When cost-effective interventions are unaffordable: Integrating cost-effectiveness and budget impact in priority setting for global health programs

Abstract Background Cryptococcal meningitis in HIV-infected patients in sub-Saharan Africa accounts for three-quarters of the global cases and 135 000 deaths per annum. Current treatment includes the use of fluconazole and amphotericin B. Recent evidence has shown that the synergistic use of flucytosine improves efficacy and reduces toxicity, however affordability and availability has hampered access to flucytosine in many countries. This study investigated the evidence and cost implications of introducing flucytosine as induction therapy for cryptococcal meningitis in HIV-infected adults in South Africa. Methods A decision analytic cost-effectiveness and budget impact model was developed based on survival estimates from the ACTA trial and local costs for flucytosine as induction therapy in HIV-infected adults with cryptococcal meningitis in a public sector setting in South Africa. The model considered four treatment arms: (a) standard of care; 2-week course of amphotericin B/fluconazole (2wk AmBd/Flu), (b) 2-week course of amphotericin B/flucytosine (2wk AmBd/5FC), (c) short course; 1-week course amphotericin B/flucytosine (1wk AmBd/5FC) and (d) oral course; 2-week oral fluconazole/flucytosine (oral). A sensitivity analysis was conducted on key variables. Results The highest total treatment costs were in the 2-week AmBd/5FC arm followed by the 2-week oral regimen, then the 1-week AmBd/5FC with the lowest cost in the standard of care arm. Compared to standard of care the 1-week flucytosine course is most cost-effective at USD31/QALY, followed by the oral 2-week course at USD155/QALY and the 2-week flucytosine course at USD568/QALY. The budget impact analysis shows that the 1-week course has the lowest incremental cost, followed by the oral course and then the 2-week flucytosine course compared to what is currently spent on standard of care. Sensitivity analyses suggest that the model is most sensitive to the price of flucytosine and hospital costs, particularly length of stay. Conclusions The addition of flucytosine as induction therapy for the treatment of cryptococcal meningitis in patients infected with HIV is cost-effective regardless of whether it is used as a 1-week, 2-week or oral regimen. Savings could be achieved with early discharge of patients as well as a reduction in the price of flucytosine.

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The Future of Priority-Setting in Global Health

Global Health Priority-Setting ◽

10.1093/oso/9780190912765.003.0018 ◽

2019 ◽

pp. 317-326

Author(s):

Trygve Ottersen ◽

Joseph Millum ◽

Jennifer Prah Ruger ◽

Stéphane Verguet ◽

Kjell Arne Johansson ◽

...

Keyword(s):

Cost Effectiveness ◽

Global Health ◽

Health Effects ◽

Priority Setting ◽

Systematic Approach ◽

Current Practice ◽

Evidence Based ◽

Normative Issues ◽

Distributional Impact

This book has sought to inform efforts to improve systematic, evidence-based priority-setting by assessing the state-of-the-art of methods for priority-setting, engaging with the fundamental normative issues at stake, and providing specific recommendations for improving current practice. This final chapter, written by the eight editors of this volume, provides seven key recommendations for future priority-setting in global health: (1) A more systematic approach to priority-setting in health is needed; (2) Information on cost-effectiveness is essential; (3) Distributional impact needs to be integrated; (4) Stillbirths need to be integrated; (5) Non-health effects need to be integrated; (6) Process needs to be emphasized alongside substantive criteria; and (7) New methods and tools need to be used and further developed.

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The Cost-Effectiveness of Hepatitis C Virus Screening Strategies among Recently Arrived Migrants in the Netherlands

International Journal of Environmental Research and Public Health ◽

10.3390/ijerph17176091 ◽

2020 ◽

Vol 17 (17) ◽

pp. 6091

Author(s):

Mohamed N.M.T. Al Khayat ◽

Job F.H. Eijsink ◽

Maarten J. Postma ◽

Jan C. Wilschut ◽

Marinus van Hulst

Keyword(s):

Hepatitis C Virus ◽

Cost Effectiveness ◽

Hepatitis C ◽

The Netherlands ◽

Budget Impact ◽

Cost Effective ◽

Life Years ◽

Screening Strategies ◽

Hcv Screening ◽

The Cost

Objective: We aimed to assess the cost-effectiveness of hepatitis C virus (HCV) screening strategies among recently arrived migrants in the Netherlands. Methods: A Markov model was used to estimate the health effects and costs of HCV screening from the healthcare perspective. A cohort of 50,000 recently arrived migrants was used. In this cohort, three HCV screening strategies were evaluated: (i) no screening, (ii) screening of migrants from HCV-endemic countries and (iii) screening of all migrants. Results: Strategy (ii) screening of migrants from HCV-endemic countries compared to strategy (i) no screening, yielded an incremental cost-effectiveness ratio (ICER) of €971 per quality-adjusted life-years (QALYs) gained. Strategy (iii) screening of all migrants compared with strategy (ii) screening of migrants from HCV-endemic countries yielded an ICER of €1005 per QALY gained. The budget impact of strategy (ii) screening of migrants from HCV-endemic countries and strategy (iii) screening of all migrants was €13,752,039 and €20,786,683, respectively. Conclusion: HCV screening is cost-effective. However, the budget impact may have a strong influence on decision making.

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Cost-effectiveness and budget impact of the microprocessor-controlled knee C-Leg in transfemoral amputees with and without diabetes mellitus

The European Journal of Health Economics ◽

10.1007/s10198-019-01138-y ◽

2020 ◽

Vol 21 (3) ◽

pp. 437-449 ◽

Cited By ~ 1

Author(s):

Alexander Kuhlmann ◽

Henning Krüger ◽

Susanne Seidinger ◽

Andreas Hahn

Keyword(s):

Diabetes Mellitus ◽

Cost Effectiveness ◽

Budget Impact ◽

Input Parameter ◽

Cost Effective ◽

Sensitivity Analyses ◽

Decision Analytic Model ◽

Life Years ◽

Transfemoral Amputees ◽

The Impact

Abstract Background The safe use of a prosthesis in activities of daily living is key for transfemoral amputees. However, the number of falls varies significantly between different prosthetic device types. This study aims to compare medical and economic consequences of falls in transfemoral amputees who use the microprocessor-controlled knee joint C-Leg with patients who use non-microprocessor-controlled (mechanical) knee joints (NMPK). The main objectives of the analysis are to investigate the cost-effectiveness and budget impact of C-Legs in transfemoral amputees with diabetes mellitus (DM) and without DM in Germany. Methods A decision-analytic model was developed that took into account the effects of prosthesis type on the risk of falling and fall-related medical events. Cost-effectiveness and budget impact analyses were performed separately for transfemoral amputees with and without DM. The study took the perspective of the statutory health insurance (SHI). Input parameters were derived from the published literature. Univariate and probabilistic sensitivity analyses (PSA) were performed to investigate the impact of changes in individual input parameter values on model outcomes and to explore parameter uncertainty. Results C-Legs reduced the rate of fall-related hospitalizations from 134 to 20 per 1000 person years (PY) in amputees without DM and from 146 to 23 per 1000 PY in amputees with DM. In addition, the C-Leg prevented 15 or 14 fall-related death per 1000 PY. Over a time horizon of 25 years, the incremental cost-effectiveness ratio (ICER) was 16,123 Euro per quality-adjusted life years gained (QALY) for amputees without DM and 20,332 Euro per QALY gained for amputees with DM. For the period of 2020–2024, the model predicted an increase in SHI expenditures of 98 Mio Euro (53 Mio Euro in prosthesis users without DM and 45 Mio Euro in prosthesis users with DM) when all new prosthesis users received C-Legs instead of NMPKs and 50% of NMPK user whose prosthesis wore out switched to C-Legs. Results of the PSA showed moderate uncertainty and a probability of 97–99% that C-Legs are cost-effective at an ICER threshold of 40,000 Euro (≈ German GDP per capita in 2018) per QALY gained. Conclusion Results of the study suggest that the C-Leg provides substantial additional health benefits compared with NMPKs and is likely to be cost-effective in transfemoral amputees with DM as well as in amputees without DM at an ICER threshold of 40,000 Euro per QALY gained.

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Cost-effectiveness of targeted screening for hepatitis C in The Netherlands

Epidemiology and Infection ◽

10.1017/s0950268811000112 ◽

2011 ◽

Vol 140 (1) ◽

pp. 58-69 ◽

Cited By ~ 15

Author(s):

C. W. HELSPER ◽

B. A. BORKENT-RAVEN ◽

N. J. DE WIT ◽

G. A. VAN ESSEN ◽

M. J. M. BONTEN ◽

...

Keyword(s):

Primary Care ◽

Cost Effectiveness ◽

Hepatitis C ◽

The Netherlands ◽

Drug Users ◽

Cost Effective ◽

Case Finding ◽

Hard Drug ◽

Effective Interventions ◽

Additional Support

SUMMARYOn account of the serious complications of hepatitis C virus (HCV) infection and the improved treatment possibilities, the need to improve HCV awareness and case-finding is increasingly recognized. To optimize a future national campaign with this objective, three pilot campaigns were executed in three regions in The Netherlands. One campaign was aimed at the general population, a second (similar) campaign was extended with a support programme for primary care and a third campaign was specifically aimed at hard-drug users. Data from the pilot campaigns were used to build a mathematical model to estimate the incremental cost-effectiveness ratio of the different campaigns. The campaign aimed at the general public without support for primary care did not improve case-finding and was therefore not cost-effective. The similar campaign accompanied by additional support for primary care and the campaign aimed at hard-drug users emerged as cost-effective interventions for identification of HCV carriers.

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Economic evaluation of disease elimination: an extension to the net benefits framework and application to human African trypanosomiasis

10.1101/2021.02.10.20181974 ◽

2021 ◽

Author(s):

Marina Antillon ◽

Ching-I Huang ◽

Kat S Rock ◽

Fabrizio Tediosi

Keyword(s):

Cost Effectiveness ◽

Global Health ◽

Human African Trypanosomiasis ◽

Cost Effective ◽

African Trypanosomiasis ◽

Disease Elimination ◽

Global Health Community ◽

Health Community ◽

Net Benefits ◽

The Cost

The net benefits framework has become a mainstay of the cost-effectiveness literature, guiding decision-makers to select among strategies in the presence of budget constraints and imperfect information. However, disease elimination programs are socially desirable but not always cost-effective. Therefore, analytical frameworks are necessary to consider the additional premium for reaching global goals that are beyond the cost-effective use of country resources. We propose a modification to the net benefits framework to consider the implications of switching from an optimal strategy (in terms of cost-per-burden-averted) to a strategy with a higher likelihood of meeting the global target (i.e. elimination of transmission by a specified date). Our expanded framework informs decisions under uncertainty, determines the share of funding necessary to align local and global priorities, enabling local partners to use their resources efficiently while cooperating to meet global health targets. We illustrate the advantages of our framework by considering the economic case of efforts to eliminate transmission by 2030 of gambiense human African trypanosomiasis (gHAT), a vector-borne parasitic disease in West and Central Africa. Significance Statement Various diseases have now been earmarked for elimination by the global health community. While the health economic implications of elimination have been discussed before, one important topic remains unexplored: uncertainty and its consideration within extant cost-effectiveness frameworks. Here we extend the ubiquitous net benefits framework to consider the comparative efficiency of alternative elimination strategies when these strategies have different probabilities of reaching elimination. We evaluate the premium of elimination, and we apply our method to efforts against human African trypanosomiasis in three settings. This method could be directly applied to simulation-based studies of the cost-effectiveness of other disease elimination efforts, therefore giving the global health community a common metric by which to budget for such initiatives.

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Cost-effectiveness and budget impact of venetoclax in combination with rituximab in relapsed/refractory chronic lymphocytic leukemia in Switzerland

The European Journal of Health Economics ◽

10.1007/s10198-021-01398-7 ◽

2021 ◽

Author(s):

Michaela Barbier ◽

Nicholas Durno ◽

Craig Bennison ◽

Mathias Örtli ◽

Christian Knapp ◽

...

Keyword(s):

Cost Effectiveness ◽

Chronic Lymphocytic Leukemia ◽

Survival Data ◽

Impact Analysis ◽

Budget Impact ◽

Treatment Strategies ◽

Progression Free Survival ◽

Cost Effective ◽

Lymphocytic Leukemia ◽

Life Years

Abstract Introduction Venetoclax in combination with rituximab (VEN + R) demonstrated prolonged overall survival (OS) and progression-free survival (PFS) for patients with relapsed/refractory (R/R) chronic lymphocytic leukemia (CLL) in comparison to standard chemoimmunotherapy [bendamustine + rituximab (BR)]. We conducted a cost-effectiveness and budget impact analysis comparing VEN + R versus six comparators from the Swiss healthcare payer perspective. Methods A three-state partitioned survival model, developed in accordance with NICE and ISPOR decision modelling guidelines, was adapted to Switzerland. Model inputs were informed by the MURANO trial (survival data, patient characteristics), publicly available Swiss sources (drug prices, inpatient and outpatient costs), Swiss National Institute of Cancer Epidemiology and Registration data (incidence and prevalence values), and Swiss medical expert feedback. We used published (dis-)utility values and adverse event probabilities. Results Over a lifetime, VEN + R resulted in an expected gain of 2.60 quality-adjusted life years (QALYs) per patient and incremental costs of Swiss Francs (CHF) 147,851 compared to BR, leading to an incremental cost-effectiveness ratio of CHF 56,881/QALY gained. Other treatment strategies (for example ibrutinib versus VEN + R) resulted in higher costs and lower QALYs. Results were not different for subgroups of patients with/without deletion of chromosome 17p/tumour protein 53 mutation. In scenario analysis, changes in post-progression treatment costs demonstrated a high impact on results. We estimated an expected value of perfect information of CHF 3,318/patient. A moderate VEN + R uptake was estimated to save CHF 12.3 million during 5 years. Conclusions Using a threshold of CHF 100,000 per QALY, VEN + R was projected to be cost-effective vs BR.

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Handling Uncertainty in Cost-Effectiveness Analysis: Budget Impact and Risk Aversion

Healthcare ◽

10.3390/healthcare9111419 ◽

2021 ◽

Vol 9 (11) ◽

pp. 1419

Author(s):

Pedram Sendi ◽

Klazien Matter-Walstra ◽

Matthias Schwenkglenks

Keyword(s):

Cost Effectiveness ◽

Risk Aversion ◽

Joint Distribution ◽

Budget Impact ◽

Cost Effective ◽

Cost Effectiveness Analysis ◽

Policy Makers ◽

North East ◽

Effectiveness Analysis ◽

The Cost

Methods to handle uncertainty in economic evaluation have gained much attention in the literature, and the cost-effectiveness acceptability curve (CEAC) is the most widely used method to summarise and present uncertainty associated with program costs and effects in cost-effectiveness analysis. Some researchers have emphasised the limitations of the CEAC for informing decision and policy makers, as the CEAC is insensitive to radial shifts of the joint distribution of incremental costs and effects in the North-East and South-West quadrants of the cost-effective plane (CEP). Furthermore, it has been pointed out that the CEAC does not incorporate risk-aversion in valuing uncertain costs and effects. In the present article, we show that the cost-effectiveness affordability curve (CEAFC) captures both dimensions of the joint distribution of incremental costs and effects on the CEP and is, therefore, sensitive to radial shifts of the joint distribution on the CEP. Furthermore, the CEAFC also informs about the budget impact of a new intervention, as it can be used to estimate the joint probability that an intervention is both affordable and cost-effective. Moreover, we show that the cost-effectiveness risk-aversion curve (CERAC) allows the analyst to incorporate different levels of risk-aversion into the analysis and can, therefore, be used to inform decision-makers who are risk-averse. We use data from a published cost-effectiveness model of palbociclib in addition to letrozole versus letrozole alone for the treatment of oestrogen-receptor positive, HER-2 negative, advanced breast cancer to demonstrate the differences between CEAC, CEAFC and CERAC, and show how these can jointly be used to inform decision and policy makers.

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Cost-effectiveness, cost-utility and the budget impact of antidepressants versus preventive cognitive therapy with or without tapering of antidepressants

BJPsych Open ◽

10.1192/bjo.2018.81 ◽

2019 ◽

Vol 5 (1) ◽

Cited By ~ 1

Author(s):

Nicola S. Klein ◽

Ben F. M. Wijnen ◽

Joran Lokkerbol ◽

Erik Buskens ◽

Hermien J. Elgersma ◽

...

Keyword(s):

Cost Effectiveness ◽

Cognitive Therapy ◽

Clinical Training ◽

Impact Analysis ◽

Budget Impact ◽

Controlled Trial ◽

Cost Effective ◽

Cost Utility ◽

The European Union ◽

Life Years

BackgroundAs depression has a recurrent course, relapse and recurrence prevention is essential.AimsIn our randomised controlled trial (registered with the Nederlands trial register, identifier: NTR1907), we found that adding preventive cognitive therapy (PCT) to maintenance antidepressants (PCT+AD) yielded substantial protective effects versus antidepressants only in individuals with recurrent depression. Antidepressants were not superior to PCT while tapering antidepressants (PCT/−AD). To inform decision-makers on treatment allocation, we present the corresponding cost-effectiveness, cost-utility and budget impact.MethodData were analysed (n = 289) using a societal perspective with 24-months of follow-up, with depression-free days and quality-adjusted life years (QALYs) as health outcomes. Incremental cost-effectiveness ratios were calculated and cost-effectiveness planes and cost-effectiveness acceptability curves were derived to provide information about cost-effectiveness. The budget impact was examined with a health economic simulation model.ResultsMean total costs over 24 months were €6814, €10 264 and €13 282 for AD+PCT, antidepressants only and PCT/−AD, respectively. Compared with antidepressants only, PCT+AD resulted in significant improvements in depression-free days but not QALYs. Health gains did not significantly favour antidepressants only versus PCT/−AD. High probabilities were found that PCT+AD versus antidepressants only and antidepressants only versus PCT/−AD were dominant with low willingness-to-pay thresholds. The budget impact analysis showed decreased societal costs for PCT+AD versus antidepressants only and for antidepressants only versus PCT/−AD.ConclusionsAdding PCT to antidepressants is cost-effective over 24 months and PCT with guided tapering of antidepressants in long-term users might result in extra costs. Future studies examining costs and effects of antidepressants versus psychological interventions over a longer period may identify a break-even point where PCT/−AD will become cost-effective.Declaration of interestC.L.H.B. is co-editor ofPLOS Oneand receives no honorarium for this role. She is also co-developer of the Dutch multidisciplinary clinical guideline for anxiety and depression, for which she receives no remuneration. She is a member of the scientific advisory board of the National Insure Institute, for which she receives an honorarium, although this role has no direct relation to this study. C.L.H.B. has presented keynote addresses at conferences, such as the European Psychiatry Association and the European Conference Association, for which she sometimes receives an honorarium. She has presented clinical training workshops, some including a fee. She receives royalties from her books and co-edited books and she developed preventive cognitive therapy on the basis of the cognitive model of A. T. Beck. W.A.N. has received grants from the Netherlands Organisation for Health Research and Development and the European Union and honoraria and speakers' fees from Lundbeck and Aristo Pharma, and has served as a consultant for Daleco Pharma.

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Economic Evaluation of Carbetocin as Prophylaxis for Postpartum Hemorrhage in the Philippines

10.21203/rs.2.23167/v1 ◽

2020 ◽

Author(s):

Jamaica Roanne Briones ◽

Pattarawalai Talungchit ◽

Montarat Thavorncharoensap ◽

Usa Chaikledkaew

Keyword(s):

Economic Evaluation ◽

Cost Effectiveness ◽

Postpartum Hemorrhage ◽

Budget Impact ◽

Hospital Setting ◽

Cost Effective ◽

The Philippines ◽

Cost Utility ◽

Third Party ◽

Additional Costs

Abstract Background: Cost-effectiveness and budget impact of carbetocin was evaluated as an alternative to oxytocin for postpartum hemorrhage (PPH) prophylaxis in the Philippines.Methods: A model-based economic evaluation was employed to assess cost-effectiveness of carbetocin compared to oxytocin for PPH. Population of interest were women undergoing either vaginal delivery (VD) or cesarean section (CS) in a public hospital setting with costs and outcomes evaluated in six weeks. Cost-utility was analyzed using a government and societal perspectives while the budget impact was determined using a third party payer’s perspective. Incremental Cost Effectiveness Ratio (ICER) was evaluated using the set threshold in the country of 150,000 PhP per QALY gained.Results: Carbetocin was not cost-effective in the Philippines. Deterministic results in a government perspective for CS was at 724,081 PhP while for VD was over 2 million PhP. Deterministic and probabilistic results in the societal perspective for CS and VD were near these respective ICER values and did not also favor carbetocin use. Moreover, the treatment effects of carbetocin in reference to oxytocin were identified as the most sensitive parameter used. On budget impact, if 50% of deliveries would switch to carbetocin for the fiscal years assessed, additional incremental cumulative costs of 1.08 billion PhP for VD and 1.86 billion PhP for CS would be needed.Conclusion: The incremental benefit of carbetocin does not justify the additional costs incurred from purchasing the drug given a Philippine context. Price reduction of carbetocin is recommended if the drug would be publicly reimbursed in the country.

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