Portfolio Theory and Cost-Effectiveness Analysis: A Further Discussion

AbstractObjectivesPortfolio theory has been suggested as a means to improve the risk–return characteristics of investments in health-care programs through diversification when costs and effects are uncertain. This approach is based on the assumption that the investment proportions are not subject to uncertainty and that the budget can be invested in toto in health-care programs.MethodsIn the present paper we develop an algorithm that accounts for the fact that investment proportions in health-care programs may be uncertain (due to the uncertainty associated with costs) and limited (due to the size of the programs). The initial budget allocation across programs may therefore be revised at the end of the investment period to cover the extra costs of some programs with the leftover budget of other programs in the portfolio.ResultsOnce the total budget is equivalent to or exceeds the expected costs of the programs in the portfolio, the initial budget allocation policy does not impact the risk–return characteristics of the combined portfolio, i.e., there is no benefit from diversification anymore.ConclusionThe applicability of portfolio methods to improve the risk–return characteristics of investments in health care is limited to situations where the available budget is much smaller than the expected costs of the programs to be funded

Treatment costs and quality of life with granulocyte-macrophage colony-stimulating factor in patients with antineoplastic therapy-related febrile neutropenia:Results of a randomised placebo-controlled trial

This study examined the costs of treatment of, and quality of life in, patients with antineoplastic therapy-induced neutropenic fever who were treated with antibacterials, with or without granulocyte-macrophage colony-stimulating factor (GM-CSF). Patients with haematological malignancies (n = 47) or solid tumours (n = 87) who had severe neutropenia (neutrophil count &lt;0.5 x 109/L) and fever (&gt;38.5°C once, or &gt;38°C twice, in a 12-hour observation period) were randomised to receive subcutaneous GM-CSF 5 μg/kg/day (n = 65) or placebo (n = 69) in conjunction with broad-spectrum antibacterials. GM-CSF enhanced neutrophil recovery compared with placebo. Median neutrophil counts at day 4 were 2.9 (range 0 to 25) x 109/L in the GM-CSF arm and 1.3 (range 0 to 9) x 109/L in the placebo group (p &lt; 0.001). No significant difference was observed with regard to median days with neutrophil count ≤1.0 x 109/L or in time to resolution of fever. Quality-of-life scores in 90 patients demonstrated significant differences in favour of the placebo group. The results for the oncology and haematology patients were similar to the results for the total group. patients in the GM-CSF and placebo groups had a mean hospital stay of 7.25 and 8.33 days, respectively. Hospital costs were higher for the GM-CSF-treated patients when GM-CSF was included in the price [mean costs: GM-CSF arm $US5177 vs placebo arm$US4178 (p &lt; 0.05; 1992 values)l. The haematology patients stayed longer in hospital than the oncology patients, resulting in higher total costs for the former group. These results indicate that GM-CSF does not affect the number of days required for resolution of fever or the hospitalisation period for this patient group, and does not provide a cost-effective contribution to the treatment of these patients. Sensitivity analyses indicate that GM-CSF would produce savings if the duration of hospitalisation with GM-CSF was ≤76.5% of that in the placebo group.</p

Cost Effectiveness of Continuous Terbinafine Compared with Intermittent Itraconazole in the Treatment of Dermatophyte Toenail Onychomycosis: An Analysis Based on Results from the L.I.ON. Study

Objective: To compare the costs and effectiveness of 2 oral antifungal treatment regimens in patients with dermatophyte toenail onychomycosis. Design and methods: A cost-effectiveness analysis using a model based on data from the Lamisil versus Itraconazole in Onychomycosis (L.I.ON.) study, a randomised controlled trial comparing continuous terbinafine with intermittent itraconazole. The trial included 4 treatment arms: terbinafine 250 mg/day for 12 or 16 weeks (T12, T16) and itraconazole 400 mg/day for 1 week in every 4 weeks for 12 or 16 weeks (I3, I4). Cost calculations for 6 countries (Finland, Germany, Iceland, Italy, The Netherlands, UK) included costs for medication, physician visits, laboratory tests, management of adverse events and management of relapse. Effectiveness was based on complete cure rates (mycological cure plus 100% toenail clearing). Costs per complete cure were determined and both average and incremental cost-effectiveness ratios were calculated. Perspective: Healthcare system. Main outcome measures and results: In the L.I.ON. study, terbinafine was seen to be more effective than itraconazole (cure rates, 45.8 vs 23.4%). In most comparisons (5 of the 6 countries), the costs of T12 were statistically significantly lower than those of I3 [range: -37 to -173 euros (EUR); 1998 values; 1.172 US dollars = EUR1], indicating that T12 was the dominant strategy (i.e. less expensive and more effective). One exception (Finland) showed an incremental cost-effectiveness ratio of EUR524 per additional cure. In the other 5 countries, T16 and I4 were essentially equal in cost, but the greater effectiveness of T16 (cure rates, 55.1 vs 25.9%) resulted in a situation of extended dominance. Conclusion: From a healthcare system perspective, continuous terbinafine is less costly and more effective than intermittent itraconazole in the treatment of dermatophyte toenail onychomycosis.Antifungals, Cost effectiveness, Itraconazole, Onychomycosis, Pharmacoeconomics, Terbinafine