• In cost-effectiveness analysis it is conventional to distinguish between the direct costs and indirect or productivity costs associated with the intervention, as well as what are termed intangibles, which, although they may be difficult to quantify, are often consequences of the
Distributional cost-effectiveness analysis (DCEA) is a framework for incorporating health inequality concerns into the economic evaluation of health sector interventions. In this tutorial we describe the technical details of how to conduct DCEA, using an illustrative example comparing alternative ways of implementing the NHS Bowel Cancer Screening Programme (BCSP). The two key stages in DCEA are (A) modelling social distributions of health associated with different interventions and (B) evaluating social distributions of health with respect to the dual objectives of improving total population health and reducing unfair health inequality. As well as describing the technical methods used, we also identify the data requirements and the social value judgements that have to be made. Finally, we demonstrate the use of sensitivity analyses to explore the impacts of alternative modelling assumptions and social value judgements.
CEA can be used in several instances. Cost-effectiveness analysis can assist decision- making about different issues, e.g. choosing between iron supplementation or rather iron fortification, between treating obstetric complications in hospitals or health centres, whether to immunize pregnant women or all women of childbearing age for tetanus toxoid. CEA does not only look at interventions in isolation, but can also be used for combinations of interventions, where costs and effects interact (e.g. cost- effectiveness of TB treatment will change is BDG vaccination is in place: higher fixed costs but fewer cases to treat). Moreover, CEA can help identify the optimal level of implementation by comparing the costs and effects of an intervention at different coverage levels (e.g. AIDS mass media at 90% or 100%).
Despite these limitations, the simulations presented pro- vide interesting information for vaccine developers on the potentials of different candidate malaria vaccines. Previ- ous simulation of the cost-effectiveness of PEV sug- gested that at moderate to low vaccine prices, a vaccine providing partial protection, and delivered via the EPI, may be a cost-effective intervention in countries where malaria is endemic. The simulations presented in this arti- cle, also show that these types of vaccines are more effec- tive and cost-effective in low transmission settings, and that the additional costs of delivering a PEV under other modalities than the EPI are likely to be higher than the additional health benefits. The only exception is for the scenario of mass vaccination (added to routine EPI) in low transmission and for high vaccine efficacies and high coverage. In contrast to PEV, BSV are predicted to be more effective and cost-effective at higher transmission settings than low transmission.
The increased emphasis on transparency is an important difference between the Cana- dian guidelines and the CDR. Interviewees report that, when the Canadian guidelines were designed and adopted, communicating the results of drug assessments to the public was not a high priority, although there were concerns about communicating to assessment users such as drug plan managers (Glennie et al. 1999). 33 However, in the decade after the Canadian guidelines’ adoption, transparency became a much higher priority for stakeholders, reflect- ing perhaps increased awareness of cost-effectiveness evaluation of pharmaceuticals as well as a broader move to transparency in health policy and government decision-making. The CDR has responded to this issue in ways the Canadian guidelines could not, and has led the way for greater transparency in some provincial drug assessment processes. The CDR’s non-technical summaries of decision rationales were an important innovation in communi- cating with the public, and Ontario’s Committee to Evaluate Drugs (CED) now publishes summaries of decisions as well (Ontario Ministry of Health and Long Term Care 2013). The CDR innovated in its introduction of public members of CEDAC, and later, a template for patient advocacy groups to submit information to the committee (Canadian Agency for Drugs and Technologies in Health 2015). This is another area where some provincial plans are following suit—Ontario’s CED now includes patient members.
Distributional cost-effectiveness analysis (DCEA) is a framework for incorporating health inequality concerns into the economic evaluation of health sector interventions. In this tutorial we describe the technical details of how to conduct DCEA, using an illustrative example comparing alternative ways of implementing the NHS Bowel Cancer Screening Programme (BCSP). The two key stages in DCEA are (A) modelling social distributions of health associated with different interventions and (B) evaluating social distributions of health with respect to the dual objectives of improving total
Because the community’s supply of informal care is obviously not unbounded from above, at ﬁrst glance it seems that the cost of unpaid caregiving labor does not ﬁt the classiﬁcation proposed, but the point is not that the quantity of this labor is limitless. Rather it is that in virtually all real-world circumstances no meaningful upper bound on the community’s supply of unpaid car- egiving labor can be deﬁned or established, and there- fore that the assumption of such a bound is not sustainable in models of health-care planning. Con- sider ﬁrst that the maximum quantity of unpaid car- egiving labor is never directly observable—especially to a cost-effectiveness analyst—and in general it can be estimated only from survey data the reliability of which is always disputable. Second, even if reliable estimates of the maximum could be obtained, the care provided by families is not usually transferable to members of other families. That is, if a family is willing to provide up to h hours per week of caregiving services to its own members, but only up to h ′ hours to a second family, up to h ″ hours to a third family, and so on, there exists no single maximum number of hours of unpaid care that the family or community is willing to supply under all circumstances unless h = h ′ = h ″ = . . . And ﬁnally, even if all unpaid care were transferable across families (and
The cost-effectiveness of safety measures is dependent on the uncertainty of safety measure. If the measure concerns more than one worker then the uncertainty is higher, but the measure can be more cost- effective as it improves working conditions of more than one person. In wood processing industry the safety measures taken have all the uncertainties from medium or high, but for example to raise the frequency of a periodical medical examination from once in two years to once every year does not give the desired effect, so that kind of measure (No.5 in wood processing industry) is not cost-effective. There are other not cost-effective measures, like two times per day wet-cleaning of the floor in garment industry (measure No. 4). There is no dust over the exposure limit or even not dust smell in the air of the work environment. Organizing safety measures in enterprises, the manager is not allowed to look only on the cost of the measure, but has to assess also the
Four cost-effectiveness analyses of statin therapy for pri- mary prevention met inclusion criteria (Table 1). All studies analyzed health care costs from the health care system perspective – inclusive of and limited to all direct medical costs to all payers resulting from the statin ther- apy. The time horizon varied from as little as 5 years to lifetime. Annual drug prices varied from $770 to over $1,500 in 2006 dollars. Models of drug effectiveness were based on clinical trials of pravastatin in three of the four studies, and in one on “low intensity” and “high in- tensity” statin regimens . Two studies segregated men and women in their analysis, while one analyzed men only and one studied all persons in aggregate. Stud- ies compared statins to placebo , diet modification
All publicly available HTA appraisals from NICE, SMC, CADTH, and PBAC were searched from January 2000 to May 2014. These agencies were chosen as they represent key agencies that use cost-effectiveness criteria to inform decision-making around the globe and release publicly available, transparent, English-language appraisal documents for each intervention evaluated. Agency ICER thresholds (expressed in cost per QALY) were assumed for each of the four HTA agencies included in this analysis, based on published literature, agency publications, and inference based on previous decision-making trends. 3,8,9 The following
There are several limitations to this study. Most importantly, this study may not have the power to detect substantively significant differences in costs or outcomes for each ethnic group. Our cost estimates clearly lack precision. Second, outcomes are self-reported and may be subject to recall or other bias. We studied only six practice networks; although they were chosen to be diverse, they may not be representative of some practice networks. We had relatively low enrollment rates; we partially account for this by weighting back to the screened depressed population. Finally, while each intervention had several components, the current design does not allow us to identify the effects of individual components. One implication of this is that we do not know whether the highly positive outcomes of QI-Therapy for Latinos – relative to both usual care and QI-Meds – are attributable to that intervention’s emphasis on psychotherapeutic treatment generally, the particular form of therapy (i.e., CBT), the quality of provider training, the reduced copayments for psychotherapy from study-trained providers, the specific adaptations made to that intervention for Latino patients, or other factors. Additional information on these issues may help guide efforts to further improve the effectiveness and cost-effectiveness of depression treatment, for all types of patients.
evidence that some caregivers benefit more than others. However, caregiver satisfaction levels for all types of respite are generally high and caregivers appear to be more satisfied with respite than with usual care. No reliable evidence was found that respite care either delays entry to residential care or adversely affects frail older people. Economic evidence suggests that day care is at least as costly as, and may be more expensive than, usual care. The cost-effectiveness of in- home respite, institutional respite, host-family respite, respite packages and video respite remains unclear, as does the cost-effectiveness of adding respite to a multidimensional package of care. Based on these findings, what implications for policy and practice can be drawn? Can policy makers or providers be confident in this evidence and use it to shape the way that respite services are configured and delivered?
Previous efforts to quantify the economic and health impact of shortened regimens have been limited; and these efforts have focused on general analyses that are not specific to any particular setting. While such studies can identify key drivers of cost-effectiveness at a general level, further work is required to characterize the cost- effectiveness of new TB regimens at country level [8–11]. Importantly, none of the previous studies were parameter- ized with locally-collected data; or reflect the influence of health system constraints. Incorporating sound empirical data on health service costs is critical, given that one of the central aims of introducing new shortened first-line regimens is to achieve a reduction in health system burden from TB treatment. Moreover, while previous studies have included estimates of provider costs, none of these studies have considered the potential cost savings to patients. The potential benefits in terms of patient costs are important in the light of the post-2015 global TB target of ensuring that no-one suffers cata- strophic expenditures from TB, in the context of Universal Health Coverage.
 and Steinmetz , and (4) costs associated with the conversion of fellow eyes with atrophic AMD to NVAMD over the 12-year model time frame . We are unaware that these unique parameters have been used together by other authors for assessing the cost- effectiveness of neovascular AMD therapy, especially in conjunction with primary utilities obtained from over 1100 ophthalmic patients. We believe they create a much more robust model than those used previously for the cost-effectiveness associated with treatment of NVAMD. As advances occur in healthcare interventions, they also take place in the economic evaluation of interventions. In this regard, it can be seen that a one-year cohort of 178,000 new neovascular AMD cases [49, 50] treated with ranibizumab will return over $50 billion to society over a 12-year period (Table 9).
Another study from Diel et al.  assessed the cost- effectiveness of the QFT assay for screening and treat- ment of close contacts in Germany. They analysed the health and economic outcomes of isoniazid treatment for 20-year-old contacts over a 20-year time period using two different cut-off values for the TST ( ≥ 5 and 10 mm), the QFT-only and then QFT as a confirmatory test for a positive TST. QFT-based treatment led to cost savings of US$ 542.9 and 3.8 life days per LTBI case compared to non-treatment, TST-based treatment at 10 mm induration size saved US$ 177.4 and saved 2.0 life days per test-positive contact. Choosing a 5 mm cut-off for the TST resulted in additional expenditures and saved only 0.9 days. Although the ICER for treatment based on a TST < 5 mm was below the commonly used willingness-to-pay threshold (US$ 30,170/LYG) it resulted in unnecessary treatment of 77% due to false- positive TST results. Combining TST at a 5 mm cut-off followed by the QFT in a dual-step screening approach was only marginally less expensive (0.6%) than using the QFT solely.
In this dissertation, we develop statistical methods for cost and cost-effectiveness estimation from observational data. The dissertation consist of three parts. In Chapter 2, we investigate propen- sity score (PS) based methods such as covariate adjustment, stratification and inverse probability weighting taking into account informative censoring of the cost outcome. We compare these more commonly used methods to doubly robust weighting. We then use a machine learning approach called Super-Learner (SL) to 1) choose among conventional regression models to estimate mean models in the DR approach and 2) choose among various covariate specifications for PS estima- tion. Our simulation studies show that when the PS model is correctly specified, weighting and DR perform well. When the PS model is misspecified, the combined approach of DR with Super Learner can still provide unbiased estimates. SL is especially useful when the underlying cost dis- tribution comes from a mixture of different distributions or when the true PS model is unknown. We apply these approaches to a cost analysis of two bladder cancer treatments, cystectomy versus bladder preservation therapy, using SEER-Medicare data.
The consequences of simulation education relevant in an economic evaluation can occur in any level of Kirkpatrick’s hierarchy. For example, we might hypothesise that the appropriate use of quality simulation practices will more deeply engage the learner, enhance their motiv- ation and improve their clinical performance, leading to behaviour changes. In turn, positive changes in clinical practice may lead to better health outcomes . All of these consequences can be relevant to the economic analyses, depending on the research ques- tion and outcome of interest. It should be remem- bered that different stakeholders may obtain different benefits. For example, a student may gain in their understanding and competency, and the health service may obtain a clinical benefit such as improved adherence to best-practice, and there may also be an organizational benefit, such as improved efficiency of patient flow through emergency. A consequence can be financial in nature or it may be less tangible. A financial benefit in simulation education may be the cost averted through students making fewer errors in real patient situations. Benefits like these that can be monetized can be included in the cost side of a cost-effectiveness analysis. Less tangible benefits may include improved patient-centred care, increased empathy, and a greater understanding of the clinical relevance of the skills and knowledge being taught, influencing future learning experiences .
Assessment of CE commonly occurs by means of mod- eling studies comparing two or more cohorts undergoing different interventions. After assembling the appropriate hypothetical population, numerous parameters are en- tered into the model, not limited to costs of primary and/ or secondary therapy, probabilities of remaining disease/ progression-free (usually based on established clinical data), probabilities of toxicities (with according manage- ment costs), and expected clinical outcomes until death (also based on clinical data and/or extrapolation thereof ). Costs and outcomes are compiled for both groups for the desired modeling duration (referred to as the time hori- zon); arms are then compared for total costs, quality- adjusted life-years (QALYs), and the costs associated with each gained QALY (termed the incremental cost- effectiveness ratio (ICER)). The ICER denotes how much payment is required for one additional year of (quality- weighted) life and is compared with a pre-determined “willingness-to-pay” (WTP) threshold that differs by pub- lication, society, economic system, time period, and other factors (most common thresholds range from $50,000 – $150,000/QALY). Comparison of the ICER with the WTP threshold concludes whether or not the intervention is deemed “ cost-effective ” . Lastly, because input parameters are often estimated and/or extrapolated, extensive sensi- tivity analyses are performed to measure changes in costs and CE by varying any number of input parameters.
recommended that reference case analyses take a societal per- spective to reflect the perspective of a decision maker whose intention is to make decisions about the broad allocation of resources across the entire population. In a cost-effectiveness analysis conducted from a societal perspective, the analyst consid- ers all parties affected by the intervention and counts all significant outcomes and costs that flow from it, regardless of who experi- ences the outcomes or bears the costs. The original panel also noted that, to address specific decision contexts, analysts might also include narrower perspectives, such as that of the health care sector, to reflect the view of a decision maker whose responsibility rests only within that sector. The Second Panel endorses the refer- ence case concept for the purposes originally intended, namely to improve the quality of cost-effectiveness analyses and promote comparability across studies.
Purpose of this paper. California’s recent earthquake history, and particularly the 1994 Northridge earthquake, show that moderate earthquakes can be costly and deadly, and that losses in woodframe construction contribute substantially to both economic and life-safety risk. To mitigate this risk, it is worthwhile to examine the structural behavior and economic seismic performance of woodframe construction. The CUREE-Caltech Woodframe Project, funded by a $5.2M grant from FEMA, involved laboratory, desktop, and field studies of the structural and economic performance of residential woodframe construction (see [CUREE 2003] for an overview). The project entailed approximately 30 awards in five general thrust areas: laboratory testing, field investigations, building codes, economic modeling, and education. This paper summarizes the economic-modeling study, which assessed the cost-effectiveness of various levels of seismic design and construction quality, both new and retrofit, for woodframe residential buildings in California [Porter et al. 2002]. This paper also includes material from a subsequent study of benefit on a broad geographic basis. The research had three objectives: (1) A fundamental improvement in loss modeling. (2) Quantification of benefit of retrofit, above-code design, and construction quality. (3) Vulnerability functions and HAZUS-compatible fragility functions. (HAZUS fragilities are not treated here.)