What, how and who: Cost-effectiveness analyses of COVID-19 vaccination to inform key policies in Nigeria.

While safe and efficacious COVID-19 vaccines have achieved high coverage in high-income settings, roll-out remains slow in sub-Saharan Africa. By April 2022, Nigeria, a country of over 200 million people, had only distributed 34 million doses. To ensure the optimal use of health resources, cost-effectiveness analyses can inform key policy questions in the health technology assessment process. We carried out several cost-effectiveness analyses exploring different COVID-19 vaccination scenarios in Nigeria. In consultation with Nigerian stakeholders, we addressed three key questions: what vaccines to buy, how to deliver them and what age groups to target. We combined an epidemiological model of virus transmission parameterised with Nigeria specific data with a costing model that incorporated local resource use assumptions and prices, both for vaccine delivery as well as costs associated with care and treatment of COVID-19. Scenarios of vaccination were compared with no vaccination. Incremental cost-effectiveness ratios were estimated in terms of costs per disability-adjusted life years averted and compared to commonly used cost-effectiveness ratios. Viral vector vaccines are cost-effective (or cost saving), particularly when targeting older adults. Despite higher efficacy, vaccines employing mRNA technologies are less cost-effective due to high current dose prices. The method of delivery of vaccines makes little difference to the cost-effectiveness of the vaccine. COVID-19 vaccines can be highly effective and cost-effective (as well as cost-saving), although an important determinant of the latter is the price per dose and the age groups prioritised for vaccination. From a health system perspective, viral vector vaccines may represent most cost-effective choices for Nigeria, although this may change with price negotiation.

USA stockpiling of remdesivir: How should the world respond?

The race to find an effective treatment for coronavirus disease 2019 (COVID-19) is still on, with only two treatment options currently authorized for emergency use and/or recommended for patients hospitalized with severe respiratory symptoms: low-dose dexamethasone and remdesivir. The USA decision to stockpile the latter has resulted in widespread condemnation and in similar action being taken by some other countries. In this commentary we discuss whether stockpiling remdesivir is justified in light of the currently available evidence.

What do we need to know? Data sources to support evidence-based decisions using health technology assessment in Ghana.

BACKGROUND: Evidence-based decision-making for prioritising health is assisted by health technology assessment (HTA) to integrate data on effectiveness, costs and equity to support transparent decisions. Ghana is moving towards universal health coverage, facilitated mainly by the National Health Insurance Scheme (NHIS) established in 2003. The Government of Ghana is committed to institutionalising HTA for priority-setting. We aimed to identify and describe the sources of accessible data to support HTA in Ghana. METHODS: We identified and described data sources encompassing six main domains using an existing framework. The domains were epidemiology, clinical efficacy, costs, health service use and consumption, quality of life, and equity. We used existing knowledge, views of stakeholders, and searches of the literature and internet. RESULTS: The data sources for each of the six domains vary in extent and quality. Ghana has several large data sources to support HTA (e.g. Demographic Health Surveys) that have rigorous quality assurance processes. Few accessible data sources were available for costs and resource utilisation. The NHIS is a potentially rich source of data on resource use and costs but there are some limits on access. There are some data on equity but data on quality of life are limited. CONCLUSIONS: A small number of quality data sources are available in Ghana but there are some gaps with respect to HTA based on greater use of local and contextualised information. Although more data are becoming available for monitoring, challenges remain in terms of their usefulness for HTA, and some information may not be available in disaggregated form to enable specific analyses. We support recent initiatives for the routine collection of comprehensive and reliable data that is easily accessible for HTA users. A commitment to HTA will require concerted efforts to leverage existing data sources, for example, from the NHIS, and develop and maintain new data (e.g. local health utility estimates). It will be critical that an overarching strategic and mandatory approach to the collection and use of health information is developed for Ghana in parallel to, and informed by, the development of HTA approaches to support resource allocation decisions. The key to HTA is to use the best available data while being open about its limitations and the impact on uncertainty.

How long has NICE taken to produce Technology Appraisal guidance? A retrospective study to estimate predictors of time to guidance.

OBJECTIVES: To assess how long the UK's National Institute for Health and Clinical Excellence's (NICE) Technology Appraisal Programme has taken to produce guidance and to determine independent predictors of time to guidance. DESIGN: Retrospective time to event (survival) analysis. SETTING: Technology Appraisal guidance produced by NICE. DATASOURCE: All appraisals referred to NICE by February 2010 were included, except those referred prior to 2001 and a number that were suspended. OUTCOME MEASURE: Duration from the start of an appraisal (when the scope document was released) until publication of guidance. RESULTS: Single Technology Appraisals (STAs) were published significantly faster than Multiple Technology Appraisals (MTAs) with median durations of 48.0 (IQR; 44.3-75.4) and 74.0 (IQR; 60.9-114.0) weeks, respectively (p <0.0001). Median time to publication exceeded published process timelines, even after adjusting for appeals. Results from the modelling suggest that STAs published guidance significantly faster than MTAs after adjusting for other covariates (by 36.2 weeks (95% CI -46.05 to -26.42 weeks)) and that appeals against provisional guidance significantly increased the time to publication (by 42.83 weeks (95% CI 35.50 to 50.17 weeks)). There was no evidence that STAs of cancer-related technologies took longer to complete compared with STAs of other technologies after adjusting for potentially confounding variables and only weak evidence suggesting that the time to produce guidance is increasing each year (by 1.40 weeks (95% CI -0.35 to 2.94 weeks)). CONCLUSIONS: The results from this study suggest that the STA process has resulted in significantly faster guidance compared with the MTA process irrespective of the topic, but that these gains are lost if appeals are made against provisional guidance. While NICE processes continue to evolve over time, a trade-off might be that decisions take longer but at present there is no evidence of a significant increase in duration.

Cost effectiveness of using carboxymethylcellulose dressing compared with gauze in the management of exuding venous leg ulcers in Germany and the USA.

OBJECTIVE: To assess the cost effectiveness of using carboxymethylcellulose dressing (CMCD; Aquacel Hydrofiber) compared to gauze in the management of exuding venous leg ulcers in Germany and the USA. DESIGN AND SETTING: This was a modelling study performed from the perspective of payers (i.e. the sickness funds in Germany and the community sector in the USA). METHODS: Clinical outcomes attributable to managing exuding venous leg ulcers were obtained from the published literature in the English language. These data were combined with resource utilisation estimates derived from a panel of clinicians enabling us to construct two decision models depicting the management of venous leg ulcers with CMCD or gauze over 18 weeks in Germany and the USA. The models were used to estimate the cost effectiveness of CMCD compared to gauze in the management of exuding venous leg ulcers in both countries. MAIN OUTCOME MEASURES AND RESULTS: Starting treatment with CMCD instead of gauze in both Germany and the USA is expected to heal 30% of ulcers within 18 weeks compared to 13% with gauze (p = 0.003). The healthcare cost of starting treatment with CMCD or gauze in Germany is expected to be Euro2020 and Euro 2654 respectively at 18 weeks. Additionally, the healthcare cost of starting treatment with CMCD or gauze in the USA is expected to be $3797 and $5288 respectively at 18 weeks. Hence, using CMCD instead of gauze is expected to increase the probability of healing within 18 weeks by 130% and reduce healthcare costs by at least 24%. The healthcare cost of managing CMCD-treated patients was less than that of gauze-treated patients in both countries due to decreased nursing and physician costs associated with a lower frequency of CMCD dressing changes compared to gauze dressing changes. If it were assumed that treatment with gauze in both countries heals 30% of ulcers within 18 weeks (i.e. is identical to CMCD), then the expected healthcare cost of using gauze would be reduced by only 3% (from Euro2654 to Euro2562 in Germany and from $5288 to $5148 in the USA). CONCLUSION: Within the limitations of our model, starting management of an exuding venous leg ulcer with CMCD instead of gauze is the cost effective strategy in both Germany and the USA. Moreover, the purchase price of a leg ulcer dressing should not be used as an indication of the cost effectiveness of a given method of care.

Modelling the cost implications of using carboxymethylcellulose dressing compared with gauze in the management of surgical wounds healing by secondary intention in the US and UK.

OBJECTIVE: To estimate the costs of using carboxymethyl cellulose dressing (CMCD; Aquacel* Hydrofiber) compared to gauze in managing surgical wounds healing by secondary intention in the US and UK. STUDY DESIGN: This was a modelling study performed from the perspective of payers (i.e. the hospital and community sector in the US and the National Health Service (NHS) in the UK). METHODS: Clinical outcomes attributable to managing surgical wounds healing by secondary intention with gauze were obtained from the published literature in the English language. There were no published studies on wounds healing by secondary intention with CMCD. Hence, the analysis conservatively assumed that wound healing rates associated with gauze would be the same for CMCD. These data were combined with resource utilisation estimates derived from a panel of clinicians enabling us to perform decision modelling. The models were used to determine the expected direct healthcare costs eight weeks after the surgical wounds were dressed by CMCD or gauze and left to heal by secondary intention in the US and UK. RESULTS: All wounds are expected to heal within eight weeks, irrespective of dressing. Managing abscesses and other surgical wounds with CMCD instead of gauze in the US is expected to reduce costs by 4% in both wound types (i.e. $247 and $507 respectively) per patient over eight weeks. In the UK, managing abscesses and other surgical wounds with CMCD instead of gauze is expected to reduce costs by 30% (574 pounds) and 12% (581 pounds) respectively per patient over eight weeks. The lower cost of managing CMCD-treated patients is due to decreased nursing costs associated with a lower frequency of CMCD changes compared to gauze dressing changes. CONCLUSION: Dressing surgical wounds healing by secondary intention with CMCD instead of gauze is expected to lead to a reduction in healthcare costs in both the US and UK. Hence, the purchase price of a dressing is not indicative of the cost effectiveness of a given method of surgical wound care.

A comparison of the resources used in advanced cancer care between two different strong opioids: an analysis of naturalistic practice in the UK.

OBJECTIVE: To assess the resource implications of using strong opioids in patients with advanced cancer in the UK, based on naturalistic practice, in order to develop the evidence base supporting better management. DESIGN AND SETTING: A modelling study performed from the perspective of the UK's National Health Service (NHS). Study participants and interventions: A data set was created from the DIN-link database comprising 986 patients with advanced cancer who were prescribed either 12-hourly sustained release morphine (SR morphine; MST Continuous) ( n = 784) or transdermal fentanyl (Durogesic) (n = 202) as their first strong opioid between 1st January 1998 and 30th September 2000 and died during that period. METHODS: Palliative care-related resource use data were obtained from the DIN-link database. Unit costs at 2000/2001 prices were applied to the resource use values to determine the mean NHS cost of palliative care from the start of treatment until death. RESULTS: Patients initially treated with transdermal fentanyl started their strong opioid regime 8.5 years after diagnosis compared to 6.4 years after diagnosis in those who started SR morphine. This equates to an overall survival period from diagnosis of 8.8 years and 7.4 years respectively. Nevertheless, the total NHS cost of palliative care was similar between treatment groups, ranging from a mean 3087-3462 pounds per patient. Hospitalisation accounted for up to 71% of the total cost and opioids accounted for up to a further 17%. Less than one-third of patients received 4-hourly morphine as part of their initial opioid treatment despite UK guidelines recommending that moderate-to-severe pain should always be managed initially with an immediate-release preparation. Additionally, patients who received transdermal fentanyl as part of their initial treatment received significantly more laxative prescriptions than patients who started with SR morphine. CONCLUSIONS: SR morphine and transdermal fentanyl seem to be used in different situations. The results also confirm previous findings that pain management in cancer patients is often sub-optimal. The low contribution of opioids to the overall costs indicates that this should not be an obstacle to starting this aspect of palliative care earlier in disease progression. This characterisation of the resource implications of using SR morphine and transdermal fentanyl should enable purchasers and providers to optimise the availability of strong opioids for cancer patients on medical, economic and humanitarian grounds.

Cost implications of post-surgical morbidity following blood transfusion in cancer patients undergoing elective colorectal resection: an evaluation in the US hospital setting.

OBJECTIVE: To estimate the cost implications of blood transfusions and related surgical site infections (SSIs) in cancer patients undergoing elective colorectal resection in the hospital setting in the United States (US). STUDY DESIGN: A modelling study was performed from the perspective of the hospital sector, based on published clinical outcomes from a study in Taiwan involving 2809 cancer patients who underwent elective colorectal resection using laparotomy and American treatment patterns. METHODS: Data on resource use were retrieved from published literature and from two American hospital centres specialising in colorectal cancer management. Decision analytical modelling was used to estimate the treatment costs and consequences of managing patients undergoing elective colorectal resection with and without blood transfusions. RESULTS: The expected treatment costs of managing patients who required and did not require a blood transfusion were estimated to be US dollars 19,869 (95% CI: 15 797; 23 150) and US dollars 14,586 (95% CI: 14 263; 14 886) per patient respectively. Expected treatment costs for those patients transfused with 1-3 units and > 3 units of blood were estimated to be US dollars 17,449 and US dollars 22,588 per patient respectively. CONCLUSION: This is one of the first studies to specifically address the cost implications of postsurgical morbidity following colorectal resection in cancer patients. The cost of managing cancer patients undergoing elective colorectal resection who require a blood transfusion is expected to be 36% more than that of non-transfused patients, largely resulting from the development of SSIs.

Switching asthma patients to a once-daily inhaled steroid improves compliance and reduces healthcare costs.

OBJECTIVE: To determine the costs and consequences of switching asthma patients, managed in primary care, from a twice-daily inhaled corticosteroid (ICS), to either a once-daily or another twice-daily ICS. DESIGN: This was a case-control study based on an interrogation of the General Practice Research Database in the UK, for patients with a Read code of asthma who were managed between 1990 and 2001, and who had received at least two prescriptions for a twice-daily ICS within 12 months, before switching to a once-daily ICS (cases) or another twice-daily ICS (controls). Data on resource use was collected for one year before and after the switch. Patients were stratified according to whether their treatment step had been stepped up, stepped down or remained unchanged. SETTING: A modelling study performed from the perspective of the UK's National Health Service (NHS). MAIN OUTCOME MEASURES: Compliance with ICS, and the cost of drug and non-drug resource use, for the year before and after the switch. RESULTS: Switching patients managed in primary care to a once-daily ICS increased compliance and reduced NHS costs, irrespective of whether patients' treatment had been stepped up or down. Switching patients to another twice-daily ICS increased compliance to a lesser extent, and increased NHS costs. We believe that this paper offers the first documented association between compliance in asthma and NHS management costs. CONCLUSIONS: Compliance and management costs among patients with asthma managed in primary care appear to be related to both changing treatment and dosing regimen. Within the limitations of our study, the results suggest that patients who are switched to a once-daily ICS rather than another twice-daily preparation are better compliers with their ICS medication. Additionally, patients who become high-compliers after being switched to a once-daily ICS incur lower management costs than patients who become high-compliers after being switched to another twice-daily ICS. These findings should now be investigated further under more controlled conditions.

Cost Effectiveness of Controlled-Release Oxybutynin Compared with Immediate-Release Oxybutynin and Tolterodine in the Treatment of Overactive Bladder in the UK, France and Austria.

OBJECTIVE: To estimate the cost effectiveness of controlled-release (CR) oxybutynin compared with immediate-release (IR) oxybutynin and tolterodine in the treatment of overactive bladder (OAB) in Austria, France and the UK. DESIGN AND SETTING: This was a modelling study on the management of patients with OAB who were >/=18 years of age, and had urge or mixed incontinence with a primary-urge component. The study was performed from the perspective of payers (i.e. the National Health Service [NHS] in the UK, Social Security in France and the Sick Funds in Austria) and patients. METHODS: Clinical outcomes attributable to managing OAB were obtained from the published literature, and resource utilisation estimates were derived from a panel of clinicians. Using decision analytical techniques, three decision models were constructed depicting the management of OAB with CR oxybutynin, IR oxybutynin and tolterodine over 6 months in the UK, France and Austria. The models were used to estimate the cost effectiveness of CR oxybutynin relative to the other two anticholinergic drugs in each of the three countries and the expected direct patient costs and indirect societal costs (at 2000/2001 prices). MAIN OUTCOME MEASURES AND RESULTS: Starting OAB treatment with CR oxybutynin instead of either IR oxybutynin or tolterodine in the UK and Austria was found to be a potentially dominant strategy, since it improves clinical outcome at a lower cost, from the payers' perspective. In France, starting OAB treatment with CR oxybutynin instead of either the IR formulation or tolterodine was found to be a potentially cost-effective strategy from the payer's perspective. The expected 6-monthly direct costs to patients were euro230, euro720-920 and euro970-1000 in the UK, France and Austria, respectively. In the UK and Austria, these costs were broadly consistent between initial treatments. However, in France, tolterodine-treated patients would be expected to incur 28% more expenditure than patients treated with the other two drugs. Transportation emerged as the primary cost driver, accounting for at least 60% of patients' out-of-pocket expenditure, in all three countries. Irrespective of the initial treatment, patients would be expected to miss 1-2 days of work over 6 months as a result of their OAB. This equates to an expected lost productivity cost of euro84, euro250 and euro98 in the UK, France and Austria, respectively. CONCLUSION: Starting OAB treatment with CR oxybutynin is expected to be a clinically more effective strategy than starting with either IR oxybutynin or tolterodine, and potentially the most cost-effective strategy in all three countries.

Costs and consequences of botulinum toxin type A use. Management of children with cerebral palsy in Germany.

This study was a retrospective survey of the management of a cohort of children with cerebral palsy at Seepark Hospital, Germany, who did (cases; n=107) and did not (controls; n=107) receive botulinum toxin injections. Data on healthcare resource use and clinical outcomes over 12 months were collected from the date cases received their first injection and from the date controls were first admitted into hospital. Botulinum toxin use led to an 85% reduction in the number of children requiring surgery. Additionally, controls used significantly more healthcare resources than cases, particularly hospital bed days (69.2+/-34.1 vs. 27.5+/-27.9 days; p <0.0001). The total cost of managing cases and controls was 16,700 and 33,800, respectively. In conclusion, use of botulinum toxin released resources for alternative use during the first year following treatment, without any loss of clinical improvement. However, it is unknown how botulinum toxin affected the need for surgery and associated outcomes in subsequent years.