Cost-Effectiveness of Mobile Stroke Unit Care in Norway

Background: Acute ischemic stroke treatment in mobile stroke units (MSUs) reduces time-to-treatment and increases thrombolytic rates, but implementation requires substantial investments. We wanted to explore the cost-effectiveness of MSU care incorporating novel efficacy data from the Norwegian MSU study, Treat-NASPP (the Norwegian Acute Stroke Prehospital Project). Methods: We developed a Markov model linking improvements in time-to-treatment and thrombolytic rates delivered by treatment in an MSU to functional outcomes for the patients in a lifetime perspective. We estimated incremental costs, health benefits, and cost-effectiveness of MSU care as compared with conventional care. In addition, we estimated a minimal MSU utilization level for the intervention to be cost-effective in the publicly funded health care system in Norway. Results: MSU care was associated with an expected quality-adjusted life-year-gain of 0.065 per patient, compared with standard care. Our analysis suggests that about 260 patients with ischemic stroke need to be treated with MSU annually to result in an incremental cost-effectiveness ratio of about NOK385 000 (US$43 780) per quality-adjusted life-year for MSU compared with standard care. The incremental cost-effectiveness ratio varies between some NOK1 000 000 (US$113 700) per quality-adjusted life-year if an MSU treats 100 patients per year and to about NOK340 000 (US$38 660) per quality-adjusted life-year if 300 patients with acute ischemic stroke are treated. Conclusions: MSU care in Norwegian settings is potentially cost-effective compared with conventional care, but this depends on a relatively high annual number of treated patients with acute ischemic stroke per vehicle. These results provide important information for MSU implementation in government-funded health care systems.publishedVersio

Minimal-invasiv glaukomkirurgi (MIGS) for individer med glaukom. En metodevurdering

Source at https://www.fhi.no/en/publ/2021/Minimally-Invasive-Glaucoma-Surgery-MIGS-for-individuals-with-glaucoma/Key messages: This health technology assessment (HTA) summarises and supplements a 2019 Canadian HTA on the effectiveness and safety of micro-invasive glaucoma surgery (MIGS) versus other treatment options. Further, it contains cost-effectiveness analysis based on the Canadian HTA, in addition to patient partners’ considerations, organizational and ethical considerations relevant to discussions of MIGS’ role in Norwegian routine care. The Canadian evidence, which included 32 studies and 24 comparisons, was inconclusive due to very low to low certainty. Our supplementary findings show that: • MIGS with Hydrus Microstent combined with cataract surgery reduces intraocular pressure (IOP) at 24 months, compared with cataract surgery alone (high-certainty evidence) • MIGS with iStent inject combined with cataract surgery probably reduces IOP at 24 months, compared with cataract surgery alone (moderate-certainty evidence) • For other techniques there is either no or little difference between the MIGS and control interventions, or it is uncertain whether there is a difference in effectiveness • Neither MIGS procedures, nor alternative surgical strategies appear to be at high risk of adverse events • Lifetime total cost for glaucoma treatment ranged from NOK 30 000 to NOK 83 000 per patient, depending on treatment strategy and baseline disease stage. The incremental Quality adjusted life years (QALYs) for MIGS between comparators ranged between – 0.080 and 0.057 • MIGS is suitable as a outpatient surgery without hospital admission. Clinicians need training. Clear criteria for patient selection shuld be developed. Experts predict that the number of MIGS procedures may increase to twice as many in 2024 than today • The clinical evidence on MIGS is limited. The main reason for this is the lack of comparative studies. Our health economic evaluation shows some scenarios where MIGS may be cost-effective, depending on comparator and disease stage. Our analysis puts individuals with glaucoma in severity class 1.Hovedbudskap: Denne metodevurderingen (HTA) oppsummerer og supplerer en kanadisk HTA fra 2019 om effekt og sikkerhet ved minimal-invasiv glaukomkirurgi (MIGS). Videre gjorde vi kost-nytteanalyser basert på den kanadiske HTAen, i tillegg til brukerperspektiv, organisatoriske og etiske vurderinger som er relevante i en diskusjon om hvorvidt MIGS bør være et rutinetilbud i norsk praksis. Det kanadiske kunnskapsgrunnlaget, som omfattet 32 studier og 24 sammenlikninger, var usikkert på grunn av svært lav til lav tillit til resultatene. Våre supplerende funn viser at: • MIGS med Hydrus Microstent kombinert med kataraktkirurgi reduserer intraokulært trykk (IOP) etter 24 måneder, sammenliknet med kataraktkirurgi alene (høy tillit til resultatet) • MIGS med iStent inject og kataraktkirurgi reduserer trolig IOP etter 24 måneder, sammenliknet med kataraktkirurgi alene (middels tillit til resultatet) • Det er usikkert hvorvidt det er noen forskjell i effekt mellom MIGS og kontrollgruppene for andre sammenligninger • Det ser ikke ut til å være noen betydelig forskjell mellom MIGS og kontrollgruppene i risiko for uønskede hendelser/skader • Total livstidskostnad per pasient for glaukombehandling ble estimert mellom 30 000 norske kroner og 83 000 norske kroner avhengig av behandlingsstrategi og sykdomsstadie ved start. Inkrementell QALY for MIGS sammenlignet med komparatorer var mellom – 0.080 og 0.057 • MIGS egner seg for poliklinisk kirurgi. Øyeleger må ha opplæring for å utføre MIGS. Det bør utvikles klare kriterier for pasientseleksjon. Eksperter predikerer en dobling av antall MIGS prosedyrer i 2024 enn antallet i dag • Kunnskapsgrunnlaget for effekt og sikkerhet om MIGS er begrenset. Hovedgrunnen er mangel på sammenliknende studier. Vår helseøkonomiske vurdering viser at MIGS kan være kostnadseffektive, avhengig av sammenliknng og sykdomsutvikling. Vår analyse setter individer med glaukom i gruppe for alvorlighetsgrad 1

Vurdering av fire intensive habiliteringsprogram for barn og unge med hjerneskade: en fullstendig metodevurdering

Background Some children and adolescents with brain damage and their families use intensive rehabilitation programs like Advanced Bio-Mechanical Rehabilitation, the Institutes for the Achievement of Human Potential program, the Family Hope Center program and the Kozijavkin method. However, the programs are controversial among medical professionals and represent major costs to health care services and society. Objective In this health technology assessment, we assessed the clinical efficacy and safety of intensive programs for children and adolescents with brain damage, performed a health economic evaluation related to the programs and two Norwegian regional programs as comparator, and highlighted some ethical challenges. Method Clinical efficacy and safety: We performed systematic literature searches in nine databases for controlled studies on the above-mentioned intensive habilitation programs. We critically assessed studies using the Risk of Bias-tool, descriptively summarized outcome data and graded overall results using Grading of Recommendations Assessment, Development and Evaluation. Health Economic Evaluation: We described costs of the four intensive habilitation programs, and two Norwegian intensive rehabilitation program as comparator. Cost description included an estimate for total costs and mean costs per participant with family. We described costs in a healthcare perspective, with a time horizon of 1 year. Ethical assessment: We used a stepwise method that included identification of stakeholders, identification of moral questions, illuminating questions through literature search, hearings and user involvement, and summarization of process. Results Clinical efficacy and safety: We found three small controlled trials involving 94 participants that assessed the effectiveness of the Institutes for the Achievement of Human Potential program and the Family Hope Center program compared to standard treatment. Over time, none of the studies found difference in gross motor, fine motor and cognitive function between the interventions and control conditions but the evidence had very low quality assessed by the Grading of Recommendations Assessment, Development and Evaluation (GRADE). None of the studies assessed safety outcomes of the programs. We found no controlled studies on efficacy and safety of Advanced Bio-Mechanical Rehabilitation and the Kozijavkin method. Health Economic Evaluation: In 2015, the total costs of the four intensive programs were 31,876,669 Norwegian kroner. The mean cost per participant with family was 426,146 Norwegian kroner. Two Norwegian intensive programs used as comparison had in 2015 an estimated total cost of 9,675,202 million Norwegian kroner and a mean cost per participant with family of 225,005 Norwegian kroner. Ethical assessment: A practice in which patients participating in foreign intensive habilitation programs receive public funding for both participation in and training between program participation may legitimize the use of non-documented treatment and in some cases impair patients' possibility for normal social participation. Discussion Clinical efficacy and safety: Despite thorough searches in nine databases and review of the programs' websites, we found only three studies with control groups on the Institutes for the Achievement of Human Potential program and the Family Hope Center program. Two of the studies were over 35 years old. The included studies used different tools for evaluation of efficacy, and lack of description of the variation in outcomes data (standard deviation or confidence interval) in two of the studies prevented synthesizing of data in meta-analysis. We identified no controlled studies on Advanced Bio-Mechanical Rehabilitation or the Kozijavkin method. Health Economic Evaluation: Absence of guidelines and lack of documentation for effectiveness of the foreign intensive habilitation programs indicated that it was not relevant to perform a full economic evaluation. Ethical assessment: Extensive use of foreign habilitation programs raises several moral questions. Our goal was to shed light on some ethical questions related to this issue, but the topic could have been wider illuminated in a complete ethical analysis. Conclusion None of the studies on the Institutes for the Achievement of Human Potential program and the Family Hope Center program found difference in the effect on gross motor, fine motor and cognitive function over time, compared to standard treatment, but the quality of the documentation was very low. Lack of data prevents us from concluding on safety of the Institutes for the Achievement of Human Potential program and the Family Hope Center program. Lack of controlled studies indicates that we cannot conclude on the efficacy and safety of Advanced Bio-Mechanical Rehabilitation and the Kozijavkin method. The mean cost per patient with brain damage and their family is about twice as high for foreign habilitation compared to two Norwegian intensive habilitation programs. Based on an ethical perspective, the practice of public funding of participation in foreign habilitation programs may contribute to legitimization of non-documented treatment. Participation in some intensive programs can also reduce children and families' opportunities for normal social interaction and self-expression. Despite this, many parents experience that they are well taken care of in the programs

Minimally Invasive Glaucoma Surgery (MIGS) for individuals with glaucoma. A health technology assessment

Key messages: This health technology assessment (HTA) summarises and supplements a 2019 Canadian HTA on the effectiveness and safety of micro-invasive glaucoma surgery (MIGS) versus other treatment options. Further, it contains cost-effectiveness analysis based on the Canadian HTA, in addition to patient partners’ considerations, organizational and ethical considerations relevant to discussions of MIGS’ role in Norwegian routine care. The Canadian evidence, which included 32 studies and 24 comparisons, was inconclusive due to very low to low certainty. Our supplementary findings show that: • MIGS with Hydrus Microstent combined with cataract surgery reduces intraocular pressure (IOP) at 24 months, compared with cataract surgery alone (high-certainty evidence) • MIGS with iStent inject combined with cataract surgery probably reduces IOP at 24 months, compared with cataract surgery alone (moderate-certainty evidence) • For other techniques there is either no or little difference between the MIGS and control interventions, or it is uncertain whether there is a difference in effectiveness • Neither MIGS procedures, nor alternative surgical strategies appear to be at high risk of adverse events • Lifetime total cost for glaucoma treatment ranged from NOK 30 000 to NOK 83 000 per patient, depending on treatment strategy and baseline disease stage. The incremental Quality adjusted life years (QALYs) for MIGS between comparators ranged between – 0.080 and 0.057 • MIGS is suitable as a outpatient surgery without hospital admission. Clinicians need training. Clear criteria for patient selection shuld be developed. Experts predict that the number of MIGS procedures may increase to twice as many in 2024 than today • The clinical evidence on MIGS is limited. The main reason for this is the lack of comparative studies. Our health economic evaluation shows some scenarios where MIGS may be cost-effective, depending on comparator and disease stage. Our analysis puts individuals with glaucoma in severity class 1

Minimally Invasive Glaucoma Surgery (MIGS) for individuals with glaucoma. A health technology assessment

Key messages: This health technology assessment (HTA) summarises and supplements a 2019 Canadian HTA on the effectiveness and safety of micro-invasive glaucoma surgery (MIGS) versus other treatment options. Further, it contains cost-effectiveness analysis based on the Canadian HTA, in addition to patient partners’ considerations, organizational and ethical considerations relevant to discussions of MIGS’ role in Norwegian routine care. The Canadian evidence, which included 32 studies and 24 comparisons, was inconclusive due to very low to low certainty. Our supplementary findings show that: • MIGS with Hydrus Microstent combined with cataract surgery reduces intraocular pressure (IOP) at 24 months, compared with cataract surgery alone (high-certainty evidence) • MIGS with iStent inject combined with cataract surgery probably reduces IOP at 24 months, compared with cataract surgery alone (moderate-certainty evidence) • For other techniques there is either no or little difference between the MIGS and control interventions, or it is uncertain whether there is a difference in effectiveness • Neither MIGS procedures, nor alternative surgical strategies appear to be at high risk of adverse events • Lifetime total cost for glaucoma treatment ranged from NOK 30 000 to NOK 83 000 per patient, depending on treatment strategy and baseline disease stage. The incremental Quality adjusted life years (QALYs) for MIGS between comparators ranged between – 0.080 and 0.057 • MIGS is suitable as a outpatient surgery without hospital admission. Clinicians need training. Clear criteria for patient selection shuld be developed. Experts predict that the number of MIGS procedures may increase to twice as many in 2024 than today • The clinical evidence on MIGS is limited. The main reason for this is the lack of comparative studies. Our health economic evaluation shows some scenarios where MIGS may be cost-effective, depending on comparator and disease stage. Our analysis puts individuals with glaucoma in severity class 1