Cost-utility analysis of prenatal diagnosis of congenital cardiac diseases using deep learning.

BACKGROUND: Deep learning (DL) is a new technology that can assist prenatal ultrasound (US) in the detection of congenital heart disease (CHD) at the prenatal stage. Hence, an economic-epidemiologic evaluation (aka Cost-Utility Analysis) is required to assist policymakers in deciding whether to adopt the new technology. METHODS: The incremental cost-utility ratios (CUR), of adding DL assisted ultrasound (DL-US) to the current provision of US plus pulse oximetry (POX), was calculated by building a spreadsheet model that integrated demographic, economic epidemiological, health service utilization, screening performance, survival and lifetime quality of life data based on the standard formula: CUR = Increase in Intervention Costs - Decrease in Treatment costs Averted QALY losses of adding DL to US & POX US screening data were based on real-world operational routine reports (as opposed to research studies). The DL screening cost of 145 USD was based on Israeli US costs plus 20.54 USD for reading and recording screens. RESULTS: The addition of DL assisted US, which is associated with increased sensitivity (95% vs 58.1%), resulted in far fewer undiagnosed infants (16 vs 102 [or 2.9% vs 15.4%] of the 560 and 659 births, respectively). Adoption of DL-US will add 1,204 QALYs. with increased screening costs 22.5 million USD largely offset by decreased treatment costs (20.4 million USD). Therefore, the new DL-US technology is considered "very cost-effective", costing only 1,720 USD per QALY. For most performance combinations (sensitivity > 80%, specificity > 90%), the adoption of DL-US is either cost effective or very cost effective. For specificities greater than 98% (with sensitivities above 94%), DL-US (& POX) is said to "dominate" US (& POX) by providing more QALYs at a lower cost. CONCLUSION: Our exploratory CUA calculations indicate the feasibility of DL-US as being at least cost-effective.

Multinational Analysis of Estimated Health Care Costs Related to Extended-Interval Fixed Dosing of Checkpoint Inhibitors.

Importance: New dosing options for immune checkpoint inhibitors have recently been approved by the US Food and Drug Administration (FDA), including fixed dosing with extended intervals. Although the dose intensity appears the same, there is expected to be some waste with extended-interval dosing, as some drug remains in the bloodstream once a decision to stop treatment is made. The economic impact of extended-interval fixed dosing is unknown compared with standard-interval fixed dosing. Objective: To analyze the potential health care costs of using extended-interval fixed dosing instead of standard-interval fixed dosing. Design, Setting, and Participants: This economic evaluation used a pharmacoeconomic model to simulate 2 cohorts of patients with platinum-resistant metastatic urothelial cancer receiving pembrolizumab as second-line therapy at different dosing intervals using 2020 pricing data. Data were analyzed from 2020 to 2022. Exposures: The simulated patients received FDA-approved regimens of either 200 mg every 3 weeks or 400 mg every 6 weeks. Main Outcomes and Measures: The progression-free survival curve from the KEYNOTE-045 trial was used to estimate treatment duration. Drug, imaging, and administration costs were included in analyses. Sensitivity analyses were performed to assess how different imaging frequencies would affect the model results. The potential overall costs of using the 2 different dosing strategies were assessed. The base case was set in the US, while sensitivity analyses were set in several other countries. Results: In the base case analysis, dosing every 6 weeks instead of every 3 weeks resulted in an estimated 8.9% increase in pembrolizumab costs for the health care payer. Accounting for a decrease in infusion costs would result in an estimated net additional cost of $7483 per patient in the US (7.9% cost increase). In the US, this would amount to an increase of approximately $28 million annually for health care payers. Similar percentages in cost estimate increases were found for health care payers around the world, such as in Israel, where the net additional cost would be $5491 per patient. Conclusions and Relevance: This economic evaluation assessed and quantified the potential increased costs related to extended-interval fixed dosing of pembrolizumab. The model method could be applied to other diseases and other drugs for which there has been a movement toward extended-interval dosing. Results may differ in other diseases owing to differing disease courses and patient profiles.

Prevention, screening and treatment of colorectal cancer: a global and regional generalized cost effectiveness analysis.

BACKGROUND: Regional generalized cost-effectiveness estimates of prevention, screening and treatment interventions for colorectal cancer are presented. METHODS: Standardised WHO-CHOICE methodology was used. A colorectal cancer model was employed to provide estimates of screening and treatment effectiveness. Intervention effectiveness was determined via a population state-transition model (PopMod) that simulates the evolution of a sub-regional population accounting for births, deaths and disease epidemiology. Economic costs of procedures and treatment were estimated, including programme overhead and training costs. RESULTS: In regions characterised by high income, low mortality and high existing treatment coverage, the addition of screening to the current high treatment levels is very cost-effective, although no particular intervention stands out in cost-effectiveness terms relative to the others.In regions characterised by low income, low mortality with existing treatment coverage around 50%, expanding treatment with or without screening is cost-effective or very cost-effective. Abandoning treatment in favour of screening (no treatment scenario) would not be cost effective.In regions characterised by low income, high mortality and low treatment levels, the most cost-effective intervention is expanding treatment. CONCLUSIONS: From a cost-effectiveness standpoint, screening programmes should be expanded in developed regions and treatment programmes should be established for colorectal cancer in regions with low treatment coverage.

Issues in estimating smoking attributable mortality in Israel.

BACKGROUND: The US Centres for Disease Control provides a widely used online user-friendly computational program, called SAMMEC (Smoking Attributable Mortality, Morbidity and Economic Costs) to produce estimates of tobacco-related mortality. However, the SAMMEC tool loses accuracy because it lacks flexibility in deciding which diseases enter into the calculations, has estimates of relative risk (RR) attributable to smoking based on old studies, and does not allow for the latency period that occurs between initial exposure and mortality. METHODS: Smoking attributable mortality (SAM) due to active smoking in Israel was estimated with the approach used by SAMMEC taking into account past and present smoking prevalence (lag-times) as well as using new and expanded disease categories. RESULTS: Around 50.3% of the increase from the un-lagged SAM estimate of 3859 deaths to the final SAM estimate of 8664 deaths in 2003 is attributable to the introduction of lag times. More robust estimates of risk accounted for a further 29.6% of the increase. While 21.2% is attributable to the inclusion of additional disease categories, only 1.5% was attributable to the widening of existing diseases categories. CONCLUSION: This difference in estimates is attributable to expansion of the list of diseases included, updating the estimates of RR for smoking-attributable death, and the use of smoking prevalence from previous years to more accurately reflect the effect of tobacco use on disease occurrence. There is a need to establish an 'authority' to implement a multi-faceted intervention strategy to decrease the considerable burden from smoking in Israel.

Burden of Underweight in Israel.

BACKGROUND: This study measures the burden of chronic diseases associated with being underweight. METHODS: Underweight prevalence in the community was obtained from national survey data, together with hospital use rates for malnourished and non-malnourished persons for diagnoses associated with underweight. Meta-analyses of published literature calculated the following disease-specific relative risks: incidence of underweight-associated disease (UAD), mortality from UAD, and all-cause and disease-specific mortality after hospitalization in underweight persons. This enabled the calculation of hospital days, deaths, and disability-adjusted life years (DALYs) attributable to underweight deconstructed into UAD and disease-associated underweight (DAU). Cost estimates were based on general hospitalization costs adjusted by estimates of pharmaceutical and other direct care costs. RESULTS: We found 60,401 (95% confidence interval [CI]: 58,257-63,095) general hospital days, 558 (95% CI: 219-879) deaths, 5258 (95% CI: 2174-8382) potential years of life lost, and 3390 lost DALYs (95% CI: 1511-5333) were attributable to underweight annually in Israeli adults aged ≥18 years. Annually, direct health costs amounted to $145.6 million (95% CI: $141.9-$150.5 million), with general hospital days accounting for $53.4 million, pharmaceuticals $18.2 million, and other direct healthcare costs $73.9 million. Musculoskeletal disorders accounted for nearly half of these costs with coronary heart disease, chronic obstructive pulmonary disease, and stroke accounting for 15.4%, 10.3%, and 9.3%, respectively. CONCLUSIONS: Underweight imposes a considerable health burden in terms of deaths, health service use, and resource costs in Israel. Identification of cost-effective interventions to reduce this burden, not only among hospitalized patients, but also among persons living in the community, is essential.

Should we use Palivizumab immunoprophylaxis for infants against respiratory syncytial virus? - a cost-utility analysis.

BACKGROUND: Passive immunization against RSV (Respiratory Syncytial Virus) is given in most western countries (including Israel) to infants of high risk groups such as premature babies, and infants with Congenital Heart Disease or Congenital Lung Disease. However, immunoprophylaxis costs are extremely high ($2800-$4200 per infant). Using cost-utility analysis criteria, we evaluate whether it is justified to expand, continue or restrict nationwide immunoprophylaxis using palivizumab of high risk infants against RSV. METHODS: Epidemiological, demographic, health service utilisation and economic data were integrated from primary (National Hospitalization Data, etc.) and secondary data sources (ie: from published articles) into a spread-sheet to calculate the cost per averted disability-adjusted life year (DALY) of vaccinating various infant risk groups. Costs of intervention included antibody plus administration costs. Treatment savings and DALYs averted were estimated from applying vaccine efficacy data to relative risks of being hospitalised and treated for RSV, including possible long-term sequelae like asthma and wheezing. RESULTS: For all the groups RSV immunoprophylaxis is clearly not cost effective as its cost per averted DALY exceeds the $105,986 guideline representing thrice the per capita Gross Domestic Product. Vaccine price would have to fall by 48.1% in order to justify vaccinating Congenital Heart Disease or Congenital Lung Disease risk groups respectively on pure cost-effectiveness grounds. For premature babies of < 29 weeks, 29-32 and 33-36 weeks gestation, decreases of 36.8%, 54.5% and 83.3% respectively in vaccine price are required. CONCLUSIONS: Based solely on cost-utility analysis, at current price levels it is difficult to justify the current indications for passive vaccination with Palivizumab against RSV. However, if the manufacturers would reduce the price by 54.5% then it would be cost-effective to vaccinate the Congenital Heart Disease or Congenital Lung Disease risk groups as well as premature babies born before the 33rd week of gestation.

Mortality, hospital days and treatment costs of current and reduced sugar consumption in Israel.

BACKGROUND: Consumption of sugar causes tooth decay, overweight and obesity related morbidities. This paper in response to the Minister of Health's request, provides estimates of the mortality, morbidity and health care costs attributable to sugar consumption in Israel along with the effects of reducing sugar consumption. METHODS: Gender specific relative risks of many diseases from overweight (25 < =BMI < 30) and obesity (BMI > =30) were applied to the national gender specific prevalence rates of overweight and obesity in order to calculate the population attributable fraction (PAF) from overweight and obesity. National expenditure on these related diseases was calculated by applying disease-specific data from a recent Canadian study to estimates of disease specific general hospital expenditures in Israel. Disease specific costs attributable to overweight and obesity were estimated from the product of these expenditures and PAF. In addition national costs of treating caries in persons under 18 years of age from sugar were calculated. Similar calculations were made to estimate the burden from sugar in terms of mortality and hospital utilisation. A recent UK modelling study was used to estimate the effect of a national program to reduce calorific consumption of sugar from 12.45 to 10% in 5 years. RESULTS: Conditions associated with overweight or obesity accounted annually for 6402 deaths (95% CI 3296-8760) and 268,009 hospital days. Dental costs attributable to sugar consumption were 264 million NIS. In total, obesity, overweight and sugar consumption accounted for 2449 million in direct treatment costs (0.21% of GDP), rising to 4027 million (0.35% of GDP) when indirect costs were included. A national program of reducing energy from sugar consumption from 12.45 to 10% over 5 years is considered have a very feasible short-term goal. Even if the program does not impose taxes on sugar consumption, this would save 778 million NIS as well as 1184 lives. CONCLUSION: Sugar consumption causes a huge monetary and mortality burden. Estimates of potential decreases in this burden justify the current prioritisation given by the health minister of creating and implementing a national program to reduce sugar consumption, which is likely to be cost-saving (ie: averted treatment costs will exceed intervention costs).

Erratum to: The burden of smoking in Israel-attributable mortality and costs (2014).

[This corrects the article DOI: 10.1186/2045-4015-3-28.].

Cost-utility analysis of a nationwide vaccination programme against serogroup B meningococcal disease in Israel.

OBJECTIVES: Using cost-utility analysis, to evaluate whether or not to adopt a Neisseria meningitidis serogroup B vaccination programme for Israeli children. METHODS: Epidemiological, demographic, health service utilisation and economic data were integrated into a spreadsheet model to calculate the cost per averted disability-adjusted life year (DALY) of the intervention. RESULTS: Assuming 78 % vaccine efficacy with no herd immunity, vaccination will prevent 223 cases and 22 deaths over a 100-year period. Based on vaccine price of $60 per dose, total intervention costs ($315,400,000) are partially offset by a $22,700,000 reduction in treatment and sequelae costs as a result of decreased morbidity. The intervention was not cost-effective since the net cost ($292,700,000) per averted DALY gained (1249 mostly due to decreased mortality) was $234,394. Additional two dose catch-up programmes vaccinating children in cohorts aged 1-2 to 1-13 were also not cost-effective. CONCLUSIONS: The vaccination will become cost-effective if vaccine costs fall below $19.44 per dose. However, in identified high risk areas, the vaccine would be cost-effective and could be recommended for use both with and without catch-up campaigns.

Mortality, hospital days and expenditures attributable to ambient air pollution from particulate matter in Israel.

BACKGROUND: Worldwide, ambient air pollution accounts for around 3.7 million deaths annually. Measuring the burden of disease is important not just for advocacy but also is a first step towards carrying out a full cost-utility analysis in order to prioritise technological interventions that are available to reduce air pollution (and subsequent morbidity and mortality) from industrial, power generating and vehicular sources. METHODS: We calculated the average national exposure to particulate matter particles less than 2.5 µm (PM2.5) in diameter by weighting readings from 52 (non-roadside) monitoring stations by the population of the catchment area around the station. The PM2.5 exposure level was then multiplied by the gender and cause specific (Acute Lower Respiratory Infections, Asthma, Circulatory Diseases, Coronary Heart Failure, Chronic Obstructive Pulmonary Disease, Diabetes, Ischemic Heart Disease, Lung Cancer, Low Birth Weight, Respiratory Diseases and Stroke) relative risks and the national age, cause and gender specific mortality (and hospital utilisation which included neuro-degenerative disorders) rates to arrive at the estimated mortality and hospital days attributable to ambient PM2.5 pollution in Israel in 2015. We utilised a WHO spread-sheet model, which was expanded to include relative risks (based on more recent meta-analyses) of sub-sets of other diagnoses in two additional models. RESULTS: Mortality estimates from the three models were 1609, 1908 and 2253 respectively in addition to 184,000, 348,000 and 542,000 days hospitalisation in general hospitals. Total costs from PM2.5 pollution (including premature burial costs) amounted to $544 million, $1030 million and $1749 million respectively (or 0.18 %, 0.35 % and 0.59 % of GNP). CONCLUSIONS: Subject to the caveat that our estimates were based on a limited number of non-randomly sited stations exposure data. The mortality, morbidity and monetary burden of disease attributable to air pollution from particulate matter in Israel is of sufficient magnitude to warrant the consideration of and prioritisation of technological interventions that are available to reduce air pollution from industrial, power generating and vehicular sources. The accuracy of our burden estimates would be improved if more precise estimates of population exposure were to become available in the future.

Cost-utility analysis of treating out of hospital cardiac arrests in Jerusalem.

BACKGROUND: Out-of-hospital cardiac arrest (OHCA) initiates a chain of responses including emergency medical service mobilization and medical treatment, transfer and admission first to a hospital Emergency Department (ED) and then usually to an intensive care unit and ward. Costly pre- and in-hospital care may be followed by prolonged post discharge expenditure on treatment of patients with severe neurological sequelae. We assessed the cost-effectiveness of treatment of OHCA by calculating the cost per Disability Adjusted Life Year (DALY) averted. METHODS AND RESULTS: We studied 3355 consecutive non-traumatic OHCAs (2005-2010) in Jerusalem, Israel, supplemented by hospital utilization data extracted from patient files (n = 570) and post-discharge follow-up (n = 196). Demographic, utilization and economic data were incorporated into a spreadsheet model to calculate the cost-utility ratio. Advanced life support was administered to 2264 of the 3355 OHCAs (67.5%) and 1048 (45.6%) patients were transferred to the ED. Of 676 (20.1%) patients who survived the ED and were admitted, there were 206 (6.1%) survivors to discharge, among them only 113 (3.4%) neurologically intact. Total cost ($39,100,000) per DALY averted (1353) was $28,864. CONCLUSIONS: The current package of OHCA interventions in Jerusalem appears to be very cost-effective as the cost per averted DALY of $28,864 is less than the Gross Domestic Product per capita ($33,261). This paper provides a basis for studying the effects of potential interventions that can be evaluated in terms of their incremental costs per averted DALY for treatment of OHCA.

Economic evaluation of vaccination programmes: a consensus statement focusing on viral hepatitis.

The methods that have been used to estimate the clinical and economic impact of vaccination programmes are not always uniform, which makes it difficult to compare results between economic analyses. Furthermore, the relative efficiency of vaccination programmes can be sensitive to some of the more controversial aspects covered by general guidelines for the economic evaluation of healthcare programmes, such as discounting of health gains and the treatment of future unrelated costs. In view of this, we interpret some aspects of these guidelines with respect to vaccination and offer recommendations for future analyses. These recommendations include more transparency and validation, more careful choice of models (tailored to the infection and the target groups), more extensive sensitivity analyses, and for all economic evaluations (also nonvaccine related) to be in better accordance with general guidelines. We use these recommendations to interpret the evidence provided by economic evaluation applied to viral hepatitis vaccination. We conclude that universal hepatitis B vaccination (of neonates, infants or adolescents) seems to be the most optimal strategy worldwide, except in the few areas of very low endemicity, where the evidence to enable a choice between selective and universal vaccination remains inconclusive. While targeted hepatitis A vaccination seems economically unattractive, universal hepatitis A vaccination strategies have not yet been sufficiently investigated to draw general conclusions.

The burden of smoking in Israel-attributable mortality and costs (2014).

BACKGROUND: Tobacco use is the single most preventable cause of death, incurring huge resource costs in terms of treating morbidity and lost productivity. This paper estimates smoking attributable mortality (SAM) as health costs in 2014 in Israel. METHODS: Longitudinal data on prevalence of smokers and ex-smokers were combined with diagnostic and gender specific data on Relative Risks (RR) to gender and disease specific population attributable risks (PAR). PAR was then applied to mortality and hospitalization data from 2011, adjusted by population growth to 2014 to calculate SAM and hospitalization days (SAHD) caused by active smoking. These were used as a base for calculating deaths, hospital days and costs attributable to passive smoking, smoking by pregnant women, residential fires and productivity losses based on international literature. RESULTS: The lagged model estimated active SAM in Israel in 2014 to be 7,025 deaths. Cardio-vascular causes accounted for 45.0% of SAM, malignant neoplasms (39.2%) and respiratory diseases (15.5%). Lung cancer alone accounted for 24.1% of SAM. There were an estimated 793, 17 and 12 deaths from passive smoking, mothers-to-be smoking and residential fires. Total SAM is around 7,847 deaths (95% CI 7,698-7,997) in 2014. We estimated 319,231 active SAHD days (95% CI 313,135-325,326). Respiratory care accounted for around one-half of active SAHD (50.5%). Cardio-Vascular causes for 33.5% and malignant neoplasms (13.2%). Lung cancer only for 4.6%. Total SAHD was around 356,601 days including 36,049 days from passive smoking. Estimated direct acute care costs of 356,601 days in a general hospital amount to around 849 (95% CI 832-865) million NIS ($244 million). Non acute care costs amount to an additional 830 million NIS ($238 million). The total health service costs amount to 1,678 million NIS (95% CI 1,646-1,710) or $482 million, 0.2% of GNP. Productivity losses account for a further 1,909 million NIS ($548 million), giving an overall smoking related cost of 3,587 million NIS (95% CI 3,519-3,656) or $1,030 million, 0.41% of GNP). CONCLUSIONS: Smoking causes a considerable burden in Israel, both in terms of the expected 7,847 lives lost and the financial costs of around 3.6 million NIS ($1,030 million or 0.42% of GNP).

Generalizability of cost-utility analyses across countries and settings.

All societies have limited resources, so decisions have to be made about which public health interventions should be provided. A major tool used for prioritisation is cost-utility analysis (CUA) where the outcomes are measured in terms of Disability Adjusted Life Years (DALYs) prevented. Collecting data and building models to calculate the ratio of net costs (i.e.: intervention costs less treatment costs averted due to decreases in morbidity and mortality) to outcomes (CUR) is complex and time consuming. Therefore, there is a great appeal in using CUA calculations that have already been published in other countries. This paper points out the many limitations and inaccuracies caused by generalizing results from CUAs across different countries. However, if time constraints are pressing then first-order estimates of results could be presented after adjustments for the major drivers of the CUR, such as incidence rates, intervention costs and averted treatment costs.

Cost-utility analysis of interventions to reduce the burden of cervical cancer in Israel.

Using World health Organization, CHOosing Interventions that are Cost Effective (WHO-CHOICE) methodology, cost-utility ratios were calculated for various interventions (Papanicolaou [Pap] smear, human papillomavirus [HPV]-DNA testing, visual inspection with acetic acid [VIA] and vaccination against HPV) at various frequencies to reduce the burden of cervical cancer and condyloma (in the case of the HPV vaccination) in Israel, which has a low prevalence of cervical cancer. All of the screening and/or vaccine interventions were very cost-effective. Attempts should be made to raise compliancy with Pap smears from the current opportunistic 12.1% per annum to screen everyone aged 20-64 once every 5 years in combination with HPV-DNA testing for persons aged 30-64 both before and/or after HPV vaccination is introduced. This article forms part of a regional report entitled "Comprehensive Control of HPV Infections and Related Diseases in Israel" Vaccine Volume 31, Supplement 8, 2013. Updates of the progress in the field are presented in a separate monograph entitled "Comprehensive Control of HPV Infections and Related Diseases" Vaccine Volume 30, Supplement 5, 2012.

Should Israel screen all mothers-to-be to prevent early-onset of neonatal group B streptococcal disease? A cost-utility analysis.

BACKGROUND: In Israel, an average of 37 children are born each year with sepsis and another four with meningitis as a result of Group B Streptococcal (GBS) disease. Israel currently only screens mothers with defined risk factors (around 15% of all pregnancies) in order to identify candidates for Intrapartum Antiobiotic Prophyhlaxis (IAP) of GBS. This paper presents a cost-utility analysis of implementing an alternative strategy, which would expand the current protocol to one aiming to screen all pregnant women at 35-37 weeks gestation based on taking a vaginal culture for GBS. METHODS: A spreadsheet model was built incorporating technical, epidemiological, health service costs, demographic and economic data based primarily on Israeli sources. RESULTS: The intervention of universal screening (compared with the current scenario) would increase screening costs from 580,000 NIS to 3,278,000 million NIS. In addition, the intervention would also increase penicillin costs from 39,000 NIS to 221,000 NIS. Current culture screening of approximately 15% of mothers-to-be with high risk factors resulted in 42 GBS births in 2008-9 (0.253/1000 births). Expanding culture screening to 85% of mothers-to-be, will decrease the number of GBS births to 17.3 (0.104/1000 births). The initial 2.9 million NIS incremental intervention costs are offset by decreased treatment costs of 1.9 million NIS and work productivity gains of 811,000 NIS as a result of a decrease in neurological sequelae from GBS caused meningitis. Thus the resultant net cost of the intervention is only around 134,000 NIS. Culture based screening will reduce the burden of disease by 12.6 discounted Quality Adjusted Life Years (QALYS), giving a very cost effective baseline incremental cost per QALY (cf. risk factor screening) of 10,641 NIS per QALY. The data was very sensitive to rates of anaphylactic shock and changes in the percentage of meningitis cases that had associated long term-sequelae. CONCLUSION: It is recommended that Israel adopt universal culture-based GBS screening.

Economic effects of interventions to reduce obesity in Israel.

BACKGROUND: Obesity is a major risk factor for many diseases. The paper calculates the economic impact and the cost per Quality-Adjusted Life Year (QALY) resulting from the adoption of eight interventions comprising the clinical and part of the community components of the National Prevention and Health Promotion Program (NPHPP) of the Israeli Ministry of Health (MOH) which represents the obesity control implementation arm of the MOH Healthy Israel 2020 Initiative. METHODS: Health care costs per person were calculated by body mass index (BMI) by applying Israeli cost data to aggregated results from international studies. These were applied to BMI changes from eight intervention programmes in order to calculate reductions in direct treatment costs. Indirect cost savings were also estimated as were additional costs due to increased longevity of program participants. Data on costs and QALYs gained from Israeli and International dietary interventions were combined to provide cost-utility estimates of an intervention program to reduce obesity in Israel over a range of recidivism rates. RESULTS: On average, persons who were overweight (25 ≤ BMI < 30)had health care costs that were 12.2% above the average health care costs of persons with normal or sub-normal weight to height ratios (BMI < 25). This differential in costs rose to 31.4% and 73.0% for obese and severely obese persons, respectively.For overweight (25 ≤ BMI < 30) and obese persons (30 ≤ BMI < 40), costs per person for the interventions (including the screening overhead) ranged from 35 NIS for a community intervention to 860 NIS, reflecting the intensity of the clinical setting intervention and the unit costs of the professionals carrying out the intervention [e.g., dietician]. Expected average BMI decreases ranged from 0.05 to 0.90. Higher intervention costs and larger BMI decreases characterized the two clinical lifestyle interventions for the severely obese (BMI ≥ 40).A program directed at the entire Israeli population aged 20 and over, using a variety of eight different interventions would cost 2.07 billion NIS overall. In the baseline scenario (with an assumed recidivism rate of 50% per annum), approximately 620,000,000 NIS would be recouped in the form of decreased treatment costs and indirect costs, increased productivity and decreased absenteeism. After discounting the 89,000,000 NIS additional health costs attributable to these extra life years, it is estimated that the total net costs to society would be 1.55 billion NIS. This total net cost was relatively stable to increases in the program's recidivism rates, but highly sensitive to reductions in recidivism rates.Under baseline assumptions, implementation of the cluster of interventions would save 32,671 discounted QALYs at a cost of only 47,559 NIS per QALY, less than half of the Israeli per capita GNP (104,000 NIS). Thus implementation of these components of the NPHPP should be considered very cost-effective. CONCLUSION: Despite the large costs of such a large national program to control obesity, cost-utility analysis strongly supports its introduction.

Cost effectiveness of strategies to combat breast, cervical, and colorectal cancer in sub-Saharan Africa and South East Asia: mathematical modelling study.

OBJECTIVE: To determine the costs and health effects of interventions to combat breast, cervical, and colorectal cancers in order to guide resource allocation decisions in developing countries. SETTING: Two World Health Organization sub-regions of the world: countries in sub-Saharan Africa with very high adult and high child mortality (AfrE); and countries in South East Asia with high adult and high child mortality (SearD). DESIGN: Cost effectiveness analysis of prevention and treatment strategies for breast, cervical, and colorectal cancer, using mathematical modelling based on a lifetime population model. DATA SOURCES: Demographic and epidemiological data were taken from the WHO mortality and global burden of disease databases. Estimates of intervention coverage, effectiveness, and resource needs were based on clinical trials, treatment guidelines, and expert opinion. Unit costs were taken from the WHO-CHOICE price database. MAIN OUTCOME MEASURES: Cost per disability adjusted life year (DALY) averted, expressed in international dollars ($Int) for the year 2005. RESULTS: In both regions certain interventions in cervical cancer control (screening through cervical smear tests or visual inspection with acetic acid in combination with treatment) and colorectal cancer control (increasing the coverage of treatment interventions) cost <$Int2000 per DALY averted and can be considered highly cost effective. In the sub-Saharan African region screening for colorectal cancer (by colonoscopy at age 50 in combination with treatment) costs $Int2000-6000 per DALY averted and can be considered cost effective. In both regions certain interventions in breast cancer control (treatment of all cancer stages in combination with mammography screening) cost $Int2000-6000 per DALY averted and can also be considered cost effective. Other interventions, such as campaigns to eat more fruit and vegetable or subsidies in colorectal cancer control, are not cost effective according to the criteria defined. CONCLUSION: Highly cost effective interventions to combat cervical and colorectal cancer are available in the African and Asian sub-regions. In cervical cancer control, these include screening through smear tests or visual inspection in combination with treatment. In colorectal cancer, increasing treatment coverage is highly cost effective (screening through colonoscopy is cost effective in the African sub-region). In breast cancer control, mammography screening in combination with treatment of all stages is cost effective.