Measuring quality effects in equilibrium.

Unlike demand studies in other industries, models of provider demand in health care often must omit a price, or any other factor that equilibrates the market such as a waiting time. Estimates of the consumer response to quality may consequently be attenuated, if the limited capacity of individual physicians prevents some consumers from obtaining higher quality. We propose a tractable method to address this problem by adding a congestion effect to standard discrete-choice models. We show analytically how this can improve forecasts of the consumer response to quality. We then apply this method to the market for heart surgery, and find that the attenuation bias in estimated quality effects can be important empirically.

Development of a Metric to Detect and Decrease Low-Value Prescribing in Older Adults.

Importance: Metrics that detect low-value care in common forms of health care data, such as administrative claims or electronic health records, primarily focus on tests and procedures but not on medications, representing a major gap in the ability to systematically measure low-value prescribing. Objective: To develop a scalable and broadly applicable metric that contains a set of quality indicators (EVOLV-Rx) for use in health care data to detect and reduce low-value prescribing among older adults and that is informed by diverse stakeholders' perspectives. Design, Setting, and Participants: This qualitative study used an online modified-Delphi method to convene an expert panel of 15 physicians and pharmacists. This panel, comprising clinicians, health system leaders, and researchers, was tasked with rating and discussing candidate low-value prescribing practices that were derived from medication safety criteria; peer-reviewed literature; and qualitative studies of patient, caregiver, and physician perspectives. The RAND ExpertLens online platform was used to conduct the activities of the panel. The panelists were engaged for 3 rounds between January 1 and March 31, 2021. Main Outcomes and Measures: Panelists used a 9-point Likert scale to rate and then discuss the scientific validity and clinical usefulness of the criteria to detect low-value prescribing practices. Candidate low-value prescribing practices were rated as follows: 1 to 3, indicating low validity or usefulness; 3.5 to 6, uncertain validity or usefulness; and 6.5 to 9, high validity or usefulness. Agreement among panelists and the degree of scientific validity and clinical usefulness were assessed using the RAND/UCLA (University of California, Los Angeles) Appropriateness Method. Results: Of the 527 low-value prescribing recommendations identified, 27 discrete candidate low-value prescribing practices were considered for inclusion in EVOLV-Rx. After round 1, 18 candidate practices were rated by the panel as having high scientific validity and clinical usefulness (scores of ≥6.5). After round 2 panel deliberations, the criteria to detect 19 candidate practices were revised. After round 3, 18 candidate practices met the inclusion criteria, receiving final median scores of 6.5 or higher for both scientific validity and clinical usefulness. Of those practices that were not included in the final version of EVOLV-Rx, 3 received high scientific validity (scores ≥6.5) but uncertain clinical usefulness (scores <6.5) ratings, whereas 6 received uncertain scientific validity rating (scores <6.5). Conclusions and Relevance: This study culminated in the development of EVOLV-Rx and involved a panel of experts who identified the 18 most salient low-value prescribing practices in the care of older adults. Applying EVOLV-Rx may enhance the detection of low-value prescribing practices, reduce polypharmacy, and enable older adults to receive high-value care across the full spectrum of health services.

Prescriber perspectives on low-value prescribing: A qualitative study.

BACKGROUND: Health systems are increasingly implementing interventions to reduce older patients' use of low-value medications. However, prescribers' perspectives on medication value and the acceptability of interventions to reduce low-value prescribing are poorly understood. OBJECTIVE: To identify the characteristics that affect the value of a medication and those factors influencing low-value prescribing from the perspective of primary care physicians. DESIGN: Qualitative study using semi-structured interviews. SETTING: Academic and community primary care practices within University of Pittsburgh Medical Center health system. PARTICIPANTS: Sixteen primary care physicians. MEASUREMENTS: We elicited 16 prescribers' perspectives on definitions and examples of low-value prescribing in older adults, the factors that incentivize them to engage in such prescribing, and the characteristics of interventions that would make them less likely to engage in low-value prescribing. RESULTS: We identified three key themes. First, prescribers viewed low-value prescribing among older adults as common, characterized both by features of the medications themselves and of the particular patients to whom they were prescribed. Second, prescribers described the causes of low-value prescribing as multifactorial, with factors related to patients, prescribers, and the health system as a whole, making low-value prescribing a default practice pattern. Third, interventions addressing low-value prescribing must minimize the cognitive load and time pressures that make low-value prescribing common. Interventions increasing time pressure or cognitive load, such as increased documentation, were considered less acceptable. CONCLUSIONS: Our findings demonstrate that low-value prescribing is a well-recognized phenomenon, and that interventions to reduce low-value prescribing must consider physicians' perspectives and address the specific patient, prescriber and health system factors that make low-value prescribing a default practice.

Economic analysis of screening for subclinical rejection in kidney transplantation using protocol biopsies and noninvasive biomarkers.

Subclinical rejection (SCR) screening in kidney transplantation (KT) using protocol biopsies and noninvasive biomarkers has not been evaluated from an economic perspective. We assessed cost-effectiveness from the health sector perspective of SCR screening in the first year after KT using a Markov model that compared no screening with screening using protocol biopsy or biomarker at 3 months, 12 months, 3 and 12 months, or 3, 6, and 12 months. We used 12% subclinical cellular rejection and 3% subclinical antibody-mediated rejection (SC-ABMR) for the base-case cohort. Results favored 1-time screening at peak SCR incidence rather than repeated screening. Screening 2 or 3 times was favored only with age <35 years and with high SC-ABMR incidence. Compared to biomarkers, protocol biopsy yielded more quality-adjusted life years (QALYs) at lower cost. A 12-month biopsy cost $13 318/QALY for the base-case cohort. Screening for cellular rejection in the absence of SC-ABMR was less cost effective with 12-month biopsy costing $46 370/QALY. Screening was less cost effective in patients >60 years. Using biomarker twice or thrice was cost effective only if biomarker cost was <$700. In conclusion, in KT, screening for SCR more than once during the first year is not economically reasonable. Screening with protocol biopsy was favored over biomarkers.

Molecular Testing Versus Diagnostic Lobectomy in Bethesda III/IV Thyroid Nodules: A Cost-Effectiveness Analysis.

Background: Molecular tests (MT) using gene expression and/or mutational analysis have been developed to reduce the need for diagnostic surgery for indeterminate (Bethesda III/IV) thyroid nodules. Prior cost-effectiveness studies have shown mixed results but none has included the recent and more comprehensive versions of the two commonly utilized MT. The aim of this study is to compare the cost-effectiveness of diagnostic lobectomy (DL), the Afirma Gene Sequencing Classifier (GSC), and ThyroSeq version 3 (TSv3). Methods: A decision tree from the payer perspective was created using a base case of a 40-year-old euthyroid woman with a solitary 2 cm Bethesda III or IV thyroid nodule. In this model, all patients in the DL arm had lobectomy, which was also performed for patients with positive MT, while those with negative MT underwent 20 years of surveillance. The outcome was a correct diagnosis, defined as malignant histology after DL or 20 years of nodule stability after negative MT. Costs were obtained from the Centers for Medicare & Medicaid Services (CMS) data and existing literature, and probabilities were obtained from the literature. Sensitivity analysis was performed for costs, pretest probability of malignancy, and performance parameters. Results: The cost per correct diagnosis was $14,277 for TSv3, $17,873 for GSC, and $38,408 for DL. TSv3 was preferred over both GSC and DL. One-way sensitivity analysis between TSv3 and GSC demonstrated that the results were robust to variations in cost, cancer prevalence, and length of surveillance. In the two-way sensitivity analysis, TSv3 was preferred over GSC at all considered test costs, and in probabilistic sensitivity analysis, TSv3 was the preferred management strategy in 68.5% of cases. Conclusions: In hypothetical modeling to determine whether surgery versus MT is optimal for indeterminate (Bethesda III/IV) nodules, either of the major MT was considerably more cost-effective than DL, although TSv3 was more likely to be cost-effective than GSC. Use of either MT adjunct should be strongly considered in the absence of other indications for thyroidectomy.

Cost Effectiveness of Transplanting HCV-Infected Livers Into Uninfected Recipients With Preemptive Antiviral Therapy.

BACKGROUND & AIMS: Guidelines do not recommend transplanting hepatitis C virus (HCV)-infected livers into HCV-uninfected recipients. Direct-acting antivirals (DAAs) can be used to treat donor-derived HCV infection. However, the added cost of DAA therapy is a barrier. We evaluated the cost effectiveness of transplanting HCV-positive livers into HCV-negative patients with preemptive DAA therapy. METHODS: A previously validated Markov-based mathematical model was adapted to simulate a virtual trial of HCV-negative patients on the liver transplant waitlist. The model compared long-term clinical and economic outcomes in patients willing to accept only HCV-negative livers vs those willing to accept any liver (HCV negative or HCV positive). Recipients of HCV-positive livers received 12 weeks of preemptive DAA therapy. The model incorporated data from the United Network for Organ Sharing and published sources. RESULTS: For patients with a model for end-stage liver disease (MELD) score ≥ 22, accepting any liver vs waiting for only HCV-negative livers was cost effective, with incremental cost-effectiveness ratios ranging from $56,100 to $91,700/quality-adjusted life-year. For patients with a MELD score of 28 (the median MELD score of patients undergoing transplantation in the United States), accepting any liver was cost effective at an incremental cost-effectiveness ratio of $62,600/quality-adjusted life year. In patients with low MELD scores, which may not accurately reflect disease severity, accepting any liver was cost effective, irrespective of MELD score. CONCLUSIONS: Using a Markov-based mathematical model, we found transplanting HCV-positive livers into HCV-negative patients with preemptive DAA therapy to be a cost-effective strategy that could improve health outcomes.

Accuracy of the Pediatric End-stage Liver Disease Score in Estimating Pretransplant Mortality Among Pediatric Liver Transplant Candidates.

Importance: Fair allocation of livers between pediatric and adult recipients is critically dependent on the accuracy of mortality estimates afforded by the Pediatric End-stage Liver Disease (PELD) and Model for End-stage Liver Disease, respectively. Widespread reliance on exceptions for pediatric recipients suggests that the 2 systems may not be comparable. Objective: To evaluate the accuracy of the PELD score in estimating 90-day pretransplant mortality among pediatric patients on the United Network for Organ Sharing (UNOS) waiting list. Design, Setting, and Participants: Patients who were listed from February 27, 2002, to March 31, 2014, for primary liver transplant were included in this retrospective analysis and were followed up for at least 2 years through June 17, 2016. The study analyzed 2 cohorts using the UNOS Standard Transplant Analysis and Research data files. The full cohort comprised 4298 patients (<18 years of age) who had chronic liver disease (excluding cancer). The reduced cohort (n = 2421) excluded patients receiving living donor transplantation or PELD exception points. Main Outcomes and Measures: Observed and expected 90-day pretransplant mortality rates evaluated at 10-point interval PELD levels. Results: Among the 4298 patients in the full cohort (mean [SD] age, 2.5 [4.2] years; 2251 [52.4%] female; 2201 [51.2%] white), PELD scores and mortality were concordant (C statistic, 0.8387 [95% CI, 0.8191-0.8584] for the full cohort and 0.8123 [95% CI, 0.7919-0.8327] for the reduced cohort). However, the estimated 90-day mortality using the PELD score underestimated the actual probability of death by as much as 17%. Conclusions and Relevance: With use of the PELD score, the ranking of risk among children was preserved, but direct comparisons between adult and pediatric candidates were not accurate. Children with chronic liver disease who are in need of transplant may be at a disadvantage compared with adults in a similar situation.

Comparison of toxicant load from waterpipe and cigarette tobacco smoking among young adults in the USA.

OBJECTIVES: To form population-level comparisons of total smoke volume, tar, carbon monoxide and nicotine consumed from waterpipe tobacco smoking (WTS) and cigarette smoking using data from a nationally representative sample of smokers and non-smokers aged 18-30 years. METHODS: In March and April 2013, we surveyed a nationally representative sample of 3254 US young adults to assess the frequency and volume of WTS and cigarette smoking. We used Monte Carlo analyses with 5000 repetitions to estimate the proportions of toxicants originating from WTS and cigarette smoking. Analyses incorporated survey weights and used recent meta-analytic data to estimate toxicant exposures associated with WTS and cigarette smoking. RESULTS: Compared with the additive estimates of WTS and cigarette smoking combined, 54.9% (95% CI 37.5% to 72.2%) of smoke volume was attributed to WTS. The proportions of tar attributable to WTS was 20.8% (95% CI 6.5% to 35.2%), carbon monoxide 10.3% (95% CI 3.3% to 17.3%) and nicotine 2.4% (95% CI 0.9% to 3.8%). CONCLUSIONS: WTS accounted for over half of the tobacco smoke volume consumed among young US adult waterpipe and cigarette smokers. Toxicant exposures to tar, carbon monoxide and nicotine were lower, but still substantial, for WTS alone compared with WTS and cigarette smoking. Public health and policy interventions to reduce harm from tobacco smoking in young US adults should explicitly address WTS toxicant exposures.

Challenges in the Analysis of Outcomes for Surgical Compared to Radiotherapy Treatment of Prostate Cancer.

BACKGROUND/AIM: Prostate cancer can be treated with radical prostatectomy (RP), external-beam radiotherapy (EBRT), or brachytherapy (BT). These modalities have similar cancer-related outcomes. We used an innovative method to analyze the cost of such treatment. MATERIALS AND METHODS: We queried our Institution's Insurance Division [University of Pittsburgh Medical Center (UPMC) Health Plan] beneficiaries from 2003-2008, who were diagnosed with prostate cancer and also queried the UPMC tumor registry for all patients with prostate cancer treated at our Institution. In a de-identified manner, data from the Health Plan and Tumor Registry were merged. RESULTS: A total of 354 patients with non-metastatic disease with treatment initiated within 9 months of diagnosis were included (RP=236, EBRT=55, and BT=63). Radiotherapy-treated patients tended to be older, higher-risk, and have more comorbidities. Unadjusted median total health care expenditures during the first year after diagnosis were: RP: $16,743, EBRT: $47,256, and BT: $23,237 (p<0.0005). A propensity score-matched model comparing RP and EBRT demonstrated median total health care expenditures during year one: RP: $8,189, EBRT: $10,081; p=0.48. In a propensity-matched model comparing RP and BT, the median total health care expenditures during year one were: RP: $18,143, BT: $26,531; p=0.015 and per year during years 2 through 5 from diagnosis were: RP: $5,913, BT: $6,110; p=0.68. CONCLUSION: This pilot study demonstrates the feasibility of combining healthcare costs from the payer's perspective with clinical data from a Tumor Registry within an IDFS and represents a novel approach to investigating the economic impact of cancer treatment.

Cost-Effective Drug Switch Options After Unsuccessful Treatment With an SSRI for Depression.

OBJECTIVE: Multiple treatment options are available for patients who do not respond to initial treatment for major depressive disorder. Previous results show that bupropion, sertraline, and venlafaxine are comparable in terms of therapeutic effectiveness following unsuccessful treatment with citalopram. In this study, we extended these results by incorporating costs of treatment to determine if one option was more cost-effective relative to others. METHODS: In the STAR*D (Sequenced Treatment Alternatives to Relieve Depression) trial, 727 patients were randomly assigned to a switch drug treatment during level 2; 239 (33%) were assigned to bupropion, 238 (33%) to sertraline, and 250 (34%) to venlafaxine. For each study medication, the total costs included the costs of the medication, other concomitant medication and antidepressants, and health care facility utilization. Effectiveness was measured as remission and response. Cost-effectiveness was assessed as net health benefits. Stochastic analysis was performed by using the bootstrapping method. RESULTS: During level 2, mean medication costs were significantly higher for venlafaxine than for bupropion and sertraline ($968, $607, and $703, respectively). There were no significant differences among the switch medications in costs for other medications and health care facility utilization. Although the total costs were significantly different for the three medications (p=.025), none of the pairwise differences between medications were significant. Also, after jointly estimating costs and effects, the analyses found that net health benefits were not significantly different among the three drugs. CONCLUSIONS: After unsuccessful treatment with citalopram, the switch options of bupropion, sertraline, and venlafaxine were not significantly different from each other in terms of cost-effectiveness.

Long-term disease and economic outcomes of prior authorization criteria for Hepatitis C treatment in Pennsylvania Medicaid.

BACKGROUND: Several highly effective but costly therapies for hepatitis C virus (HCV) are available. As a consequence of their high price, 36 state Medicaid programs limited treatment coverage to patients with more advanced HCV stages. States have only limited information available to predict the long-term impact of these decisions. METHODS: We adapted a validated hepatitis C microsimulation model to the Pennsylvania Medicaid population to estimate the existing HCV prevalence in Pennsylvania Medicaid and estimate the impact of various HCV drug coverage policies on disease outcomes and costs. Outcome measures included rates of advanced-stage HCV outcomes and treatment and disease costs in both Medicaid and Medicare. RESULTS: We estimated that 46,700 individuals in Pennsylvania Medicaid were infected with HCV in 2015, 33% of whom were still undiagnosed. By expanding treatment to include mild fibrosis stage (Metavir F2), Pennsylvania Medicaid will spend an additional $273 million on medications in the next decade with no substantial reduction in the incidence of liver cancer or liver-related death. Medicaid patients who are not eligible for treatment under restricted policies would get treatment once they transition to the Medicare program, which would incur 10% reduction in HCV-related costs due to early treatment in Medicaid. Further expanding treatment to patients with early fibrosis stages (F0 or F1) would cost Medicaid an additional $693 million during the next decade but would reduce the number of individuals in need of treatment in Medicare by 46% and decrease Medicare treatment costs by 23%. In some scenarios, outcomes could worsen with eligibility expansion if there is inadequate capacity to treat all patients. CONCLUSIONS AND RELEVANCE: Expansion of HCV treatment coverage to less severe stages of liver disease may not substantially improve liver related outcomes for patients in Pennsylvania Medicaid in scenarios in which coverage through Medicare is widely available.

Cost-Effectiveness Analysis of Stereotactic Body Radiation Therapy Compared With Radiofrequency Ablation for Inoperable Colorectal Liver Metastases.

PURPOSE: To conduct a cost-effectiveness analysis to determine whether stereotactic body radiation therapy (SBRT) is a cost-effective therapy compared with radiofrequency ablation (RFA) for patients with unresectable colorectal cancer (CRC) liver metastases. METHODS AND MATERIALS: A cost-effectiveness analysis was conducted using a Markov model and 1-month cycle over a lifetime horizon. Transition probabilities, quality of life utilities, and costs associated with SBRT and RFA were captured in the model on the basis of a comprehensive literature review and Medicare reimbursements in 2014. Strategies were compared using the incremental cost-effectiveness ratio, with effectiveness measured in quality-adjusted life years (QALYs). To account for model uncertainty, 1-way and probabilistic sensitivity analyses were performed. Strategies were evaluated with a willingness-to-pay threshold of $100,000 per QALY gained. RESULTS: In base case analysis, treatment costs for 3 fractions of SBRT and 1 RFA procedure were $13,000 and $4397, respectively. Median survival was assumed the same for both strategies (25 months). The SBRT costs $8202 more than RFA while gaining 0.05 QALYs, resulting in an incremental cost-effectiveness ratio of $164,660 per QALY gained. In 1-way sensitivity analyses, results were most sensitive to variation of median survival from both treatments. Stereotactic body radiation therapy was economically reasonable if better survival was presumed (>1 month gain) or if used for large tumors (>4 cm). CONCLUSIONS: If equal survival is assumed, SBRT is not cost-effective compared with RFA for inoperable colorectal liver metastases. However, if better local control leads to small survival gains with SBRT, this strategy becomes cost-effective. Ideally, these results should be confirmed with prospective comparative data.

Hepatitis C Disease Burden in the United States in the era of oral direct-acting antivirals.

Oral direct-acting antivirals (DAAs) represent a major advance in hepatitis C virus (HCV) treatment. Along with recent updates in HCV screening policy and expansions in insurance coverage, treatment demand in the United States is changing rapidly. Our objective was to project the characteristics and number of people needing antiviral treatment and HCV-associated disease burden in the era of oral DAAs. We used a previously developed and validated Hepatitis C Disease Burden Simulation model (HEP-SIM). HEP-SIM simulated the actual clinical management of HCV from 2001 onward, which included antiviral treatment with pegylated interferon (Peg-IFN)-based therapies as well as the recent oral DAAs, risk-based and birth-cohort HCV screening, and the impact of the Affordable Care Act. We also simulated two hypothetical scenarios-no treatment and treatment with Peg-IFN-based therapies only. We estimated that in 2010, 2.5 (95% confidence interval [CI], 1.9-3.1) million noninstitutionalized people were viremic, which dropped to 1.9 (95% CI, 1.4-2.6) million in 2015, and projected to drop below 1 million by 2020. A total of 1.8 million HCV patients will receive HCV treatment from the launch of oral DAAs in 2014 until 2030. Based on current HCV management practices, it will take 4-6 years to treat the majority of patients aware of their disease. However, 560,000 patients would still remain unaware by 2020. Even in the oral DAA era, 320,000 patients will die, 157,000 will develop hepatocellular carcinoma, and 203,000 will develop decompensated cirrhosis in the next 35 years. CONCLUSIONS: HCV-associated disease burden will still remain substantial in the era of oral DAAs. Increasing HCV screening and treatment capacity is essential to further decreasing HCV burden in the United States. (Hepatology 2016;64:1442-1450).

Prevention of Hepatitis C by Screening and Treatment in U.S. Prisons.

BACKGROUND: The prevalence of hepatitis C virus (HCV) in U.S. prisoners is high; however, HCV testing and treatment are rare. Infected inmates released back into society contribute to the spread of HCV in the general population. Routine hepatitis screening of inmates followed by new therapies may reduce ongoing HCV transmission. OBJECTIVE: To evaluate the health and economic effect of HCV screening and treatment in prisons on the HCV epidemic in society. DESIGN: Agent-based microsimulation model of HCV transmission and progression of HCV disease. DATA SOURCES: Published literature. TARGET POPULATION: Population in U.S. prisons and general community. TIME HORIZON: 30 years. PERSPECTIVE: Societal. INTERVENTIONS: Risk-based and universal opt-out hepatitis C screening in prisons, followed by treatment in a portion of patients. OUTCOME MEASURES: Prevention of HCV transmission and associated disease in prisons and society, costs, quality-adjusted life-years (QALYs), incremental cost-effectiveness ratio (ICER), and total prison budget. RESULTS OF BASE-CASE ANALYSIS: Implementing risk-based and opt-out screening could diagnose 41,900 to 122,700 new HCV cases in prisons in the next 30 years. Compared with no screening, these scenarios could prevent 5500 to 12,700 new HCV infections caused by released inmates, wherein about 90% of averted infections would have occurred outside of prisons. Screening could also prevent 4200 to 11,700 liver-related deaths. The ICERs of screening scenarios were $19,600 to $29,200 per QALY, and the respective first-year prison budget was $900 to $1150 million. Prisons would require an additional 12.4% of their current health care budget to implement such interventions. RESULTS OF SENSITIVITY ANALYSIS: Results were sensitive to the time horizon, and ICERs otherwise remained less than $50,000 per QALY. LIMITATION: Data on transmission network, reinfection rate, and opt-out HCV screening rate are lacking. CONCLUSION: Universal opt-out HCV screening in prisons is highly cost-effective and would reduce HCV transmission and HCV-associated diseases primarily in the outside community. Investing in U.S. prisons to manage hepatitis C is a strategic approach to address the current epidemic. PRIMARY FUNDING SOURCE: National Institutes of Health.

The changing burden of hepatitis C virus infection in the United States: model-based predictions.

BACKGROUND: Chronic hepatitis C virus (HCV) infection causes a substantial health and economic burden in the United States. With the availability of direct-acting antiviral agents, recently approved therapies and those under development, and 1-time birth-cohort screening, the burden of this disease is expected to decrease. OBJECTIVE: To predict the effect of new therapies and screening on chronic HCV infection and associated disease outcomes. DESIGN: Individual-level state-transition model. SETTING: Existing and anticipated therapies and screening for HCV infection in the United States. PATIENTS: Total HCV-infected population in the United States. MEASUREMENTS: The number of cases of chronic HCV infection and outcomes of advanced-stage HCV infection. RESULTS: The number of cases of chronic HCV infection decreased from 3.2 million in 2001 to 2.3 million in 2013. One-time birth-cohort screening beginning in 2013 is expected to identify 487,000 cases of HCV infection in the next 10 years. In contrast, 1-time universal screening could identify 933,700 cases. With the availability of highly effective therapies, HCV infection could become a rare disease in the next 22 years. Recently approved therapies for HCV infection and 1-time birth-cohort screening could prevent approximately 124,200 cases of decompensated cirrhosis, 78,800 cases of hepatocellular carcinoma, 126,500 liver-related deaths, and 9900 liver transplantations by 2050. Increasing the treatment capacity would further reduce the burden of HCV disease. LIMITATION: Institutionalized patients with HCV infection were excluded, and empirical data on the effectiveness of future therapies and on the future annual incidence and treatment capacity of HCV infection are lacking. CONCLUSION: New therapies for HCV infection and widespread implementation of screening and treatment will play an important role in reducing the burden of HCV disease. More aggressive screening recommendations are needed to identify a large pool of infected patients. PRIMARY FUNDING SOURCE: National Institutes of Health.

Twelve-month cost-effectiveness of telephone-delivered collaborative care for treating depression following CABG surgery: a randomized controlled trial.

OBJECTIVE: To determine the 12-month cost-effectiveness of a collaborative care (CC) program for treating depression following coronary artery bypass graft (CABG) surgery versus physicians' usual care (UC). METHODS: We obtained 12 continuous months of Medicare and private medical insurance claims data on 189 patients who screened positive for depression following CABG surgery, met criteria for depression when reassessed by telephone 2 weeks following hospitalization (nine-item Patient Health Questionnaire ≥10) and were randomized to either an 8-month centralized, nurse-provided and telephone-delivered CC intervention for depression or to their physicians' UC. RESULTS: At 12 months following randomization, CC patients had $2068 lower but statistically similar estimated median costs compared to UC (P=.30) and a variety of sensitivity analyses produced no significant changes. The incremental cost-effectiveness ratio of CC was -$9889 (-$11,940 to -$7838) per additional quality-adjusted life-year (QALY), and there was 90% probability it would be cost-effective at the willingness to pay threshold of $20,000 per additional QALY. A bootstrapped cost-effectiveness plane also demonstrated a 68% probability of CC "dominating" UC (more QALYs at lower cost). CONCLUSIONS: Centralized, nurse-provided and telephone-delivered CC for post-CABG depression is a quality-improving and cost-effective treatment that meets generally accepted criteria for high-value care.

Gray's time-varying coefficients model for posttransplant survival of pediatric liver transplant recipients with a diagnosis of cancer.

Transplantation is often the only viable treatment for pediatric patients with end-stage liver disease. Making well-informed decisions on when to proceed with transplantation requires accurate predictors of transplant survival. The standard Cox proportional hazards (PH) model assumes that covariate effects are time-invariant on right-censored failure time; however, this assumption may not always hold. Gray's piecewise constant time-varying coefficients (PC-TVC) model offers greater flexibility to capture the temporal changes of covariate effects without losing the mathematical simplicity of Cox PH model. In the present work, we examined the Cox PH and Gray PC-TVC models on the posttransplant survival analysis of 288 pediatric liver transplant patients diagnosed with cancer. We obtained potential predictors through univariable (P < 0.15) and multivariable models with forward selection (P < 0.05) for the Cox PH and Gray PC-TVC models, which coincide. While the Cox PH model provided reasonable average results in estimating covariate effects on posttransplant survival, the Gray model using piecewise constant penalized splines showed more details of how those effects change over time.

Impact of generic alendronate cost on the cost-effectiveness of osteoporosis screening and treatment.

INTRODUCTION: Since alendronate became available in generic form in the Unites States in 2008, its price has been decreasing. The objective of this study was to investigate the impact of alendronate cost on the cost-effectiveness of osteoporosis screening and treatment in postmenopausal women. METHODS: Microsimulation cost-effectiveness model of osteoporosis screening and treatment for U.S. women age 65 and older. We assumed screening initiation at age 65 with central dual-energy x-ray absorptiometry (DXA), and alendronate treatment for individuals with osteoporosis; with a comparator of "no screening" and treatment only after fracture occurrence. We evaluated annual alendronate costs of $20 through $800; outcome measures included fractures; nursing home admission; medication adverse events; death; costs; quality-adjusted life-years (QALYs); and incremental cost-effectiveness ratios (ICERs) in 2010 U.S. dollars per QALY gained. A lifetime time horizon was used, and direct costs were included. Base-case and sensitivity analyses were performed. RESULTS: Base-case analysis results showed that at annual alendronate costs of $200 or less, osteoporosis screening followed by treatment was cost-saving, resulting in lower total costs than no screening as well as more QALYs (10.6 additional quality-adjusted life-days). When assuming alendronate costs of $400 through $800, screening and treatment resulted in greater lifetime costs than no screening but was highly cost-effective, with ICERs ranging from $714 per QALY gained through $13,902 per QALY gained. Probabilistic sensitivity analyses revealed that the cost-effectiveness of osteoporosis screening followed by alendronate treatment was robust to joint input parameter estimate variation at a willingness-to-pay threshold of $50,000/QALY at all alendronate costs evaluated. CONCLUSIONS: Osteoporosis screening followed by alendronate treatment is effective and highly cost-effective for postmenopausal women across a range of alendronate costs, and may be cost-saving at annual alendronate costs of $200 or less.

The cost-effectiveness of immediate treatment, percutaneous biopsy and active surveillance for the diagnosis of the small solid renal mass: evidence from a Markov model.

PURPOSE: The most effective diagnostic strategy for the very small, incidentally detected solid renal mass is uncertain. We assessed the cost-effectiveness of adding percutaneous biopsy or active surveillance to the diagnosis of a 2 cm or less solid renal mass. MATERIALS AND METHODS: A Markov state transition model was developed to observe a hypothetical cohort of healthy 60-year-old men with an incidentally detected, 2 or less cm solid renal mass, comparing percutaneous biopsy, immediate treatment and active surveillance. The primary outcomes assessed were the incremental cost-effectiveness ratio measured by cost per life-year gained at a willingness to pay threshold of $50,000. Model results were assessed by sensitivity analysis. RESULTS: Immediate treatment was the highest cost, most effective diagnostic strategy, providing the longest overall survival of 18.53 life-years. Active surveillance was the lowest cost, least effective diagnostic strategy. On cost-effectiveness analysis using a societal willingness to pay threshold of $50,000 active surveillance was the preferred choice at a $75,000 willingness to pay threshold while biopsy and treatment were acceptable ($56,644 and $70,149 per life-year, respectively). When analysis was adjusted for quality of life, biopsy dominated immediate treatment as the most cost-effective diagnostic strategy at $33,840 per quality adjusted life-year gained. CONCLUSIONS: Percutaneous biopsy may have a greater role in optimizing the diagnosis of an incidentally detected, 2 cm or less solid renal mass.

Cost-effectiveness of different screening strategies for osteoporosis in postmenopausal women.

BACKGROUND: The best strategies to screen postmenopausal women for osteoporosis are not clear. OBJECTIVE: To identify the cost-effectiveness of various screening strategies. DESIGN: Individual-level state-transition cost-effectiveness model. DATA SOURCES: Published literature. TARGET POPULATION: U.S. women aged 55 years or older. TIME HORIZON: Lifetime. PERSPECTIVE: Payer. INTERVENTION: Screening strategies composed of alternative tests (central dual-energy x-ray absorptiometry [DXA], calcaneal quantitative ultrasonography [QUS], and the Simple Calculated Osteoporosis Risk Estimation [SCORE] tool) initiation ages, treatment thresholds, and rescreening intervals. Oral bisphosphonate treatment was assumed, with a base-case adherence rate of 50% and a 5-year on/off treatment pattern. OUTCOME MEASURES: Incremental cost-effectiveness ratios (2010 U.S. dollars per quality-adjusted life-year [QALY] gained). RESULTS OF BASE-CASE ANALYSIS: At all evaluated ages, screening was superior to not screening. In general, quality-adjusted life-days gained with screening tended to increase with age. At all initiation ages, the best strategy with an incremental cost-effectiveness ratio (ICER) of less than $50,000 per QALY was DXA screening with a T-score threshold of -2.5 or less for treatment and with follow-up screening every 5 years. Across screening initiation ages, the best strategy with an ICER less than $50,000 per QALY was initiation of screening at age 55 years by using DXA -2.5 with rescreening every 5 years. The best strategy with an ICER less than $100,000 per QALY was initiation of screening at age 55 years by using DXA with a T-score threshold of -2.0 or less for treatment and then rescreening every 10 years. No other strategy that involved treatment of women with osteopenia had an ICER less than $100,000 per QALY. Many other strategies, including strategies with SCORE or QUS prescreening, were also cost-effective, and in general the differences in effectiveness and costs between evaluated strategies was small. RESULTS OF SENSITIVITY ANALYSIS: Probabilistic sensitivity analysis did not reveal a consistently superior strategy. LIMITATIONS: Data were primarily from white women. Screening initiation at ages younger than 55 years were not examined. Only osteoporotic fractures of the hip, vertebrae, and wrist were modeled. CONCLUSION: Many strategies for postmenopausal osteoporosis screening are effective and cost-effective, including strategies involving screening initiation at age 55 years. No strategy substantially outperforms another. PRIMARY FUNDING SOURCE: National Center for Research Resources.