Applied Health Economics and Health Policy最新文献

Objectives

Our aim was to review the evidence for the cost effectiveness of elective surgeries with long waiting lists within the NHS in England. This is to inform understanding of national spending priorities in the context of significant demand for elective surgeries and to inform the debate on appropriate cost-effectiveness thresholds across healthcare decision making.

Methods

We conducted a targeted literature review to identify published cost-effectiveness analyses for nine elective procedures with long waiting lists in the NHS, selected based on previous reviews. These were percutaneous coronary intervention (PCI), coronary artery bypass graft surgery (CABG), hysterectomy, cholecystectomy, knee replacement, groin hernia repair, hip replacement, prostatectomy, and cataract surgery. We made comparisons adjusted for currency and price year (2024).

Results

We identified 21 evaluations; in these, the cost effectiveness of surgeries was compared with no surgery (n = 9), medical management (n = 5), and between early and delayed surgery (n = 10). The evaluations reported that almost all procedures would be considered cost effective yielding incremental cost-effectiveness ratios (ICERs) below £20,000 per quality-adjusted life-year gained. Cholecystectomy, prostatectomy, hip and knee replacement surgeries were associated with ICERs of between £5,000 and £10,000.

Conclusions

These findings offer insights for policymakers on optimising finite healthcare resources, particularly post-COVID-19, with surgical waiting lists a priority for the NHS. Prioritising these elective procedures is likely to be a highly cost-effective use of NHS resources. Allocation of investment to areas that are more cost effective than others is likely to increase the efficiency of the NHS, resulting in a net health gain compared with the reimbursement of less cost-effective interventions.

Introduction

Antimicrobial resistance (AMR) is a complex, inter-sectoral and international problem. Economic evaluation (EE) methods offer systematic, evidence-driven approaches to inform policy decisions about which AMR interventions to fund. EE of AMR interventions is complicated owing to diffuse effects, complex mechanics of the problem and high levels of uncertainty. Current AMR EE literature restricts the analytical scope, potentially resulting in omissions of effects that may limit the utility of EE to inform policy decisions. We aimed to systemise the key evolutionary and ecological processes of AMR to elucidate the paths through which AMR interventions impact population health and healthcare costs to support EE design and to support decision makers in understanding the limitations of EE evidence for decision-making.

Methods

A conceptual map and a corresponding tool were developed on the basis of a literature review in consultation with experts across the relevant disciplines of molecular biology, infectious disease modelling, health economics and ecology.

Results

The AMR development map: (1) distils the key AMR processes and process drivers behind AMR development and maps the available types of AMR interventions to AMR process drivers; (2) proposes a way to conceptualise the spatial scope of analysis through considering the connectivity of the wider ecosystem and (3) outlines the key dimensions that AMR burden and intervention effects could be measured across. An AMR development map tool was developed to support conceptual modelling, with the focus on the choice of scope in the EE of AMR interventions, and an illustrative case study was provided.

Discussion

This work summarises the key underlying biological principles of AMR development to provide mechanistical grounding for considering the scope of effects of AMR interventions and the appropriate system of analysis to support conceptual modelling in EE of AMR interventions. In addition, this map can facilitate the identification of effects that cannot be considered or quantified, thus enabling transparency about these omissions within decision-making.

Background and Objective

Ankylosing spondylitis is a complex rheumatic disease, characterised by chronic and progressive inflammation of the spine, causing an important health and economic burden for the person with the condition. Evidence shows the unequal impact of the disease in different groups of people, with a higher burden for lower socioeconomic groups. The objective of this study is to evaluate the impact of the use of biologics for the treatment of ankylosing spondylitis on health inequities in Chile.

Methods

We conducted an aggregate distributional cost-effectiveness analysis. Data on health outcomes and costs were derived from a cost-effectiveness model of secukinumab, etanercept, certolizumab pegol, infliximab, adalimumab and golimumab versus treatment as usual for the treatment of ankylosing spondylitis from the Chilean healthcare system perspective. Health gains and health opportunity costs were distributed across socioeconomic subgroups. Health and equity impacts, measured using the Atkinson index, were assessed on an equity-efficiency impact plane.

Results

All treatments had a positive impact on equity relative to treatment as usual. At an opportunity cost threshold of 1 Gross Domestic Product per capita/quality-adjusted life-year, secukinumab improved societal welfare irrespective of the Atkinson index value. When varying thresholds (2 and 3 Gross Domestic Product), all assessed technologies contributed to an increase in societal welfare, regardless of the Atkinson index.

Conclusions

Biologic treatment for ankylosing spondylitis, such as secukinumab, may reduce health inequity in the Chilean population. An aggregate distributional cost-effectiveness analysis framework is feasible to implement alongside a cost-effectiveness analysis in the context of the Chilean healthcare system to provide additional information of equity impacts for health technology assessment recommendations and policy making.

Background

Access to safe, timely and affordable surgical care is lacking globally. Less than 6% of all surgical operations are carried out in low- and middle-income countries, where over a third of the world’s population lives. CapaCare, an NGO operating in Sierra Leone, have developed a surgical training programme (STP) for Associate Clinicians based on principles of task-shifting to improve access. Interventions to increase healthcare access have the same value evidence requirements as new technologies but their evaluation presents methodological challenges as access is not routinely incorporated explicitly in economic evaluations.

Objective

To evaluate the cost-effectiveness of surgical task-shifting in Sierra Leone, implemented through the CapaCare STP, to increase provision of caesarean section (C-section).

Methods

We evaluated the impact of the STP on the provision of C-section and subsequent maternal and child outcomes, measured in disability-adjusted life-years (DALYs), relative to the costs using a healthcare system perspective and decision-tree model parameterised using data from surgical logbooks, national data, and the literature.

Results

Results indicate that the surgical task-shifting programme in Sierra Leone would be considered cost-effective in increasing provision for C-section. It is cost saving (USD − 16.77) and results in 2.14 DALYs averted, per women with an indication for C-section, due to avoidance of maternal and child deaths as well as reduced complications.

Conclusion

Investment in surgical task-shifting initiatives should be considered by policymakers as a potentially cost-effective way to increase access to quality surgical services. Future evaluations of access-increasing interventions should seek to capture the distributional impact of this strategy and system benefits.

Objectives

The objective was to evaluate the cost effectiveness of caplacizumab for the treatment of patients with acquired immune thrombocytopenic thrombotic purpura (iTTP) compared to standard of care from the perspective of the Brazilian Unified Health System (SUS).

Methods

A decision tree followed by a Markov model with a lifetime horizon was developed. Patients entered the model with an acute iTTP event. All patients were assumed to be admitted to hospital where they either respond to treatment or die. The model offered three health states: remission, relapse or death. Input data were obtained from literature searches with the data on efficacy of caplacizumab based on the HERCULES trial. The incremental cost-effectiveness ratio (ICER) was compared to the willingness-to-pay threshold for rare diseases of Brazilian reais (R$)120,000/quality-adjusted life years (QALYs). In addition to various sensitivity analyses, a value of information (VOI) analysis was conducted.

Results

In the base case, caplacizumab resulted in 0.70 QALYs gained, and cost R$1,333,601 more, with an ICER of R$1,901,729/QALY. The cost of the caplacizumab vial was the most influential parameter. Probabilistic analysis showed that caplacizumab was not cost effective in any iterations for the threshold of the rare disease. The expected value of perfect information per year is R$0.

Conclusion

Although caplacizumab results in incremental QALYs, based on the proposed cost, caplacizumab is not cost effective from the SUS perspective, and VOI results indicate that further research would not be worthwhile.

Although compulsory licensing of medicines is traditionally discussed in the context of low- and middle-income countries tackling high prices, it has recently sparked debate in several high-income countries. This study aims to examine the industrial and health consequences of compulsory licensing when applied by a high-income country. Our literature review found that the impact of compulsory licensing is challenging to predict as it can have multiple (opposing) consequences in terms of economic activity, patient outcomes and public health. Compulsory licensing can, under particular circumstances, serve as a lever of industrial policy in a country that wishes to develop its domestic generic pharmaceutical industry. However, originator pharmaceutical companies and other industries may reduce investment, which can be negative for countries with a high presence of innovators, adversely impacting long-term economic activity. Compulsory licensing may also induce state retaliation against the license-issuing country. From a health policy perspective, compulsory licensing likely increases patient access to expensive medicines and frees up resources that can be invested in other (health) programs. However, pharmaceutical companies may delay medicine launches or cancel clinical trials in the license-issuing country. Although there are benefits resulting from a credible threat to use compulsory licensing, the overall desirability of actually using it depends on the specific context and needs to be assessed on a case-by-case basis.