The cost-effectiveness of using results-based financing to reduce maternal and perinatal mortality in Malawi

IntroductionResults-based financing (RBF) is being promoted to increase coverage and quality of maternal and perinatal healthcare in sub-Saharan Africa (SSA) countries. Evidence on the cost-effectiveness of RBF is limited. We assessed the cost-effectiveness within the context of an RBF intervention, including performance-based financing and conditional cash transfers, in rural Malawi.MethodsWe used a decision tree model to estimate expected costs and effects of RBF compared with status quo care during single pregnancy episodes. RBF effects on maternal case fatality rates were modelled based on data from a maternal and perinatal programme evaluation in Zambia and Uganda. We obtained complementary epidemiological information from the published literature. Service utilisation rates for normal and complicated deliveries and associated costs of care were based on the RBF intervention in Malawi. Costs were estimated from a societal perspective. We estimated incremental cost-effectiveness ratios per disability adjusted life year (DALY) averted, death averted and life-year gained (LYG) and conducted sensitivity analyses to how robust results were to variations in key model parameters.ResultsRelative to status quo, RBF implied incremental costs of US$1122, US$26 220 and US$987 per additional DALY averted, death averted and LYG, respectively. The share of non-RBF facilities that provide quality care, life expectancy of mothers at time of delivery and the share of births in non-RBF facilities strongly influenced cost-effectiveness values. At a willingness to pay of US$1485 (3 times Malawi gross domestic product per capita) per DALY averted, RBF has a 77% probability of being cost-effective.ConclusionsAt high thresholds of wiliness-to-pay, RBF is a cost-effective intervention to improve quality of maternal and perinatal healthcare and outcomes, compared with the non-RBF based approach. More RBF cost-effectiveness analyses are needed in the SSA region to complement the few published studies and narrow the uncertainties surrounding cost-effectiveness estimates.

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Cost and cost-effectiveness of indoor residual spraying with pirimiphos-methyl in a high malaria transmission district of Mozambique with high access to standard insecticide-treated nets

Malaria Journal ◽

10.1186/s12936-021-03687-1 ◽

2021 ◽

Vol 20 (1) ◽

Author(s):

Sergi Alonso ◽

Carlos J. Chaccour ◽

Joseph Wagman ◽

Baltazar Candrinho ◽

Rodaly Muthoni ◽

...

Keyword(s):

Cost Effectiveness ◽

Indoor Residual Spraying ◽

Cost Effective ◽

Sensitivity Analyses ◽

Model Parameters ◽

Insecticide Treated Nets ◽

High Transmission ◽

Life Years ◽

Pirimiphos Methyl ◽

The Cost

Abstract Background As malaria cases increase in some of the highest burden countries, more strategic deployment of new and proven interventions must be evaluated to meet global malaria reduction goals. Methods The cost and cost-effectiveness of indoor residual spraying (IRS) with pirimiphos-methyl (Actellic®300 CS) were assessed in a high transmission district (Mopeia) with high access to pyrethroid insecticide-treated nets (ITNs), compared to ITNs alone. The major mosquito vectors in the area were susceptible to primiphos-methyl, but resistant to pyrethoids. A decision analysis approach was followed to conduct deterministic and probabilistic sensitivity analyses in a theoretical cohort of 10,000 children under five years of age (U5) and 10,000 individuals of all ages, separately. Model parameters and distributions were based on prospectively collected cost and epidemiological data from a cluster-randomized control trial and a literature review. The primary analysis used health facility-malaria incidence, while community cohort incidence and cross-sectional prevalence rates were used in sensitivity analyses. Lifetime costs, malaria cases, deaths and disability-adjusted life-years (DALYs) were calculated to determine the incremental costs per DALY averted through IRS. Results The average IRS cost per person protected was US$8.26 and 51% of the cost was insecticide. IRS averted 46,609 (95% CI 46,570–46,646) uncomplicated and 242 (95% CI 241–243) severe lifetime cases in a theoretical children U5 cohort, yielding an incremental cost-effectiveness ratio (ICER) of US$400 (95% CI 399–402) per DALY averted. In the all-age cohort, the ICER was higher: US$1,860 (95% CI 1,852–1,868) per DALY averted. Deterministic and probabilistic results were consistent. When adding the community protective effect of IRS, the cost per person protected decreased (US$7.06) and IRS was highly cost-effective in children U5 (ICER = US$312) and cost-effective in individuals of all ages (ICER = US$1,431), compared to ITNs alone. Conclusion This study provides robust evidence that IRS with pirimiphos-methyl can be cost-effective in high transmission regions with high pyrethroid ITN coverage where the major vector is susceptible to pirimiphos-methyl but resistant to pyrethroids. The finding that insecticide cost is the main driver of IRS costs highlights the need to reduce the insecticide price without jeopardizing effectiveness. Trial registration: ClinicalTrials.gov identifier NCT02910934 (Registered 22 September 2016). https://clinicaltrials.gov/ct2/show/NCT02910934?term=NCT02910934&draw=2&rank=1

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Cost-effectiveness of endoscopic ultrasound-directed transgastric ERCP compared with device-assisted and laparoscopic-assisted ERCP in patients with Roux-en-Y anatomy

Endoscopy ◽

10.1055/a-0938-3918 ◽

2019 ◽

Vol 51 (11) ◽

pp. 1051-1058 ◽

Cited By ~ 7

Author(s):

Hailey J. James ◽

Theodore W. James ◽

Stephanie B. Wheeler ◽

Jennifer C. Spencer ◽

Todd H. Baron

Keyword(s):

Cost Effectiveness ◽

Endoscopic Ultrasound ◽

Cost Effective ◽

The United States ◽

Sensitivity Analyses ◽

Model Parameters ◽

Total Quality ◽

Life Years ◽

Laparoscopic Assisted ◽

The Cost

Abstract Background Roux-en-Y gastric bypass (RYGB) surgery is the second most common weight loss surgery in the United States. Treatment of pancreaticobiliary disease in this patient population is challenging due to the altered anatomy, which limits the use of standard instruments and techniques. Both nonoperative and operative modalities are available to overcome these limitations, including device-assisted (DAE) endoscopic retrograde cholangiopancreatography (ERCP), laparoscopic-assisted (LA) ERCP, and endoscopic ultrasound-directed transgastric ERCP (EDGE). The aim of this study was to compare the cost-effectiveness of ERCP-based modalities for treatment of pancreaticobiliary diseases in post-RYGB patients. Methods A decision tree model with a 1-year time horizon was used to analyze the cost-effectiveness of EDGE, DAE-ERCP, and LA-ERCP in post-RYGB patients. Monte Carlo simulation was used to assess a plausible range of incremental cost-effectiveness ratios, net monetary benefit calculations, and a cost-effectiveness acceptability curve. One-way sensitivity analyses and probabilistic sensitivity analyses were also performed to assess how changes in key parameters affected model conclusions. Results EDGE resulted in the lowest total costs and highest total quality-adjusted life-years (QALY) for a total of $5188/QALY, making it the dominant alternative compared with DAE-ERCP and LA-ERCP. In probabilistic analyses, EDGE was the most cost-effective modality compared with LA-ERCP and DAE-ERCP in 94.4 % and 97.1 % of simulations, respectively. Conclusion EDGE was the most cost-effective modality in post-RYGB anatomy for treatment of pancreaticobiliary diseases compared with DAE-ERCP and LA-ERCP. Sensitivity analysis demonstrated that this conclusion was robust to changes in important model parameters.

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The cost–effectiveness of oral semaglutide versus empagliflozin in Type 2 diabetes in Denmark

Journal of Comparative Effectiveness Research ◽

10.2217/cer-2021-0169 ◽

2021 ◽

Author(s):

Lars H Ehlers ◽

Mark Lamotte ◽

Mafalda C Ramos ◽

Susanne Sandgaard ◽

Pia Holmgaard ◽

...

Keyword(s):

Type 2 Diabetes ◽

Cost Effectiveness ◽

Cost Effective ◽

Sensitivity Analyses ◽

Duration Of Treatment ◽

Diabetes Model ◽

Life Years ◽

The Cost

Aim: To evaluate the cost–effectiveness of oral semaglutide+metformin versus empagliflozin+metformin in people with Type 2 diabetes uncontrolled on msetformin alone. Materials and methods: The IQVIA Core Diabetes Model was populated with efficacy data from a head-to-head study between oral semaglutide+metformin and empagliflozin+metformin. Danish costs and quality-of-life data were sourced from literature. Price per day was Danish Krone (DKK) 25.53 for oral semaglutide and DKK11.40 for empagliflozin. Discounting was fixed at 4%. Scenario and sensitivity analyses were performed. Results: Over a lifetime, Core Diabetes Model projected 8.78 and 8.75 quality-adjusted life-years and a total cost of DKK 447,633 and DKK 387,786; thereby, generating an incremental cost–effectiveness ratio of DKK 1,930,548 for oral semaglutide+metformin versus empagliflozin+metformin. Scenario and sensitivity analyses showed the robustness of the outcomes. Duration of treatment with oral semaglutide is the key driver of the analyses. Conclusion: Oral semaglutide+metformin seems not cost-effective versus empagliflozin+metformin in patients uncontrolled on metformin in Denmark.

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Do dietary and physical activity interventions in adolescents provide a cost-effective use of healthcare resources? Model development and illustration based on the Engaging Adolescents in Changing Behaviour (EACH-B) programme

10.1101/2021.05.05.21256672 ◽

2021 ◽

Author(s):

Neelam Kalita ◽

Keith Cooper ◽

Janis Baird ◽

Kathryn Woods-Townsend ◽

Keith M Godfrey ◽

...

Keyword(s):

Physical Activity ◽

Cost Effectiveness ◽

Behavioural Change ◽

Cost Effective ◽

Sensitivity Analyses ◽

Secondary Outcome ◽

Model Parameters ◽

Healthcare Resources ◽

Effective Use

Objective: To assess costs, health outcomes and cost-effectiveness of interventions that aim to improve quality of diet and level of physical activity in adolescents. Design: A Markov model was developed to assess four potential benefits of healthy behaviour for adolescents: better mental health, Type 2 diabetes, higher earnings and reduced incidences of adverse pregnancy outcomes. The model parameters were informed by published literature. The analysis took a societal perspective over a 20-year period. One-way and probabilistic sensitivity analyses were conducted. Setting: Secondary schools. Participants: A hypothetical cohort of adolescents aged 12-13 years. Interventions: An exemplar school-based, multi-component intervention that was developed by the Engaging Adolescents for Changing Behaviour programme, compared with usual schooling. Primary and secondary outcome measures: Incremental cost-effectiveness ratio as measured by cost per quality-adjusted life year (QALY) gained. Results The model suggested that an intervention for improving diet and physical activity has the potential to offer a cost-effective use of healthcare resources for adolescents in the UK at a willingness-to-pay threshold of GBP 20,000 per QALY. The key model drivers are the intervention effect on levels of physical activity, quality of life gain for high levels of physical activity, the duration of the intervention effects and the period over which effects wane. Conclusions: The model focused on short to medium-term benefits of healthy eating and physical activity exploiting the strong evidence base that exists for this age group. Other benefits in later life, such as reduced cardiovascular risk, are more sensitive to assumptions about the persistence of behavioural change and discounting.

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National and provincial impact and cost-effectiveness of Haemophilus influenzae type b conjugate vaccine in China: a modeling analysis

BMC Medicine ◽

10.1186/s12916-021-02049-7 ◽

2021 ◽

Vol 19 (1) ◽

Author(s):

Haijun Zhang ◽

Cristina Garcia ◽

Wenzhou Yu ◽

Maria Deloria Knoll ◽

Xiaozhen Lai ◽

...

Keyword(s):

Cost Effectiveness ◽

Haemophilus Influenzae ◽

Birth Cohort ◽

Disease Burden ◽

Cost Effective ◽

Sensitivity Analyses ◽

Model Parameters ◽

Type B ◽

Private Market ◽

The Cost

Abstract Background Globally, Haemophilus influenzae type b (Hib) vaccine has substantially reduced the burden of Hib invasive disease. However, China remains the only country not to include Hib vaccine into its national immunization program (NIP), although it accounts for 11% of global Hib deaths. We aimed to assess the cost-effectiveness of including Hib vaccine in China’s NIP at the national and provincial levels. Methods Using a decision-tree Markov state transition model, we estimated the cost-effectiveness of Hib vaccine in the NIP compared to the status quo of Hib vaccine in the private market for the 2017 birth cohort. Treatment costs and vaccine program costs were calculated from Chinese Center for Disease Control and Prevention (CDC) and national insurance databases. Epidemiological data and other model parameters were obtained from published literature. Cases and deaths averted, quality-adjusted life years (QALYs) gained, and incremental cost-effectiveness ratios (ICER) were predicted by province. Deterministic and probabilistic sensitivity analyses were performed to explore model uncertainty. Results Including Hib vaccine in the NIP was projected to prevent approximately 2700 deaths (93% reduction) and 235,700 cases of Hib disease (92% reduction) for the 2017 birth cohort at the national level. Hib vaccine was cost-effective nationally (US$ 8001 per QALY gained) compared to the GDP per capita and cost-effective in 15 of 31 provinces. One-way and scenario sensitivity analyses indicated results were robust when varying model parameters, and in probabilistic sensitivity analysis, Hib vaccine had a 64% probability of being cost-effective nationally. Conclusion Introducing Hib vaccine in China’s NIP is cost-effective nationally and in many provinces. Less socioeconomically developed provinces with high Hib disease burden and low access to Hib vaccine in the current private market, such as those in the west region, would benefit the most from adding Hib vaccine to the NIP. In the absence of a national policy decision on Hib vaccine, this analysis provides evidence for provincial governments to include Hib vaccine into local immunization programs to substantially reduce disease burden and treatment costs.

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Cost-effectiveness of TAS-102 plus bevacizumab versus TAS-102 monotherapy in patients with metastatic colorectal cancer

BMC Gastroenterology ◽

10.1186/s12876-021-01771-z ◽

2021 ◽

Vol 21 (1) ◽

Author(s):

Kiyoaki Sugiura ◽

Yuki Seo ◽

Takayuki Takahashi ◽

Hideyuki Tokura ◽

Yasuhiro Ito ◽

...

Keyword(s):

Colorectal Cancer ◽

Health Care ◽

Sensitivity Analysis ◽

Cost Effectiveness ◽

Combination Therapy ◽

Metastatic Colorectal Cancer ◽

Cost Effective ◽

Model Parameters ◽

Combination Regimen ◽

The Cost

Abstract Background TAS-102 plus bevacizumab is an anticipated combination regimen for patients who have metastatic colorectal cancer. However, evidence supporting its use for this indication is limited. We compared the cost-effectiveness of TAS-102 plus bevacizumab combination therapy with TAS-102 monotherapy for patients with chemorefractory metastatic colorectal cancer. Method Markov decision modeling using treatment costs, disease-free survival, and overall survival was performed to examine the cost-effectiveness of TAS-102 plus bevacizumab combination therapy and TAS-102 monotherapy. The Japanese health care payer’s perspective was adopted. The outcomes were modeled on the basis of published literature. The incremental cost-effectiveness ratio (ICER) between the two treatment regimens was the primary outcome. Sensitivity analysis was performed and the effect of uncertainty on the model parameters were investigated. Results TAS-102 plus bevacizumab had an ICER of $21,534 per quality-adjusted life-year (QALY) gained compared with TAS-102 monotherapy. Sensitivity analysis demonstrated that TAS-102 monotherapy was more cost-effective than TAS-102 and bevacizumab combination therapy at a willingness-to-pay of under $50,000 per QALY gained. Conclusions TAS-102 and bevacizumab combination therapy is a cost-effective option for patients who have metastatic colorectal cancer in the Japanese health care system.

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Cost-Effectiveness of Peer-Delivered HIV Self-Tests for MSM in Uganda

Frontiers in Public Health ◽

10.3389/fpubh.2021.651325 ◽

2021 ◽

Vol 9 ◽

Author(s):

Stephen Okoboi ◽

Barbara Castelnuovo ◽

Jean-Pierre Van Geertruyden ◽

Oucul Lazarus ◽

Lung Vu ◽

...

Keyword(s):

Cost Effectiveness ◽

Incremental Cost ◽

Hiv Testing ◽

Cost Effective ◽

Hiv Infections ◽

Standard Of Care ◽

Sub Saharan Africa ◽

High Risk Population ◽

Self Testing ◽

The Cost

Introduction: Distribution of HIV self-testing (HIVST) kits through MSM peer networks is a novel and effective strategy to increase HIV testing coverage in this high-risk population. No study has evaluated the cost or cost effectiveness of peer distribution of HIVST strategies among MSM in sub-Saharan Africa.Methods: From June to August 2018, we conducted a pilot study of secondary MSM peer HIVST kit distribution at The AIDS Support Organization at Entebbe and Masaka. We used an ingredients approach to estimate the cost of MSM peer HIVST kit distribution relative to standard-of-care (SOC) hotspot testing using programme expenditure data reported in US dollars. The provider perspective was used to estimate incremental cost-effective ratios per HIV infection averted using the difference in HIV annual transmission rates between MSM with HIV who knew their status and were not virologically suppressed and MSM with HIV who did not know their status.Results: We enrolled 297 participants of whom 150 received MSM peer HIVST kit distribution (intervention group) and 147 received TASO standard of care HIV testing (control group). Provider cost for the intervention was $2,276 compared with $1,827 for SOC during the 3-month study period. Overall, the intervention resulted in higher HIV positivity yield (4.9 vs. 1.4%) and averted more HIV infections per quarter (0.364 vs. 0.104) compared with SOC. The cost per person tested was higher for the intervention compared to SOC ($15.90 vs. $12.40). Importantly, the cost per new HIV diagnosis ($325 vs. $914) and cost per transmission averted ($6,253 vs. $ 17,567) were lower for the intervention approach relative to SOC. The incremental cost per HIV transmission averted by the self-testing program was $1,727. The incremental cost to providers per additional HIV-positive person identified by the intervention was $147.30.Conclusion: The intervention strategy was cost-effective, and identified more undiagnosed HIV infections than SOC hotspot testing at a cost-effectiveness threshold of US $2,129. Secondary distribution of HIVST kits through peers should further be evaluated with longer duration aimed at diagnosing 95% of all persons with HIV by 2030; the first UNAIDS 95-95-95 target.

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Cladribine tablets are a cost-effective strategy in high-disease activity relapsing multiple sclerosis patients in Iran

Current Journal of Neurology ◽

10.18502/cjn.v20i3.7690 ◽

2021 ◽

Author(s):

Nayyereh Ayati ◽

Lora Fleifel ◽

Mohammad Ali Sahraian ◽

Shekoufeh Nikfar

Keyword(s):

Multiple Sclerosis ◽

Cost Effectiveness ◽

Disease Activity ◽

Cost Effective ◽

High Disease Activity ◽

Sensitivity Analyses ◽

Life Years ◽

Multiple Sclerosis Patients ◽

The Cost ◽

Relapsing Multiple Sclerosis

Background: Cladribine tablets are the foremost oral immune-reconstitution therapy for high disease activity relapsing multiple sclerosis (HDA-RMS). We aimed to assess the cost-effectiveness of cladribine tablets compared to natalizumab in patients with HDA-RMS in Iran. Methods: A 5-year cohort-based Markov model was developed with 11 expanded disability status score (EDSS) health states, including patients with HDA-RMS as on and off-treatment. All costs were identified from the literature and expert opinion and were measured in Iranian Rial rates, changed to the 2020 USD rate and were discounted by 7.2%. Quality adjusted life years (QALY), discounted by 3.5%, and life years gained (LYG) were adopted to measure efficacy. The final results were presented as incremental cost-effectiveness ratio that was compared to a national willingness to pay (WTP) threshold of 1 to 3 gross domestic product (GDP) per capita. Deterministic and probabilistic sensitivity analyses (D/PSA) were employed to evaluate uncertainty. Results: Cladribine tablets dominated natalizumab and yielded 6,607 USD cost-saving and 0.003 additional QALYs per patient. LYG was comparable. The main cost component was drug acquisition cost in both arms. DSA indicated the sensitivity of the results to the cost discount rates and also the patients’ body weight; while they were less sensitive to the main clinical variables. PSA indicated that cladribine tablets were cost-effective in Iran, with a probability of 57.5% and 58.6% at lower and higher limits of threshold, respectively. Conclusion: Cladribine tablets yielded higher QALYs and lower costs compared to natalizumab, in patients with HDA-RMS in Iran.

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First-Line Pembrolizumab Plus Chemotherapy for Extensive-Stage Small-Cell Lung Cancer: A Cost-Effectiveness Analysis

10.21203/rs.3.rs-725799/v1 ◽

2021 ◽

Author(s):

Youwen Zhu ◽

Huabin Hu ◽

Dong Ding ◽

Shuosha Li ◽

Mengting Liao ◽

...

Keyword(s):

Cost Effectiveness ◽

Cost Effective ◽

Small Cell ◽

Sensitivity Analyses ◽

Small Cell Lung ◽

First Line ◽

The Us ◽

Extensive Stage ◽

The Cost ◽

First Line Treatment

Abstract Background：The phase III clinical trial Keynote-604 indicated that pembrolizumab plus chemotherapy could generate clinical benefits in Extensive-Stage Small-Cell Lung Cancer (ES-SCLC). We aim to evaluate the cost-effectiveness of pembrolizumab plus chemotherapy as the first-line treatment of ES-SCLC from the United States (US) payers’ perspective.Methods: A synthetical Markov model was used to evaluate cost and effectiveness of pembrolizumab plus platinum-etoposide (EP) versus EP in first-line therapy for ES-SCLC from the data of Keynote-604. Lifetime costs life-years (LYs), quality adjusted LYs (QALYs), and incremental cost-effectiveness ratios (ICERs) were estimated. One-way and probabilistic sensitivity analyses were performed. In addition, We also considered subgroup cost-effectiveness.Results: Pembrolizumab plus EP resulted in additional 0.18 QALYs (0.32 LYs) and corresponding incremental costs $113,625, resulting an ICER of $647,509 per QALY versus EP. The most influential factor in this model was the cost of pembrolizumab. Probabilistic sensitivity analysis showed there was 0% probability that pembrolizumab combination chemotherapy was cost-effective at willingness-to-pay (WTP) values of $150,000 per QALY in the US. The results of subgroup probabilistic sensitivity analyses suggested that all subgroups were not cost-effective.Conclusion: From the perspective of the US payer, pembrolizumab plus EP is not a cost-effective option as first-line treatment for patients with ES-SCLC at a WTP threshold of $150,000 per QALY.

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P14.41 Cost-effectiveness of FET PET for early treatment response assessment in glioma patients following adjuvant temozolomide chemotherapy

Neuro-Oncology ◽

10.1093/neuonc/noab180.158 ◽

2021 ◽

Vol 23 (Supplement_2) ◽

pp. ii46-ii46

Author(s):

J Rosen ◽

G Ceccon ◽

E K Bauer ◽

J M Werner ◽

C Kabbasch ◽

...

Keyword(s):

Cost Effectiveness ◽

Cost Effective ◽

Response Assessment ◽

Sensitivity Analyses ◽

Tree Model ◽

Fet Pet ◽

Conventional Mri ◽

Adjuvant Temozolomide ◽

The Cost ◽

Temozolomide Chemotherapy

Abstract BACKGROUND In light of increasing healthcare costs, higher medical expenses should be justified socio-economically. Therefore, we calculated the effectiveness and cost-effectiveness of PET using the radiolabeled amino acid O-(2-[18F]-fluoroethyl)-L-tyrosine (FET) compared to conventional MRI for early identification of responders to adjuvant temozolomide chemotherapy. A recent study in IDH-wildtype glioma patients suggested that after two cycles, FET-PET parameter changes predicted a significantly longer survival while MRI changes were not significant. MATERIALS AND METHODS To determine the effectiveness and cost-effectiveness of serial FET-PET imaging, we analyzed published clinical data and calculated the associated costs in the context of the German healthcare system.Based on a decision-tree model, FET-PET and MRI’s effectiveness was calculated, i.e., the probability to correctly identify a responder as defined by an overall survival ≥15 months. To determine the cost-effectiveness, the incremental cost-effectiveness ratio (ICER) was calculated, i.e., the cost for each additionally identified responder by FET-PET who would have remained undetected by MRI. The robustness of the results was tested by deterministic and probabilistic (Monte Carlo simulation) sensitivity analyses. RESULTS Compared to MRI, FET-PET increases the rate of correctly identified responders to chemotherapy by 26%; thus, four patients need to be examined by FET-PET to identify one additional responder. Considering the respective cost for serial FET-PET and MRI, the ICER resulted in €4,396.83 for each additional correctly identified responder by FET-PET. The sensitivity analyses confirmed the robustness of the results. CONCLUSION In contrast to conventional MRI, the model suggests that FET PET is cost-effective in terms of ICER values. Concerning the high cost of temozolomide, the integration of FET-PET has the potential to avoid premature chemotherapy discontinuation at a reasonable cost.

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