RESUMO
This study aims to estimate the theoretical excess expenditure that would be incurred by the Irish state-payer, should drugs be reimbursed at their original asking ("list") price rather than at a price at which the drug is considered cost-effective. In Ireland, all new drugs are evaluated by the National Centre for Pharmacoeconomics. For this study, drugs that were submitted by pharmaceutical companies from 2012 to 2017 and considered not cost-effective at list price were reviewed. A total of 43 such drugs met our inclusion criteria, and their pharmacoeconomic evaluations were further assessed. The price at which the drug could be considered cost-effective (cost-effective price) at the upper cost-effectiveness threshold used in Ireland ( 45 000/quality adjusted life-year) was estimated for 18 drugs with an available cost-effectiveness model. Then, for each drug, the list price and cost-effective price (both per unit) were both individually applied to 1 year of national real-world drug utilization data. This allowed the estimation of the expected expenditures under the assumptions of list price paid and cost-effective price paid. The resulting theoretical excess expenditure, the expenditure at list price minus the expenditure at the cost-effective price, was estimated to be 108.2 million. This estimate is theoretical because of the confidentiality of actual drug prices. The estimation is calculated using the list price and likely overestimates the actual excess expenditure, which would reduce to zero if cost-effective prices are agreed. Nevertheless, this estimate illustrates the importance of a process to assess the value of new drugs so that potential excess drug expenditure is identified.
Assuntos
Análise Custo-Benefício/métodos , Custos de Cuidados de Saúde/estatística & dados numéricos , Resultado do Tratamento , Análise Custo-Benefício/estatística & dados numéricos , Uso de Medicamentos/normas , Uso de Medicamentos/estatística & dados numéricos , Custos de Cuidados de Saúde/normas , Humanos , Irlanda , Programas Nacionais de Saúde/economia , Programas Nacionais de Saúde/normas , Programas Nacionais de Saúde/estatística & dados numéricosRESUMO
Aim: To estimate current real-world costs of drugs and supportive care for the treatment of multiple myeloma in a tax-based health system. Methods: Forty-one patients were included from a personalized medicine study (2016-2019). Detailed information was collected from patient journals and hospital registries to estimate the total and mean costs using inverse probability weighting of censored data. Results: Total observed (censored) costs for the 41 patients was 8.84 million during 125 treatment years, with antineoplastic drugs as the main cost driver (5.6 million). Individual costs showed large variations. Mean 3-year cost per patient from first progression was 182,103 (131,800-232,405). Conclusion: Prediction of real-world costs is hindered by the availability of detailed costing data. Micro-costing analyses are needed for budgeting and real-world evaluation of cost-effectiveness.
Lay abstract In recent years, there has been a dramatic improvement in the treatment of multiple myeloma due to the introduction of new drugs. These drugs have significantly increased survival but have also had an immense impact on healthcare budgets. In this study, we used detailed treatment information for multiple myeloma patients in combination with billing data from the hospital pharmacy at a Danish hospital to calculate individual cost histories for both drugs and supportive care. Using these data, we estimated the mean 3-year cost of a multiple myeloma patient to be 182.103, but we also found large variation between patients, causing an uncertainty of 50.000 in either direction. We believe that detailed costing studies, similar to the present one, are necessary for evaluation of cost-effectiveness of drugs in clinical practice.
Assuntos
Protocolos de Quimioterapia Combinada Antineoplásica/economia , Efeitos Psicossociais da Doença , Custos de Cuidados de Saúde/estatística & dados numéricos , Mieloma Múltiplo/economia , Cuidados Paliativos/economia , Idoso , Idoso de 80 Anos ou mais , Protocolos de Quimioterapia Combinada Antineoplásica/uso terapêutico , Análise Custo-Benefício/estatística & dados numéricos , Dinamarca/epidemiologia , Progressão da Doença , Feminino , Seguimentos , Humanos , Masculino , Oncologia/economia , Oncologia/normas , Oncologia/estatística & dados numéricos , Pessoa de Meia-Idade , Mieloma Múltiplo/mortalidade , Mieloma Múltiplo/terapia , Programas Nacionais de Saúde/economia , Programas Nacionais de Saúde/normas , Programas Nacionais de Saúde/estatística & dados numéricos , Cuidados Paliativos/estatística & dados numéricos , Guias de Prática Clínica como Assunto , Intervalo Livre de Progressão , Sistema de Registros/estatística & dados numéricos , Fatores de TempoRESUMO
OBJECTIVE: Patients requiring abdominal aortic aneurysm (AAA) repair are at risk of post-operative complications due to poor pre-operative state. Pre-habilitation describes the enhancement of functional capacity and tolerance to an upcoming physiological stressor, intended to reduce those complications. The ability to provide such an intervention (physical, pharmacological, nutritional, or psychosocial) between diagnosis and surgery is a growing interest, but its role in AAA repair is unclear. This paper aimed to systematically review existing literature to better describe the effect of pre-habilitative interventions on post-operative outcomes of patients undergoing AAA repair. DATA SOURCES: EMBASE and Medline were searched from inception to October 2020. Retrieved papers, systematic reviews, and trial registries were citation tracked. REVIEW METHODS: Randomised controlled trials (RCTs) comparing post-operative outcomes for adult patients undergoing a period of pre-habilitation prior to AAA repair (open or endovascular) were eligible for inclusion. Two authors screened titles for inclusion, assessed risk of bias, and extracted data. Primary outcomes were post-operative 30 day mortality, composite endpoint of 30 day post-operative complications, hospital length of stay (LOS), and health related quality of life (HRQL) outcomes. The content of interventions was extracted and a narrative analysis of results undertaken. RESULTS: Seven RCTs with 901 patients were included (three exercise based, two pharmacological based, and two nutritional based). Risk of bias was mostly unclear or high and the clinical heterogeneity between the trials precluded data pooling for meta-analyses. The quality of intervention descriptions was highly variable. One exercise based RCT reported significantly reduced hospital LOS and another improved HRQL outcomes. Neither pharmacological nor nutritional based RCTs reported significant differences in primary outcomes. CONCLUSION: There is limited evidence to draw clinically robust conclusions about the effect of pre-habilitation on post-operative outcomes following AAA repair. Well designed RCTs, adhering to reporting standards for intervention content and trial methods, are urgently needed to establish the clinical and cost effectiveness of pre-habilitation interventions.
Assuntos
Aneurisma da Aorta Abdominal/cirurgia , Procedimentos Endovasculares/efeitos adversos , Complicações Pós-Operatórias/prevenção & controle , Cuidados Pré-Operatórios/métodos , Aneurisma da Aorta Abdominal/economia , Aneurisma da Aorta Abdominal/mortalidade , Análise Custo-Benefício/estatística & dados numéricos , Suplementos Nutricionais/economia , Suplementos Nutricionais/estatística & dados numéricos , Mortalidade Hospitalar , Hormônio do Crescimento Humano/administração & dosagem , Hormônio do Crescimento Humano/economia , Humanos , Tempo de Internação/estatística & dados numéricos , Complicações Pós-Operatórias/economia , Complicações Pós-Operatórias/epidemiologia , Complicações Pós-Operatórias/etiologia , Cuidados Pré-Operatórios/economia , Cuidados Pré-Operatórios/estatística & dados numéricos , Exercício Pré-Operatório , Qualidade de Vida , Ensaios Clínicos Controlados Aleatórios como Assunto , Resultado do TratamentoRESUMO
OBJECTIVE: Endoscopic full-thickness resection (EFTR) has shown efficacy and safety in the colorectum. The aim of this analysis was to investigate whether EFTR is cost-effective in comparison with surgical and endoscopic treatment alternatives. DESIGN: Real data from the study cohort of the prospective, single-arm WALL RESECT study were used. A simulated comparison arm was created based on a survey that included suggested treatment alternatives to EFTR of the respective lesions. Treatment costs and reimbursement were calculated in euro according to the coding rules of 2017 and 2019 (EFTR). R0 resection rate was used as a measure of effectiveness. To assess cost-effectiveness, the average cost-effectiveness ratio (ACER) and the incremental cost-effectiveness ratio (ICER) were determined. Calculations were made both from the perspective of the care provider as well as of the payer. RESULTS: The cost per case was 2852.20 for the EFTR group, 1712 for the standard endoscopic resection (SER) group, 8895 for the surgical resection group and 5828 for the pooled alternative treatment to EFTR. From the perspective of the care provider, the ACER (mean cost per R0 resection) was 3708.98 for EFTR, 3115.10 for SER, 8924.05 for surgical treatment and 7169.30 for all pooled and weighted alternatives to EFTR. The ICER (additional cost per R0 resection compared with EFTR) was 5196.47 for SER, 26 533.13 for surgical resection and 67 768.62 for the pooled rate of alternatives. Results from the perspective of the payer were similar. CONCLUSION: EFTR is cost-effective in comparison with surgical and endoscopic treatment alternatives in the colorectum.
Assuntos
Neoplasias Colorretais/cirurgia , Análise Custo-Benefício/estatística & dados numéricos , Endoscopia Gastrointestinal/economia , Trato Gastrointestinal Inferior/cirurgia , Neoplasias Colorretais/patologia , Análise Custo-Benefício/tendências , Endoscopia Gastrointestinal/métodos , Endoscopia Gastrointestinal/estatística & dados numéricos , Humanos , Trato Gastrointestinal Inferior/patologia , Estudos Prospectivos , Anos de Vida Ajustados por Qualidade de Vida , Segurança , Inquéritos e Questionários/estatística & dados numéricos , Resultado do TratamentoRESUMO
Aim: To investigate the cost-effectiveness of lenvatinib and sorafenib in the treatment of patients with nonresected hepatocellular carcinoma in China. Materials & methods: Markov model was used to simulate the direct medical cost and quality-adjusted life years (QALY) of patients with hepatocellular carcinoma. Clinical data were derived from the Phase 3 randomized clinical trial in a Chinese population. Results: Sorafenib treatment resulted in 1.794 QALYs at a cost of $43,780.73. Lenvatinib treatment resulted in 2.916 QALYs for patients weighing <60 and ≥60 kg at a cost of $57,049.43 and $75,900.36, The incremental cost-effectiveness ratio to the sorafenib treatment group was $11,825.94/QALY and $28,627.12/QALY, respectively. Conclusion: According to WHO's triple GDP per capita, the use of lenvatinib by providing drugs is a cost-effective strategy.
Assuntos
Carcinoma Hepatocelular/tratamento farmacológico , Análise Custo-Benefício/métodos , Custos de Cuidados de Saúde/estatística & dados numéricos , Neoplasias Hepáticas/tratamento farmacológico , Compostos de Fenilureia/uso terapêutico , Quinolinas/uso terapêutico , Sorafenibe/uso terapêutico , Antineoplásicos/economia , Antineoplásicos/uso terapêutico , Carcinoma Hepatocelular/economia , China , Análise Custo-Benefício/economia , Análise Custo-Benefício/estatística & dados numéricos , Feminino , Humanos , Neoplasias Hepáticas/economia , Masculino , Compostos de Fenilureia/economia , Anos de Vida Ajustados por Qualidade de Vida , Quinolinas/economia , Sensibilidade e Especificidade , Sorafenibe/economia , Resultado do TratamentoRESUMO
BACKGROUND: Hepatic encephalopathy (HE) is a complication of cirrhosis of the liver causing neuropsychiatric abnormalities. Clinical manifestations of overt HE result in increased health care resource utilization and effects on patient quality of life. While lactulose has historically been the mainstay of treatment for acute HE and maintenance of remission, there is an unmet need for additional therapeutic options with a favorable adverse event profile. Compared with lactulose alone, rifaximin has demonstrated proven efficacy in complete reversal of HE and reduction in the incidence of HE recurrence, mortality, and hospitalizations. Evidence suggests the benefit of long-term prophylactic therapy with rifaximin; however, there is a need to assess the economic impact of rifaximin treatment in patients with HE. OBJECTIVE: To assess the incremental cost-effectiveness of rifaximin ± lactulose versus lactulose monotherapy in patients with overt HE. METHODS: A Markov model was developed in Excel with 4 health states (remission, overt HE, liver transplantation, and death) to predict costs and outcomes of patients with HE after initiation of maintenance therapy with rifaximin ± lactulose to avoid recurrent HE episodes. Cost-effectiveness of rifaximin was evaluated through estimation of incremental cost per quality-adjusted life-year (QALY) or life-year (LY) gained. Analyses were conducted over a lifetime horizon. One-way deterministic and probabilistic sensitivity analyses were conducted to assess uncertainty in results. RESULTS: The rifaximin ± lactulose regimen provided added health benefits despite an additional cost versus lactulose monotherapy. Model results showed an incremental benefit of $29,161 per QALY gained and $27,762 per LY gained with rifaximin ± lactulose versus lactulose monotherapy. Probabilistic sensitivity analyses demonstrated that the rifaximin ± lactulose regimen was cost-effective ~99% of the time at a threshold of $50,000 per QALY/LY gained, which falls within the commonly accepted threshold for incremental cost-effectiveness. CONCLUSIONS: The clinical benefit of rifaximin, combined with an acceptable economic profile, demonstrates the advantages of rifaximin maintenance therapy as an important option to consider for patients at risk of recurrent HE. DISCLOSURES: This analysis was funded by Salix Pharmaceuticals, a division of Bausch Health US. Salix and Xcenda collaborated on the methods, and Salix, Xcenda, Jesudian, and Ahmad collaborated on the writing of the manuscript and interpretation of results. Bozkaya and Migliaccio-Walle are employees of Xcenda. Ahmad reports speaker fees from Salix Pharmaceuticals, unrelated to this study. Jesudian reports consulting and speaker fees from Salix Pharmaceuticals, unrelated to this study. The results from this model were presented at AASLD: The Liver Meeting 2014; November 7-11; Boston, MA.
Assuntos
Análise Custo-Benefício/estatística & dados numéricos , Encefalopatia Hepática/terapia , Cirrose Hepática/terapia , Rifaximina/uso terapêutico , Prevenção Secundária/métodos , Custos de Medicamentos/estatística & dados numéricos , Quimioterapia Combinada/economia , Quimioterapia Combinada/métodos , Encefalopatia Hepática/economia , Encefalopatia Hepática/etiologia , Encefalopatia Hepática/mortalidade , Hospitalização/economia , Hospitalização/estatística & dados numéricos , Humanos , Incidência , Lactulose/economia , Lactulose/uso terapêutico , Cirrose Hepática/complicações , Cirrose Hepática/economia , Cirrose Hepática/mortalidade , Transplante de Fígado/economia , Transplante de Fígado/estatística & dados numéricos , Quimioterapia de Manutenção/economia , Quimioterapia de Manutenção/métodos , Cadeias de Markov , Modelos Econômicos , Qualidade de Vida , Anos de Vida Ajustados por Qualidade de Vida , Recidiva , Rifaximina/economia , Prevenção Secundária/economiaRESUMO
BACKGROUND: Globally, rural populations have poorer health and considerably lower levels of access to healthcare compared with urban populations. Although the drive to ensure universal coverage through community healthcare worker programmes has shown significant results elsewhere, their value has yet to be realised in South Africa. AIM: The aim of this study was to determine the potential impact, cost-effectiveness and benefit-to-cost ratio (BCR) of information and communications technology (ICT)-enabled community-oriented primary care (COPC) for rural and remote populations. SETTING: The Waterberg district of Limpopo province in South Africa is a rural mining area. The majority of 745 000 population are poor and in poor health. METHODS: The modelling considers condition-specific effectiveness, population age and characteristics, health-determined service demand, and costs of delivery and resources. RESULTS: Modelling showed 122 teams can deliver a full ICT-enabled COPC service package to 630 565 eligible people. Annually, at scale, it could yield 35 877 unadjusted life years saved and 994 deaths avoided at an average per capita service cost of R170.37, and R2668 per life year saved. There could be net annual savings of R120 million (R63.4m for Waterberg district) from reduced clinic (110.7m) and hospital outpatient (23 646) attendance and admissions. The service would inject R51.6m into community health worker (CHW) households and approximately R492m into district poverty reduction and economic growth. CONCLUSION: With a BCR of 3.4, ICT-enabled COPC is an affordable systemic investment in universal, pro-poor, integrated healthcare and makes community-based healthcare delivery particularly compelling in rural and remote areas.
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Serviços de Saúde Comunitária/economia , Análise Custo-Benefício/economia , Atenção Primária à Saúde/economia , Serviços de Saúde Rural/economia , Adolescente , Adulto , Criança , Pré-Escolar , Serviços de Saúde Comunitária/métodos , Serviços de Saúde Comunitária/estatística & dados numéricos , Análise Custo-Benefício/métodos , Análise Custo-Benefício/estatística & dados numéricos , Feminino , Humanos , Lactente , Masculino , Pessoa de Meia-Idade , Modelos Econômicos , Atenção Primária à Saúde/métodos , Atenção Primária à Saúde/estatística & dados numéricos , Serviços de Saúde Rural/estatística & dados numéricos , População Rural , África do Sul , Adulto JovemRESUMO
BACKGROUND: Multiple specialized nutritious food options are programmed for supplementation in humanitarian and development settings. However, comparative cost-effectiveness evidence is lacking, let alone incorporation of perspectives from uncompensated stakeholders. A Burkina Faso trial evaluated the cost-effectiveness of Corn Soy Blend Plus w/ oil (CSB+ w/oil, reference arm), Corn Soy Whey Blend w/oil (CSWB w/oil), Super Cereal Plus (SC+), and Ready-to-Use Supplementary Food (RUSF) in reducing stunting and wasting among children 6-23 months old. This paper presents cost-effectiveness findings from multiple stakeholders' perspectives, including caregivers and program volunteers. METHODS: An activity-based costing with ingredients approach was used to summarize cost of the 18-month-long blanket supplementary feeding for each enrolled child (in 2018 USD). Time data were collected using self-reported and observational instruments. Cost-effectiveness relative to CSB+ w/oil assessed incremental cost per enrolled child against incremental outcomes: prevalence of stunting at 23 months of age and number of months of wasting. Two combined perspectives were compared: program (donor, implementer, and volunteer) versus program and caregiver (adding caregiver). RESULTS: A total of 6112 children were enrolled. While similar effectiveness was found in three arms (CSWB w/oil was less effective), costs differed. Product cost and caregiver time to prepare study foods were major drivers of cross-arm cost differences from the respective combined perspective. The two major drivers were used to construct uncertainty ranges of cost per enrolled child from program and caregiver perspective: $317 ($279- $355) in CSB+ w/oil, $350 ($327- $373) in CSWB w/oil, $387 ($371- $403) in RUSF, and $434 ($365- $503) in SC+. Cost from program and caregiver perspective was a substantial increase from program perspective. CSB+ w/oil was most cost-effective in reducing stunting and wasting, and this main finding was robust to changing perspectives and all corresponding sensitivity analyses when uncompensated time was valued at minimum wage ($0.36/h). The break-even point for uncompensated time valuation is >$0.84/h, where RUSF became the most cost-effective from the program and caregiver perspective. Relative cost-effectiveness rankings among the other three arms depended on choice of perspectives, and were sensitive to values assigned to product cost, international freight cost, opportunity cost of time, and outcomes of a hypothetical control. Volunteer opportunity cost did not affect arm comparisons, but lack of compensation resulted in negative financial consequences for caregivers. CONCLUSIONS: Evaluating cost-effectiveness by incorporating uncompensated stakeholders provided crucial implementation insights around nutrition products and programming. TRIAL REGISTRATION: Trial registration number: NCT02071563. Name of registry: ClinicalTrials.gov URL of registry: https://clinicaltrials.gov/ct2/show/NCT02071563?type=Intr&cond=Malnutrition&cntry=BF&draw=2&rank=9 Date of registration: February 26, 2014. Date of enrollment of first participant: July 2014.
Assuntos
Análise Custo-Benefício/métodos , Alimentos Especializados/economia , Transtornos do Crescimento/prevenção & controle , Desnutrição/prevenção & controle , Síndrome de Emaciação/prevenção & controle , Burkina Faso , Análise Custo-Benefício/economia , Análise Custo-Benefício/estatística & dados numéricos , Feminino , Transtornos do Crescimento/economia , Humanos , Lactente , Masculino , Desnutrição/economia , Micronutrientes , Síndrome de Emaciação/economiaRESUMO
BACKGROUND AND AIMS: The efficacy of nutritional intervention to enhance short- and long-term outcomes of pulmonary rehabilitation in COPD is still unclear, hence this paper aims to investigate the clinical outcome and cost-effectiveness of a 12-month nutritional intervention strategy in muscle-wasted COPD patients. METHODS: Prior to a 4-month pulmonary rehabilitation programme, 81 muscle-wasted COPD patients (51% males, aged 62.5 ± 0.9 years) with moderate airflow obstruction (FEV1 55.1 ± 2.2% predicted) and impaired exercise capacity (Wmax 63.5 ± 2.4% predicted) were randomized to 3 portions of nutritional supplementation per day (enriched with leucine, vitamin D and polyunsaturated fatty acids) [NUTRITION] or PLACEBO (phase 1). In the unblinded 8-month maintenance phase (phase 2), both groups received structured feedback on their physical activity level assessed by accelerometry. NUTRITION additionally received 1 portion of supplemental nutrition per day and motivational interviewing-based nutritional counselling. A 3-month follow-up (phase 3) was included. RESULTS: After 12 months, physical capacity measured by quadriceps muscle strength and cycle endurance time were not different, but physical activity was higher in NUTRITION than in PLACEBO (Δ1030 steps/day, p = 0.025). Plasma levels of the enriched nutrients (p < 0.001) were higher in NUTRITION than PLACEBO. Trends towards weight gain in NUTRITION and weight loss in PLACEBO led to a significant between-group difference after 12 months (Δ1.54 kg, p = 0.041). The HADS anxiety and depression scores improved in NUTRITION only (Δ-1.92 points, p = 0.037). Generic quality of life (EQ-5D) was decreased in PLACEBO but not in NUTRITION (between-group difference after 15 months 0.072 points, p = 0.009). Overall motivation towards exercising and healthy eating was high and did not change significantly after 12 months; only amotivation towards healthy eating yielded a significant between-group difference (Δ1.022 points, p = 0.015). The cost per quality-adjusted life-year after 15 months was EUR 16,750. CONCLUSIONS: Nutritional intervention in muscle-wasted patients with moderate COPD does not enhance long-term outcome of exercise training on physical capacity but ameliorates plasma levels of the supplemented nutrients, total body weight, physical activity and generic health status, at an acceptable increase of costs for patients with high disease burden.
Assuntos
Análise Custo-Benefício/métodos , Terapia Nutricional/economia , Terapia Nutricional/métodos , Avaliação de Programas e Projetos de Saúde/métodos , Doença Pulmonar Obstrutiva Crônica/terapia , Análise Custo-Benefício/economia , Análise Custo-Benefício/estatística & dados numéricos , Aconselhamento/métodos , Suplementos Nutricionais , Ácidos Graxos Insaturados/uso terapêutico , Feminino , Humanos , Leucina/uso terapêutico , Masculino , Pessoa de Meia-Idade , Entrevista Motivacional/métodos , Atrofia Muscular/complicações , Países Baixos , Avaliação de Programas e Projetos de Saúde/economia , Avaliação de Programas e Projetos de Saúde/estatística & dados numéricos , Doença Pulmonar Obstrutiva Crônica/complicações , Resultado do Tratamento , Vitamina D/uso terapêuticoRESUMO
OBJECTIVE: To compare cost-effectiveness of integrated care with therapeutic assertive community treatment (IC-TACT) versus standard care (SC) in multiple-episode psychosis. METHOD: Twelve-month IC-TACT in patients with schizophrenia-spectrum and bipolar I disorders were compared with a historical control group. Primary outcomes were entropy-balanced cost-effectiveness based on mental healthcare costs from a payers' perspective and quality-adjusted life years (QALYs) as a measure of health effects during 12-month follow-up. RESULTS: At baseline, patients in IC-TACT (n = 214) had significantly higher illness severity and lower functioning than SC (n = 56). Over 12 months, IC-TACT had significantly lower days in inpatient (10.3 ± 20.5 vs. 28.2 ± 44.9; P = 0.005) and day-clinic care (2.6 ± 16.7 vs. 16.4 ± 33.7; P = 0.004) and correspondingly lower costs (-55 084). Within outpatient care, IC-TACT displayed a higher number of treatment contacts (116.3 ± 45.3 vs. 15.6 ± 6.3) and higher related costs (+1417). Both resulted in lower total costs in IC-TACT (mean difference = -13 248 ± 2975, P < 0.001). Adjusted incremental QALYs were significantly higher for IC-TACT versus SC (+0.10 ± 0.37, P = 0.05). The probability of cost-effectiveness of IC-TACT was constantly higher than 99%. CONCLUSION: IC-TACT was cost-effective compared with SC. The use of prima facies 'costly' TACT teams is highly recommended to improve outcomes and save total cost for patients with severe psychotic disorders.
Assuntos
Serviços Comunitários de Saúde Mental/economia , Análise Custo-Benefício/estatística & dados numéricos , Prestação Integrada de Cuidados de Saúde/estatística & dados numéricos , Transtornos Psicóticos/terapia , Adulto , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Adulto JovemRESUMO
STUDY OBJECTIVES: Limited evidence exists on the cost-effectiveness of mandibular advancement device (MAD) compared to continuous positive airway pressure (CPAP) therapy in moderate obstructive sleep apnea (OSA). Therefore, this study compares the clinical and cost-effectiveness of MAD therapy with CPAP therapy in moderate OSA. METHODS: In a multicentre randomized controlled trial, patients with an apnea-hypopnea index (AHI) of 15 to 30 events/h were randomized to either MAD or CPAP. Incremental cost-effectiveness and cost-utility ratios (ICER/ICUR, in terms of AHI reduction and quality-adjusted life-years [QALYs, based on the EuroQol Five-Dimension Quality of Life questionnaire]) were calculated after 12 months, all from a societal perspective. RESULTS: In the 85 randomized patients (n = 42 CPAP, n = 43 MAD), AHI reduction was significantly greater with CPAP (median reduction AHI 18.3 [14.8-22.6] events/h) than with MAD therapy (median reduction AHI 13.5 [8.5-18.4] events/h) after 12 months. Societal costs after 12 months were higher for MAD than for CPAP (mean difference 2.156). MAD was less cost-effective than CPAP after 12 months (ICER -305 [-3.003 to 1.572] per AHI point improvement). However, in terms of QALY, MAD performed better than CPAP after 12 months (33.701 [-191.106 to 562.271] per QALY gained). CONCLUSIONS: CPAP was more clinically effective (in terms of AHI reduction) and cost-effective than MAD. However, costs per QALY was better with MAD as compared to CPAP. Therefore, CPAP is the first-choice treatment option in moderate OSA and MAD may be a good alternative. CLINICAL TRIAL REGISTRATION: Registry: ClinicalTrials.gov; Identifier: NCT01588275.
Assuntos
Pressão Positiva Contínua nas Vias Aéreas/economia , Análise Custo-Benefício/métodos , Análise Custo-Benefício/estatística & dados numéricos , Avanço Mandibular/economia , Apneia Obstrutiva do Sono/economia , Apneia Obstrutiva do Sono/terapia , Pressão Positiva Contínua nas Vias Aéreas/métodos , Pressão Positiva Contínua nas Vias Aéreas/estatística & dados numéricos , Análise Custo-Benefício/economia , Feminino , Humanos , Masculino , Avanço Mandibular/métodos , Avanço Mandibular/estatística & dados numéricos , Pessoa de Meia-Idade , Cooperação do Paciente/estatística & dados numéricos , Polissonografia/métodos , Qualidade de Vida , Apneia Obstrutiva do Sono/diagnóstico , Resultado do TratamentoRESUMO
Improved strategies and scalable interventions to engage low-socioeconomic status (SES) smokers in tobacco treatment are needed. We tested an intervention designed to connect low-SES smokers to treatment services, implemented through Minnesota's National Breast and Cervical Cancer Early Detection Program (Sage) in 2017; the trial was designed to last 3â¯months (July through October). Participants were female smokers who were 250% below the federal poverty level (randomized Nâ¯=â¯3723; analyzed Nâ¯=â¯3365). Using a factorial design, participants were randomized to six intervention groups consisting of a proactive call (no call vs call) and/or a financial incentive offered for being connected to treatment services ($0 vs $10 vs $20). Simple randomization was conducted using Stata v.13. All individuals received direct mail. Participants and staff were blinded to allocation. The outcome was connection via phone to QUITPLAN Services®, Minnesota's population-based cessation services. Groups that received $10 or $20 incentives had higher odds of treatment engagement compared to the no incentive group [respectively, ORâ¯=â¯1.94; 95% CI (1.19-3.14); ORâ¯=â¯2.18; 95% CI (1.36-3.51)]. Individuals that received proactive calls had higher odds of treatment engagement compared to individuals not called [ORâ¯=â¯1.59; 95% CI (1.11-2.29)]. Economic evaluation revealed that the $10 incentive, no call group had the best cost-benefit ratio compared to the no incentive, no call group. Direct mail with moderate incentives or proactive calling can successfully encourage connections to population-based tobacco treatment services among low-SES smokers. The intervention could be disseminated to similar programs serving low-SES populations. This trial is registered at ClinicalTrials.gov (NCT03760107).
Assuntos
Análise Custo-Benefício/estatística & dados numéricos , Motivação , Fumantes/estatística & dados numéricos , Abandono do Hábito de Fumar/estatística & dados numéricos , Telefone , Feminino , Humanos , Pessoa de Meia-Idade , Minnesota , Pobreza , Nicotiana/efeitos adversosRESUMO
Renal cancer is the 13th most frequent neoplasm in the world. From 2010 to 2014, renal cancer accounted for 1.43% of cancer deaths in Brazil. The treatment of choice for metastatic renal cancer is tyrosine kinase inhibitors (TKI) sunitinib and pazopanib. This article assesses cost-effectiveness between pazopanib and sunitinib in the treatment of metastatic renal cancer. A cost-effectiveness study was performed from the perspective of a federal hospital under the Brazilian Unified National Health System (SUS). TKI effectiveness and safety outcomes were applied to the decision tree model. Clinical data were extracted from patient charts, and direct costs were consulted from official Ministry of Health sources. The cost of 10 months of treatment, including the costs of the TKI, procedures and management of adverse events, was BRL 98,677.19 for pazopanib and BRL 155,227.11 for sunitinib. The drugs displayed statistically equivalent effectiveness and statistically different safety outcomes, with pazopanib displaying better results. In this setting, pazopanib is the dominant technology when the treatment costs are analyzed together with the costs of managing adverse events.
O câncer renal é a 13ª neoplasia mais frequente no mundo. Entre 2012 e 2016, representou 1,48% das mortes por câncer no Brasil. A terapia de escolha para o tratamento de câncer renal metastático são os inibidores de tirosina quinase (ITK), sunitinibe e pazopanibe. Este artigo avalia o custo-efetividade do pazopanibe comparado ao sunitinibe no tratamento de câncer renal metastático. Foi realizada uma análise de custo-efetividade sob a perspectiva de um hospital federal do Sistema Único de Saúde. No modelo de árvore de decisão foram aplicados os desfechos de efetividade e segurança dos ITK. Os dados clínicos foram extraídos de prontuários e os custos diretos consultados em fontes oficiais do Ministério da Saúde. O custo de 10 meses de tratamento, englobando o valor dos ITK, procedimentos e manejo de eventos adversos, foi de R$ 98.677,19 para o pazopanibe e R$ 155.227,11 para o sunitinibe. Os medicamentos apresentaram efetividade estatisticamente equivalente e diferença estatisticamente significativa para o desfecho de segurança, no qual o pazopanibe obteve o melhor resultado. O pazopanibe, nesse contexto, é a tecnologia dominante quando os custos de tratamento são associados aos de manejo de eventos adversos.
El cáncer renal es la 13ª neoplasia más frecuente en el mundo. Entre 2010 y 2014, representó un 1,43% de las muertes por cáncer en Brasil. La terapia de elección para el tratamiento de cáncer renal metastásico son los inhibidores de tirosina quinasa (ITK), sunitinib y pazopanib. Este artículo evalúa el costo-efectividad entre pazopanib y sunitinib en el tratamiento de cáncer renal metastásico. Se realizó un análisis de costo-efectividad desde la perspectiva de un hospital federal del Sistema Único de Salud. En el modelo de árbol de decisión se aplicaron los desenlaces de efectividad y seguridad de los ITK. Los datos clínicos se extrajeron de registros médicos, y los costos directos consultados en fuentes oficiales del Ministerio de Salud. El costo de 10 meses de tratamiento, englobando el valor de los ITK, procedimientos y gestión de eventos adversos, fue de BRL 98.677,19 con el pazopanib y BRL 155.227,11 con el sunitinib. Los medicamentos presentaron efectividad estadísticamente equivalente y diferencia estadísticamente significativa para el desenlace de seguridad, en el que el pazopanib obtuvo el mejor resultado. El pazopanib, en este contexto, es la tecnología dominante cuando los costes de tratamiento están asociados a los de la gestión de eventos adversos.
Assuntos
Antineoplásicos/economia , Análise Custo-Benefício/estatística & dados numéricos , Neoplasias Renais/tratamento farmacológico , Inibidores de Proteínas Quinases/economia , Pirimidinas/economia , Sulfonamidas/economia , Sunitinibe/economia , Adulto , Idoso , Antineoplásicos/administração & dosagem , Feminino , Humanos , Indazóis , Estimativa de Kaplan-Meier , Masculino , Pessoa de Meia-Idade , Programas Nacionais de Saúde , Metástase Neoplásica , Inibidores de Proteínas Quinases/administração & dosagem , Pirimidinas/administração & dosagem , Sulfonamidas/administração & dosagem , Sunitinibe/administração & dosagem , Resultado do TratamentoRESUMO
OBJECTIVES: To compare neonatal and maternal outcomes, and the relative risk of interventions between mothers attended to by midwives, general practitioners, and obstetricians, and to assess the cost-effectiveness of the employee-model of midwifery-led care in Nova Scotia, Canada, when compared with general practitioners. DESIGN, SETTING, AND PARTICIPANTS: The study was a retrospective cohort study involving routinely collected clinical and administrative data from all low-risk births from January 1st, 2013 to December 31st, 2017. There were 24,662 observations. MEASUREMENTS: Descriptive statistics were used to summarise the mother's socio-demographic characteristics. We used a nearest-neighbour matching estimator in assessing differences in outcomes, and generalized linear models in the estimation of the risks of interventions, adjusting for potential confounders. An analytic decision tree served as the vehicle for the cost-effectiveness analysis, assessed using the net monetary benefit approach. All health care resources utilized were measured and valued. Neonatal intensive care admissions avoided was the measure of outcome. We performed probabilistic sensitivity and subgroup analyses. FINDINGS: Mothers attended to by midwives spent less time at the hospital during birth admissions, were less likely to have interventions, instrumental births, and more likely to have exclusive breastfeeding at discharge from birth admission. There were no differences in Apgar scores and neonatal intensive care unit admissions. The employee-model of midwifery-led care was found to be cost-effective. KEY CONCLUSIONS: The midwifery program is both effective and cost-effective for low-risk pregnancies IMPLICATIONS FOR PRACTICE: Increasing the number of midwives will increase access and represents value for money.
Assuntos
Análise Custo-Benefício/normas , Tocologia/métodos , Padrões de Prática em Enfermagem/normas , Qualidade da Assistência à Saúde/normas , Adulto , Estudos de Coortes , Análise Custo-Benefício/estatística & dados numéricos , Feminino , Humanos , Recém-Nascido , Tocologia/organização & administração , Tocologia/estatística & dados numéricos , Nova Escócia , Padrões de Prática em Enfermagem/organização & administração , Padrões de Prática em Enfermagem/estatística & dados numéricos , Gravidez , Qualidade da Assistência à Saúde/estatística & dados numéricos , Estudos RetrospectivosRESUMO
BACKGROUND: A model for triaging patients in primary care to provide immediate contact with the most appropriate profession to treat the condition in question has been developed and implemented in parts of Sweden. Direct triaging of patients with musculoskeletal disorders (MSD) to physiotherapists at primary healthcare centres has been proposed as an alternative to initial assessment by general practitioners (GPs) and has been shown to have many positive effects. The aim of this study was to evaluate the cost-effectiveness from the societal perspective of this new care-pathway through primary care regarding triaging patients with MSD to initial assessment by physiotherapists compared to standard practice with initial GP assessment. METHODS: Nurse-assessed patients with MSD (N = 55) were randomised to initial assessment and treatment with either physiotherapists or GPs and were followed for 1 year regarding health-related quality of life, utilization of healthcare resources and absence from work for MSD. Quality-adjusted life-years (QALYs) were calculated based on EQ5D measured at 5 time-points. Costs for healthcare resources and production loss were compiled. Incremental cost-effectiveness ratios (ICERS) were calculated. Multiple imputation was used to compensate for missing values and bootstrapping to handle uncertainty. A cost-effectiveness plane and a cost-effectiveness acceptability curve were construed to describe the results. RESULTS: The group who were allocated to initial assessment by physiotherapists had slightly larger gains in QALYs at lower total costs. At a willingness-to-pay threshold of 20,000 , the likelihood that the intervention was cost-effective from a societal perspective including production loss due to MSD was 85% increasing to 93% at higher thresholds. When only healthcare costs were considered, triaging to physiotherapists was still less costly in relation to health improvements than standard praxis. CONCLUSION: From the societal perspective, this small study indicated that triaging directly to physiotherapists in primary care has a high likelihood of being cost-effective. However, further larger randomised trials will be necessary to corroborate these findings. TRIAL REGISTRATION: ClinicalTrials.gov NCT02218749 . Registered August 18, 2014.
Assuntos
Análise Custo-Benefício/estatística & dados numéricos , Doenças Musculoesqueléticas/terapia , Atenção Primária à Saúde/economia , Triagem/economia , Adolescente , Adulto , Idoso , Procedimentos Clínicos/economia , Procedimentos Clínicos/organização & administração , Feminino , Seguimentos , Clínicos Gerais/economia , Clínicos Gerais/estatística & dados numéricos , Custos de Cuidados de Saúde/estatística & dados numéricos , Humanos , Masculino , Pessoa de Meia-Idade , Doenças Musculoesqueléticas/diagnóstico , Doenças Musculoesqueléticas/psicologia , Enfermeiras e Enfermeiros/economia , Enfermeiras e Enfermeiros/estatística & dados numéricos , Aceitação pelo Paciente de Cuidados de Saúde/estatística & dados numéricos , Fisioterapeutas/economia , Fisioterapeutas/estatística & dados numéricos , Atenção Primária à Saúde/organização & administração , Qualidade de Vida , Anos de Vida Ajustados por Qualidade de Vida , Suécia , Resultado do Tratamento , Triagem/estatística & dados numéricos , Adulto JovemRESUMO
BACKGROUND: Palliative care can improve end-of-life care and reduce health care expenditures, but the optimal timing for initiation remains unclear. We sought to characterize the association between timing of palliative care, in-hospital deaths, and health care costs. METHODS: This is a retrospective cohort study including all patients who were diagnosed and died of colorectal cancer between 2004 and 2012 in Manitoba, Canada. The primary exposure was timing of palliative care, defined as no involvement, late involvement (less than 14 d before death), early involvement (14 to 60 d before death), and very early involvement (>60 d before death). The primary outcome was in-hospital deaths and end-of-life health care costs. RESULTS: A total of 1607 patients were included; 315 (20%) received palliative care and 162 (10%) died in hospital. Compared to those who did not receive palliative care, patients with early and very early involvement experienced significantly decreased odds of dying in hospital (OR 0.21 95% CI 0.06-0.69 P = 0.01 and OR 0.11 95% CI 0.01-0.78 P = 0.03, respectively) and significantly lower health care costs. There were no significant differences in in-hospital deaths and health care costs between patients without palliative care and those who received late palliative care. CONCLUSIONS: Early palliative care involvement is associated with decreased odds of dying in hospital and lower health care utilization and costs in patients with colorectal cancer. These findings provide real-world evidence supporting early integration of palliative care, although the optimal timing (early versus very early) remains a matter of debate.
Assuntos
Neoplasias Colorretais/terapia , Prestação Integrada de Cuidados de Saúde/métodos , Cuidados Paliativos/métodos , Assistência Terminal/métodos , Idoso , Idoso de 80 Anos ou mais , Canadá/epidemiologia , Neoplasias Colorretais/economia , Neoplasias Colorretais/mortalidade , Análise Custo-Benefício/estatística & dados numéricos , Prestação Integrada de Cuidados de Saúde/economia , Prestação Integrada de Cuidados de Saúde/estatística & dados numéricos , Medicina Baseada em Evidências/economia , Medicina Baseada em Evidências/métodos , Medicina Baseada em Evidências/estatística & dados numéricos , Feminino , Gastos em Saúde/estatística & dados numéricos , Mortalidade Hospitalar , Humanos , Masculino , Oncologia/economia , Oncologia/métodos , Oncologia/estatística & dados numéricos , Pessoa de Meia-Idade , Cuidados Paliativos/economia , Cuidados Paliativos/estatística & dados numéricos , Aceitação pelo Paciente de Cuidados de Saúde/estatística & dados numéricos , Sistema de Registros/estatística & dados numéricos , Estudos Retrospectivos , Assistência Terminal/economia , Assistência Terminal/estatística & dados numéricos , Fatores de TempoRESUMO
Healthcare consumerism, costs, and price transparency are garnering unprecedented attention from hospitals and health systems in the United States. To many observers of the US healthcare delivery system, the inability to provide accurate pricing information and the variability in prices for comparable services are utter failures of the administrative infrastructure that supports patient care processes.Price transparency and the affordability of healthcare have also become top concerns for professional and trade organizations, which are devoting significant resources to assist member institutions in facing these issues. In many states, elected officials have passed legislation requiring pricing support for consumers. When the value equation (cost divided by quality) is considered, comparisons of healthcare providers can become even more confusing.Price transparency and demonstration of cost-effective, high-quality service to patients have become strategic imperatives at Maricopa Integrated Health System (MIHS). A safety-net system and one of Arizona's largest providers of graduate medical education and other teaching programs, MIHS faced an operating deficit of more than $74 million in fiscal year 2014. In 2015, financial concerns prompted the CEO and board to hold weekly meetings to appraise cash availability and management interventions. Over the next four years, MIHS achieved a cumulative improvement in net income of more than $150 million. Today, MIHS is reinventing itself through a major capital campaign made possible in part by a $935 million public bond referendum passed by the voters of Maricopa County. Ultimately, our ability to better serve the community involves connecting with our patients and addressing their need for price transparency.
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Análise Custo-Benefício/estatística & dados numéricos , Análise Custo-Benefício/tendências , Atenção à Saúde/economia , Custos de Cuidados de Saúde/estatística & dados numéricos , Custos de Cuidados de Saúde/tendências , Hospitais Públicos/estatística & dados numéricos , Hospitais de Ensino/estatística & dados numéricos , Arizona , Atenção à Saúde/tendências , Previsões , Hospitais Públicos/tendências , Hospitais de Ensino/tendências , Humanos , Modelos OrganizacionaisRESUMO
AIM: To assess the cost-effectiveness of onabotulinumtoxinA (onabotA), implantable sacral nerve stimulation devices, percutaneous tibial nerve stimulation, anticholinergic medications and mirabegron compared with best supportive care (BSC) for management of refractory overactive bladder (OAB). METHODS: A Markov model was developed to compare the cost-effectiveness of treatment options with BSC over a 10-year time horizon. Resource utilization, discontinuation rates and costs were derived from unpublished and published sources. Quality-adjusted life-years (QALYs) and incremental cost-effectiveness ratios were reported. RESULTS: Treatment with onabotA 100U produced the largest gain in QALYs (7.179) and lowest estimated incremental cost-effectiveness ratio ($32,680/QALY) of all assessed treatments compared with BSC. CONCLUSION: Compared with BSC, onabotA 100U was the most cost-effective treatment option for patients with refractory OAB.
Assuntos
Análise Custo-Benefício/estatística & dados numéricos , Custos de Cuidados de Saúde/estatística & dados numéricos , Bexiga Urinária Hiperativa/economia , Bexiga Urinária Hiperativa/terapia , Acetanilidas/economia , Acetanilidas/uso terapêutico , Toxinas Botulínicas Tipo A/economia , Toxinas Botulínicas Tipo A/uso terapêutico , Antagonistas Colinérgicos/economia , Antagonistas Colinérgicos/uso terapêutico , Terapia por Estimulação Elétrica/economia , Eletrodos Implantados/economia , Humanos , Pessoa de Meia-Idade , Fármacos Neuromusculares/economia , Fármacos Neuromusculares/uso terapêutico , Tiazóis/economia , Tiazóis/uso terapêutico , Resultado do Tratamento , Estados Unidos , Agentes Urológicos/economia , Agentes Urológicos/uso terapêuticoRESUMO
AIM: To evaluate the cost-effectiveness of trifluridine and tipiracil hydrochloride (FTD/TPI) compared with best supportive care (BSC) or regorafenib for the treatment of patients with metastatic colorectal cancer who have been previously treated with or are not considered candidates for available therapies including fluoropyrimidine-, oxaliplatin- and irinotecan-based chemotherapies, anti-VEGF agents and anti-EGFR agents in Greece. METHODS: A partitioned survival model was locally adapted from a third-party payer perspective over a 10 year time horizon. Efficacy data and utility values were extracted from published studies. Resource consumption data were obtained from local experts using a questionnaire developed for the purpose of the study and was combined with unit costs obtained from official sources. All costs reflect the year 2017 in euros. Primary outcomes were patients' life years (LYs), quality-adjusted life years (QALYs), total costs and incremental cost-effectiveness ratios (ICERs) per QALY and LYs gained. RESULTS: Total life time cost per patient for FTD/TPI, BSC and regorafenib was estimated to be 10,087, 1,879 and 10,850, respectively. In terms of health outcomes, FTD/TPI was associated with 0.25 and 0.11 increment in LYs compared with BSC and regorafenib, respectively. Furthermore, FTD/TPI was associated with 0.17, and 0.07 increment in QALYs compared with BSC and regorafenib, resulting in ICERs of 32,759 per LY gained and 49,326 per QALY gained versus BSC. Moreover, FTD/TPI was a dominant alternative over regorafenib. CONCLUSION: The results indicate that FTD/TPI may represent a cost-effective treatment option compared with other alternative therapies as a third-line treatment of metastatic colorectal cancer in Greece.
Assuntos
Neoplasias Colorretais/tratamento farmacológico , Análise Custo-Benefício/estatística & dados numéricos , Pirrolidinas/economia , Pirrolidinas/uso terapêutico , Timina/economia , Timina/uso terapêutico , Trifluridina/economia , Trifluridina/uso terapêutico , Adulto , Antimetabólitos/economia , Antimetabólitos/uso terapêutico , Neoplasias Colorretais/patologia , Análise Custo-Benefício/economia , Grécia , Humanos , Análise de SobrevidaRESUMO
This project evaluated the cost effectiveness of integrating behavioral health services into a primary care practice using a prospective, case-control design. New Directions Behavioral Health collaborated with a large Kansas City primary care practice to integrate a licensed psychologist (i.e., behavioral health clinician) into the practice. Patient claims data were examined 21 months prior to and 14 months after the psychologist began providing full-time behavioral health services within the practice. Claims data from patients with Blue Cross Blue Shield of Kansas City insurance (BCBSKC) who had at least one encounter with the psychologist (N = 239) were compared to control patients (BCBSKC fully insured patients at large) to calculate cost savings. The results demonstrated that integrating behavioral health services into the practice was associated with $860.16 per member per year savings or 10.8% savings in costs for BCBSKC patients. Integrating behavioral health services into primary care may lead to reductions in health care costs.