Liothyronine for hypothyroidism: a candidate for disinvestment or in need of further research? A value of information analysis

ObjectiveMedicines with limited evidence of effectiveness are prime candidates for disinvestment. However, investment in further research may be preferable to deimplementation, given that the absence of evidence is not evidence of absence, and research can inform formulary decisions. A case in point is liothyronine, which is sometimes prescribed to levothyroxine-treated patients who continue to experience hypothyroid symptoms. It is a putative low value medicine, associated with uncertainties in both clinical and cost-effectiveness. The aim was to assess the cost-effectiveness of liothyronine in this context, and estimate the value of conducting further research.DesignCost utility and value of information analyses.SettingPrimary care within the National Health Service in the UK.ParticipantsFifty-four levothyroxine-treated patients with persistent symptoms of hypothyroidism.InterventionsLiothyronine plus levothyroxine versus levothyroxine alone.Primary and secondary outcome measuresIncremental cost per quality-adjusted life year (QALY) gained, and the expected monetary value of sample information.Results20/54 (37%) of patients who responded to the survey reported severe problems in carrying out usual activities of everyday living and 12/54 (22%) reported severe anxiety or depression symptoms. Mean (SD) utility was 0.53 (0.23). The differences in expected total, 10-year costs and QALYs between a treatment strategy of liothyronine/levothyroxine combination therapy, and levothyroxine alone, was £12 053 and 1.014, respectively. The incremental cost-effectiveness ratio of £11 881 per QALY gained was sensitive to the price of liothyronine. The probability of liothyronine/levothyroxine combination therapy being cost effective at a threshold of £20 000 per QALY was 0.56. The value of reducing uncertainty in the efficacy of treatment was £3.64 m per year in the UK.ConclusionsA definitive clinical trial to confirm clinical effectiveness may be preferable to immediate disinvestment, and would be justified given the value of the information gained far exceeds the cost.

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Cost-effectiveness analysis of different methods of treatment of tubal ectopic pregnancy in the south of Iran

10.21203/rs.3.rs-25488/v2 ◽

2020 ◽

Author(s):

Bahia Namavar Jahromi ◽

Elahe esmaili ◽

Mozhgan Fardid ◽

Jafari Abdosaleh ◽

Zahra Kavosi ◽

...

Keyword(s):

Single Dose ◽

Cost Effectiveness ◽

Incremental Cost ◽

Ectopic Pregnancy ◽

Cost Effective ◽

Cost Utility ◽

Double Dose ◽

Tubal Ectopic Pregnancy ◽

Dose Methotrexate ◽

The Cost

Abstract Background: Ectopic pregnancy is one of the most important causes of maternal mortality and infertility that may impose many costs on patients. Today, Surgery and pharmaceutical treatments are the common methods of treating the disease. The aim of this study was to evaluate the cost-effectiveness of different methods of treating tubal ectopic pregnancy in the south of Iran.Methods: This study was an economic evaluation which analysed and compared the cost-effectiveness and cost-utility of three treatment methods, including single-dose methotrexate, double-dose methotrexate, and surgery in patients with tubal ectopic pregnancy. In this study, a decision tree model was used. The outcomes included in the model were the percentage of successful treatment and the average utility score of each treatment method. The study was conducted from the social perspective and a one-way and probabilistic sensitivity analysis was performed to measure the effects of uncertainty. The analysis of the collected data was performed using Excel and TreeAge software.Results: The incremental cost-effectiveness ratio of the surgery versus single-dose methotrexate was positive and equal to $5812 PPP; since it was less than the threshold, surgery was considered as a cost-effective method. The incremental cost-utility ratio also identified surgery as the best option. Moreover, the results of one-way showed the highest sensitivity to the effectiveness of single-dose methotrexate. Scatter plots also revealed that surgery in 82% and 96% of simulations was at the acceptable region compared with a single dose and double-dose methotrexate, respectively and below the threshold. It was identified as a more cost-effective strategy. Furthermore, the acceptability curves showed that in 81.4% of simulations, surgery was the most cost-effective treatment for thresholds less than 21011 PPP dollars.Conclusions: Based on the results of the present study, it is recommended that surgery can be used as the first line of treatment for ectopic. Also, the best drug strategy was single-dose methotrexate. Since these strategies reduce costs and increase treatment success and QALYs compared to double-dose methotrexate.

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Cost-effectiveness of exercise therapy in patients with coronary heart disease, chronic heart failure and associated risk factors: A systematic review of economic evaluations of randomized clinical trials

European Journal of Preventive Cardiology ◽

10.1177/2047487319881839 ◽

2019 ◽

Vol 27 (10) ◽

pp. 1045-1055 ◽

Cited By ~ 3

Author(s):

Neil Oldridge ◽

Rod S Taylor

Keyword(s):

Heart Failure ◽

Cost Effectiveness ◽

Incremental Cost ◽

Intermittent Claudication ◽

Exercise Therapy ◽

Cost Effective ◽

Cost Utility ◽

Economic Evaluations ◽

Value For Money ◽

The Cost

Aims Prescribed exercise is effective in adults with coronary heart disease (CHD), chronic heart failure (CHF), intermittent claudication, body mass index (BMI) ≥25 kg/m2, hypertension or type 2 diabetes mellitus (T2DM), but the evidence for its cost-effectiveness is limited, shows large variations and is partly contradictory. Using World Health Organization and American Heart Association/American College of Cardiology value for money thresholds, we report the cost-effectiveness of exercise therapy, exercise training and exercise-based cardiac rehabilitation. Methods Electronic databases were searched for incremental cost-effectiveness and incremental cost–utility ratios and/or the probability of cost-effectiveness of exercise prescribed as therapy in economic evaluations conducted alongside randomized controlled trials (RCTs) published between 1 July 2008 and 28 October 2018. Results Of 19 incremental cost–utility ratios reported in 15 RCTs in patients with CHD, CHF, intermittent claudication or BMI ≥25 kg/m2, 63% met both value for money thresholds as ‘highly cost-effective’ or ‘high value’, with 26% ‘not cost-effective’ or of ‘low value’. The probability of intervention cost-effectiveness ranged from 23 to 100%, probably due to the different populations, interventions and comparators reported in the individual RCTs. Confirmation with the Consolidated Health Economic Evaluation Reporting checklist varied widely across the included studies. Conclusions The findings of this review support the cost-effectiveness of exercise therapy in patients with CHD, CHF, BMI ≥25 kg/m2 or intermittent claudication, but, with concerns about reporting standards, need further confirmation. No eligible economic evaluation based on RCTs was identified in patients with hypertension or T2DM.

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To determine the cost-effectiveness of pemetrexed (PEM) compared to current standards of care in 2nd-line advanced non-small cell lung cancer (NSCLC) from the UK National Health Service (NHS) perspective

Journal of Clinical Oncology ◽

10.1200/jco.2007.25.18_suppl.6540 ◽

2007 ◽

Vol 25 (18_suppl) ◽

pp. 6540-6540 ◽

Cited By ~ 1

Author(s):

S. Bhalla ◽

C. Hibbert ◽

J. Watkins ◽

S. Beard ◽

M. Cetty ◽

...

Keyword(s):

Cost Effectiveness ◽

Incremental Cost ◽

Clinical Trial Data ◽

Clinical Excellence ◽

Cost Utility ◽

Phase Iii ◽

Standards Of Care ◽

Life Years ◽

The Uk ◽

Current Standards

6540 Objective: To assess the clinical and cost-effectiveness of pemetrexed (PEM) compared with current standards of care (SOC) in 2nd-line advanced NSCLC from a UK perspective. The SOC selected for the evaluation were: (i) docetaxel (DOC) as it is the standard active therapy in the UK and is recommended by the National Institute for Health and Clinical Excellence (NICE) and (ii) best supportive care (BSC) as the majority patients in the UK who fail 1st-line therapy do not receive further chemotherapy. Methods: The analytic technique used was a cost-utility analysis (CUA) in the form of a Markov model. Utilities were generated from 100 members of the general public, considering tumor response status and toxicity, in accordance with the standard NICE appraisal methodology. Clinical inputs were derived from a pooled analysis phase III clinical trial data. Costs were taken from the British National Formulary and UK national databases. The incremental cost-effectiveness ratios (ICERs) are presented for both life-years gained (LYG) and quality-adjusted life- years (QALY) gained. Conclusions: The incremental cost per LY and cost per QALY for pemetrexed in 2nd-line NSCLC are below £20,000, compared to docetaxel and BSC. Based on its survival and toxicity benefits PEM is a cost-effective option in within the UK. No significant financial relationships to disclose. [Table: see text]

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Cost-effectiveness of immune checkpoint inhibition in metastatic gastric and esophageal tumors.

Journal of Clinical Oncology ◽

10.1200/jco.2018.36.4_suppl.56 ◽

2018 ◽

Vol 36 (4_suppl) ◽

pp. 56-56 ◽

Cited By ~ 1

Author(s):

Sassan Ostvar ◽

Jin G. Choi ◽

Jacqueline N. Chu ◽

Michael Lawrence Dougan ◽

Justin F. Gainor ◽

...

Keyword(s):

Cost Effectiveness ◽

Combination Therapy ◽

Adverse Events ◽

Incremental Cost ◽

Immune Checkpoint ◽

Base Case ◽

Checkpoint Inhibition ◽

Immune Checkpoint Inhibition ◽

Life Years ◽

The Cost

56 Background: Immune checkpoint inhibition has shown early promising results in patients with chemotherapy-refractory metastatic or advanced tumors of the esophagus, gastroesophageal junction, and stomach. We explore the cost-effectiveness of checkpoint inhibitors as second-line treatment agents for this group of patients using a decision analytic approach. Methods: A Markov model was developed to simulate the course of a virtual cohort of patients treated by (i) nivolumab 3 mg/kg, (ii) combination of ipilimumab 3 mg/kg and nivolumab 1 mg/kg, and (iii) best supportive care (BSC). Patients in the hypothetical cohort were 55-year-olds in an advanced/metastatic stage who had received at least one prior line of chemotherapy. Patients who remained stable in treatment were monitored for adverse events until death. Rates of cancer-specific mortality, disease progression, and drug-related adverse events were estimated using results from the CheckMate 032 clinical trial. The primary endpoints were survival, measured in life-years (LY), quality adjusted life years (QALY), and incremental cost-effectiveness ratios (ICER). Cost-effectiveness of each strategy was evaluated from a US-payer perspective considering costs of drugs, treatment, and management of immune-related adverse events. Cost-effectiveness was defined with a willingness to pay threshold of $100,000/QALY. Results: Combination therapy with nivolumab and ipilimumab yielded the highest effectiveness (QALYs = 0.47, LYs = 1.09) in our base case modeling results, compared with nivolumab (QALYs = 0.43, LYs = 1.03), and BSC (QALYs = 0.19, LYs = 0.42). Nivolumab had an incremental cost of $84,555/QALY compared with BSC, while nivolumab with ipilimumab resulted in an incremental cost of $1.1M/QALY compared with nivolumab alone. The cost gap between the two was associated with the higher price of ipilimumab, and costs of managing increased toxicity. Conclusions: Our modeling analysis finds that combination therapy of ipilimumab and nivolumab is the most effective, but from a cost-effectiveness perspective, it is expensive, making nivolumab monotherapy the cost-effective option. Additional clinical data are needed to confirm our modeling results.

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Mechanical thrombectomy in patients with acute ischemic stroke: A cost-effectiveness and value of implementation analysis

International Journal of Stroke ◽

10.1177/1747493019879656 ◽

2019 ◽

Vol 15 (8) ◽

pp. 881-898 ◽

Cited By ~ 1

Author(s):

Robert Heggie ◽

Olivia Wu ◽

Phil White ◽

Gary A Ford ◽

Joanna Wardlaw ◽

...

Keyword(s):

Clinical Trials ◽

Ischemic Stroke ◽

Cost Effectiveness ◽

Medical Care ◽

Incremental Cost ◽

Acute Ischemic Stroke ◽

Mechanical Thrombectomy ◽

Cost Effective ◽

The Uk ◽

The Cost

Background Recent clinical trials have demonstrated the efficacy of mechanical thrombectomy in acute ischemic stroke. Aims To determine the cost-effectiveness, value of future research, and value of implementation of mechanical thrombectomy. Methods Using UK clinical and cost data from the Pragmatic Ischemic Stroke Thrombectomy Evaluation (PISTE) trial, we estimated the cost-effectiveness of mechanical thrombectomy over time horizons of 90-days and lifetime, based on a decision-analytic model, using all existing evidence. We performed a meta-analysis of seven clinical trials to estimate treatment effects. We used sensitivity analysis to address uncertainty. Value of implementation analysis was used to estimate the potential value of additional implementation activities to support routine delivery of mechanical thrombectomy. Results Over the trial period (90 days), compared with best medical care alone, mechanical thrombectomy incurred an incremental cost of £5207 and 0.025 gain in QALY (incremental cost-effectiveness ratio (ICER) £205,279), which would not be considered cost-effective. However, mechanical thrombectomy was shown to be cost-effective over a lifetime horizon, with an ICER of £3466 per QALY gained. The expected value of perfect information per patient eligible for mechanical thrombectomy in the UK is estimated at £3178. The expected value of full implementation of mechanical thrombectomy is estimated at £1.3 billion over five years. Conclusion Mechanical thrombectomy was cost-effective compared with best medical care alone over a patient’s lifetime. On the assumption of 30% implementation being achieved throughout the UK healthcare system, we estimate that the population health benefits obtained from this treatment are greater than the cost of implementation. Trial registration NCT01745692.

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PRS36 The Cost-Effectiveness of Step Down from High Dose ICS/Laba Combination Therapy in Asthma in the UK Setting

Value in Health ◽

10.1016/j.jval.2011.08.1423 ◽

2011 ◽

Vol 14 (7) ◽

pp. A493-A494 ◽

Cited By ~ 1

Author(s):

P. Paggiaro ◽

G. Buseghin ◽

G. Nicolini ◽

S. Patel ◽

S. Iannazzo ◽

...

Keyword(s):

Cost Effectiveness ◽

Combination Therapy ◽

High Dose ◽

Step Down ◽

The Uk ◽

The Cost

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Economic evaluation of drug-eluting stents: A systematic literature review and model-based cost–utility analysis

International Journal of Technology Assessment in Health Care ◽

10.1017/s0266462307070560 ◽

2007 ◽

Vol 23 (4) ◽

pp. 473-479 ◽

Cited By ~ 13

Author(s):

Pekka Kuukasjärvi ◽

Pirjo Räsänen ◽

Antti Malmivaara ◽

Pasi Aronen ◽

Harri Sintonen

Keyword(s):

Cost Effectiveness ◽

Incremental Cost ◽

Cost Effective ◽

Cost Utility ◽

Drug Eluting Stents ◽

Economic Evaluations ◽

Model Based ◽

Drug Eluting ◽

The Cost

Objectives:The aim of this study was to systematically review economic analyses comparing drug-eluting stents (DES) to bare metal stents (BMS) in patients who undergo percutaneous coronary intervention to form an overall view about cost-effectiveness of DES and to construct a simple decision analysis model to evaluate the cost–utility of DES.Methods:Electronic databases searched from January 2004 to January 2006 were Cochrane Database of Systematic Reviews; DARE, HTA, EED (NHS CRD); MEDLINE(R) In-Process, Other Non-Indexed Citations, MEDLINE(R). References of the papers identified were checked. We included randomized controlled trials (RCT) or model-based cost-effectiveness analyses comparing DES to BMS in patients with coronary artery disease. The methodological quality of the papers was assessed by Drummond's criteria. Baseline characteristics and results of the studies were extracted and data synthesized descriptively. A decision tree model was constructed to evaluate the cost–utility of DES in comparison to BMS, where health-related quality of life was measured by the 15D.Results:We identified thirteen good-quality economic evaluations. In two of these based on RCTs, DES was found cost-effective. In six studies, it was concluded that DES might probably be a cost-effective strategy in some circumstances, but not as a single strategy, and four studies concluded that DES is not cost-effective. One study did not draw a clear conclusion. In our analysis, the overall incremental cost-effectiveness ratio was €98,827 per quality-adjusted life-years gained. Avoiding one revascularization with DES would cost €4,794, when revascularization with BMS costs €3,260.Conclusions:The evidence is inconsistent of whether DES would be a cost-effective treatment compared with BMS in any healthcare system where evaluated. A marked restenosis risk reduction should be achieved before use of DES is justifiable at present prices. When considering adoption of a new health technology with a high incremental cost within a fixed budget, opportunity cost in terms of untreated patients should be seriously considered as a question of collective ethics.

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Cost-effectiveness analysis of different methods of treatment of tubal ectopic pregnancy in the south of Iran

10.21203/rs.3.rs-25488/v1 ◽

2020 ◽

Author(s):

Bahia Namavar Jahromi ◽

Elahe esmaili ◽

Mozhgan Fardid ◽

Jafari Abdosaleh ◽

Zahra Kavosi ◽

...

Keyword(s):

Single Dose ◽

Cost Effectiveness ◽

Incremental Cost ◽

Ectopic Pregnancy ◽

Cost Effective ◽

Cost Utility ◽

Double Dose ◽

Tubal Ectopic Pregnancy ◽

Dose Methotrexate ◽

The Cost

Abstract Background: Ectopic pregnancy is one of the most important causes of maternal mortality and infertility that may impose many costs on patients. Today, Surgery and pharmaceutical treatments are the common methods of treating the disease. The aim of this study was to evaluate the cost-effectiveness of different methods of treating tubal ectopic pregnancy in the south of Iran.Methods: This study was an economic evaluation which analysed and compared the cost-effectiveness and cost-utility of three treatment methods, including single-dose methotrexate, double-dose methotrexate, and surgery in patients with tubal ectopic pregnancy. In this study, a decision tree model was used. The outcomes included in the model were the percentage of successful treatment and the average utility score of each treatment method. The study was conducted from the social perspective and a one-way and probabilistic sensitivity analysis was performed to measure the effects of uncertainty. The analysis of the collected data was performed using Excel and TreeAge software.Results: The incremental cost-effectiveness ratio of the surgery versus single-dose methotrexate was positive and equal to $5812 PPP; since it was less than threshold, surgery was considered as a cost-effective method. The incremental cost-utility ratio also identified surgery as the best option. Moreover, the results of one-way showed the highest sensitivity to the effectiveness of single-dose methotrexate. Scatter plots also revealed that surgery in 82% and 96% of simulations was at the acceptable region compared with single dose and double-dose methotrexate, respectively and below the threshold. It was identified as the more cost effective strategy. Furthermore, the acceptability curves showed that in 81.4% of simulations, surgery was the most cost effective treatment for thresholds less than 21011 PPP dollars.Conclusions: Based on the results of the present study, it is recommended that surgery can be used as the first line of treatment for ectopic. Also, the best drug strategy was single dose methotrexate. Since these strategies reduce costs and increase treatment success and QALYs compared to double-dose methotrexate.

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Cost–utility analysis of antimicrobial stewardship programme at a tertiary teaching hospital in Ethiopia

BMJ Open ◽

10.1136/bmjopen-2020-047515 ◽

2021 ◽

Vol 11 (12) ◽

pp. e047515

Author(s):

Gebremedhin Beedemariam Gebretekle ◽

Damen Haile Mariam ◽

Stephen Mac ◽

Workeabeba Abebe ◽

Tinsae Alemayehu ◽

...

Keyword(s):

Cost Effectiveness ◽

Health Outcomes ◽

Incremental Cost ◽

Usual Care ◽

Tertiary Care Hospital ◽

Tertiary Care ◽

Cost Utility ◽

Care Hospital ◽

Life Years ◽

The Cost

ObjectiveAntimicrobial stewardship (AMS) significantly reduces inappropriate antibiotic use and improves patient outcomes. In low-resource settings, AMS implementation may require concurrent strengthening of clinical microbiology capacity therefore additional investments. We assessed the cost-effectiveness of implementing AMS at Tikur Anbessa Specialised Hospital (TASH), a tertiary care hospital in Ethiopia.DesignWe developed a Markov cohort model to assess the cost–utility of pharmacist-led AMS with concurrent strengthening of laboratory capacity compared with usual care from a ‘restricted societal’ perspective. We used a lifetime time horizon and discounted health outcomes and cost at 3% annually. Data were extracted from a prospective study of bloodstream infections among patients hospitalised at TASH, supplemented by published literature. We assessed parameter uncertainty using deterministic and probabilistic sensitivity analyses.SettingTertiary care hospital in Ethiopia, with 800 beds and serves over half a million patients per year.PopulationCohort of adults and children inpatient population aged 19.8 years at baseline.InterventionLaboratory-supported pharmacist-led AMS compared with usual care. Usual care is defined as empirical initiation of antibiotic therapy in the absence of strong laboratory and AMS.Outcome measuresExpected life-years, quality-adjusted life-years (QALYs), costs (US$2018) and incremental cost-effectiveness ratio.ResultsLaboratory-supported AMS strategy dominated usual care, that is, AMS was associated with an expected incremental gain of 38.8 QALYs at lower expected cost (incremental cost savings:US$82 370) per 1000 patients compared with usual care. Findings were sensitive to medication cost, infection-associated mortality and AMS-associated mortality reduction. Probabilistic sensitivity analysis demonstrated that AMS programme was likely to be cost-effective at 100% of the simulation compared with usual care at 1%–51% of gross domestic product/capita.ConclusionOur study indicates that laboratory-supported pharmacist-led AMS can result in improved health outcomes and substantial healthcare cost savings, demonstrating its economic advantage in a tertiary care hospital despite greater upfront investments in a low-resource setting.

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Cost-Effectiveness of Maintenance Olaparib for Germline BRCA-Mutated Metastatic Pancreatic Cancer

Journal of the National Comprehensive Cancer Network ◽

10.6004/jnccn.2020.7587 ◽

2020 ◽

Vol 18 (11) ◽

pp. 1528-1536 ◽

Cited By ~ 1

Author(s):

Bin Wu ◽

Lizheng Shi

Keyword(s):

Pancreatic Cancer ◽

Cost Effectiveness ◽

Incremental Cost ◽

Subgroup Analysis ◽

Transition Probabilities ◽

Health Benefit ◽

Cost Utility ◽

Sensitivity Analyses ◽

Metastatic Pancreatic Cancer ◽

The Cost

Background: Maintenance therapy with the PARP inhibitor olaparib for metastatic pancreatic cancer (MPC) with a germline BRCA1 or BRCA2 mutation has been shown to be effective. We aimed to evaluate the cost-effectiveness of maintenance olaparib for MPC from the US payer perspective. Materials and Methods: A partitioned survival model was adopted to project the disease course of MPC. Efficacy and toxicity data were gathered from the Pancreas Cancer Olaparib Ongoing (POLO) trial. Transition probabilities were estimated from the reported survival probabilities in each POLO group. Cost and health preference data were derived from the literature. The incremental cost-utility ratio, incremental net-health benefit, and incremental monetary benefit were measured. Subgroup analysis, one-way analysis, and probabilistic sensitivity analysis were performed to explore the model uncertainties. Results: Maintenance olaparib had an incremental cost-utility ratio of $191,596 per additional progression-free survival (PFS) quality-adjusted life-year (QALY) gained, with a high cost of $132,287 and 0.691 PFS QALY gained, compared with results for a placebo. Subgroup analysis indicated that maintenance olaparib achieved at least a 16.8% probability of cost-effectiveness at the threshold of $200,000/QALY. One-way sensitivity analyses revealed that the results were sensitive to the hazard ratio of PFS and the cost of olaparib. When overall survival was considered, maintenance olaparib had an incremental cost-utility ratio of $265,290 per additional QALY gained, with a high cost of $128,266 and 0.483 QALY gained, compared with results for a placebo. Conclusions: Maintenance olaparib is potentially cost-effective compared with placebo for patients with a germline BRCA mutation and MPC. Economic outcomes could be improved by tailoring treatment based on individual patient factors.

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