The aim of this study was to assess the costs and cost-effectiveness of intravenous thrombolysis treatment with alteplase (Actilyse) of acute ischemic stroke with 24-hour in-house neurology coverage and use of magnetic resonance imaging.
A health economic model was designed to calculate the marginal cost-effectiveness ratios for time spans of 1, 2, 3 and 30 years. Effect data were extracted from a meta-analysis of six large-scale randomized and placebo-controlled studies of thrombolytic therapy with alteplase. Cost data were extracted from thrombolysis treatment at Aarhus Hospital, Denmark, and from previously published literature.
The calculated cost-effectiveness ratio after the first year was $55,591 US per quality-adjusted life-year (base case). After the second year, computation of the cost-effectiveness ratio showed that thrombolysis was cost-effective. The long-term computations (30 years) showed that thrombolysis was a dominant strategy compared with conservative treatment given the model premises.
A high-quality thrombolysis treatment with 24-hour in-house neurology coverage and magnetic resonance imaging might not be cost-effective in the short term compared with conservative treatment. In the long term, there are potentially large-scale health economic cost savings.
To assess the cost-effectiveness of etravirine (INTELENCE), a novel nonnucleoside reverse transcriptase inhibitor, used in combination with a background regimen that included darunavir/ritonavir, from a Canadian Provincial Ministry of Health perspective.
A Markov model with a 3-month cycle time and six health states based on CD4 cell count ranges was developed to follow a hypothetical cohort of treatment-experienced adults with HIV-1 infection through initial and subsequent treatment regimens.
Costs (in 2009 Canadian dollars), utilities, and HIV-related mortality data for each health state as well as non-HIV-related mortality data were estimated from Canadian sources and published literature. Transition probabilities between health states and first-year hospitalization and mortality rates were derived from clinical trial data. Incremental 1-year costs per additional adult with viral load less than 50 copies/ml at 48 weeks and incremental lifetime costs per quality-adjusted life-year (QALY) gained were estimated using a 5% discount rate. Sensitivity and variability analyses and model validation were performed.
Etravirine was associated with an increased probability of achieving less than 50 copies/ml at 48 weeks of 0.205 and an estimated gain of 0.66 discounted (1.48 undiscounted) QALYs over a lifetime. The incremental 1-year cost per additional person with viral load less than 50 copies/ml was $23,862. The lifetime incremental cost per QALY gained was $49,120. For the uncertainty ranges and variability scenarios tested for the lifetime horizon, the cost-effectiveness ratio was between $28,859 and 66,249.
When compared with optimized standard of care including darunavir/ritonavir, adding etravirine represents a cost-effective option for treatment-experienced adults in Canada.
Cancer is a major cause of morbidity and mortality, and colorectal cancer (CRC) is the third most common cancer in the world. The estimated costs of CRC treatment vary considerably, and if CRC costs in a model are based on empirically estimated total costs of stage I, II, III, or IV treatments, then they lack some flexibility to capture future changes in CRC treatment. The purpose was 1) to describe how to model CRC costs and survival and 2) to validate the model in a transparent and reproducible way.
We applied a semi-Markov model with 70 health states and tracked age and time since specific health states (using tunnels and 3-dimensional data matrix). The model parameters are based on an observational study at Oslo University Hospital (2049 CRC patients), the National Patient Register, literature, and expert opinion. The target population was patients diagnosed with CRC. The model followed the patients diagnosed with CRC from the age of 70 until death or 100 years. The study focused on the perspective of health care payers.
The model was validated for face validity, internal and external validity, and cross-validity. The validation showed a satisfactory match with other models and empirical estimates for both cost and survival time, without any preceding calibration of the model.
The model can be used to 1) address a range of CRC-related themes (general model) like survival and evaluation of the cost of treatment and prevention measures; 2) make predictions from intermediate to final outcomes; 3) estimate changes in resource use and costs due to changing guidelines; and 4) adjust for future changes in treatment and trends over time. The model is adaptable to other populations.
The purpose of this study was to estimate the cost-effectiveness of two screening methods for detection of silent AF, intermittent electrocardiogram (ECG) recordings using a handheld recording device, at regular time intervals for 30 days, and short-term 24 h continuous Holter ECG, in comparison with a no-screening alternative in 75-year-old patients with a recent ischaemic stroke.
The long-term (20-year) costs and effects of all alternatives were estimated with a decision analytic model combining the result of a clinical study and epidemiological data from Sweden. The structure of a cost-effectiveness analysis was used in this study. The short-term decision tree model analysed the screening procedure until the onset of anticoagulant treatment. The second part of the decision model followed a Markov design, simulating the patients' health states for 20 years. Continuous 24 h ECG recording was inferior to intermittent ECG in terms of cost-effectiveness, due to both lower sensitivity and higher costs. The base-case analysis compared intermittent ECG screening with no screening of patients with recent stroke. The implementation of the screening programme on 1000 patients resulted over a 20-year period in 11 avoided strokes and the gain of 29 life-years, or 23 quality-adjusted life years, and cost savings of €55 400.
Screening of silent AF by intermittent ECG recordings in patients with a recent ischaemic stroke is a cost-effective use of health care resources saving costs and lives and improving the quality of life.
Acellular pertussis vaccine is safe and effective in adults. An explicit recommendation for pertussis booster vaccination in pediatric health care workers is based on the importance of health care workers as a potential source of infection for patients. However, limited information is available on the economic attractiveness of this intervention. We sought to evaluate the health-economic attractiveness of a diphtheria-tetanus-acellular pertussis booster vaccination program for health care workers in a pediatric intensive care setting.
We developed a Markov model to calculate the cost-effectiveness of vaccinating NICU health care workers in different proportions ranging from the current strategy of no pertussis booster vaccination program to a vaccination program that achieves between 25% and 95% vaccine coverage.
Implementation of a vaccination program that achieves 25% coverage was projected to be cost-saving compared with no vaccine program. At all coverage levels the intervention reduced costs, increased life expectancy, and was cost-effective. Projections were most sensitive to the risk of a pertussis introduction via an infected health care worker. Once the monthly risk of an introduction exceeded ~0.3%, implementation of an immunization program with at least 25% coverage provided both greater health and greater economic benefits than having no vaccine program.
The implementation of a hospital-based and funded diphtheria-tetanus-acellular pertussis vaccine program administered through an occupational health program is cost-effective or cost-saving in the context of pediatric health care facilities in which many of the patients are at risk of serious morbidity and mortality should they acquire pertussis while hospitalized.
A head-to-head comparator study has shown that the clinical efficacy of ustekinumab is superior to that of etanercept over a 12-week period in patients with psoriasis. Economic models are often hindered by the lack of trials directly comparing outcomes between relevant alternative therapies. The aim of this analysis was to evaluate the cost-effectiveness of ustekinumab versus etanercept among adults with moderate-to-severe plaque psoriasis based on a Phase 3 head-to-head trial.
The Markov model incorporates trial data from the Active Comparator (CNTO 1275/Enbrel) Psoriasis Trial study (ustekinumab 45 mg at Weeks 0 and 4; etanercept 50 mg biweekly) to follow patient response to initial treatment using the modeling approach developed by the Centre for Reviews and Dissemination, University of York, and often cited by others conducting economic analyses of psoriasis. Beyond the initial trial period, the Canadian model extrapolates results up to 10 years.
Over the 10-year time horizon of the model, the mean annual costs were $16,807 for ustekinumab (45 mg) and $19,525 for etanercept (50 mg). The incremental difference in costs and utilities remained in favour of ustekinumab across a range of sensitivity analyses.
This model highlights the advantage of having head-to-head comparative trial data relevant to the at-risk population. Our model shows that ustekinumab is more cost-effective than etanercept for patients with moderate-to-severe plaque psoriasis.
The cost-effectiveness of memantine for the treatment of moderate and severe Alzheimer's disease has been assessed in several European countries. Objective of the study was to assess it in Norwegian settings.
This cost-utility analysis used a Markov modelling approach to simulate the evolution of patients until their need for full-time care (FTC) over a 5-year period. FTC was defined as a patient becoming either dependent or institutionalised. Transition probabilities were estimated using a newly developed predictive equation of time to FTC. Health resource use and utilities were obtained from the Scandinavian Study of Cost and Quality of Life in Alzheimer's Disease study, and mortality was obtained from the Oslo study. Memantine efficacy was based on a meta-analysis of six large trials. The model compared memantine with its alternative in this population, that is no pharmacological treatment or background therapy with acetylcholinesterase inhibitors. The model underwent extensive sensitivity analyses.
In Norway, memantine was found to delay the need for FTC by 4.4 weeks compared with standard care and was associated with increased quality-adjusted life years. Memantine was the dominant strategy with cost savings of €3739 (30?041 NOK) per patient. The probability of being the dominant strategy was 98.8%. This result was confirmed across multiple sensitivity analyses.
The model suggests that memantine prolongs time to FTC for no additional cost to the healthcare system and society. It can be regarded as a cost-effective choice in the management of moderate and severe Alzheimer's disease.
The prevalence of chronic hepatitis B (CHB) infection among the immigrants of North America ranges from 2 to 15%, among whom 40% develop advanced liver disease. Screening for hepatitis B surface antigen is not recommended for immigrants.
The objective of this study is to estimate the health and economic effects of screening strategies for CHB among immigrants.
We used the Markov model to examine the cost-effectiveness of three screening strategies: (i) 'No screening'; (ii) 'Screen and Treat' and (iii) 'Screen, Treat and Vaccinate' for 20-65 years old individuals who were born abroad but are currently living in Canada. Model data were obtained from the published literature. We measured predicted hepatitis B virus (HBV)-related deaths, costs (2008 Canadian Dollars), quality-adjusted life-years (QALYs), and incremental cost-effectiveness ratio (ICER).
Our results show that screening all immigrants will prevent 59 HBV-related deaths per 10, 000 persons screened over the lifetime of the cohort. Screening was associated with an increase in quality-adjusted life expectancy (0.024 QALYs) and cost ($1665) per person with an ICER of $69, 209/QALY gained compared with 'No screening'. The 'Screen, Treat and Vaccinate' costs an additional $81, generates an additional 0.000022 QALYs per person, with an ICER of $3, 648,123/QALY compared with the 'Screen and Treat'. Sensitivity analyses suggested that the 'Screen and Treat' is likely to be moderately cost-effective.
We show that a selective hepatitis B screening programme targeted at all immigrants in Canada is likely to be moderately cost-effective. Identification of silent CHB infection with the offer of treatment when appropriate can extend the lives of immigrants at reasonable cost.
To estimate the cost-utility of adjuvant high-dose interferon in high-risk melanoma patients in Quebec compared to a watchful waiting strategy.
A Markov model was developed that replicates the findings of the pivotal E1684 trial. It was then used to extrapolate survival over a period of 35 years. Costs of medical resources used during the first year were derived through a detailed analysis of a sample (n = 13) of patients treated in a leading academic hospital. Follow-up costs were assessed through a medical decision algorithm. Utilities were derived from a population-based survey (n = 104) in different locations in Quebec using the time trade-off method.
The mean incremental cost per quality-adjusted life-year of adjuvant Interferon therapy is equal to 55,090 CAN dollars over a follow-up of 7 years but drops down to 14,003 CAN dollars when extrapolated over 35 years.
Estimates of the cost-effectiveness of high-dose interferon in melanoma patients show an acceptable cost-effectiveness ratio if long-term survival is taken into account. Estimates are, however, strongly influenced by the observed trial differences in survival, the utility associated to health states, and the discount rate.
A recent randomized, controlled trial in chronic heart failure patients showed that NT-proBNP-guided, intensive patient management (BMC) on top of multidisciplinary care reduced all-cause mortality and heart failure hospitalizations compared with multidisciplinary care (MC) or usual care (UC). We now performed a cost-utility analysis of these interventions from a payer's perspective.
Costs related to hospitalizations, ambulatory physician and nurse visits, and NT-proBNP testing for the three management strategies were acquired for both Austria (€) and Canada ($) and combined with the survival and quality of life data from the clinical trial for cost-effectiveness analysis. Data on long-term survival, costs, and quality-adjusted life-years (QALY) were extrapolated for a 20-year time horizon using a Markov model, which simulated the progression of disease through beta-blocker use, hospitalizations, and mortality.
BMC was the most cost-effective strategy as it was dominant (cost-saving with improved health outcome) over both MC and UC based on both Austrian and Canadian costs. Incremental cost-effectiveness ratios for MC relative to UC were €3,746 and $5,554 per QALY gained for Austrian and Canadian costs, respectively. The probabilities for BMC being the most cost-effective strategy were 92 percent at a threshold value of Austrian €40,000 and 93 percent at a threshold value of Canadian $50,000.
NT-proBNP-guided, intensive HF patient management in addition to multidisciplinary care not only reduces death and hospitalization but also proves to be cost-effective.