Health-related quality of life in Thai patients with chronic hepatitis B.

Background: Chronic hepatitis B (CHB) significantly impacts the health-related quality of life (HRQoL), but remains underexplored in the Thai population. Health state utilities (HSU) are indicators reflecting HRQoL which serve as fundamental inputs for economic evaluation analyses. This study aimed at assessing differences in HRQoL across five CHB stages in Thai patients, including non-cirrhotic CHB, compensated cirrhosis, decompensated cirrhosis, early-/intermediate-stage hepatocellular carcinoma (HCC) and advanced-/terminal-stage HCC. Methods: We conducted a cross-sectional study to collect HRQoL data from patients with CHB at five stages. The study included patients with CHB who were followed up at a super-tertiary care centre between March 2021 and February 2022. The participants completed the EQ-5D-5L questionnaire and provided demographic data. Disease stage and relevant data were obtained from medical records. HSU and Euroqol-visual analogue scale (EQ-VAS) scores, calculated using Thai-specific conversion coefficients, were assessed. Results: Among 422 patients, 236 did not have cirrhosis, 92 had compensated cirrhosis, 13 had decompensated cirrhosis, 55 had early-/intermediate-stage HCC, and 26 had advanced-/terminal-stage HCC. The HSU scores for non-cirrhotic, compensated cirrhosis, decompensated cirrhosis, early-/intermediate-stage HCC and advanced-/terminal-stage HCC were 0.95 ± 0.08, 0.89 ± 0.16, 0.79 ± 0.19, 0.89 ± 0.12 and 0.52 ± 0.39, respectively. Similarly, the EQ-VAS scores for various CHB stages were 83.56 ± 12.90, 80.48 ± 13.03, 68.76 ± 17.40, 79.00 ± 14.38 and 62.92 ± 20.62, respectively. A significant correlation (r = 0.469, P < 0.001) was observed between the HSU and EQ-VAS scores. The disease progression led to a notable HSU decline, particularly in the advanced-/terminal-stage HCC group (regression coefficient: -0.436, P < 0.001). The EQ-VAS scores indicated reduced quality of life in advanced liver disease. Conclusions: Later CHB stages compromise the HRQoL. Decompensated cirrhosis and advanced-/terminal-stage HCC profoundly affect physical health and quality of life, whereas patients with compensated cirrhosis and early-/intermediate-stage HCC report better HRQoL.

Cost-utility and budget impact analyses of cervical cancer screening using self-collected samples for HPV DNA testing in Thailand.

INTRODUCTION: Cervical cancer ranks as the third most prevalent cancer among women in Thailand. However, the effectiveness of cervical cancer screening programs is limited by several factors that impede the screening rate. The utilization of self-collected samples for screening purposes has the potential to alleviate barriers to screening in Thai women. This study assessed the cost-utility and budget impact of implementing cervical cancer screening using self-collected samples for human papillomavirus (HPV) deoxyribonucleic acid (DNA) testing in Thailand. MATERIALS AND METHODS: We employed a decision tree integrated with a Markov model to estimate the lifetime costs and health benefits associated with the cervical cancer screening program for women aged 25-65. The analysis was conducted from a societal perspective. Four screening policy options were compared: (1) additional self-collected samples for HPV DNA testing, (2) clinician-collected samples for HPV DNA testing only, (3) clinician-collected samples for cytology test (i.e., status quo), and (4) no screening. The model inputs were based on unvaccinated women. The screening strategies and management in those with positive results were assumed followed to the Thai clinical practice guideline. Costs were reported in 2022 Thai baht. Sensitivity analyses were conducted. The ten-year budget impacts of the additional self-collected samples for HPV DNA testing were calculated from a payer perspective. RESULTS: All screening policies were cost-saving compared to no screening. When comparing the additional self-collected samples for HPV DNA testing with the clinician-collected samples policy, it emerged as the dominant strategy. The incremental benefit in cervical cancer prevention achieved by incorporating self-collected samples for screening was observed at any additional screening rate that could be achieved through their use. Sensitivity analyses yielded consistently favorable results for the screening policies. The average annual budget impact of the additional self-collected samples for screening policy amounted to 681 million Thai baht. This budget allocation could facilitate cervical cancer screening for over 10 million women. CONCLUSIONS: An addition of self-collected samples for HPV DNA testing into the cervical cancer screening program is cost-saving. The benefits of this screening policy outweigh the associated incremental costs. Policymakers should consider this evidence during the policy optimization process.

Cost-Utility and Budget Impact Analyses of Oral Chemotherapy for Stage III Colorectal Cancer: Real-World Evidence after Policy Implementation in Thailand.

This study conducted a cost-utility analysis and a budget impact analysis (BIA) of outpatient oral chemotherapy versus inpatient intravenous chemotherapy for stage III colorectal cancer (CRC) in Thailand. A Markov model was constructed to estimate the lifetime cost and health outcomes based on a societal perspective. Eight chemotherapy strategies were compared. Clinical and cost data on adjuvant chemotherapy were collected from the medical records of 1747 patients at Siriraj Hospital, Thailand. The cost-effectiveness results were interpreted against a Thai willingness-to-pay threshold of USD 5003/quality-adjusted life year (QALY) gained. A 5-year BIA was performed. Of the eight strategies, CAPOX then FOLFIRI yielded the highest life-year and QALY gains. Its total lifetime cost was also the highest. An incremental cost-effectiveness ratio of CAPOX then FOLFIRI compared to 5FU/LV then FOLFOX, a commonly used regimen USD was 4258 per QALY gained.The BIA showed that when generic drug prices were applied, 5-FU/LV then FOLFOX had the smallest budgetary impact (USD 9.1 million). CAPOX then FOLFIRI required an approximately three times higher budgetary level (USD 25.1 million). CAPOX then FOLFIRI is the best option. It is cost-effective compared with 5-FU/LV then FOLFOX. However, policymakers should consider the relatively high budgetary burden of the CAPOX then FOLFIRI regimen.

A cost-effectiveness analysis of the 13-valent pneumococcal conjugated vaccine and the 23-valent pneumococcal polysaccharide vaccine among Thai older adult.

Introduction: This study aims to assess the economic impact of introducing the 13-valent pneumococcal conjugate vaccine (PCV13) and 23-valent pneumococcal polysaccharide vaccine (PPSV23) to Thai older adult aged ≥ 65 years who are healthy or with chronic health conditions and immunocompromised conditions from a societal perspective in order to introduce the vaccine to Thailand's National Immunization Program for the older adult. Methods: A Markov model was adopted to simulate the natural history and economic outcomes of invasive pneumococcal diseases using updated published sources and Thai databases. We reported analyses as incremental cost-effectiveness ratios (ICER) in USD per quality-adjusted life year (QALY) gained. In addition, sensitivity analyses and budget impact analyses were conducted. Results: The base-case analysis of all interventions (no vaccinations [current standard of care in Thailand], PPSV23, and PCV13) showed that PPSV23 was extendedly dominated by PCV13. Among healthy individuals or those with chronic health conditions, ICER for PCV13 was 233.63 USD/QALY; meanwhile, among individuals with immunocompromised conditions, ICER for PCV13 was 627.24 USD/QALY. PCV13 are economical vaccine for all older adult Thai individuals when compared to all interventions. Conclusions: In the context of Thailand, PCV13 is recommended as the best buy and should be primarily prioritized when both costs and benefits are considered. Also, this model will be beneficial to the two-next generation pneumococcal vaccines implementation in Thailand.

An effectiveness and economic analyses of tricalcium phosphate combined with iliac bone graft versus RhBMP-2 in single-level XLIF surgery in Thailand.

STUDY DESIGN: Retrospective study. OBJECTIVES: To perform effectiveness and economic analyses using data from a retrospective study of patients who underwent XLIF surgery using tricalcium phosphate combined with iliac bone graft (TCP + IBG) or BMP-2 in Thailand. METHODS: Data were collected from retrospective review of the medical charts and the spine registry of Siriraj Hospital, Bangkok, Thailand. The patients were divided into two groups (TCP + IBG group and BMP-2 group). Demographic, perioperative data, radiographic, clinical results, and quality of life related to health were collected and analyzed at 2-year follow-up. All economic data were collected during the perioperative period and presented as total charge, bone graft, implant/instrumentation, operative service, surgical supply, transfusion, medication, anesthesia, laboratory, and physical therapy. RESULTS: Twenty-five TCP + IBG and 30 BMP-2 patients with spondylolisthesis and spinal stenosis as primary diagnosis were included. There were no significant differences in all demographic parameters (gender, age, underlying disease, diagnosis, and level of spine) between these two groups. During the perioperative period, the TCP + IBG group had more mean blood loss and more postoperative complications compared to the BMP-2 group. At 2 years of follow-up, there were no significant differences between the radiographic and clinical outcomes of the TCP + IBG and BMP-2 groups. The fusion rate for TCP + IBG and BMP-2 at 2 years of follow-up was 80% and 96.7%, respectively, and no statistically significant differences were observed. All clinical outcomes (Utility, Oswestry Disability Index, and EuroQol Visual Analog Scale) at 2-year follow-up improved significantly compared to preoperative outcomes, but there were no significant differences between the TCP + IBG and BMP-2 groups, either at preoperatively or at 2-year follow-up. The total charge of TCP + IBG was statistically significantly lower than that of BMP-2. Furthermore, the charges of TCP + IBG and BMP-2 during the perioperative period in Thailand were up to three times less than those in the United States. CONCLUSIONS: Using TCP + IBG as a standalone bone substitution for XLIF surgery with additional posterior instrumentation resulted in significantly lower direct medical charge compared to those using BMP-2 in the perioperative period. However, we could not detect a difference in the long-term radiographic and clinical outcomes of patients with TCP + IBG and BMP-2. These suggest that TCP + IBG may be a valuable alterative bone graft, especially in low- and middle-income countries.

Cost-utility Analysis of Anterior Cervical Discectomy and Fusion for Cervical Spondylosis Patients Comparing Polyetheretherketone Versus Tricortical Iliac Crest Bone Graft.

STUDY DESIGN: Prospective cohort study. OBJECTIVES: To perform a cost-utility analysis and to investigate the clinical outcomes and patient's quality of life after anterior cervical discectomy and fusion (ACDF) to treat cervical spondylosis compared between fusion with polyetheretherketone (PEEK) and fusion with tricortical iliac bone graft (IBG) in Thailand. SUMMARY OF BACKGROUND DATA: ACDF is one of the standard treatments for cervical spondylosis. The fusion material options include PEEK and tricortical IBG. No previous studies have compared the cost-utility between these 2 fusion material options. PATIENTS AND METHODS: Patients with cervical spondylosis who were scheduled for ACDF at Siriraj Hospital (Bangkok, Thailand) during 2019-2020 were prospectively enrolled. Patients were allocated to the PEEK or IBG fusion material group according to the patient's choice of fusion material. EuroQol-5 dimensions 5 levels and relevant costs were collected during the operative and postoperative periods. A cost-utility analysis was performed using a societal perspective. All costs were converted to 2020 United States dollars (USD), and a 3% discount rate was used. The outcome was expressed as the incremental cost-effectiveness ratio. RESULTS: Thirty-six patients (18 ACDF-PEEK and 18 ACDF-IBG) were enrolled. Except for Nurick grading, there was no significant difference in patient baseline characteristics between groups. The average utility at 1 year after ACDF-PEEK and ACDF-IBG were 0.939 ± 0.061 and 0.798 ± 0.081, respectively ( P < 0.001). The total lifetime cost of ACDF-PEEK and ACDF-IBG was 83,572 USD and 73,329 USD, respectively. The incremental cost-effectiveness ratio of ACDF-PEEK when compared with that of ACDF-IBG showed a gain of 4468.52 USD/quality-adjusted life-years, which is considered cost-effective at the Thailand willingness-to-pay threshold of 5115 USD/quality-adjusted life-year gained. CONCLUSIONS: ACDF-PEEK was found to be more cost-effective than ACDF-IBG for treating cervical spondylosis in Thailand. LEVEL OF EVIDENCE: Level II.

Cost-Utility and Cost-Effectiveness Analysis of Spinal Cord Stimulation for Chronic Refractory Pain in the Context of Developing Country.

BACKGROUND: Spinal cord stimulation (SCS) is an effective treatment for chronic refractory pain. The evidence of pain reduction, improvement of function, quality of life, and cost-effectiveness are strong in developed countries. Nevertheless, there is still a lack of economic studies of SCS in the context of low- and middle-income countries. OBJECTIVES: To evaluate the cost-effectiveness and cost-utility of additional SCS to conventional management (CMM) in patients with chronic refractory pain in Thailand. STUDY DESIGN: Prospective observational study. SETTING: The pain clinic at Siriraj Hospital, a tertiary care center in Thailand. METHODS: This study recruited patients undergoing SCS implants due to refractory pain to CMM from varieties of conditions and followed up to 36 months. The clinical outcomes, quality of life, and costs of treatment were collected before and after SCS implantation. A decision tree and Markov model were developed to estimate the total lifetime costs and health benefits of SCS using a societal perspective. The results were presented as an incremental cost-utility ratio (ICUR) in 2021 Thai Baht (THB) per quality-adjusted life year (QALY) gained and an incremental cost-effective ratio (ICER) in 2021 THB per numeric rating pain score (NRS) reduction. RESULTS: Twenty-nine patients who underwent SCS implantation reported pain intensity and increased utility at every point in time. Compared to pre-implantation, the QALY gained in both rechargeable and non-rechargeable SCS was 2.13 QALYs. The economic analysis showed the ICUR in the rechargeable and non-rechargeable SCS + CMM group was 660,106.96, and 620,120.59 THB/QALY gained, respectively, which was higher than Thais' willingness-to-pay (WTP) threshold at 160,000 THB/QALY gained. Pain score reduction was 2.49/10 at the 3-year point, and the ICER was 496,932.08 and 337,341.77 THB/NRS reduction for rechargeable and non-rechargeable SCS, respectively. LIMITATIONS: As this is a single-center prospective cohort study, the results might be subject to selection bias and may not truly represent all patients from a developing country. The cost-effectiveness results should also be carefully interpreted for generalizability. CONCLUSION: Spinal cord stimulation is effective in pain control and improves the quality of life for patients with chronic refractory pain. However, the ICUR of SCS is above the WTP, leading to the interpretation that SCS is still not a cost-effective treatment in the current context in Thailand.

"MURAL" model to predict bleeding from mural-based lesions in potential small bowel bleeding may improve diagnostic capability and decrease cost.

In potential small bowel bleeding, video capsule endoscopy (VCE) is excellent to detect mucosal lesions, while mural-based lesions are better detected by computed tomography enterography (CTE). A predictive tool to identify mural-based lesions should guide selecting investigations. In this retrospective study, we developed and validated the "MURAL" model based on logistic regression to predicts bleeding from mural-based lesions. Cost-effectiveness analysis comparing diagnostic strategy among VCE, CTE, and MURAL model was performed. Of 296 patients, 196 and 100 patients were randomly included in the derivative and validation cohorts, respectively. The MURAL model comprises 5 parameters: age, presence of atherosclerosis, chronic kidney disease, antiplatelet use, and serum albumin level. The area under the receiver operating characteristic curve was 0.778 and 0.821 for the derivative and validation cohorts, respectively. At a cutoff value of 24.2%, the model identified mural-based lesions with 70% sensitivity and 83% specificity in the validation cohort. Cost-effectiveness analysis revealed that application of the MURAL model demonstrated a comparable missed lesion rate but had a lower missed tumor rate, and lower cost compared to VCE strategy. The model for predicting mural-based lesions provide some guidance in investigative decision-making, which may improve diagnostic efficiency and reduce costs.

Preemptive Living-Related Kidney Transplantation Is a Cost-Saving Strategy Compared With Post-dialysis Kidney Transplantation in Thailand.

Background: Compared with other kidney replacement therapies, preemptive kidney transplantation (KT) provides better clinical outcomes, reduces mortality, and improves the quality of life of patients with end-stage kidney disease (ESKD). However, evidence related to the cost-effectiveness of preemptive living-related KT (LRKT) is limited, especially in low- and middle-income countries, such as Thailand. This study compared the cost-effectiveness of LRKT with those of non-preemptive KT strategies. Methods: Cost and clinical data were obtained from adult patients who underwent KT at Siriraj Hospital, Mahidol University, Thailand. A decision tree and Markov model were used to evaluate and compare the lifetime costs and health-related outcomes of LRKT with those of 2 KT strategies: non-preemptive LRKT and non-preemptive deceased donor KT (DDKT). The model's input parameters were sourced from the hospital's database and a systematic review. The primary outcome was incremental cost-effectiveness ratios (ICERs). Costs are reported in 2020 United States dollars (USD). One-way and probabilistic sensitivity analyses were performed. Results: Of 140 enrolled KT patients, 40 were preemptive LRKT recipients, 50 were non-preemptive LRKT recipients, and the rest were DDKT recipients. There were no significant differences in the baseline demographic data, complications, or rejection rates of the three groups of patients. The average costs per life year gained were $10,647 (preemptive LRKT), $11,708 (non-preemptive LRKT), and $11,486 (DDKT). The QALY gained of the preemptive option was 0.47 compared with the non-preemptive strategies. Preemptive LRKT was the best-buy strategy. The sensitivity analyses indicated that the model was robust. Within all varied ranges of parameters, preemptive LRKT remained cost-saving. The probability of preemptive LRKT being cost-saving was 79.4%. Compared with non-preemptive DDKT, non-preemptive LRKT was not cost-effective at the current Thai willingness-to-pay threshold of $5113/QALY gained. Conclusions: Preemptive LRKT is a cost-saving strategy compared with non-preemptive KT strategies. Our findings should be considered during evidence-based policy development to promote preemptive LRKT among adults with ESKD in Thailand.

Cost-Utility Analysis Compared Between Radiotherapy Alone and Combined Surgery and Radiotherapy for Symptomatic Spinal Metastases in Thailand.

OBJECTIVE: To investigate the patient quality of life and cost-utility compared between radiotherapy alone and combined surgery and radiotherapy for spinal metastasis (SM) in Thailand. METHODS: Patients with SM with an indication for surgery during 2018-2020 were prospectively recruited. Patients were assigned to either the combination surgery and radiotherapy group or the radiotherapy alone group. Quality of life was assessed by EuroQol-5D-5L (EQ-5D-5L) questionnaire, and relevant healthcare costs were collected pretreatment, and at 3-month and 6-month posttreatment. Total lifetime cost and quality-adjusted life-years (QALYs) were estimated for each group. RESULTS: Twenty-four SM patients (18 females, 6 males) were included. Of those, 12 patients underwent combination treatment, and 12 underwent radiotherapy alone. At 6-month posttreatment, 10 patients in the surgery group, and 11 patients in the nonsurgery group remained alive for a survival rate of 83.3% and 91.7%, retrospectively. At 6-month posttreatment, the mean utility in the combination treatment group was significantly better than in the radiotherapy alone group (0.804 ± 0.264 vs. 0.518 ± 0.282, respectively; p = 0.011). Total lifetime costs were 59,863.14 United States dollar (USD) in the combination treatment group and 24,526.97 USD in the radiation-only group. The incremental cost-effectiveness ratio using 6-month follow-up data was 57,074.01 USD per QALY gained. CONCLUSION: Surgical treatment combined with radiotherapy to treat SM significantly improved patient quality of life compared to radiotherapy alone during the 6-month posttreatment period. However, combination treatment was found not to be cost-effective compared to radiotherapy alone for SM at the Thailand willingness-to-pay threshold of 5,113 USD/QALY.

Economic burden of non-alcoholic steatohepatitis with significant fibrosis in Thailand.

BACKGROUND: Non-alcoholic steatohepatitis (NASH) has been recognised as a significant form of chronic liver disease and a common cause of cirrhosis and hepatocellular carcinoma, resulting in a considerable financial burden on healthcare resources. Currently, there is no information regarding the economic burden of NASH in low- and middle-income countries (LMICs). The aim of this study was to estimate the economic burden of NASH in Thailand as a lesson learned for LMICs. METHODS: To estimate the healthcare costs and prevalence of NASH with significant fibrosis (fibrosis stage ≥ 2) in the general Thai population, an eleven-state lifetime horizon Markov model with 1-year cycle length was performed. The model comprised Thai population aged 18 years and older. The cohort size was based on Thailand Official Statistic Registration Systems. The incidence of NASH, transitional probabilities, and costs-of-illness were based on previously published literature, including systematic reviews and meta-analyses. The age-specific prevalence of NASH was based on Thai NASH registry data. Costs were expressed in 2019 US Dollars ($). As we undertook analysis from the payer perspective, only direct medical costs were included. All future costs were discounted at an annual rate of 3%. A series of sensitivity analyses were performed. RESULTS: The estimated total number of patients with significant NASH was 2.9 million cases in 2019, based on a NASH prevalence of 5.74%. The total lifetime cost of significant NASH was $15.2 billion ($5,147 per case), representing approximately 3% of the 2019 GDP of Thailand. The probabilistic sensitivity analysis showed that the lifetime costs of significant NASH varied from $11.4 billion to $18.2 billion. CONCLUSIONS: The economic burden associated with NASH is substantial in Thailand. This prompts clinicians and policy makers to consider strategies for NASH prevention and management.

Very-low-dose aspirin and surveillance colonoscopy is cost-effective in secondary prevention of colorectal cancer in individuals with advanced adenomas: network meta-analysis and cost-effectiveness analysis.

BACKGROUND: Individuals with advanced colorectal adenomas (ACAs) are at high risk for colorectal cancer (CRC), and it is unclear which chemopreventive agent (CPA) is safe and cost-effective for secondary prevention. We aimed to determine, firstly, the most suitable CPA using network meta-analysis (NMA) and secondly, cost-effectiveness of CPA with or without surveillance colonoscopy (SC). METHODS: Systematic review and NMA of randomised controlled trials were performed, and the most suitable CPA was chosen based on efficacy and the most favourable risk-benefit profile. The economic benefits of CPA alone, 3 yearly SC alone, and a combination of CPA and SC were determined using the cost-effectiveness analysis (CEA) in the Malaysian health-care perspective. Outcomes were reported as incremental cost-effectiveness ratios (ICERs) in 2018 US Dollars ($) per quality-adjusted life-year (QALY), and life-years (LYs) gained. RESULTS: According to NMA, the risk-benefit profile favours the use of aspirin at very-low-dose (ASAVLD, ≤ 100 mg/day) for secondary prevention in individuals with previous ACAs. Celecoxib is the most effective CPA but the cardiovascular adverse events are of concern. According to CEA, the combination strategy (ASAVLD with 3-yearly SC) was cost-saving and dominates its competitors as the best buy option. The probability of being cost-effective for ASAVLD alone, 3-yearly SC alone, and combination strategy were 22%, 26%, and 53%, respectively. Extending the SC interval to five years in combination strategy was more cost-effective when compared to 3-yearly SC alone (ICER of $484/LY gain and $1875/QALY). However, extending to ten years in combination strategy was not cost-effective. CONCLUSION: ASAVLD combined with 3-yearly SC in individuals with ACAs may be a cost-effective strategy for CRC prevention. An extension of SC intervals to five years can be considered in resource-limited countries.

Cost-effectiveness and budget impact analysis of infliximab and its biosimilar in patients with refractory moderate-to-severe Crohn's disease using real world evidence in Thailand.

AIMS: This study aimed to conduct a cost-effectiveness analysis of infliximab and its biosimilar compared to conventional therapy in refractory moderate-to-severe Crohn's disease (CD) in Thailand. MATERIALS AND METHODS: A Markov model was used to estimate lifetime costs and health benefits of infliximab from a societal perspective. Our analyses consisted of three choices of treatment (conventional therapy, infliximab originator, and biosimilar) and three treatment scenarios (infliximab 2 years and 3 years if relapse, infliximab 2 years and lifelong if relapse, and infliximab lifelong). The input parameters were obtained from the CD registry and systematic literature reviews. The results were reported as incremental cost-effectiveness ratios (ICERs) in 2017 USD per quality-adjusted life year (QALY) gained. The sensitivity analyses were performed to assess the influence of parameter uncertainty. Threshold sensitivity analyses were carried out to determine the optimal drug prices. Finally, budget impact analyses were conducted. RESULTS: None of the scenarios was cost-effective at Thai willingness-to-pay threshold (4,706 USD/QALY gained). The lowest ICER of 30,121 USD/QALY gained was reported in the scenario that included only standard dose of infliximab biosimilar with the maximum of 5-year treatment. The drug prices need to be reduced by at least 72% to allow infliximab biosimilar to be cost-effective. The 5-year budget impact was only 695,958 USD for the current biosimilar price. CONCLUSIONS: Infliximab for the treatment of refractory moderate-to-severe CD in Thailand would be cost-effective if the drug prices were significantly decreased. The best value for money strategy was infliximab biosimilar with a restricted duration of treatment. Key points The use of infliximab and its biosimilar in a restricted duration of maximum 5-year is not cost-effective for patients with moderate-to-severe Crohn's disease refractory to conventional therapy, unless their price was lowered around 72-90% in Thailand. The estimated budget impact for adopting infliximab or its biosimilar for such indication has potential financial feasibility. Policy makers may consider cost-effectiveness and budget impact findings as well as other aspects such as rarity of disease as a part of the decision making process.

Cost-effectiveness and budget impact analyses of colorectal cancer screenings in a low- and middle-income country: example from Thailand.

Objectives: Colorectal cancer (CRC) screening programs have been reported to be cost-effective in many high-income countries. However, there was no such study in low- and middle-income countries. This study aimed to evaluate cost-effectiveness and budget impact of CRC screening modalities for average-risk persons in Thailand.Methods: A decision tree coupled with a Markov model was used to estimate lifetime costs and health benefits of fecal immunochemical test (FIT) and colonoscopy using a societal perspective. The input parameters were obtained from a CRC screening project at a Thai tertiary care hospital, Thai health care costs and databases, and systematic literature review. Results were reported as incremental cost-effectiveness ratios (ICERs) in 2017 US Dollars (USD) per quality-adjusted life year (QALY) gained. Sensitivity analyses were performed to assess the influence of parameter uncertainty. Finally, budget impact analysis was conducted.Results: At the Thai ceiling threshold of societal willingness-to-pay of 4,706 USD, the screening colonoscopy every 10 years and annual FIT, starting at age 50, was cost-effective, as compared to no screening resulting in 15.09 and 15.00 QALYs with the ICERs of 600.20 and 509.84 USD/QALY gained, respectively. Colonoscopy every 10 years and annual FIT could prevent 17.9% and 5.7% of early stage cancer and 27.8% and 9.2% of late stage cancer per 100,000 screening over lifetime when compared to no screening, respectively. The colonoscopy screening was cost-effective with the ICER of 646.53 USD/QALY gained when compared to FIT. The probabilities of being cost-effective for the colonoscopy and FIT were 75% and 25%, respectively. Budget impact analysis showed the colonoscopy screening required an 8-times higher budget than FIT.Conclusions: Colonoscopy offers the best value for money of CRC screenings in Thailand. Annual FIT is potentially feasible since it requires less resources. Our findings can be used as part of evidence for informing policy decision making.Key points for decision makersThere was a lack of cost-effective study of colorectal cancer screening programs in low- and middle-income countries.This study evaluated lifetime health outcomes and costs, and the cost-effectiveness of colorectal screening options for average-risk persons in Thailand.Colonoscopy screening every 10 years is cost-effective with high probability of being cost-effective as compared with annual fecal immunochemical test.Screening by annual fecal immunochemical test is more feasible in terms of human resource and budgetary burden.Colorectal screening programs provides an opportunity for early diagnosis and treatments to prevent advance colorectal stages and avoid higher consequent costs.This study contributes a new evidence-based knowledge for Thailand and can be used to support policy decision making process.

Weight Reduction and Pioglitazone are Cost-Effective for the Treatment of Non-Alcoholic Fatty Liver Disease in Thailand.

INTRODUCTION: This study evaluated lifetime liver-related clinical outcomes, costs of treatment, and the cost-effectiveness of treatment options for non-alcoholic fatty liver disease (NAFLD) in Thailand. METHODS: A cost-utility analysis using a lifetime Markov model was conducted among Thai patients with NAFLD, from a societal perspective. Pioglitazone, vitamin E, a weight reduction program, and usual care were investigated, with the outcomes of interest being the number of cirrhosis and hepatocellular carcinoma (HCC) cases, life expectancy, quality-adjusted life-years (QALYs), lifetime costs, and the incremental cost-effectiveness ratios (ICERs). One-way and probabilistic sensitivity analyses were performed. RESULTS: When compared with usual care, a weight reduction program can prevent cirrhosis and HCC cases by 13.91% (95% credible interval [CrI] 0.97, 20.59) and 2.12% (95% CrI 0.43, 4.56), respectively; pioglitazone can prevent cirrhosis and HCC cases by 9.30% (95% CrI -2.52, 15.24) and 1.42% (95% CrI -0.18, 3.74), respectively; and vitamin E can prevent cirrhosis and HCC cases by 7.32% (95% CrI -4.64, 15.56) and 1.12% (95% CrI -0.81, 3.44), respectively. Estimated incremental life expectancy and incremental QALYs for all treatment options compared with usual care were approximately 0.06 years and 0.07 QALYs, respectively. The lifetime costs of both a weight reduction program and pioglitazone were less than usual care, while vitamin E was $3050 (95% CrI 2354, 3650). The weight reduction program dominated all other treatment options. The probability of being cost-effective in Thailand's willingness-to-pay threshold ($4546/QALY gained) was 76% for the weight reduction program, 22% for pioglitazone, 2% for usual care, and 0% for vitamin E. CONCLUSIONS: A weight reduction program can prevent cirrhosis and HCC occurrences, and dominates all other treatment options. Pioglitazone and vitamin E demonstrated a trend towards decreasing the number of cirrhosis and HCC cases.

Correction to: Weight Reduction and Pioglitazone are Cost-Effective for the Treatment of Non-alcoholic Fatty Liver Disease in Thailand.

Weight Reduction is Cost-Effective for the Treatment of Non-alcoholic Fatty Liver Disease in Thailand.

Cost-effectiveness analysis of ultrasonography screening for nonalcoholic fatty liver disease in metabolic syndrome patients.

BACKGROUND: Nonalcoholic fatty liver disease (NAFLD) can be diagnosed early by noninvasive ultrasonography; however, the cost-effectiveness of ultrasonography screening with intensive weight reduction program in metabolic syndrome patients is not clear. This study aims to estimate economic and clinical outcomes of ultrasonography in Thailand. METHODS: Cost-effectiveness analysis used decision tree and Markov models to estimate lifetime costs and health benefits from societal perspective, based on a cohort of 509 metabolic syndrome patients in Thailand. Data were obtained from published literatures and Thai database. Results were reported as incremental cost-effectiveness ratios (ICERs) in 2014 US dollars (USD) per quality-adjusted life year (QALY) gained with discount rate of 3%. Sensitivity analyses were performed to assess the influence of parameter uncertainty on the results. RESULTS: The ICER of ultrasonography screening of 50-year-old metabolic syndrome patients with intensive weight reduction program was 958 USD/QALY gained when compared with no screening. The probability of being cost-effective was 67% using willingness-to-pay threshold in Thailand (4848 USD/QALY gained). Screening before 45 years was cost saving while screening at 45 to 64 years was cost-effective. CONCLUSIONS: For patients with metabolic syndromes, ultrasonography screening for NAFLD with intensive weight reduction program is a cost-effective program in Thailand. Study can be used as part of evidence-informed decision making. TRANSLATIONAL IMPACTS: Findings could contribute to changes of NAFLD diagnosis practice in settings where economic evidence is used as part of decision-making process. Furthermore, study design, model structure, and input parameters could also be used for future research addressing similar questions.

Causes of prolonged hospitalization among general internal medicine patients of a tertiary care center.

BACKGROUND: Unnecessary days of prolonged hospitalization may lead to the increase in hospital-related complications and costs, especially in tertiary care center Currently, there have not been many studies about the causes of prolonged hospitalization. Some identified causes could, however, be prevented and improved. OBJECTIVE: To identify the prevalence, causes, predictive factors, prognosis, and economic burden of prolonged hospitalization in patients who had been in general internal medicine wards of the tertiary care center for 7 days or more. MATERIAL AND METHOD: Retrospective chart review study was conducted among all patients who were admitted for 7 days or more in general internal medicine wards of Siriraj Hospital, the largest tertiary care center in Thailand. The period of this study was from 1 August 2012 to 30 September 2012. Demographic data, principle diagnosis, comorbid diseases, complications, discharge status, total costs of admission and percentage of reimbursement were collected. The causes of prolonged hospitalization at day 7, 14, 30, and 90 were assessed. RESULTS: Five hundred and sixty-two charts were reviewed. The average length of stay was 25.9 days. The two most common causes of prolonged admission at day 7 were treatment of main diagnosed disease with stable condition (27.6%) and waiting for completion of intravenous antibiotics administration with stable condition (19.5%). The causes of prolonged hospitalization at day 14 were unstable condition from complications (22.6%) and those waiting for completion of intravenous antibiotics administration with stable condition (15.8%). The causes of prolonged admission at day 30 were unstable conditions from complications (25.6%), difficulty weaning or ventilator dependence (17.6%), and caregiver problems (15.2%). The causes of prolonged hospitalization at day 90 were unstable condition from complications (30.0%), caregiver problems (30.0%), and palliative care (25.0%). Poor outcomes were shown in the patients admitted more than 90 days. Percentage of death, being bedridden, and re-admission were 55, 40, and 22, respectively. The goal of treatment was only palliative care in 80 percent of this patient group. Respiratory failure among the hospitalized was the strongest predictive factors of death (Odds ratio = 7.5, p < 0.001). The average costs of admission per patient was 163,870 THB and the percentage of reimbursement was only 72%. For total costs of admission in these two months, Siriraj Hospital lost a large amount of money (about 26 million THB) for patients admitted for 7 days or more and almost 50% of this was spent on the patients admitted for 90 days or more. The average cost of admission per patient in the latter group was 1,073,004 THB. CONCLUSION: Prolonged hospitalization had adverse outcomes for the patients and the hospital, such as high complications, poor outcomes, high costs of treatment and low reimbursement ratio that created an enormous economic burden for the hospital. Therefore possible preventable causes of prolonged admission must be identified, prevented and managed by improving quality of multidisciplinary health care system and ancillary services.

Awareness of and factors influencing willingness to receive a tetanus-diphtheria toxoid booster vaccine among Thai adults.

Adults who complete the diphtheria tetanus pertussis (DTP) vaccine series during childhood should receive a tetanus-diphtheria toxoid (Td) booster vaccine every 10 years. We studied awareness of and willingness to receive the Td booster vaccine as well as factors influencing these attitudes. A total of 1,284 participants were interviewed using a questionnaire at the out-patient department (OPD) of Siriraj Hospital, Bangkok, Thailand from January 31 to February 28, 2011. The sample population included: OPD patients, family members accompanying patients and medical personnel other than doctors. Seven percent of the 961 general participants and 26.3% of the 320 medical personnel who completed the questionnaire were aware of the need to receive the Td booster vaccine. Eighty-six point five percent of participants stated they be willing to receive the vaccine if they were instructed by their doctors. Logistic regression analyses showed the following factors correlated with awareness of the need to receive the vaccine: born after 1978 (aOR = 2.17; 95% CI: 1.59-2.97), higher income (aOR = 1.93; 95% CI: 1.37-2.72), and higher general preventive awareness score (aOR = 1.08; 95% CI: 1.02-1.14). Factors that correlated with willingness to receive the vaccine were: higher education (aOR = 2.17; 95% CI: 1.54-3.05), a higher score on general knowledge of tetanus-diphtheria (aOR = 2.00; 95% CI: 1.15-3.51), a higher general preventive awareness score (aOR = 1.06; 95% CI: 1.007-1.115), and previous experience with the Td booster vaccine (aOR = 2.85; 95% CI: 1.71-4.76), Under-awareness of the adult vaccination program remains a problem in Thailand especially among older generations and low-socioeconomic groups. As passive immunity wanes with time, public health authorities need to take action to educate the general population and health care workers about the importance of the Td booster vaccine.