Considering equity in priority setting using transmission models: Recommendations and data needs.

OBJECTIVES: Disease transmission models are used in impact assessment and economic evaluations of infectious disease prevention and treatment strategies, prominently so in the COVID-19 response. These models rarely consider dimensions of equity relating to the differential health burden between individuals and groups. We describe concepts and approaches which are useful when considering equity in the priority setting process, and outline the technical choices concerning model structure, outputs, and data requirements needed to use transmission models in analyses of health equity. METHODS: We reviewed the literature on equity concepts and approaches to their application in economic evaluation and undertook a technical consultation on how equity can be incorporated in priority setting for infectious disease control. The technical consultation brought together health economists with an interest in equity-informative economic evaluation, ethicists specialising in public health, mathematical modellers from various disease backgrounds, and representatives of global health funding and technical assistance organisations, to formulate key areas of consensus and recommendations. RESULTS: We provide a series of recommendations for applying the Reference Case for Economic Evaluation in Global Health to infectious disease interventions, comprising guidance on 1) the specification of equity concepts; 2) choice of evaluation framework; 3) model structure; and 4) data needs. We present available conceptual and analytical choices, for example how correlation between different equity- and disease-relevant strata should be considered dependent on available data, and outline how assumptions and data limitations can be reported transparently by noting key factors for consideration. CONCLUSIONS: Current developments in economic evaluations in global health provide a wide range of methodologies to incorporate equity into economic evaluations. Those employing infectious disease models need to use these frameworks more in priority setting to accurately represent health inequities. We provide guidance on the technical approaches to support this goal and ultimately, to achieve more equitable health policies.

Don't forget about the future: The impact of including future costs on the cost-effectiveness of adult pneumococcal conjugate vaccination with PCV13 in the Netherlands.

BACKGROUND: When vaccines increase longevity, vaccinated people may experience costs and benefits during added life-years. These future benefits and costs may include increased productivity as well as medical and non-medical costs. Such impacts should be considered in cost-effectiveness analyses (CEA) of vaccines but are often omitted. Here, we illustrate the impact of including future costs on the cost-effectiveness of vaccination against pneumococcus disease. We emphasize the relevance of differentiating cost estimates between risk groups. METHODS: We updated an existing Dutch CEA of vaccination against pneumococcus disease with the 13-valent pneumococcal conjugate vaccine (PCV13) to include all future medical and non-medical costs. We linked costs by age and risk with survival information and estimates of cases prevented per vaccination strategy based on the original study to calculate the impact of inclusion. Future medical costs were adjusted for relevant risk groups. RESULTS: For the base-case strategy, the original incremental cost-effectiveness ratio (ICER) of PVC13 was €9,157 per quality adjusted life-year (QALY). Including all future medical costs increased the ICER to €28,540 per QALY. Also including future non-medical costs resulted in an ICER of €45,691 per QALY. The impact of future medical costs varied considerably per risk group and generally increased with age. DISCUSSION AND CONCLUSION: This study showed a substantial effect of the inclusion of future costs on the ICER of vaccinating with PCV13. Especially when lives of people with underlying health conditions are extended, the impact of future medical costs is large. This inclusion may make vaccination a less attractive option, especially in relation to low thresholds as often applied for prevention. Although this raises important questions, ignoring these real future costs may lead to an inefficient use of healthcare resources. Our results may imply that prices for some vaccines need to be lowered to be cost-effective.

A randomised comparison of the effect of haemodynamic monitoring with CardioMEMS in addition to standard care on quality of life and hospitalisations in patients with chronic heart failure : Design and rationale of the MONITOR HF multicentre randomised clinical trial.

BACKGROUND: Assessing haemodynamic congestion based on filling pressures instead of clinical congestion can be a way to further improve quality of life (QoL) and clinical outcome by intervening before symptoms or weight gain occur in heart failure (HF) patients. The clinical efficacy of remote monitoring of pulmonary artery (PA) pressures (CardioMEMS; Abbott Inc., Atlanta, GA, USA) has been demonstrated in the USA. Currently, the PA sensor is not reimbursed in the European Union as its benefit when applied in addition to standard HF care is unknown in Western European countries, including the Netherlands. AIMS: To demonstrate the efficacy and cost-effectiveness of haemodynamic PA monitoring in addition to contemporary standard HF care in a high-quality Western European health care system. METHODS: The current study is a prospective, multi-centre, randomised clinical trial in 340 patients with chronic HF (New York Heart Association functional class III) randomised to HF care including remote monitoring with the CardioMEMS PA sensor or standard HF care alone. Eligible patients have at least one hospitalisation for HF in 12 months before enrolment and will be randomised in a 1:1 ratio. Minimum follow-up will be 1 year. The primary endpoint is the change in QoL as measured by the Kansas City Cardiomyopathy Questionnaire (KCCQ). Secondary endpoints are the number of HF hospital admissions and changes in health status assessed by EQ-5D-5L questionnaire including health care utilisation and formal cost-effectiveness analysis. CONCLUSION: The MONITOR HF trial will evaluate the efficacy and cost-effectiveness of haemodynamic monitoring by CardioMEMS in addition to standard HF care in patients with chronic HF. Clinical Trial Registration number NTR7672.

Developing a framework to assess the costeffectiveness of COMPARE - a global platform for the exchange of sequence-based pathogen data.

Analysing the genomic data of pathogens with the help of next-generation sequencing (NGS) is an increasingly important part of disease outbreak investigations and helps guide responses. While this technology has already been successfully employed to elucidate and control disease outbreaks, wider implementation of NGS also depends on its cost-effectiveness. COMPARE - short for 'Collaborative Management Platform for detection and Analyses of (Re-) emerging and foodborne outbreaks' - is a major project, funded by the European Union, to develop a global platform for sharing and analysing NGS data and thereby improve the rapid identification, containment and mitigation of emerging infectious diseases and foodborne outbreaks. This article introduces the project and presents the results of a review of the literature, composed of previous relevant cost-benefit and cost-effectiveness analyses. The authors also outline the implications for a methodological framework to assess the costeffectiveness of COMPARE and similar systems.

L'analyse des données sur le génome des agents pathogènes grâce au séquençage de nouvelle génération (SNG) joue un rôle de plus en plus important dans les enquêtes sur les foyers de maladies et contribue à l'élaboration de stratégies de réponse. Si cette technologie a été utilisée avec succès pour élucider la cause des certains foyers et pour les contrôler, une application plus large du SNG dépend également de sa rentabilité. La plate-forme COMPARE (plate-forme de gestion collaborative pour la détection et l'analyse des foyers émergents et ré-émergents et des toxi-infections alimentaires) est un projet de grande envergure financé par l'Union européenne, visant à mettre en place une plate-forme mondiale d'échanges et d'analyse des données de séquençage de nouvelle génération et à améliorer ainsi l'identification précoce, le confinement et l'atténuation des maladies infectieuses émergentes et des foyers de toxiinfections alimentaires. Les auteurs présentent le projet ainsi que les résultats d'une étude bibliographique intégrant des analyses pertinentes coûts­avantages et coûts­efficacité réalisées dans le passé. Ils soulignent également les enseignements de ces analyses pour l'élaboration d'un cadre méthodologique d'évaluation de la relation coûts­efficacité applicable au système COMPARE et à d'autres systèmes similaires.

El análisis de datos genómicos de los patógenos con ayuda de técnicas de secuenciación de próxima generación es un componente cada vez más importante de la investigación de brotes infecciosos, que resulta de utilidad para guiar las medidas de respuesta. Aunque estas técnicas ya se han utilizado con éxito para elucidar y combatir brotes de enfermedad, su aplicación generalizada también dependerá de la relación costo-eficacia que ofrezcan. COMPARE (acrónimo inglés de «plataforma de gestión colectiva para la detección y análisis de brotes (re)emergentes y de transmisión alimentaria¼) es un vasto proyecto financiado por la Unión Europea que apunta a instituir un dispositivo mundial de intercambio y análisis de datos de secuenciación de próxima generación y lograr así más eficacia en la rápida identificación, contención y mitigación de brotes de transmisión alimentaria y de enfermedades infecciosas emergentes. Los autores exponen el proyecto y presentan los resultados de un repaso bibliográfico de anteriores análisis de las relaciones costo-beneficio y costo-eficacia de estas técnicas. Además, explican brevemente lo que puede aportar un marco metodológico para evaluar la relación costo-eficacia del sistema COMPARE y de otros sistemas similares.

[We are living longer, but in good health? Inequality in quality-adjusted life expectancy]. / We leven langer, maar ook in goede gezondheid?

OBJECTIVE: Quantifying trends in quality-adjusted life expectancy (QALE) by level of education in the Netherlands 2001-2011. DESIGN: Retrospective study. METHOD: For this study we used data from several sources. Using regression models we estimated mortality rates and quality of life as functions of age, gender, calendar year and educational level. Quality of life was measured using the SF-6D questionnaire. In order to calculate QALE we combined estimates of mortality rates and quality of life into Sullivan's life tables. RESULTS: Over the period 2001-2011 quality of life and survival increased at all educational levels. This resulted in an increase of QALE varying from 1.5 to 3 years depending on gender and education. QALE increased less strongly in people with lower education than in those with higher education, which to a large extent was due to widening inequalities in mortality. CONCLUSION: The Dutch are living longer and have a better quality of life but inequalities in QALE have increased.

Cost-effectiveness analyses of health promotion programs: a case study of smoking prevention and cessation among Dutch students.

Little research has been done to connect health promotion programs to outcomes in terms of life expectancy, health care costs and cost-effectiveness. For a policy maker, economic evaluation may be an important tool to support decisions on how to allocate the health care budget. The aim of this paper was to determine the cost-effectiveness of a Dutch school-based smoking education program. The incremental cost-effectiveness ratio of the school program was estimated at euro19 900 per quality adjusted life year gained. For a complete analysis, not only intervention costs but also savings for smoking-related diseases and differences in total health care costs should be taken into account. As several assumptions had to be made in order to estimate cost-effectiveness, the study outcomes should be interpreted with caution. Main problem in estimating the cost-effectiveness was the lack of proper effectiveness data on daily smokers among adolescents. Absence of specific effectiveness data often is an obstacle in the economic evaluation of public health interventions. While some problems may be the result of insufficient sample size or follow-up, another possible explanation might be the different basic principles of analysis of health promoters and economists.