Search

While the quality-adjusted life-year construct has advantages of simplicity and consistency, simplicity requires strong assumptions. In particular, standard assumptions result in health-state utility functions that are unrealistically linear and separable in risk and duration. Consequently, sequencing of a series of health improvements has no effect on the total value of the sequence because each increment is assessed independently of previous increments. Utility functions in nearly all other areas of applied economics are assumed to be nonlinear with diminishing marginal utility so it matters where an improvement occurs in a sequence. We construct a conceptual framework that that demonstrates how diminishing marginal utility for health improvements could affect preferences for different sequence patterns. Using this framework, we derive conditions for which the sum of conventional health-state utilities understates, overstates, or approximates the sequence-sensitive value of health improvements. These patterns suggest the direction and magnitude of possible adjustments to conventional value calculations. We provide numerical examples and identify recent studies whose results are consistent with the conceptual model. [ABSTRACT FROM AUTHOR]

In this article the author discusses the use of applied economics in the health technology assessment. He says that constructive responses to new pressures to economize on healthcare spending require that health economists argue from within their discipline for adopting more rigorous economic methods and techniques. It is said that an easily proved theorem in economic theory is that transfers of purchasing power are more efficient than transfers in kind.

Background: The concept of pharmaceutical care is operationalized through pharmaceutical professional services, which are patient-oriented to optimize their pharmacotherapy and to improve clinical outcomes. Objective: The objective of this study was to estimate the incremental cost-effectiveness ratio (ICER) of a medication review with follow-up (MRF) service for older adults with polypharmacy in Spanish community pharmacies against the alternative of having their medication dispensed normally. Methods: The study was designed as a cluster randomized controlled trial, and was carried out over a time horizon of 6 months. The target population was older adults with polypharmacy, defined as individuals taking five or more medicines per day. The study was conducted in 178 community pharmacies in Spain. Cost-utility analysis adopted a health service perspective. Costs were in euros at 2014 prices and the effectiveness of the intervention was estimated as quality-adjusted life-years (QALYs). In order to analyze the uncertainty of ICER results, we performed a non-parametric bootstrapping with 5000 replications. Results: A total of 1403 older adults, aged between 65 and 94 years, were enrolled in the study: 688 in the intervention group (IG) and 715 in the control group (CG). By the end of the follow-up, both groups had reduced the mean number of prescribed medications they took, although this reduction was greater in the IG (0.28 ± 1.25 drugs; p < 0.001) than in the CG (0.07 ± 0.95 drugs; p = 0.063). Older adults in the IG saw their quality of life improved by 0.0528 ± 0.20 ( p < 0.001). In contrast, the CG experienced a slight reduction in their quality of life: 0.0022 ± 0.24 ( p = 0.815). The mean total cost was €977.57 ± 1455.88 for the IG and €1173.44 ± 3671.65 for the CG. In order to estimate the ICER, we used the costs adjusted for baseline medications and QALYs adjusted for baseline utility score, resulting in a mean incremental total cost of −€250.51 ± 148.61 (95 % CI −541.79 to 40.76) and a mean incremental QALY of 0.0156 ± 0.004 (95 % CI 0.008-0.023). Regarding the results from the cost-utility analysis, the MRF service emerged as the dominant strategy. Conclusion: The MRF service is an effective intervention for optimizing prescribed medication and improving quality of life in older adults with polypharmacy in community pharmacies. The results from the cost-utility analysis suggest that the MRF service is cost effective. [ABSTRACT FROM AUTHOR]

Missing data are a frequent problem in cost-effectiveness analysis (CEA) within a randomised controlled trial. Inappropriate methods to handle missing data can lead to misleading results and ultimately can affect the decision of whether an intervention is good value for money. This article provides practical guidance on how to handle missing data in within-trial CEAs following a principled approach: (i) the analysis should be based on a plausible assumption for the missing data mechanism, i.e. whether the probability that data are missing is independent of or dependent on the observed and/or unobserved values; (ii) the method chosen for the base-case should fit with the assumed mechanism; and (iii) sensitivity analysis should be conducted to explore to what extent the results change with the assumption made. This approach is implemented in three stages, which are described in detail: (1) descriptive analysis to inform the assumption on the missing data mechanism; (2) how to choose between alternative methods given their underlying assumptions; and (3) methods for sensitivity analysis. The case study illustrates how to apply this approach in practice, including software code. The article concludes with recommendations for practice and suggestions for future research. [ABSTRACT FROM AUTHOR]

The National Institute for Health and Clinical Excellence (NICE) invited the manufacturer of golimumab (Schering-Plough/Centocor) to submit evidence for the clinical and cost effectiveness of this drug for the treatment of active and progressive psoriatic arthritis (PsA) in patients who have responded inadequately to previous diseasemodifying antirheumatic drugs (DMARDs). The Centre for Reviews and Dissemination and the Centre for Health Economics at the University of York were commissioned to act as the Evidence Review Group (ERG) to critically appraise the evidence presented by the manufacturer. This article provides a description of the company submission, the ERG review and the resulting NICE guidance. The ERG critically reviewed the evidence presented in the manufacturer's submission and identified areas requiring clarification, for which the manufacturer provided additional evidence. The main clinical effectiveness data were derived from a single phase III randomized controlled trial (GO-REVEAL) that compared golimumab with placebo for the treatment of active and progressive patients who were symptomatic despite the use of previous DMARDs or NSAIDs. The 14-week data showed that, compared with placebo, golimumab 50 mg significantly improved joint disease response as measured by American College of Rheumatology (ACR) 20 (relative risk [RR] 5.73, 95%CI 3.24, 10.56) and Psoriatic Arthritis Response Criteria (PsARC) [RR 3.45, 95% CI 2.49, 4.87], and significantly improved skin disease response as measured by Psoriasis Area and Severity Index (PASI) 75 (RR 15.95, 95% CI 4.62, 59.11). The 24-week absolute data showed that these treatment benefits were maintained. There was a significant improvement in patients' functional status as measured by Health Assessment Questionnaire change from baseline at 24 weeks (-0.33; p < 0.001). The open-label extension data showed that these beneficial effects were also maintained at 52 and 104 weeks. The ERG identified several issues relating to the clinical effectiveness results. Analyses of the 24-week data were less robust, failing to adjust for treatment contamination due to patient crossover at week 16. It was also unclear if these results were generalizable to clinical practice. No randomized controlled trial compared the effectiveness of different biologic therapies head-to-head. To compare the effectiveness of the biologics etanercept, infliximab, adalimumab and golimumab, the manufacturer conducted a network metaanalysis, including the comparator palliative care (usual care including use of NSAIDs or DMARDs). The ERG considered the assumption of exchangeability between the trials for the purpose of the network metaanalysis to be acceptable and the statistical approach to be reliable. The results indicated somewhat lower efficacy with golimumab than with comparator biologics. The ERG identified a number of issues relating to the costeffectiveness results. The manufacturer calculated incremental cost-effectiveness ratios (ICERs) incorrectly by comparing golimumab with palliative care instead of the most cost-effective alternative (etanercept). Despite the manufacturer's claim that golimumab was a cost-effective treatment option, the manufacturer's own model showed that golimumab was unlikely to be cost effective, relative to currently accepted thresholds, when the ICERs were correctly calculated using an incremental analysis (i.e. comparing each treatment to the next best alternative). None of the sensitivity analyses carried out by the manufacturer or the ERG regarding uncertainty in the estimates of clinical effectiveness, the acquisition and administration cost of drugs, the cost of treating psoriasis and the utility functions estimated to generate health outcomes changed this conclusion. However, a key area in determining the cost effectiveness of biologics was whether they should be treated as a class. The ERG concluded that if all biologics were considered equally effective, then etanercept, adalimumab and 258 Yang et al. 2012 golimumab had almost equal costs and equal QALYs, and all had an ICER of about d15 000 per QALY versus palliative care, whilst infliximab, with a higher acquisition cost, was dominated by the other biologics. The Appraisal Committee altered its position between the Appraisal Consultation Document and the Final Appraisal Determination. It ultimately recommended that golimumab be provided as an option for the treatment of active and progressive PsA in adults only if (i) it is used as described for other tumour necrosis factor inhibitor treatments in 'Etanercept, infliximab and adalimumab for the treatment of psoriatic arthritis' (NICE clinical guideline 199); and (ii) the manufacturer provides the 100mg dose of golimumab at the same cost as the 50mg dose. [ABSTRACT FROM AUTHOR]

Objective: To estimate the cost effectiveness of olanzapine and risperidone for the treatment of schizophrenia in Belgium. Methods: Data were retrieved from a prospective, observational, nonrandomized, follow-up survey. Clinical investigators assigned 265 patients with schizophrenia to either olanzapine (n = 136) or risperidone (n = 129). Patients were followed up for 2 years. Total healthcare costs were determined from the public payer perspective and calculated by multiplying resource use with official tariffs; effectiveness of the drugs was measured with the EQ-5D. This study uses a net-benefit regression approach to accommodate for baseline differences between treatment groups and uncertainty. Results: Total 2-year costs were very similar for patients receiving risperidone and olanzapine (€20 915.33 and €20 569.69, respectively; p = 0.925) [year 2002 values]. The health condition of the patients receiving risperidone was better than that of patients receiving olanzapine but not significantly so (1.46 and 1.41, respectively; p = 0.191). Simple ordinary least squares (OLS) regressions indicated that, for λ = €40 000, we could not reject the null hypothesis that the drugs provide similar net monetary benefits to the patient (risperidone vs olanzapine €2046.95; p = 0.656).When we controlled for several patient characteristics, risperidone moved further away from olanzapine but the difference did not reach statistical significance (risperidone vs olanzapine €3198.07; p = 0.595). Numerous sensitivity analyses confirmed the robustness of the results. Conclusion: Results of this study suggest that it is important to control for baseline patient characteristics when performing a cost-effectiveness analysis. No significant difference in net monetary benefit was found between risperidone and olanzapine. [ABSTRACT FROM AUTHOR]

Patients with schizophrenia suffer numerous relapses and rehospitalizations that are associated with high direct and indirect medical expense. Suboptimal therapeutic efficacy and, in particular, problems with compliance are major factors leading to relapse. Atypical antipsychotic agents offer improved efficacy and a lower rate of extrapyramidal adverse effects compared with conventional antipsychotic drugs. Long-acting intramuscular risperidone combines these benefits with improvements in compliance associated with depot injections. To assist decision making regarding the place of long-acting risperidone in therapy, a cost-effectiveness analysis of strategies involving first-line treatment with long-acting risperidone, oral olanzapine or depot haloperidol was performed from the perspective of the Belgian healthcare system. A decision tree model was created to compare the cost effectiveness of three first-line treatment strategies in a sample of young schizophrenic patients who had been treated for 1 year and whose disease had not been diagnosed for longer than 5 years. The model used a time horizon of 2 years, with health state transition probabilities, resource use and cost estimates derived from clinical trials, expert opinion and published prices. The four health states in the model were derived from an analysis of the literature. The principal efficacy measure was the proportion of patients successfully treated, defined as those who responded to initial treatment and who had none to two episodes of clinical deterioration without needing a change of treatment over the 2-year period. Comprehensive sensitivity analysis was carried out to test the robustness of the model. A greater proportion of patients were successfully treated with long-acting risperidone (82.7%) for 2 years, compared with those treated with olanzapine (74.8%) or haloperidol (57.3%). Total mean costs per patient over 2 years were €16 406 with long-acting risperidone, €17 074 with olanzapine and €21 779 with haloperidol (year of costing 2003). The mean cost-effectiveness ratios were €19 839, €22 826 and €38 008 per successfully treated patient for long-acting risperidone, olanzapine and haloperidol, respectively. Results of the sensitivity analysis confirmed that the results were robust to a wide variation of different input variables (effectiveness, dosing distribution, patient status according to healthcare system). Long-acting risperidone was the dominant strategy, being both more effective and less costly than either oral olanzapine or depot haloperidol. Long-acting risperidone appears to represent a favourable first-line strategy for patients with schizophrenia requiring long-term maintenance treatment. [ABSTRACT FROM AUTHOR]

In this review, the economic aspects of pneumococcal pneumonia are analysed, including the costs, cost effectiveness and cost benefit of treatment and prevention. We identified eight cost-of-illness studies, 15 analyses comparing the costs of different treatment options and 15 economic evaluations of prevention that met our search criteria. The studies were conducted largely in Europe and the US. Most pertained to community-acquired pneumonia (CAP) in general, without specific analysis of pneumococcus-related illness. Many of the studies were considered to be of poor quality for the following reasons: comparison without randomisation or control variables, disregard of health outcomes, small sample size, restriction of costs to drug costs and vague or disputable sources of cost information. In the US, hospitalisation costs resulting from CAP can be estimated to be between $US7000 and $US8000 per admission or $US4 million per 100 000 population. Hospitalisation costs are significant (representing about 90% of total costs), but are much lower in Europe than in the US (one-third to one-ninth of the US estimates in the UK and Spain, respectively). In general, economic studies of treatment for pneumococcal pneumonia are in line with clinical evidence. A drug with proven clinical effectiveness would also appear to be supported from an economic stand point. Furthermore, economic data support an early switch from an intravenous to an oral antibacterial, the use of quinolones for inpatients with CAP, and also the use of guidelines built on clinical evidence. Of all the possible preventive strategies for pneumococcal pneumonia, only vaccination has been subjected to economic evaluation. Pneumococcal polysaccharide vaccine seems relatively cost effective (and potentially cost saving) for those between 65 and 75 years of age, for military recruits and for HIV positive patients with a sufficiently high CD4 cell count. Evaluations of the pneumococcal conjugate vaccine (PCV) indicate the price of the vaccine to be the main determinant of cost effectiveness. As the current price is high (in the order of $US50 per dose), the economic attractiveness of the universal PCV vaccination strategies hinges on the potential for price reductions and the willingness of decision makers to adopt a societal perspective. [ABSTRACT FROM AUTHOR]

This article reviews recent evidence on changes over time in the direct medical costs of treating three of the more common mental health disorders in the US: the acute (16-week) phase of major depressive disorder, the ongoing treatment of schizophrenia, and the ongoing treatment of bipolar I disorders. The three studies discussed in this article cover various time intervals over the decade from 1991 through 2000, and encompass both private sector and governmental funding sources. Although there has been a shift over time away from intensive psychosocial/psychotherapy and towards increasingly expensive psychopharmacotherapy for all three disorders, total direct medical costs of treatment for each of these three mental health disorders have been declining over time. However, a substantial portion of treatment is not supported by clinical evidence. [ABSTRACT FROM AUTHOR]

Objective: To weigh the costs and benefits of a pharmacy-based health promotion programme implemented in four pharmacies of the Quebec City area, Canada. This programme was developed to improve blood pressure control through activities aimed at improving the quality of prescribing and the adherence to treatment.Design: Nine pharmacies in Quebec City were included, of which four pharmacies were assigned to the implementation of the health promotion programme. Each time a study participant came to one of these pharmacies to refill his/her antihypertensive medication, the pharmacist would measure and record the participant's blood pressure and assess adherence to drug treatment. The other five pharmacies delivered usual care. The duration of the intervention programme was 9 months. Costs included direct, indirect, and fixed costs, and the costs of pharmacist intervention. Benefits were measured using cost savings induced by pharmacist intervention. Willingness to pay was also considered. A bootstrap method was used to test the between-group difference.Perspective: The study was performed from a societal perspective.Study Participants: 100 individuals aged between 34 and 80 years residing in the Quebec City area and taking antihypertensive medication.Main Outcome Measures and Results: Participants exposed to the programme had a significant decrease in mean direct costs and a significant increase in mean indirect costs compared with non-exposed participants. Pharmacist interventions involved a mean cost of 30.68 Canadian dollars ($ Can) per participant exposed to the programme. On average, exposed participants were willing to pay $ Can 0.54 per month after the intervention period. Benefits were about ten times higher than costs (1998 values).Conclusions: The implementation of this intervention programme seems promising in the quest to improve blood pressure control in terms of both costs and benefits. [ABSTRACT FROM AUTHOR]

For practical reasons, in order to carry out economic evaluations of collective decisions, total costs will generally be compared with total benefits; hence, individuals' willingness to pay (WTP) or quality-adjusted life-years (QALYs) have to be estimated at an aggregate level. So far, aggregation has usually been done by taking the individuals' mean WTP or the unweighted number of QALYs. Since the aggregation process is closely related to the way that income, health and/or utility of different individuals are compared and weighted, it also has significant equity implications. Thus. the explicit (or, more often, implicit) assumptions behind the aggregation process will largely affect how health and welfare are distributed is society. The aggregation problem in economic evaluation is certainly not trivial, but is seldom addressed in current practice. This paper shows the underlying assumptions of aggregate cost-benefit analysis (CBA) and cost-effectiveness analysis/cost-utility analysis (CEA/CUA), and it emphasises the particularly strong assumptions which have to be made when QALYs are interpreted as utilities in the welfare economics sense. Naturally, the appropriate method to choose depends on what is to be maximised: welfare or health. If decisions of resource allocation are to be based on economic welfare theory, then CBA should be preferred. However, if QALYs are interpreted as measures of health, rather than as utilities, then CEA/CUA would be appropriate. [ABSTRACT FROM AUTHOR]

Objective: To analyse the direct medical costs and effectiveness of vaccinating adults aged between 18 and 64 years and elderly persons > or = 65 years of age with the 23-valent pneumococcal polysaccharide vaccine.Design and Setting: This was a decision-analytic modelling study from the societal perspective in Belgium. The analysis compared 'vaccination' with 'no vaccination and treatment'.Methods: Calculations were based on the assumption that vaccination is as effective against all pneumococcal infections as it is against invasive pneumococcal disease. Data on the incidence of pneumococcal pneumonia and meningitis, frequency of hospitalisation, mortality rates and vaccine effectiveness were derived from the international literature. Costs were derived from analysis of historical data for cases of pneumococcal infection in Belgium.Results: Vaccinating 1000 adults between the ages of 18 and 64 years gains approximately 2 life-years in comparison with the no vaccination option. However, to realise these additional health benefits requires additional costs of 11,800 European Currency Units (ECU; 1995 values) per life-year saved. Vaccinating 1000 elderly people (> or = 65 years) leads to > 9 life-years gained as well as a small monetary benefit of ECU1250. An extensive sensitivity analysis did not greatly affect the results for the elderly population: vaccination in this age group always remained favourable, and thus it is clearly indicated from an economic point of view. A crucial assumption for both age groups is that the effectiveness of the vaccine holds for all pneumococcal pneumonia. It is clear that the results will become less favourable if this assumption is dropped.Conclusions: Preventing pneumococcal infections by vaccination clearly benefits people's health. Reimbursement can be recommended for the elderly group; however, more accurate epidemiological data are still needed to make decisions concerning routine pneumococcal vaccination in adults < 65 years of age. Unfortunately, the issue of whether the effectiveness of the vaccine holds for all pneumococcal pneumonia is as yet unresolved in the medical literature. [ABSTRACT FROM AUTHOR]

A response from the authors of the article "Valuing benefits to inform a clinical trial in pharmacy: do differences in utility measures at baseline affect the effectiveness of the intervention?" in the 2013 issue is presented.