Cost effectiveness of implantable cardioverter defibrillators for 1.5 primary prevention of sudden cardiac arrest in China: an analysis from the Improve SCA study.

OBJECTIVES: Implantable cardioverter defibrillator (ICDs) for primary prevention (PP) of sudden cardiac arrest (SCA) is underutilized in developing countries. The Improve SCA study has identified a subset of 1.5 primary prevention (1.5PP) patients with a higher risk of SCA and a significant mortality benefit from ICD therapy. From the perspective of China's healthcare system, we evaluated the cost-effectiveness of ICD therapy vs. no ICD therapy among 1.5PP patients with a view to informing clinical and policy decisions. METHODS: A published Markov model was adjusted and verified to simulate the course of the disease and describe different health states of 1.5PP patients. The patient characteristics, mortality, utility and complication estimates were obtained from the Improve SCA study and other literature. Cost inputs were sourced from government tender prices, medical service prices and clinical experts' surveys in 9 Chinese public hospitals. For both ICD and no ICD therapy, the total medical costs and quality-adjusted life-years (QALYs) were modelled over a lifetime horizon and the incremental cost-effectiveness ratio (ICER) was calculated. Deterministic and probabilistic sensitivity analyses were performed to assess the uncertainty of the model parameters. We used the willingness-to-pay (WTP) threshold recommended by China Guidelines for Pharmacoeconomic Evaluations, one to three times China's GDP per capita (CNY85,698-CNY257,094) in 2022 Chinese Yuan. RESULTS: The incremental cost effectiveness ratio (ICER) of ICD therapy compared to no ICD therapy is 139,652 CNY/QALY, which is about 1-2 times China's GDP per capita. The probability that ICD therapy is cost effective was 92.1%. Results from sensitivity analysis supported the findings of the base case. CONCLUSIONS: ICD therapy compared to no ICD therapy is cost-effective for the 1.5PP patients in China.

A comprehensive value-based method for new nuclear medical service pricing: with case study of radium [223Ra] bone metastases treatment.

IMPORTANCE: Innovative nuclear medicine services offer substantial clinical value to patients. However, these advancements often come with high costs. Traditional payment strategies do not incentivize medical institutes to provide new services nor determine the fair price for payers. A shift towards a value-based pricing strategy is imperative to address these challenges. Such a strategy would reconcile the cost of innovation with incentives, foster transparent allocation of healthcare resources, and expedite the accessibility of essential medical services. OBJECTIVE: This study aims to develop and present a comprehensive, value-based pricing model for new nuclear medicine services, illustrated explicitly through a case study of the radium [223Ra] treatment for bone metastases. In constructing the pricing model, we have considered three primary value determinants: the cost of the new service, associated service risk, and the difficulty of the service provision. Our research can help healthcare leaders design an evidence-based Fee-For-Service (FFS) payment reference pricing with nuclear medicine services and price adjustments. DESIGN, SETTING AND PARTICIPANTS: This multi-center study was conducted from March 2021 to February 2022 (including consultation meetings) and employed both qualitative and quantitative methodologies. We organized focus group consultations with physicians from nuclear medicine departments in Beijing, Chongqing, Guangzhou, and Shanghai to standardize the treatment process for radium [223Ra] bone metastases. We used a specially designed 'Radium Nuclide [223Ra] Bone Metastasis Data Collection Form' to gather nationwide resource consumption data to extract information from local databases. Four interviews with groups of experts were conducted to determine the add-up ratio, based on service risk and difficulty. The study organized consultation meeting with key stakeholders, including policymakers, service providers, clinical researchers, and health economists, to finalize the pricing equation and the pricing result of radium [223Ra] bone metastases service. MAIN OUTCOMES AND MEASURES: We developed and detailed a pricing equation tailored for innovative services in the nuclear medicine department, illustrating its application through a step-by-step guide. A standardized service process was established to ensure consistency and accuracy. Adhering to best practice guidelines for health cost data analysis, we emphasized the importance of cross-validation of data, where validated data demonstrated less variation. However, it required a more advanced health information system to manage and analyze the data inputs effectively. RESULTS: The standardized service of radium [223Ra] bone metastases includes: pre-injection assessment, treatment plan, administration, post-administration monitoring, waste disposal and monitoring. The average duration for each stage is 104 min, 39 min, 25 min, 72 min and 56 min. A standardized monetary value for medical consumables is 54.94 yuan ($7.6), and the standardised monetary value (medical consumables cost plus human input) is 763.68 yuan ($109.9). Applying an agreed value add-up ratio of 1.065, the standardized value is 810.19 yuan ($116.9). Feedback from a consultation meeting with policymakers and health economics researchers indicates a consensus that the pricing equation developed was reasonable and well-grounded. CONCLUSION: This research is the first study in the field of nuclear medicine department pricing methodology. We introduce a comprehensive value-based nuclear medical service pricing method and use radium[223Ra] bone metastases treatment pricing in China as a case study. This study establishes a novel pricing framework and provides practical instructions on its implementation in a real-world healthcare setting.

Alzheimer's disease with frailty: Prevalence, screening, assessment, intervention strategies and challenges.

Alzheimer's disease (AD) is a neurodegenerative disorder that affects millions worldwide and is expected to surge in prevalence due to aging populations. Frailty, characterized by muscle function decline, becomes more prevalent with age, imposing substantial burdens on patients and caregivers. This paper aimed to comprehensively review the current literature on AD coupled with frailty, encompassing prevalence, screening, assessment, and treatment while delving into the field's challenges and future trajectories. Frailty and AD coexist in more than 30% of cases, with hazard ratios above 120% indicating a mutually detrimental association.Various screening tools have emerged for both frailty and AD, including the Fried Frailty Phenotype (FP), FRAIL scale, Edmonton Frailty Scale (EFS), Mini-Mental State Examination (MMSE), Montreal Cognitive Assessment (MoCA), Clock Drawing Test (CDT), and General Practitioner Assessment of Cognition (GPCOG). However, none has solidified its role as the definitive gold standard. The convergence of electronic health records and brain aging biomarkers heralds a new era in AD with frailty screening and assessment. In terms of intervention, non-pharmacological strategies spanning nutrition, horticulture, exercise, and social interaction, along with pharmacological approaches involving acetylcholinesterase inhibitors (AChEIs), N-methyl-D-aspartate (NMDA) receptor antagonists, and anti-amyloid beta-protein medications, constituted cornerstones for treating AD coupled with frailty. Technological interventions like repetitive transcranial magnetic stimulation (rTMS) also entered the fold. Notably, multi-domain non-pharmacological interventions wield considerable potential in enhancing cognition and mitigating disability. However, the long-term efficacy and safety of pharmacological interventions necessitate further validation. Diagnosing and managing AD with frailty present several daunting challenges, encompassing low rates of early co-diagnosis, limited clinical trial evidence, and scarce integrated, pioneering service delivery models. These challenges demand heightened attention through robust research and pragmatic implementation.

Cost-effectiveness of stereotactic body radiotherapy versus conventional fractionated radiotherapy for medically inoperable, early-stage non-small cell lung cancer.

BACKGROUND: Stereotactic body radiotherapy (SBRT) is a novel radio-therapeutic technique that has recently emerged as standard-of-care treatment for medically inoperable, early-stage non-small cell lung cancer (NSCLC). In this study, we compared the cost-effectiveness of SBRT with that of conventional fractionated radiotherapy (CFRT) in patients with medically inoperable, early-stage NSCLC from the perspective of the Chinese health system. METHODS: A Markov model was developed to describe health states of patients after treatment with SBRT and CFRT. The recurrence risks, treatment toxicities, and utilities inputs were obtained from the literature. The costs were based on listed prices and real-world evidence. A simulation was conducted to determine the post-treatment lifetime years. For each treatment, the total costs, quality-adjusted life-years (QALYs), and incremental cost-effectiveness ratios (ICERs) per QALY were calculated. Deterministic and probabilistic sensitivity analyses were performed to assess the uncertainty of the model parameters. RESULTS: In the base case analysis, SBRT was associated with a mean cost of USD16,933 and 2.05 QALYs, whereas CFRT was associated with a mean cost of USD17,726 and 1.61 QALYs. SBRT is a more cost-effective strategy compared with CFRT for medically inoperable, early-stage NSCLC, with USD 1802 is saved for every incremental QALY. This result was validated by DSA and PSA, in which SBRT remained the most cost-effective option. CONCLUSIONS: The findings suggested that, compared to CFRT, SBRT may be considered a more cost-effective strategy for medically inoperable, early-stage NSCLC.

Cost-effectiveness of stereotactic body radiotherapy in the treatment of non-small-cell lung cancer (NSCLC): a systematic review.

OBJECTIVES: This study aims to systematically review the studies on the cost-effectiveness of stereotactic body radiotherapy (SBRT) in the treatment of non-small-cell lung cancer (NSCLC). METHODS: A systematic literature search was performed in databases from 2000 through April 2021. The search terms included 'economics,' 'cost,' 'cost effectiveness,' 'SBRT,' and all names for NSCLC. Two reviewers independently screened the titles, abstracts and full texts to determine the studies for the final sample. The quality of the included studies was assessed using the Quality of Health Economic Studies checklist. RESULTS: Eleven studies were identified and included in our final review. SBRT was reported to be a cost-effective (5 of 5) option compared to conventional radiotherapy, radiofrequency ablation, and best supportive care for medically inoperable, early-stage NSCLC. However, the identified studies revealed that no single treatment was found to be more cost-effective than others between SBRT and surgical interventions. The key drivers of this cost-effectiveness were the cost of the treatment, utility value, and the rate of surgical mortality. CONCLUSIONS: SBRT may be considered a more cost-effective strategy for medically inoperable, early-stage NSCLC. Considering the limited studies available, more related research should be conducted to further validate these results.

Cost-effectiveness analysis of hemodialysis plus hemoperfusion versus hemodialysis alone in adult patients with end-stage renal disease in China.

BACKGROUND: This study evaluates the cost-effectiveness of hemodialysis (HD) plus hemoperfusion (HP) with HD alone in adult patients with end-stage renal disease (ESRD) in China. METHODS: A Markov model was constructed to assess the cost-effectiveness of interventions over a lifetime horizon. Model parameters were informed by the HD/HP trial, the first randomized, open-label multicenter trial comparing survival outcomes and incidence of cardiovascular disease (CVD) for HD + HP versus HD alone, and supplemented by published literature and expert opinion. The primary outcome was the incremental cost-effectiveness ratio (ICER) with respect to quality adjusted life-years (QALY). The robustness of the results was examined in extensive sensitivity analyses. Analyses were conducted from a healthcare perspective. Costs were reported in both Chinese Renminbi (RMB) and US Dollars (USD) in 2019 values. RESULTS: The base case ICER of HD + HP is RMB 174,486 (USD 25,251) per QALY, which is lower than the RMB 212,676 (USD 30,778) willingness-to-pay threshold of three times Gross Domestic Product. This conclusion is sensitive to the mortality for patients with no severe CVD events, the incidence of CVD events, and the cost of HP and HD. At a willingness-to-pay threshold of RMB 212,676 (USD 30,778) per QALY gained, the probability that HD + HP is cost-effective is 58%. CONCLUSIONS: Our results indicate a potential for HD + HP to be cost-effective for patients with ESRD. Further evidence on the longer-term impact of HD + HP on CVD event rates and mortality unrelated to CVD is needed to robustly demonstrate the cost-effectiveness of HD + HP. TRIAL REGISTRATION: The HD/HP trial was registered with the Chinese Clinical Trial Registry (ChiCTR-IOR-16009332).

Disease Burden Attributable to the First Wave of COVID-19 in China and the Effect of Timing on the Cost-Effectiveness of Movement Restriction Policies.

OBJECTIVES: Movement restriction policies (MRPs) are effective in preventing/delaying COVID-19 transmission but are associated with high societal cost. This study aims to estimate the health burden of the first wave of COVID-19 in China and the cost-effectiveness of early versus late implementation of MRPs to inform preparation for future waves. METHODS: The SEIR (susceptible, exposed, infectious, and recovered) modeling framework was adapted to simulate the health and cost outcomes of initiating MRPs at different times: rapid implementation (January 23, the real-world scenario), delayed by 1 week, delayed by 2 weeks, and delayed by 4 weeks. The end point was set as the day when newly confirmed cases reached zero. Two costing perspectives were adopted: healthcare and societal. Input data were obtained from official statistics and published literature. The primary outcomes were disability-adjusted life-years, cost, and net monetary benefit. Costs were reported in both Chinese renminbi (RMB) and US dollars (USD) at 2019 values. RESULTS: The first wave of COVID-19 in China resulted in 38 348 disability adjusted life-years lost (95% CI 19 417-64 130) and 2639 billion RMB losses (95% CI 1347-4688). The rapid implementation strategy dominated all other delayed strategies. This conclusion was robust to all scenarios tested. At a willingness-to-pay threshold of 70 892 RMB (the national annual GDP per capita) per disability-adjusted life-year saved, the probability for the rapid implementation to be the optimal strategy was 96%. CONCLUSIONS: Early implementation of MRPs in response to COVID-19 reduced both the health burden and societal cost and thus should be used for future waves of COVID-19.

Economic burden of COVID-19, China, January-March, 2020: a cost-of-illness study.

OBJECTIVE: To estimate the economic cost of coronavirus disease 19 (COVID-19) in 31 provincial-level administrative regions and in total, in China. METHODS: We used data from government reports, clinical guidelines and other publications to estimate the main cost components of COVID-19 during 1 January-31 March 2020. These components were: identification and diagnosis of close contacts; suspected cases and confirmed cases of COVID-19; treatment of COVID-19 cases; compulsory quarantine of close contacts and suspected cases; and productivity losses for all affected residents. Primary outcomes were total health-care and societal costs. FINDINGS: The total estimated health-care and societal costs associated with COVID-19 were 4.26 billion Chinese yuan (¥; 0.62 billion United States dollars, US$) and ¥ 2646.70 billion (US$ 383.02 billion), respectively. Inpatient care accounted for 44.2% (¥ 0.95 billion/¥ 2.15 billion) of routine health-care costs followed by medicines, accounting for 32.5% (¥ 0.70 billion/¥ 2.15 billion). Productivity losses accounted for 99.8% (¥ 2641.61 billion/¥ 2646.70 billion) of societal costs, which were mostly attributable to the effect of movement-restriction policies on people who did not have COVID-19. Societal costs were most sensitive to salary costs and number of working days lost due to movement-restriction policies. Hubei province had the highest health-care cost while Guangdong province had the highest societal cost. CONCLUSION: Our results highlight the high economic burden of the COVID-19 outbreak in China. The control measures to prevent the spread of disease resulted in substantial costs from productivity losses amounting to 2.7% (US$ 382.29 billion/US$ 14.14 trillion) of China's annual gross domestic product.

Informing a Cost-Effectiveness Threshold for Health Technology Assessment in China: A Marginal Productivity Approach.

BACKGROUND: Health technology assessment has been increasingly used in China, having been legally mandated in 2019, to inform reimbursement decisions and price negotiations between the National Healthcare Security Administration and pharmaceutical companies around the price of new pharmaceuticals. The criteria currently used to judge cost effectiveness and inform pricing negotiations, 3 × GDP per capita, is based on the rule of thumb previously recommended by the World Health Organization rather than an estimate based on an empirical assessment of health opportunity costs. OBJECTIVE: The objective of this study was to inform a cost-effectiveness threshold for health technology assessment in China that accounts for health opportunity cost. METHODS: The elasticity of health outcomes with respect to health expenditure was estimated using variations across 30 provincial-level administrative divisions in 2017 controlling for a range of other factors and using an instrumental variable approach to account for endogeneity to assess robustness of results. The estimated elasticity was then used to calculate the cost per disability-adjusted life-year (DALY) averted by variations in Chinese health expenditure at the margin. RESULTS: The range estimated from this study, 27,923-52,247 (2017 RMB) (central estimate 37,446) per DALY averted or 47-88% of GDP per capita (central estimate 63%), shows that a cost per DALY averted cost-effectiveness threshold that reflects health opportunity costs is below 1 × GDP per capita. CONCLUSION: Our results suggest that the current cost-effectiveness threshold used in China is too high; continuing to use it risks decisions that reduce overall population health.

Effects of different mark-up drug policies on drug-related expenditures in tertiary public hospitals: an interrupted time series study in Shanghai, China, 2015-2018.

Irrational use of drugs remains a major challenge especially in developing countries, which contributed to a heavy pharmaceutical expenditure burden. Price regulation has been taken to curb the growth of pharmaceutical expenditures in many countries. This study aimed to investigate the impact of different mark-up drug policies on drug-related expenditures in tertiary public hospitals in Shanghai, China. Data were drawn from the audited financial statement in 24 tertiary public hospitals in Shanghai from January 2015 to December 2018. Drug-related revenue data and per capita cost data pre- and post-intervention were included. Interrupted time series design was applied to assess the actual effects of Fixed Percent Mark-up Drug (FPM) policy and Zero Mark-up Drug (ZMD) policy respectively. Results showed that ZMD policy achieved better intervention effects on declining drug-related expenditures than FPM policy. Apart from a declining trend in drug proportion (coefficient = -0.0017, p = 0.031), no other significant changes were found during FPM implementation. However, ZMD policy was associated with a level decline in per capita outpatient drug cost (coefficient = -12.21, p = 0.025) and a trend decline in per capita inpatient drug cost (coefficient = -25.12, p < 0.001), as well as a level decrease (coefficient = -0.0256, p = 0.001) and a downward tendency (coefficient = -0.0018, p < 0.001) in drug proportion. ZMD policy was effective in regulating drug-related expenditures, while FPM policy was difficult to achieve expected results due to the existence of profit space. Further regulation should be strengthened in the future, especially on drug revenue and per capita drug cost.

Health economic evaluation of stereotactic body radiotherapy (SBRT) for hepatocellular carcinoma: a systematic review.

Stereotactic body radiotherapy (SBRT) is a novel noninvasive treatment for hepatocellular carcinoma. SBRT can achieve effective local control, but it requires a relatively high input of resources; this systematic review was performed to assess the cost effectiveness of SBRT in the treatment of hepatocellular carcinoma to provide a basis for government pricing and medical insurance decision-making. The PubMed, EMBASE, Cochrane Library, CNKI, Wanfang and SinoMed databases were searched to collect economic evaluations of SBRT for the treatment of hepatocellular carcinoma from the date of database inception through December 31, 2018. Two reviewers independently screened the studies, extracted the data and performed a descriptive analysis of the basic characteristics, methods of economic evaluation and main results, as well as the quality and heterogeneity of the reports. A total of 5 studies were included. Among them, the level of heterogeneity was relatively acceptable, with a median score of 90%. Four studies were cost-utility analyses (CUAs), and 1 was a cost-effectiveness analysis (CEA). The incremental cost effectiveness ratio (ICER) for sorafenib compared to SBRT was US $114,795 per quality-adjusted life year gained (cost/QALY) in patients with advanced hepatocellular carcinoma. The ICER for proton beam therapy compared to SBRT was US $6465 in patients with inoperable advanced hepatocellular carcinoma. The ICER for SBRT compared to RFA was US $164,660 for patients with unresectable colorectal cancer (CRC) with liver metastases and US $56,301 for patients with early-stage hepatocellular carcinoma. For patients with inoperable localized hepatocellular carcinoma, compared with RFA-SBRT therapy, the ICERs for SBRT-SBRT and SBRT-RFA were US $558,679 and US $2197,000, respectively; RFA-RFA was dominated. In conclusion, there is limited evidence suggesting that SBRT could be cost-effective for highly specific subpopulations of HCC patients, and further economic evaluations based on randomized controlled trials (RCTs) or cohort studies are needed.

Precise exposure assessment revealed the cancer risk and disease burden caused by trihalomethanes and haloacetic acids in Shanghai indoor swimming pool water.

Swimming pool disinfection byproducts (DBPs) are becoming increasingly common worldwide. Precise exposure and health risk assessment for DBPs in swimming pool water with optimized parameters for local and specific population is more urgently needed. This study aimed to determine the levels of trihalomethanes (THMs) and haloacetic acids (HAAs) in 16 public indoor swimming pools in Shanghai, China. Swimming habits were also investigated to obtain more accurate exposure assessment parameters. Precise exposure assessment through multiple pathways, resulting cancer risk, and disability-adjusted life years (DALYs) were assessed. Results indicated that the highest total level of THMs and HAAs occurred in autumn. The surveyed swimmers 9-17 years of age had higher average daily dose (ADD) of DBPs than swimmers ≥18 years of age. The total lifetime cancer risk (LCR) attributable to THMs and HAAs exceeded 10-6, which represents a negligible risk level (NRL). The cancer risk from inhalation exposure predominantly by THMs contributed more than 99% of the total risk. Annual disease burden was 19.0 person-years attributed to exposure of DBPs in swimming pool water in Shanghai. This study provides a paradigm and strategic reference of precise exposure assessments, risk assessments, and disease burden estimation of hazards in swimming pool water for other regions.

Driving factors and mode transformation regarding health technology assessment (HTA) in China: Problems and recommendations.

As the reform of Chinese medical and health undertakings has advanced (since 2015), the admission, pricing and payment policies regarding the new health technologies of China have undergone significant changes, and health technology assessment (HTA) has gradually become one of the current reform and research hotspots in China. Based on the perspective of HTA driving factors and the development mode, this paper proposes a two-stage mode of HTA development in China, namely, the mode driven by the management of new heath technology admission and another one driven by new health technology pricing and medical insurance payment. In addition, the paper also proposes the challenges that HTA faces in China under the current mode, including the development system, process standard, data mechanism, and policy application. Besides, recommendations are provided for the further development of HTA construction in China, including strengthening the development system of regional HTA centers, formulating HTA process guidance, building a database, improving evaluation quality and intensifying policy integration.

Price adjustment for traditional Chinese medicine procedures: Based on a standardized value parity model.

Traditional Chinese medicine (TCM) is an important part of China's medical system. Due to the prolonged low price of TCM procedures and the lack of an effective mechanism for dynamic price adjustment, the development of TCM has markedly lagged behind Western medicine. The World Health Organization (WHO) has emphasized the need to enhance the development of alternative and traditional medicine when creating national health care systems. The establishment of scientific and appropriate mechanisms to adjust the price of medical procedures in TCM is crucial to promoting the development of TCM. This study has examined incorporating value indicators and data on basic manpower expended, time spent, technical difficulty, and the degree of risk in the latest standards for the price of medical procedures in China, and this study also offers a price adjustment model with the relative price ratio as a key index. This study examined 144 TCM procedures and found that prices of TCM procedures were mainly based on the value of medical care provided; on average, medical care provided accounted for 89% of the price. Current price levels were generally low and the current price accounted for 56% of the standardized value of a procedure, on average. Current price levels accounted for a markedly lower standardized value of acupuncture, moxibustion, special treatment with TCM, and comprehensive TCM procedures. This study selected a total of 79 procedures and adjusted them by priority. The relationship between the price of TCM procedures and the suggested price was significantly optimized (p < 0.01). This study suggests that adjustment of the price of medical procedures based on a standardized value parity model is a scientific and suitable method of price adjustment that can serve as a reference for other provinces and municipalities in China and other countries and regions that mainly have fee-for-service (FFS) medical care.