Applied Health Economics and Health Policy最新文献

Objectives

A distributional cost-effectiveness analysis (DCEA) was conducted to evaluate how alteplase for acute ischemic stroke affected overall health and disparities in the USA.

Methods

Using an existing, published, cost-effectiveness analysis, a DCEA was developed from a US payer perspective. The population was divided into 25 equity-relevant subgroups based on race and ethnicity (5 census-based groups), and county-level social vulnerability index (quintiles). Inputs for stroke outcomes, incidence and alteplase utilization varied across subgroups. Opportunity costs were estimated by converting total spend on alteplase into quality-adjusted life-years (QALYs) using an equal distribution across subgroups. Various scenarios explored the impact of health system changes to improve stroke care access.

Results

Alteplase treatment resulted in larger relative QALY gains in more vulnerable versus less vulnerable subgroups owing to increased acute ischemic stroke incidence and lower receipt of thrombolysis. Using an opportunity cost threshold of US$150,000/QALY, alteplase was estimated to improve social welfare by increasing population health (45,606 QALYs gained) and reducing existing overall US inequities by 0.0001% annually. Results were robust across all levels of population inequality aversion and alternate opportunity cost thresholds. Health system scenarios that reduced care gaps promoted additional reductions in existing inequalities, because more patients with lower baseline health were eligible for treatment.

Conclusions

Under current treatment patterns, this DCEA demonstrated that alteplase for acute ischemic stroke increased population health and improved health equity. It is critical to address existing care gaps to enable equitable access to alteplase across race, ethnicity and geography.

The realities of ecosystem breakdown and climate change pose a significant threat to the health of individuals around the world, disproportionately affecting poor and vulnerable populations. Every sector in society, including healthcare, needs to be engaged in the tremendous collective effort and transformational change needed to limit global warming. We see priority setting as having a key role to play in reallocating existing budgets within healthcare systems whilst at the same time being used to facilitate sustainable and more efficient resource allocation across countries. Priority setting looks to fairly distribute resources with the goal of improving patient and population health outcomes. However, these goals can be broadened to include consideration of environmental impact based on our understanding of the necessity of emissions reduction to address the climate crisis and promote population health. In this paper, we introduce key concepts of priority setting and identify the interplay between priority setting and the realities of resource scarcity in the realm of planetary healthcare. We propose that applying priority-setting principles could serve at least three goals; (1) protect and improve health outcomes; (2) limit unnecessary and marginal care; and (3) facilitate a just transition to a sustainable healthcare system.

Introduction

Manufacture, distribution, use, excretion, and disposal of health technologies all have environmental impacts (EIs). In the health technology assessment (HTA) definition, EI is recognized as a domain that should be assessed. However, EIs in HTA methods are lacking. The aim of this scoping review was to identify current advances and limitations in incorporating EI in HTA evaluation.

Methods

We searched two databases, PubMed and Embase (01/01/2019–20/10/2023, updated on 15/05/2025), using the following keywords: “HTA” and “environmental impact.” Articles published in English were included. Additionally, no filters by study design or type of evaluated technology were used.

Results

In total, 264 studies were screened after duplicates had been removed. Among them, 15 articles were included. Identified publications highlighted the necessity of robust and clear methods of EI assessment and its inclusion in the HTA process. Several authors have outlined the importance of assessing the EI of health technology throughout its life cycle, including raw materials, manufacturing, use, and disposal. However, the EI assessment in HTA presents significant challenges, such as determining a clear domain of EI, the perspective, and the time horizon for the assessment. EI assessment challenges also include the lack of disaggregated data on pollutant emissions and natural resource consumption, as well as recommendations on the use of the EI data by decision makers and HTA agencies. In the literature, different methods and approaches have been proposed to incorporate EI in HTA; some rely on already establish assessment methods (“enriched” cost-utility analysis, adjusted willingness to pay, and multicriteria decision analysis) and others proposed more specific approaches, such as “information conduit,” “parallel evaluation,” “integrated evaluation,” and “environment-focused evaluation.”

Conclusion

HTA framework needs adjustments to incorporate environmental information, including environmental healthcare technology impact. Clear and robust methods on EI assessment and inclusion in the HTA process should be provided by HTA agencies and international societies. Further, manufacturers should improve the data generation on the EI of their products, with new studies able to generate individual-level data on environmental technology impact.

Aim

The aim of this study was to analyse the real-world health and economic effect of an outpatient screening and continuing-care programme for early detection and care of microvascular complications in patients with type 2 diabetes (T2D) delivered through a selective contract between a large statutory health insurance company and ambulatory care physicians in the German health care system.

Methods

Building on methods of target trial emulation and programme impact evaluation, we used a quasi-experimental approach and health insurance claims data from 790,375 patients with T2D over a time horizon of 5.75 years. We applied a two-stage matching approach in which we exploited the staggered implementation of the selective contract across federal states in Germany to control for selection bias at the physician level and used propensity scores to control for selection bias at the patient level, where we considered socio-demographic, health consciousness-related, care-related, and comorbidity-related potential confounders in the matching process.

Results

Within a matched sample of 16,490 patients, over 1 year, enrolment into the programme increased the number of visits to primary care physicians (relative risk [RR]: 1.09, 95% confidence interval [CI] 1.07, 1.10), increased the frequency of prescriptions for sodium-glucose cotransporter-2 (SGLT2) inhibitors (RR: 1.30, 95% CI 1.12, 1.50) and for statins (RR: 1.08, 95% CI 1.03, 1.13) and decreased the risk of hospitalisations (RR: 0.88, 95% CI 0.84, 0.92). Outpatient costs in the enrolled patients were on average 14% (cost ratio: 1.14, 95% CI 1.09, 1.20) or €194.4 higher, but overall, the programme was budget neutral over a time horizon of 1 year.

Conclusion

Investing in secondary prevention to detect and manage the early stages of microvascular complications is likely a cost-effective or cost-saving approach to improve health in patients with T2D.

Discrete event simulation (DES) provides enhanced flexibility over modelling techniques that have been traditionally used for assessing health-economic outcomes, making it a particularly interesting technique for modelling complex clinical pathways. Discrete event simulation also facilitates consideration of resources and capacity constraints, making it suitable for addressing a wide range of research questions in health care and beyond. However, those unfamiliar with DES often perceive it to be more complex compared to traditional health-economic modelling techniques, such as state-transition modelling. To address this perceived complexity, this tutorial provides a detailed illustration of implementing DES in the open-source R software using the simmer package, through a case study in colon cancer. The tutorial is aimed at those who have a conceptual model that they want to implement as a DES in R, and are looking for practical guidance. It discusses methodological aspects related to DES and individual-level modelling in general that have not been extensively covered in literature, the conceptual model structure and corresponding pseudocode, data analysis, model implementation, and the deterministic and probabilistic analysis of the model. The documented code provides all building blocks required to develop a wide range of DES models in R using the simmer package.

Objective

This study aims to evaluate the cost-effectiveness of a school-based mental health prevention program in a limited income context to inform investment decisions.

Methods

The Resourceful Adolescent Program, an evidence-based resilience intervention designed for adolescents, was culturally adapted as Happy House (HH) in a two-arm, controlled trial in selected high schools in Vietnam. A Markov model assessed HH’s cost-effectiveness in preventing depression compared with doing nothing from a societal perspective over 5-year, 10-year, and lifetime horizons. The model underwent face, internal, and cross-validation with experts in health economics, mental health, and education. Effect size was drawn from the HH trial, utility values from an EuroQol 5-Dimension 5-Level (EQ-5D-5L) survey of 1004 adolescents and systematic reviews, and costs from the HH trial and Vietnam data. Incremental cost-effectiveness ratios (ICERs) were expressed in 2020 Vietnamese dong (VND) per quality-adjusted life year (QALY) gained, with costs and benefits discounted at 3%. Sensitivity analyses and a scenario on nationwide HH scaling were also conducted.

Results

Compared with do-nothing, HH had ICERs of 43.8 million VND (US $5512), 30.4 million VND (US $3831), and 22.9 million VND (US $2886) per QALY gained over 5-year, 10-year, and lifetime horizons, respectively. Nationwide scaling reduced ICERs to 27.6 million VND (US $3470), 18.8 million VND (US $2370), and 13.5 million VND (US $1698) per QALY over the same periods. ICERs were sensitive to changes in effect size, disease incidence, and intervention costs. Sensitivity analyses demonstrated that the results were robust despite parameter uncertainty and variations in key assumptions

Conclusions

Investing in a universal school-based mental health prevention program is cost-effective compared with doing nothing in a limited income context such as Vietnam. Scaling up HH implementation amidst rising depression incidence further enhances the cost-effectiveness of this investment.

Background

Efficient resource allocation in the health technology assessment process of medical devices requires a robust selection and prioritization of medical devices for evaluation. Despite its importance, there is currently no generally accepted approach for such a prioritization task, and a comprehensive review of adaptable approaches is needed.

Objective

Our study aimed to provide a comprehensive review of existing approaches that could be used or adapted to select and prioritize medical devices for health technology assessment (HTA) evaluation.

Methods

Searches were conducted in PubMed, Web of Science, Scopus, and the databases of the International Network of Agencies for Health Technology Assessment and the Centre for Reviews and Dissemination. Following the screening, analyses and comparisons were based on data such as publication year, target jurisdiction, decision context, health technology focus, methods used for value assessment and included attributes, and the social methods used for stakeholder engagement.

Results

From 1055 identified records, 51 studies were eligible for review. Only 31 records mentioned the value assessment method used and, although there was a wide variety of techniques found in this sample, the majority of them (77%) applied multicriteria decision analysis. A total of 22 studies were specifically focused on HTA prioritization and, within this set, the most frequently used value attributes were Clinical efficacy and/or effectiveness (n = 21, 95%), Impact of the disease (n = 13, 59%), and Ethical, social and legal aspects (n = 11, 50%). Social methods commonly implemented were questionnaires/surveys and the Delphi technique, with 15 and 7 reported applications, respectively.

Conclusions

A wide variety of methods have been reported to assess value in HTA contexts, and our premise that a generally accepted approach for prioritizing medical devices for HTA is still lacking was confirmed. Despite such heterogeneity, it was noticed that a multicriteria decision analysis is predominantly applied, with both intervention- and disease-related attributes being considered. Underreporting of the approaches used was recurrent, which should be avoided in the future to ensure their transparency and replicability.

Objectives

Kidney failure can be treated at home with peritoneal dialysis or home haemodialysis. The combination of reduced staffing, transport and overhead costs and improved quality of life through treatment at home could make initiating dialysis at home highly cost-effective. The primary objective is to estimate the cost-effectiveness of initiating patients on home dialysis therapy (HDT) compared with in-centre haemodialysis (ICHD). The secondary objective is to determine the upper limit of net benefit from removing potential service barriers within dialysis centres that hinder the adoption of HDT.

Method

A multistate model using UK Renal Registry data combined with national survey data was developed to estimate patient and dialysis centre influences on dialysis treatment modality changes and the duration in each modality. These are used as inputs to a microsimulation estimating the lifetime quality-adjusted life years (QALYs) and UK National Health Service (NHS) costs incurred for patients, the cost-effectiveness of HDT compared with ICHD and the differences in costs and health outcomes associated with removing specific barriers to HDT uptake.

Results

Commencing HDT compared with ICHD resulted in 0.30 additional QALYs and saved Great British (GB) £15,272. HDT has an 82% probability of being cost-effective. Implementing quality-improvement initiatives and alleviating stresses on staff capacity are identified as influential in the multistate model. Addressing these led to QALY gains of 0.22 and 0.08 and cost increases of GB £10,059 and GB £5127 from an increase of life years lived of 0.54 and 0.22, respectively.

Conclusions

Initiating patients on HDT is cost-effective compared with ICHD. Alleviating stresses on staff capacity and implementing quality improvement initiatives in dialysis centres leads to health improvements, although these changes are not cost-effective owing to the associated increase in healthcare costs.