Cost Effectiveness and Resource Allocation最新文献

Background: Many advantages of hospital at home (HaH), as a modality of acute care, have been highlighted, but controversies exist regarding the cost-benefit trade-offs. The objective is to assess health outcomes and analytical costs of hospital avoidance (HaH-HA) in a consolidated service with over ten years of delivery of HaH in Barcelona (Spain).

Methods: A retrospective cost-consequence analysis of all first episodes of HaH-HA, directly admitted from the emergency room (ER) in 2017-2018, was carried out with a health system perspective. HaH-HA was compared with a propensity-score-matched group of contemporary patients admitted to conventional hospitalization (Controls). Mortality, re-admissions, ER visits, and direct healthcare costs were evaluated.

Results: HaH-HA and Controls (n = 441 each) were comparable in terms of age (73 [SD16] vs. 74 [SD16]), gender (male, 57% vs. 59%), multimorbidity, healthcare expenditure during the previous year, case mix index of the acute episode, and main diagnosis at discharge. HaH-HA presented lower mortality during the episode (0 vs. 19 (4.3%); p < 0.001). At 30 days post-discharge, HaH-HA and Controls showed similar re-admission rates; however, ER visits were lower in HaH-HA than in Controls (28 (6.3%) vs. 34 (8.1%); p = 0.044). Average costs per patient during the episode were lower in the HaH-HA group (€ 1,078) than in Controls (€ 2,171). Likewise, healthcare costs within the 30 days post-discharge were also lower in HaH-Ha than in Controls (p < 0.001).

Conclusions: The study showed higher performance and cost reductions of HaH-HA in a real-world setting. The identification of sources of savings facilitates scaling of hospital avoidance.

Registration: ClinicalTrials.gov (26/04/2017; NCT03130283).

Background: Integrated care, in particular the 'Blended Collaborative Care (BCC)' strategy, may have the potential to improve health-related quality of life (HRQoL) in multimorbid patients with heart failure (HF) and psychosocial burden at no or low additional cost. The ESCAPE trial is a randomised controlled trial for the evaluation of a BCC approach in five European countries. For the economic evaluation of alongside this trial, the four main objectives were: (i) to document the costs of delivering the intervention, (ii) to assess the running costs across study sites, (iii) to evaluate short-term cost-effectiveness and cost-utility compared to providers' usual care, and (iv) to examine the budgetary implications.

Methods: The trial-based economic analyses will include cross-country cost-effectiveness and cost-utility assessments from a payer perspective. The cost-utility analysis will calculate quality-adjusted life years (QALYs) using the EQ-5D-5L and national value sets. Cost-effectiveness will include the cost per hospital admission avoided and the cost per depression-free days (DFD). Resource use will be measured from different sources, including electronic medical health records, standardised questionnaires, patient receipts and a care manager survey. Uncertainty will be addressed using bootstrapping.

Discussion: The various methods and approaches used for data acquisition should provide insights into the potential benefits and cost-effectiveness of a BCC intervention. Providing the economic evaluation of ESCAPE will contribute to a country-based structural and organisational planning of BCC (e.g., the number of patients that may benefit, how many care managers are needed). Improved care is expected to enhance health-related quality of life at little or no extra cost.

Trial registration: The study follows CHEERS2022 and is registered at the German Clinical Trials Register (DRKS00025120).

Background: Chronic diseases, or non-communicable diseases (NCD), are conditions of long duration and often influenced and contributed by complex interactions of several variables, including genetic, physiological, environmental, and behavioral factors. These conditions contribute to death, disability, and subsequent health care costs. Primary and secondary school settings provide an opportunity to deliver relatively low cost and effective interventions to improve public health outcomes. However, there lacks systematic evidence on the cost-effectiveness of these interventions.

Methods: We systematically searched four databases (PubMed/Medline, Cochrane, Embase, and Web of Science) for published studies on the cost-effectiveness of chronic-disease interventions in school settings. Studies were eligible for inclusion if they assessed interventions of any chronic or non-communicable disease, were conducted in a school setting, undertook a full cost-effectiveness analysis and were available in English, Spanish, or French.

Results: Our review identified 1029 articles during our initial search of the databases, and after screening, 33 studies were included in our final analysis. The most used effectiveness outcome measures were summary effectiveness units such as quality-adjusted life years (QALYs) (22 articles; 67%) or disability-adjusted life years (DALYs) (4 articles; 12%). The most common health condition for which an intervention targets is overweight and obesity. Almost all school-based interventions were found to be cost-effective (30 articles; 81%).

Conclusion: Our review found evidence to support a number of cost-effective school-based interventions targeting NCDs focused on vaccination, routine physical activity, and supplement delivery interventions. Conversely, many classroom-based cognitive behavioral therapy for mental health and certain multi-component interventions for obesity were not found to be cost-effective.

Background: There is growing evidence to support the benefits of transcatheter aortic valve implantation (TAVI) over surgical aortic valve replacement (SAVR) in patients with symptomatic severe aortic stenosis (sSAS) who are at high- or intermediate-risk of surgical mortality. The PARTNER 3 trial showed clinical benefits with SAPIEN 3 TAVI compared with SAVR in patients at low risk of surgical mortality. Whether TAVI is also cost-effective compared with SAVR for low-risk patients in the Dutch healthcare system remains uncertain. This article presents an analysis using PARTNER 3 outcomes and costs data from the Netherlands to inform a cost-utility model and examine cost implications of TAVI over SAVR in a Dutch low-risk population.

Methods: A two-stage cost-utility analysis was performed using a published and validated health economic model based on adverse events with both TAVI and SAVR interventions from a published randomized low risk trial dataset, and a Markov model that captured lifetime healthcare costs and patient outcomes post-intervention. The model was adapted using Netherlands-specific cost data to assess the cost-effectiveness of TAVI and SAVR. Uncertainty was addressed using deterministic and probabilistic sensitivity analyses.

Results: TAVI generated 0.89 additional quality-adjusted life years (QALYs) at a €4742 increase in costs per patient compared with SAVR over a lifetime time horizon, representing an incremental cost-effectiveness ratio (ICER) of €5346 per QALY gained. Sensitivity analyses confirm robust results, with TAVI remaining cost-effective across several sensitivity analyses.

Conclusions: Based on the model results, compared with SAVR, TAVI with SAPIEN 3 appears cost-effective for the treatment of Dutch patients with sSAS who are at low risk of surgical mortality. Qualitative data suggest broader societal benefits are likely and these findings could be used to optimize appropriate intervention selection for this patient population.

Rationale: Economic evaluations play an important role in the development and implementation of healthcare innovations. For pharmaceutical products, the methodologies used are laid down in guidelines, whereas for medical technologies the guidelines are not as strenuous. The aim of this review was therefore to analyze what types of methodologies are used in economic evaluations of medical technologies.

Methods: We performed a mapping review to identify economic evaluations for medical technologies. We decided to limit our search to one year (2022) and included cost utility and cost effectiveness analyses in which health technologies were evaluated. For each included study we identified the main methodological characteristics.

Results: A total of 364 papers were included in the analysis, 268 (74%) contained cost-utility analyses and 91 (25%) cost-effectiveness analyses. A model was used in 236 (64%) analyses, 117 analyses were trial based evaluations. Probabilistic sensitivity analyses and/or bootstrapping was performed in 266 (73%) analyses. Deterministic sensitivity analyses were used in 306 (84%). Time horizon and perspective were underreported in 15-25% of the included studies.

Conclusions: This review shows the wide range of methodologies used in economic evaluations as well as the extent and rigor in which these methodologies are used. Many of the included papers did no use or did not sufficiently report the use of appropriate standard methods. This may lead to research waste, a delay in successful implementation of valuable innovations and in the end may delay improvement patient outcomes.

Background: Stroke readmissions are considered a marker of health quality and may pose a burden to healthcare systems. However, information on the costs of post-stroke readmissions has not been systematically reviewed.

Objectives: To systematically review information about the costs of hospital readmissions of patients whose primary diagnosis in the index admission was a stroke.

Methods: A rapid systematic review was performed on studies reporting post-stroke readmission costs in EMBASE, MEDLINE, and Web of Science up to June 2021. Relevant data were extracted and presented by readmission and stroke type. The original study's currency values were converted to 2021 US dollars based on the purchasing power parity for gross domestic product. The reporting quality of each of the included studies was assessed using the Consolidated Health Economic Evaluation Reporting Standards (CHEERS) checklist.

Results: Forty-four studies were identified. Considerable variability in readmission costs was observed among countries, readmissions, stroke types, and durations of the follow-up period. The UK and the USA were the countries reporting the highest readmission costs. In the first year of follow-up, stroke readmission costs accounted for 2.1-23.4%, of direct costs and 3.3-21% of total costs. Among the included studies, only one identified predictors of readmission costs.

Conclusion: Our review showed great variability in readmission costs, mainly due to differences in study design, countries and health services, follow-up duration, and reported readmission data. The results of this study can be used to inform policymakers and healthcare providers about the burden of stroke readmissions. Future studies should not solely focus on improving data standardization but should also prioritize the identification of stroke readmission cost predictors.

Background: Triple-negative breast cancer (TNBC) is responsible for 10-20% cases of breast cancer and is resulting in rising healthcare costs. Thus, health-economic evaluations are needed to relate clinical outcomes and costs of treatment options and to provide recommendations of action from a health-economic perspective.

Methods: We investigated the cost-benefit-ratio of approved treatment options in metastatic TNBC in Germany by applying the efficiency frontier approach. These included sacituzumab-govitecan (SG), eribulin, vinorelbine, and capecitabine. Clinical benefit was measured as (i) median overall survival (mOS) and (ii) health-related quality of life (HRQoL) in terms of time to symptom worsening (TSW). To assess medical benefits, literature was systematically reviewed in PubMed for (i) and (ii), respectively. Treatment costs were calculated considering annual direct outpatient treatment costs from a statutory healthcare payer perspective. It was intended that both, (i) and (ii), yield an efficiency frontier.

Results: Annual direct outpatient treatment costs amounted to EUR 176,415.21 (SG), EUR 47,414.14 (eribulin), EUR 13,711.35 (vinorelbine), and EUR 3,718.84 (capecitabine). Systematic literature review of (i) and statistical analysis resulted in OS values of 14.3, 9.56, 9.44, and 7.46 months, respectively. Capecitabine, vinorelbine, and SG are part of the efficiency frontier including OS. The highest additional benefit per additional cost was determined for vinorelbine, followed by SG. Systematic review of (ii) revealed that no TSW data of TNBC patients receiving vinorelbine were available, preventing the presentation of an efficiency frontier including HRQoL.

Conclusions: Vinorelbine is most cost-effective, followed by SG. Health-economic evaluations support decision-makers to assess treatment options within one indication area. In Germany, the efficiency frontier can provide decision support for the pricing of innovative interventions. Results of our analysis may thus guide reimbursement determination.

Background: The emergence of high-priced potential cures has sparked significant health policy discussions in South Korea, where the healthcare system is funded through a single-payer National Health Insurance model. We conducted focus group interviews (FGIs) and accompanying surveys with diverse stakeholders to comprehensively understand related issues and find better solutions to the challenges brought by these technologies.

Methods: From October to November 2022, 11 FGIs were conducted with stakeholders from various sectors, including government payers, policy and clinical experts, civic and patient organisations, and the pharmaceutical industry, involving a total of 25 participants. These qualitative discussions were supplemented by online surveys to effectively capture and synthesise stakeholder perspectives.

Results: Affordability was identified as a critical concern by 84% of stakeholders, followed by clinical uncertainty (76%) and limited value for money (72%). Stakeholders expressed a preference for both financial-based controls and outcome-based pricing strategies to mitigate these challenges. Despite the support for outcome-based refunds, payers raised concerns about the feasibility of instalment payment models, whether linked to outcomes or not, due to the specific challenges of the Korean reimbursement system and the potential risk of 'cumulative liabilities' from ongoing payments for previously administered treatments. In addition, the FGIs highlighted the need for clear budgetary limits for drugs with high uncertainties, with mixed opinions on the creation of special silo funds (64.0% agreement). Less than half (48%) endorsed the use of external reference pricing, currently applied to such essential drugs in South Korea. A significant majority (84%), predominantly non-pharma stakeholders, advocated for addressing cost-effectiveness uncertainty through re-assessment once long-term clinical data become available.

Conclusions: This study uncovers a broad agreement among stakeholders on the need for more effective value assessment methodologies for high-priced potential cures, stressing the importance of more robust and comprehensive re-assessment supported by long-term data collection, rather than primarily relying on external reference pricing. Each type of stakeholders exhibited a cautious approach to their specific uncertainties, suggesting that new funding strategies should accommodate these uncertainties with predefined guidelines and agreements prior to the initiation of managed entry agreements.

Background: Chronic obstructive pulmonary disease (COPD) is associated with a high readmission rate and poses a significant disease burden. South Korea initiated pilot projects on transitional care services (TCS) to reduce readmissions. However, evidence from cost-effectiveness analyses remains undiscovered. This study aimed to evaluate the cost-effectiveness of TCS in patients with COPD from the healthcare system' perspective.

Method: A cost-utility analysis was conducted using a Markov model containing six components of possible medical use after discharge. Transition probabilities and medical costs were extracted from the National Health Insurance Service Senior Cohort (NHIS-SC), and utility data were obtained from published literature. Sensitivity analyses were performed to test the robustness of the results.

Results: Conducting TCS produced an incremental quality-adjusted life years gain of 0.231, 0.275, 0.296 for those in their 60s, 70s, and 80s, respectively, and cost savings of $225.16, $1668, and $2251.64 for those in their 60s, 70s, and 80s, respectively, per patient over a 10-year time horizon. The deterministic sensitivity analysis indicated that the TCS cost and the cost of readmission by other diseases immensely impact the results. The probabilistic sensitivity analyses showed that the probability that the incremental cost-effectiveness ratio is below $23,050 was over 85%, 93%, and 97% for those in the 60s, 70s, and 80s, respectively.

Conclusions: TCS was the dominant option compared to usual care. However, it is advantageous to the healthcare budget preferentially consider patients aged over 70 years with severe TCS symptoms. In addition, it is essential to include the management of underlying comorbidities in TCS intervention.

Trial registration: Clinical Research Information Service (CRIS), KCT0007937. Registered on 24 November 2022.

Background: This study aimed to evaluate the cost-effectiveness of a telehealth coaching intervention to prevent gestational diabetes mellitus (GDM) and to calculate the breakeven point of preventing GDM.

Methods: Data to inform the economic evaluation model was sourced directly from the large quaternary hospital in Brisbane, where the Living Well during Pregnancy (LWdP) program was implemented, and further supplemented with literature-based estimates where data had not been directly collected in the trial. A cost-effectiveness model was developed using a decision tree framework to estimate the potential for cost savings and quality of life improvement. A total of 1,315 pregnant women (49% with a BMI 25-29.9, and 51% with a BMI ≥ 30) were included in the analyses.

Results: The costs of providing routine care and routine care plus LWdP coaching intervention to pregnant women were calculated to be AUD 20,933 and AUD 20,828, respectively. The effectiveness of the LWdP coaching program (0.894 utility) was slightly higher compared to routine care (0.893). Therefore, the value of the incremental cost-effectiveness ratio (ICER) was negative, and it indicates that the LWdP coaching program is a dominant strategy to prevent GDM in pregnant women. We also performed a probabilistic sensitivity analysis using Monte Carlo simulation through 1,000 simulations. The ICE scatter plot showed that the LWdP coaching intervention was dominant over routine care in 93.60% of the trials using a willingness to pay threshold of AUD 50,000.

Conclusion: Findings support consideration by healthcare policy and decision makers of telehealth and broad-reach delivery of structured lifestyle interventions during pregnancy to lower short-term costs associated with GDM to the health system.