomy was cost-effective was 67%. Immediate cystectomy was the dominant (more effective and less expensive) therapy for patients aged <60 years, whereas BCG therapy was dominant for patients aged >75 years. With increasing comorbidity, BCG therapy was dominant at lower age thresholds. CONCLUSIONS: Compared with BCG therapy, immediate radical cystectomy for average patients with high-risk, T1G3 bladder cancer yielded better health outcomes and lower costs. Tailoring therapy based on patient age and comorbidity may increase survival while yielding significant cost-savings for the healthcare system. Cancer 2009. © 2009 American Cancer Society. [source] | |||||||||||||||||||||||||