A cost-benefit analysis of genetic screening test for breast cancer in Iran.

BACKGROUND: This study aimed to evaluate the implementation of the population- and family history (FH) -based screening for BReast CAncer (BRCA) in Iran, a country where less than 10% of breast cancer cases are attributable to a gene mutation. METHODS: This was an economic evaluation study. The Benefit-Cost Ratio (BCR) for genetic screening test strategies in Iranian women older than 30 was calculated. To this end, the monetary value of the test was estimated using the willingness-to-pay (WTP) approach using the contingent valuation method (CVM) by payment card. From a healthcare perspective, direct medical and non-medical costs were considered and a decision model for the strategies was developed to simulate the costs. A one-way sensitivity analysis assessed the robustness of the analysis. The data were analyzed using Excel 2010. RESULTS: 660 women were included for estimating WTP and 2,176,919 women were considered in the costing model. The cost per genetic screening test for population- and FH-based strategies was $167 and $8, respectively. The monetary value of a genetic screening test was $20 and it was $27 for women with a family history or gene mutation in breast cancer. The BCR for population-based and FH-based screening strategies was 0.12 and 3.37, respectively. Sensitivity analyses confirmed the robustness of the results. CONCLUSIONS: This study recommends the implementation of a FH-based strategy instead of a population-based genetic screening strategy in Iran, although a cascade genetic screening test strategy should be evaluated in future studies.

Economical Evaluation of Prostate Cancer Treatment Using Intensity-Modulated Radiation Therapy, 3-Dimensional Conformal Radiation Therapy and Radical Prostatectomy: A Systematic Review.

OBJECTIVES: Prostate cancer is a common form of cancer among men worldwide. The objective of this study was to conduct a systematic review of the economic evaluations of prostate cancer treatment strategies. METHODS: This systematic review was conducted using multiple electronic databases up to May 2021. English-language economic evaluation studies that compared intensity-modulated radiation therapy (IMRT), 3-dimensional conformal radiation therapy (3DCRT), and radical prostatectomy (RP) were included. The studies were evaluated using the Consolidated Health Economic Evaluation Reporting Standards checklist. The search yielded 1151 potentially relevant publications, which were screened based on the title and abstract. After the removal of duplicates, 55 studies remained, and 9 studies were screened in full text. Finally, textual data were analyzed manually using by-content analysis method. RESULTS: All studies were cost-effective and evaluated quality-adjusted life year as the efficacy indicator. The studies were conducted from either payers' or health systems' perspectives, and the time horizon varied from 5 to 20 years. We included only full economic evaluation studies. The use of IMRT in comparison with 3DCRT was evaluated in 6 studies, based on which IMRT increased health and reduced side effects of treatment. According to incremental cost-effectiveness ratio (ICER) results, IMRT was more cost-effective than 3DCRT. Three studies evaluated the use of RP in comparison with radiotherapy. Based on these studies, radiotherapy was more effective than RP. CONCLUSION: IMRT was found to be more cost-effective than 3DCRT in all 6 studies compared with the threshold. Radiotherapy was found to be more effective than RP. However, long-term clinical trial studies are needed to confirm these findings and to provide more definitive conclusions.

Subjective valuation of Iranian women for screening for gene-related diseases: a case of breast cancer.

BACKGROUND: About 5-10% of breast cancer cases are attributed to a gene mutation. To perform preventive interventions for women with a gene mutation, genetic screening BRCA tests have recently been implemented in Iran. The present study aimed to determine Iranian women's subjective valuation for screening BRCA tests for early detection of breast cancer to help policymakers to make decisions about genetic screening tests for breast cancer and to know the applicants. METHODS: An online survey was completed by women older than 30 years old in Tehran, the capital of Iran in 2021. A hypothetical scenario about genetic screening tests for breast cancer was defined. The subjective valuation for the tests was assessed by a willingness to pay (WTP) using the contingent valuation method (CVM) by payment card. Demographics, history of breast cancers, knowledge, and physiological variables were considered as independent variables, and a logistic regression model assessed the relationship between WTP and the variables. RESULTS: 660 women were included. 88% of participants intended to participate in BRCA genetic screening for breast cancer if it were free. The mean WTP for the tests was about $ 20. Based on the logistic regression, income, family history of breast or ovarian cancer, and positive attitude were associated with WTP. CONCLUSIONS: Iranian women were willing to intend for genetic screening BRCA tests and pay for them as well. The result of the present study is of great importance for policy makers when it comes to funding and determining co-payments for BRCA genetic screening tests. To achieve a high participation rate of women in breast cancer screening plans, a positive attitude should be promoted as a psychological factor. Educational and informative programs can help.

A systemmatic literature review on indirect costs of women with breast cancer.

INTRODUCTION: The rising incidence of breast cancer places a financial burden on national health services and economies. The objective of this review is to present a detailed analysis of the research and literature on indirect costs of breast cancer. METHODS: English literature databases from 2000 to 2020 were searched to find studies related to the objective of the present review. Study selection and data extraction was undertaken independently by two authors. Also, quality assessment was done using a checklist designed by Stunhldreher et al. RESULTS: The current study chose 33 studies that were eligible from a total of 2825 records obtained. The cost of lost productivity due to premature death based on human capital approach ranged from $22,386 to $52 billion. The cost burden from productivity lost due to premature death based on friction cost approach ranged from $1488.61 to $4,518,628.5. The cost burden from productivity lost due to morbidity with the human capital approach was reported as $126,857,360.69 to $596,659,071.28. The cost of lost productivity arising from informal caregivers with the human capital approach was $297,548.46 to $308 billion. CONCLUSION: Evaluation of the existing evidence revealed the indirect costs of breast cancer in women to be significantly high. This study did a thorough review on the indirect costs associated with breast cancer in women which could serve as a guide to help pick the appropriate method for calculating the indirect costs of breast cancer based on existing methods, approach and data. There is a need for calculations to be standardised since the heterogeneity of results in different domains from various studies makes it impossible for comparisons to be made among different countries.

Systematic review of women's knowledge, attitude, and practice towards breast cancer.

The present study aims to systematically review the women's knowledge, attitude, and practice (KAP) of breast cancer (BC) screening methods to get enough information for policymakers to orient the screening strategies. All English KAP studies on BC screening methods in five databases up to January 2021 were included. The quality of the final articles was assessed using the STROBE checklist. The qualitative synthesis was performed. Out of 5574 retrieved articles, 28 were included. About 64% of the articles were of high quality. Overall, there were poor knowledge, negative attitude, and low practice between women. The educational programs and cultural plans can encourage regular screening. Women's excessive optimism to their BC risk should be eliminated by focusing on the risk of the disease, more.

Population or family history based BRCA gene tests of breast cancer? A systematic review of economic evaluations.

BACKGROUND: Nearly 56% of at-risk carriers are not identified and missed as a result of the current family-history (FH) screening for genetic testing. The present study aims to review the economic evaluation studies on BRCA genetic testing strategies for screening and early detection of breast cancer. METHODS: This systematic literature review is conducted within the Cochrane Library, PubMed, Scopus, Web of Science, ProQuest, and EMBASE databases. In this paper, the relevant published economic evaluation studies are identified by following the standard Cochrane Collaboration methods and adherence to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement reporting some recommendations for articles up to March 2020. Thereafter, the inclusion and exclusion criteria are applied to screen the articles. Disagreements are resolved through a consensus meeting. The Consolidated Health Economic Evaluation Reporting Standards (CHEERS) checklist is used in the evaluation of quality. Finally, a narrative synthesis is performed. To compare the different levels of incremental cost-effectiveness ratio (ICER), the net present value is calculated based on a discount rate of 3% in 2019. RESULTS: Among 788 initially retrieved citations, 12 studies were included. More than 60% of the studies were originated from high-income countries and were published after 2016. It is noteworthy that most of the studies evaluated the payer perspective. Moreover, the robustness of the results were analyzed through one-way and probabilistic sensitivity analyses in nearly 66% of these studies. Nearly, 25% of the studies are focused and defined population-based and family history BRCA tests as comparators; afterwards, the cost-effectiveness of the former was confirmed. The highest and lowest absolute values for the ICERs were $65,661 and $9 per quality adjusted life years, respectively. All studies met over 70% of the CHEERs criteria checklist, which was considered as 93% of high quality on average as well. CONCLUSIONS: The genetic BRCA tests for the general population as well as unselected breast cancer patients were cost-effective in high and upper-middle income countries and those with prevalence of gene mutation while population-based genetic tests for low-middle income countries are depended on the price of the tests.

A comparison of global surgery tariffs and the actual cost of bills at Hazrate Rasoole Akram educational and medical center.

BACKGROUND: the health service tariff is an appropriate policymaking tool and the financial leverage of the health system control which affects quality, availability, cost, efficiency, equity and accountability of health services. Global surgeries include 91 common cases of general and specialized surgeries in hospitals; fixed tariffs are annually defined for these surgeries, and insurance companies must pay medical centers based on these tariffs. The aim of this study was to examine and compare hospital bills with global surgery tariffs at Hazrate Rasoole Akram Educational and Medical Center in 2017. METHODS: This descriptive-analytic study was conducted retrospectively and compared the global and actual costs of global surgeries performed in the third quarter of the year 2017 at Hazrate Rasoole Akram Educational and Medical Center. Required data on the actual costs of surgeries was collected through the Hospital Information System (HIS) and patients' records. Information on the global costs was obtained from the Annual Circulars of Insurance Council for the studied period about the cost of global surgeries. Linear regression (STATA13 software) was used to investigate the effect of items on tariff and invoice differences; concerning other calculations, EXCEL software was used. RESULTS: The highest frequency of global surgeries was related to ophthalmic surgery which accounted for approximately half of total surgeries performed at Hazrate Rasoole Akram Hospital. The most significant difference between global tariff and invoice was also related to ophthalmic surgery (188709.3 Dollar a year).Overall, the actual hospital bills were much higher than the tariffs approved for global surgeries, and the total difference was 461805.5 Dollar. The results revealed that there was a significant relationship between some of the items such as the cost of operating rooms, anesthesia and other services. CONCLUSIONS: Referral hospitals which are at the level three of referral networks usually treat more complex patients; this should be taken into account when defining surgery tariffs of these centers. On the other hand, hospitals need to control the costs and reduce the end cost of these surgeries by improving clinical management and cost management. In addition, prospective and case-based payment methods can control health costs.

Medical costs of osteoporosis in the Iranian elderly patients.

Background: In the coming years and near future, Iran will experience a main demographic transition resulting in an aging phenomenon and increased number of people over 65 years. Aging leads to increased medical expenditures associated with chronic diseases such as osteoporosis. This study aimed to investigate the patient-specific hospitalization costs of osteoporosis treatment in elderly patients. Methods: A retrospective cost analysis of hospitalization arising from osteoporosis conducted on all the elderly patients (adults aged 65 years and above) in a teaching hospital in Tehran through examining hospital admissions during 2017. The elderly patients consisted of 295 with a length of stay ≥ 24 hours. Cost analysis was performed using a bottom-up micro-costing approach and payer perspective (patient and insurer); and the result was statistically significant (p≤0.05). Nonparametric tests, including Mann-Whitney and Kruskal-Wallis tests, were used to investigate the relationship between affecting variables. Hospital training was considered as a control variable. The data were analyzed using SPSS 11 software Results: The mean age of the patients was 71.3 years; of the patients, 79% were female and 21% male. The overall crude prevalence of osteoporosis was 80% among people ≥ 65 years and 85% among patients who experienced relevant surgeries. The average cost of hospitalization was $3794.13. Also, 3 main areas of hospital costs were identified: consumables (57.70%), hoteling (17.24%), and surgical services (15.76%). The prevalence of osteoporosis was 4 times higher in women compared with men. Moreover, there were significant differences between the variables affecting hospital costs, such as gender, length of stay, diagnosis, intensive care unit services, and surgery (p<0.05). Conclusion: Age-associated diseases such as osteoporosis increase the health care costs. The dominant cost drivers in this study were the consumables, hoteling, and surgical services, respectively. Policymakers and health care planners should consider such variables as gender, previous surgeries in the patients' records, length of stay, and intensive care unit services as driving factors and determinants of hospital costs for older seniors with osteoporosis.

Factors affecting the informal payments in public and teaching hospitals.

BACKGROUND: Informal payments in the health sector of many developing countries are considered as a major impediment to health care reforms. Informal payments are a form of systemic fraud and have adverse effects on the performance of the health system. In this study, the frequency and extent of informal payments as well as the determinants of these payments were investigated in general hospitals affiliated to Tehran University of Medical Sciences. METHODS: In this cross-sectional study, 300 discharged patients were selected using multi-stage random sampling method. First, three hospitals were selected randomly; then, through a simple random sampling, we recruited 300 discharged patients from internal, surgery, emergency, ICU & CCU wards. All data were collected by structured telephone interviews and questionnaire. We analyzed data using Chi- square, Kruskal-Wallis and Mann-Whitney tests. RESULTS: The results indicated that 21% (n=63) of individuals paid informally to the staff. About 4% (n=12) of the participants were faced with informal payment requests from hospital staff. There was a significant relationship between frequency of informal payments with marital status of participants and type of hospitals. According to our findings, none of the respondents had informal payments to physicians. The most frequent informal payments were in cash and were made to the hospitals' housekeeping staff to ensure more and better services. There was no significant relationship between the informal payments with socio-demographic characteristics, residential area and insurance status. CONCLUSION: Our findings revealed that many strategies can be used for both controlling and reducing informal payments. These include training patients and hospitals' staff, increasing income levels of employees, improving the quantity and quality of health services and changing the entrenched beliefs that necessitate informal payments.

Cost-effectiveness analysis of trastuzumab in the adjuvant treatment for early breast cancer.

BACKGROUND: Evidence from randomized controlled trials (RCTs) has shown a significant survival advantage of trastuzumab. Although extant work in developed countries examined economic evaluation of trastuzumab in adjuvant treatment for early breast cancer based on the 1-year treatment, there is uncertainty about cost-effectiveness of trastuzumab in the Adjuvant Treatment of early breast cancer in developing countries. This study aimed to estimate cost-effectiveness of adjuvant trastuzumab therapy compared to AC-T regimen in early breast cancer in Iran. METHODS: A cost-effectiveness analysis was performed using a Markov model to estimate outcomes and costs over a 20-year time period using a cohort of women with HER2 positive early breast cancer, treated with or without 12 months trastuzumab adjuvant chemotherapy. Transition probabilities were derived mainly from the BCIRG006 trial. Costs were estimated from the perspective of the Iranian health care system. Both costs and outcomes were discounted by 3%. One-way sensitivity analysis was undertaken to assess the associated uncertainties in the expected output measures. RESULTS: On the basis of BCIRG006 trial, our model showed that adjuvant trastuzumab treatment in early breast cancer, yield 0.87 quality-adjusted life-years (QALY) compared with AC-T regimen. Adjuvant trastuzumab treatment yielded an incremental cost-effectiveness ratio (ICER) of US$ 51302 per QALY. CONCLUSION: By using threshold of 3 times GDP per capita, as per World Health Organization (WHO) recommendation, 12 months trastuzumab adjuvant chemotherapy is not a cost-effective therapy for patients with HER2-positive breast cancer in Iran.