Cost-Consequence Analysis of Deprescribing to Optimize Health Outcomes for Frail Older People: A Within-Trial Analysis.

OBJECTIVES: The structured, clinically supervised withdrawal of medicines, known as deprescribing, is one strategy to address inappropriate polypharmacy. This study aimed to evaluate the costs and consequences of deprescribing in frail older people living in residential aged care facilities (RACFs) in Australia. DESIGN: A within-trial cost-consequence analysis of a deprescribing intervention-Opti-Med. The Opti-Med double-blind randomized controlled trial of deprescribing included 3 groups: blinded control, blinded intervention, and an open intervention group. SETTING AND PARTICIPANTS: Seventeen RACFs in Western Australia and New South Wales. Participants were 303 older people living in participating RACFs from March 2014 to February 2019. METHODS: Analysis was conducted from the health sector perspective. Health economic outcomes assessed include cost saved from deprescribed medicines and the incremental quality-adjusted life-years. Costs were presented in 2022 Australian dollars. RESULTS: The total cost of the Opti-Med intervention was $239.13 per participant. The costs saved through deprescribed medicines over 12 months after adjusting for mortality within the trial period was $328.90 per participant in the blinded intervention group and $164.00 per participant in the open intervention group. On average, the cost of the intervention was more than offset by the cost saved from deprescribed medicines. Extrapolating these findings to the Australian population suggests a potential net cost saving of about $1 to $16 million per annum for the health system nationally. The incremental quality-adjusted life-years were very similar across the 3 groups within the trial period. CONCLUSIONS AND IMPLICATIONS: Deprescribing for frail older people living in RACFs can be a cost-saving intervention without reducing the quality of life. Systemwide implementation of deprescribing across RACFs in Australia has the potential to improve health care delivery through the cost savings, which could be reapplied to further optimize care within RACFs.

Is 2-Stage Septic Revision Worth the Money? A Cost-Utility Analysis of a 1-Stage Versus 2-Stage Septic Revision of Total Knee Arthroplasty.

BACKGROUND: Two-stage exchange arthroplasty remains the gold standard for the management of prosthetic joint infection (PJI) of the knee, but several studies have demonstrated that 1-stage exchange is as effective as 2-stage exchange. This study aimed to support decision-making via an economic evaluation of 1-stage compared to 2-stage exchange for total knee arthroplasty septic revision in patients who did not have compelling indication PJI (ie, Methicillin-resistant Staphylococcus aureus, multiorganism, systemic sepsis, comorbidities, culture negative, resistant organism, and immunocompromised) to undergo a 2-stage exchange. METHODS: A cost-utility analysis was performed using a Markov cohort model from the health care provider perspective using Australia data. One-stage septic knee revisions were compared with 2-stage exchange procedures for chronic PJI using a patient-lifetime horizon. Health outcomes were expressed as quality-adjusted life-years (QALY), whereas costs were presented in 2020 Australian dollars. Sensitivity analyses, population expected values of perfect information, and the perfect information for parameters (EVPPI) were assessed to estimate the opportunity costs surrounding the decision made at a willingness-to-pay threshold of $50,000 per QALY. RESULTS: The incremental cost-effectiveness ratio of 2-stage exchange compared with 1-stage exchange was $231,000 per QALY, with 98.5% of the probabilistic sensitivity simulations above the willingness-to-pay threshold. The population expected value of perfect information was $882,000, whereas the expected value of perfect information for parameters for the "cost parameters" was $207,000. CONCLUSION: The adoption of 1-stage septic knee revision is the optimal choice for patients who have a PJI and who do not have a compelling need for a 2-stage exchange arthroplasty. One-stage exchange for PJI should be advocated in patients who meet the eligibility criteria.

Introducing rotavirus vaccine in eight sub-Saharan African countries: a cost-benefit analysis.

BACKGROUND: Stimulated by the economic challenges faced by many sub-Saharan African countries and the changes in the rotavirus burden across these countries, this study aimed to inform the decision of health policy makers of eight sub-Saharan countries, who are yet to introduce the rotavirus vaccine as of Dec 31, 2020, on the health economic consequences of the introduction of the vaccine in terms of the costs and benefits. METHODS: We did a cost-benefit analysis using a simulation-based decision-analytic model for children aged younger than 1 year, who were followed up to 259 weeks, in the Central African Republic, Chad, Comoros, Equatorial Guinea, Gabon, Guinea, Somalia, and South Sudan. Data were collected and analysed between Jan 13, 2020, and Dec 11, 2020. Cost-effectiveness analysis and budget impact analysis were done as secondary analyses. Four rotavirus vaccinations (Rotarix, Rotateq, Rotavac, and Rotasiil) were compared with no vaccination. The primary outcome was disability-adjusted life-years averted, converted to monetary terms. The secondary outcomes include rotavirus gastroenteritis averted, and rotavirus vaccine-associated intussusception. The primary economic evaluation measure was the benefit-cost ratio (BCR). FINDINGS: For the modelling period, Jan 1, 2021, to Dec 31, 2030, we found that the benefits of introducing the rotavirus vaccine outweighed the costs in all eight countries, with Chad and the Central African Republic having the highest BCR of 19·42 and 11·36, respectively. Guinea had the lowest BCR of 3·26 amongst the Gavi-eligible countries. Equatorial Guinea and Gabon had a narrow BCR of 1·86 and 2·06, respectively. Rotarix was the optimal choice for all the Gavi-eligible countries; Rotasiil and Rotavac were the optimal choices for Equatorial Guinea and Gabon, respectively. INTERPRETATION: Introducing the rotavirus vaccine in all eight countries, but with caution in Equatorial Guinea and Gabon, would be worthwhile. With the narrow BCR for Equatorial Guinea and Gabon, cautious, pragmatic, and stringent measures need to be employed to ensure optimal health benefits and cost minimisation of the vaccine introduction. The final decision to introduce the rotavirus vaccine should be preceded by comparing its BCR to the BCRs of other health-care projects. FUNDING: Copenhagen Consensus Center and the Bill & Melinda Gates Foundation.

Promoting the integrated community case management of pneumonia in children under 5 years in Nigeria through the proprietary and patent medicine vendors: a cost-effectiveness analysis.

BACKGROUND: While evidence-based recommendations for the management pneumonia in under-5-year-olds at the community level with amoxicillin dispersible tablets (DT) were made by the World Health Organisation, initiatives to promote the integrated community case management (iCCM) of pneumonia through the proprietary and patent medicine vendors (PPMVs) have been poorly utilized in Nigeria, possibly due to low financial support and perceived benefit. This study provides costs, benefits and cost-effectiveness estimates and implications of promoting the iCCM through the PPMVs' education and support. The outcome of this study will help inform healthcare decisions in Nigeria. METHODS: This study was a cost-effectiveness analysis using a simulation-based Markov model. Two approaches were compared, the 'no promotion' and the 'promotion' scenarios. The health outcomes include disability-adjusted life years averted and severe pneumonia hospitalisation cost averted. The costs were expressed in 2019 US dollars. RESULTS: The promotion of iCCM through the PPMVs was very cost effective with an incremental cost-effectiveness ratio of US$143.77 (95% CI US$137.42-150.50)/DALY averted. The promotion will prevent 28,359 cases of severe pneumonia hospitalisation with an estimated healthcare cost of US$390,578. It will also avert 900 deaths in a year. CONCLUSION: Promoting the iCCM for the treatment of pneumonia in children under 5 years through education and support of the PPMVs holds promise to harness the benefits of amoxicillin DT and provide a high return on investment. A nationwide promotion exercise should be considered especially in remote areas of the country.

Management of Chest Indrawing Pneumonia in Children Under Five Years at the Outpatient Health Facilities in Nigeria: An Economic Evaluation.

BACKGROUND: The recommendation of the World Health Organization (WHO) for the management of children aged < 5 years with chest indrawing pneumonia with oral amoxicillin dispersible tablets (DT) at the outpatient health facilities is imperative, especially in a high pneumonia mortality and low-resource setting like Nigeria. However, this recommendation has not been widely adopted in Nigeria due to poor access to healthcare and sub-optimal outpatient management and follow-up system to ensure patients' safety and management effectiveness. This study aimed to evaluate the cost effectiveness and the cost benefit of the WHO recommendation relative to usual practices in Nigeria. The outcome of this study will provide supporting evidence to healthcare providers and inform their management decisions. METHODS: A cost-effectiveness and cost-benefit analyses of this study used a Markov cohort model from the healthcare provider perspective for a time horizon of five years. Three approaches were compared: a conventional approach (base-comparator); the amoxicillin DT (WHO) approach; and a parenteral approach. Bottom-up costing method was used. Health outcome was expressed as disability-adjusted life years averted and converted to monetary terms (benefit). RESULTS: The incremental cost-effectiveness ratio (ICER) and the benefit-cost ratio (BCR) of the amoxicillin DT approach dominate the conventional approach. The parenteral approach was more effective and more beneficial than the amoxicillin DT approach but the ICER and BCR were $75,655/DALY averted and 0.035, respectively. CONCLUSIONS: The use of amoxicillin DT proves to be the optimal choice with high benefit and low cost. The opportunity cost of not adopting an approach more effective than amoxicillin DT will be offset by the cost saved. Its use in chest indrawing pneumonia management needs to be scaled up.

Cost-effectiveness analysis of diarrhoea management approaches in Nigeria: A decision analytical model.

BACKGROUND: Diarrhoea is a leading cause of death in Nigerian children under 5 years. Implementing the most cost-effective approach to diarrhoea management in Nigeria will help optimize health care resources allocation. This study evaluated the cost-effectiveness of various approaches to diarrhoea management namely: the 'no treatment' approach (NT); the preventive approach with rotavirus vaccine; the integrated management of childhood illness for diarrhoea approach (IMCI); and rotavirus vaccine plus integrated management of childhood illness for diarrhoea approach (rotavirus vaccine + IMCI). METHODS: Markov cohort model conducted from the payer's perspective was used to calculate the cost-effectiveness of the four interventions. The markov model simulated a life cycle of 260 weeks for 33 million children under five years at risk of having diarrhoea (well state). Disability adjusted life years (DALYs) averted was used to quantify clinical outcome. Incremental cost-effectiveness ratio (ICER) served as measure of cost-effectiveness. RESULTS: Based on cost-effectiveness threshold of $2,177.99 (i.e. representing Nigerian GDP/capita), all the approaches were very cost-effective but rotavirus vaccine approach was dominated. While IMCI has the lowest ICER of $4.6/DALY averted, the addition of rotavirus vaccine was cost-effective with an ICER of $80.1/DALY averted. Rotavirus vaccine alone was less efficient in optimizing health care resource allocation. CONCLUSION: Rotavirus vaccine + IMCI approach was the most cost-effective approach to childhood diarrhoea management. Its awareness and practice should be promoted in Nigeria. Addition of rotavirus vaccine should be considered for inclusion in the national programme of immunization. Although our findings suggest that addition of rotavirus vaccine to IMCI for diarrhoea is cost-effective, there may be need for further vaccine demonstration studies or real life studies to establish the cost-effectiveness of the vaccine in Nigeria.

Cost-utility analysis of antihypertensive medications in Nigeria: a decision analysis.

BACKGROUND: Many drugs are available for control of hypertension and its sequels in Nigeria but some are not affordable for majority of the populace. This serious pharmacoeconomic question has to be answered by the nation's health economists. The objective of this study was to evaluate the cost-effectiveness of drugs from 4 classes of antihypertensive medications commonly used in Nigeria in management of hypertension without compelling indication to use a particular antihypertensive drug. METHODS: The study employed decision analytic modeling. Interventions were obtained from a meta-analysis. The Markov process model calculated clinical outcomes and costs during a life cycle of 30 years of 1000 hypertensive patients stratified by 3 cardiovascular risk groups, under the alternative intervention scenarios. Quality adjusted life year (QALY) was used to quantify clinical outcome. The average cost of treatment for the 1000 patient was tracked over the Markov cycle model of the alternative interventions and results were presented in 2010 US Dollars. Probabilistic cost-effectiveness analysis was performed using Monte Carlo simulation, and results presented as cost-effectiveness acceptability frontiers. Expected value of perfect information (EVPI) and expected value of parameter perfect information (EVPPI) analyses were also conducted for the hypothetical population. RESULTS: Thiazide diuretic was the most cost-effective option across the 3 cardiovascular risk groups. Calcium channel blocker was the second best for Moderate risk and high risk with a willingness to pay of at least 2000$/QALY. The result was robust since it was insensitive to the parameters alteration. CONCLUSIONS: The result of this study showed that thiazide diuretic followed by calcium channel blocker could be a feasible strategy in order to ensure that patients in Nigeria with hypertension are better controlled.