Exploring the potential cost-effectiveness of a new computerised decision support tool for identifying fetal compromise during monitored term labours: an early health economic model.

BACKGROUND: Around 60% of term labours in the UK are continuously monitored using cardiotocography (CTG) to guide clinical labour management. Interpreting the CTG trace is challenging, leading to some babies suffering adverse outcomes and others unnecessary expedited deliveries. A new data driven computerised tool combining multiple clinical risk factors with CTG data (attentive CTG) was developed to help identify term babies at risk of severe compromise during labour. This paper presents an early health economic model exploring its potential cost-effectiveness. METHODS: The model compared attentive CTG and usual care with usual care alone and simulated clinical events, healthcare costs, and infant quality-adjusted life years over 18 years. It was populated using data from a cohort of term pregnancies, the literature, and administrative datasets. Attentive CTG effectiveness was projected through improved monitoring sensitivity/specificity and potential reductions in numbers of severely compromised infants. Scenario analyses explored the impact of including litigation costs. RESULTS: Nationally, attentive CTG could potentially avoid 10,000 unnecessary alerts in labour and 2400 emergency C-section deliveries through improved specificity. A reduction of 21 intrapartum stillbirths amongst severely compromised infants was also predicted with improved sensitivity. Attentive CTG could potentially lead to cost savings and health gains with a probability of being cost-effective at £25,000 per QALY ranging from 70 to 95%. Potential exists for further cost savings if litigation costs are included. CONCLUSIONS: Attentive CTG could offer a cost-effective use of healthcare resources. Prospective patient-level studies are needed to formally evaluate its effectiveness and economic impact in routine clinical practice.

Clinical and economic impact of first-line or drug-naïve catheter ablation and delayed second-line catheter ablation for atrial fibrillation using a patient-level simulation model.

AIMS: To determine the clinical and economic implications of first-line or drug-naïve catheter ablation compared to antiarrhythmic drugs (AADs), or shorter AADs-to-Ablation time (AAT) in atrial fibrillation (AF) patients in France and Italy, using a patient level-simulation model. MATERIALS AND METHODS: A patient-level simulation model was used to simulate clinical pathways for AF patients using published data and expert opinion. The probabilities of adverse events (AEs) were dependent on treatment and/or disease status. Analysis 1 compared scenarios of treating 0%, 25%, 50%, 75% or 100% of patients with first-line ablation and the remainder with AADs. In Analysis 2, scenarios compared the impact of delaying transition to second-line ablation by 1 or 2 years. RESULTS: Over 10 years, increasing first-line ablation from 0% to 100% (versus AAD treatment) decreased stroke by 12%, HF hospitalization by 29%, and cardioversions by 45% in both countries. As the rate of first-line ablation increased from 0% to 100%, the overall 10-year per-patient costs increased from €13,034 to €14,450 in Italy and from €11,944 to €16,942 in France. For both countries, the scenario with no delay in second-line ablation had fewer AEs compared to the scenarios where ablation was delayed after AAD failure. Increasing rates of first-line or drug-naïve catheter ablation, and shorter AAT, resulted in higher cumulative controlled patient years on rhythm control therapy. LIMITATIONS: The model includes assumptions based on the best available clinical data, which may differ from real-world results, however, sensitivity analyses were included to combat parameter ambiguity. Additionally, the model represents a payer perspective and does not include societal costs, providing a conservative approach. CONCLUSION: Increased first-line or drug-naïve catheter ablation, and shorter AAT, could increase the proportion of patients with controlled AF and reduce AEs, offsetting the small investment required in total AF costs over 10 years in Italy and France.

This study created an individual patient level simulation to estimate the clinical and economic implications of catheter ablation, which is a non-pharmacological option to treat patients with atrial fibrillation (AF). This study examines the impact of the updated 2020 ESC guidelines to managing AF in Italian and French patients comparing antiarrhythmic drug treatment to first- and second-line catheter ablation. Differences in AF-related adverse events (AEs) such as stroke, hospitalization, cardioversions, and bleeding events were considered in the model to inform the overall per-patient costs. The model was tested with 50,000 patient simulations to limit random effects. The results of the patient simulation model revealed that as the frequency of utilizing first-line catheter ablation increased from 0% to 100% compared to pharmacological treatment, AEs were reduced in both countries, resulting in a slightly increased 10-year-per-patient cost. Additionally, for patients who fail first-line pharmacological treatment, those who receive second-line catheter ablation in the next year, versus a delay of one or two years, had the highest rate of cumulative controlled patient years on rhythm control therapy and the lowest AE rate by year 10 of the model. Overall, 10-year per-patient costs were similar, regardless of whether second-line ablation was delivered with no delay or a one-or two-year delay. In conclusion, increased use of first-line catheter ablation and earlier second-line catheter ablation can reduce the rates of adverse clinical events and increase the proportion of patients with controlled AF for a similar investment in per-patient costs over 10-years.

Economic values of some important traits for smallholder dairy production in Central Ethiopia.

Economic value (EV), sensitivity of EV and relative economic importance of milk yield (MY), age at first calving (AFC), calving interval (CI) and herd life (HL) traits were estimated for smallholder dairy cattle production in the central part of Ethiopia. The data on biological and economic parameters were collected using household interview and group discussions methods participating 238 farmers who had crossbred dairy cattle. Bio-economic model was used to calculate EV, sensitivity of EV and relative importance of EV. Cost of animal feed takes the highest share which accounted 81.35% of the total expenditure. The overall average profit per farmer expressed in Ethiopia currency (ETB, 1 US-$ = 39.55696 ETB) was 72,458.10 ± 5068 per year. Profitability of crossbred dairy cattle significantly varied (P < 0.05) between zones. Economic value estimated for MY, AFC, CI and HL in ETB were 13.38/kg, -16.19/day, -33.58/day and 79.55/day. The associated EV per additive standard deviation were 6083.62, -1311.59, -1271.05 and 117.73 ETB for MY, AFC, CI and HL, respectively. Analysis of sensitivity to scenario change (± 20%) showed that milk price had positive association with profit and EV, whereas feed price has inversely influenced both profit and EV. The profit obtained by farmers was altered by ± 29.08% and ± 12.31% as milk price and feed price fluctuated by ± 20%, respectively. Similarly, the EV of MY was changed by ± 20% with change in milk price and ± 7% with feed price. Scenario change in feed price (± 20%) has also caused ± 13.63% change on EV for AFC and ± 17.58% for CI. It can be noted that profit and EV of the traits were less sensitive to the change in price of milk, feed and labor. In general, the results of EV and profitability were encouraging for dairy farmers and the estimates can be used as an input for development of breeding program in the study area.

Clinical and cost-effectiveness of clopidogrel resistance genotype testing after ischaemic stroke or transient ischaemic attack: a systematic review and economic model.

Background: Stroke or transient ischaemic attack patients are at increased risk of secondary vascular events. Antiplatelet medications, most commonly clopidogrel, are prescribed to reduce this risk. Factors including CYP2C19 genetic variants can hinder clopidogrel metabolism. Laboratory-based or point-of-care tests can detect these variants, enabling targeted treatment. Objective: To assess the effectiveness of genetic testing to identify clopidogrel resistance in people with ischaemic stroke or transient ischaemic attack. Specific objectives: Do people tested for clopidogrel resistance, and treated accordingly, have a reduced risk of secondary vascular events? Do people with loss-of-function alleles associated with clopidogrel resistance have a reduced risk of secondary vascular events if treated with alternative interventions compared to clopidogrel? Do people with loss-of-function alleles associated with clopidogrel resistance have an increased risk of secondary vascular events when treated with clopidogrel? What is the accuracy of point-of-care tests for detecting variants associated with clopidogrel resistance? What is the technical performance and cost of CYP2C19 genetic tests? Is genetic testing for clopidogrel resistance cost-effective compared with no testing? Design: Systematic review and economic model. Results: Objective 1: Two studies assessed secondary vascular events in patients tested for loss-of-function alleles and treated accordingly. They found a reduced risk, but confidence intervals were wide (hazard ratio 0.50, 95% confidence interval 0.09 to 2.74 and hazard ratio 0.53, 95% confidence interval 0.24 to 1.18). Objective 2: Seven randomised controlled trials compared clopidogrel with alternative treatment in people with genetic variants. Ticagrelor was associated with a lower risk of secondary vascular events than clopidogrel (summary hazard ratio 0.76, 95% confidence interval 0.65 to 0.90; two studies). Objective 3: Twenty-five studies compared outcomes in people with and without genetic variants treated with clopidogrel. People with genetic variants were at an increased risk of secondary vascular events (hazard ratio 1.72, 95% confidence interval 1.43 to 2.08; 18 studies). There was no difference in bleeding risk (hazard ratio 0.98, 95% confidence interval 0.68 to 1.40; five studies). Objective 4: Eleven studies evaluated Genomadix Cube accuracy; no studies evaluated Genedrive. Summary sensitivity and specificity against laboratory reference standards were both 100% (95% confidence interval 94% to 100% and 99% to 100%). Objective 5: Seventeen studies evaluated technical performance of point-of-care tests. Test failure rate ranged from 0.4% to 19% for Genomadix Cube. A survey of 8/10 genomic laboratory hubs revealed variation in preferred technologies for testing, and cost per test ranging from £15 to £250. Most laboratories expected test failure rate to be < 1%. Additional resources could enhance testing capacity and expedite turnaround times. Objective 6: Laboratory and point-of-care CYP2C19 testing strategies were cost-saving and increase quality-adjusted life-years compared with no testing. Both strategies gave similar costs, quality-adjusted life-years and expected net monetary benefit. Conclusions: Our results suggest that CYP2C19 testing followed by tailored treatment is likely to be effective and cost-effective in both populations. Future work: Accuracy and technical performance of Genedrive. Test failure rate of Genomadix Cube in a National Health Service setting. Value of testing additional loss-of-function alleles. Appropriateness of treatment dichotomy based on loss-of-function alleles. Limitations: Lack of data on Genedrive. No randomised 'test-and-treat' studies of dipyramidole plus aspirin. Study registration: This study is registered as PROSPERO CRD42022357661. Funding: This award was funded by the National Institute for Health and Care Research (NIHR) Evidence Synthesis programme (NIHR award ref: NIHR135620) and is published in full in Health Technology Assessment; Vol. 28, No. 57. See the NIHR Funding and Awards website for further award information.

The most common type of stroke occurs when the supply of blood to the brain is cut off. Symptoms of stroke happen suddenly and vary depending on which part of the brain is affected. They usually include problems with movement, speech, vision and the face drooping on one side. A 'transient ischaemic attack' is a milder related condition. There are around 100,000 strokes and 60,000 transient ischaemic attacks every year in the UK. People who have a stroke or transient ischaemic attack are at greater risk of having another stroke. To reduce the chances of this happening, doctors will often prescribe medication. The most common medication used is called 'clopidogrel'. However, clopidogrel does not work for everyone. One reason for this is having specific variations of a gene called the CYP2C19 gene. Around one in three people in the UK have this variation. We wanted to know whether introducing genetic testing to identify variations in the CYP2C19 gene for people who have had a stroke or transient ischaemic attack can help doctors prescribe a treatment that will work for them, reducing the risk of having another stroke. We also wanted to know if doing this test would be a good use of NHS money. Doing a genetic test to identify variations in the CYP2C19 gene, and prescribing an alternative medication for people with these variations, may reduce the chances of having a new stroke. It is likely that a genetic test for variations of the CYP2C19 gene would represent value for money for the NHS.

Bridging Hepatitis C Care Gaps: A Modeling Approach for Achieving the WHO's Targets in Ontario, Canada.

BACKGROUND: The World Health Organization (WHO) has set hepatitis C (HCV) elimination targets for 2030. Understanding existing gaps in the "HCV care-cascade" is essential for meeting these targets. We aimed to identify the level of service scale-up needed along the "HCV care-cascade" to achieve the WHO's HCV elimination targets in Ontario, Canada. METHODS: By employing a decision analytic model, we projected the quality-adjusted life years (QALYs) and healthcare costs for individuals with HCV in Ontario. We increased RNA testing and treatment rates to 98%, followed by increasing antibody testing uptake until we achieved the WHO's mortality target (i.e., a 65% reduction in liver-related mortality by 2030 vs. 2015). RESULTS: Without scaling up by 2030, the expected QALYs and costs per person were 9.156 and CAD 48,996, respectively. Improved RNA testing and treatment rates reduced liver-related deaths to 3.3/100,000, a 57% reduction from 2015. Further doubling the antibody testing rates can achieve the WHO's mortality target in 2035, but not in 2030. Compared to the status quo, such program would be cost-effective considering a 50,000 CAD/QALY gained threshold if annual implementation costs stayed under 2.3 M CAD/100,000 people. CONCLUSIONS: Doubling the antibody testing rates, along with increased RNA testing and treatment rates, showed promise in meeting the WHO's goals by 2035.

Economic impact of government health expenditure: An application of the computable general equilibrium model to the Iran.

BACKGROUND: Considering the increase in health expenses and the government's role in health financing, this study investigated the economic impact of increases in the share of the health sector in the government budget while taxes remain unchanged and government spending is fixed. MATERIAL AND METHODS: The economic model used in this study was a macroeconomic Computable General Equilibrium (CGE) model. This model was calibrated using a 2011 Social Accounting Matrix (SAM) Of Iran. The CGE model was solved with non-linear programming using the General Algebraic Modeling System package, version 2.50. The effect of this simulation on the government budget deficit, the production of different sectors of the economy, and the employment rate was investigated. RESULTS: Based on our fundings the elasticity of substitution in the agricultural and industrial sectors is higher than in the health and service sector. Also, the biggest decrease in production occurred in the industry, agriculture, and service sectors, respectively. With the doubling of the share of government spending in the health sector, the employment rate of this sector has increased by 40.9%, but the highest decrease in the ignition rate is related to the service sectors (-2.7%), agriculture (-0.23%), and industry (-0.14%). CONCLUSION: Increasing the share of government spending in the health sector in comparison with other sectors of the economy, provided that government spending is maintained in general, leads to a decrease in production and economic welfare. It seems that the Iranian government should seek to increase the sources of health financing and the share of government expenditures in the health sector with other ways in order to improve the health level of the society and have a positive effect on other economic sectors.

Continuous decision to wait for a future reward is guided by fronto-hippocampal anticipatory dynamics.

Deciding whether to wait for a future reward is crucial for surviving in an uncertain world. While seeking rewards, agents anticipate a reward in the present environment and constantly face a trade-off between staying in their environment or leaving it. It remains unclear, however, how humans make continuous decisions in such situations. Here, we show that anticipatory activity in the anterior prefrontal cortex, ventrolateral prefrontal cortex, and hippocampus underpins continuous stay-leave decision-making. Participants awaited real liquid rewards available after tens of seconds, and their continuous decision was tracked by dynamic brain activity associated with the anticipation of a reward. Participants stopped waiting more frequently and sooner after they experienced longer delays and received smaller rewards. When the dynamic anticipatory brain activity was enhanced in the anterior prefrontal cortex, participants remained in their current environment, but when this activity diminished, they left the environment. Moreover, while experiencing a delayed reward in a novel environment, the ventrolateral prefrontal cortex and hippocampus showed anticipatory activity. Finally, the activity in the anterior prefrontal cortex and ventrolateral prefrontal cortex was enhanced in participants adopting a leave strategy, whereas those remaining stationary showed enhanced hippocampal activity. Our results suggest that fronto-hippocampal anticipatory dynamics underlie continuous decision-making while anticipating a future reward.

Water, nitrogen, and phosphorus coupling improves gray jujube fruit quality and yield.

Irrigation and fertilization are indispensable links in the jujube planting industry in southern Xinjiang, China. Regulating the relationship between fertilization and irrigation can effectively reduce costs and improve economic efficiency. A 2-year water and fertilizer optimization coupling test was conducted to determine the optimal water and nutrient supply scheme. The three-factor randomized block experiment included water (W), nitrogen (N), and phosphorus (P). According to the principal component analysis of each index, each treatment's comprehensive score was obtained. Using yield and economic regression models, the theoretical value and yield value of the optimal economic benefit are inferred. When W, N, and P were applied together, the fruit quality and yield of each treatment significantly differed, and the vitamin C, soluble sugar, and sugar-acid ratio increased significantly with an increase in N fertilizer. However, the titratable acid decreased. An increase in irrigation and nitrogen application significantly increased fruit yield. The comprehensive score was the highest in the N4P3W2 treatment, which improved fruit quality, and the lowest in the N3P3W2 treatment. When the amounts of N, P, and W were 275.56 kg hm-2, 413. 66 kg hm-2, and 7278.19 m3 hm-2, respectively, the theoretical economic benefit was the best. The N4P3W2 treatment is the optimal treatment.

Cost-effectiveness of rimegepant oral lyophilisate compared to best supportive care for the acute treatment of migraine in the UK.

AIMS: Migraine is the most common disabling headache disorder and is characterized by recurrent throbbing head pain and symptoms of photophobia, phonophobia, nausea, and vomiting. Rimegepant 75 mg, an oral lyophilisate calcitonin gene-related peptide antagonist, is the first treatment approved for both the acute and preventative treatment of migraine, and the first acute therapy approved in over 20-years. The objective was to assess the cost-utility of rimegepant compared with best supportive care (BSC) in the UK, for the acute treatment of migraine in the adults with inadequate symptom relief after taking at least 2 triptans, or for whom triptans are contraindicated or not tolerated. MATERIALS AND METHODS: A de novo model was developed to estimate incremental costs and quality-adjusted life years (QALYs), structured as a decision tree followed by Markov model. Patients received rimegepant or BSC for a migraine attack and were assessed for response (pain relief at 2-h). Responders and non-responders followed different pain trajectories over 48-h cycles. Non-responders discontinued treatment while responders continued treatment for subsequent attacks, with a proportion discontinuing over time. Data sources included a post-hoc pooled analysis of the phase 3 acute rimegepant trials (NCT03235479, NCT03237845, NCT03461757), and a long-term safety study (NCT03266588). The analysis was conducted from the perspective of the UK National Health Service and Personal Social Services over a 20-year time horizon. RESULTS: Rimegepant resulted in an incremental cost-utility ratio (ICUR) of £10,309 per QALY gained vs BSC, which is cost-effectiveness at a willingness to pay threshold of £30,000/QALY. Rimegepant generated +0.44 incremental QALYs and higher incremental lifetime costs (£4,492). Improved QALYs for rimegepant were a result of less time spent with severe and moderate headache pain. CONCLUSION: This study highlights the economic value of rimegepant which was found to be cost-effective for the acute treatment of migraine in adults unsuitable for triptans.

Validating Health Economic Models With the Probabilistic Analysis Check dashBOARD.

OBJECTIVES: Health economic (HE) models are often considered as "black boxes" because they are not publicly available and lack transparency, which prevents independent scrutiny of HE models. Additionally, validation efforts and validation status of HE models are not systematically reported. Methods to validate HE models in absence of their full underlying code are therefore urgently needed to improve health policy making. This study aimed to develop and test a generic dashboard to systematically explore the workings of HE models and validate their model parameters and outcomes. METHODS: The Probabilistic Analysis Check dashBOARD (PACBOARD) was developed using insights from literature, health economists, and a data scientist. Functionalities of PACBOARD are (1) exploring and validating model parameters and outcomes using standardized validation tests and interactive plots, (2) visualizing and investigating the relationship between model parameters and outcomes using metamodeling, and (3) predicting HE outcomes using the fitted metamodel. To test PACBOARD, 2 mock HE models were developed, and errors were introduced in these models, eg, negative costs inputs, utility values exceeding 1. PACBOARD metamodeling predictions of incremental net monetary benefit were validated against the original model's outcomes. RESULTS: PACBOARD automatically identified all errors introduced in the erroneous HE models. Metamodel predictions were accurate compared with the original model outcomes. CONCLUSIONS: PACBOARD is a unique dashboard aiming at improving the feasibility and transparency of validation efforts of HE models. PACBOARD allows users to explore the working of HE models using metamodeling based on HE models' parameters and outcomes.

Modeling the implications of policy reforms on pesticide risk for Switzerland.

Growing public awareness of the negative effects of pesticides on the environment, ecosystems, and human health has led governments to set targets for reducing pesticide risk. Switzerland introduced in 2023 two new policy measures to reduce pesticide risk by 50 % by 2027: (1) voluntary direct payment programs supporting pesticide-reduced and pesticide-free but non-organic cropping systems for most crops on arable land, and (2) restrictions of harmful pesticides for farmers managing under Swiss cross-compliance standards. This study aims to (1) develop a method to assess pesticide risk on a national scale and (2) carry out an ex-ante impact assessment to predict whether these policies can effectively reduce pesticide risks in Switzerland. Therefore, we introduced crop-specific pesticide quantities and pesticide risk scores into a sample of 1907 bio-economic farm optimization models. The models were used to predict farmers' adoption decisions regarding voluntary direct payment programs from 2019 to 2030. By combining the bio-economic farm optimization models with an agent-based modeling approach, we assessed the evolution of pesticide-related risks at the national level. Simulations for pesticide risk from 2019 to 2022 reflected the observed pesticide risk monitored by the Swiss government. In surface waters and semi-natural habitats, achieving the target depends on reducing pyrethroids, a class of insecticides with high-risk potential. Further, we highlight significant uncertainty in projecting the risk potential for surface waters and semi-natural habitats due to uncertainty about the amounts of pyrethroid used for different crops. The results underline the need for comprehensive datasets on pesticide use in Switzerland.

Is the Comparator in Your Diagnostic Cost-Effectiveness Model "Standard of Care"? Recommendations from Literature Reviews and Expert Interviews on How to Identify and Operationalize It.

OBJECTIVES: This research aimed to develop best-practice recommendations for identifying the "standard of care" (SoC) and integrate it when it is the comparator in diagnostic economic models (SoC comparator). METHODS: A multi-methods approach comprising 2 pragmatic literature reviews and 9 expert interviews was used. Experts rated their agreement with draft recommendations based on the authors' analysis of the reviews. These were refined iteratively to produce final recommendations. RESULTS: Fourteen best-practice recommendations are provided. Care pathway mapping (using quantitative, qualitative, or mixed-methods approaches) should be used for identifying the SoC comparator. Guidelines analysis can be integrated with expert opinion to identify pathway variability and discrepancies from clinical practice. For integrating the SoC comparator into the model, recommendations around structure, input sourcing, data aggregation and reporting, input uncertainty, and model variability are presented. For example, modelers should consider that the reference standard is not synonymous with the SoC, and the SoC may not be the only comparator. The comparator limitations should be discussed with clinical experts, but elicitation of its diagnostic accuracy is not recommended. Probabilistic sensitivity analysis is recommended when evaluating the overall input uncertainty, and deterministic sensitivity analysis is useful when there is high model uncertainty or SoC variability. Consensus could not be reached for some topics (eg, the role of real-world data, model averaging, and alternative model structures), but the reported discussions provide points for consideration. CONCLUSIONS: To our knowledge, this is the first guidance to support modelers when identifying and operationalizing the SoC comparator in diagnostic cost-effectiveness models.

Dataset of 2012-2020 U.S. National- and State-Level Greenhouse Gas Emissions by Sector.

The dataset contains ∼1.1 million records of total greenhouse gases directly emitted annually by economic sectors and households in the US from 2012-2020. Data are given for 16 unique greenhouse gases by 118 aggregate sectors for each state, and as totals by these aggregate sectors as well as by 540 detailed sectors at the national level. The dataset is a product of updated sector attribution models that improve upon the National Greenhouse Gas Industry Attribution Model. This paper provides documentation of the methods used to produce these datasets and proof of validation of the dataset, along with relevant supporting tables, figures, and source code.

Incorporating frailty to address the key challenges to geriatric economic evaluation.

BACKGROUND: The multidimensional and dynamically complex process of ageing presents key challenges to economic evaluation of geriatric interventions, including: (1) accounting for indirect, long-term effects of a geriatric shock such as a fall; (2) incorporating a wide range of societal, non-health outcomes such as informal caregiver burden; and (3) accounting for heterogeneity within the demographic group. Measures of frailty aim to capture the multidimensional and syndromic nature of geriatric health. Using a case study of community-based falls prevention, this article explores how incorporating a multivariate frailty index in a decision model can help address the above key challenges. METHODS: A conceptual structure of the relationship between geriatric shocks and frailty was developed. This included three key associations involving frailty: (A) the shock-frailty feedback loop; (B) the secondary effects of shock via frailty; and (C) association between frailty and intervention access. A case study of economic modelling of community-based falls prevention for older persons aged 60 + was used to show how parameterising these associations contributed to addressing the above three challenges. The English Longitudinal Study of Ageing (ELSA) was the main data source for parameterisation. A new 52-item multivariate frailty index was generated from ELSA. The main statistical methods were multivariate logistic and linear regressions. Estimated regression coefficients were inputted into a discrete individual simulation with annual cycles to calculate the continuous variable value or probability of binary event given individuals' characteristics. RESULTS: All three conceptual associations, in their parameterised forms, contributed to addressing challenge (1). Specifically, by worsening the frailty progression, falls incidence in the model increased the risk of falling in subsequent cycles and indirectly impacted the trajectories and levels of EQ-5D-3 L, mortality risk, and comorbidity care costs. Intervention access was positively associated with frailty such that the greater access to falls prevention by frailer individuals dampened the falls-frailty feedback loop. Association (B) concerning the secondary effects of falls via frailty was central to addressing challenge (2). Using this association, the model was able to estimate how falls prevention generated via its impact on frailty paid and unpaid productivity gains, out-of-pocket care expenditure reduction, and informal caregiving cost reduction. For challenge (3), frailty captured the variations within demographic groups of key model outcomes including EQ-5D-3 L, QALY, and all-cause care costs. Frailty itself was shown to have a social gradient such that it mediated socially inequitable distributions of frailty-associated outcomes. CONCLUSION: The frailty-based conceptual structure and parameterisation methods significantly improved upon the methods previously employed by falls prevention models to address the key challenges for geriatric economic evaluation. The conceptual structure is applicable to other geriatric and non-geriatric intervention areas and should inform the data selection and statistical methods to parameterise structurally valid economic models of geriatric interventions.

Budget Impact Analysis of Minimally Invasive versus Open Transforaminal Lumbar Interbody Fusion for Lumbar Degenerative Disease: A European Hospital Perspective.

Purpose: When traditional therapies fail to provide relief from debilitating lower back pain, surgeries such as transforaminal lumbar interbody fusion (TLIF) may be required. This budget impact analysis (BIA) compared minimally-invasive (MI)-TLIF versus open (O)-TLIF for single-level fusion from an Italian hospital perspective. Methods: The BIA compared costs of 100 MI-TLIF and 100 O-TLIF procedures from an Italian hospital perspective over a one-year time horizon. The base case included costs for length of hospital stay (LOS), blood loss, and sterilizing surgical trays. The scenario analysis also included operating room (OR) time and complication costs. Base case inputs were from the Miller et al meta-analysis; scenario analysis inputs were from the Hammad et al meta-analysis. The device costs for MI-TLIF and O-TLIF procedures were from Italian tender prices for Viper Prime™ System and Expedium™ Spine System, respectively. Results: Base case deterministic analysis results showed cost savings of €207,370 for MI-TLIF compared with O-TLIF. MI-TLIF costs were lower for LOS (€215,277), transfusion for blood loss (€16,881), and surgical tray sterilization (€28,232), whereas device costs were lower for O-TLIF (€53,020). The probabilistic result was similar, with MI-TLIF resulting in savings of €211,026 (95% credible interval [CR]: €208,725 - €213,327). All 1000 base case probabilistic sensitivity analysis runs were cost saving. Deterministic scenario analysis results showed cost savings of €166,719 for MI-TLIF. MI-TLIF costs were lower for LOS (€190,813), transfusion for blood loss (€16,881), surgical tray sterilization (€28,232), and complications (€2076), whereas O-TLIF costs were lower for OR time (€18,263) and devices used (€53,020). Conclusion: Despite the increase incremental cost for medical device innovation and OR time, this study demonstrates the economic savings of MI-TLIF compared to O-TLIF from a European hospital perspective. The findings will be useful to policy and hospital decision makers in assessing purchasing, funding and reimbursement decisions.

Flexibility trade-offs in conservation offsets.

Conservation offsets promise cost-effective conservation of biodiversity, especially under economic and environmental change, because they represent a more flexible approach to biodiversity conservation, allowing for the economic development of ecologically valuable land provided that this development is offset by restoration of previously developed areas. The level of flexibility is determined by the trading rules. Lax rules allow for more flexibility, which promises cost savings, but will likely lead to unintended loss of biodiversity. I analyzed the trade-off between economic costs and ecological benefits (biodiversity conservation) in biodiversity offsetting with an ecological-economic model that considered the three main types of offset flexibility: spatial, temporal, and ecosystem type. I sought to examine the influence of ecological and economic conditions on offset flexibility trade-offs. Large variation in the conservation costs and small costs of habitat restoration strongly increased trading activity and reduced the ecological benefit. The ecological benefit was most sensitive to spatial flexibility when a short range of ecological interaction was considered. At a large interaction range, spatial flexibility delivered large cost savings without overly reducing the ecological benefit. Risks and time lags associated with habitat restoration favored an offsetting scheme in which credits are awarded with the initiation of restoration projects rather than their successful completion-given appropriate offsetting multipliers were chosen. Altogether, under scarce resources, the level of flexibility in an offsetting scheme should be chosen by carefully balancing ecological benefits and economic costs.

Compromisos de flexibilidad en las compensaciones por conservación Resumen Las compensaciones por conservación prometen conservar la biodiversidad de forma rentable, especialmente de frente al cambio ambiental y económico. Ya que representan una estrategia más flexible para la conservación de la biodiversidad, esto permite el desarrollo económico de suelo con valor ecológico siempre y cuando este desarrollo esté compensado por la restauración de áreas con desarrollo previo. El nivel de flexibilidad está determinado por las reglas de intercambio. Las reglas laxas permiten una mayor flexibilidad, que promete ahorros, pero probablemente derive en la pérdida no intencionada de la biodiversidad. Analicé los compromisos entre los costos económicos y los beneficios ecológicos (conservación de la biodiversidad) en las compensaciones por biodiversidad con un modelo ecológico-económico que consideraba los tres tipos principales de flexibilidad: espacial, temporal y por tipo de ecosistema. Traté de examinar la influencia de las condiciones ecológicas y económicas sobre los compromisos de flexibilidad en las compensaciones. Una gran variación en los costos de conservación y los pequeños costos de la restauración del hábitat incrementaron fuertemente la actividad de intercambio y redujeron el beneficio ecológico. El beneficio ecológico fue más sensible a la flexibilidad espacial cuando consideré un corto alcance de la interacción ecológica. Con un alcance extenso, la flexibilidad espacial ofreció grandes ahorros son reducir por mucho el beneficio ecológico. Los riesgos y retrasos temporales asociados con la restauración del hábitat favorecieron un esquema de compensaciones en el que los créditos se otorgan al inicio del proyecto de restauración en lugar de con la conclusión exitosa del mismo-siempre y cuando se hayan elegido multiplicadores de compensación adecuados. En conjunto, si se tienen pocos recursos, el nivel de flexibilidad en un esquema de compensaciones debería elegirse con un balance cuidadoso entre los beneficios ecológicos y los costos económicos.

Cost-effectiveness analysis of emicizumab prophylaxis in patients with haemophilia A in India.

INTRODUCTION: Emicizumab is the initial subcutaneously administered bispecific antibody approved as a prophylactic treatment for patients with haemophilia A (PwHA). AIM: This study assessed the economic evaluation of emicizumab treatment for non-inhibitor severe haemophilia A (HA) patients in India. METHODS: A Markov model evaluated the cost-effectiveness of emicizumab prophylaxis compared to on-demand therapy (ODT), low-dose prophylaxis (LDP; 1565 IU/kg/year), intermediate-dose prophylaxis (IDP; 3915 IU/kg/year) and high-dose prophylaxis (HDP; 7125 IU/kg/year) for HA patients without factor VIII inhibitors. Inputs from HAVEN-1 and HAVEN-3 trials included transition probabilities of different bleeding types. Costs and benefits were discounted at a 3.5% annual rate. RESULTS: In the base-case analysis, emicizumab was cost-effective compared to HDP, with an incremental cost-effectiveness ratio (ICER) per quality-adjusted life-years (QALY) of Indian rupees (INR) 27,869. Compared to IDP, ODT and LDP, emicizumab prophylaxis could be considered a cost-effective option if the paying threshold is >1 per capita gross domestic product (GDP) with ICER/QALY values of INR 264,592, INR 255,876 and INR 305,398, respectively. One-way sensitivity analysis (OWSA) highlighted emicizumab cost as the parameter with the greatest impact on ICERs. Probabilistic sensitivity analysis (PSA) indicated that emicizumab had a 94.7% and 49.4% probability of being cost-effective at willingness-to-pay (WTP) thresholds of three and two-times per capita GDP. CONCLUSION: Emicizumab prophylaxis is cost-effective compared to HDP and provides value for money compared to ODT, IDP, and LDP for severe non-inhibitor PwHA in India. Its long-term humanistic, clinical and economic benefits outweigh alternative options, making it a valuable choice in resource-constrained settings.

Análisis coste-utilidad del modelo de unidad de terapia intravítrea (UTI) frente a la administración tradicional de terapia intravítrea / Cost-utility model of new intravítreous units vs. current patient journey model in Spain

Objetivo Comparar la efectividad y los costes de la implantación del Modelo de Unidad de Terapia Intravítrea (UTI), avalado por la Sociedad Española de Retina y Vítreo (SERV), Sociedad Española de Calidad Asistencial (SECA), Sociedad Española de Oftalmología (SEO) y Sociedad Española de Directivos Sanitarios (SEDISA) vs. el procedimiento habitual. Método Modelo de decisión analítico que compara una organización asistencial tipo UTI con cuatro escenarios de práctica habitual en España, en cuanto al resultado en la calidad de vida por pérdida de agudeza visual y la utilización de recursos. Se estimó la probabilidad, el coste y los años de vida ajustados por calidad (AVAC) para cada escenario planteado. Se realizó un análisis de sensibilidad univariante para cada uno de los parámetros empleados. Resultado Se observó que la implantación del modelo UTI mejora la calidad de vida de los pacientes y presenta un menor coste frente a la práctica habitual. Se produjo ahorro de costes y ganancia de AVAC. El análisis de sensibilidad mostró que el resultado no cambiaría de signo con la modificación de ninguna variable de partida. Conclusiones En las patologías oculares con indicación de tratamiento intravítreo, cualquier reducción en el tiempo que transcurre desde la sospecha diagnóstica hasta la primera inyección intravítrea disminuye la pérdida de agudeza visual. Así, actuar para acortar los tiempos sospecha-aguja es clave para mantener la visión funcional de los pacientes. La mejora de la eficiencia de los servicios de oftalmología que se organizan siguiendo el modelo UTI puede generar ahorros que varían entre los 175 € y 85 € por paciente atendido y año (AU)

Aim To compare the effectiveness and costs of the implementation of the intravitreal therapy unit model, endorsed by the SERV, SECA, SEO and SEDISA, compared to the usual procedure. Method Analytical decision model that compares an UTI-type healthcare organization with four usual practice scenarios in Spain, in terms of quality-of-life results due to loss of visual acuity and the use of resources. The probability, cost, and quality-adjusted life years (QALYs) were estimated for each scenario proposed. A univariate sensitivity analysis was performed for each of the parameters used in the model. Result The model showed that from any of the initial scenarios of the usual practice, transitioning to the UTI-type implementation improves the quality of life of patients and requires lower cost. UTI-type is dominant respect usual practice. The sensitivity analysis showed that the results would not change sign with the variation of any starting variable. Conclusions Shorten suspicion-needle times is key to maintaining functional vision in patients requiring intravitreal treatment. The UTI-type model seeks the efficiency of ophthalmology services and can produce savings that vary between €175 and €85 per patient attended per year (AU)

Economic values of reproductive and growth traits in Chinese Yiling sheep.

This study aimed to calculate the economic value (EV) of reproductive and growth traits for Yiling sheep. A bio-economic model was developed to assess the economic value of litter size (LS), litter size at weaning (LSW), age at first lambing (AFL), lambing interval (LI), birth weight (BW), weaning weight (WW), and 6-month body weight (6MW). The sensitivity of the economic value of traits to changes in market prices was also analyzed. In this study, the trait with the highest EV was LSW (427.97 ¥), followed by LS (419.96 ¥), BW (52.13 ¥), 6MW (14.46 ¥), WW (11.03 ¥), AFL (-0.51 ¥), and LI (-9.09 ¥). LS was the most important trait in the production system with a relative economic weight of 22.81%, followed by 6MW and LSW with relative economic weights of 18.98% and 19.01%, respectively. All traits assessed, except AFL and LI, had positive economic values, indicating that genetic improvement of these traits would have a positive impact on profitability. The results of the sensitivity analysis showed that the economic value of AFL was not sensitive to price changes. All growth traits were unaffected by price changes in labor and medical costs. In addition, the LS, LSW, LI, WW, and 6MW were sensitive to changes in liveweight and feed prices. Generally, as feed prices increased, the economic value of all traits except LI and BW decreased. Except for LI and BW, the economic value of all traits increased due to the rise in liveweight prices. This suggested that liveweight and feed prices significantly affect the profitability of the production system.

Cost-effectiveness of terlipressin for hepatorenal syndrome: the United States hospital perspective.

BACKGROUND: Hepatorenal syndrome (HRS) is characterized by severely reduced renal perfusion that precipitates rapid morbidity and mortality. Terlipressin is the only US Food and Drug Administration-approved treatment to improve kidney function for adults with HRS with a rapid reduction in kidney function. Prior to the approval of terlipressin, unapproved vasoconstrictive agents used in HRS treatment were octreotide/midodrine and norepinephrine with albumin. METHODS: A cohort decision-tree model representing a US hospital perspective assessed the clinical outcomes and direct medical costs (based primarily on hospital charges) of treating HRS with terlipressin + albumin (ALB) versus midodrine/octreotide (MID/OCT)+ALB, or norepinephrine (NorEp)+ALB. Treatment efficacy was defined by clinical response (complete/HRS reversal, partial, or no response) based on change of serum creatinine derived from published clinical trial reports. The proportions of patients with complete response were: terlipressin + ALB (36.2%), NorEp + ALB (19.1%), and MID/OCT + ALB (3.1%). Model outcomes included utilization of HRS-related healthcare resources (hospital and intensive care, outpatient and emergency department, dialysis, and transplantations), adverse events, and HRS-related mortality. Outcomes were assessed for the initial hospitalization in the base case and at 30, 60, and 90 days post-discharge. RESULTS: Total costs incurred over the initial hospitalization with terlipressin + ALB were lower vs NorEp + ALB, primarily due to higher ICU costs with NorEp + ALB ($7,433 vs $61,897). TER + ALB was associated with higher total costs vs MID/OCT + ALB due to higher pharmacy costs with terlipressin + ALB. The cost per complete response achieved of terlipressin + ALB ($451,605) was half that of NorEp + ALB ($930,571) and one-tenth that of MID/OCT + ALB ($4,942,123). CONCLUSIONS: HRS patients treated with terlipressin experienced better clinical outcomes and a lower cost per treatment response vs other unapproved treatments. ICU days and pharmacy costs were key cost drivers distinguishing the treatment groups. These outcomes suggest that terlipressin is cost-effective on the basis of total cost per response achieved.

Hepatorenal syndrome (HRS) is a rare and sudden life-threatening complication of the liver. Patients with HRS should receive immediate treatment with a drug that narrows blood vessels known as a vasoconstrictor. Terlipressin is the most common vasoconstrictor used for patients with HRS. Other common vasoconstrictors are midodrine with octreotide and norepinephrine. This study aimed to compare the cost of terlipressin with those of midodrine with octreotide and norepinephrine while also considering how well each of them worked to reverse HRS. This was done using an economic model. This economic model assessed the costs of the vasoconstrictor drugs and the costs of treating HRS, including costs attributable to drug acquisition, adverse events, organ transplantation, dialysis, and institutional encounters (i.e. hospitalization, ICU, emergency department, and outpatient visits). The magnitude of these costs depends on how well each drug reversed HRS. Based on inputs derived from their respective clinical trials, 36% of patients who were given terlipressin had a complete response (HRS was reversed), 19% of patients who were given norepinephrine had a complete response, and 3% of patients who were given midodrine with octreotide had a complete response. The total cost per patient was approximately $163,481 for terlipressin, $177,298 for norepinephrine, and $155,030 for midodrine with octreotide. When the costs were evaluated against how well the drugs worked to reverse HRS, the lowest cost per HRS reversal was $451,605 when treated with terlipressin. The cost per reversal for norepinephrine was $930,571 and for midodrine with octreotide was $4,942,123. These results show that terlipressin works well and is more cost-effective for US hospitals compared with the other unapproved treatment options for HRS with rapid reduction in kidney function.