Lifetime costs of alcohol consumption in Thailand: protocol for an incidence-based cost-of-illness study using Markov model.

INTRODUCTION: Several prevalence-based cost-of-illness (COI) studies have been conducted to estimate the economic burden of alcohol consumption borne by a particular society in a given year. Yet there are few studies examining the economic costs incurred by an individual drinker over his/her lifetime. Thus, this study aims to estimate the costs incurred by an individual drinker's alcohol consumption over his or her lifetime in Thailand. METHODS AND ANALYSIS: An incidence-based COI approach will be employed. To project individuals' associated costs over a lifetime, a Markov modelling technique will be used. The following six alcohol-related diseases/conditions will be considered in the model: hypertension, haemorrhagic stroke, liver cirrhosis, liver cancer, alcohol use disorders and road injury. The analysis will cover both direct (ie, direct healthcare cost, costs of property damage due to road traffic accidents) and indirect costs (ie, productivity loss due to premature mortality and hospital-related absenteeism). The human capital approach will be adopted to estimate the cost of productivity loss. All costs will be presented in Thai baht, 2022. ETHICS AND DISSEMINATION: The Institutional Review Board of Mahidol University, Faculty of Dentistry/Faculty of Pharmacy has confirmed that no ethical approval is required (COE.No.MU-DT/PY-IRB 2021/010.0605). Dissemination of the study findings will be carried out through peer-reviewed publications, conferences and engagement with policy-makers and public health stakeholders.

Economic costs of alcohol consumption in Thailand, 2021.

BACKGROUND: Alcohol is one of the leading risk factors contributing to avoidable economic loss worldwide. Estimates from the economic cost of alcohol consumption studies play an important role in prioritizing healthcare resource use, supporting policy decisions, and justifying budgets for alcohol policy. This study aimed to estimate the economic burden associated with alcohol consumption in Thailand in 2021. METHODS: Prevalence-based cost of illness methodology was employed. The following costs were included in the analysis: healthcare costs; cost of law enforcement; cost of property damage due to road traffic accidents; cost of premature mortality; and cost of absenteeism from out-patient hospital visits and hospitalization. Human capital approach was adopted. All costs were presented in Thai baht, 2021. RESULTS: Alcohol consumption incurred a total estimated economic cost of 165,450.5 million baht, equivalent to 1.02% of Gross Domestic Product (GDP) and 2500 baht per capita. Cost of premature mortality was estimated at 157,918.7 million baht and accounted for the largest proportion of the total cost (95.45%). Healthcare cost was found to be the second highest share representing 4370.1 million baht (2.7% of the total cost). The number of premature death attributable to alcohol consumption in 2021 was estimated at 22,804. CONCLUSIONS: Alcohol continues to impose a substantial economic burden in Thailand. Enforcement of existing well-formulated alcohol control policies is urgently required to mitigate the economic impact of alcohol consumption in the country.

Cost-effectiveness analysis of isolation strategies for asymptomatic and mild symptom COVID-19 patients.

BACKGROUND: Management of COVID-19 patients with mild and moderate symptoms could be isolated at home isolation (HI), community isolation (CI) or hospitel. However, it was still unclear which strategy was more cost-effective. Therefore, this study was conducted to evaluate this. METHODS: This study used data from patients who initially stayed at HI, CI, and hospitel under supervision of Ramathibodi Hospital between April and October 2021. Outcomes of interest were hospitalisation and mortality. An incremental cost-effectiveness ratios (ICER) was calculated based on hospital perspective using home isolation as the reference. RESULTS: From 7,077 patients, 4,349 2,356, and 372 were admitted at hospitel, HI, and CI, respectively. Most patients were females (57.04%) and the mean age was 40.42 (SD = 16.15). Average durations of stay were 4.47, 3.35, and 3.91 days for HI, CI, and hospitel, respectively. The average cost per day for staying in these corresponding places were 24.22, 63.69, and 65.23 US$. For hospitalisation, the ICER for hospitel was at 41.93 US$ to avoid one hospitalisation in 1,000 patients when compared to HI, while CI had more cost, but less cases avoided. The ICER for hospitel and CI were at 46.21 and 866.17 US$ to avoid one death in 1,000 patients. CONCLUSIONS: HI may be cost-effective isolated strategy for preventing hospitalisation and death in developing countries with limited resources.

Cost-effectiveness analysis of liver transplantation in biliary atresia according to the severity of end-stage liver disease.

BACKGROUND: Timing for liver transplantation (LT) in biliary atresia (BA) children with end-stage liver disease (ESLD) is associated with all-cause mortality. The cut-off value of pediatric end-stage liver disease (PELD) score for LT consideration varies across institutions. We aimed to determine the cost-effectiveness of LT to prevent death among BA children registered on the waiting list with different severities of ESLD. METHODS: Subjects were BA children aged < 12 years at a transplant center between 2010 and 2021. A decision tree was developed for cost-effectiveness analysis from a hospital perspective to compare all-cause death between patients initially registered with a low PELD score (< 15) and a high PELD score (≥ 15). Each patient's direct medical cost was retrieved from the beginning of registration until 5 years after LT, adjusted with an inflation rate to 2022 Thai Baht (THB). RESULTS: Among 176 children, 138 (78.4%) were initially registered with the high PELD score. The cost and mortality rate of the low PELD score group (THB1,413,424 or USD41,904 per patient and 31.6% mortality) were less than the high PELD score group (THB1,781,180 or USD52,807 per patient and 47.9% mortality), demonstrating the incremental cost-effectiveness ratio (ICER) of THB2,259,717 or USD66,994 per death prevented. The cost of early post-operative admission had the highest effect on the ICER. Considering the break-even analysis, cost among children initially registered at the low PELD score was also less expensive over time. CONCLUSIONS: Registration for LT at PELD score < 15 was more cost-effective to prevent death among BA children with ESLD.

Cost-Effectiveness and Cost-Utility Analyses in Thailand of Continuous Intrathecal Morphine Infusion Compared with Conventional Therapy in Cancer Pain: A 10-year Multicenter Retrospective Study.

Background: Because of the high initial cost of intrathecal drug delivery (ITDD) therapy, this study investigated the cost-effectiveness and cost-utility of ITDD therapy in refractory cancer pain management in Thailand over the past 10 years. Methods: The retrospective study was conducted in patients with cancer pain who underwent ITDD therapy from January 2011 to 2021 at three university hospitals. Clinical outcomes included the numerical rating scale (NRS), Palliative Performance Scale, and the EQ-5D. The direct medical and nonmedical as well as indirect costs were also recorded. Cost-effectiveness and cost-utility analyses were performed comparing ITDD therapy with conventional therapy (extrapolated from costs of the same patient before ITDD therapy) from a societally oriented economic evaluation. Results: Twenty patients (F:M: 10:10) aged 60 ± 15 years who underwent implantation of an intrathecal percutaneous port (IT port; n = 15) or programmable intrathecal pump (IT pump; n = 5) were included. The median survival time was 78 (interquartile range = 121-54) days after ITDD therapy. At 2-month follow-up, the incremental cost-effectiveness ratio (ICER)/pain reduction of an IT port (US$2065.36 (CA$2829.54)/2-point NRS reduction/lifetime) was lower than for patients with an IT pump (US$5479.26 (CA$7506.58)/2-point NRS reduction/lifetime) compared with continued conventional therapy. The ICER/quality-adjusted life years (QALYs) gained for an IT port compared with conventional treatment was US$93,999.31(CA$128,799.06)/QALY gained, which is above the cost-effectiveness threshold for Thailand. Conclusion: The cost-effectiveness and cost-utility of IT port therapy for cancer pain was high relative to the cost of living in Thailand, above the cost-effectiveness threshold. Prospective cost analysis studies enrolling more patients with diverse cancers that investigate the benefit of early ITDD therapy with devices over a range of prices are warranted.

Contexte: En raison du coût initial élevé du traitement par administration intrathécale de médicaments (AIM), cette étude a étudié le rapport coût-efficacité et le rapport coût-utilité du traitement par AIM dans la prise en charge de la douleur cancéreuse réfractaire en Thaïlande au cours des 10 dernières années.Méthodes: L'étude rétrospective a été menée auprès de patients souffrant de douleur cancéreuse ayant subi un traitement par AIM de janvier 2011 et 2021 dans trois hôpitaux universitaires. Les résultats cliniques comprenaient l'échelle d'évaluation numérique (EEN), l'échelle de performance palliative et l'EQ-5D. Les coûts médicaux et non médicaux directs et indirects ont également été consignés. Les analyses coûts-efficacité et coût-utilité ont été effectuées en comparant le traitement par AIM au traitement conventionnel (extrapolé à partir des coûts pour le même patient avant le traitement par AIM) à partir d'une évaluation économique sociétale.Résultats: Vingt patients (F : M : 10 : 10) âgés de 60 ± 15 ans ayant subi l'implantation d'un port percutané intrathécal (port IT; n = 15) ou d'une pompe intrathécale programmable (pompe IT; n = 5) ont été inclus. Le temps de survie médian était de 78 jours (intervalle interquartile = 121­54) après le traitement par AIM. À deux mois de suivi, le ratio coût-efficacité incrémental (RCEI/réduction de la douleur d'un port IT (2 065,36 $ US (2 829,54 $ CA) /réduction de 2 points sur l'EEN/durée de vie) était inférieur à celui des patients avec une pompe IT (5479,26 $ US (7506,58 $ CA) /réduction de 2 points sur l'EEN/durée de vie) comparativement au traitement conventionnel en continu. Le RCEI/année de vie pondérée par la qualité (AVPQ) gagnée pour un port IT comparativement au traitement conventionnel était de 93 999,31 $ US (128 799,06 $ CA) /AVPQ gagné, ce qui est au-dessus du seuil de rentabilité pour la Thaïlande.Conclusion: Le rapport coût-efficacité et le rapport coût-utilité du traitement par port IT pour la douleur cancéreuse étaient élevés par rapport au coût de la vie en Thaïlande, soit au-dessus du seuil de rentabilité. Les études d'analyse de coût prospectives portant sur un plus grand nombre de patients atteints de divers cancers qui étudient les avantages des traitements par AIM précoces à l'aide d'appareils de prix différents sont justifiées.

Economic and Clinical Outcomes of Pediatric Patients Under Two With Respiratory Syncytial Virus Infection in Thailand: A Real-world Retrospective Cohort Study.

BACKGROUND: Respiratory syncytial virus (RSV) is a common cause of acute respiratory tract infection in children, including in Thailand. We conducted this study to evaluate the economic and clinical outcomes of patients <2 years old with RSV infection at a tertiary teaching hospital in Thailand. METHODS: This was a retrospective cohort study during 2014-2021. To be eligible, patients had to report at least 1 positive RSV test and were <2 years old. Descriptive statistics were used to describe baseline characteristics, healthcare resource utilization, direct medical costs (1 US dollars [USD] = 31.98 Thai Baht) and clinical outcomes. RESULTS: Among 1370 RSV-positive patients, 49.9% of the patients (n = 683) were hospitalized at or within 3 days of RSV diagnosis with a median length of stay of 6 days (interquartile range [IQR]: 4-9 days), 38.8% were diagnosed with RSV-related respiratory complications (n = 532) and 1.5% died during the hospitalization episode (n = 20). A total of 22.5% of hospitalized patients (n = 154) received critical care during the hospitalization episode. The median cost of each RSV episode was USD539 (IQR: USD167-USD2106) and was higher among hospitalized patients (median: USD2112; IQR: USD1379-USD3182) compared with nonhospitalized patients (median: USD167; IQR: USD112-USD276). CONCLUSIONS: RSV infection represents a potentially important contributor to healthcare resource use and medical costs among children <2 years old in Thailand. Coupled with epidemiologic data, findings from our study will be useful to illustrate the overall economic burden associated with RSV infection among children in Thailand.

Evaluation of the Effectiveness of Behavioral Economic Incentive Programs for Goal Achievement on Healthy Diet, Weight Control and Physical Activity: A Systematic Review and Network Meta-analysis.

BACKGROUND: Healthy diet, weight control and physical activity to reduce obesity can be motivated by financial incentives (FI). Behavioral-economic approaches may improve the incentivization effectiveness. This study compares and ranks the effectiveness of standard and behavioral incentivization for healthy diet, weight control, and physical activity promotion. PURPOSE: To investigate whether behavioral-economic insights improve incentivization effectiveness. METHODS: A systematic search of Medline and Scopus was performed from database inception to December 2020. Study characteristics, program designs, and risk ratio (RR) were extracted. A two-stage network meta-analysis pooled and ranked intervention effects. RESULTS: There were 35 eligible RCTs. For diet-weight control, standard FI, deposit contract (deposit), lottery-based incentive (lottery), and standard-FI + lottery increased goal achievement compared to no-FI but only deposit was statistically significant with pooled RRs and 95% confidence intervals (CI) of 1.21 (0.94, 1.56), 1.79 (1.04, 3.05), 1.45 (0.99, 2.13), and 1.73 (0.83, 3.63). For physical activity, standard-FI, deposit, and lottery significantly increased goal achievement compared to no-FI, with pooled RRs of 1.38 (1.13, 1.68), 1.63 (1.24, 2.14) and 1.43 (1.14, 1.80), respectively. In a follow-up period for physical activity, only deposit significantly increased goal achievement compared to no-FI, with pooled RRs of 1.39 (1.11, 1.73). CONCLUSION: Deposit, followed by lottery, were best for motivating healthy diet, weight control and physical activity at program end. Post-intervention, deposit then standard-FI were best for motivating physical activity. Behavioral insights can improve incentivization effectiveness, although lottery-based approaches may offer only short-term benefit regarding physical activity. However, the imprecise intervention effects were major concerns.

Healthy diet, weight control and physical activity to reduce obesity can be motivated by financial incentives (FI). Behavioral-economic approaches may improve the effectiveness of FI programs. This study aims to investigate whether behavioral-economic insights improve incentivization effectiveness for healthy diet, weight control, and physical activity promotion. We conducted a systematic review of published randomized controlled trials (RCTs), then pooled the interested results, compared and ranked the effectiveness of standard and behavioral incentivization programs by a two-stage network meta-analysis. There were 35 eligible RCTs. For diet-weight control, standard FI, deposit contract (deposit), lottery-based incentive (lottery), and standard-FI + lottery increased goal achievement compared to no-FI but only deposit was statistically significant. For physical activity, standard-FI, deposit, and lottery significantly increased goal achievement compared to no-FI. In a follow-up period for physical activity, only deposit significantly increased goal achievement compared to no-FI. In conclusion, deposit, followed by lottery, were best for motivating healthy diet, weight control and physical activity at program end. Post-intervention, deposit then standard-FI were best for motivating physical activity. This shows that behavioral insights can improve incentivization effectiveness, although lottery-based approaches may offer only short-term benefit regarding physical activity.

Economic evaluation of peritoneal dialysis and hemodialysis in Thai population with End-stage Kidney Disease.

BACKGROUND: This study aimed to conduct a cost-utility analysis of the "Peritoneal Dialysis (PD)-First" policy in 2008 under a universal health coverage scheme and hemodialysis (HD) in Thai patients with End-stage Kidney Disease (ESKD) using updated real-practice data. METHODS: Markov model was used to evaluate the cost-utility of two modalities, stratified into five age groups based on the first modality taken at 20, 30, 40, 50, and 60 years old from government and societal perspectives. Input parameters related to clinical aspects and cost were obtained from 15 hospitals throughout Thailand and Thai Renal Replacement Therapy databases. Both costs and outcomes were discounted at 3%, adjusted to 2021, and converted to USD (1 USD = 33.57 Thai Baht). One-way analysis and probabilistic sensitivity analysis were performed to assess the uncertainty surrounding model parameters. RESULTS: From the government perspective, compared to PD-first policy, the incremental cost-effectiveness ratio (ICER) was between 19,434 and 23,796 USD per QALY. Conversely, from a societal perspective, the ICER was between 31,913 and 39,912 USD per QALY. Both are higher than the willingness to pay threshold of 4,766 USD per QALY. CONCLUSION: By applying the updated real-practice data, PD-first policy still remains more cost-effective than HD-first policy at the current willingness to pay. However, HD gained more quality-adjusted life years than PD. This information will assist clinicians and policymakers in determining the future direction of dialysis modality selection and kidney replacement therapy reimbursement policies for ESKD patients.

Cost-effectiveness analysis of mesh fixation techniques for laparoscopic and open inguinal hernia surgeries.

PURPOSE: This study reports economic evaluation of mesh fixation in open and laparoscopic hernia repair from a prospective real-world cohort study, using cost-effectiveness analysis (CEA) and cost-utility analysis (CUA). METHODS: A prospective real-world cohort study was conducted in two university-based hospitals in Thailand from November 2018 to 2019. Patient data on hernia features, operative approaches, clinical outcomes, associated cost data, and quality of life were collected. Models were used to determine each group's treatment effect, potential outcome means, and average treatment effects. An incremental cost-effectiveness ratio was used to evaluate the incremental risk of hernia recurrences. RESULTS: The 261 patients in this study were divided into six groups: laparoscopic with tack (LT, n = 47), glue (LG, n = 26), and self-gripping mesh (LSG, n = 30), and open with suture (OS, n = 117), glue (OG, n = 18), and self-gripping mesh (OSG, n = 23). Hernia recurrence was most common in LSG. The mean utility score was highest in OG and OSG (both 0.99). Treatment costs were generally higher for laparoscopic than open procedures. The cost-effectiveness plane for utility and hernia recurrence identified LSG as least cost effective. Cost-effectiveness acceptability curves identified OG as having the highest probability of being cost effective at willingness to pay levels between $0 and $3,300, followed by OSG. CONCLUSION: Given the similarity of hernia recurrence among all major procedures, the cost of surgery may impact the decision. According to our findings, open hernia repair with adhesive or self-gripping mesh appears most cost-effective.

Risk-benefit assessment of onlay and retrorectus mesh augmentation for incisional hernia prophylaxis: A secondary analysis from network meta-analysis.

BACKGROUND: Mesh augmentation has proved efficacious for the prevention of incisional hernia (IH). A recent network meta-analysis (NMA) identified onlay and retrorectus mesh (OM and RM) as the most effective therapeutic options, but the risk of surgical site infection (SSI) and other complications require additional consideration. METHODS: The NMA generated pooled risk differences (RD) for the benefits of reducing IH and the risk of SSI and composite seroma/hematoma (CSH) for use in Monte-Carlo data simulations with 1000 replications. Mean incremental risk-benefit ratios (IRBR), i.e., the ratio of incremental risk (or RD) and incremental benefit, and 95% confidence intervals (95% CI) were estimated with a probability of risk-benefits (PRB) across risk-benefit acceptability thresholds from the acceptability curves generated. RESULTS: The RDs of IH were 0.237 and 0.201 lower in OM and RM than primary suture closure, compared to 0.027 and -0.001 for SSI. IRBRs (95% CI) for SSI risk were -0.118 (-0.124, -0.112) and 0.006 (-0.002, 0.013) for OM and RM, respectively. PRBs were much higher in RM than OM, especially at low acceptability thresholds of 0.05 and 0.1. IRBRs (95% CI) for CSH were -0.388 (-0.395, -0.381) and -0.105 (-0.111, -0.100) for OM and RM, respectively. RM yielded a PRB of 0.87 at an acceptability threshold of 0.2, in contrast to OM, which did not. CONCLUSION: Overall, RM offered improved benefit in IH prophylaxis over the risk of complications relative to OM and appeared to be the preferred treatment option for this indication.

Cost-minimization analysis of sequential genetic testing versus targeted next-generation sequencing gene panels in patients with pheochromocytoma and paraganglioma.

INTRODUCTION: Pheochromocytomas and paragangliomas (PPGLs) are highly heritable tumours, with up to 40% of cases carrying germline variants. Current guidelines recommend genetic testing for all patients with PPGLs. Next-generation sequencing (NGS) enables accurate, fast, and inexpensive genetic testing. This study aimed to compare the costs related to PPGL genetic testing between the sequential testing using the decisional algorithm proposed in the 2014 Endocrine Society guidelines and targeted NGS gene panels. METHODS: Patients with proven PPGLs were enrolled. A gene list covering 17 susceptibility genes related to hereditary PPGLs was developed for targeted sequencing. Validation was carried out by Sanger sequencing. We simulated the diagnostic workflow to examine the anticipated costs based on each strategy for genetic testing. RESULTS: Twenty-nine patients were included, among whom a germline variant was identified in 34.5%. A total of 22.7% with apparently sporadic PPGL carried a variant. Five genes were involved (RET, n = 3; SDHB, n = 3; SDHD, n = 2; EGLN1, n = 1; and NF1, n = 1). According to the diagnostic workflow, the average cost of the targeted NGS (534.7 US dollars per patient) is lower than that of the sequential testing (734.5 US dollars per patient). The targeted NGS can also reduce the number of hospital visits from 4.1 to 1 per person. The cost can be further reduced to 496.24 US dollars per person (32% reduction) if we apply a new syndromic-driven diagnostic algorithm to establish priorities for specific genetic testing for syndromic and selected cases, and targeted NGS for non-syndromic patients. CONCLUSIONS: Targeted NGS can reduce both the cost of PPGL genetic testing and the number of hospital visits, compared with the conventional approach. Our proposed algorithm is the preferred approach due to its significant reduction of the cost of genetic testing.Key messagePheochromocytomas and paragangliomas are highly heritable neoplasms.The targeted next-generation sequencing (NGS) gene panels have proven to be fast, accurate, and inexpensive for the genetic analysis.According to this cost analysis, it is economically reasonable to use targeted NGS gene panels for genetic screening.

Evaluation of the cost-utility of phosphate binders as a treatment option for hyperphosphatemia in chronic kidney disease patients: a systematic review and meta-analysis of the economic evaluations.

BACKGROUND: Uncontrolled hyperphosphatemia in chronic kidney disease (CKD) patients commonly results in vascular calcification leading to increased risk of cardiovascular disease. Phosphate binders (PBs) are used for hyperphosphatemia and can be calcium-based (CBPBs) or non-calcium-based (NCBPBs), the latter being more expensive than CBPBs. In this study, we used meta-analysis approaches to assess the cost-utility of PBs for hyperphosphatemia in CKD patients. METHODS: Relevant studies published prior to June 2019 were identified from PubMed, Scopus, the Cochrane Library, the National Health Service Economic Evaluation Database, and the Cost-Effectiveness Analysis Registry. Studies were eligible if they included CKD patients with hyperphosphatemia, compared any PBs and reported economic outcomes. Meta-analysis was applied to pool incremental net benefit (INB) across studies stratified by country income. RESULTS: A total of 25 studies encompassing 32 comparisons were eligible. Lanthanum carbonate, a NCBPB, was a more cost-effective option than CBPBs in high-income countries (HICs), with a pooled INB of $3984.4 (599.5-7369.4), especially in pre-dialysis patients and used as a second-line option with INBs of $4860.2 (641.5-9078.8), $4011.0 (533.7-7488.3), respectively. Sevelamer, also a NCBPB, was not more cost-effective as a first-line option compared to CBPBs with a pooled INB of $6045.8 (- 23,453.0 to 35,522.6) and $34,168.9 (- 638.0 to 68,975.7) in HICs and upper middle-income countries, respectively. CONCLUSIONS: Lanthanum carbonate was significantly more cost-effective than CBPBs as a second-line option for hyperphosphatemia in pre-dialysis patients in HICs. However, the use of sevelamer is not more cost-effective as a first-line option compared to CBPBs.

Evaluation of the effectiveness of behavioural economic incentive programmes for the promotion of a healthy diet and physical activity: a protocol for a systematic review and network meta-analysis.

INTRODUCTION: Obesity and being overweight are major risk factors for metabolic syndrome and non-communicable diseases. Despite the recommendation that a healthy diet and physical activity can reduce the severity of these diseases, many fail to adhere to these measures. From a behavioural economic perspective, adherence to such measures can be encouraged through financial incentives. However, additional related behavioural economic approaches may improve the effectiveness of an incentive programme. As such, we have developed a protocol for a systematic review and network meta-analysis to summarise the current evidence from financial incentive programmes with and without behavioural economic insights for promoting healthy diet and physical activity. METHODS AND ANALYSIS: Previous systematic reviews, meta-analyses and individual studies were identified from Medline and Scopus in June 2020 and will be updated until December 2020. Individual studies will be selected and data extracted by two reviewers. Disagreement will be resolved by consensus or adjudicated by a third reviewer. A descriptive analysis will summarise the effectiveness of behavioural economic incentive programmes for promoting healthy diet and physical activity. Moreover, individual studies will be pooled using network meta-analyses where possible. I2 statistics and Cochran's Q test will be used to assess heterogeneity. Risk of bias and publication bias, if appropriate, will be evaluated, as well as the overall strength of the evidence. ETHICS AND DISSEMINATION: Ethics approval for a systematic review and meta-analysis is not required. The findings will be published in a peer-reviewed journal. PROSPERO REGISTRATION NUMBER: CRD42020198024.

Cost-effectiveness analysis of epilepsy surgery in children and adolescents with drug resistant focal epilepsy at three years in a tertiary care epilepsy center in Thailand.

Epilepsy surgery is proven as a cost-effective treatment in developed countries, especially in adults with drug resistant epilepsy (DRE). This study is aimed to demonstrate the cost-effectiveness of epilepsy surgery in children and adolescents with DRE at three years compared with those who were eligible for surgery but received medical treatment. This study was conducted from January 2014 to December 2018. Clinical data were obtained from a retrospective chart review. Direct medical costs, including epilepsy surgery, inpatient and outpatient treatment were retrieved from the finance department. Direct non-medical costs were collected from the family interview. The effectiveness was determined by percent seizure reduction and quality of life assessed by EQ-5D scores. Decision tree analysis using TreeAge Pro® 2018 was deployed to determine the cost-effectiveness. Seventeen patients had epilepsy surgery and 19 were in the medical group. Seizure freedom was noted in 52% and 16% in the surgical and medical groups, respectively. Incremental cost-effectiveness ratio (ICER) was 743,040 THB (22,793 USD) per 1 QALY and 3302 THB (101 USD) per 1% seizure reduction. The study did not demonstrate cost-effectiveness of epilepsy surgery in the short term compared with Thailand's threshold (160,000 THB (4908 USD) per 1 QALY). Epilepsy surgery may be cost-effective if evaluated beyond three years.

Efficacy and economic evaluation of delivery of care with tele-continuous EEG in critically ill patients: a multicentre, randomised controlled trial (Tele-cRCT) study protocol.

INTRODUCTION: Some critically ill patients are confirmed by continuous electroencephalography (cEEG) monitoring that non-convulsive seizure (NCS) and/or non-convulsive status epilepticus (NCSE) are causes of their depressed level of consciousness. Shortage of epilepsy specialists, especially in developing countries, is a major limiting factor in implementing cEEG in general practice. Delivery of care with tele-continous EEG (tele-cEEG) may be a potential solution as this allows specialists from a central facility to remotely assist local neurologists from distant areas in interpreting EEG findings and suggest proper treatment. No tele-cEEG programme has been implemented to help improve quality of care. Therefore, this study is conducted to assess the efficacy and cost utility of implementing tele-cEEG in critical care. METHODS AND ANALYSIS: The Tele-cRCT study is a 3-year prospective, randomised, controlled, parallel, multicentre, superiority trial comparing delivery of care through 'Tele-cEEG' intervention with 'Tele-routine EEG (Tele-rEEG)' in patients with clinical suspicion of NCS/NCSE. A group of EEG specialists and a tele-EEG system were set up to remotely interpret EEG findings in six regional government hospitals across Thailand. The primary outcomes are functional neurological outcome (modified Rankin Scale, mRS), mortality rate and incidence of seizures. The secondary outcomes are cost utility, length of stay, emergency visit/readmission, impact on changing medical decisions and health professionals' perceptions about tele-cEEG implementation. Functional outcome (mRS) will be assessed at 3 and 7 days after recruitment, and again at time of hospital discharge, and at 90 days, 6 months, 9 months and 1 year. Costs and health-related quality of life will be assessed using the Thai version of the EuroQol-five dimensions-five levels (EQ-5D-5L) at hospital discharge, and at 90 days, 6 months, 9 months and 1 year. ETHICS AND DISSEMINATION: This study has been approved by the ethics committees of the Faculty of Medicine, Chulalongkorn University, and of Ramathibodi Hospital, Mahidol University, and registered on Thai Clinical Trials Registry. The results will be disseminated in a peer-reviewed journal. TRIAL REGISTRATION NUMBER: TCTR20181022002; preresults.

Basal serum luteinising hormone cut-off, and its utility and cost-effectiveness for aiding the diagnosis of the onset of puberty in girls with early stages of breast development.

OBJECTIVE: To determine basal and gonadotrophin-releasing hormone analogue (GnRHa)-stimulated peak luteinising hormone (LH) cut-offs to diagnose onset of early or normal puberty in girls with each Tanner stage of breast (II and III). DESIGN, PATIENTS AND MEASUREMENTS: A retrospective study of 601 girls with breast onset before 8 years of age who underwent GnRHa test was conducted. Patients were categorized as CPP and premature thelarche. Each group was divided into two subgroups; Tanner II and III. Cost-effectiveness analysis was performed. RESULTS: In comparison with basal LH cut-off of 0.3 IU/L, basal LH cut-off of 0.2 IU/L had comparable specificity (Tanner II: 98.0% vs 94.8%, Tanner III: 98.8% vs 93.8%), but greater sensitivity (Tanner II: 28.3% vs 41.7%, Tanner III: 45.2% vs 59.3%). Specificity of basal LH cut-off of 0.2 IU/L was not inferior to that of the traditionally used peak LH of 5 IU/L. Using basal LH cut-off of 0.2 IU/L followed by GnRHa test in girls with negative basal LH was more cost-saving when compared with using the cut-off of 0.3 IU/L. Moreover, using basal LH cut-off of 0.2 IU/L followed by GnRHa test provided a cost reduction when compared with performing GnRHa test in all patients. CONCLUSIONS: Basal serum LH cut-off of 0.2 IU/L could be a simple and cost-saving tool for initial diagnosis of onset of early or normal puberty in girls with Tanner II and III before proceeding to GnRH testing.

From Research to Policy Implementation: Trastuzumab in Early-Stage Breast Cancer Treatment in Thailand.

OBJECTIVES: To evaluate the adjuvant therapy of trastuzumab cost and quality-adjusted life-years (QALYs) in lifetime horizon and describe the use of an economic evaluation in supporting policy-making decisions in the treatment of early-stage breast cancer in Thailand. METHODS: A Markov model was used to evaluate the cost effectiveness of 1-year adjuvant trastuzumab for patients with early-stage breast cancer who were considered human epidermal growth factor receptor 2/neu-positive with a societal perspective and lifetime horizon. The research variables were probability of health state change, health utility, and cost of treatment. A sensitivity analysis was conducted using probabilistic methods. A budget impact analysis was also performed. RESULTS: The results revealed that the treatment cost and QALYs in the trastuzumab group yielded 4.59 QALYs. The incremental cost-effectiveness ratio was $3387 (THB 118 572; THB = Thai baht) per QALY. On the basis of the willingness-to-pay threshold in Thailand, a 1-year adjuvant trastuzumab treatment for breast cancer was a cost-effective therapy. CONCLUSIONS: A combination therapy that includes trastuzumab is a preferable choice and should be used in early-stage breast cancer treatment. The Thai government has listed trastuzumab on the National List of Essential Medicines to be used for the early stages of breast cancer since 2014.

Cost-Effectiveness Analysis of Renin-Angiotensin Aldosterone System Blockade in Progression of Chronic Kidney Disease.

OBJECTIVES: To assess the cost effectiveness of renin-angiotensin aldosterone system (RAAS) blockade in the progression of chronic kidney disease using Thai clinical data in 2014. METHODS: A Markov model for cost-effectiveness analysis was applied to estimate from a societal perspective the cost per quality-adjusted life-year (QALY) gained and the incremental cost-effectiveness ratio of RAAS versus non-RAAS used in preventing the progression of end-stage renal disease and death stratified by diabetic and nondiabetic patients. Input parameters related to clinical outcomes were obtained from a cohort study of treatment effectiveness, whereas costs were retrieved from the Ramathibodi Hospital electronic database in 2015 and the Health Intervention and Technology Assessment Program in Thailand. One-way analysis and probabilistic sensitivity analysis were performed to evaluate uncertainty surrounding model parameters. RESULTS: From the model, using RAAS improved QALY from 2.41 to 3.16 years and from 2.37 to 3.20 years in diabetic and nondiabetic groups, respectively. The incremental cost-effectiveness ratios for these groups were 78,250 baht (US $2,353.39) and 66,674 baht (US $2,005.22), respectively. CONCLUSIONS: Using RAAS in patients with chronic kidney disease improved QALY in both diabetic and nondiabetic patients and proved to be cost-effective.

Hospitalization and cost after switching from atypical to typical antipsychotics in schizophrenia patients in Thailand.

BACKGROUND: Several clinical practice guidelines suggest using atypical over typical antipsychotics in patients diagnosed with schizophrenia. Nevertheless, cost-containment policy urged restricting usage of atypical antipsychotics and switching from atypical to typical antipsychotics. OBJECTIVE: This study aimed to evaluate clinical and economic impacts of switching from atypical to typical antipsychotics in schizophrenia patients in Thailand. METHODS: From October 2010 through September 2013, a retrospective cohort study was performed utilizing electronic database of two tertiary hospitals. Schizophrenia patients aged 18 years or older and being treated with atypical antipsychotics were included. Patients were classified as atypical antipsychotic switching group if they switched to typical antipsychotics after 180 days of continual atypical antipsychotics therapy. Outcomes were schizophrenia-related hospitalization and total health care cost. Logistic and Poisson regression were used to evaluate the risk of hospitalization, and generalized linear model with gamma distribution was used to determine the health care cost. All analyses were adjusted by employing propensity score and multivariable analyses. All cost estimates were adjusted according to 2013 consumer price index and converted to US$ at an exchange rate of 32.85 Thai bahts/US$. RESULTS: A total of 2,354 patients were included. Of them, 166 (7.1%) patients switched to typical antipsychotics. The adjusted odds ratio for schizophrenia-related hospitalization in atypical antipsychotic switching group was 1.87 (95% confidence interval [CI] 1.23-2.83). The adjusted incidence rate ratio was 2.44 (95% CI 1.57-3.79) for schizophrenia-related hospitalizations. The average total health care cost was lower in patients with antipsychotic switching (-$64; 95% CI -$459 to $332). CONCLUSION: Switching from atypical to typical antipsychotics is associated with an increased risk of schizophrenia-related hospitalization. Nonetheless, association with average total health care cost was not observed. These findings can be of use as a part of evidence in executing prospective cost-containment policy.

Direct medical cost of Thai pediatric asthma management: a pilot study.

BACKGROUND: The prevalence of asthma in Bangkok increased steadily over the last couple of decades and warrants an assessment of the costs associated with its treatment, particularly in the case of children. OBJECTIVE: To estimate the direct medical costs of asthma care in children at the Allergy unit of the Department of Pediatrics, Ramathibodi hospital. METHODS: In this retrospective study, we included asthmatic children aged less than 20 year-old having visited the allergy unit at least 4 times in 12 months between January and December, 2011. Cost data, retrieved from the allergy unit electronic database included billing invoices of inpatient care, outpatient and emergency room visits. From this dataset we estimated drug costs, physician and nursing services, diagnostic tests and procedures, supplies and room charges, and assessed an overall asthma-related direct medical cost. RESULTS: Ninety-seven asthmatic children (aged 11.5 ± 3.7 years) were included in the study. Annual median direct medical cost was 8,537.9 Baht or 278 USD per patient. Annual direct medical cost was the highest in patients younger than 5 years old (p < 0.001). Moreover, expenses of patients who had at least one exacerbation increased significantly compared to patients without exacerbation (p = 0.02). Furthermore, direct medical cost was the highest when patients had exacerbation requiring hospitalization (p = 0.03). CONCLUSIONS: Cases of patients having asthma exacerbation or being diagnosed with asthma before 5 years of age were associated with higher treatment expenses. Policies developed to achieve asthma control and prevention should identify young children and patients presenting risk factors for asthma exacerbation as high risk groups deserving particular attention.