Cost-effectiveness of pelvic exenteration for locally advanced malignancy.

BACKGROUND: The rising cost of healthcare is well documented. The purpose of this study was to determine the cost-effectiveness of pelvic exenteration (PE). METHODS: Consecutive patients referred for consideration of PE between 2008 and 2011 were recruited into a prospective non-randomized study that compared quality of life (QoL) between patients who did or did not undergo PE. Information on QoL and cost (in Australian dollars, AUD) was collected at baseline, during admission and up to 24 months after discharge. QoL data were converted into a utility-based measure. Quality-adjusted life-years (QALYs) were calculated. Bottom-up costing was performed. The incremental cost-effectiveness ratio (ICER) was calculated per life-year saved and per QALY. RESULTS: There were 174 patients with sufficient data for analysis. Of these, 139 underwent PE. R0 was achieved in 78·4 per cent of patients. The survival rate at 24 months after PE was 74·8 per cent compared with 43 per cent in those without exenteration (P = 0·001). Treatment costs were significantly higher for patients who had PE compared with those who did not (mean AUD 137 407 versus 79 174; P < 0·001). The ICER was AUD 124 147 (95 per cent c.i. 71 585 to 261 876) per life-year saved and AUD 227 330 (109 974 to 1 100 449) per QALY. Curative PE (R0) was found to be more cost-effective than non-curative PE (R1/R2), with an ICER of AUD 101 518 (60 105 to 200 428) versus 390 712 (74 368 to 82 256 739) per life-year saved. CONCLUSION: Treatment of advanced pelvic cancers is expensive regardless of the treatment intent. For a cost difference of only AUD 58 000 (€38 264), PE offers a chance of cure, and improves survival and QoL.

Weighing up the benefits and harms of a new anti-cancer drug: a survey of Australian oncologists.

BACKGROUND: Little is known about the relative importance that oncologists attribute to the benefits and harms of anti-cancer drugs when considering treatment options with their patients. AIM: To quantify the trade-offs made between overall survival, progression-free survival and adverse effects. METHODS: A web-based survey elicited importance weights for the benefits and harms of bevacizumab or everolimus. Combining the importance weights with trial-based probabilities produced a score and ranking for each treatment option. RESULTS: A total of 40 responses was received for the bevacizumab scenario and 32 for the everolimus scenario. All respondents regarded overall survival and progression-free survival as the most important attributes - more important than avoiding the potential harms regardless of drugs. Among the potential harms, respondents allocated the highest mean importance weight to gastrointestinal (GI) perforation and rated absolute improvement in overall survival as 1.6 times and 2.3 times as important as avoiding GI perforation in the two versions of the bevacizumab scenario respectively. For the everolimus scenario, stomatitis and pneumonitis were allocated the highest mean importance weights with absolute improvement in overall survival rated as 2.2 times as important as avoiding stomatitis/pneumonitis. All 40 respondents (100%) favoured treatment option with bevacizumab to no bevacizumab based on respondents' determined weights for treatment attributes. The converse was found for everolimus with 22 (69%) of respondents preferring the 'no everolimus' option. CONCLUSION: Oncologists' preferences over the benefits and harms of treatment do, when combined with evidence of effect, influence treatment decisions for anti-cancer drugs.

Rising cost of anticancer drugs in Australia.

BACKGROUND: Anticancer drugs are often expensive and are contributing to the growing cost of cancer care. Concerns have been raised about the effect rising costs may have on availability of new anticancer drugs. AIM: This study aims to determine the recent changes in the costs of anticancer drugs in Australia. METHODS: Publicly available expenditure and prices paid by the Australian Pharmaceutical Benefits Scheme (PBS) for anticancer drugs from 2000 to 2012 were reviewed. The measures used to determine changes in cost were total PBS expenditure and average price paid by the PBS per prescription for anticancer drugs and for all PBS listed drugs. An estimated monthly price paid for newly listed anticancer drugs was also calculated. RESULTS: Annual PBS expenditure on anticancer drugs rose from A$65 million in 1999-2000 to A$466 million in 2011-2012; an average increase of 19% per annum. The average price paid by the PBS per anticancer drug prescription, adjusted for inflation, increased 133% from A$337 to A$786. The real average annual increase in the price per anticancer drug prescription was more than double that for all other PBS drugs combined (7.6% vs 2.8%, difference 4.8%, 95% confidence interval -0.4% to 10.1%, P = 0.07). The median price for a month's treatment of the new anticancer drugs listed was A$4919 (range A$1003 to A$12 578, 2012 prices). CONCLUSIONS: PBS expenditure and the price of anticancer drugs in Australia rose substantially from 2000 to 2012. Dealing with these burgeoning costs will be a major challenge for our health system and for those affected by cancer.

A comparative case study of bowel cancer screening in the UK and Australia: evidence lost in translation?

OBJECTIVES: (i) To document the current state of the English, Scottish, Welsh, Northern Irish and Australian bowel cancer screening programmes, according to seven key characteristics, and (ii) to explore the policy trade-offs resulting from inadequate funding. SETTING: United Kingdom and Australia. METHODS: A comparative case study design using document and key informant interview analysis. Data were collated for each national jurisdiction on seven key programme characteristics: screening frequency, population coverage, quality of test, programme model, quality of follow-up, quality of colonoscopy and quality of data collection. A list of optimal features for each of the seven characteristics was compiled, based on the FOBT screening literature and our detailed examination of each programme. RESULTS: Each country made different implementation choices or trade-offs intended to conserve costs and/or manage limited and expensive resources. The overall outcome of these trade-offs was probable lower programme effectiveness as a result of compromises such as reduced screening frequency, restricted target age range, the use of less accurate tests, the deliberate setting of low programme positivity rates or increased inconvenience to participants from re-testing. CONCLUSIONS: Insufficient funding has forced programme administrators to make trade-offs that may undermine the potential net population benefits achieved in randomized controlled trials. Such policy compromise contravenes the principle of evidence-based practice which is dependent on adequate funding being made available.

Consumer impact of an interactive decision aid for rectal cancer patients offered adjuvant therapy.

OBJECTIVE: There is increasing interest in the use of decision aids (DAs) to facilitate patient involvement in clinical decisions. This study explored the views of patients with colorectal cancer and participants in a community bowel screening service regarding an interactive DA concerning adjuvant treatment for rectal cancer, and the impact of the aid on knowledge, anxiety, attitudes and preferences for treatment options. METHOD: Fourteen patients with colorectal cancer participated in four focus groups. Eighty-nine participants in a community bowel screening service completed a questionnaire before and 1 week after viewing the DA. Thirty were randomly selected to participate in a telephone interview to obtain qualitative feedback about the DA. RESULTS: Focus group participants reported using information to evaluate their doctor's care and expertise, or to prepare themselves for future symptoms and side-effects. Most supported the use of a DA and preferred pie charts to convey risk information. Within the community sample, anxiety remained stable and knowledge increased after exposure to the DA. Almost all participants found the DA useful and easy to understand, and felt it would make the process of decision making easier. CONCLUSION: A DA regarding adjuvant therapy for rectal cancer appears to be valued and to produce positive outcomes. A randomized controlled trial of this intervention is now required.

Discrete-choice experiment to measure patient preferences for the surgical management of colorectal cancer.

BACKGROUND: Establishing trust between a patient and his or her surgeon is of paramount importance. The aim of this study was to assess the relative importance of the 'attributes of trust' between surgeon and patient with colorectal cancer. METHODS: A discrete-choice questionnaire was conducted with 60 men and 43 women who had completed primary treatment for colorectal cancer in two teaching hospitals in Sydney, Australia. RESULTS: Forty-seven of the 103 patients based their choice of surgical management on a single attribute and the remainder were willing to trade between different attributes. In order of importance, patients based their choice of surgical management on specialty training (beta coefficient = 0.83), surgeon's communication (beta = 0.82), type of hospital (beta = 0.72) and who decides treatment (beta = 0.01). Patients who were vigilant in their decision-making style and those who did not have tertiary education were more likely to change their preferences in the repeat interview. CONCLUSION: Clinicians may have a better chance of meeting a patient's expectations about the process of care if they assess the patient's desire for knowledge and give those who do not have tertiary education more time to assimilate information about their treatment.

Economic impact of laparoscopic versus open abdominal rectopexy.

BACKGROUND: The introduction of new laparoscopic techniques has important cost implications. The aim of this study was to compare the cost effectiveness of laparoscopic rectopexy with that of open abdominal rectopexy for full-thickness rectal prolapse. METHODS: A cost effectiveness study was conducted alongside a randomized trial of laparoscopic versus open abdominal rectopexy. RESULTS: The efficacy trial demonstrated significant subjective and objective differences in favour of the laparoscopic technique. The mean operating time was 51 min longer for laparoscopic rectopexy than for the open procedure. Laparoscopic disposables incurred a mean cost of pound 291 per patient. The mean duration of hospital stay was significantly shorter for the laparoscopic group (P = 0.001). Laparoscopic rectopexy was associated with an overall mean cost saving of pound 357 (95 per cent confidence interval pound 164 to pound 592; P = 0.042) per patient. CONCLUSION: Laparoscopic rectopexy is associated with superior clinical outcomes and is cheaper than the open approach.

What constitutes success in preventive health care? A case study in assessing the benefits of hip protectors.

The economic success of preventive health programs is typically assessed by the net health-related utility gain or loss to society relative to the cost. Issues relating to the positive or negative utility associated with participating in a preventive health program are often ignored. However, it is likely that calls for informed consumer choice and respect for patient autonomy will provide an impetus to examine utility associated with the process and outcomes of preventive health programs. In this paper, we outline the nature of the ex ante and ex post perspective in evaluating benefits and the presence of process utility and the utility of gambling in individual's utility function for preventive health care. The implications of including process attributes and psychological states when assessing benefits to society are discussed in relation to an empirical study on the value of external hip protectors for the prevention of hip fractures. We demonstrate that wearing hip protectors and the psychological outcomes of being a participant in the program can have a significant impact on individual's assessment of the benefits. Furthermore, point of reference plays a crucial role in their valuation. Individuals who did not consent to participate in a trial of hip protectors valued all states significantly lower than those who did participate in the trial. We argue that the utility associated with adherence to the intervention is an important issue for preventive health policy. From the viewpoint of applied welfare economics, evaluation of preventive health programs should allow for both process and outcome utility when assessing benefits. In this context, success might be viewed as maximising the opportunity for individuals to make an informed choice.

Cost utility of photodynamic therapy for predominantly classic neovascular age related macular degeneration.

BACKGROUND/AIM: Age related macular degeneration (AMD) is the leading cause of severe vision impairment and blindness in older people throughout the developed world and currently affects around 420 000 UK citizens. Choroidal neovascularisation (CNV) is treatable with photodynamic therapy (PDT) but is expensive at over pound 1200 per treatment. The aim of this study was to assess the cost utility of PDT for better eye, predominantly classic, subfoveal choroidal neovascular lesions secondary to AMD. METHODS: Cost utility analysis (CUA) was conducted to estimate the cost effectiveness of PDT for scenarios involving reasonable (6/12) and poor (6/60) visual acuity. The models incorporated data from the Treatment of Age-related Macular Degeneration with PDT (TAP) Study and patient based utilities. The incremental CUA was based on decision analytical models, comparing treatment to a placebo comparator. Extensive one way sensitivity analysis of parameters was conducted to determine the robustness of the model. A discount rate of 6% was used for costs and quality adjusted life years (QALY). RESULTS: Model 1: in people with reasonable initial visual acuity, the cost utility of treating applicable neovascular AMD lesions was pound 31 607 per QALY saved, with a sensitivity analysis range from pound 25 285 to pound 37 928. Model 2: in people with poor initial visual acuity, the cost utility was pound 63 214 per QALY saved, with a sensitivity analysis range from pound 54 183 to pound 75 856. CONCLUSIONS: PDT treatment is the only available treatment for some forms of neovascular ("wet") AMD. Under these assumptions, PDT can be considered moderately cost effective for those with reasonable visual acuity but less cost effective for those with initial poor visual acuity. These findings have implications for ophthalmic practice and healthcare planning.

Cost utility of screening and treatment for early age related macular degeneration with zinc and antioxidants.

AIM: To assess the cost effectiveness of high dose zinc and antioxidants for delaying and reducing the progression of early age related macular degeneration (AMD). BACKGROUND: AMD is the leading cause of severe vision impairment and blindness in older people throughout the developed world. It currently affects around 420 000 people in the United Kingdom. METHODS: A cost utility analysis (CUA) was conducted to estimate the cost per quality adjusted life year (QALY) for screening a cohort of men and women, aged 55 years and over, for early AMD and then treating them with zinc and antioxidants. The incremental CUA was based on a decision analytic model, comparing screening with a no screening comparator (current practice). Extensive one way sensitivity analysis of parameters was conducted to determine the robustness of the model. RESULTS: In this model the cost effectiveness of screening for early AMD was pound 22 722 per quality adjusted life year (QALY) saved. The cost per QALY decreased to pound 18 948 if photodynamic therapy with verteporfin savings were included. CONCLUSIONS: Screening for, and prophylactic treatment of, early AMD is estimated to cost around pound 22 700 per QALY saved. This cost falls within accepted levels to warrant further investigation. These findings have implications for ophthalmic practice and healthcare planning.

Home bowel cancer tests and informed choice--is current information sufficient?

OBJECTIVES: To evaluate the type of information that is available to purchasers of home-based bowel cancer test kits. METHODS: Manufacturers, pharmacies and independent testing programs were contacted to obtain faecal occult blood test (FOBT) kits. State cancer organisations were contacted for information on bowel cancer screening. Information on bowel cancer, the FOBT kit, the testing process and potential benefits and harms of the screening process were assessed using guidelines provided by the UK General Medical Council (GMC). RESULTS: FOBT kits and cancer organisation information provided adequate information on the purpose of screening, the screening process itself and potential benefits, but provided no information concerning uncertainties of screening or potential harms. CONCLUSIONS: On the basis of both the UK GMC criteria and patient desires for information, the information available at present falls short of being considered adequate for an informed decision to purchase a home-based FOBT. IMPLICATIONS: We must ensure adequate and balanced information is available to redress the present information asymmetry to facilitate informed participation in a potentially valuable public health initiative.

A randomised trial of hip protector use by frail older women living in their own homes.

OBJECTIVES: To investigate the efficacy and effectiveness of hip protectors in frail community living older women. DESIGN: Randomised controlled trial. SETTING: Aged care health services in New South Wales, Australia. PATIENTS: 600 women 74 years of age or more (mean age 83 years), who had two or more falls or one fall requiring hospital admission in the previous year, and who lived in their own homes. INTERVENTION: Use of hip protectors. MAIN OUTCOME MEASURES: Adherence with use of hip protectors, falls, incidence of hip fracture, and adverse effects of use of hip protectors. RESULTS: Adherence was approximately 53% over the duration of the study and hip protectors were worn at the time of 51% of falls in the intervention group. The risk of hip fracture when falling while wearing hip protectors, compared with a fall with no hip protectors in place, was significantly reduced (relative risk (RR) 0.23, 95% confidence interval (CI) 0.08 to 0.67). On an intention to treat analysis, 21 and 22 hip fractures occurred in the intervention and control groups respectively (adjusted RR 0.92, 95% CI 0.51 to 1.68). Three users of hip protectors sustained a hip fracture while wearing properly applied protectors, while 16 hip protector users (5%) developed minor local complications. CONCLUSIONS: Hip protectors prevent hip fractures in community dwelling older women if worn at the time of a fall. The overall effectiveness of hip protectors was not established in this study, because of incomplete adherence with use of the protectors, and limited statistical power.

Feasibility study of the early detection and treatment of renal disease by mass screening.

AIM: To determine whether mass screening for proteinuria may be worthwhile in the detection of early renal disease in Australians. METHODS: A feasibility study was conducted using systematic review, meta-analysis and cost-effectiveness methods. RESULTS: End-stage renal disease (ESRD) develops in about 1500 Australians each year. Of these, about 1000 are over 50 years of age (an incidence of about 200 per million, per year). Proteinuria, which is present in about 5% of the general population, confers an approximately 15-fold increased risk for ESRD. Twelve randomized trials of angiotensin-converting enzyme inhibitors (ACEi), in 1943 patients with varying degrees of renal impairment, hypertension and proteinuria, showed that the risk of developing ESRD can be reduced by about 30% over a 2- to 3-year period. In a general-practice-based screening model involving: (i) an opportunistic single dipstick test for protein, (ii) a confirming 24-h urine test for protein and (iii) commencement of ACEi in appropriate individuals, 20 000 people over 50 years of age would need to be screened to prevent one case of ESRD. To achieve this, approximately 100 people would need to be treated with ACEi for 2 to 3 years, and 1,000 would need to have a 24-h urine protein test (and of these, 700 would be false positives). Such a strategy may save health dollars but some critical research questions are still unanswered. What is an individual's risk of developing ESRD, given values for proteinuria, blood pressure and renal function? What is the benefit of ACEi in screen-detected cases, which are at low risk of ESRD? What psychological and physical harm is caused by screening, including the specific renal investigations and treatments that follow on from proteinuria detection? CONCLUSIONS: Given available data, screening middle-aged and older Australians for proteinuria and treating some with ACEi is, at best, a promising primary prevention strategy for preventing ESRD. However, a large population-based cohort study, with nested trial of ACEi, is still required to evaluate whether this model of screening for renal disease does more harm than good.

Adherence to occupational therapist recommendations for home modifications for falls prevention.

OBJECTIVE: This study examined adherence to home modification recommendations made by an occupational therapist and attempted to identify predictors of adherence. METHOD: An experienced occupational therapist visited the homes of 178 people (mean age = 764 years) to evaluate for and recommend appropriate home modifications for falls prevention. One year later, a research assistant visited these persons' homes to assess adherence. RESULTS: At least one home modification was recommended in 150 of the 178 homes visited. The most common recommendations were to remove mats and throw rugs (48%), to change footwear (24%), and to use a nonslip bathmat (21%). In the 121 homes revisited after 12 months, 419 home modifications had been recommended, and 216 (52%) were met with partial or complete adherence. The only significant predictors of adherence were a belief that home modifications can prevent falls and having help at home from relatives. CONCLUSION: A major barrier to adherence to home modification recommendations is that many older people do not believe that home modifications can reduce their risk of falling.

The cost effectiveness of a home hazard reduction program to reduce falls among older persons.

BACKGROUND: The effectiveness of individual components (other than exercise) of multifactorial intervention packages aimed to reduce the incidence of falls in older people is uncertain. There have been no randomised trials of home modifications alone for the prevention of falls. OBJECTIVES: To estimate the cost-effectiveness of just one component of a multifactorial approach to falls prevention, that is, a home hazard reduction program. The study estimates the size and direction of change in resource use within and between the hospital, home and community sectors. METHODS: A randomised trial was conducted to evaluate the effectiveness of home modifications for prevention of falls among older people. An occupational therapist (O/T) with experience in aged care assessed homes for environmental hazards and supervised the necessary home modifications. SUBJECTS: The subjects in this study were people aged 65 years and older and most were recruited during a hospital stay. The cost-effectiveness analysis was based on a randomised trial with a total of 530 subjects. RESULTS: The incremental cost per fall prevented was $4,986. A sensitivity analysis was conducted by removing 12 outlier subjects (6 control and 6 intervention). The incremental cost per fall prevented was $1,921 for all subjects and was cost saving for subjects who had fallen in the 12 months prior to randomisation. CONCLUSIONS & IMPLICATIONS: A single factor home hazard reduction program is more likely to be most cost-effective amongst older people who have a history of falls.

The veil of experience: do consumers prefer what they know best?

There is growing interest from health policy makers in eliciting consumer preferences for health care services. This is particularly the case when assessing the likely impact of innovations. Some people may be wary of innovations because they prefer the service they have previously experienced. Consumer preferences for an existing and a hypothetical new bowel cancer testing programme were measured using a discrete choice experiment questionnaire. The results showed that consumers had a statistically significant preference for the existing service (status quo) when all other factors remained constant. It suggested that consumers make decisions under a 'veil of experience'. Possible explanations for this result include the endowment effect, status quo bias and loss aversion. Future evaluations of health service innovation should be aware of this tendency to favour the status quo.

A. V. Hernandez, 'Duplicate coverage and demand for health care. The case of Catalonia'. Health economics 8(7) 1999, 579-598

The original article to which this Erratum refers was published in Health Economics 8(7) 1999, 579-598.