Catastrophic costs incurred by tuberculosis affected households from Thailand's first national tuberculosis patient cost survey.

Tuberculosis (TB) causes an economic impact on the patients and their households. Although Thailand has expanded the national health benefit package for TB treatment, there was no data on out-of-pocket payments and income losses due to TB from patients and their household perspectives. This national TB patient cost survey was conducted to examine the TB-related economic burden, and assess the proportion of TB patients and their households facing catastrophic total costs because of TB disease. A cross-sectional TB patient cost survey was employed following WHO methods. Structured interviews with a paper-based questionnaire were conducted from October 2019 to July 2021. Both direct and indirect costs incurred from the patient and their household perspective were valued in 2021 and estimated throughout pre- and post-TB diagnosis episodes. We assessed the proportion of TB-affected households facing costs > 20% of household expenditure due to TB. We analyzed 1400 patients including 1382 TB (first-line treatment) and 18 drug-resistant TB patients (DR-TB). The mean total costs per TB episode for all study participants were 903 USD (95% confident interval; CI 771-1034 USD). Of these, total direct non-medical costs were the highest costs (mean, 402 USD, and 95%CI 334-470 USD) incurred per TB-affected household followed by total indirect costs (mean, 393 USD, and 95%CI 315-472 USD) and total direct medical costs (mean, 107 USD, and 95%CI 81-133 USD, respectively. The proportion of TB-affected households facing catastrophic costs was 29.5% (95%CI 25.1-34.0%) for TB (first-line), 61.1% (95%CI 29.6-88.1%) for DR-TB and 29.9% (95%CI 25.6-34.4%) overall. This first national survey highlighted the economic burden on TB-affected households. Travel, food/nutritional supplementation, and indirect costs contribute to a high proportion of catastrophic total costs. These suggest the need to enhance financial and social protection mechanisms to mitigate the financial burden of TB-affected households.

Economic Evaluation of Screening Strategy for Latent Tuberculosis Infection (LTBI) in Contacts of Tuberculosis Patients: Systematic Review and Quality Assessment.

A tuberculin skin test (TST) or interferon-gamma release assay (IGRA) can be used to screen for latent tuberculosis infection (LTBI). Due to its low cost, TST has been used particularly in underdeveloped countries. The limitations of TST were poor specificity in populations with a high prevalence of Bacille Calmette-Guérin (BCG) vaccination and variability of test readers. IGRA is used as an alternative to TST in settings where higher costs can be supported. The lack of studies conducted in high TB incidence countries since previous review, and using relevant assessment tools of the quality appraisal make the need for updated studies and a more comprehensive systematic review. This study aimed to conduct a systematic review of published economic evaluations of screening strategies for LTBI in contacts of TB patients, assess the quality of these studies, and compare the assessment results related to a country's income level in order to provide information to other countries. The databases were searched in January 2022 including MEDLINE and Scopus. Two independent reviewers evaluated the included studies based on eligibility criteria, data extraction, and quality assessment. Eleven economic evaluations of LTBI diagnostic tests in TB contacts were included. Most studies were conducted in high-income countries (91%) and used cost-effectiveness analysis methods (73%). The quality assessment of reporting and data sources was appropriate, ranging from 71% to 89%. Interventions varied from study to study. The outcomes were cost per life years gained (27%), cost per quality-adjusted life year gained (27%), cost per TB case prevented (36%), and cost per close contact case (10%). In high-income countries which were not countries with high TB burden, the use of IGRA alone for screening TB contacts was cost-effective, whereas TST was cost-effective in only two studies. In comparison to TST, IGRA could reduce false-positive results, resulting in fewer patients undergoing TB treatment and preventive treatment.

Economic Evaluation of Multiple-Pharmacogenes Testing for the Prevention of Adverse Drug Reactions in People Living with HIV.

Purpose: Pharmacogenetics (PGx) testing is one of the methods for determining whether individuals are at risk of adverse drug reactions (ADRs). It has been reported that multiple-PGx testing, a sequencing technology, has a higher predictive value than single-PGx testing. Therefore, this study aimed to determine the most cost-effective PGx testing strategies for preventing drug-induced serious ADRs in human immunodeficiency virus (HIV)-infected patients. Patients and Methods: Potential strategies, including 1) single-PGx esting (ie, HLA-B*57:01 testing before prescribing abacavir, HLA-B*13:01 testing before prescribing co-trimoxazole and dapsone, and NAT2 testing before prescribing isoniazid) and 2) multiple-PGx testing as a combination of four single-gene PGx tests in one panel, were all compared to no PGx testing (current practice). To evaluate total cost in Thai baht (THB) and quality-adjusted life years (QALYs) for each strategy-based approach to a societal perspective, a hybrid decision tree and Markov model was constructed. Incremental cost-effectiveness ratios (ICERs) were estimated. Uncertainty, threshold, and scenario analyses were all performed. Results: Before prescribing HIV therapy, providing single or multiple-PGx testing might save roughly 68 serious ADRs per year, and the number needed to screen (NNS) to avoid one serious ADR was 40. Consequently, approximately 35% and 40% of the cost of ADR treatment could be avoided by the implementation of single- and multiple-PGx testing, respectively. Compared with no PGx testing strategy, the ICERs were 146,319 THB/QALY gained for single-PGx testing and 152,014 THB/QALY gained for multiple-PGx testing. Moreover, the probability of multiple-PGx testing being cost-effective was 45% at the Thai willingness to pay threshold of 160,000 THB per QALY. Threshold analyses showed that multiple-PGx testing remained cost-effective under the range of cost, sensitivity at 0.95-1.00 and specificity at 0.98-1.00. Conclusion: Single and multiple-PGx testing might be cost-effective options for reducing the incidence of drug-induced serious ADRs in people living with HIV.

Economic evaluation of rotavirus vaccination: an important step of the introduction to the national immunization program in Thailand.

INTRODUCTION: World Health Organization recommends rotavirus vaccine for all national immunization programs (NIPs). To provide country-specific evidence, we conducted economic evaluation of a monovalent rotavirus vaccination using specific data of the pilot phase in Thailand. METHOD: A Markov model was adopted to compare the 2020 birth cohort once receiving rotavirus vaccination versus no vaccination from healthcare and societal perspective over five years. Data on disease burden, vaccine effectiveness, costs, and utilities were taken from a cohort study in two provinces of Thailand.  Sensitivity analyses were performed to test the robustness of the results. RESULTS: Rotavirus vaccination would reduce rotavirus diarrhea and costs of illness by 48% and 71%, respectively, over the first five years of life. At USD 13 per dose, vaccine was cost-effective with the ICERs of USD 4,114 and USD 1,571per QALY gained from healthcare and societal perspective, respectively. Results were sensitive to incidence and vaccine cost.  The budget for vaccine purchasing was estimated at USD13 million per year. CONCLUSION: Incorporating rotavirus vaccination into the NIP substantially reduced health and cost outcomes and was cost-effective for both perspectives. However, the government needs to negotiate vaccine price prior to program implementation to achieve favorable budget impact.

Incorporating economies of scale in the cost estimation in economic evaluation of PCV and HPV vaccination programmes in the Philippines: a game changer?

BACKGROUND: Many economic evaluations ignore economies of scale in their cost estimation, which means that cost parameters are assumed to have a linear relationship with the level of production. Economies of scale is the situation when the average total cost of producing a product decreases with increasing volume caused by reducing the variable costs due to more efficient operation. This study investigates the significance of applying the economies of scale concept: the saving in costs gained by an increased level of production in economic evaluation of pneumococcal conjugate vaccines (PCV) and human papillomavirus (HPV) vaccinations. METHODS: The fixed and variable costs of providing partial (20% coverage) and universal (100% coverage) vaccination programs in the Philippines were estimated using various methods, including costs of conducting questionnaire survey, focus-group discussion, and analysis of secondary data. Costing parameters were utilised as inputs for the two economic evaluation models for PCV and HPV. Incremental cost-effectiveness ratios (ICERs) and 5-year budget impacts with and without applying economies of scale to the costing parameters for partial and universal coverage were compared in order to determine the effect of these different costing approaches. RESULTS: The program costs of the partial coverage for the two immunisation programs were not very different when applying and not applying the economies of scale concept. Nevertheless, the program costs for universal coverage were 0.26 and 0.32 times lower when applying economies of scale compared to not applying economies of scale for the pneumococcal and human papillomavirus vaccinations, respectively. ICERs varied by up to 98% for pneumococcal vaccinations, whereas the change in ICERs in the human papillomavirus vaccination depended on both the costs of cervical cancer screening and the vaccination program. This results in a significant difference in the 5-year budget impact, accounting for 30 and 40% of reduction in the 5-year budget impact for the pneumococcal and human papillomavirus vaccination programs. CONCLUSIONS: This study demonstrated the feasibility and importance of applying economies of scale in the cost estimation in economic evaluation, which would lead to different conclusions in terms of value for money regarding the interventions, particularly with population-wide interventions such as vaccination programs. The economies of scale approach to costing is recommended for the creation of methodological guidelines for conducting economic evaluations.

A Comparison of EQ-5D-3L Index Scores Using Malaysian, Singaporean, Thai, and UK Value Sets in Indonesian Cervical Cancer Patients.

OBJECTIVES: To gain insight into the most suitable foreign value set among Malaysian, Singaporean, Thai, and UK value sets for calculating the EuroQol five-dimensional questionnaire index score (utility) among patients with cervical cancer in Indonesia. METHODS: Data from 87 patients with cervical cancer recruited from a referral hospital in Yogyakarta province, Indonesia, from an earlier study of health-related quality of life were used in this study. The differences among the utility scores derived from the four value sets were determined using the Friedman test. Performance of the psychometric properties of the four value sets versus visual analogue scale (VAS) was assessed. Intraclass correlation coefficients and Bland-Altman plots were used to test the agreement among the utility scores. Spearman ρ correlation coefficients were used to assess convergent validity between utility scores and patients' sociodemographic and clinical characteristics. With respect to known-group validity, the Kruskal-Wallis test was used to examine the differences in utility according to the stages of cancer. RESULTS: There was significant difference among utility scores derived from the four value sets, among which the Malaysian value set yielded higher utility than the other three value sets. Utility obtained from the Malaysian value set had more agreements with VAS than the other value sets versus VAS (intraclass correlation coefficients and Bland-Altman plot tests results). As for the validity, the four value sets showed equivalent psychometric properties as those that resulted from convergent and known-group validity tests. CONCLUSIONS: In the absence of an Indonesian value set, the Malaysian value set was more preferable to be used compared with the other value sets. Further studies on the development of an Indonesian value set need to be conducted.

A cost-utility analysis of cervical cancer screening and human papillomavirus vaccination in the Philippines.

BACKGROUND: Cervical cancer is the second leading cause of cancer cases and deaths among Filipino women because of inadequate access to screening and treatment services. This study aims to evaluate the health and economic benefits of HPV vaccination and its combination with different screening strategies to find the most optimal preventive strategy in the Philippines. METHODS: A cost-utility analysis was conducted using an existing semi-Markov model to evaluate different screening (i.e., Pap smear, visual inspection with acetic acid) and vaccination strategies against HPV infection implemented alone or as part of a combination strategy at different coverage scenarios. The model was run using country-specific epidemiologic, cost and clinical parameters from a health system perspective. Sensitivity analysis was performed for vaccine efficacy, duration of protection and costs of vaccination, screening and treatment. RESULTS: Across all coverage scenarios, VIA has been shown to be a dominant and cost-saving screening strategy with incremental cost-effectiveness ratio (ICER) ranging from dominant to Php 61,059 (1443 USD) per QALY gained. VIA can reduce cervical cancer cases and deaths by 25%. Pap smear screening was found to be not cost-effective due to its high cost in the Philippines. Adding HPV vaccination at a cost of 54 USD per vaccinated girl on top of VIA screening was found to be potentially cost-effective using a threshold of 1 GDP per capita (i.e., Php 120,000 or 2835 USD/ QALY) with the most favorable assumption of providing lifelong immunity against high-risk oncogenic HPV types 16/18. The highest incremental QALY gain was achieved with 80% coverage of the combined strategy of VIA at 35 to 45 years old done every five years following vaccination at 11 years of age with an ICER of Php 33,126 (783 USD). This strategy may result in a two-thirds reduction in cervical cancer burden. HPV vaccination is not cost-effective when vaccine protection lasts for less than 20 years. CONCLUSION: High VIA coverage targeting women aged 35-45 years old at five-year intervals is the most efficient and cost-saving strategy in reducing cervical cancer burden in the Philippines. Adding a vaccination program at high coverage among 11-year-old girls is potentially cost-effective in the Philippines assuming a life-long duration of vaccine efficacy.

Seasonal influenza vaccination for children in Thailand: a cost-effectiveness analysis.

BACKGROUND: Seasonal influenza is a major cause of mortality worldwide. Routine immunization of children has the potential to reduce this mortality through both direct and indirect protection, but has not been adopted by any low- or middle-income countries. We developed a framework to evaluate the cost-effectiveness of influenza vaccination policies in developing countries and used it to consider annual vaccination of school- and preschool-aged children with either trivalent inactivated influenza vaccine (TIV) or trivalent live-attenuated influenza vaccine (LAIV) in Thailand. We also compared these approaches with a policy of expanding TIV coverage in the elderly. METHODS AND FINDINGS: We developed an age-structured model to evaluate the cost-effectiveness of eight vaccination policies parameterized using country-level data from Thailand. For policies using LAIV, we considered five different age groups of children to vaccinate. We adopted a Bayesian evidence-synthesis framework, expressing uncertainty in parameters through probability distributions derived by fitting the model to prospectively collected laboratory-confirmed influenza data from 2005-2009, by meta-analysis of clinical trial data, and by using prior probability distributions derived from literature review and elicitation of expert opinion. We performed sensitivity analyses using alternative assumptions about prior immunity, contact patterns between age groups, the proportion of infections that are symptomatic, cost per unit vaccine, and vaccine effectiveness. Vaccination of children with LAIV was found to be highly cost-effective, with incremental cost-effectiveness ratios between about 2,000 and 5,000 international dollars per disability-adjusted life year averted, and was consistently preferred to TIV-based policies. These findings were robust to extensive sensitivity analyses. The optimal age group to vaccinate with LAIV, however, was sensitive both to the willingness to pay for health benefits and to assumptions about contact patterns between age groups. CONCLUSIONS: Vaccinating school-aged children with LAIV is likely to be cost-effective in Thailand in the short term, though the long-term consequences of such a policy cannot be reliably predicted given current knowledge of influenza epidemiology and immunology. Our work provides a coherent framework that can be used for similar analyses in other low- and middle-income countries.

Evaluation of Health-Related Quality of Life among Patients with Cervical Cancer in Indonesia.

BACKGROUND: Evaluation of health-related quality of life (HRQOL) in cervical cancer patients is important in order to design the interventions for improving patient outcomes. Reports of HRQOL among cervical cancer patients in Indonesia are limited. Moreover, measurement using EQ-5D-3L is to our best knowledge has hitherto not been performed. This study aimed to examine the HRQOL of cervical cancer patients in Indonesia using EQ- 5D-3L. MATERIALS AND METHODS: A cross-sectional study was conducted by interviewing cervical cancer patients using the EQ-5D-3L questionnaire. Percentages of patients who reported having problems in each dimension of EQ-5D as well as EQ-5D index score (utility) were calculated. RESULTS: Our findings indicated that the most frequent reported problems were pain/discomfort (67.8%) followed by anxiety/depression (57.5%). The mean of EQ-5D VAS was 75.8 (SD=17.0). The mean (SD) utility scores were 0.85 (0.19), 0.76 (0.20), 0.71 (0.21), and 0.77 (0.13) for cervical cancer patients in stage I, II, III, and IV, respectively. CONCLUSIONS: Cervical cancer significantly affects patient HRQOL. Efforts should be made to improve the quality of life of cervical cancer patients especially in terms of pain /discomfort and anxiety/depression reduction.

Mortality attributable to seasonal influenza A and B infections in Thailand, 2005-2009: a longitudinal study.

Influenza epidemiology differs substantially in tropical and temperate zones, but estimates of seasonal influenza mortality in developing countries in the tropics are lacking. We aimed to quantify mortality due to seasonal influenza in Thailand, a tropical middle-income country. Time series of polymerase chain reaction-confirmed influenza infections between 2005 and 2009 were constructed from a sentinel surveillance network. These were combined with influenza-like illness data to derive measures of influenza activity and relationships to mortality by using a Bayesian regression framework. We estimated 6.1 (95% credible interval: 0.5, 12.4) annual deaths per 100,000 population attributable to influenza A and B, predominantly in those aged ≥60 years, with the largest contribution from influenza A(H1N1) in 3 out of 4 years. For A(H3N2), the relationship between influenza activity and mortality varied over time. Influenza was associated with increases in deaths classified as resulting from respiratory disease (posterior probability of positive association, 99.8%), cancer (98.6%), renal disease (98.0%), and liver disease (99.2%). No association with circulatory disease mortality was found. Seasonal influenza infections are associated with substantial mortality in Thailand, but evidence for the strong relationship between influenza activity and circulatory disease mortality reported in temperate countries is lacking.

Economic evaluation of screening for disease.

There is an increasing number of attempts to provide screening test or other interventions to prevent individuals from having disease. For the success of screening programs, appropriate screening tests should be provided to the right people, at the right time and at the desirable rate. Therefore, conducting a disease model and economic evaluation would help decision-makers and stakeholders to assess the surrounding factors and ensure the successfulness of the program prior to an implementation in the real setting. Because the evaluation of screening tests is particularly specific, this chapter aims to conclude that the needed information and examples must be made clearer.

Cost-utility analysis of treatments for stage IB cervical cancer.

OBJECTIVE: To analyze the cost-utility of two common clinical practices for stage IB cervical cancer patients from provider and societal viewpoints. METHODS: A DECISION TREE MODEL WAS CONDUCTED TO EXAMINE VALUE FOR EXPENDITURE BETWEEN THE FOLLOWING: (1) radical hysterectomy with pelvic lymph node dissection (RHPLND) with or without postoperative adjuvant therapy according to the risk of recurrence and (2) concurrent chemoradiotherapy (CCRT). The relevant studies were identified to extract the probability data, and meta-analysis was performed. Direct medical costs were estimated from hospital database and medical records review. Direct non-medical costs and utility parameters were obtained through interviews with patients to estimate quality-adjusted life years (QALYs) outcome. The time horizon was according to the life expectancy of Thai women. RESULTS: From provider viewpoint, RHPLND and CCRT resulted in approximate costs of US $5,281 and US $5,218, respectively. The corresponding costs from societal viewpoint were US $6,533 and US $6,335, respectively. QALYs were 16.40 years for RHPLND and 15.94 years for CCRT. The estimated incremental cost effectiveness ratio of RHPLND in comparison to CCRT from provider and societal viewpoints were US $100/QALY and US $430/QALY, respectively. RHPLND had more cost-effectiveness than CCRT if patients did not need adjuvant therapy. The most effective parameter in model was a direct medical cost of CCRT. At the current ceiling ratio in Thailand, RHPLND provides better value for money than CCRT, with a probability of 75%. CONCLUSION: RHPLND is an efficient treatment for stage IB cervical cancer. This advantage is only for patients who require no adjuvant treatment.

A cost-utility analysis of alternative drug regimens for newly diagnosed severe lupus nephritis patients in Thailand.

OBJECTIVE: The aim of this study was to assess the value of four drug regimens for newly diagnosed severe LN from a societal perspective. METHODS: A model-based cost-utility analysis was devised to measure lifetime costs and health outcomes. Current treatment options consisting of different combinations of i.v. CYC, AZA and MMF were compared with a baseline regimen of i.v. CYC in both the induction and maintenance phases. Resource use and costs were derived from medical records reviews and databases. Event rates were elicited from randomized controlled trials. Relative treatment effects were obtained from meta-analyses. Health utilities were obtained from a real cohort of patients to estimate the outcome of quality-adjusted life years. RESULTS: It was found that a treatment regimen that combined i.v. CYC in the induction phase with AZA in the maintenance phase was cost saving compared with the baseline regimen. Treatment with i.v. CYC in the induction phase and MMF in the maintenance phase and treatment with MMF in the induction phase and a reduced dose of the same in the maintenance phase turned out to be a negatively dominated regimen. CONCLUSION: In the Thai context, the combination of i.v. CYC for the induction phase followed by AZA for the maintenance phase should be considered as the first-line therapy for newly diagnosed severe LN, as it seems to be the most cost-saving regimen.

A Cost-Utility Analysis Comparing Standard Axillary Lymph Node Dissection with Sentinel Lymph Node Biopsy in Patients with Early Stage Breast Cancer in Thailand.

OBJECTIVES: In Thailand, axillary lymph node dissection (ALND) is the dominant form of treatment for breast cancer, even though the treatment often leaves patients with some degree of arm morbidity. Sentinel lymph node biopsy (SNB) is widely accepted globally as a preferable alternative procedure because of its lower rates of associated morbidity. This study compared the cost-utility of SNB and ALND in patients with early stage breast cancer in Thailand. METHODS: A decision tree with a 5-year time horizon was developed. Outcomes that were relevant to SNB and ALND were included, along with locoregional recurrence of cancer and lymphedema scenarios. The model parameters were derived from a meta-analysis of international clinical trials and other relevant literature. The resources and cost data were derived from the medical records of tertiary hospitals. Health utilities were measured by using the standard gamble technique. A sensitivity analysis was performed using a set of plausible parameters. RESULTS: The incremental cost-effectiveness ratio (ICER) in the base-case analysis showed that SNB was more cost-effective than ALND. ICERs were -275,140 and -470,600 Thailand baht/quality-adjusted life-year gained from the provider perspective and the societal perspective, respectively. The most sensitive parameter was the utility score of patients with early stage breast cancer who had received breast-conserving therapy with lymphedema; the sensitivity and specificity of SNB had no impact on the ICER. CONCLUSIONS: The study confirmed that SNB was an economically viable alternative treatment to ALND. In developing countries, where resources are limited, nationwide implementation of SNB warrants widespread support from relevant stakeholders, including medical personnel and policymakers.

Assessing key model parameters for economic evaluation of pandemic influenza interventions: the data source matters.

BACKGROUND: In our previous systematic review of economic evaluations of pandemic influenza interventions, five model parameters, namely probability of pandemic, duration of pandemic, severity, attack rate, and intervention efficacy, were not only consistently used in all studies but also considered important by authors. OBJECTIVES: Because these parameters originated from sources of varying quality ranging from experimental studies to expert opinion, this study aims to analyze the variation in values used according to sources of information across studies. METHODS: An analysis of estimated values of key parameters for economic modeling was performed against their different data sources, following the standard hierarchy of evidence. RESULTS: A lack of good-quality evidence to estimate pandemic duration, pandemic probability, and mortality reduction from antiviral treatment results in a large variation of values used in economic evaluations. Although there are variations in quality of evidence used for attack rate, basic reproduction number, and reduction in hospitalizations from antiviral treatment, the estimated values do not vary significantly. The use of higher-quality evidence results in better precision of estimated values compared to lower-quality sources. CONCLUSION: Hierarchies of evidence are a necessary tool to identify appropriate model parameters to populate economic evaluations and should be included in methodological guidelines. Knowledge gaps in some key parameters should be addressed, because if good-quality evidence is available, future economic evaluations will be more reliable. Some gaps may not be fulfilled by research but consensus among experts to ensure consistency in the use of these assumptions.

Economic evaluation of HLA-B*15:02 screening for carbamazepine-induced severe adverse drug reactions in Thailand.

PURPOSE: There is strong evidence of an association between the presence of the human leukocyte antigen (HLA)-B*15:02 and two severe adverse drug reactions-Stevens-Johnson syndrome (SJS) and toxic epidermal necrolysis (TEN)-in patients taking carbamazepine (CBZ), a common treatment for patients with epilepsy and neuropathic pain. As a result, there are calls for all patients that are due to undergo CBZ therapy to be screened for this genetic marker before commencing their therapy. This study aims to determine the value for money of HLA-B*15:02 screening compared to the following: (1) administering CBZ therapy without conducting patient screening, and (2) not prescribing CBZ but alternative drugs that are less likely to result in severe reactions, but that come at a higher cost. METHOD: An economic evaluation was carried out by using a decision tree and Markov models to examine the cost-utility of providing HLA-B*15:02 screening for all patients with either newly diagnosed epilepsy or neuropathic pain in the Thai setting. All transitional probabilities were derived from the national and international literature. The majority of the data on direct medical care costs were collected from 10 community, provincial, and regional hospitals throughout Thailand. Direct non-medical cost and health-related quality of life (HRQoL) data were obtained from interviews that were conducted with 33 patients, some of whom had experienced severe drug reactions. KEY FINDINGS: The incremental cost-effectiveness ratio (ICER) of adopting a universal HLA-B*15:02 screening policy was estimated at 222,000 Thai baht, THB/quality-adjusted life year (QALY) gained for epilepsy patients and 130,000 THB/QALY gained for patients with neuropathic pain. Furthermore, we found that 343 patients need to be tested for HLA-B*15:02 allele to prevent one case of SJS/TEN. SIGNIFICANCE: Universal HLA-B*15:02 screening represents good value for the money in terms of preventing SJS/TEN in CBZ-treated patients with neuropathic pain at the Thai ceiling ratio of 120,000 THB/QALY gained. However, the prevalence of CBZ-induced SJS/TEN in the Thai population and the positive predictive value (PPV) are major factors that influence the cost-effectiveness of HLA-B*15:02 screening. Therefore, an active surveillance system to make a more accurate assessment of the prevalence CBZ-induced SJS/TEN in the Thai population would enhance the generalizability of the results.

Systematic review of economic evaluations of preparedness strategies and interventions against influenza pandemics.

BACKGROUND: Although public health guidelines have implications for resource allocation, these issues were not explicitly considered in previous WHO pandemic preparedness and response guidance. In order to ensure a thorough and informed revision of this guidance following the H1N1 2009 pandemic, a systematic review of published and unpublished economic evaluations of preparedness strategies and interventions against influenza pandemics was conducted. METHODS: The search was performed in September 2011 using 10 electronic databases, 2 internet search engines, reference list screening, cited reference searching, and direct communication with relevant authors. Full and partial economic evaluations considering both costs and outcomes were included. Conversely, reviews, editorials, and studies on economic impact or complications were excluded. Studies were selected by 2 independent reviewers. RESULTS: 44 studies were included. Although most complied with the cost effectiveness guidelines, the quality of evidence was limited. However, the data sources used were of higher quality in economic evaluations conducted after the 2009 H1N1 pandemic. Vaccination and drug regimens were varied. Pharmaceutical plus non-pharmaceutical interventions are relatively cost effective in comparison to vaccines and/or antivirals alone. Pharmaceutical interventions vary from cost saving to high cost effectiveness ratios. According to ceiling thresholds (Gross National Income per capita), the reduction of non-essential contacts and the use of pharmaceutical prophylaxis plus the closure of schools are amongst the cost effective strategies for all countries. However, quarantine for household contacts is not cost effective even for low and middle income countries. CONCLUSION: The available evidence is generally inconclusive regarding the cost effectiveness of preparedness strategies and interventions against influenza pandemics. Studies on their effectiveness and cost effectiveness should be readily implemented in forthcoming events that also involve the developing world. Guidelines for assessing the impact of disease and interventions should be drawn up to facilitate these studies.

Economic evaluation of policy options for prevention and control of cervical cancer in Thailand.

BACKGROUND: The Thai healthcare setting has seen patients with cervical cancer experience an increasing burden of morbidity and mortality, a stagnation in the performance of cervical screening programmes and the introduction of a vaccine for the prevention of human papillomavirus (HPV) infection. OBJECTIVE: This study aims to identify the optimum mix of interventions that are cost effective, from societal and healthcare provider perspectives, for the prevention and control of cervical cancer. METHODS: A computer-based Markov model of the natural history of cervical cancer was used to simulate an age-stratified cohort of women in Thailand. The strategy comparators, including both control and prevention programmes, were (i) conventional cytology screening (Pap smears); (ii) screening by visual inspection with acetic acid (VIA); and (iii) HPV-16, -18 vaccination. Input parameters (e.g. age-specific incidence of HPV infection, progression and regression of the infection, test performance of screening methods and efficacy of vaccine) were synthesized from a systematic review and meta-analysis. Costs (year 2007 values) and outcomes were evaluated separately, and compared for each combination. The screening strategies were started from the age of 30-40 years and repeated at 5- and 10-year intervals. In addition, HPV vaccines were introduced at age 15-60 years. RESULTS: All of the screening strategies showed certain benefits due to a decreased number of women developing cervical cancer versus 'no intervention'. Moreover, the most cost-effective strategy from the societal perspective was the combination of VIA and sequential Pap smear (i.e., VIA every 5 years for women aged 30-45 years, followed by Pap smear every 5 years for women aged 50-60 years). This strategy was dominant, with a QALY gain of 0.01 and a total cost saving of Baht (Bt) 800, compared with doing nothing. From the societal perspective, universal HPV vaccination for girls aged 15 years without screening resulted in a QALY gain of 0.06 at an additional cost of Bt 8,800, based on the cost of Bt 15,000 for a full immunization schedule. The incremental cost-effectiveness ratio, comparing HPV vaccinations for girls aged 15 years with the current national policy of Pap smears for women aged 35-60 years every 5 years, was approximately Bt 18,1000 per QALY gained. This figure was relatively high for the Thai setting. CONCLUSIONS: The results suggest that controlling cervical cancer by increasing the numbers of women accepting the VIA and Pap smear screening as routine and by improving the performance of the existing screening programmes is the most cost-effective policy option in Thailand.

Human papillomavirus vaccine introduction in low-income and middle-income countries: guidance on the use of cost-effectiveness models.

BACKGROUND: The World Health Organization (WHO) recommends that the cost effectiveness of introducing human papillomavirus (HPV) vaccination is considered before such a strategy is implemented. However, developing countries often lack the technical capacity to perform and interpret results of economic appraisals of vaccines. To provide information about the feasibility of using such models in a developing country setting, we evaluated models of HPV vaccination in terms of their capacity, requirements, limitations and comparability. METHODS: A literature review identified six HPV vaccination models suitable for low-income and middle-income country use and representative of the literature in terms of provenance and model structure. Each model was adapted by its developers using standardised data sets representative of two hypothetical developing countries (a low-income country with no screening and a middle-income country with limited screening). Model predictions before and after vaccination of adolescent girls were compared in terms of HPV prevalence and cervical cancer incidence, as was the incremental cost-effectiveness ratio of vaccination under different scenarios. RESULTS: None of the models perfectly reproduced the standardised data set provided to the model developers. However, they agreed that large decreases in type 16/18 HPV prevalence and cervical cancer incidence are likely to occur following vaccination. Apart from the Thai model (in which vaccine and non-vaccine HPV types were combined), vaccine-type HPV prevalence dropped by 75% to 100%, and vaccine-type cervical cancer incidence dropped by 80% to 100% across the models (averaging over age groups). The most influential factors affecting cost effectiveness were the discount rate, duration of vaccine protection, vaccine price and HPV prevalence. Demographic change, access to treatment and data resolution were found to be key issues to consider for models in developing countries. CONCLUSIONS: The results indicated the usefulness of considering results from several models and sets of modelling assumptions in decision making. Modelling groups were prepared to share their models and expertise to work with stakeholders in developing countries. Please see related article: http://www.biomedcentral.com/1741-7007/9/55.

A determination of topics for health technology assessment in Thailand: making decision makers involved.

This study is to describe experiences and findings from the topic selection process for health technology assessment (HTA) conducted by Health Intervention and Technology Assessment Program. The process comprised of 5 stages namely: (1) determining objectives, scope and involved stakeholders; (2) requesting potential topics for assessment from decision makers at the national health authorities; (3) reviewing related literature on and prioritizing the proposed HTA topics by HITAP researchers; (4) selecting the HTA topics by decisionmakers; (5) analyzing the strengths and weaknesses of the current topic selection processes by HITAP staff The strengths of the topic selection were systematic and transparent. It also required participation from stakeholders; however the limitations were topics prioritization methods and time constraints. Lessons learnt from this procedure can be useful for improving the next HTA topic selection in order to increase the usefulness of the future HTA results.