Cost-Effectiveness of Comprehensive Genomic Profiling in Patients With Non-Small Cell Lung Cancer for the Colombian Health System.

INTRODUCTION: The use of comprehensive genomic profiling (CGP) and target therapies is associated with substantial improvements in clinical outcomes among patients with non-small cell lung cancer (NSCLC). However, the costs of CGP may increase the financial pressures of NSCLC on health systems worldwide, especially in low- and middle-income countries. This study aimed to estimate the cost-effectiveness of CGP compared with current genomic tests in patients with NSCLC from the perspective of the Colombian Health System. METHODS: To estimate the costs and benefits of CGP and its comparators, we developed a 2-stage cohort model with a lifetime horizon. In the first stage, we made up a decision tree that calculated the probability of receiving each therapy as result of identifying a specific, actionable target. In the second stage, we developed a partitioned survival model that estimated the time spent at each health state. Incremental cost-effectiveness ratios were calculated for life-years (LYs) and quality-adjusted LYs gained. All costs were expressed in 2019 international dollars (INT$). RESULTS: CGP is associated with gains of 0.06 LYs and 0.04 quality-adjusted LYs compared with current genomic tests. Incremental cost-effectiveness ratios for CGP ranged from INT$861 to INT$7848, depending on the outcome and the comparator. Sensitivity analyses show that the cost-effectiveness decision was sensitive to prices of CGP above INT$7170 per test. These results are robust to most deterministic and probabilistic sensitivity analyses. CONCLUSIONS: CGP may be cost-effective in patients with NSCLC from the perspective of the Colombian Health System (societal willingness-to-pay threshold of INT$15 630 to INT$46 890).

Fragmentation of Care and Its Association With Survival and Costs for Patients With Breast Cancer in Colombia.

PURPOSE: Breast cancer care requires a multimodal approach and a multidisciplinary team who must work together to obtain good clinical results. The fragmentation of care can affect the breast cancer care; however, it has not been measured in a low-resource setting. The aim of this study was to identify fragmentation of care, the geographic variation of this and its association with 4-year overall survival (OS), and costs of care for patients with breast cancer enrolled in Colombia's contributory health care system. MATERIALS AND METHODS: A retrospective cohort study was conducted using administrative databases. Women with breast cancer who were treated from January 1, 2013, to December 31, 2015, were included. Fragmentation of care was the exposure, which was measured by the number of different health care provider institutions (HCPIs) that treated a patient during the first year after diagnosis. Crude mortality rates were estimated, survival functions were calculated using the nonparametric Kaplan-Meier approach, and adjusted hazard ratios (HRs) were estimated using multivariate Cox regression model to identify the association of fragmentation with 4-year OS. The association between fragmentation and costs of care was assessed using a multivariate linear regression model. RESULTS: A total of 10,999 patients with breast cancer were identified, and 1,332 deaths were observed. The 4-year crude mortality rate was 31.97 (95% CI, 30.25 to 33.69) per 1,000 person-years for the whole cohort, and the highest rate was in the cohort defined for the fourth quartile of the fragmentation measurement (eight or more HCPIs), 40.94 (95% CI, 36.49 to 45.39). The adjusted HR for 4-year OS was 1.04 (95% CI, 1.01 to 1.07) for each HCPI additional. The cost of care is increased for each additional HCPIs (cost ratio, 1.25; 95% CI, 1.23 to 1.26). CONCLUSION: Fragmentation of care decreases overall 4-year OS and increases the costs of care in women with breast cancer for Colombia.

Análisis de Costo Efectividad del Contacto Piel a Piel al Nacimiento, Temprano vs Inmediato, en la Morbilidad Neonatal de Recién Nacidos de Bajo Riesgo.

OBJECTIVES: This study aimed to evaluate the cost-effectiveness of immediate skin-to-skin contact compared with early skin-to-skin contact in the prevalent neonatal morbidity of the low-risk newborn in Colombia. METHODS: A cost-effectiveness analysis was conducted. The perspective of the third payer (health system) was used, and the time horizon was the first month of life. Low-risk term infants were included at birth. The cost estimate was obtained from an expert consensus and a retrospective cohort of neonates hospitalized in a neonatal unit. The effectiveness of the interventions was obtained from a clinical trial and was defined as an avoided case of hospitalization. A decision tree was built, and the incremental cost-effectiveness ratio was calculated. Deterministic and probabilistic sensitivity analyses of the effects and costs were performed. RESULTS: Early skin-to-skin contact was a dominated intervention. In the probabilistic sensitivity analyses, early skin-to-skin contact was not an option to choose in any scenario and it was dominated in 68% of the simulations. CONCLUSIONS: The findings suggest that early skin-to-skin contact is a dominated intervention. From an economic perspective, immediate skin-to-skin contact is a desired intervention for the prevention of prevalent diseases of the low-risk newborn at birth.

Direct costs of neonatal infection acquired in the community in full-term newborns and low risk at birth, Cundinamarca, Colombia / Costos directos de la infección adquirida en la comunidad en neonatos a término con bajo riesgo al nacer, Cundinamarca, Colombia.

Introduction: Half of the episodes of neonatal sepsis are acquired in the community with a high percentage of mortality and complications. Objective: To estimate the direct costs of hospitalizations due to systemic neonatal infection acquired in the community in low-risk newborns. Materials and methods: For the estimation of costs, we used the perspective of the health systems and the microcosting technique and we established the duration of hospitalization as the time horizon. We identified cost-generating events through expert consensus and the quantification was based on the detailed bill of 337 hospitalized newborns diagnosed with neonatal infection. The costs of the medications were calculated based on the drug price information system (SISMED) and the ISS 2001 rate manuals adjusting percentage, and the mandatory insurance rates for traffic accidents (SOAT). We used the bootstrapping method for cost distribution to incorporate data variability in the estimate. Results: We included the medical care invoices for 337 newborns. The average direct cost of care per patient was USD$ 2,773,965 (Standard Deviation, SD=USD$ 198,813.5; 95% CI: $ 2,384,298 - $ 3,163,632). The main cost-generating categories were hospitalization in intensive care units and health technologies. The costs followed a log-normal distribution. Conclusions: The categories generating the greatest impact on the care costs of newborns with infection were hospitalization in neonatal units and health technologies. The costs followed a log-normal distribution.

Introducción. El 50 % de los episodios de sepsis neonatal se originan en la comunidad, con un gran porcentaje de mortalidad y complicaciones. Objetivo. Estimar los costos directos de la hospitalización por infección neonatal adquirida en la comunidad en neonatos a término con bajo riesgo al nacer. Materiales y métodos. Se utilizó la perspectiva del tercer pagador y la técnica de microcosteo; el horizonte de tiempo fue la duración de la hospitalización. La determinación de las situaciones generadoras de costos se obtuvo por medio de un consenso de expertos y se cuantificaron con base en la factura detallada de la atención de 337 neonatos hospitalizados. Los costos de los medicamentos se calcularon con base en el Sistema de Información de Precios de Medicamentos (SISMED) y, el de los procedimientos, según los manuales tarifarios ISS 2001 con porcentaje de ajuste y el seguro obligatorio de accidentes de tráfico (SOAT). Para incorporar la variabilidad de la información en la estimación, se obtuvo una distribución de los costos usando el método de bootstrapping. Resultados. Se incluyeron las facturas por la atención de 337 recién nacidos. El promedio de costos directos de la atención por paciente fue de COL$ 2'773.965 (desviación estándar, DE=$ 198.813,5; IC95%: $ 2'384.298 - $ 3'163.632). Las principales categorías generadoras de costos fueron la internación en la unidad de cuidados intensivos y las tecnologías en salud. Los costos siguieron una una distribución logarítmica normal (log-normal). Conclusiones. Las categorías con mayor impacto en los costos fueron la internación en la unidad neonatal y las tecnologías en salud. Los costos se ajustaron a una distribución logarítmica normal.

Costos directos de la infección adquirida en la comunidad en neonatos a término con bajo riesgo al nacer, Cundinamarca, Colombia / Direct costs of neonatal infection acquired in the community in full-term newborns and low risk at birth, Cundinamarca, Colombia

Resumen | Introducción. El 50 % de los episodios de sepsis neonatal se originan en la comunidad, con un gran porcentaje de mortalidad y complicaciones. Objetivo. Estimar los costos directos de la hospitalización por infección neonatal adquirida en la comunidad en neonatos a término con bajo riesgo al nacer. Materiales y métodos. Se utilizó la perspectiva del tercer pagador y la técnica de microcosteo; el horizonte de tiempo fue la duración de la hospitalización. La determinación de las situaciones generadoras de costos se obtuvo por medio de un consenso de expertos y se cuantificaron con base en la factura detallada de la atención de 337 neonatos hospitalizados. Los costos de los medicamentos se calcularon con base en el Sistema de Información de Precios de Medicamentos (SISMED) y, el de los procedimientos, según los manuales tarifarios ISS 2001 con porcentaje de ajuste y el seguro obligatorio de accidentes de tráfico (SOAT). Para incorporar la variabilidad de la información en la estimación, se obtuvo una distribución de los costos usando el método de bootstrapping. Resultados. Se incluyeron las facturas por la atención de 337 recién nacidos. El promedio de costos directos de la atención por paciente fue de COL$ 2'773.965 (desviación estándar, DE=$ 198.813,5; IC95%: $ 2'384.298 - $ 3'163.632). Las principales categorías generadoras de costos fueron la internación en la unidad de cuidados intensivos y las tecnologías en salud. Los costos siguieron una una distribución logarítmica normal (log-normal). Conclusiones. Las categorías con mayor impacto en los costos fueron la internación en la unidad neonatal y las tecnologías en salud. Los costos se ajustaron a una distribución logarítmica normal.

Abstract | Introduction: Half of the episodes of neonatal sepsis are acquired in the community with a high percentage of mortality and complications. Objective: To estimate the direct costs of hospitalizations due to systemic neonatal infection acquired in the community in low-risk newborns. Materials and methods: For the estimation of costs, we used the perspective of the health systems and the microcosting technique and we established the duration of hospitalization as the time horizon. We identified cost-generating events through expert consensus and the quantification was based on the detailed bill of 337 hospitalized newborns diagnosed with neonatal infection. The costs of the medications were calculated based on the drug price information system (SISMED) and the ISS 2001 rate manuals adjusting percentage, and the mandatory insurance rates for traffic accidents (SOAT). We used the bootstrapping method for cost distribution to incorporate data variability in the estimate. Results: We included the medical care invoices for 337 newborns. The average direct cost of care per patient was USD$ 2,773,965 (Standard Deviation, SD=USD$ 198,813.5; 95% CI: $ 2,384,298 - $ 3,163,632). The main cost-generating categories were hospitalization in intensive care units and health technologies. The costs followed a log-normal distribution. Conclusions: The categories generating the greatest impact on the care costs of newborns with infection were hospitalization in neonatal units and health technologies. The costs followed a log-normal distribution.

Carga de enfermedad atribuible al uso de tabaco en Colombia y potenciales beneficios sanitarios y económicos del aumento del precio del cigarrillo mediante impuestos / Disease burden attributable to smoking in Colombia and potential economic and health benefits of price increase through taxes

Resumen Objetivo: estimar la carga de enfermedad asociada al consumo de tabaco en Colombia y evaluar el potencial efecto sanitario y económico del aumento de precio en los cigarrillos mediante impuestos. Materiales y métodos: se diseñó un modelo de simulación de Monte Cario de primer orden que incorporó la historia natural, los costos y la calidad de vida de enfermedades relacionadas con el consumo de tabaco en adultos. Se estimó el impacto en la prevalencia de tabaquismo y en la recaudación de diferentes escenarios de aumento de precio a través de impuestos. Resultados: en Colombia cada año mueren 32.088 personas como consecuencia del consumo de cigarrillo y pueden atribuírsele los siguientes porcentajes: el 16% de las muertes cardiovasculares, el 13% de las producidas por accidentes cerebrovasculares, el 77% de las muertes ocasionadas por enfermedad pulmonar obstructiva crónica y el 80% de las muertes por cáncer de pulmón. Las enfermedades relacionadas con el cigarrillo representan un costo directo anual al sistema de salud de más de 4,5 billones de pesos, mientras la recaudación impositiva por la venta de cigarrillos apenas logra cubrir un 10% de este gasto. Un aumento en el precio de los cigarrillos del 50% podría evitar, en un horizonte de 10 años, más de 45.000 muertes y generar recursos por 8 billones por ahorro en gastos sanitarios y aumento de recaudación. Conclusiones: la carga de enfermedad y el costo para el sistema de salud asociados al consumo de tabaco son muy elevados en Colombia. Un aumento del precio de los cigarrillos a través de los impuestos tendría importantes beneficios tanto sanitarios como económicos.

Abstract Objective: to estimate the burden of disease associated with tobacco consumption in Colombia and to evaluate the potential health and economic effect of the price increase in cigarettes through taxes. Materials and methods: to estimate the burden of disease, a first-order Monte Carlo simulation model was designed that incorporated the natural history, costs and quality of life of diseases related to tobacco consumption in adults. A tax model was designed to calculate the impact on the prevalence of smoking and on the collection of different price increase scenarios. Results: according to the proposed model, it can be estimated that in Colombia 26,464 people die every year as a result of cigarette smoking. 13% of cardiovascular deaths, 13% of those caused by strokes, 77% of deaths caused by chronic lung disease and 81 % of deaths from lung cancer can be attributed to their consumption. The diseases related to cigarettes in Colombia represent a direct annual cost of more than 4 billion pesos, while the tax collection from the sale of cigarettes barely covers 10% of this expense. An increase in the price of cigarettes of 50% could prevent more than 30,000 deaths in ten years and generate resources for 7.9 billion savings in health spending and increased collection. Conclusions: the burden of disease and the cost to the health system associated with tobacco use are very high in Colombia. An increase in the price of cigarettes through taxes would have important health and economic benefits for Colombia.

Estimación de la carga económica de las lesiones preneoplásicas y el cáncer de cuello uterino en Colombia. Implicaciones para la vacunación contra el VPH / Estimate of the economic burden of pre-neoplastic lesions and cervical cancer in Colombia. Implications for HPV vaccination

Objetivo: Calcular la carga económica de las enfermedades neoplásicas del cuello uterino en Colombia y el efecto de su prevención. Métodos: Se calculó la incidencia a partir de un modelo de Markov sobre historia natural de la infección por VPH. Se estimaron costos directos en pesos colombianos (COP) a partir de eventos generadores de costos identificados en guías nacionales e internacionales. El valor monetario de los procedimientos se basó en manuales tarifarios vigentes (ISS 2001 con ajuste del 30% y SOAT). Las frecuencias de uso se definieron por consenso de expertos. Se incluyeron costos programáticos en tamización (citología) y vacunación (VPH). Resultados: Los casos esperados por a˜no para NIC I, NIC II-III y cáncer fueron 177.317,46.911 y 5.110. El valor de la citología fue de COP$19.070 (US$10,8) y cada dosis de vacuna costó COP$23.700. La tamización representa el mayor costo en el control de la enfermedad (COP$126.933 millones). La vacuna genera un costo adicional de COP$11.977 millones y un ahorro de COP$15.969 millones; este último inició luego de 20 años de introducir la estrategia. Reducir el costo de la vacuna contribuye al ahorro y disminuir el costo de la tamización acorta su tiempo de inicio. Conclusiones: La vacunación contra VPH reduce los costos del control del cáncer de cuello uterino pero requiere una inversión sostenida por un periodo largo de tiempo. La reducción del costo de la vacunación y la tamización traería beneficios económicos importantes, donde las nuevas alternativas tecnológicas pueden jugar un papel relevante.

Objective: To estimate the economic burden cervical neoplastic disease in Colombia and the effects of its prevention. Methods: The incidence was calculated from a Markov model on the natural history of human papillomavirus (HPV) infection. Direct costs were estimated, in Colombian Pesos (COP), from cost-generating events identified in national and international guides. The monetary value of the procedures was based on current tariff manuals (ISS 2001 with a 30% adjustment and mandatory insurance (SOAT). The frequencies of use were defined by expert consensus. Screening program (cytology) and vaccination (HPV) costs were included. Results: The expected cases per year for IFRS (NIC) 1 (International Financial Reporting Standards), IFRS 2-3 and cancer were 177,317, 46,911, and 5,110, respectively. The cost of cytology was COP$19,070 (D 9.80) and each vaccine dose cost COP$23,700 (D 10.00). Screening represented the highest cost in the control of the disease (COP$126.933 million; D 38.5 million). The vaccine generated an additional cost of COP$11.977 million (D 3.5 million) and a saving of COP$15.969 million (D 4.8 million). This latter started 20 years after introducing the strategy. To reduce the cost of the vaccination contributes to a saving and to decrease the cost of screening shortens its start-up time. Conclusions: Vaccination against HPV reduces the costs of controlling uterine cervical cancer, but it requires a sustained investment for a long period of time. The reduction in the vaccine and screening costs would bring significant economic benefits, where the new, alternative technologies could play an important role.

Costos directos de la atención del cáncer de mama en Colombia / Direct costs of breast cancer care in Colombia

Objetivo: Estimar el costo del manejo de cada uno de los estadios del cáncer de mama en Colombia. Métodos: La estimación de costos se realizó usando la metodología de un estudio de caso, dividida en tres etapas: identificar el consumo de recursos asociados a las diferentes fases de la enfermedad, cuantificar el consumo físico de recursos y valorizar el consumo de estos. La cantidad, frecuencia de uso y cumplimiento de los procedimientos y medicamentos se obtuvo mediante opinión de expertos de centros de oncología de cinco regiones el país (Bogotá, Barranquilla-Cartagena, Cali, Medellín y Bucaramanga). Los costos de los medicamentos se calcularon con base en el Sistema de Información de Precios de Medicamentos (SISMED) 2010 y la Resolución 4316 de 2011. Los costos de los procedimientos fueron obtenidos de los manuales ISS 2001 + 30%, SOAT y la información del estudio de suficiencia de la UPC. Resultados: Los estadios más costosos para el cáncer fueron el metastásico con un costo total de $144.400.865, seguido del cáncer de mama regional que alcanzó un costo total de $65.603.537. Se observó una contribución importante de la quimioterapia en el costo total para los diferentes estadios y en la recaída sistémica y local. Conclusiones: La diferencia en los costos del cáncer de mama entre estadios está altamente influenciada por el valor de los costos asociados al tratamiento de quimioterapia.

Objective: To estimate the cost of managing each of the stages of breast cancer in Colombia. Methods: The estimation of costs was performed using case study methodology, divided into three stages: the identification of the use of resources associated with the different stages of the disease, the quantification of the resource use, and the evaluation of this use. The quantity, frequency of use, and the percentage of compliance with procedures and medications were obtained by expert opinion in the cancer centres in five regions of the country (Bogotá, Barranquilla-Cartagena, Cali, Medellin and Bucaramanga). The drug costs were calculated using prices reported in the Price of Medications Information System (SISMED) 2010, and Resolution 4316 of 2011. The procedure costs were obtained from the ISS 2001 manuals + 30%, SOAT and information from the UPC sufficiency study. Results: The most expensive stages of breast cancer were metastatic cancer at a cost of COP $144,400,865 and regional cancer with COP $65,603,537 (D 56 million). A significant contribution by chemotherapy was observed in the total cost for the different stages and systemic and local recurrence. Conclusion: The difference in costs between the stages of breast cancer is highly influenced by the value of the costs associated with chemotherapy treatment.

ErbB2+ metastatic breast cancer treatment after progression on trastuzumab: a cost-effectiveness analysis for a developing country.

OBJECTIVE: Breast cancer (BC) and metastatic breast cancer (MBC) are significant causes of deaths amongst women worldwide, including developing countries. The cost of treatment in the latter is even more of an issue than in higher income countries. ErbB2 overexpression is a marker of poor prognosis and the goal for targeted therapy. This study was aimed at evaluating the cost-effectiveness in Colombia of ErbB2+ MBC treatment after progression on trastuzumab. METHODS: A decision analytic model was constructed for evaluating such treatment in a hypothetical cohort of ErbB2+MBC patients who progressed after a first scheme involving trastuzumab. The alternatives compared were lapatinib+capecitabine (L+C), and trastuzumab+a chemotherapy agent (capecitabine, vinorelbine or a taxane). Markov models were used for calculating progression-free time and the associated costs. Effectiveness estimators for such therapy were identified from primary studies; all direct medical costs based on national fees-guidelines were included. Sensitivity was analyzed and acceptability curves estimated. A 3 % discount rate and third-payer perspective were used within a 5-year horizon. RESULTS: L+C dominated its comparators. Its cost-effectiveness ratio was COP $49,725,045 per progression-free year. The factors most influencing the results were the alternatives' hazard ratios and the cost of trastuzumab. CONCLUSION: Lapatinib was cost-effective compared to its alternatives for treating MBC after progression on trastuzumab using a Colombian decision analytic model.

ErbB2+ metastatic breast cancer treatment after progression on trastuzumab: a cost-effectiveness analysis for a developing country / Tratamientos para cáncer de seno metastásico ErbB2+ en progresión Post-Trastuzumab: Análisis de costo-efectividad para un país en vía de desarrollo

Objective Breast cancer (BC) and metastatic breast cancer (MBC) are significant causes of deaths amongst women worldwide, including developing countries. The cost of treatment in the latter is even more of an issue than in higher income countries. ErbB2 overexpression is a marker of poor prognosis and the goal for targeted therapy. This study was aimed at evaluating the cost-effectiveness in Colombia of ErbB2+ MBC treatment after progression on trastuzumab. Methods A decision analytic model was constructed for evaluating such treatment in a hypothetical cohort of ErbB2+MBC patients who progressed after a first scheme involving trastuzumab. The alternatives compared were lapatinib+capecitabine (L+C), and trastuzumab+a chemotherapy agent (capecitabine, vinorelbine or a taxane). Markov models were used for calculating progression-free time and the associated costs. Effectiveness estimators for such therapy were identified from primary studies; all direct medical costs based on national fees-guidelines were included. Sensitivity was analyzed and acceptability curves estimated. A 3 % discount rate and third-payer perspective were used within a 5-year horizon. Results L+C dominated its comparators. Its cost-effectiveness ratio was COP $49,725,045 per progression-free year. The factors most influencing the results were the alternatives' hazard ratios and the cost of trastuzumab. Conclusion Lapatinib was cost-effective compared to its alternatives for treating MBC after progression on trastuzumab using a Colombian decision analytic model.

Objetivo El cáncer de seno (CS) y cáncer de seno metastásico (CSM) son importantes causas de muerte entre las mujeres a nivel mundial y en países en vía de desarrollo. En estos últimos los costos de los tratamientos son aún más preocupantes que en países de alto ingreso. La sobreexpresión de ErbB2 es marcador de pobre pronóstico y objetivo de terapias dirigidas. Se evaluó la costo-efectividad de los tratamientos de CSM ErbB2+ en progresión post-trastuzumab en Colombia. Métodos Se desarrolló un modelo analístico de decisiones para evaluar los tratamientos en una cohorte hipotética de CSM ErbB2+ que progresaron después de un primer esquema con trastuzumab. Las alternativas comparadas fueron: lapatinib+capecitabina (L+C), y trastuzumab más un agente quimioterápico (capecitabina, vinorelbinao un taxano). Se usaron modelos de Markov para calcular el tiempo libre de progresión y los costos asociados. Estimaciones de efectividad fueron identificadas de estudios primarios. Se incluyeron todos los costos médicos directos basados en los manuales tarifarios nacionales. Se realizaron análisis de sensibilidad y curvas de aceptabilidad. Se descontaron costos y resultados a una tasa anual de 3 %, la perspectiva de análisis fue del tercer pagador y el horizonte de 5 años. Resultados L+C domina a sus comparadores con un razón de costo-efectividad de COP $49 725 045 por año libre de progresión. Los factores que más influencian los resultados son los hazard ratios de las alternativas y el costo de trastuzumab. Conclusión Lapatinib es costo-efectivo comparado con sus alternativas para el tratamiento del CSM después de la progresión con trastuzumab en el escenario colombiano.

Cost-effectiveness analysis of the bivalent and quadrivalent human papillomavirus vaccines from a societal perspective in Colombia.

OBJECTIVE: To compare costs and effectiveness of three strategies used against cervical cancer (CC) and genital warts: (i) Screening for CC; (ii) Bivalent Human Papillomavirus (HPV) 16/18 vaccine added to screening; (iii) Quadrivalent HPV 6/11/16/18 vaccine added to screening. METHODS: A Markov model was designed in order to simulate the natural history of the disease from 12 years of age (vaccination) until death. Transition probabilities were selected or adjusted to match the HPV infection profile in Colombia. A systematic review was undertaken in order to derive efficacy values for the two vaccines as well as for the operational characteristics of the cytology test. The societal perspective was used. Effectiveness was measured in number of averted Disability Adjusted Life Years (DALYS). RESULTS: At commercial prices reported for 2010 the two vaccines were shown to be non-cost-effective alternatives when compared with the existing screening strategy. Sensitivity analyses showed that results are affected by the cost of vaccines and their efficacy values, making it difficult to determine with certainty which of the two vaccines has the best cost-effectiveness profile. To be 'cost-effective' vaccines should cost between 141 and 147 USD (Unite States Dollars) per vaccinated girl at the most. But at lower prices such as those recommended by WHO or the price of other vaccines in Colombia, HPV vaccination could be considered very cost-effective. CONCLUSIONS: HPV vaccination could be a convenient alternative for the prevention of CC in Colombia. However, the price of the vaccine should be lower for this vaccination strategy to be cost-effective. It is also important to take into consideration the willingness to pay, budgetary impact, and program implications, in order to determine the relevance of a vaccination program in this country, as well as which vaccine should be selected for use in the program.

Barreras para la implementación de la prueba ADN-VPH como técnica de tamización primaria para cáncer de cuello uterino en un área demostrativa en Colombia / Barriers for implementing the HPV-DNA test as a primary cervical cancer-screening technique in a demonstrative area of Colombia

Objetivo: Describir las barreras para la implementación de un programa de tamización para cáncer de cuello uterino basado en la prueba de virus del papiloma humano (VPH) en Colombia. Métodos: Se aplicó el modelo de planeación Precede-Procede en cuatro municipios de Cundinamarca y dos de Boyacá; se realizó análisis de fuentes secundarias y primarias obtenidas de 74 encuestas a instituciones de salud, 18 grupos focales (GF), con líderes comunitarios, gerentes y profesionales de la salud y 12 entrevistas (autoridades locales). Resultados: Se identificaron las siguientes barreras: 1) la infección por VPH se asocia a una enfermedad venérea; 2) barreras epidemiológicas: la ausencia de un adecuado registro de diagnóstico definitivo de lesiones preneoplásicas; 3) barreras del comportamiento del sistema, tales como la no centralización de la lectura de citologías, laboratorios no habilitados que prestan servicios y la no estandarización de la colposcopia ni el tratamiento; 4) barreras educacionales: los profesionales de la salud sobreestiman la sensibilidad de la citología y les preocupa demasiado la infección por VPH en mujeres menores de 30 años, y 5) barreras administrativas de acceso a la colposcopia y a la biopsia de lesiones preneoplásicas. Conclusiones: Colombia presenta barreras que impiden el funcionamiento de un programa organizado de tamización, las cuales hacen difícil lograr los objetivos esperados con el cambio tecnológico de citología a pruebas moleculares.

Objective: To identify the barriers for the implementation of a cervical cancer-screening program based on human papillomavirus (HPV) testing in Colombia. Methods: The Precede-Proceed model was applied in four municipalities of Cundinamarca and two of Boyacá. Secondary and primary data were analyzed from 74 institutional surveys, 18 focus groups (with community leaders and health professionals), and 12 interviews (health authorities). Results: The most relevant barriers were identifi ed as follows: 1) Social barriers: in Duitama, the municipality with a religious tradition, HPV infection is represented as a venereal disease. 2) Epidemiological barrier: the absence of a register for defi nitive diagnosis of pre-neoplasic lesions. 3) Behavioral barriers: Pap smear laboratories are not centralized, some are not accredited and colposcopies are not standardized. 4) Health professionals overestimate Papsmear sensitivity and they are over worried about HPV infection among women younger than 30 years. 5) Administrative barriers: positive screened women need to have an authorization from Health Insurance Enterprises in order to access the diagnosis and treatment of cervical lesions. Conclusions: Colombia presents barriers to the operation of an organized screening program that make it diffi cult to achieve the expected objectives with the technological change from the use of cytology to molecular testing.

The cost-effectiveness of open or thoracoscopic thymectomy compared to medical treatment in managing Myasthenia gravis without thymomas.

OBJECTIVE: Assessing the cost-effectiveness of open or thoracoscopic thymectomy compared to medical therapy in managing myasthenia gravis not associated with thymoma. METHODS: A Markov model was designed for evaluating three strategies' cost-effectiveness. Transition probabilities were taken from the pertinent literature; the costs were estimated from official tariff manuals. Incremental cost-effectiveness ratios were estimated and probabilistic and deterministic sensitivity analysis was used for clinical variables, costs and the model's assumptions. RESULTS: Thoracoscopic thymectomy was the most effective and least costly strategy and dominated the other two alternatives. The cost per life year gained was Col $ 1 129 531 without discount and Col $ 805 179 with discount. Univariate sensitivity analysis showed that the main variables affecting the results were the effects' discount rate, the cost of a myasthenic crisis and the probability of complete remission. Thoracoscopy thymectomy was the most cost-effective strategy for different thresholds of willingness to pay in probabilistic analysis. CONCLUSIONS: Thoracoscopic thymectomy is a cost-effective strategy in the treatment of MG without thymoma.

Cost-effectiveness of iso- versus low-osmolality contrast media in outpatients with high risk of contrast medium-induced nephropathy.

INTRODUCTION: Contrast media can cause acute renal failure by direct toxic effects on the tubular cells and kidney ischemia. Diabetics and hospitalized patients have a greater risk of developing contrast-induced nephropathy than the general population. OBJECTIVE: The cost effectiveness of iso and low-osmolality contrast media was assessed in high risk outpatients. MATERIALS AND METHODS: The analysis was based on a systematic literature review comparing the nephrotoxic effects of iso- to low-osmolality contrast media. Only direct costs were considered; these were obtained from the official tariff manual. Incremental cost-effectiveness ratios, efficiency curves and acceptability curves were calculated. Univariate sensitivity analyses were performed for costs and effects, as well as probabilistic analyses. Zero and 3% discounts were applied to results. The cost-effectiveness threshold was equal to the per capita GDP per life-year gained. RESULTS: Alternatives with Iopamidol and Iodixanol are preferable to the others, because both reduce risk of contrast-induced nephropathy and are less costly. The incremental cost-effectiveness of the Iodixanol alternative compared to the Iopamidol alternative is US$ 14,660 per additional life year gained; this is more than twice the threshold. CONCLUSION: The low-osmolality contrast medium, Iopamidol, appears to be cost-effective when compared with Iohexol or other low-osmolality contrast media (Iopromide, Iobitridol, Iomeprol, Iopentol and Ioxilan) in contrast-induced nephropathy, high-risk outpatients. The choice of the iso-osmolality contrast medium, Iodixanol, depends on its cost per vial and on the willingness to pay.

Cost-effectiveness of iso- versus low-osmolality contrast media in outpatients with high risk of contrast medium-induced nephropathy / Costo-efectividad de medios de contraste isoosmolales e hiposmolales en pacientes con alto riesgo de nefropatía inducida por medio de contraste

Introduction. Contrast media can cause acute renal failure by direct toxic effects on the tubular cells and kidney ischemia. Diabetics and hospitalized patients have a greater risk of developing contrast-induced nephropathy than the general population. Objective. The cost effectiveness of iso and low-osmolality contrast media was assessed in high risk outpatients. Materials and methods. The analysis was based on a systematic literature review comparing the nephrotoxic effects of iso- to low-osmolality contrast media. Only direct costs were considered; these were obtained from the official tariff manual. Incremental cost-effectiveness ratios, efficiency curves and acceptability curves were calculated. Univariate sensitivity analyses were performed for costs and effects, as well as probabilistic analyses. Zero and 3% discounts were applied to results. The cost-effectiveness threshold was equal to the per capita GDP per life-year gained. Results. Alternatives with Iopamidol and Iodixanol are preferable to the others, because both reduce risk of contrast-induced nephropathy and are less costly. The incremental cost-effectiveness of the Iodixanol alternative compared to the Iopamidol alternative is US$ 14,660 per additional life year gained; this is more than twice the threshold. Conclusion. The low-osmolality contrast medium, Iopamidol, appears to be cost-effective when compared with Iohexol or other low-osmolality contrast media (Iopromide, Iobitridol, Iomeprol, Iopentol and Ioxilan) in contrast-induced nephropathy, high-risk outpatients. The choice of the iso-osmolality contrast medium, Iodixanol, depends on its cost per vial and on the willingness to pay.

Introducción. Los medios de contraste pueden provocar falla renal aguda por toxicidad directa sobre las células tubulares e isquemia medular renal. Los pacientes diabéticos y los hospitalizados presentan mayor riesgo de desarrollar nefropatía inducida por medios de contraste que la población general. Objetivo. Establecer el costo-efectividad de los medios de contraste isosmolales e hiposmolales en pacientes con alto riesgo. Materiales and métodos. El análisis se basó en una revisión sistemática de la literatura científica, comparando los efectos nefrotóxicos de los medios isosmolales e hipoosmolales. Se consideraron sólo los costos directos, obtenidos del manual tarifario. Se calcularon las tasas del incremento del costo-efectividad, las curvas de eficiencia y de aceptabilidad. Se hicieron análisis univariados de sensibilidad para costos y efectos, así como probabilísticos. Se aplicaron tasas de descuento de 0 y 3 % a los resultados. Se usó como umbral de costo-efectividad por año de vida ganado, el producto interno bruto per cápita. Resultados. Las alternativas con Iopamidol y Iodixanol dominan a las demás porque reducen el riesgo de nefropatía inducida por contraste a un menor costo. La razón del incremento del costo-efectividad del iodixanol comparado con el iopamidol es de US$ 14.660 por año de vida ganado que más que duplica el umbral. Conclusión. El medio de baja osmolalidad, iopamidol, parece ser costo-efectivo comparado con iohexol u otros medios hiposmolares (iopromide, iobitridol, iomeprol, iopentol y ioxilan), en pacientes con alto riesgo de nefropatía inducida por contraste. La elección del medio hiposmolar, depende de la disponibilidad a pagar o del costo por ampolleta.

[Epidemiological and economic impact of tetanus vaccination in Colombian adults]. / Impacto epidemiológico y económico de la vacunación contra el tétanos en adultos de Colombia.

OBJECTIVE: Assess the potential epidemiological and economic impact of vaccinating the over-15 Colombian population against tetanus with a booster dose every 10 years. METHODS: A cost-effectiveness analysis of tetanus vaccination with a booster dose every 10 years was conducted in Colombia and compared with the current strategy (2, 4, 6, 18, and 60 months). Estimates of the burden of disease were based on three official data sources. A Markov model from the perspective of the third party payer was developed. The time horizon was the lifetime of a person. Deterministic and probabilistic sensitivity analyses were conducted. RESULTS: In Colombia, 30 to 48 cases of tetanus resulting in 9.6 to 10.1 deaths are reported each year. Although booster vaccination for the entire population was cost-effective (the cost per disability-adjusted life year [DALY] avoided was US$ 11,314 in the entire population), gender-based differentiation of the results showed that it would not be cost-effective in women (cost per DALY avoided was US$ 4,903 in men and US$ 22,332 in women). CONCLUSIONS: This is the first study that evaluates the cost-effectiveness of a tetanus vaccine booster dose every 10 years in a developing country. Use of this measure would be cost-effective in Colombia, especially for men. As a result of the gender-based differences in the results, any decision about its use in women of childbearing age should take current vaccination into account.

Impacto epidemiológico y económico de la vacunación contra el tétanos en adultos de Colombia / Epidemiological and economic impact of tetanus vaccination in Colombian adults

OBJETIVO: Evaluar el potencial impacto epidemiológico y económico de la vacunación antitetánica en la población colombiana mayor de 15 años de edad, con dosis de refuerzo cada 10 años. MÉTODOS: Se realizó un análisis de costo-efectividad de la vacunación con refuerzo cada 10 años contra el tétanos en Colombia, comparándola con la actual estrategia (2, 4, 6, 18 y 60 meses). La carga de enfermedad se estimó con base en tres fuentes oficiales de datos. Se realizó un modelo de Markov desde la perspectiva del tercer pagador. El horizonte temporal fue el tiempo de vida de una persona. Se realizaron análisis de sensibilidad determinístico y probabilístico. RESULTADOS: En Colombia se notifican anualmente entre 30 y 48 casos de tétanos que ocasionan entre 9,6 y 10,1 muertes. Si bien la vacunación con refuerzo resultó costo-efectiva para toda la población (el costo por año de vida ajustado por discapacidad [AVAD] evitado fue de US$ 11 314 en toda la población), al discriminar los resultados por género no sería costoefectiva en las mujeres (el costo por AVAD evitado en hombres fue de US$ 4 903, y en mujeres de US$ 22 332). CONCLUSIONES: Este es el primer estudio que evalúa la costo- efectividad de una dosis de refuerzo cada 10 años de la vacuna contra el tétanos en un país en desarrollo. La aplicación de esta medida sería costo-efectiva en Colombia, especialmente para los hombres. Las diferencias en los resultados por género obliga a que cualquier decisión de implementación deba tener en cuenta la vacunación actual en mujeres en edad fértil.

OBJECTIVE: Assess the potential epidemiological and economic impact of vaccinating the over-15 Colombian population against tetanus with a booster dose every 10 years. METHODS: A cost-effectiveness analysis of tetanus vaccination with a booster dose every 10 years was conducted in Colombia and compared with the current strategy (2, 4, 6, 18, and 60 months). Estimates of the burden of disease were based on three official data sources. A Markov model from the perspective of the third party payer was developed. The time horizon was the lifetime of a person. Deterministic and probabilistic sensitivity analyses were conducted. RESULTS: In Colombia, 30 to 48 cases of tetanus resulting in 9.6 to 10.1 deaths are reported each year. Although booster vaccination for the entire population was cost-effective (the cost per disability-adjusted life year [DALY] avoided was US$ 11,314 in the entire population), gender-based differentiation of the results showed that it would not be cost-effective in women (cost per DALY avoided was US$ 4,903 in men and US$ 22,332 in women). CONCLUSIONS: This is the first study that evaluates the cost-effectiveness of a tetanus vaccine booster dose every 10 years in a developing country. Use of this measure would be cost-effective in Colombia, especially for men. As a result of the gender-based differences in the results, any decision about its use in women of childbearing age should take current vaccination into account.

[Cost-benefit analysis of anastrazol and tamoxifen in adjuvant treatment of hormone receptor-positive, post-menopausal breast cancer]. / Análisis de costo-efectividad en Colombia de anastrazol Vs. tamoxifeno como terapia inicial en mujeres con cáncer temprano de mama y receptor hormonal positivo.

INTRODUCTION: In high-income countries, tamoxifen has been replaced by aromatase inhibitors such as anastrozole in adjuvant hormone therapy for early breast cancer. These drugs target patients with positive hormone receptors, due to the better results achieved for disease-free survival. The cost-effectiveness of this treatment change has not been evaluated in middle income countries. OBJECTIVE: The cost effectiveness of anastrozole vs tamoxifen was assessed during five-years of adjuvant treatment of hormone receptor-positive, post-menopausal early breast cancer patients. MATERIALS AND METHODS: This is a literature-based analysis. The natural history of the breast cancer and the effects of treatment were modeled as a Markov process. Effectiveness was defined as disease-free survival. Transition probabilities for the disease and adverse effects were obtained from the literature. Costs were defined as the median of actual costs provided by health insurance companies and the Colombian National Cancer Institute expressed in 2007 Colombian pesos. Probabilistic sensitivity analysis was performed, along with one way sensitivity analysis was for the costs. RESULTS: Compared with tamoxifen, anastrazol results in an additional relapse-free period of 0.5 years. Each relapse-free year obtained by tamoxifen cost 27,210,604 pesos, or with anastrazol 37,071,337 pesos with a discount rate of 3%. The cost for a sustained-effects scenario were 23,617,400 pesos for tamoxifen and $16,140.282 for anastrazol. CONCLUSIONS: The use of anastrazol has an additional cost per relapse-free year of 7,521,363 pesos (2007). Therefore, for postmenopausal, early breast cancer hormone receptor positive women in Colombia, the cost-effective alternative is tamoxifen used as adjuvant therapy for five years.