scholarly journals COST-EFFECTIVENESS FOR RETURN-TO-PLAY (RTP) PROGRAMS AFTER ANTERIOR CRUCIATE LIGAMENT RECONSTRUCTION

2020 ◽  
Vol 8 (4_suppl3) ◽  
pp. 2325967120S0019
Author(s):  
Christopher DeFrancesco ◽  
Drake Lebrun ◽  
Joseph Molony ◽  
Peter D. Fabricant
Keyword(s):  
Cost Effectiveness ◽  
Cruciate Ligament ◽  
Cost Effective ◽  
Return To Play ◽  
Base Case ◽  
Rehabilitation Protocol ◽  
Graft Rupture ◽  
Anterior Cruciate ◽  
The Cost

Background: Rupture of the anterior cruciate ligament (ACL) is a common injury in young athletes. Safe return-to-play (RTP, i.e. sports competition) is important to patient satisfaction, and appropriate criteria for RTP may reduce the risk of graft injury. Purpose: The purpose of this study is to assess the cost-effectiveness of a comprehensive RTP rehabilitation protocol relative to standard post-ACL reconstruction rehabilitation. Methods: A decision-analysis model was utilized to compare standard rehabilitation with an RTP program which included supplemental neuromuscular retraining, functional testing, and clinical follow-up. Cost-effectiveness was evaluated from a payer perspective. Costs of surgical procedures and rehabilitation protocols, risks of ipsilateral graft rupture and contralateral ACL injury, risk reductions due to the RTP program, and relevant utilities based on International Knee Documentation Committee (IKDC) outcomes were derived from the available literature. An incremental cost-effectiveness ratio (ICER) of <$100,000/QALY was used to determine cost-effectiveness. Sensitivity analyses were performed on pertinent model parameters to measure their effect on base-case conclusions. In the base-case analysis, the cost of an RTP program was conservatively assumed to be $1,721 more than the standard rehabilitation protocol. The relative risk of ACL graft rupture following completion of the RTP program was assumed to be 0.75 (25% reduction). Results: In the base-case analysis, the RTP program was cost-effective compared with the standard rehabilitation protocol (ICER $54,939/QALY). Based on one-way threshold analyses, the RTP program was cost-effective as long as the additional cost was <$2,092 or the RTP program decreased the incidence of graft rupture by >7.7%. Conclusion: Our data suggests that, assuming modest associated decreases in graft failure, the addition of neuromuscular retraining, functional testing, and clinical follow-up to a formal rehabilitation program is cost-effective. The cost-effectiveness of such additions is related to the costs as well as any associated decreases in subsequent event risk, as shown in Figure 1. Figures: [Figure: see text]

Safer and Cheaper: An Enhanced Milestone-Based Return to Play Program After Anterior Cruciate Ligament Reconstruction in Young Athletes Is Cost-Effective Compared With Standard Time-Based Return to Play Criteria

2020 ◽  
Vol 48 (5) ◽  
pp. 1100-1107 ◽  
Author(s):  
Christopher J. DeFrancesco ◽  
Drake G. Lebrun ◽  
Joseph T. Molony ◽  
Madison R. Heath ◽  
Peter D. Fabricant
Keyword(s):  
Cost Effectiveness ◽  
Acl Reconstruction ◽  
Cruciate Ligament ◽  
Cost Effective ◽  
Return To Play ◽  
Sensitivity Analyses ◽  
Base Case ◽  
Graft Rupture ◽  
Anterior Cruciate ◽  
The Cost

Background: Safe return to play (RTP) after anterior cruciate ligament (ACL) reconstruction is critical to patient satisfaction. Enhanced rehabilitation after ACL reconstruction with appropriate objective criteria for RTP may reduce the risk of subsequent injury. The cost-effectiveness of an enhanced RTP (eRTP) strategy relative to standard post-ACL reconstruction rehabilitation has not been investigated. Purpose: To determine if an eRTP strategy after ACL reconstruction is cost-effective compared with standard rehabilitation. Study Design: Economic and decision analysis. Methods: A decision-analysis model was utilized to compare standard rehabilitation with an eRTP strategy, which includes additional neuromuscular retraining, advanced testing, and follow-up physician visits. Cost-effectiveness was evaluated from a payer perspective. Costs of surgical procedures and rehabilitation protocols, risks of graft rupture and contralateral ACL injury, risk reductions as a result of the eRTP strategy, and relevant health utilities were derived from the literature. An incremental cost-effectiveness ratio of <$100,000/quality-adjusted life-year was used to determine cost-effectiveness. Sensitivity analyses were performed on pertinent model parameters to assess their effect on base case conclusions. In the base case analysis, the eRTP strategy cost was conservatively estimated to be $969 more than the standard rehabilitation protocol. Completion of the eRTP strategy was considered to confer a 25% risk reduction for graft rupture in comparison with standard rehabilitation. Results: The eRTP strategy was more cost-effective than standard rehabilitation alone. Based on 1-way threshold analyses, the eRTP strategy was cost-effective as long as its additional cost over standard rehabilitation was <$2092 or the eRTP strategy decreased the incidence of contralateral ACL rupture by >13.8%. Conclusion: The eRTP strategy in this study adds additional neuromuscular retraining and additional physician follow-up—as well as advanced testing goals upon which RTP is contingent—to traditional physical therapy. Our data suggest that these additions are cost-effective, even assuming only modest associated decreases in ACL graft failure. This study also determined that the only variable that had the potential to change the cost-effectiveness conclusion based on predetermined ranges was the additional cost of rehabilitation based on 1-way sensitivity analysis. Clinical Relevance: This study provides evidence of cost-effectiveness for payers, supporting the use of enhanced RTP programs. The sensitivity analyses herein may be used to determine if any given RTP program going forward is cost-effective, regardless of the exact components of the program.

scholarly journals Cost-effectiveness of Memory Assessment Services for the diagnosis and early support of patients with dementia in England

2017 ◽  
Vol 22 (4) ◽  
pp. 226-235 ◽  
Author(s):  
Manuel Gomes ◽  
Mark Pennington ◽  
Raphael Wittenberg ◽  
Martin Knapp ◽  
Nick Black ◽  
...  
Keyword(s):  
Cost Effectiveness ◽  
Cost Effective ◽  
Base Case ◽  
Memory Assessment ◽  
Life Years ◽  
Follow Up Care ◽  
Related Quality ◽  
Mean Differences ◽  
The Cost

Background Policy makers in England advocate referral of patients with suspected dementia to Memory Assessment Services (MAS), but it is unclear how any improvement in patients’ health-related quality of life (HRQL) compares with the associated costs. Aims To evaluate the cost-effectiveness of MAS for the diagnosis and follow-up care of patients with suspected dementia. Method We analysed observational data from 1318 patients referred to 69 MAS, and their lay carers (n = 944), who completed resource use and HRQL questionnaires at baseline, three and six months. We reported mean differences in HRQL (disease-specific DEMQOL and generic EQ-5D-3L), quality-adjusted life years (QALYs) and costs between baseline and six months after referral to MAS. We also assessed the cost-effectiveness of MAS across different patient subgroups and clinic characteristics. Results Referral to MAS was associated with gains in DEMQOL (mean gain: 3.48, 95% confidence interval: 2.84 to 4.12), EQ-5D-3L (0.023, 0.008 to 0.038) and QALYs (0.006, 0.002 to 0.01). Mean total cost over six months, assuming a societal perspective, was £1899 (£1277 to £2539). This yielded a negative incremental net monetary benefit of −£1724 (−£2388 to −£1085), assuming NICE’s recommended willingness-to-pay threshold (£30,000 per QALY). These base case results were relatively robust to alternative assumptions about costs and HRQL. There was some evidence that patients aged 80 or older benefitted more from referral to MAS (p < 0.01 from adjusted mean differences in net benefits) compared to younger patients. MAS with over 75 new patients a month or cost per patient less than £2500 over six months were relatively more cost-effective (p < 0.01) than MAS with fewer new monthly patients or higher cost per patient. Conclusions Diagnosis, treatment and follow-up care provided by MAS to patients with suspected dementia appears to be effective, but not cost-effective, in the six months after diagnosis. Longer term evidence is required before drawing conclusions about the cost-effectiveness of MAS.

The Cost-Effectiveness of Anterior Cruciate Ligament Reconstruction in Competitive Athletes

2016 ◽  
Vol 45 (1) ◽  
pp. 23-33 ◽  
Author(s):  
Bruce A. Stewart ◽  
Amit M. Momaya ◽  
Marc D. Silverstein ◽  
David Lintner
Keyword(s):  
Cost Effectiveness ◽  
Physical Therapy ◽  
Acl Reconstruction ◽  
Cruciate Ligament ◽  
Return To Play ◽  
Acl Injuries ◽  
Competitive Athletes ◽  
Anterior Cruciate ◽  
The Cost

Background: Competitive athletes value the ability to return to competitive play after the treatment of anterior cruciate ligament (ACL) injuries. ACL reconstruction has high success rates for return to play, but some studies indicate that patients may do well with nonoperative physical therapy treatment. Purpose: To evaluate the cost-effectiveness of the treatment of acute ACL tears with either initial surgical reconstruction or physical therapy in competitive athletes. Study Design: Economic and decision analysis; Level of evidence, 2. Methods: The incremental cost, incremental effectiveness, and incremental cost-effectiveness ratio (ICER) of ACL reconstruction compared with physical therapy were calculated from a cost-effectiveness analysis of ACL reconstruction compared with physical therapy for the initial management of acute ACL injuries in competitive athletes. The ACL reconstruction strategy and the physical therapy strategy were represented as Markov models. Costs and quality-adjusted life-years (QALYs) were evaluated over a 6-year time horizon and were analyzed from a societal perspective. Quality of life and probabilities of clinical outcomes were obtained from the peer-reviewed literature, and costs were compiled from a large academic hospital in the United States. One-way, 2-way, and probabilistic sensitivity analyses were used to assess the effect of uncertainty in variables on the ICER of ACL reconstruction. Results: The ICER of ACL reconstruction compared with physical therapy was $22,702 per QALY gained. The ICER was most sensitive to the quality of life of returning to play or not returning to play, costs, and duration of follow-up but relatively insensitive to the rates and costs of complications, probabilities of return to play for both operative and nonoperative treatments, and discount rate. Conclusion: ACL reconstruction is a cost-effective strategy for competitive athletes with an ACL injury.

Preoperative Short Form Health Survey Score Is Predictive of Return to Play and Minimal Clinically Important Difference at a Minimum 2-Year Follow-up After Anterior Cruciate Ligament Reconstruction

2017 ◽  
Vol 45 (12) ◽  
pp. 2784-2790 ◽  
Author(s):  
Benedict U. Nwachukwu ◽  
Brenda Chang ◽  
Pramod B. Voleti ◽  
Patricia Berkanish ◽  
Matthew R. Cohn ◽  
...  
Keyword(s):  
Short Form ◽  
Cruciate Ligament ◽  
Multivariable Analysis ◽  
Return To Play ◽  
Short Form Health Survey ◽  
Clinically Important Difference ◽  
Patient Reported ◽  
Anterior Cruciate ◽  
Short Form Health

Background: There is increased interest in understanding the preoperative determinants of postoperative outcomes. Return to play (RTP) and the patient-reported minimal clinically important difference (MCID) are useful measures of postoperative outcomes after anterior cruciate ligament reconstruction (ACLR). Purpose: To define the MCID after ACLR and to investigate the role of preoperative outcome scores for predicting the MCID and RTP after ACLR. Study Design: Case-control study; Level of evidence, 3. Methods: There were 294 active athletes enrolled as part of an institutional ACL registry with a minimum 2-year follow-up who were eligible for inclusion. A questionnaire was administered to elicit factors associated with RTP. Patient demographic and clinical data as well as patient-reported outcome measures were captured as part of the registry. Outcome measures included the International Knee Documentation Committee (IKDC) subjective knee evaluation form, Lysholm scale, and 12-Item Short Form Health Survey (SF-12) physical component summary (PCS) and mental component summary (MCS). Preoperative outcome score thresholds predictive of RTP were determined using a receiver operating characteristic (ROC) with area under the curve (AUC) analysis. The MCID was calculated using a distribution-based method. Multivariable logistic models were fitted to identify predictors for achieving the MCID and RTP. Results: At a mean (±SD) follow-up of 3.7 ± 0.7 years, 231 patients were included from a total 294 eligible patients. The mean age and body mass index were 26.7 ± 12.5 years and 23.7 ± 3.2 kg/m2, respectively. Of the 231 patients, 201 (87.0%) returned to play at a mean time of 10.1 months. Two-year postoperative scores on all measures were significantly increased from preoperative scores (IKDC: 50.1 ± 15.6 to 87.4 ± 10.7; Lysholm: 61.2 ± 18.1 to 89.5 ± 10.4; SF-12 PCS: 41.5 ± 9.0 to 54.7 ± 4.6; SF-12 MCS: 53.6 ± 8.1 to 55.7 ± 5.7; P < .001 for all). The corresponding MCID values were 9.0 (IKDC), 10.0 (Lysholm), 5.1 (SF-12 PCS), and 4.3 (SF-12 MCS). Preoperative score thresholds predictive of RTP were the following: IKDC, 60.9; Lysholm, 57.0; SF-12 PCS, 42.3; and SF-12 MCS, 48.3. These thresholds were not independently predictive but achieved significance as part of the multivariable analysis. In the multivariable analysis for RTP, preoperative SF-12 PCS scores above 42.3 (odds ratio [OR], 2.73; 95% CI, 1.09-7.62) and SF-12 MCS scores above 48.3 (OR, 4.41; 95% CI, 1.80-10.98) were predictive for achieving RTP; an ACL allograft (OR, 0.26; 95% CI, 0.06-1.00) was negatively predictive of RTP. In the multivariable analysis for the MCID, patients with higher preoperative scores were less likely to achieve the MCID ( P < .0001); however, a higher preoperative SF-12 MCS score was predictive of achieving the MCID on the IKDC form (OR, 1.27; 95% CI, 1.11-1.52) and Lysholm scale (OR, 1.08; 95% CI, 1.00-1.16). Medial meniscal injuries, older age, and white race were also associated with a decreased likelihood for achieving the MCID. Conclusion: Preoperative SF-12 MCS and PCS scores were predictive of RTP after ACLR; patients scoring above 42.3 on the SF-12 PCS and 48.3 on the SF-12 MCS were more likely to achieve RTP. Additionally, we defined the MCID after ACLR and found that higher SF-12 MCS scores were predictive of achieving the MCID on knee-specific questionnaires.

scholarly journals GRAFT CHOICE FOR ADOLESCENT ATHLETES RETURNING TO HIGH-RISK SPORTS: A MATCHED COHORT ANALYSIS OF PATELLAR TENDON AND HAMSTRING AUTOGRAFTS

2019 ◽  
Vol 7 (3_suppl) ◽  
pp. 2325967119S0007
Author(s):  
Crystal Perkins ◽  
Michael Busch ◽  
Melissa Christino ◽  
Belinda Schaafsma ◽  
S. Clifton Willimon
Keyword(s):  
Anterior Cruciate Ligament ◽  
High Risk ◽  
Acl Reconstruction ◽  
Patellar Tendon ◽  
Graft Failure ◽  
Cruciate Ligament ◽  
Graft Rupture ◽  
Graft Choice ◽  
Anterior Cruciate

Background: Graft selection for skeletally mature adolescents undergoing anterior cruciate ligament (ACL) reconstruction is guided by surgeon and patient preference. In young patients returning to high-risk cutting and pivoting sports, graft rupture is the most feared complication of ACL reconstruction. Some studies have demonstrated slightly lower rates of graft failure and decreased laxity in the short term associated with patellar tendon (BTB) autografts as compared to hamstring (HS) autografts, but these studies are limited by their heterogeneity of ages and activity level1-3. The purpose of this study is to compare the rates of graft failure between BTB and HS ACL reconstruction cohorts matched by age, sex, and sport. Methods: A single-institution retrospective review was performed of consecutive patients less than 19 years of age treated with ACL reconstructions using either patellar tendon (BTB) or hamstring (HS) autograft performed by a single surgeon. Skeletally mature or nearly mature patients in “high-risk” ACL injury sports (basketball, football, soccer, lacrosse, and gymnastics) were initially treated with hamstring autografts but the graft preference transitioned to BTB autografts as the preferred graft choice during the study period. This transition in graft preference for adolescents participating in “high risk” sports allows for a comparison of outcomes based on graft types. Inclusion criteria were ages 13 – 18 years, participation in a “high risk” sport, and minimum 6-month follow-up. The two cohorts of patients were matched by age, gender, and sport. The primary outcome measure was graft rupture. Results: One hundred fifty-two patients with an average age of 16 years (range 13 – 18 years) underwent ACL reconstruction during the study period. There were 71 BTB reconstructions and 81 HS reconstructions. There were 64 females and 88 males. There was no difference in age, sex, BMI, or laterality between groups. There were more patients who played soccer in the BTB cohort (44%) vs HS cohort (20%) and fewer who played basketball in the BTB cohort (24%) vs HS cohort (41%), p = 0.005. There were no differences between the BTB and HS cohorts in terms of meniscus tears (61% v 72%, p = 0.15), meniscus repair (21% v 32%, p = 0.13), or partial meniscectomy (32% v 33%, p = 0.90). Mean duration of follow-up was 28 months (range 7-57 months). There was no difference in follow-up between cohorts (BTB 28 months and HS 29 months, p = 0.19). There were a total of 16 graft ruptures (10.5%). There was no difference in the rate of graft rupture between cohorts (BTB 8.5% vs HS 12.3%, p = 0.60). Mean time to graft rupture was 21 months (range 8 – 35 months) and Kaplan-Meier survival curves demonstrated no difference between cohorts. Conclusions: ACL reconstruction in adolescents returning to high-risk sports can be performed utilizing BTB or HS autografts with similar rates of graft rupture. There is a trend toward lower rates of graft rupture associated with BTB autografts, but additional patients will be necessary to determine if this trend will become a statistically significant difference. Beynnon BD, Johnson RJ, Fleming BC, et al. Anterior cruciate ligament replacement: comparison of bone-patellar tendon bone grafts with two-strand hamstring grafts. A prospective, randomized study. J Bone Joint Surg Am 2002;84(9):1503-1513. Ho B, Edmonds EW, Chambers HG et al. Risk factors for early ACL reconstruction failure in pediatric and adolescent patients: a review of 561 cases. J Pediatr Orthop 2016. Samuelsen BT, Webster KE, Johnson NR, et al. Hamstring autograft versus patellar tendon autograft for ACL reconstruction: is there a difference in graft failure rate? A meta-analysis of 47,613 patients. Clin Orthop Relat Res 2017;475(10):2459-2468.

scholarly journals Cytomegalovirus Screening in Pregnancy: A Cost-Effectiveness and Threshold Analysis

2018 ◽  
Vol 36 (07) ◽  
pp. 678-687 ◽  
Author(s):  
Catherine M. Albright ◽  
Erika F. Werner ◽  
Brenna L. Hughes
Keyword(s):  
Cost Effectiveness ◽  
Behavioral Intervention ◽  
Universal Screening ◽  
Cost Effective ◽  
Base Case ◽  
Design Decision ◽  
Intervention Effectiveness ◽  
Behavioral Counseling ◽  
The Cost ◽  
In Pregnancy

Objective To determine threshold cytomegalovirus (CMV) infectious rates and treatment effectiveness to make universal prenatal CMV screening cost-effective. Study Design Decision analysis comparing cost-effectiveness of two strategies for the prevention and treatment of congenital CMV: universal prenatal serum screening and routine, risk-based screening. The base case assumptions were a probability of primary CMV of 1% in seronegative women, hyperimmune globulin (HIG) effectiveness of 0%, and behavioral intervention effectiveness of 85%. Screen-positive women received monthly HIG and screen-negative women received behavioral counseling to decrease CMV seroconversion. The primary outcome was the cost per maternal quality-adjusted life year (QALY) gained with a willingness to pay of $100,000 per QALY. Results In the base case, universal screening is cost-effective, costing $84,773 per maternal QALY gained. In sensitivity analyses, universal screening is cost-effective only at a primary CMV incidence of more than 0.89% and behavioral intervention effectiveness of more than 75%. If HIG is 30% effective, primary CMV incidence can be 0.82% for universal screening to be cost-effective. Conclusion The cost-effectiveness of universal maternal screening for CMV is highly dependent on the incidence of primary CMV in pregnancy. If efficacious, HIG and behavioral counseling allow universal screening to be cost-effective at lower primary CMV rates.

scholarly journals Physiologic Preoperative Knee Hyperextension Is a Predictor of Failure in an Anterior Cruciate Ligament Revision Cohort: A Report From the MARS Group

2018 ◽  
Vol 46 (12) ◽  
pp. 2836-2841 ◽  
Author(s):  
◽  
Daniel E. Cooper ◽  
Warren R. Dunn ◽  
Laura J. Huston ◽  
Amanda K. Haas ◽  
...  
Keyword(s):  
Anterior Cruciate Ligament ◽  
Regression Model ◽  
Failure Rate ◽  
Graft Failure ◽  
Cruciate Ligament ◽  
Knee Hyperextension ◽  
Graft Rupture ◽  
Acl Surgery ◽  
Anterior Cruciate

Background: The occurrence of physiologic knee hyperextension (HE) in the revision anterior cruciate ligament reconstruction (ACLR) population and its effect on outcomes have yet to be reported. Hypothesis/Purpose: The prevalence of knee HE in revision ACLR and its effect on 2-year outcome were studied with the hypothesis that preoperative physiologic knee HE ≥5° is a risk factor for anterior cruciate ligament (ACL) graft rupture. Study Design: Cohort study; Level of evidence, 2. Methods: Patients undergoing revision ACLR were identified and prospectively enrolled between 2006 and 2011. Study inclusion criteria were patients undergoing single-bundle graft reconstructions. Patients were followed up at 2 years and asked to complete an identical set of outcome instruments (International Knee Documentation Committee, Knee injury and Osteoarthritis Outcome Score, WOMAC, and Marx Activity Rating Scale) as well as provide information regarding revision ACL graft failure. A regression model with graft failure as the dependent variable included age, sex, graft type at the time of the revision ACL surgery, and physiologic preoperative passive HE ≥5° (yes/no) to assess these as potential risk factors for clinical outcomes 2 years after revision ACLR. Results: Analyses included 1145 patients, for whom 2-year follow-up was attained for 91%. The median age was 26 years, with age being a continuous variable. Those below the median were grouped as “younger” and those above as “older” (age: interquartile range = 20, 35 years), and 42% of patients were female. There were 50% autografts, 48% allografts, and 2% that had a combination of autograft plus allograft. Passive knee HE ≥5° was present in 374 (33%) patients in the revision cohort, with 52% being female. Graft rupture at 2-year follow-up occurred in 34 cases in the entire cohort, of which 12 were in the HE ≥5° group (3.2% failure rate) and 22 in the non-HE group (2.9% failure rate). The median age of patients who failed was 19 years, as opposed to 26 years for those with intact grafts. Three variables in the regression model were significant predictors of graft failure: younger age (odds ratio [OR] = 3.6; 95% CI, 1.6-7.9; P = .002), use of allograft (OR = 3.3; 95% CI, 1.5-7.4; P = .003), and HE ≥5° (OR = 2.12; 95% CI, 1.1-4.7; P = .03). Conclusion: This study revealed that preoperative physiologic passive knee HE ≥5° is present in one-third of patients who undergo revision ACLR. HE ≥5° was an independent significant predictor of graft failure after revision ACLR with a >2-fold OR of subsequent graft rupture in revision ACL surgery. Registration: NCT00625885 ( ClinicalTrials.gov identifier).

Abstract 200: Cost-Effectiveness of Newer Anticoagulants for Stroke Prevention in Atrial Fibrillation

2013 ◽  
Vol 6 (suppl_1) ◽  
Author(s):  
Brendan L Limone ◽  
William L Baker ◽  
Craig I Coleman
Keyword(s):  
Atrial Fibrillation ◽  
Cost Effectiveness ◽  
Stroke Prevention ◽  
Indirect Comparison ◽  
Cost Effective ◽  
The United States ◽  
Base Case ◽  
Treatment Comparison ◽  
Newer Anticoagulants ◽  
The Cost

Background: A number of new anticoagulants for stroke prevention in atrial fibrillation (SPAF) have gained regulatory approval or are in late-stage development. We sought to conduct a systematic review of economic models of dabigatran, rivaroxaban and apixaban for SPAF. Methods: We searched the Medline, Embase, National Health Service Economic Evaluation Database and Health Technology Assessment database along with the Tuft’s Registry through October 10, 2012. Included models assessed the cost-effectiveness of dabigatran (150mg, 110mg, sequential), rivaroxaban or apixaban for SPAF using a Markov model or discrete event simulation and were published in English. Results: Eighteen models were identified. All models utilized a lone randomized trial (or an indirect comparison utilizing a single study for any given direct comparison), and these trials were clinically and methodologically heterogeneous. Dabigatran 150mg was assessed in 9 of models, dabigatran 110mg in 8, sequential dabigatran in 9, rivaroxaban in 4 and apixaban in 4. Adjusted-dose warfarin (either trial-like, real-world prescribing or genotype-dosed) was a potential first-line therapy in 94% of models. Models were conducted from the perspective of the United States (44%), European countries (39%) and Canada (17%). In base-case analyses, patients typically were at moderate-risk of ischemic stroke, initiated anticoagulation between 65 and 73 years of age, and were followed for or near a lifetime. All models reported cost/quality-adjusted life-year (QALY) gained, and while 22% of models reported using a societal perspective, no model included costs of lost productivity. Four models reported an incremental cost-effectiveness ratio (ICER) for a newer anticoagulant (dabigatran 110mg (n=4)/150mg (n=2); rivaroxaban (n=1)) vs. warfarin above commonly reported willingness-to-pay thresholds. ICERs (in 2012US$) vs. warfarin ranged from $3,547-$86,000 for dabigatran 150mg, $20,713-$150,000 for dabigatran 110mg, $4,084-$21,466 for sequentially-dosed dabigatran and $23,065-$57,470 for rivaroxaban. In addition, apixaban was demonstrated to be an economically dominant strategy compared to aspirin and to be dominant or cost-effective ($11,400-$25,059) vs. warfarin. Based on separate indirect treatment comparison meta-analyses, 3 models compared the cost-effectiveness of these new agents and reported conflicting results. Conclusions: Cost-effectiveness models of newer anticoagulants for SPAF have been extensively published. Models have frequently found newer anticoagulants to be cost-effective, but due to the lack of head-to-head trial comparisons and heterogeneity in clinical characteristic of underlying trials and modeling methods, it is currently unclear which of these newer agents is most cost-effective.

scholarly journals P14.12 The cost-effectiveness of tumor-treating fields in patients with newly diagnosed glioblastoma

2019 ◽  
Vol 21 (Supplement_3) ◽  
pp. iii68-iii69
Author(s):  
X Armoiry ◽  
P Auguste ◽  
C Dussart ◽  
J Guyotat ◽  
M Connock
Keyword(s):  
Cost Effectiveness ◽  
Cost Effective ◽  
Survival Model ◽  
Sensitivity Analyses ◽  
Base Case ◽  
Tumor Treating Fields ◽  
Kaplan Meier ◽  
Life Years ◽  
Secondary Analyses ◽  
The Cost

Abstract BACKGROUND The addition of novel therapy “Tumor-Treating fields” (TTF) to standard radio-chemotherapy with Temozolomide (TMZ) has recently shown superiority over conventional TMZ regimen in patients with glioblastoma. Despite the clinical benefit of TTF, there is a strong concern regarding the cost of this new treatment. A first cost-effectiveness analysis, which was published in 2016, was based on effectiveness outcomes from an interim analysis of the pivotal trial and used a “standard” Markov model. Here, we aimed to update the cost-effectiveness evaluation using a partitioned survival model design and using the latest effectiveness data. MATERIAL AND METHODS A partitioned survival model was developed with three mutually exclusive health states: stable disease, progressive disease, and dead. Parametric models were fitted to the Kaplan-Meier data for overall and progression-free survival. These generated clinically plausible extrapolations beyond the observed data. The perspective of the French national health insurance was adopted and the time horizon was 20 years. Base case results were expressed as cost/life-years (LY) gained (LYG). Secondary analyses were undertaken, with the results presented as cost/per quality adjusted life years (QALY) gained. Last, we undertook deterministic and probabilistic sensitivity analyses. RESULTS After applying 4% annual discounting of benefits and costs, the base case model generated incremental benefit of 0.507 LY at a incremental cost of €258,695 yielding an incremental cost effectiveness ratio (ICER) of €510,273 / LYG. Secondary analyses yielded an ICER of €667,173/QALY. Sensitivity analyses and bootstrapping methods showed the model was relatively robust. The model was sensitive to TTF device costs and the parametric model fitted to the Kaplan-Meier data for overall survival. The cost-effectiveness acceptability curve showed TTF has 0% of being cost-effective under conventional thresholds. CONCLUSION Using a partitioned survival model, uprated costs and more mature survival outcomes, TTF when compared to standard radio-chemotherapy with TMZ is not likely to be cost-effective. This has major implications in terms of access of newly eligible patients

Cost-effectiveness of zoledronic (ZOL) acid plus endocrine therapy (ET) in premenopausal women with early breast cancer (EBC) from a Canadian perspective

2009 ◽  
Vol 27 (15_suppl) ◽  
pp. 557-557
Author(s):  
K. E. Ougari ◽  
C. Taneja ◽  
O. Sofrygin ◽  
S. Kaura ◽  
T. Delea
Keyword(s):  
Breast Cancer ◽  
Cost Effectiveness ◽  
Premenopausal Women ◽  
Cost Effective ◽  
System Perspective ◽  
Healthcare System Perspective ◽  
The Cost ◽  
Canadian Healthcare System ◽  
Canadian Healthcare

557 Background: The Austrian Breast and Colorectal Cancer Study Group Trial 12 (ABCSG-12) examined the efficacy of 3 years (yrs) of treatment with goserelin in combination with ET (anastrozole or tamoxifen) with or without ZOL 4 mg q6 mos in 1,803 premenopausal women with EBC (median age 45 yrs). After a median follow-up of 47.8 mos (max 84 mos), risk of disease-free survival (DFS) events was reduced by 36% (HR = 0.64; p = 0.01) in patients (pts) who received ZOL (ZOL+ET) compared with those who did not (ET). Methods: A Markov model was used to estimate the cost per quality adjusted life years (QALYs) gained of 3 years treatment duration of ZOL+ET versus ET-only in premenopausal women with EBC based on results of the ABCSG-12. A Canadian healthcare system perspective and a lifetime timeframe were used. Outcomes and cost of breast cancer recurrence were based on recent published studies. Results were generated under 2 scenarios regarding duration of benefit (reduction in risk of recurrence) with ZOL: (1) Benefits persist to maximum follow-up in ABCSG-12 (trial benefit); (2) Benefits persist until death (lifetime benefit). Results: The cost of 3 years of ZOL (medication and administration) is 4 191 $CDN. Under the lifetime benefit scenario, 73% of these costs are offset by savings in the cost of recurrences. Under the trial benefit scenario, 12% are offset. QALYs gained are 1.63 yrs and 0.52 yrs under the lifetime and trial benefit scenarios respectively; cost-effectiveness is 1 122 $CDN and 3 675 $CDN per QALY gained respectively, which is well below the 50 000 $CDN per QALY threshold frequently used to assess whether therapies are cost-effective. Conclusions: The combination of ZOL + ET is a cost-effective use of healthcare resources from a Canadian healthcare system perspective. [Table: see text]

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