Aspirin with Low-Dose Ticagrelor or with Low-Dose Rivaroxaban for Secondary Prevention: A Cost Per Outcome Analysis

Introduction: Secondary prevention of cardiovascular events among patients with diagnosed cardiovascular disease and high ischemic risk poses a significant challenge in clinical practice. The combinations of aspirin with low dose (LD) Ticagrelor or LD-Rivaroxaban have shown superiority in preventing major adverse cardiovascular events (MACE) than aspirin treatment alone. The comparative value for money of these two regimens remains unexplored.Methods: We analyzed each regimen's annual cost needed to treat (CNT) by multiplying the annualized number needed to treat (aNNT) by the annual cost of each drug. The aNNTs were based on outcome data from PEGASUS TIMI-54 and COMPASS trials. Scenario analyses were performed to overcome variances in terms of population risk. Costs were based on 2021 US prices. The primary outcome was defined as CNT to prevent one MACE across the two regimens. Secondary value analysis was performed for myocardial infarction (MI), stroke, and CV death as separate outcomes. Results: The aNNTs to prevent MACE with LD-Ticagrelor and with LD-Rivaroxaban were 229 [95% confidence interval (CI):141-734] and 147 (95%CI:104-252), respectively. At an annual cost of 3,618$ versus 4,308$, the corresponding CNTs were 828,478$ (95%CI:510,111$-2,655,471$) with LD-Ticagrelor and 633,270$ (95%CI:448,028$-1,085,607$) with LD-Rivaroxaban. LD-Rivaroxaban.Conclusion: Combining aspirin with LD-Rivaroxaban provides better value for money than with LD-Ticagrelor for secondary prevention of MACE.

Exploring drug cost and disease outcome in rheumatoid arthritis patients treated with biologic and targeted synthetic DMARDs in Norway in 2010–2019 – a country with a national tender system for prescription of costly drugs

Background In Norway, an annual tender system for the prescription of biologic and targeted synthetic disease-modifying antirheumatic drugs (b/tsDMARDs) has been used since 2007. This study aimed to explore annual b/tsDMARDs costs and disease outcomes in Norwegian rheumatoid arthritis (RA) patients between 2010 and 2019 under the influence of the tender system. Methods RA patients monitored in ordinary clinical practice were recruited from 10 Norwegian centers. Data files from each center for each year were collected to explore demographics, disease outcomes, and the prescribed treatment. The cost of b/tsDMARDs was calculated based on the drug price given in the annual tender process. Results The number of registered RA patients increased from 4909 in 2010 to 9335 in 2019. The percentage of patients receiving a b/tsDMARD was 39% in 2010 and 45% in 2019. The proportion of b/tsDMARDs treated patients achieving DAS28 remission increased from 42 to 67%. The estimated mean annual cost to treat a patient on b/tsDMARDs fell by 47%, from 13.1 thousand euros (EUR) in 2010 to 6.9 thousand EUR in 2019. The mean annual cost to treat b/tsDMARDs naïve patients was reduced by 75% (13.0 thousand EUR in 2010 and 3.2 thousand EUR in 2019). Conclusions In the period 2010–2019, b/tsDMARD treatment costs for Norwegian RA patients were significantly reduced, whereas DAS28 remission rates increased. Our data may indicate that the health authorities’ intention to reduce treatment costs by implementing a tender system has been successful.

Cost of illness of oral lichen planus: a multicenter university hospital–based outpatient observational study

Objectives To estimate the economic costs of oral lichen planus (OLP) through a multicenter university hospital–based outpatient study conducted in Italy and Finland. Materials and methods A multicenter retrospective study was conducted on patients affected by OLP to evaluate the economic cost of managing the disease. Direct costs concerning diagnostic procedures, therapeutic management, and follow-up visits were obtained from clinical records. Statistics was performed with IBM SPSS Statistics. Results One hundred and eight patients with a confirmed diagnosis of OLP (81 women and 27 men), 58 Italians and 50 Finnish, were enrolled in this study. The mean annual cost was 1087.2 euros per patient. The mean annual cost was higher in Finnish than in Italian cohort (1558.7 euros vs. 680.7 euros—p < 0.05). Within the Italian cohort, the local immunosuppressive therapy group and atrophic and erosive OLP type had a higher cost (p < 0.05). Within the Finnish cohort, the local immunosuppressive therapy group had a higher cost (p < 0.05). Conclusions OLP-related costs are very similar to other chronic oral disorders (i.e., periodontitis) with differences between investigated countries. Moreover, patients with more severe clinical features, who need immunosuppressive therapy, are facing more expensive costs. Clinical relevance. In this multicenter cost of illness study, we estimated the direct health care costs of OLP and we found that patients with more severe clinical features, who therefore need symptomatic therapy, are facing more expensive costs.

Reducing total annual cost and CO2 emissions in batch distillation for separating ternary wide boiling mixtures using vapor recompression heat pump

This paper presents cost-effective heat pump assisted vapor recompression (VRC) design algorithms for the separation of ternary wide boiling mixture in batch distillation in order to reduce total annual cost (TAC) and carbon dioxide (CO2) emissions. A minimum TAC and CO2 is required by the batch distillation process industry for any investments in heat integrated systems, such as VRC. Consequently, the design conditions for implementing VRC should be chosen such that the energetic performance is maximum at minimum TAC. The model system selected in this paper is an application involving high temperature lift, that is, hexanol–octanol–decanol ternary wide boiling mixture. First, a systematic simulation algorithm was developed for conventional multicomponent batch distillation (CMBD) and single-stage vapor recompressed multicomponent batch distillation (SiVRMBD) to determine the optimal number of stages based on the maximum TAC savings. The SiVRMBD saves more energy and TAC than CMBD. However, SiVRMBD has a high compression ratio (CR) throughout the operation, which is not practically feasible for the batch distillation processing. Second, in order to increase the performance and minimize the SiVRMBD weakness, a novel optimal multi-stage vapor recompression algorithm was proposed to operate at the lowest possible CR (<3.5) throughout the batch operation while also conserving the most TAC. Overall, the findings suggest that the proposed optimal multi-stage VRC reduces TAC and CO2 emissions significantly when compared to CMBD. Finally, the influence of the different feed compositions on VRC performance is also studied.

Optimization and technical-economic analysis of the production of 5-hydroxymethylfurfural from glucose / Otimização e análise técnico-econômica da produção de 5-hidroximetilfurfural a partir da glicose

In this study, the optimization of four processing schemes were developed for the production of 5 hydroxymethylfurfural (HMF), a chemical platform compound obtained from lignocellulosic biomass and used to make the connection with products from fossil resources. Despite its wide applicability, problems associated with its synthesis hindered its greater use. In this scenario the use of a computer program stands out, as the optimization of processes can be used, evaluating the factors and finding parameters that minimize the costs associated with its production. The optimization of these systems was made from the minimization of the total annual cost of the process carried out through the Aspen Plus® v.11 software, in addition, the economic feasibility of the process was analyzed and it was possible to obtain the HMF at 1.00$ .kg-1 and the co-product levulinic acid between 1.92 and 3.08 $.kg-1. It was also possible to note that among the operating costs, those from glucose had the greatest effect on its value, whereas in relation to equipment costs, reactors and distillation columns were the ones that had the greatest influence.

The early-stage comprehensive costs of routine PrEP implementation and scale-up in Zambia

Introduction: Pre-exposure prophylaxis (PrEP) is effective at preventing HIV infection, but PrEP cost-effectiveness is sensitive to PrEP implementation and program costs. Preliminary studies indicate that, in addition to direct delivery cost, PrEP provision requires substantial demand creation and user support to encourage PrEP initiation and persistence. We estimated the cost of providing PrEP in Zambia through different PrEP delivery models. Methods: Taking a guidelines-based approach for visits, labs and drugs assuming fidelity to the expanded 2018 Zambian PrEP guidelines, we estimated the annual cost of providing PrEP per client for five delivery models: one focused on key populations (men-who-have-sex-with-men (MSM) and female sex workers (FSW), one on adolescent girls and young women (AGYW), and three integrated programs (operated within the HIV counselling and testing service at primary healthcare centres). Program start-up, provider, and user support costs were based on program expenditure data and number of PrEP sites and clients in 2018. PrEP clinic visit costs were based on micro-costing at two PrEP delivery sites (in 2018 USD). Results: The annual cost per PrEP client varied greatly by program type, from $394 (AGYW) to $760 in an integrated program. Cost differences were driven largely by volume (i.e. the number of clients initiated/model/site) which impacted the relative costs of program support and technical assistance assigned to each PrEP client. Direct service delivery costs, including staff and overheads, labs and monitoring, drugs and consumables ranged narrowly from $208-217/PrEP-user. Service delivery costs were a key component in the cost of PrEP, representing 36-65% of total costs. Reductions in service delivery costs per PrEP client are expected with further scale-up. Conclusions: The results show that, even when integrated into full service delivery models, accessing vulnerable, marginalised populations at substantial risk of HIV infection is likely to cost more than previously estimated due to the programmatic costs involved in community sensitization and user support. Improved data on individual client resource usage (e.g. drugs, labs, visits) and outcomes (e.g. initiation, persistence) is required to get a better understanding of the true resource utilization, cost and expected outcomes and annual costs of different PrEP programs in Zambia.

Real-World Comparative Cost-Effectiveness Analysis of Different Classes of Disease-Modifying Therapies for Relapsing-Remitting Multiple Sclerosis in Saudi Arabia

The very fact that multiple sclerosis (MS) is incurable and necessitates life-long care makes it one of the most burdensome illnesses. The aim of this study was to compare the cost-effectiveness of orally administered medications (e.g., fingolimod, dimethyl fumarate, and teriflunomide), interferon (IFN)-based therapy, and monoclonal antibodies (MABs) (e.g., natalizumab and rituximab) in the management of relapsing-remitting multiple sclerosis (RRMS) in Saudi Arabia using real-world data. This was a retrospective cohort study in which patients with RRMS aged ≥18 years without any other chronic health conditions with non-missing data for at least 12 months were recruited from the electronic health records of a university-affiliated tertiary care center. Multiple logistic regressions controlling for age, sex, and duration of therapy were conducted to examine the odds of disability progression, clinical relapse, MRI lesions, and composite outcome (e.g., relapse, lesion development on MRI, disability progression). The number of patients who met the inclusion criteria and were included in the analysis was 146. Most of the patients were female (70.51%) and young (e.g., ≤35 years of age). There were 40 patients on the orally administered agents (e.g., dimethyl fumarate, teriflunomide, fingolimod), 66 patients were on IFN-based therapy (e.g., Rebif®), and 40 patients were on monoclonal antibodies (e.g., rituximab and natalizumab). Patients on MABs had lower odds of the composite outcome (OR = 0.17 (95% CI: 0.068–0.428)). The use of orally administered agents was dominant (e.g., more effective and less costly), with average annual cost savings of USD −4336.65 (95% CI: −5207.89–−3903.32) and 8.11% higher rate of effectiveness (95% CI: −14.81–18.07) when compared with Rebif®. With regard to the use of MABs in comparison to Rebif®, MABs were associated with higher cost but a better rate of effectiveness, with an average additional annual cost of USD 1381.54 (95% CI: 421.31–3621.06) and 43.11% higher rate of effectiveness (95% CI: 30.38–61.15) when compared with Rebif®. In addition, the use of MABs was associated with higher cost but a better rate of effectiveness, with an average additional annual cost of USD 5717.88 (95% CI: 4970.75–8272.66) and 35% higher rate of effectiveness (95% CI: 10.0–42.50) when compared with orally administered agents. The use of MABs in the management of RRMS among the young patient population has shown to be the most effective therapy in comparison to both IFN-based therapy (e.g., Rebif®) and orally administered agents, but with higher cost. Orally administered agents resulted in better outcomes and lower costs in comparison to IFN-based therapy. Future studies should further examine the cost-effectiveness of different disease-modifying therapies for the management of RRMS using more robust study designs.

Cost Disclosure of Surgeon “Scorecards”: Effects on Operating Room Costs for Total Hip and Knee Arthroplasty

Background: Rising health care costs, coupled with an emphasis on cost containment, continue to gain importance. Surgeon cost scorecards developed to track case-based expenditures can help surgeons compare themselves with their peers and identify areas of potential quality improvement. Purpose: We sought to investigate what effect surgeon scorecards had on operating room (OR) costs in orthopedic surgery. Methods: Our hospital distributed OR cost scorecards to 4 adult reconstruction fellowship-trained orthopedic surgeons beginning in 2012. The average direct per-case supply cost of procedures was calculated quarterly and collected over a 5-year period, and each surgeon’s data were compared with that of their peers. All 4 surgeons were made aware of the costs of other surgeons at the 2-year mark. The initial 2 years of data was compared with that of the final 2 years. Results: The average direct per-case supply cost ranged from $4955 to $5271 for total knee arthroplasty (TKA) and $5469 to $5898 for total hip arthroplasty (THA) during the initial 2-year period. After implementing disclosures, the costs for TKA and THA, respectively, ranged from $4266 to $4515 (14% annual cost savings) and from $5073 to $5727 (5% annual cost savings); 3 of the 4 surgeons said that cost transparency altered their practice. Conclusion: Our comparison suggests that orthopedic surgeons’ participation in a program of operative cost disclosure may be useful to them; we found a possible association with reduced per-case costs for TKA and THA at our institution over a 5-year period. More rigorous study that incorporates the effects of the scorecards on patient outcomes is warranted.

Annual Cost and Loss Minimization in a Radial Distribution Network by Capacitor Allocation Using PSO

Increasing power demand from passive distribution networks has led to deteriorated voltage profiles and increased line flows. This has increased the annual operations and installation costs due to unavoidable reinforcement equipment. This work proposes the reduction in annual costs by optimal placement of capacitors used to alleviate power loss in radial distribution networks (RDNs). The optimization objective function is formulated for the reduction in operation costs by (i) reducing the active and reactive power losses, and (ii) the cost and installation of capacitors, necessary to provide the reactive power support and maintain the voltage profile. Initially, the network buses are ranked according to two loss sensitivity indices (LSIs), i.e., active loss sensitivity with respect to node voltage (LSI1) and reactive power injection (LSI2). The sorted bus list is then fed to the particle swarm optimization (PSO) for solving the objective function. The efficacy of the proposed work is tested on different IEEE standard networks (34 and 85 nodes) for different use cases and load conditions. In use case 1, the values finalized by the algorithm are selected without considering their market availability, whereas in use case 2, market-available capacitor sizes close to the optimal solution are selected. Furthermore, the static and seasonal load profiles are considered. The results are compared with recent methods and have shown significant improvement in terms of annual cost, losses and line flows reduction, and voltage profile.