HEALTH ECONOMICS LETTERS A view from the bridge: agreement between the SF-6D utility algorithm and the Health Utilities Index

Summary Background: The SF-6D is a new health state classification and utility scoring system based on 6 dimensions ('6D') of the Short Form 36, and permits a ''bridging'' transformation between SF-36 responses and utilities. The Health Utilities Index, mark 3 (HUI3) is a valid and reliable multi-attribute health utility scale that is widely used. We assessed within-subject agreement between SF-6D utilities and those from HUI3. Methods: Patients at increased risk of sudden cardiac death and participating in a randomized trial of implantable defibrillator therapy completed both instruments at baseline. Score distributions were inspected by scatterplot and histogram and mean score differences compared by paired t-test. Pearson correlation was computed between instrument scores and also between dimension scores within instruments. Between-instrument agreement was by intra-class correlation coefficient (ICC). Results: SF-6D and HUI3 forms were available from 246 patients. Mean scores for HUI3 and SF-6D were 0.61 (95% CI 0.60-0.63) and 0.58 (95% CI 0.54-0.62) respectively; a difference of 0.03 (p50.03). Score intervals for HUI3 and SF-6D were (-0.21 to 1.0) and (0.30-0.95). Correlation between the instrument scores was 0.58 (95% CI 0.48-0.68) and agreement by ICC was 0.42 (95% CI 0.31-0.52). Correlations between dimensions of SF-6D were higher than for HUI3. Conclusions: Our study casts doubt on the whether utilities and QALYs estimated via SF-6D are comparable with those from HUI3. Utility differences may be due to differences in underlying concepts of health being measured, or different measurement approaches, or both. No gold standard exists for utility measurement and the SF-6D is a valuable addition that permits SF-36 data to be transformed into utilities to estimate QALYs. The challenge is developing a better understanding as to why these classification-based utility instruments differ so markedly in their distributions and point estimates of derived utilities

Is Total Hip Arthroplasty a Cost-Effective Option for Management of Displaced Femoral Neck Fractures? A Trial-Based Analysis of the HEALTH Study

BACKGROUND: Displaced femoral neck fractures are a significant source of morbidity and mortality and can be treated with either hemiarthroplasty (HA) or total hip arthroplasty (THA). Proponents of THA have argued THA offers lower risk of revision, with improved functional outcomes when compared to HA. To evaluate cost effectiveness of THA compared with HA, a trial-based economic analysis of the HEALTH study was undertaken. METHODS: Health care resource utilization (HRU) and health-related quality of life (HRQoL) data were collected postoperatively and costed using publicly available databases. Using EuroQol-5 Dimensions (EQ-5D) scores, we derived quality adjusted life years (QALYs). A 1.5% discount rate to both costs and QALYs was applied. Age analyses per age group were conducted. All costs are reported in 2019 Canadian dollars. RESULTS: When compared with HA, THA was not cost-effective for all patients with displaced femoral neck fractures ($150,000/QALY gained). If decision makers were willing to spend$50,000 or $100,000 to gain one QALY, the probability of THA being cost-effective was 12.8% and 32.8%, respectively. In a subgroup of patients younger than 73 (first quartile), THA was both more effective and less costly. Otherwise, THA was more expensive and yielded marginal HRQoL gains. CONCLUSIONS: Our results suggest that for most patients, THA is not a cost-effective treatment for displaced femoral neck fracture management versus HA. However, THA may be cost effective for younger patients. These patients experience more meaningful improvements in quality of life with less associated cost because of shorter hospital stay and fewer postoperative complications. LEVEL OF EVIDENCE: Economic Level II. See Instructions for Authors for a complete description of levels of evidence

Economic evaluation of an influenza immunization strategy of healthy children.

OBJECTIVES: Vaccinating healthy children is proposed as a strategy to produce a herd effect and protect vulnerable groups. The Hutterite Influenza Prevention Study investigated this strategy, comparing communities with or without childhood influenza immunization programs. There are costs associated with vaccination therefore there may be a trade-off between these costs and the benefits of avoiding influenza cases. This evaluation estimates the cost-effectiveness of immunizing only healthy children in preventing cases of influenza within entire communities. METHODS: Effect data and resource utilization were collected during the trial. Cost data were collected from payer, literature and Internet sources. A two-stage bootstrap (TSB) with shrinkage correction was used to estimate average costs and effects. The incremental cost effectiveness ratio (ICER) and sample uncertainty around this estimate were calculated from the TSB results. RESULTS: Mean costs per patient for the treatment and control arms were $69.07 and$32.66 (difference $36.41). Mean number of influenza cases for the treatment and control arms were 0.04 and 0.27 (difference 0.23). ICER was$164.12 ($28.38,$2767.75) per case of influenza averted. CONCLUSIONS: Immunizing healthy children for influenza is more costly, yet more effective than no immunization in preventing cases in the sample. At a cost of $164.12 to prevent a case of influenza, immunizing healthy children to protect all community members may be considered costeffective. Estimated results are conservative as the influenza season was mild and the sample population was healthy. In a more severe season with a less healthy population the ICER is expected to decrease

Economic Evaluation of Long Term Management Strategies for Erosive Oesophagitis

Objective: To compare the expected costs and outcomes of alternative strategies for the management of patients with erosive oesophagitis. Design: There were 3 components to the overall analytic approach. First, a decision model was constructed to compare expected costs and outcomes of 6 management strategies. Second, principles of quantitative literature review and meta-analysis were used to determine probabilities of clinical events (i.e. oesophagitis healing and recurrence). Finally, principles of cost-effectiveness analysis were used to compare treatment alternatives in terms of dominance and incremental cost effectiveness. The viewpoint for the study was that of a provincial government payer for healthcare over a 1-year period. Main outcome measures and results: Healing rates were significantly higher for proton pump inhibitors (PPI) [pPharmacoeconomics, Reflux-oesophagitis, H2-antagonists, Proton-pump-inhibitors, Gastrokinetics, Cost-effectiveness

Economic Evaluation of Rivastigmine in Patients with Parkinson's Disease Dementia

Background: The positive results of a randomised clinical trial of rivastigmine in patients with dementia associated with Parkinson's disease have been published recently. Patient-level healthcare utilisation data were also collected, and this report is the economic evaluation based on these data. Objective: To determine the cost effectiveness of rivastigmine 3-12 mg/day in patients in whom mild to moderate dementia developed at least 2 years after they received a clinical diagnosis of Parkinson's disease. Methods: A cost-effectiveness analysis was performed by applying Canadian and UK cost weights (year 2004 values) to healthcare utilisation data collected prospectively during a randomised, double-blind, multinational, 24-week trial of rivastigmine 3-12 mg/day (n = 362) versus placebo (n = 179). Patients were >=50 years of age, had a Mini-Mental State Examination (MMSE) score of between 20 and 24 and had contact with a responsible caregiver at least 3 days a week. Quality-adjusted survival time, transformed from MMSE scores, was the measure of effectiveness. Caregiver costs included paid and unpaid time, and direct costs included concomitant medications, outpatient care, hospitalisations, long-term care and study medications. Analysis was conducted from a societal perspective with a time horizon of 24 weeks. Results: Consistent with the improvement in clinical outcomes, there was an observed increase in quality-adjusted survival time in the rivastigmine arm of 2.81 quality-adjusted life-days (two-sided p-value 0.13 [90% CI -0.243, 5.86]). Using Canadian price weights, there was an observed increase in cost in the rivastigmine arm of $Can55.76 (two-sided p-value 0.98 [90$Can7429 per QALY. Using UK price weights, there was an observed decrease in cost in the rivastigmine arm of Lstg 26.18 (two-sided p-value 0.99 [90% CI -2407, 2355]). Conclusion: Although no between-treatment differences in cost were seen, the small sample size, highly variable cost distributions and short time horizon prevent us from making strong conclusions with regard to the effect of rivastigmine on total costs and, by inference, on cost effectiveness.Cost-utility, Dementia, Parkinson's-disease, Rivastigmine

Predictive Genetic Tests and Health Care Costs: A Policy Framework and Illustrative Estimates

Genetic testing has long been part of Canada’s health system, but the scope of genetic testing is growing into new areas. Whereas traditional tests predominantly foretell the health of future generations, new tests increasingly tell individuals about their own health and risks. And whereas traditional tests have focused on rare, single-gene, genetically determined disorders, new tests target common, complex, and multifactorial diseases in which genetics plays only a part. These trends lead to unprecedented clinical and popular interest in genetic tests, and the expanded use of testing will affect both population health and health care costs. Whether the net effects will be positive or negative is a matter of heated debate. Early policy decisions about how tests will be disseminated, provided, and funded will greatly influence the cost and other impacts of new predictive genetic tests. This report examines the potential effect of new predictive genetic test services on health care costs. We offer a general framework that identifies key factors determining the cost impact of a predictive genetic test service and suggests how the choices of health system decision makers influence costs. We also present cost analyses of four specific predictive genetic tests. The report focuses solely on financial cost implications from the formal health care system’s point of view, and does not address the very important questions of impacts on health, wellbeing, productivity, societal costs, or informal care giving. The cost impact of a predictive genetic test depends on, among other things, characteristics of the test, the scope of its application, and the changes in health care utilization (disease surveillance, prevention, and treatment) induced by the test result. For many tests, the cost of performing the test itself makes up only a small proportion of the total health care costs that follow from its use.

Cost Effectiveness in Canada of a Multidrug Prepackaged Regimen (Hp-PAC(R)) Use of tradenames is for product identification only and does not imply endorsement. for Helicobacter pylori Eradication

Objective: To assess the cost effectiveness of a multidrug prepackaged regimen for Helicobacter pylori, the Hp-PAC(R) (lansoprazole 30mg, clarithromycin 500mg, amoxicillin 1g, all twice daily), relative to alternative pharmacological strategies in the management of confirmed duodenal ulcer over a 1-year period from 2 perspectives: (i) a strict healthcare payer perspective (Ontario Ministry of Health) excluding the patient copayment; and (ii) a healthcare payer perspective including the patient copayment. Design: A decision-analytical model was developed to estimate expected per patient costs [1998 Canadian dollars ($Can)], weeks without ulcer and symptomatic ulcer recurrences for the Hp-PAC(R) compared with: proton pump inhibitor (PPI)-clarithromycin-amoxicillin (PPI-CA), PPI-clarithromycin-metronidazole (PPI-CM), PPI-amoxicillin-metronidazole (PPI-AM) and ranitidine-bismuth-metronidazole-tetracycline (RAN-BMT). Main outcome measures and results: All PPI-based regimens had higher expected costs but better outcomes relative to RAN-BMT. From a strict healthcare payer perspective, PPI-CM ($Can209) yielded lower expected costs than PPI-CA ($Can221) and slightly lower costs than Hp-PAC(R) ($Can211). However, these 3 regimens all shared identical outcomes (51.2 weeks without ulcer). When the current Ontario, Canada, $Can2 patient copayment was added to the dispensing fee, Hp-PAC(R) yielded lower costs ($Can214) than PPI-CM ($Can216). Conclusion: From a strict healthcare payer perspective, Hp-PAC(R) is weakly dominated by PPI-CM with an incremental cost effectiveness (relative to RAN-BMT) of$Can5.77 per ulcer week averted. When the patient copayment is added to this perspective, Hp-PAC(R) weakly dominates PPI-CM ($Can5 per ulcer week averted). Regardless of perspective, Hp-PAC(R) and PPI-CM differed by only$Can2 per patient over 1 year and the expected time without ulcer was 51.2 weeks for both. More data on the clinical and statistical differences in H. pylori eradication with Hp-PAC(R) and PPI-CM would be useful. This analysis does not include the possible advantage of Hp-PAC(R) in terms of compliance and antibacterial resistance.Amoxicillin, Clarithromycin, Cost effectiveness, Duodenal ulcer, Helicobacter pylori eradication therapies, Lansoprazole, Metronidazole, Pharmacoeconomics, Ranitidine bismutrex, Tetracycline

Economic evaluation of reamed versus unreamed intramedullary nailing in patients with closed and open tibial fractures : results from the study to prospectively evaluate reamed intramedullary nails in patients with tibial fractures (SPRINT)

Recently, results from the large, randomized study to prospectively evaluate reamed intramedullary nails in patients with tibial fractures (SPRINT) trial suggested a benefit for reamed intramedullary nail insertion in patients with closed tibial shaft fractures largely based on cost-neutral autodynamizations and a potential advantage for unreamed intramedullary nailing in open fractures. We performed an economic evaluation to compare resource use and effectiveness of reamed and unreamed intramedullary nailing using a cost-utility analysis