Estimation of a Relative Risk Effect Size when Using Continuous Outcomes Data: An Application of Methods in the Prevention of Major Depression and Eating Disorders.

INTRODUCTION: The raw mean difference (RMD) and standardized mean difference (SMD) are continuous effect size measures that are not readily usable in decision-analytic models of health care interventions. This study compared the predictive performance of 3 methods by which continuous outcomes data collected using psychiatric rating scales can be used to calculate a relative risk (RR) effect size. METHODS: Three methods to calculate RR effect sizes from continuous outcomes data are described: the RMD, SMD, and Cochrane conversion methods. Each conversion method was validated using data from randomized controlled trials (RCTs) examining the efficacy of interventions for the prevention of depression in youth (aged ≤17 years) and adults (aged ≥18 years) and the prevention of eating disorders in young women (aged ≤21 years). Validation analyses compared predicted RR effect sizes to actual RR effect sizes using scatterplots, correlation coefficients ( r), and simple linear regression. An applied analysis was also conducted to examine the impact of using each conversion method in a cost-effectiveness model. RESULTS: The predictive performances of the RMD and Cochrane conversion methods were strong relative to the SMD conversion method when analyzing RCTs involving depression in adults (RMD: r = 0.89-0.90; Cochrane: r = 0.73; SMD: r = 0.41-0.67) and eating disorders in young women (RMD: r = 0.89; Cochrane: r = 0.96). Moderate predictive performances were observed across the 3 methods when analyzing RCTs involving depression in youth (RMD: r = 0.50; Cochrane: r = 0.47; SMD: r = 0.46-0.46). Negligible differences were observed between the 3 methods when applied to a cost-effectiveness model. CONCLUSION: The RMD and Cochrane conversion methods are both valid methods for predicting RR effect sizes from continuous outcomes data. However, further validation and refinement are required before being applied more broadly.

Population cost-effectiveness of the Triple P parenting programme for the treatment of conduct disorder: an economic modelling study.

Parenting programmes are the recommended treatments of conduct disorders (CD) in children, but little is known about their longer term cost-effectiveness. This study aimed to evaluate the population cost-effectiveness of one of the most researched evidence-based parenting programmes, the Triple P-Positive Parenting Programme, delivered in a group and individual format, for the treatment of CD in children. A population-based multiple cohort decision analytic model was developed to estimate the cost per disability-adjusted life year (DALY) averted of Triple P compared with a 'no intervention' scenario, using a health sector perspective. The model targeted a cohort of 5-9-year-old children with CD in Australia currently seeking treatment, and followed them until they reached adulthood (i.e., 18 years). Multivariate probabilistic and univariate sensitivity analyses were conducted to incorporate uncertainty in the model parameters. Triple P was cost-effective compared to no intervention at a threshold of AU$50,000 per DALY averted when delivered in a group format [incremental cost-effectiveness ratio (ICER) = $1013 per DALY averted; 95% uncertainty interval (UI) 471-1956] and in an individual format (ICER = $20,498 per DALY averted; 95% UI 11,146-39,470). Evidence-based parenting programmes, such as the Triple P, for the treatment of CD among children appear to represent good value for money, when delivered in a group or an individual face-to-face format, with the group format being the most cost-effective option. The current model can be used for economic evaluations of other interventions targeting CD and in other settings.

The modeled cost-effectiveness of family-based and adolescent-focused treatment for anorexia nervosa.

BACKGROUND: Anorexia nervosa (AN) is a prevalent, serious mental disorder. We aimed to evaluate the cost-effectiveness of family-based treatment (FBT) compared to adolescent-focused individual therapy (AFT) or no intervention within the Australian healthcare system. METHOD: A Markov model was developed to estimate the cost and disability-adjusted life-year (DALY) averted of FBT relative to comparators over 6 years from the health system perspective. The target population was 11-18 year olds with AN of relatively short duration. Uncertainty and sensitivity analyses were conducted to test model assumptions. Results are reported as incremental cost-effectiveness ratios (ICER) in 2013 Australian dollars per DALY averted. RESULTS: FBT was less costly than AFT. Relative to no intervention, the mean ICER of FBT and AFT was $5,089 (95% uncertainty interval (UI): dominant to $16,659) and $51,897 ($21,591 to $1,712,491) per DALY averted. FBT and AFT are 100% and 45% likely to be cost-effective, respectively, at a threshold of AUD$50,000 per DALY averted. Sensitivity analyses indicated that excluding hospital costs led to increases in the ICERs but the conclusion of the study did not change. CONCLUSION: FBT is the most cost-effective among treatment arms, whereas AFT was not cost-effective compared to no intervention. Further research is required to verify this result.

The modelled cost-effectiveness of cognitive dissonance for the prevention of anorexia nervosa and bulimia nervosa in adolescent girls in Australia.

BACKGROUND: Eating disorders (EDs), including anorexia nervosa (AN) and bulimia nervosa (BN), are prevalent disorders that carry substantial economic and social burden. The aim of the current study was to evaluate the modelled population cost-effectiveness of cognitive dissonance (CD), a school-based preventive intervention for EDs, in the Australian health care context. METHOD: A population-based Markov model was developed to estimate the cost per disability adjusted life-year (DALY) averted by CD relative to no intervention. We modelled the cases of AN and BN that could be prevented over a 10-year time horizon in each study arm and the subsequent reduction in DALYs associated with this. The target population was 15-18 year old secondary school girls with high body-image concerns. This study only considered costs of the health sector providing services and not costs to individuals. Multivariate probabilistic and one-way sensitivity analyses were conducted to test model assumptions. RESULTS: Findings showed that the mean incremental cost-effectiveness ratio at base-case for the intervention was $103,980 per DALY averted with none of the uncertainty iterations falling below the threshold of AUD$50,000 per DALY averted. The evaluation was most sensitive to estimates of participant rates with higher rates associated with more favourable results. The intervention would become cost-effective (84% chance) if the effect of the intervention lasted up to 5 years. CONCLUSION: As modelled, school-based CD intervention is not a cost-effective preventive intervention for AN and BN. Given the burden of EDs, understanding how to improve participation rates is an important opportunity for future research.

Surgically avertable burden of digestive diseases at first-level hospitals in low and middle-income regions.

BACKGROUND: To quantify the burden of digestive diseases avertable by surgical care at first-level hospitals in low- and middle-income countries (LMICs). METHODS: We examined 4 digestive diseases from the Global Burden of Disease (GBD) 2010 STUDY: Appendicitis, intestinal obstruction, inguinal and femoral hernia, and gallbladder and bile duct disease. Using demographic and epidemiologic data from the GBD 2010 STUDY, we calculated the potential decrease in burden of digestive diseases if quality surgical services were available universally and accessible at first-level hospitals. The lowest case fatality rates for each age and sex grouping from all GBD regions were assumed to reflect the best possible state of full surgical coverage and treatment. These best scenario rates were applied to the GBD 2010 results from all LMIC regions to estimate surgically avertable burden. RESULTS: Overall, 4.8 million disability-adjusted life-years (DALYs) or 65% of burden related to the 4 digestive diseases are avertable potentially with first-level surgical care in LMICs. Sub-Saharan Africa has the greatest avertable burden in absolute DALYs (1.7 million) and avertable proportion (83%). Intestinal obstruction accounted for the largest portion of avertable burden among the 4 digestive diseases (2.2 million DALYs; 64% avertable). CONCLUSION: Improving the capacity of surgical services at first-level hospitals is essential for averting the burden of digestive diseases in LMICs. Practicable strategies for scaling up surgical capacities in rural districts are available potentially, which must be given due attention.

Burden of injuries avertable by a basic surgical package in low- and middle-income regions: a systematic analysis from the Global Burden of Disease 2010 Study.

BACKGROUND: Injuries accounted for 11 % of the global burden of disease in 2010. This study aimed to quantify the burden of injury in low- and middle-income countries (LMICs) that could be averted if basic surgical services were made available and accessible to the entire population. METHODS: We examined all causes of injury from the Global Burden of Disease 2010 Study. We split the disability-adjusted life years (DALYs) for these conditions between surgically "avertable" and "nonavertable" burdens. For estimating the avertable fatal burden, we applied the lowest fatality rates among the 21 epidemiologic regions to each LMIC region, assuming that the differences in death rates between each region and the lowest rates reflect the gap in surgical care. We adjusted for fatal cases that occur prior to reaching hospitals as they are not surgically avertable. Similarly, we applied the lowest nonfatal burden per case to each LMIC region. RESULTS: Overall, 21 % of the injury burden in LMICs was potentially avertable by basic surgical care (52.3 million DALYs). The avertable proportion was greater for deaths than for nonfatal burden (23 vs. 20 %), suggesting that surgical services for injuries more effectively save lives than ameliorate disability. Sub-Saharan Africa had the largest proportion of potentially avertable burden (25 %). South Asia had the highest total avertable DALYs (17.4 million). Road injury comprised the largest total avertable burden in LMICs (16.1 million DALYs). CONCLUSIONS: Basic surgical care has the potential to play a major role in reducing the injury-related burden in LMICs.

The burden of selected congenital anomalies amenable to surgery in low and middle-income regions: cleft lip and palate, congenital heart anomalies and neural tube defects.

OBJECTIVE: To quantify the burden of selected congenital anomalies in low and middle-income countries (LMICs) that could be reduced should surgical programmes cover the entire population with access to quality care. DESIGN: Burden of disease and epidemiological modelling. SETTING: LMICs from all global regions. POPULATION: All prevalent cases of selected congenital anomalies at birth in 2010. MAIN OUTCOME MEASURES: Disability-adjusted life years (DALYs). INTERVENTIONS AND METHODS: Surgical programmes for three congenital conditions were analysed: clefts (lip and palate); congenital heart anomalies; and neural tube defects. Data from the Global Burden of Disease 2010 Study were used to estimate the combination of fatal burden that could be addressed by surgical care and the additional long-term non-fatal burden associated with increased survival. RESULTS: Of the estimated 21.6 million DALYs caused by these three conditions in LMICs, 12.4 million DALYs (57%) are potentially addressable by surgical care among the population born with such conditions. Neural tube defects have the largest potential with 76% of burden amenable by surgery, followed by clefts (59%) and congenital heart anomalies (49%). Sub-Saharan Africa and South Asia have the greatest proportion of surgically addressable burden for clefts (68%), North Africa and Middle East for congenital heart anomalies (73%), and South Asia for neural tube defects (81%). CONCLUSIONS: There is an important and neglected role surgical programmes can play in reducing the burden of congenital anomalies in LMICs.

The Quik Fix study: a randomised controlled trial of brief interventions for young people with alcohol-related injuries and illnesses accessing emergency department and crisis support care.

BACKGROUND: Alcohol is a major preventable cause of injury, disability and death in young people. Large numbers of young people with alcohol-related injuries and medical conditions present to hospital emergency departments (EDs). Access to brief, efficacious, accessible and cost effective treatment is an international health priority within this age group. While there is growing evidence for the efficacy of brief motivational interviewing (MI) for reducing alcohol use in young people, there is significant scope to increase its impact, and determine if it is the most efficacious and cost effective type of brief intervention available. The efficacy of personality-targeted interventions (PIs) for alcohol misuse delivered individually to young people is yet to be determined or compared to MI, despite growing evidence for school-based PIs. This study protocol describes a randomized controlled trial comparing the efficacy and cost-effectiveness of telephone-delivered MI, PI and an Assessment Feedback/Information (AF/I) only control for reducing alcohol use and related harm in young people. METHODS/DESIGN: Participants will be 390 young people aged 16 to 25 years presenting to a crisis support service or ED with alcohol-related injuries and illnesses (including severe alcohol intoxication). This single blinded superiority trial randomized young people to (i) 2 sessions of MI; (ii) 2 sessions of a new PI or (iii) a 1 session AF/I only control. Participants are reassessed at 1, 3, 6 and 12 months on the primary outcomes of alcohol use and related problems and secondary outcomes of mental health symptoms, functioning, severity of problematic alcohol use, alcohol injuries, alcohol-related knowledge, coping self-efficacy to resist using alcohol, and cost effectiveness. DISCUSSION: This study will identify the most efficacious and cost-effective telephone-delivered brief intervention for reducing alcohol misuse and related problems in young people presenting to crisis support services or EDs. We expect efficacy will be greatest for PI, followed by MI, and then AF/I at 1, 3, 6 and 12 months on the primary and secondary outcome variables. Telephone-delivered brief interventions could provide a youth-friendly, accessible, efficacious, cost-effective and easily disseminated treatment for addressing the significant public health issue of alcohol misuse and related harm in young people. TRIAL REGISTRATION: This trial is registered with the Australian and New Zealand Clinical Trials Registry ACTRN12613000108718.

The cost-effectiveness of laparoscopic adjustable gastric banding in the morbidly obese adult population of Australia.

BACKGROUND: To examine the cost-effectiveness of providing laparoscopic adjustable gastric banding (LAGB) surgery to all morbidly obese adults in the 2003 Australian population. METHODS AND FINDINGS: Analyzed costs and benefits associated with two intervention scenarios, one providing LAGB surgery to individuals with BMI >40 and another to individuals with BMI >35, with each compared relative to a 'do nothing' scenario. A multi-state, multiple cohort Markov model was used to determine the cost-effectiveness of LAGB surgery over the lifetime of each cohort. All costs and health outcomes were assessed from an Australian health sector perspective and were discounted using a 3% annual rate. Uncertainty and sensitivity analyzes were conducted to test the robustness of model outcomes. Incremental cost-effectiveness ratios (ICERs) were measured in 2003 Australian dollars per disability adjusted life year (DALY) averted. The ICER for the scenario providing LAGB surgery to all individuals with a BMI >40 was dominant [95% CI: dominant -$588] meaning that the intervention led to both improved health and cost savings. The ICER when providing surgery to those with a BMI >35 was $2,154/DALY averted [95% CI: dominant -$6,033]. Results were highly sensitive to changes in the likelihood of long-term complications. CONCLUSION: LAGB surgery is highly cost-effective when compared to the $50,000/DALY threshold for cost-effectiveness used in Australia. LAGB surgery also ranks highly in terms of cost-effectiveness when compared to other population-level interventions for weight loss in Australia. The results of this study are in line with other economic evaluations on LAGB surgery. This study recommends that the Australian federal government provide a full subsidy for LAGB surgery to morbidly obese Australians with a BMI >40.

Which interventions offer best value for money in primary prevention of cardiovascular disease?

BACKGROUND: Despite many decades of declining mortality rates in the Western world, cardiovascular disease remains the leading cause of death worldwide. In this research we evaluate the optimal mix of lifestyle, pharmaceutical and population-wide interventions for primary prevention of cardiovascular disease. METHODS AND FINDINGS: In a discrete time Markov model we simulate the ischaemic heart disease and stroke outcomes and cost impacts of intervention over the lifetime of all Australian men and women, aged 35 to 84 years, who have never experienced a heart disease or stroke event. Best value for money is achieved by mandating moderate limits on salt in the manufacture of bread, margarine and cereal. A combination of diuretic, calcium channel blocker, ACE inhibitor and low-cost statin, for everyone with at least 5% five-year risk of cardiovascular disease, is also cost-effective, but lifestyle interventions aiming to change risky dietary and exercise behaviours are extremely poor value for money and have little population health benefit. CONCLUSIONS: There is huge potential for improving efficiency in cardiovascular disease prevention in Australia. A tougher approach from Government to mandating limits on salt in processed foods and reducing excessive statin prices, and a shift away from lifestyle counselling to more efficient absolute risk-based prescription of preventive drugs, could cut health care costs while improving population health.

Improving the cost-effectiveness of cardiovascular disease prevention in Australia: a modelling study.

BACKGROUND: Cardiovascular disease is the leading cause of death worldwide. Like many countries, Australia is currently changing its guidelines for cardiovascular disease prevention from drug treatment for everyone with 'high blood pressure' or 'high cholesterol', to prevention based on a patient's absolute risk. In this research, we model cost-effectiveness of cardiovascular disease prevention with blood pressure and lipid drugs in Australia under three different scenarios: (1) the true current practice in Australia; (2) prevention as intended under the current guidelines; and (3) prevention according to proposed absolute risk levels. We consider the implications of changing to absolute risk-based cardiovascular disease prevention, for the health of the Australian people and for Government health sector expenditure over the long term. METHODS: We evaluate cost-effectiveness of statins, diuretics, ACE inhibitors, calcium channel blockers and beta-blockers, for Australian men and women, aged 35 to 84 years, who have never experienced a heart disease or stroke event. Epidemiological changes and health care costs are simulated by age and sex in a discrete time Markov model, to determine total impacts on population health and health sector costs over the lifetime, from which we derive cost-effectiveness ratios in 2008 Australian dollars per quality-adjusted life year. RESULTS: Cardiovascular disease prevention based on absolute risk is more cost-effective than prevention under the current guidelines based on single risk factor thresholds, and is more cost-effective than the current practice, which does not follow current clinical guidelines. Recommending blood pressure-lowering drugs to everyone with at least 5% absolute risk and statin drugs to everyone with at least 10% absolute risk, can achieve current levels of population health, while saving $5.4 billion for the Australian Government over the lifetime of the population. But savings could be as high as $7.1 billion if Australia could match the cheaper price of statin drugs in New Zealand. CONCLUSIONS: Changing to absolute risk-based cardiovascular disease prevention is highly recommended for reducing health sector spending, but the Australian Government must also consider measures to reduce the cost of statin drugs, over and above the legislated price cuts of November 2010.

Cost-effectiveness of various tuberculosis control strategies in Thailand.

OBJECTIVE: To evaluate the cost-effectiveness of different tuberculosis control strategies in Thailand. METHODS: Different tuberculosis control strategies, which included health-worker, community-member, and family-member directly observed treatment (DOT) and a mobile phone "contact-reminder" system, were compared with self-administered treatment (SAT). Cost-effectiveness analysis was undertaken by using a decision tree model. Costs (2005 international dollars [I$]) were calculated on the basis of treatment periods and treatment outcomes. Health outcomes were estimated over the lifetime of smear-positive pulmonary tuberculosis patients in disability-adjusted life years (DALYs) averted on the basis of Thai evidence on the efficacy of the selected strategies. RESULTS: Cost-effectiveness results indicate no preference for any strategy. The uncertainty ranges surrounding the health benefits were wide, including a sizeable probability that SAT could lead to more health gain than DOT strategies. The health gain for family-member DOT was 9400 DALYs (95% uncertainty interval -7200 to 25,000), for community-member DOT was 13,000 DALYs (95% uncertainty interval -21,000 to 37,000), and for health-worker DOT was 7900 DALYs (95% uncertainty interval -50,000 to 43,000). There were cost savings (from less multi-drug resistant tuberculosis treatment) associated with family-member DOT (-I$9 million [95% uncertainty interval -I$12 million to -I$5 million]) because the trial treatment failure rate was significantly lower than that for SAT. The mobile phone reminder system was not cost-effective, because the mortality rate associated with it was much higher than that associated with other treatment strategies. CONCLUSIONS: Because of the large uncertainty intervals around health gain for DOT strategies, it remains inconclusive whether DOT strategies are more cost-effective than SAT. It is evident, however, that family-member DOT is a cost-saving intervention.

Would vaccination against nicotine be a cost-effective way to prevent smoking uptake in adolescents?

AIMS: We used epidemiological modelling to assess whether nicotine vaccines would be a cost-effective way of preventing smoking uptake in adolescents. DESIGN, SETTING, PARTICIPANTS AND MEASUREMENTS: We built an epidemiological model using Australian data on age-specific smoking prevalence; smoking cessation and relapse rates; life-time sex-specific disability-adjusted life years lived for cohorts of 100,000 smokers and non-smokers; government data on the costs of delivering a vaccination programme by general practitioners; and a range of plausible and optimistic estimates of vaccine cost, efficacy and immune response rates based on clinical trial results. We first estimated the smoking uptake rates for Australians aged 12-19 years. We then used these estimates to predict the expected smoking prevalence in a birth cohort aged 12 in 2003 by age 20 under (i) current policy and (ii) different vaccination scenarios that varied in cost, initial vaccination uptake, yearly re-vaccination rates, efficacy and a favourable vaccine immune response rate. FINDINGS: Under the most optimistic assumptions, the cost to avert a smoker at age 20 was $44,431 [95% confidence interval (CI) $40,023-49,250]. This increased to $296,019 (95% CI $252,307-$355,930) under more plausible scenarios. The vaccine programme was not cost-effective under any scenario. CONCLUSIONS: A preventive nicotine vaccination programme is unlikely to be cost-effective. The total cost of a universal vaccination programme would be high and its impact on population smoking prevalence negligible. For these reasons, such a programme is unlikely to be publicly funded in Australia or any other developed country.

Cost-effectiveness of tobacco control policies in Vietnam: the case of personal smoking cessation support.

AIMS: To examine the cost-effectiveness of personal smoking cessation support in Vietnam. DESIGN, SETTING AND PARTICIPANTS: We followed-up the population aged 15 years and over in 2006 to model the costs and health gains associated with five interventions: physician brief advice; nicotine replacement therapy (patch and gum); bupropion; and varenicline. Threshold analysis was undertaken to determine the price levels of pharmaceuticals for the interventions to be cost-effective. A multi-state life table model was constructed such that the interventions affect the smoking cessation behaviour of the age cohorts, and the resulting smoking prevalence defines their health outcomes. A health-care perspective was employed. MEASUREMENTS: Cost-effectiveness is measured in 2006 Vietnamese Dong (VND) per disability-adjusted life year (DALY) averted. We adopted the World Health Organization thresholds of being 'cost-effective' if less than three times gross domestic product (GDP) per capita (VND 34,600,000) and 'very cost-effective' if less than GDP per capita (VND 11,500,000). FINDINGS: The cost-effectiveness result of physician brief advice was VND 1,742,000 per DALY averted (international dollars 543), which was 'very cost-effective'. Varenicline dominated bupropion and nicotine-replacement therapies, although it did not fall within the range of being 'cost-effective' under different scenarios. The threshold analysis revealed that prices of pharmaceuticals must be substantially lower than the levels from other countries if pharmacological therapies are to be cost-effective in Vietnam. CONCLUSIONS: Physician brief advice is a cost-effective intervention and should be included in the priority list of tobacco control policy in Vietnam. Pharmacological therapies are not cost-effective, and so they are not recommended in Vietnam at this time unless pharmaceuticals could be produced locally at substantially lower costs in the future.

Cost-effectiveness of pharmacotherapy to reduce obesity.

AIMS: Obesity causes a high disease burden in Australia and across the world. We aimed to analyse the cost-effectiveness of weight reduction with pharmacotherapy in Australia, and to assess its potential to reduce the disease burden due to excess body weight. METHODS: We constructed a multi-state life-table based Markov model in Excel in which body weight influences the incidence of stroke, ischemic heart disease, hypertensive heart disease, diabetes mellitus, osteoarthritis, post-menopausal breast cancer, colon cancer, endometrial cancer and kidney cancer. We use data on effectiveness identified from PubMed searches, on mortality from Australian Bureau of Statistics, on disease costs from the Australian Institute of Health and Welfare, and on drug costs from the Department of Health and Ageing. We evaluate 1-year pharmacological interventions with sibutramine and orlistat targeting obese Australian adults free of obesity-related disease. We use a lifetime horizon for costs and health outcomes and a health sector perspective for costs. Incremental Cost-Effectiveness Ratios (ICERs) below A$50 000 per Disability Adjusted Life Year (DALY) averted are considered good value for money. RESULTS: The ICERs are A$130 000/DALY (95% uncertainty interval [UI] 93 000-180 000) for sibutramine and A$230 000/DALY (170 000-340 000) for orlistat. The interventions reduce the body weight-related disease burden at the population level by 0.2% and 0.1%, respectively. Modest weight loss during the interventions, rapid post-intervention weight regain and low adherence limit the health benefits. CONCLUSIONS: Treatment with sibutramine or orlistat is not cost-effective from an Australian health sector perspective and has a negligible impact on the total body weight-related disease burden.

Cost-effectiveness of total hip and knee replacements for the Australian population with osteoarthritis: discrete-event simulation model.

BACKGROUND: Osteoarthritis constitutes a major musculoskeletal burden for the aged Australians. Hip and knee replacement surgeries are effective interventions once all conservative therapies to manage the symptoms have been exhausted. This study aims to evaluate the cost-effectiveness of hip and knee replacements in Australia. To our best knowledge, the study is the first attempt to account for the dual nature of hip and knee osteoarthritis in modelling the severities of right and left joints separately. METHODOLOGY/PRINCIPAL FINDINGS: We developed a discrete-event simulation model that follows up the individuals with osteoarthritis over their lifetimes. The model defines separate attributes for right and left joints and accounts for several repeat replacements. The Australian population with osteoarthritis who were 40 years of age or older in 2003 were followed up until extinct. Intervention effects were modelled by means of disability-adjusted life-years (DALYs) averted. Both hip and knee replacements are highly cost effective (AUD 5,000 per DALY and AUD 12,000 per DALY respectively) under an AUD 50,000/DALY threshold level. The exclusion of cost offsets, and inclusion of future unrelated health care costs in extended years of life, did not change the findings that the interventions are cost-effective (AUD 17,000 per DALY and AUD 26,000 per DALY respectively). However, there was a substantial difference between hip and knee replacements where surgeries administered for hips were more cost-effective than for knees. CONCLUSIONS/SIGNIFICANCE: Both hip and knee replacements are cost-effective interventions to improve the quality of life of people with osteoarthritis. It was also shown that the dual nature of hip and knee OA should be taken into account to provide more accurate estimation on the cost-effectiveness of hip and knee replacements.

Cost effectiveness of tobacco control policies in Vietnam: the case of population-level interventions.

BACKGROUND: Tobacco smoking is one of the leading public health problems in the world. It is also possible to prevent and/or reduce the harm from tobacco use through the use of cost-effective tobacco control measures. However, most of this evidence comes from developed countries and little research has been conducted on this issue in developing countries. OBJECTIVE: The objective of this study was to analyse the cost effectiveness of four population-level tobacco control interventions in Vietnam. METHODS: Four tobacco control interventions were evaluated: excise tax increase; graphic warning labels on cigarette packs; mass media campaigns; and smoking bans (in public or in work places). A multi-state life table model was constructed in Microsoft® Excel to examine the cost effectiveness of the tobacco control intervention options. A government perspective was adopted, with costing conducted using a bottom-up approach. Health improvement was considered in terms of disability-adjusted life-years (DALYs) averted. All assumptions were subject to sensitivity and uncertainty analysis. RESULTS: All the interventions fell within the definition of being very cost effective according to the threshold level suggested by the WHO (i.e.

Reducing inequalities in lung cancer incidence through smoking policies.

INTRODUCTION: Lower social class has higher lung cancer incidence, largely attributable to higher smoking prevalence among the lower social classes. We assessed the magnitude and time dimension of potential impact of targeted interventions on smoking on socioeconomic inequalities in lung cancer. METHODS: Using population dynamic modelling, we projected lung cancer incidence up to 2050 in lowest and highest socioeconomic groups under two intervention scenarios (annual 10% increase in cigarette prices and health advertisement) and compared this to a scenario of no intervention. For the analysis we retrieved smoking prevalence data from the General Household Survey of England and Wales between 1980 and 2006 and cancer incidence data from the national cancer registry. RESULTS: By 2050, the model projected that lung cancer incidence inequality would almost double (Incidence Rate Ratio (IRR)=4.2 in 2050 vs. 2.5 in 2005) in men and slightly decrease (IRR=2.4 in 2050 vs. 2.7 in 2005) in women compared to what was observed in 2005. If annual increase in cigarette price targeting the lowest socioeconomic group was implemented, socioeconomic inequality in lung cancer incidence in 2050 might be largely reduced (IRR=1.5 and 1.4 among men and women, respectively). If in addition to annual price increase (targeted to the lowest socioeconomic group) health advertisement was implemented and successfully reduced smoking prevalence in the highest socioeconomic group, the lung cancer gap between the socioeconomic groups would be reduced by 78% and 58% in men and women by 2050. CONCLUSION: Even under the best scenarios, inequality in lung cancer was not fully eliminated within 45 years period. Though the process is lengthy, rigorous interventions may reduce the expected widening of the future inequalities in lung cancer. Modelling exercise such as ours relies heavily on the quality of the input data and the assumptions, thus caution is needed in interpretation of our findings and should consider all the assumptions taken in the analysis.

Is endoscopic surveillance for non-dysplastic Barrett's esophagus cost-effective? Review of economic evaluations.

BACKGROUND AND AIM: Several health economic evaluations have explored the cost-effectiveness of endoscopic surveillance for patients with non-dysplastic Barrett's esophagus, with conflicting results. By comparing results across studies and highlighting key methodological and data limitations a platform for future, more rigorous analyses, can be developed. METHODS: A systematic literature review was undertaken of studies evaluating cost-effectiveness of surveillance for non-dysplastic Barrett's esophagus. Articles were included if they assessed both cost and health outcomes for surveillance versus no surveillance. A descriptive review was undertaken and the quality of the studies appraised against best-practice recommendations for economic evaluations and modeling studies. RESULTS: Seven publications met the inclusion criteria. All used decision-analytic Markov models. Half of the evaluations found surveillance was not cost-effective. At best, surveillance produced improved outcomes at a cost of US$16 640 per quality-adjusted life-year, and at worst it did more harm than good and at a greater cost. The quality of the evaluations and generalizability to the Asia-Pacific region was diminished as a result of inadequate or inconsistent evidence supporting parameter estimates, such as quality of life, endoscopic sensitivity and specificity and cancer recurrence rates. CONCLUSIONS: Unless newly emerging technologies improve the quality-adjusted survival benefit conferred by endoscopic surveillance, this strategy is unlikely to be cost-effective. Obsolete assumptions and incomplete analyses reduce the quality of published evaluations. For these reasons new evaluations are required that encompass the growing evidence base for new technologies, such as new endoscopic therapies for high-grade dysplasia and intramucosal cancer.