Optimal strategies to screen health care workers for COVID-19 in the US: a cost-effectiveness analysis

Background Transmission of SARS-CoV-2 in health care facilities poses a challenge against pandemic control. Health care workers (HCWs) have frequent and high-risk interactions with COVID-19 patients. We undertook a cost-effectiveness analysis to determine optimal testing strategies for screening HCWs to inform strategic decision-making in health care settings. Methods We modeled the number of new infections, quality-adjusted life years lost, and net costs related to six testing strategies including no test. We applied our model to four strata of HCWs, defined by the presence and timing of symptoms. We conducted sensitivity analyses to account for uncertainty in inputs. Results When screening recently symptomatic HCWs, conducting only a PCR test is preferable; it saves costs and improves health outcomes in the first week post-symptom onset, and costs $83,000 per quality-adjusted life year gained in the second week post-symptom onset. When screening HCWs in the late clinical disease stage, none of the testing approaches is cost-effective and thus no testing is preferable, yielding $11 and 0.003 new infections per 10 HCWs. For screening asymptomatic HCWs, antigen testing is preferable to PCR testing due to its lower cost. Conclusions Both PCR and antigen testing are beneficial strategies to identify infected HCWs and reduce transmission of SARS-CoV-2 in health care settings. IgG tests’ value depends on test timing and immunity characteristics, however it is not cost-effective in a low prevalence setting. As the context of the pandemic evolves, our study provides insight to health-care decision makers to keep the health care workforce safe and transmissions low.

Ulcus cruris venosum: Was bringt die frühzeitige endovenöse Ablation bei venösen Ulzerationen?

<b>Importance:</b> One-year outcomes from the Early Venous Reflux Ablation (EVRA) randomized trial showed accelerated venous leg ulcer healing and greater ulcer-free time for participants who are treated with early endovenous ablation of lower extremity superficial reflux. <b>Objective:</b> To evaluate the clinical and cost-effectiveness of early endovenous ablation of superficial venous reflux in patients with venous leg ulceration. <b>Design, Setting, and Participants:</b> Between October 24, 2013, and September 27, 2016, the EVRA randomized clinical trial enrolled 450 participants (450 legs) with venous leg ulceration of less than 6 months’ duration and superficial venous reflux. Initially, 6555 patients were assessed for eligibility, and 6105 were excluded for reasons including ulcer duration greater than 6 months, healed ulcer by the time of randomization, deep venous occlusive disease, and insufficient superficial venous reflux to warrant ablation therapy, among others. A total of 426 of 450 participants (94.7%) from the vascular surgery departments of 20 hospitals in the United Kingdom were included in the analysis for ulcer recurrence. Surgeons, participants, and follow-up assessors were not blinded to the treatment group. Data were analyzed from August 11 to November 4, 2019. <b>Interventions:</b> Patients were randomly assigned to receive compression therapy with early endovenous ablation within 2 weeks of randomization (early intervention, n = 224) or compression with deferred endovenous treatment of superficial venous reflux (deferred intervention, n = 226). Endovenous modality and strategy were left to the preference of the treating clinical team. <b>Main Outcomes and Measures:</b> The primary outcome for the extended phase was time to first ulcer recurrence. Secondary outcomes included ulcer recurrence rate and cost-effectiveness. <b>Results:</b> The early-intervention group consisted of 224 participants (mean [SD] age, 67.0 [15.5] years; 127 men [56.7%]; 206 White participants [92%]). The deferred-intervention group consisted of 226 participants (mean [SD] age, 68.9 [14.0] years; 120 men [53.1%]; 208 White participants [92%]). Of the 426 participants whose leg ulcer had healed, 121 (28.4%) experienced at least 1 recurrence during follow-up. There was no clear difference in time to first ulcer recurrence between the 2 groups (hazard ratio, 0.82; 95% CI, 0.57–1.17; P = .28). Ulcers recurred at a lower rate of 0.11 per person-year in the early-intervention group compared with 0.16 per person-year in the deferred-intervention group (incidence rate ratio, 0.658; 95% CI, 0.480–0.898; P = .003). Time to ulcer healing was shorter in the early-intervention group for primary ulcers (hazard ratio, 1.36; 95% CI, 1.12–1.64; P = .002). At 3 years, early intervention was 91.6% likely to be cost-effective at a willingness to pay of £20 000 ($26 283) per quality-adjusted life year and 90.8% likely at a threshold of £35 000 ($45 995) per quality-adjusted life year. <b>Conclusions and Relevance:</b> Early endovenous ablation of superficial venous reflux was highly likely to be cost-effective over a 3-year horizon compared with deferred intervention. Early intervention accelerated the healing of venous leg ulcers and reduced the overall incidence of ulcer recurrence. <b>Trial Registration:</b> ClinicalTrials.gov identifier: ISRCTN02335796.

Benefits, risks, and cost-effectiveness of COVID-19 self-tests from a consumer’s perspective

Background The aim of this study is to quantify the health benefits, risks, and cost-effectiveness of COVID-19 self-tests from a consumer’s perspective in Germany. Methods The analysis is based on a modelling approach using secondary data. The clinical endpoints considered in this analysis are avoided SARS-CoV-2 infections and secondary severe clinical events (death, intensive care unit (ICU) admission, and long COVID syndrome). The study determines the number of self-tests that need to be conducted under a 7-day incidence of 75 per 100,000 population to prevent one infection or severe clinical event. Furthermore, the study calculates the cost of testing per avoided clinical event and quality-adjusted life year (QALY) gained from a consumer perspective. Results Disregarding the rate of unreported COVID-19 cases, 4556 self-tests need to be conducted (over 12 years) in order to avoid one undesirable event (death, intensive care unit stay, or long COVID syndrome). Ninety percent of infections are not avoided among direct contacts but along the chain of infection. The costs per quality-adjusted life year gained from a consumer’s perspective are €5870. This ratio is particularly sensitive to the 7-day incidence, effective reproduction number, and the age of contacts. Conclusions The benefits of self-testing in the general population at a 7-day incidence rate of 75 per 100,000 appear to be minor. Nevertheless, cost-effectiveness may still be acceptable in the presence of higher-risk contacts given the low costs of self-test kits in Germany.

Análise de ferramentas utilizadas para avaliar o impacto da disfagia em qualidade de vida

Introdução: Disfagia orofaríngea é um sintoma presente em diversas patologias, que sabidamente leva a um comprometimento na qualidade de vida. Algumas ferramentas, principalmente questionários auto aplicados, estão disponíveis para investigar qualidade de vida nos pacientes com disfagia. Entretanto, eles diferem em vários aspectos, como os domínios avaliados, número de itens, opções de resposta e sistemas de pontuação. A presente revisão sistemática tem como objetivo avaliar as ferramentas disponíveis para análise e quantificação objetiva do impacto na qualidade de vida de pacientes com desordens da deglutição, e quais estão devidamente validadas com esse propósito. Metodologia: Foi realizada uma busca sistemática nas bases de dados MEDLINE (EBSCO), SciELO e PubMed, que incluiu os descritores: “deglutition disorders” AND “quality adjusted life years” OR “sickness impact profile” OR “indicators of quality of life”, englobando os artigos publicados nos últimos 10 anos. Os critérios de inclusão foram: 1) abordar disfagia orofaríngea em humanos; 2) correlacionar essa condição clínica com seu impacto na qualidade de vida; 3) avaliar qualidade de vida através de instrumentos objetivos. Em cada estudo, avaliou-se: O desenho, a população-alvo do instrumento desenvolvido, a validação dos questionários, a conclusão do estudo e a aplicabilidade real da ferramenta avaliada. Resultados: Um total de 335 artigos foram encontrados com essa estratégia de busca. Após exclusão dos duplicados, 310 evidências foram analisadas pelo título e resumo, e destas 295 foram excluídas imediatamente por não preencherem os critérios de inclusão. Quinze artigos foram lidos na íntegra, dos quais dez foram incluídos na análise qualitativa. Conclusão: Diversas ferramentas são utilizadas para avaliar a qualidade de vida relacionada à saúde em pacientes com disfagia orofaríngea, mas a maioria não está devidamente validada, ou seu uso é sustentado por estudos de baixa qualidade metodológica. O SWAL-QOL é a ferramenta mais estudada, traduzida para mais línguas e cujas análises psicométricas mostraram melhores resultados, mas novos estudos vêm questionando a qualidade desse instrumento. Assim, reforçamos a importância de estudar objetivamente a correlação entre qualidade de vida de disfagia orofaríngea, mas reiteramos a necessidade de melhores estudos para desenvolvimento de ferramentas com melhor acurácia.

Cost-effectiveness analysis of COVID-19 vaccination in Poland

IntroductionTo assess the potential value of the Comirnaty COVID-19 vaccination in Poland.Material and methodsMarkov model with 1-week cycles was used to estimate patient events, direct medical costs, utilities and cost-effectiveness for one year with and without implementing the Comirnaty vaccine in Poland. The incremental cost per quality-adjusted life-year (QALY) gained vs. no vaccine was calculated for the general population as well as for selected age-groups.ResultsIn the base case analysis the incremental cost per QALY gained associated with vaccinating the whole population amounted 6,249 PLN. For individuals aged 60-69 and >80 vaccination proved to be less costly and more effective than no vaccination. The incremental cost per QALY gained when vaccinating individuals aged 40-49 and 30-39 amounted 28,135 PLN and 67,823 PLN, respectively. In the general population and in younger subpopulations the incremental cost-effectiveness ratio was most sensitive to the vaccine effectiveness, vaccine price and SARS-CoV-2 infection rates.ConclusionsWhen prioritization is required due to supply constraints, vaccination of elderly is justified as it allows to achieve highest number of QALY gained and generates savings to the health care system. Continual update of the model concerning vaccine real-life effectiveness and epidemic course is required to refine the prioritisation scheme in the future.

Quality-adjusted life expectancy norms for the English population

Objective The National Institute for Health and Care Excellence in England has proposed severity-of-disease modifiers that give greater weight to health benefits accruing to patients who experience a larger shortfall in quality-adjusted life years (QALYs) under current standard of care compared to healthy individuals. This requires an estimate of quality-adjusted life expectancy (QALE) of the general population by age and sex. Previous QALE population norms are based on nearly 30-year old assessments of HRQoL in the general population. This study provides updated QALE estimates for the English population by age and sex. Methods EQ-5D-5L data for 14,412 participants from the Health Survey for England (waves 2017 and 2018) were pooled and HRQoL population norms were calculated. These norms were combined with official life tables from the Office for National Statistics for 2017-2019 using the Sullivan method to derive QALE estimates by age and sex. Values were discounted using 0%, 1.5% and 3.5% discount rates. Results QALE at birth is 68.04 QALYs for men and 68.48 QALYs for women. These values are lower than previously published QALE population norms based on older HRQoL data. Additional data tables and figures are made available through an interactive web application: https://r4scharr.shinyapps.io/shortfall/. Conclusions This study provides new QALE population norms for England that serve to establish absolute and relative QALY shortfalls for the purpose of health technology assessments.

Cost-effectiveness of home non-invasive ventilation in COPD group GOLD D patients

Introduction. Chronic obstructive pulmonary disease (COPD) is a major cause of morbidity and mortality, estimated to be the third most common cause of death by 2020. The natural evolution of the disease is characterized by frequent exacerbations, severe exacerbations evolving with respiratory acidosis. Introducing home non-invasive ventilation (NIV) in the management of COPD group GOLD (Global Initiative for Chronic Obstructive Lung Disease) D patients generates supplementary costs, but the decreasing of the number of severe exacerbations will decrease the costs of drug treatment and hospitalization. This balance can be verified through a careful study of cost-effectiveness through modern methods of assessing the costs and years of life gained in relation to quality of life. Material and method. This prospective study took place in the Emergency Department of the Bihor County Clinical Emergency Hospital, Oradea, between 01 October 2017 – 31 October2018, with a follow-up period of 2 years. We included 36 Group risk D COPD patients, presented with severe exacerbation that required NIV; the patients were divided into two study groups according to the treatment scheme after discharge (standard medication according to GOLD guidelines and long-term oxygen therapy - LTOT vs. LTOT + NIV). We follow-up at 2 years with the study group, and analyze the following: number of exacerbations (moderate and severe), number of hospitalizations, mortality rate in two years, average costs for the treatment of exacerbations and for stable COPD periods, quality adjusted life year (QALY). Results and discussions. From 36 enrolled, 10 patients benefited from home NIV. The number of exacerbations was significantly lower in the NIV group compared with the LTOT group (1.72±0.79 vs 3.54±1.18). The incremental cost-effectiveness ratio (ICER) showed a net gain of 31% from gross product (GDP) per capita (5,641.71 ± 1,737.0-euro vs 9,272.3 ± 3,681.9 euro) per quality adjusted life year (QALY) for each patient. Conclusions. Introduction home-NIV demonstrated clinical improvement and higher cost-effectiveness over LTOT alone in Class Risk D, COPD patients after discharge following a severe exacerbation. Keywords: chronic obstructive pulmonary disease, non-invasive ventilation, cost-effectiveness, quality adjusted life year,

Cost–effectiveness of brentuximab vedotin for the treatment of cutaneous T-cell lymphoma

Aim: To assess the cost–effectiveness of brentuximab vedotin (BV) versus physician’s choice (methotrexate or bexarotene) for treating advanced cutaneous T-cell lymphoma. Materials & methods: A partitioned-survival model was developed from the National Health Service perspective in England and Wales. Model inputs were informed by the ALCANZA trial, real-world UK data, published literature or clinical experts. Results: Over the modeled lifetime, BV dominated physician’s choice and provided an additional 1.58 life-years and 1.09 higher quality-adjusted life years with a net cost saving of £119,565. The net monetary benefit was £152,326 using a willingness-to-pay threshold of £30,000/quality-adjusted life year. Results were robust in sensitivity and scenario analyses. Conclusion: BV is a highly cost-effective treatment for advanced cutaneous T-cell lymphoma.