Partial herd hoof trimming results in a higher economic net benefit than whole herd hoof trimming in dairy herds.

Sole ulcers, a common cause of lameness is the costliest non-infectious foot lesion in dairy cows and one of the most prevalent non-infectious foot lesions in freestall housing systems. Costs associated with sole ulcers are treatment costs, plus increased labor and decreased productivity and fertility. Routine hoof trimming is part of a strategy to manage sole ulcers. However, hoof trimming strategies differ among farms. The two most frequently applied strategies are: 1) partial herd hoof trimming with a 2-month interval between trims; and 2) whole herd hoof trimming at 6-month intervals. A Markov model was developed to investigate whether every 2 months partial herd hoof trimming or whole herd hoof trimming every 6 months was the most cost-effective strategy to avoid costs associated with sole ulcers. In this model, the net benefits for a 100-cow herd and the average productive life span of a dairy cow in intensive dairy systems of 3 years were evaluated. Partial herd hoof trimming was the most cost-effective strategy 100% of the time compared to whole herd hoof trimming, with a difference in 3-year net benefits of US$4,337 (95% CI: US$2,713-US$5,830). Based on sensitivity analyses, variables that were the sources of the biggest uncertainty in the model were herd size, the probability of being trimmed in a partial herd trim, and the prevalence of sole ulcers. To further investigate the impacts of herd size and of probability of being trimmed, various scenario analyses were conducted. With increasing herd size, the difference in net benefits in favor of partial herd hoof trimming increased even more. Scenario analyses about the probability of getting trimmed all indicated that targeted intervention increased the difference in net benefits in favor of partial herd hoof trimming. However, if the selection of cows to be trimmed in a partial herd trim was random, the whole herd hoof trimming strategy became cost-effective. Therefore, targeted selection and early intervention are necessary to decrease costs associated with sole ulcers.

Logical Inconsistencies in the Health Years in Total and Equal Value of Life-Years Gained.

OBJECTIVES: This study aimed to assess whether recently proposed alternatives to the quality-adjusted life-year (QALY), intended to address concerns about discrimination, are suitable for informing resource allocation decisions. METHODS: We consider 2 alternatives to the QALY: the health years in total (HYT), recently proposed by Basu et al, and the equal value of life-years gained (evLYG), currently used by the Institute for Clinical and Economic Review. For completeness we also consider unweighted life-years (LYs). Using a hypothetical example comparing 3 mutually exclusive treatment options, we consider how calculations are performed under each approach and whether the resulting rankings are logically consistent. We also explore some further challenges that arise from the unique properties of the HYT approach. RESULTS: The HYT and evLYG approaches can result in logical inconsistencies that do not arise under the QALY or LY approaches. HYT can violate the independence of irrelevant alternatives axiom, whereas the evLYG can produce an unstable ranking of treatment options. HYT have additional issues, including an implausible assumption that the utilities associated with health-related quality of life and LYs are "separable," and a consideration of "counterfactual" health-related quality of life for patients who are dead. CONCLUSIONS: The HYT and evLYG approaches can result in logically inconsistent decisions. We recommend that decision makers avoid these approaches and that the logical consistency of any approaches proposed in future be thoroughly explored before considering their use in practice.

Examining the Relationship Between Screening for Postpartum Depression and Associated Child Health Service Utilization and Costs: A Study Using the All Our Families Cohort and Administrative Data.

INTRODUCTION: Despite a recognized association between maternal postpartum depression (PPD) and adverse child health outcomes, evidence examining the relationship between PPD symptoms and associated child health service utilization and costs remains unclear. In addition, there is a paucity of evidence describing the relationship between early identification of maternal PPD and associated health service utilization and costs for children. This study aims to address this gap by describing the secondary associations of screening for maternal PPD and annual health service utilization and costs for children over their first five years of life. METHODS: Mothers and children enrolled in the prospective All Our Families cohort were linked to provincial administrative data in Alberta, Canada. Multivariable generalized linear models were used to estimate the average annual inpatient, outpatient, physician, and total health service utilization and costs from a public health system perspective for children of mothers screened high risk for PPD, low/moderate risk for PPD, or unscreened. RESULTS: Total mean costs were greatest for children during their first year of life than other years. Those whose mothers were not screened had significantly lower costs compared to those whose mothers were screened low/moderate risk, despite equivalent health service utilization. DISCUSSION: Findings from this study describe the secondary associations of screening for maternal PPD using a public health system perspective. More research is required to fully understand variations in health costs for children across maternal PPD screening categories.

This study describes the relationship between maternal PPD screening status and annual child health service utilization and costs over the first five years of age. Findings from this administrative data study will support decision-makers in understanding the secondary effects associated with maternal PPD screening and inform future cost-effectiveness analyses of PPD screening interventions using a maternal-child health perspective.

The Impact of Providing Material Benefits to Improve Access to Food on Clinical Parameters, Dietary Intake, and Household Food Insecurity in People with Diabetes: A Systematic Review with Narrative Synthesis.

The high cost of healthy foods makes maintaining a healthy dietary pattern challenging, particularly among people with diabetes who are experiencing food insecurity. The objectives of this study were to: 1) review evidence on the impact of providing material benefits (e.g., food coupons/vouchers, free food, or financial subsidies/incentives) to improve access to food on clinical parameters, dietary intake, and household food insecurity in people with diabetes, and 2) review relevant economic evidence. Six databases were searched from inception to March 2023 for longitudinal studies with quantitative outcomes. Twenty-one studies were included in the primary review and 2 in the economic analysis. Risk of bias was high in 20 studies and moderate in 1 study. The number of randomized controlled trials and nonrandomized studies reporting statistically significant improvement, alongside Grading of Recommendations Assessment, Development, and Evaluation (GRADE) certainty of the evidence was: HbA1c: 1/6 and 4/12 (very low), systolic blood pressure: 0/3 and 1/8 (very low), diastolic blood pressure: 0/3 and 1/7 (very low), BMI: 0/5 and 2/8 (very low), body weight: 0/0 and 1/3 (very low), hypoglycemia: 1/2 and 1/2 (very low), daily intake of fruits and vegetables: 1/1 and 1/3 (very low), daily intake of whole grains: 0/0 and 0/2 (very low), overall diet quality: 2/2 and 1/1 (low), and household food insecurity: 2/3 and 0/0 (very low). The 2 studies included in the economic analysis showed no difference in Medicare spending from Supplemental Nutrition Assistance Program participation and cost-savings from medically tailored meals in an economic simulation. Overall, providing material benefits to improve access to food for people with diabetes may improve household food insecurity, fruit and vegetable intake, and overall diet quality, but effects on clinical parameters and whole grain intake are unclear. The certainty of evidence was very low to low by GRADE. PROSPERO (CRD42021212951).

Cost analysis of COVID-19 test result notification using an automated messaging system compared to a staff caller practice in Alberta.

SETTING: In Alberta, polymerase chain reaction (PCR) COVID-19 tests were an important step in detecting and isolating contagious individuals throughout the pandemic. Initially, a staff member provided results to all PCR COVID-19 test clients by phone. As the number of tests increased, new approaches were essential for timely result notification. INTERVENTION: An innovative automated IT system was introduced during the pandemic to reduce workloads and support timely result notification. At the time of the COVID-19 test booking and again following swabbing, clients had an option to consent to receive their test results via an automated text or voice message. Prior to implementation, a privacy impact assessment was approved, a pilot was undertaken, and changes to lab information systems were made. OUTCOMES: Health administration data were used in a cost analysis to compare the unique costs associated with the novel automated IT practice (e.g., administration, integration, messages, staffing costs) and a hypothetical staff caller practice (e.g., administration, staffing costs) for negative test results. The costs of sharing 2,161,605 negative test results in 2021 were assessed. The automated IT practice demonstrated a cost savings of $6,272,495 over the staff caller practice. A follow-up analysis determined the cost savings threshold of 46,463 negative tests to break even. IMPLICATIONS: Using an automated IT practice for consenting clients can be a cost-effective approach to reach clients in a timely manner during a pandemic or other instances warranting direct notification. This approach is being explored for test result notification of other communicable diseases in other contexts.

RéSUMé: LIEU: En Alberta, les tests de réaction de polymérisation en chaîne (PCR) pour la COVID-19 ont représenté une étape importante dans la détection et l'isolement des personnes contagieuses tout au long de la pandémie. Au début, un membre du personnel communiquait par téléphone les résultats de tous les tests PCR de la COVID-19 aux usagers et usagères. Avec l'augmentation du nombre de tests, il a absolument fallu trouver de nouvelles façons de communiquer les résultats rapidement. INTERVENTION: Un système de TI automatisé novateur a été introduit durant la pandémie pour alléger la charge de travail et favoriser la communication rapide des résultats des tests. Au moment de la réservation d'un test de dépistage de la COVID-19 et après l'écouvillonnage, les usagers et usagères pouvaient consentir à recevoir leurs résultats via un message texte automatisé ou un message vocal. Avant la mise en œuvre, une évaluation des facteurs relatifs à la vie privée a été approuvée, un projet pilote a été mené, et des changements ont été apportés aux systèmes d'information des laboratoires. RéSULTATS: Les données administratives sanitaires ont servi à effectuer une analyse des coûts visant à comparer les coûts spécifiquement associés à la nouvelle pratique de TI automatisée (p. ex. frais d'administration, d'intégration, de messages, de personnel) et ceux d'une hypothétique pratique d'appel par un membre du personnel (p. ex. frais d'administration, de personnel) pour les tests négatifs. Les coûts de communication des résultats de 2 161 605 tests négatifs en 2021 ont été évalués. La pratique de TI automatisée a représenté des économies de 6 272 495 $ par rapport à la pratique d'appel par un membre du personnel. Selon une analyse de suivi, le seuil de rentabilité était atteint après 46 463 tests négatifs. CONSéQUENCES: L'utilisation d'une pratique de TI automatisée pour les usagers et usagères ayant consenti à cette option peut être une méthode efficace par rapport au coût pour joindre rapidement les usagères et usagers lors d'une pandémie ou dans d'autres cas où une notification directe est justifiée. Cette méthode est explorée pour la communication des résultats de tests d'autres maladies transmissibles dans d'autres contextes.

Cost-effectiveness models for Alzheimer's disease and related dementias: IPECAD modeling workshop cross-comparison challenge.

INTRODUCTION: The credibility of model-based economic evaluations of Alzheimer's disease (AD) interventions is central to appropriate decision-making in a policy context. We report on the International PharmacoEconomic Collaboration on Alzheimer's Disease (IPECAD) Modeling Workshop Challenge. METHODS: Two common benchmark scenarios, for the hypothetical treatment of AD mild cognitive impairment (MCI) and mild dementia, were developed jointly by 29 participants. Model outcomes were summarized, and cross-comparisons were discussed during a structured workshop. RESULTS: A broad concordance was established among participants. Mean 10-year restricted survival and time in MCI in the control group ranged across 10 MCI models from 6.7 to 9.5 years and 3.4 to 5.6 years, respectively; and across 4 mild dementia models from 5.4 to 7.9 years (survival) and 1.5 to 4.2 years (mild dementia). DISCUSSION: The model comparison increased our understanding of methods, data used, and disease progression. We established a collaboration framework to assess cost-effectiveness outcomes, an important step toward transparent and credible AD models.

The economic value of liquid biopsy for genomic profiling in advanced non-small cell lung cancer.

Background: Liquid biopsy (LB) can detect actionable genomic alterations in plasma circulating tumor circulating tumor DNA beyond tissue testing (TT) alone in advanced non-small cell lung cancer (NSCLC) patients. We estimated the cost-effectiveness of adding LB to TT in the Canadian healthcare system. Methods: A cost-effectiveness analysis was conducted using a decision analytic Markov model from the Canadian public payer (Ontario) perspective and a 2-year time horizon in patients with treatment-naïve stage IV non-squamous NSCLC and ⩽10 pack-year smoking history. LB was performed using the comprehensive genomic profiling Guardant360™ assay. Standard of care TT for each participating institution was performed. Costs and outcomes of molecular testing by LB + TT were compared to TT alone. Transition probabilities were calculated from the VALUE trial (NCT03576937). Sensitivity analyses were undertaken to assess uncertainty in the model. Results: Use of LB + TT identified actionable alterations in more patients, 68.5 versus 52.7% with TT alone. Use of the LB + TT strategy resulted in an incremental cost savings of $3065 CAD per patient (95% CI, 2195-3945) and a gain in quality-adjusted life-years of 0.02 (95% CI, 0.01-0.02) versus TT alone. More patients received chemo-immunotherapy based on TT with higher overall costs, whereas more patients received targeted therapy based on LB + TT with net cost savings. Major drivers of cost-effectiveness were drug acquisition costs and prevalence of actionable alterations. Conclusion: The addition of LB to TT as initial molecular testing of clinically selected patients with advanced NSCLC did not increase system costs and led to more patients receiving appropriate targeted therapy.

A Cost-Utility Analysis of the Syncope: Pacing or Recording in The Later Years (SPRITELY) Trial.

Background: The Syncope: Pacing or Recording in the Later Years (SPRITELY) trial reported that a strategy of empiric permanent pacing in patients with syncope and bifascicular block reduces major adverse events more effectively than acting on the results of an implantable cardiac monitor (ICM). Our objective was to determine the cost-effectiveness of using the ICM, compared with a pacemaker (PM), in the management of older adults (age > 50 years) with bifascicular block and syncope enrolled in the SPRITELY trial. Methods: SPRITELY was a pragmatic, open-label randomized controlled trial with a median follow-up of 33 months. The primary outcome of this analysis is the cost per additional quality-adjusted life-year (QALY). Resource utilization and utility data were collected prospectively, and outcomes at 2 years were compared between the 2 arms. A decision analytic model simulated a 3-year time horizon. Results: The mean cost incurred by participants randomized to the PM arm was $9918, compared to $15,416 (both in Canadian dollars) for participants randomized to the ICM arm. The ICM strategy resulted in 0.167 QALYs fewer than the PM strategy. Cost and QALY outcomes are sensitive to the proportion of participants randomized to the ICM arm who subsequently required PM insertion. In 40,000 iterations of probabilistic sensitivity analysis, the PM strategy resulted in cost-savings in 99.7% of iterations, compared with the ICM strategy. Conclusions: The PM strategy was dominant-that is, less costly and estimated to result in a greater number of QALYs. For patients with unexplained syncope, bifascicular block, and age > 50 years, a PM is more likely to be cost-effective than an ICM.

Contexte: L'essai SPRITELY ( S yncope: P acing or R ecording i n t h e L ater Y ears) a été mené auprès de patients ayant subi une syncope et un bloc bifasciculaire. Elle a montré qu'une méthode de stimulation électrique permanente et empirique du cœur permet de réduire les événements indésirables majeurs plus efficacement qu'une méthode reposant sur les résultats d'un moniteur cardiaque implantable. Notre objectif était de déterminer le rapport coût-efficacité de l'utilisation du moniteur cardiaque implantable par rapport à un stimulateur cardiaque dans la prise en charge de personnes âgées de plus de 50 ans présentant un bloc bifasciculaire et une syncope, inscrits à l'essai SPRITELY. Méthodologie: SPRITELY était un essai contrôlé ouvert et pragmatique à répartition aléatoire, dont le suivi médian était de 33 mois. Le paramètre d'évaluation principal de cette analyse était le coût supplémentaire par année de vie ajustée en fonction de la qualité (AVAQ). Les données sur l'utilisation des ressources et l'utilité ont été recueillies de manière prospective, et les résultats à deux ans ont été comparés entre les deux groupes. Un modèle décisionnel analytique a été utilisé pour simuler un horizon temporel de trois ans. Résultats: Le coût moyen pour les participants répartis aléatoirement dans le groupe utilisant un stimulateur cardiaque était de 9 918 $ CAN comparativement à 15 416 $ CAN pour ceux utilisant un moniteur cardiaque implantable. La stratégie du moniteur cardiaque implantable s'est traduite par une réduction de 0,167 du nombre d'AVAQ par rapport à la stratégie reposant sur le stimulateur cardiaque. Les résultats relatifs aux coûts et aux AVAQ sont sensibles à la proportion de participants répartis aléatoirement dans le groupe du moniteur cardiaque implantable qui ont par la suite dû recevoir un stimulateur cardiaque. Sur 40 000 itérations de l'analyse de sensibilité probabiliste, la stratégie du stimulateur cardiaque a occasionné des économies dans 99,7 % des itérations comparativement à la stratégie du moniteur cardiaque implantable. Conclusions: La stratégie du stimulateur cardiaque était dominante, autrement dit moins coûteuse et, selon les estimations, entraînerait un plus grand nombre d'AVAQ. Pour les patients de plus de 50 ans présentant une syncope idiopathique et un bloc bifasciculaire, un stimulateur cardiaque est plus susceptible d'être moins coûteux qu'un moniteur cardiaque implantable.

Healthy food prescription incentive programme for adults with type 2 diabetes who are experiencing food insecurity: protocol for a randomised controlled trial, modelling and implementation studies.

INTRODUCTION: The high cost of many healthy foods poses a challenge to maintaining optimal blood glucose levels for adults with type 2 diabetes mellitus who are experiencing food insecurity, leading to diabetes complications and excess acute care usage and costs. Healthy food prescription programmes may reduce food insecurity and support patients to improve their diet quality, prevent diabetes complications and avoid acute care use. We will use a type 2 hybrid-effectiveness design to examine the reach, effectiveness, adoption, implementation and maintenance (RE-AIM) of a healthy food prescription incentive programme for adults experiencing food insecurity and persistent hyperglycaemia. A randomised controlled trial (RCT) will investigate programme effectiveness via impact on glycosylated haemoglobin (primary outcome), food insecurity, diet quality and other clinical and patient-reported outcomes. A modelling study will estimate longer-term programme effectiveness in reducing diabetes-related complications, resource use and costs. An implementation study will examine all RE-AIM domains to understand determinants of effective implementation and reasons behind programme successes and failures. METHODS AND ANALYSIS: 594 adults who are experiencing food insecurity and persistent hyperglycaemia will be randomised to a healthy food prescription incentive (n=297) or a healthy food prescription comparison group (n=297). Both groups will receive a healthy food prescription. The incentive group will additionally receive a weekly incentive (CDN$10.50/household member) to purchase healthy foods in supermarkets for 6 months. Outcomes will be assessed at baseline and follow-up (6 months) in the RCT and analysed using mixed-effects regression. Longer-term outcomes will be modelled using the UK Prospective Diabetes Study outcomes simulation model-2. Implementation processes and outcomes will be continuously measured via quantitative and qualitative data. ETHICS AND DISSEMINATION: Ethical approval was obtained from the University of Calgary and the University of Alberta. Findings will be disseminated through reports, lay summaries, policy briefs, academic publications and conference presentations. TRIAL REGISTRATION NUMBER: NCT04725630. PROTOCOL VERSION: Version 1.1; February 2022.

Mathematical model of the cost-effectiveness of the BioFire FilmArray Blood Culture Identification (BCID) Panel molecular rapid diagnostic test compared with conventional methods for identification of Escherichia coli bloodstream infections.

BACKGROUND: Gram-negative pathogens, such as Escherichia coli, are common causes of bloodstream infections (BSIs) and increasingly demonstrate antimicrobial resistance. Molecular rapid diagnostic tests (mRDTs) offer faster pathogen identification and susceptibility results, but higher costs compared with conventional methods. We determined the cost-effectiveness of the BioFire FilmArray Blood Culture Identification (BCID) Panel, as a type of mRDT, compared with conventional methods in the identification of E. coli BSIs. METHODS: We constructed a decision analytic model comparing BCID with conventional methods in the identification and susceptibility testing of hospitalized patients with E. coli BSIs from the perspective of the public healthcare payer. Model inputs were obtained from published literature. Cost-effectiveness was calculated by determining the per-patient admission cost, the QALYs garnered and the incremental cost-effectiveness ratios (ICERs) where applicable. Monte Carlo probabilistic sensitivity analyses and one-way sensitivity analyses were conducted to assess the robustness of the model. All costs reflect 2019 Canadian dollars. RESULTS: The Monte Carlo probabilistic analyses resulted in cost savings ($27 070.83 versus $35 649.81) and improved QALYs (8.65 versus 7.10) in favour of BCID. At a willingness to pay up to $100 000, BCID had a 72.6%-83.8% chance of being cost-effective. One-way sensitivity analyses revealed length of stay and cost per day of hospitalization to have the most substantial impact on costs and QALYs. CONCLUSIONS: BCID was found to be cost-saving when used to diagnose E. coli BSI compared with conventional testing. Cost savings were most influenced by length of stay and cost per day of hospitalization.

Connect 2 Care, a Novel Community Outreach Program for Vulnerably Housed Patients With High Acute Care Use: A Mixed-Methods Study Protocol.

Introduction: Vulnerably housed individuals, especially those experiencing homelessness, have higher acute care use compared with the general population. Despite available primary care and social services, many face significant challenges accessing needed services. Connect 2 Care (C2C) is a novel transitional case management program that includes registered nurses and health navigators with complementary expertise in chronic disease management, mental health and addictions, social programs, community health, and housing, financial, transportation and legal resources. C2C bridges acute care and community services to improve care coordination. Methods and Analysis: We will perform a mixed-methods evaluation of the C2C program according to the Donabedian framework of structure, process and outcome, to understand how program structure and process, coupled with contextual factors, influence outcomes in a novel intervention. Eligible patients are homeless or unstably housed adults with complex health conditions and high acute care use. Change in emergency department visit rate 12-months after program enrolment is the primary outcome. Secondary outcomes include 12-month post-enrolment hospital admissions, cumulative hospital days, health-related quality of life, housing status, primary care attachment and substance use. Qualitative methods will explore experiences with the C2C program from multiple perspectives and an economic evaluation will assess cost-effectiveness. Discussion: Academic researchers partnered with community service providers to evaluate a novel transitional case management intervention for vulnerably housed patients with high acute-care use. The study uses mixed-methods to evaluate the Connect 2 Care program according to the Donabedian framework of structure, process and outcome, including an assessment of contextual factors that influence program success. Insights gained through this comprehensive evaluation will help refine the C2C program and inform decisions about sustainability and transferability to other settings in Canada.

Innovation in unruptured intracranial aneurysm coiling: At which price or efficacy are new technologies cost-effective?

BACKGROUND: Unruptured intracranial aneurysms (UIA) are increasingly being treated by endovascular coiling as opposed to open surgical clipping. Unfortunately, endovascular coiling imparts an approximate 25% recanalization rate, leading to additional procedures and increased rupture risk. While a new health technology innovation (HTI) that reduces this recanalization rate would benefit patients, few advancements have been made. We aim to determine whether cost-effectiveness has been a barrier to HTI. METHODS: A probabilistic Markov model was constructed from the healthcare payer perspective to compare standard endovascular treatment of UIA to standard treatment plus the addition of a HTI adjunct. Costs were measured in 2018 USD and health outcomes were measured in quality-adjusted life-years (QALY). In the base case, the HTI was a theoretical mesenchymal stem cell therapy which reduced the aneurysm recanalization rate by 50% and cost $10,000 per procedure. All other model inputs were derived from the published scientific literature. RESULTS: Based on the model results, we found that for a given HTI price (y) and relative risk reduction of aneurysm recanalization (x), the HTI was always cost-effective if the following equation was satisfied: y ≤ 20268 ∙ x, using a willingness-to-pay threshold of $50,000 per QALY. The uncertainty surrounding whether an aneurysm would recanalize was a significant driver within the model. When the uncertainty around the risk of aneurysm recanalization was eliminated, the 10-year projected additional benefit to the United States healthcare system was calculated to be $113,336,994. CONCLUSION: Cost-effectiveness does not appear to be a barrier to innovation in reducing the recanalization rate of UIA treated by endovascular coil embolization. Our model can now be utilized by academia and industry to accentuate economically feasible HTI and by healthcare payers to calculate their maximum willingness-to-pay for a new technology. Our results also indicate that predicting a patient's baseline risk of aneurysm recanalization is a critical area of future research.

Reimagining Pharmaceutical Market Exclusivities: Should the Duration of Guaranteed Monopoly Periods Be Value Based?

OBJECTIVES: To describe the main features of a pharmaceutical market in which the duration of guaranteed monopoly periods would correspond to a new pharmaceutical product's value. METHODS: After reviewing patent and regulatory exclusivity-based mechanisms for protecting prescription drug markets from competition to incentivize drug innovation in developed countries, we model market protection mechanisms within the current framework to give the longest-lasting market protections to drug developers that bring the most affordable products to market with highest public health and clinical value. RESULTS: An approach tying pharmaceutical market exclusivity to value would have 3 main features. First, it would be based on regulatory exclusivity (ie, the drug regulator refrains from authorizing generic entry for a certain amount of time), rather than patents. Second, the duration of exclusivity period would be pegged to the magnitude of a product's anticipated health impact and its proposed price by using modified methods from the field of health technology assessment. Third, the duration of the value-based exclusivity period would be reassessed routinely 3 years after the product's launch to account for its real-world effectiveness. CONCLUSIONS: Linking a drug's proposed price to the duration of its regulatory-based exclusivities would both incentivize the development of high impact, low-cost products and motivate drug developers to introduce these products at lower prices.

First-line pharmacotherapy for incident type 2 diabetes: Prescription patterns, adherence and associated costs.

AIMS: To use real-world prescription data from Alberta, Canada to: (a) describe the prescribing patterns for initial pharmacotherapy for those with newly diagnosed uncomplicated type 2 diabetes; (b) describe medication-taking behaviours (adherence and persistence) in the first year after initiating pharmacotherapy; and (c) explore healthcare system costs associated with prescribing patterns. METHODS: We employed a retrospective cohort design using linked administrative datasets from 2012 to 2017 to define a cohort of those with uncomplicated incident diabetes. We summarized the initial prescription patterns, adherence and costs (healthcare and pharmaceutical) over the first year after initiation of pharmacotherapy. Using multivariable regression, we determined the association of these outcomes with various sociodemographic characteristics. RESULTS: The majority of individuals for whom metformin was indicated as first-line therapy received a prescription for metformin monotherapy (89%). Older individuals, those with higher baseline A1C and those with no comorbidities, were most likely to be started on non-metformin agents. Adherence with the initially prescribed regimen was suboptimal overall, with nearly half (48%) being non-adherent over the first year. One-third of those who started metformin discontinued it in the first 3 months. Those started on non-metformin agents had roughly twice the healthcare costs, and five to seven times higher medication costs, compared to those started on metformin, in the first year after starting therapy. CONCLUSIONS: With the addition of new classes of medications, healthcare providers who look after those with type 2 diabetes have more pharmaceutical options than ever. Most individuals continue to be prescribed metformin monotherapy. However, adherence is suboptimal, and drops off considerably within the first 3 months.

The cost-effectiveness of schistosomiasis screening and treatment among recently resettled refugees to Canada: an economic evaluation.

BACKGROUND: Many refugees and asylum seekers from countries where schistosomiasis is endemic are infected with the Schistosoma parasite when they arrive in Canada. We assessed, from a systemic perspective, which of the following management strategies by health care providers is cost-effective: testing for schistosomiasis and treating if the individual is infected, treating presumptively or waiting for symptoms to emerge. METHODS: We constructed a decision-tree model to examine the cost-effectiveness of 3 management strategies: watchful waiting, screening and treatment, and presumptive treatment. We obtained data for the model from the literature and other sources, to predict deaths and chronic complications caused by schistosomiasis, as well as costs and net monetary benefit. RESULTS: Presumptive treatment was cost-saving if the prevalence of schistosomiasis in the target population was greater than 2.1%. In our baseline analysis, presumptive treatment was associated with an increase of 0.156 quality-adjusted life years and a cost saving of $405 per person, compared with watchful waiting. It was also more effective and less costly than screening and treatment. INTERPRETATION: Among recently resettled refugees and asylum claimants in Canada, from countries where schistosomiasis is endemic, presumptive treatment was predicted to be less costly and more effective than watchful waiting or screening and treatment. Our results support a revision of the current Canadian recommendations.

Model to Determine the Cost-Effectiveness of Screening Psoriasis Patients for Psoriatic Arthritis.

OBJECTIVE: Screening psoriasis patients for psoriatic arthritis (PsA) is intended to identify patients at earlier stages of the disease. Early treatment is expected to slow disease progression and delay the need for biologic therapy. Our objective was to determine the cost-effectiveness of screening for PsA in patients with psoriasis in Canada. METHODS: A Markov model was built to estimate the costs and quality-adjusted life years (QALYs) of screening tools for PsA in psoriasis patients. The screening tools included the Toronto Psoriatic Arthritis Screen, Psoriasis Epidemiology Screening Tool, Psoriatic Arthritis Screening and Evaluation, and Early Psoriatic Arthritis Screening Questionnaire (EARP) questionnaires. States of health were defined by disability levels as measured by the Health Assessment Questionnaire. State transitions were modeled based on annual disease progression. Incremental cost-effectiveness ratios and incremental net monetary benefits were estimated. Sensitivity analyses were undertaken to account for parameter uncertainty and to test model assumptions. RESULTS: Screening was cost-effective compared to no screening. The EARP tool had the lowest total cost ($2,000 per patient per year saved compared to no screening) and the highest total QALYs (additional 0.18 per patient compared to no screening). The results were most sensitive to test accuracy and the efficacy of disease-modifying antirheumatic drugs (DMARDs). No screening was cost-effective (at $50,000 per QALY) relative to screening when DMARDs failed to slow disease progression. CONCLUSION: If early therapy with DMARDs delays biologic treatment, implementing screening in patients with psoriasis in Canada is expected to represent a cost savings of $220 million per year and improve the quality of life.

Maximizing maternal health and value for money in postpartum depression screening: a cost-effectiveness analysis using the All Our Families cohort and administrative data in Alberta, Canada.

BACKGROUND: Postpartum depression (PPD) affects 10-15% of women, is costly and debilitating, yet often remains undiagnosed. Within Alberta, Canada, screening is conducted at public health well child clinics using the Edinburgh Postnatal Depression Scale. If screened high-risk, women are offered referral to their family physicians for follow up diagnosis and treatment. METHODS: We developed a decision tree to estimate the cost-effectiveness of PPD screening versus not screening in Alberta over a two-year time horizon using a public healthcare payer perspective. Both the current practice (51% attending referral) and a scenario analysis (100% attending referral) are presented. RESULTS: Current practice results suggest screening leads to an incremental cost-effectiveness ratio (ICER) of $17,644 USD per quality adjusted life year (QALY). At a population-level, this resulted in an annual 813 (11%) additional cases diagnosed, 120 additional QALYs gained, and an additional cost of $2.1 million relative to not screening. With 100% attending referral, the ICER fell to $13,908 per QALY, resulting in an annual 1997 (27%) additional cases diagnosed, 249 additional QALYs gained, and an additional cost of $3.5 million relative to not screening. LIMITATIONS: We were unable to explore the cost-effectiveness of PPD screening versus not screening for secondary populations, including children. CONCLUSIONS: The results suggest screening may be most valuable when participation and compliance are maximized, where all women screened high-risk attend referral. This leads to greater value for money and increased maternal health gains across the population. Collaboration among public health and primary care services is encouraged to improve outcomes.

Economic evaluation of extended electrocardiogram monitoring for atrial fibrillation in patients with cryptogenic stroke.

BACKGROUND: Timely identification of occult atrial fibrillation following cryptogenic stroke facilitates consideration of oral anticoagulation therapy. Extended electrocardiography monitoring beyond 24 to 48 h Holter monitoring improves atrial fibrillation detection rates, yet uncertainty remains due to upfront costs and the projected long-term benefit. We sought to determine the cost-effectiveness of three electrocardiography monitoring strategies in detecting atrial fibrillation after cryptogenic stroke. METHODS: A decision-analytic Markov model was used to project the costs and outcomes of three different electrocardiography monitoring strategies (i.e. 30-day electrocardiography monitoring, three-year implantable loop recorder monitoring, and conventional Holter monitoring) in acute stroke survivors without previously documented atrial fibrillation. RESULTS: The lifetime discounted costs and quality-adjusted life years were $206,385 and 7.77 quality-adjusted life years for conventional monitoring, $207,080 and 7.79 quality-adjusted life years for 30-day extended electrocardiography monitoring, and $210,728 and 7.88 quality-adjusted life years for the implantable loop recorder strategy. Additional quality-adjusted life years could be attained at a more favorable incremental cost per quality-adjusted life year with the implantable loop recorder strategy, compared with the 30-day electrocardiography monitoring strategy, thereby eliminating the 30-day strategy by extended dominance. The implantable loop recorder strategy was associated with an incremental cost per quality-adjusted life year gained of $40,796 compared with conventional monitoring. One-way sensitivity analyses indicated that the model was most sensitive to the rate of recurrent ischemic stroke. CONCLUSIONS: An implantable loop recorder strategy for detection of occult atrial fibrillation in patients with cryptogenic stroke is more economically attractive than 30-day electrocardiography monitoring compared to conventional monitoring and is associated with a cost per quality-adjusted life year gained in the range of other publicly funded therapies. The value proposition is improved when considering patients at the highest risk of recurrent ischemic stroke. However, the implantable loop recorder strategy is associated with increased health care costs, and the opportunity cost of wide scale implementation must be considered.

Cost-Effectiveness of Extended Electrocardiogram Monitoring for Atrial Fibrillation After Stroke: A Systematic Review.

BACKGROUND AND PURPOSE: Management of cryptogenic stroke involves the identification of modifiable risk factors, such as atrial fibrillation (AF). Extended rhythm monitoring increases AF detection rates but at an increased device cost compared with conventional Holter monitoring. The objective of the study was to identify and synthesize the existing literature on the cost-effectiveness of prolonged rhythm monitoring devices for AF detection in cryptogenic stroke. METHODS: We conducted a systematic review of available economic evaluations of prolonged ECG monitoring for AF detection following cryptogenic stroke compared with standard care. RESULTS: Of the 530 unique citations, 8 studies assessed the cost-utility of prolonged ECG monitoring compared with standard care following cryptogenic stroke. The prolonged ECG monitoring strategies included 7-day ambulatory monitoring, 30-day external loop recorders or intermittent ECG monitoring, and implantable loop recorders. The majority of cost-utility analyses reported incremental cost-effectiveness ratios below $50 000 per QALY gained; and two studies reported a cost-savings. CONCLUSIONS: There is limited economic literature on the cost-effectiveness of extended ECG monitoring devices for detection of atrial fibrillation in cryptogenic stroke. In patients with cryptogenic stroke, extended ECG monitoring for AF detection may be economically attractive when traditional willingness-to-pay thresholds are adopted. However, there was substantial variation in the reported ICERs. The direct comparison of cost-effectiveness across technologies is limited by heterogeneity in modeling assumptions.

Economic evaluation of 4 bovine leukemia virus control strategies for Alberta dairy farms.

Bovine leukemia virus (BLV) is a production-limiting disease common in North American dairy herds. To make evidence-based recommendations to Canadian dairy producers and their consultants regarding cost and financial benefits of BLV on-farm control, an economic model that takes the supply-managed milk quota system into account is necessary. Alberta-specific input variables were used for the presented analysis. A decision tree model program was used to evaluate economic aspects of decreasing a 40% BLV within-herd prevalence on dairy farms by implementing various control strategies over 10 yr. Investigated strategies were (1) all management strategies, including 3 options for colostrum management; (2) some management strategies; (3) test and cull; and (4) test and segregate. Each of these strategies was compared with a no control on-farm approach. The prevalence for this no-control approach was assumed to stay constant over time. Each control strategy incurred specific yearly cost and yielded yearly decreases in prevalence, thereby affecting yearly partial net revenue. Infection with BLV was assumed to decrease milk production, decrease cow longevity, and increase condemnation of carcasses at slaughter from cattle with enzootic bovine leukosis, thereby decreasing net revenue. Cows infected with BLV generated a yearly mean partial net revenue of Can$7,641, whereas noninfected cows generated Can$8,276. Mean cost for the control strategies ranged from Can$193 to Can$847 per animal over 10 yr in a 146-animal herd. Net benefits of controlling BLV on farm, as compared with not controlling BLV, per cow in a 146-animal herd over a 10-yr period for each strategy was: Can$1,315 for all management strategies (freezer); Can$1,243 for all management strategies (pasteurizer); Can$785 for all management strategies (powdered colostrum); Can$1,028 for some management strategies; Can$1,592 for test and cull; and Can$1,594 for test and segregate. Consequently, on-farm BLV control was financially beneficial. Even though negative net benefits were possible and expected for some iterations, our sensitivity analysis highlighted the overall robustness of our model. In summary, this model provided evidence that Canadian dairy farmers should be encouraged to control BLV on their farm.