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Background: Compared to treatment as usual (TAU), early psychosis intervention programs (EPI) have been shown to reduce mortality, hospitalizations and days of assisted living while improving employment status.Aims: The study aim was to conduct a cost-benefit analysis (CBA) and a cost-effectiveness analysis (CEA) to compare EPI and TAU in Canada.Methods: A decision-analytic model was used to estimate the 5-year costs and benefits of treating patients with a first episode of psychosis with EPI or TAU. EPI benefits were derived from randomized controlled trials (RCTs) and Canadian administrative data. The cost of EPI was based on a published survey of 52 EPI centers in Canada while hospitalizations, employment and days of assisted living were valued using Canadian unit costs. The outcomes of the CBA and CEA were expressed in terms of net benefit (NB) and incremental cost per life year gained (LYG), respectively. Scenario analyses were conducted to examine the impact of key assumptions. Costs are reported in 2019 Canadian dollars.Results: Base case results indicated that EPI had a NB of $85,441 (95% CI: $41,140; $126,386) compared to TAU while the incremental cost per LYG was $26,366 (95% CI: EPI dominates TAU (less costs, more life years); $102,269). In all sensitivity analyses the NB of EPI remained positive and the incremental cost per LYG was less than $50,000.Conclusions: In addition to EPI demonstrated clinical benefits, our results suggest that large-scale implementation of EPI in Canada would be desirable from an economic point of view . [ABSTRACT FROM AUTHOR]

Abstract Objectives Intravenous immunoglobulin (IVIG) has demonstrated improvement in chronic inflammatory demyelinating polyneuropathy (CIDP) patients in placebo controlled trials. However, IVIG is also much more expensive than alternative treatments such as corticosteroids. The objective of the paper is to evaluate, from a Canadian perspective, the cost-effectiveness of IVIG compared to corticosteroid treatment of CIDP. Methods A markov model was used to evaluate the costs and QALYs for IVIG and corticosteroids over 5 years of treatment for CIDP. Patients initially responding to IVIG could remain a responder or relapse every 12 week model cycle. Non-responding IVIG patients were assumed to be switched to corticosteroids. Patients on corticosteroids were at risk of a number of adverse events (fracture, diabetes, glaucoma, cataract, serious infection) in each cycle. Results Over the 5 year time horizon, the model estimated the incremental costs and QALYs of IVIG treatment compared to corticosteroid treatment to be $124,065 and 0.177 respectively. The incremental cost per QALY gained of IVIG was estimated to be $687,287. The cost per QALY of IVIG was sensitive to the assumptions regarding frequency and dosing of maintenance IVIG. Conclusions Based on common willingness to pay thresholds, IVIG would not be perceived as a cost effective treatment for CIDP.

Abstract Objective To evaluate cost-utility of infliximab and adalimumab for the treatment of moderate-to-severe ulcerative colitis (UC) refractory to conventional therapies in Canada. Methods A Markov model was constructed to evaluate incremental cost-utility ratios (ICUR) of 5 mg/kg and 10 mg/kg infliximab and adalimumab therapies compared to 'usual care' in treating a hypothetical cohort of patients (aged 40 years and weighing 80 kg) over a five-year time horizon from the perspective of a publicly-funded health care system. Clinical parameters were derived from the Active Ulcerative Colitis Trials 1 and 2. Costs were obtained through provincial drug benefit plans. ICUR was the main outcome measure and both deterministic and probabilistic sensitivity analyses were conducted. Results Compared to the strategy A ('usual care') in the base case analysis, the ICURs were CA$358,088/QALY for the strategy B ('5 mg/kg infliximab + adalimumab') and CA$575,540/QALY for the strategy C ('5 mg/kg and 10 mg/kg infliximab + adalimumab'). The results were sensitive to: the remission rates maintained in responders to 'usual care' and to 5 mg/kg infliximab, the rate of remission induced by adalimumab in non-responders to 5 mg/kg infliximab, early surgery rate, and utility values. When the willingness to pay (WTP) was less than CA$150,000/QALY, the probability of 'usual care' being the optimal strategy was 1.0. The probability of strategy B being optimal was 0.5 when the WTP approximated CA$400,000/QALY. Conclusions The ICURs of anti-TNF-α drugs were not satisfactory in treating patients with moderate-to-severe refractory UC. Future research could be aimed at the long-term clinical benefits of these drugs, especially adalimumab for patients intolerant or unresponsive to infliximab treatment.

When choosing a modeling approach for health economic evaluation, certain criteria are often considered (e.g., population resolution, interactivity, time advancement mechanism, resource constraints). However, whether these criteria and their associated modeling approach impacts results remain poorly understood. A systematic review was conducted to identify cross-validation studies (i.e., modeling a problem using different approaches with the same body of evidence) to offer insight on this topic. With respect to population resolution, reviewed studies suggested that both aggregate- and individual-level models will generate comparable results, although a practical trade-off exists between validity and feasibility. In terms of interactivity, infectious-disease models consistently showed that, depending on the assumptions regarding probability of disease exposure, dynamic and static models may produce dissimilar results with opposing policy recommendations. Empirical evidence on the remaining criteria is limited. Greater discussion will therefore be necessary to promote a deeper understanding of the benefits and limits to each modeling approach. [ABSTRACT FROM AUTHOR]

Objective. The objective of this study is to evaluate the cost-effectiveness of catheter ablation for rhythm control compared to antiarrhythmic drug (AAD) therapy in patients with atrial fibrillation (AF) who have previously failed on an AAD. Methods. An economic model was developed to compare (1) catheter ablation and (2) AAD (amiodarone 200mg/day). At the end of the initial 12 month phase of the model, patients are classified as being in normal sinus rhythm or with AF, based on data from a meta analysis. In the 5-year Markov phase of the model, patients are at risk of ischemic stroke each 3-month model cycle. Results. The model estimated that, compared to the AAD strategy, ablation had $8,539 higher costs, 0.033 fewer strokes, and 0.144 more QALYS over the 5-year time horizon. The incremental cost per QALY of ablation compared to AAD was estimated to be $59,194. The probability of ablation being cost-effective for willingness to pay thresholds of $50,000 and $100,000 was estimated to be 0.89 and 0.90, respectively. Conclusion. Based on current evidence, pulmonary vein ablation for treatment of AF is cost-effective if decision makers willingness to pay for a QALY is $59,194 or higher. [ABSTRACT FROM AUTHOR]

Background: Pulmonary vein isolation (PVI) forms the basis of catheter ablation strategies for atrial fibrillation (AF). Ablation of additional sites has been used to increase the efficacy of ablation procedures in restoring and maintaining normal sinus rhythm. Objective: The aim of this paper was to compare the effectiveness of PVI versus PVI plus adjuvant atrial ablations (PVI+) in patients with AF. Methods: A systematic search using bibliographic databases and gray literature was undertaken. Randomized and non-randomized controlled trials evaluating clinical efficacy, effectiveness, or safety of ablation procedures in adults with AF were included in this review. Results: Of 3,204 potential citations identified by the original search, 21 randomized controlled trials and three non-randomized trials were included. Meta-analysis results reveal that in the first year after ablation, AF patients who underwent PVI+ strategies had a significantly higher rate of maintaining sinus rhythm than those who underwent PVI alone (RR 1.10, 95 % CI 1.02, 1.17). However, a subgroup meta-analysis was statistically significant for only PVI+ left atrial (LA) linear ablations (RR 1.16, 95 % CI 1.04, 1.29). The pooled success rates were higher in PVI+ group for both paroxysmal (RR 1.14, 95 % CI 1.06, 1.24) and non-paroxysmal AF (RR 1.53, 95 % CI 1.10, 2.14). Conclusion: PVI+ strategies, particularly PVI+ LA ablations, appear to result in higher success rates than PVI alone in the first year after the procedure. Studies of longer duration are needed to evaluate the long-term benefits and safety of different adjunctive ablation approaches for rhythm control in AF patients. [ABSTRACT FROM AUTHOR]

Triple therapy for COPD consists of a long-acting anti-cholinergic bronchodilator, a long-acting beta-agonist bronchodilator, and an inhaled corticosteroid. Guidelines from the Canadian Thoracic Society advocate triple therapy for some patients with moderate-to-severe COPD. The objective of this review was to evaluate the evidence based clinical efficacy of triple therapy compared to dual bronchodilator therapy (long-acting anti-cholinergic bronchodilator ++ beta-agonist bronchodilator) or long-acting anti-cholinergic bronchodilator monotherapy for managing COPD. A systematic literature search was conducted to identify relevant clinical evaluations of triple therapy in the management of moderate to severe COPD. Databases searched included: Medline; EMBASE; CINAHL and PubMed (non-Medline records only). Of 2,314 publications, 4 articles evaluated triple therapy for the management of COPD. Hospitalization rates for COPD exacerbations, reported in 2 trials, were significantly reduced with triple therapy compared to long-acting anti-cholinergic bronchodilator monotherapy, with reported relative risks of 0.53 (95%% CI: 0.33, 0.86, p == 0.01) and 0.35 (95%% CI: 0.16--0.78, p == 0.011). Exacerbation data is inconsistent between the two trials reporting this outcome. Lung function, dyspnea and quality of life data show statistical significant changes with triple therapy compared to long-acting anti-cholinergic bronchodilator monotherapy but the changes do not reach clinical importance. Triple therapy does decrease the number of hospitalizations for severe/acute COPD exacerbations compared with long-acting anti-cholinergic bronchodilator monotherapy. There is insufficient evidence to determine if triple therapy is superior to dual bronchodilator therapy. [ABSTRACT FROM AUTHOR]

Objectives: Intravenous immunoglobulin (IVIG) has demonstrated improvement in chronic inflammatory demyelinating polyneuropathy (CIDP) patients in placebo controlled trials. However, IVIG is also much more expensive than alternative treatments such as corticosteroids. The objective of the paper is to evaluate, from a Canadian perspective, the cost-effectiveness of IVIG compared to corticosteroid treatment of CIDP. Methods: A markov model was used to evaluate the costs and QALYs for IVIG and corticosteroids over 5 years of treatment for CIDP. Patients initially responding to IVIG could remain a responder or relapse every 12 week model cycle. Non-responding IVIG patients were assumed to be switched to corticosteroids. Patients on corticosteroids were at risk of a number of adverse events (fracture, diabetes, glaucoma, cataract, serious infection) in each cycle. Results: Over the 5 year time horizon, the model estimated the incremental costs and QALYs of IVIG treatment compared to corticosteroid treatment to be $124,065 and 0.177 respectively. The incremental cost per QALY gained of IVIG was estimated to be $687,287. The cost per QALY of IVIG was sensitive to the assumptions regarding frequency and dosing of maintenance IVIG. Conclusions: Based on common willingness to pay thresholds, IVIG would not be perceived as a cost effective treatment for CIDP. [ABSTRACT FROM AUTHOR]

Objectives: The aim of this study was to present a review of economic evaluations conducted from a Canadian perspective and to characterize sources of evidence and statistical methods to analyze effectiveness measures, resource utilization, and uncertainty. Methods: A search strategy was developed to identify Canadian economic evaluations published between January 2001 and June 2006. A standardized abstraction form was used to extract key data (e.g., study design, data sources, statistical methods). Results: A total of 153 unique studies were included for review, of which 75 were evaluations of drug therapies and less than half were funded by industry. Cost-effectiveness analysis was the most common type of economic evaluation and 80 percent of the studies used modeling techniques. A single source of evidence for effectiveness measures was used in half of the studies. Statistical methods were commonly reported to compare effectiveness measures when the economic evaluation was conducted alongside a clinical trial but less commonly when determining effectiveness input parameters in model-based economic evaluations, or to analyze resource utilization data. Authors relied mostly on univariate sensitivity analyses to explore uncertainty. Conclusions: This review identifies the need to improve the conduct and reporting of statistical methods for economic evaluations to improve confidence in the results. [ABSTRACT FROM AUTHOR]

Objectives: To determine the cost-effectiveness (CE) and cost-utility (CU) of drug-eluting stents (DES) compared to bare metal stents (BMS) in Ontario using a large prospective "real-world" cohort study and determine the extent to which results vary by patient risk subgroups. Methods: A field evaluation was conducted based on all stent procedures in the province of Ontario between December 1, 2003, and March 31, 2005, with a minimum subject follow-up of 1 year. Effectiveness data from the study using a propensity-score matched cohort were combined with resource utilization and cost data and quality of life (QOL) data from the published literature in a decision analytic modeling framework to determine 2-year cost-effectiveness (cost per revascularization avoided) and cost-utility (cost per quality-adjusted life-year ([QALY] gained). Stochastic model parameter uncertainty was expressed using probability distributions and analyzed using a probabilistic model. Modeling assumptions were assessed using traditional deterministic sensitivity analysis. Results: Significant differences in revascularization rates were found for patients with two or more high risk factors. Despite these differences, the CE and CU of DES remained high (e.g., $419,000 per QALY gained in the most favorable patient risk subgroup). In sensitivity analysis, the difference in cost between DES and BMS had an impact on the CE and CU results. For example, at a price differential of $500, the CU of DES was $20,000/QALY for one patient subgroup and DES was dominant (i.e., less costly and more effective) in another. Conclusions: At current prices, the CE/CU of DES compared with BMS is high even in patient high risk subgroups. As the relative price of DES decrease, the value for money attractiveness of DES increases, especially for selected high risk patients. [ABSTRACT FROM AUTHOR]

The article examines the effectiveness and safety of using sirolimus versus paclitaxel stents in reducing restenosis in diabetic and nondiabetic patients. The study found no difference in rates of target-vessel revascularization, myocardial infarction, or death. It also revealed the association of the use of sirolimus stents with a significantly lower 3-year rate of target-vessel revascularization in nondiabetic patients. The study noted the similar mortality rates among patients receiving paclitaxel and sirolimus stents.

Background: Geographic transferability of economic evaluation data from one country to another has the potential to make a more efficient use of national and international evaluation resources. However, inappropriate transferability of economic data can provide misleading results and lead to an inefficient use of scarce health care resources.Objectives: The objective of this study was to review, summarize and categorize the literature on: (i) factors affecting the geographic transferability of economic evaluation data; and (ii) approaches which have either been proposed or used for transferability.Methods: A systematic literature review on transferability was conducted. Electronic databases, hand searching and bibliographic searching techniques were utilized. Inclusion criteria for the review included conceptual or empirical papers with mention of factors affecting, or approaches for, transferability of economic evaluation data across geographic locations. Exclusion criteria included papers published prior to 1966, non-English language papers, pure science studies and animal studies. Three databases were involved in the primary search: Ovid MEDLINE, EMBASE, and CINAHL. In addition to the primary search, the Heath Economic Evaluation Database (OHE HEED), the NHS EED database and the EconLit databases were searched. Transferability factors were classified into major and minor categories, a classification of alternative transferability approaches was developed, and the number of empirical studies was catalogued according to this classification.Results: There is a substantial amount of literature on factors potentially affecting transferability. Based on these papers we identified 77 factors and subsequently developed a classification system which grouped these factors into five broad categories based on characteristics of the patient, the disease, the provider, the health care system and methodological conventions. Another 40 studies were identified which attempted to transfer economic evaluation data from one country to another and these were classified according to the sources for clinical efficacy, resource utilization and unit cost data.Conclusions: There is strong evidence indicating that transferability of economic evaluation data is a difficult and complex task. Approaches which have been used for transferability suggest that, at a minimum, there is a need for country-specific substitution of practice pattern data as well as unit cost data. A limitation of this review relates to the lack of empirical studies which prevents stronger conclusions regarding which transferability factors are most important to consider and under which circumstances. [ABSTRACT FROM AUTHOR]

When choosing between mutually exclusive treatment options, it is common to construct a cost-effectiveness frontier on the cost-effectiveness plane that represents efficient points from among the treatment choices. Treatment options internal to the frontier are considered inefficient and are excluded either by strict dominance or by appealing to the principle of extended dominance. However, when uncertainty is considered, options excluded under the baseline analysis may form part of the cost-effectiveness frontier. By adopting a Bayesian approach, where distributions for model parameters are specified, uncertainty in the decision concerning which treatment option should be implemented is addressed directly. The approach is illustrated using an example from a recently published cost-effectiveness analysis of different possible treatment strategies for gastroesophageal reflux disease. It is argued that probabilistic analyses should be encouraged because they have potential to quantify the strength of evidence in favor of particular treatment choices. [ABSTRACT FROM PUBLISHER]