# cost-effectiveness ratios

## Top PDF cost-effectiveness ratios:

### Acceptance of health technology assessment submissions with incremental cost-effectiveness ratios above the cost-effectiveness threshold

The objective of HTA programs is to make decisions regarding the acceptance, restriction, or rejection of inter- ventions on a rational basis. Many HTA agencies use cost-effectiveness analysis to inform such decisions, where cost-effectiveness is expressed using incremental cost- effectiveness ratios (ICERs). ICERs are calculated by dividing the incremental cost of an intervention by the incremental benefit, which is often expressed in quality-adjusted life years (QALYs). QALYs are captured by applying a quality- adjusted weight to each health state of a disease (by balancing the quantity of life [or life-years gained] against the quality of that life), multiplying this by the time in each health state, and summing. Alternatively, disability-adjusted life-years or life-years gained may be used to estimate health benefit in cost-effectiveness analyses. 1

### On Projection of Costs and Incremental Cost-Effectiveness Ratios: A Data Example

In cost-effectiveness analysis in order to compare different treatments and eval- uate the economic impact of new treatment options, there are two measure of cost- effectiveness: incremental net benefit (INB) and incremental cost-effectiveness ratio (ICER) (Willan and Briggs 2006). The INB is equivalent to the difference between the extra cost and the λ multiply the extraeffectiveness. The INB is mathematically more convenient to deal with, but it depends upon decision makers willingness-to-pay for an additional unit ofeffectiveness λ, which is usually unknown or not well defined. Here we will focus on the ICER. The incremental cost- effectiveness ratio (ICER), is a ratio between the difference in mean cost and the difference in the effectiveness for two therapies. It is a measure that describes the new therapy in terms of the additional cost for each incremental unit of health effect, such as per life of year saved, has been widely used in evaluating the relative health benefits from new treatments. Many researchers have used it (e.g., Phelps and Mushlin, 1991; Mushlinetal., 1998; Marketal., 2000) to assess the cost of new therapies relative to health benefits. Because the ICER involves the estimating of mean cost and mean effectiveness (usually survival time or quality-adjusted-lifetime), the estimating of ICER unavoidably faces the same challenge as that in estimating mean medical cost.

### Bias within economic evaluations &ndash; the impact of considering the future entry of lower-cost generics on currently estimated incremental cost-effectiveness ratios of a new drug

parameter will only result in an underestimation of the ICER under specific conditions (ie, Equation 10). In the context where the comparator drug is already a generic drug and lower-cost generic versions of the new drug are expected to be introduced within the examined time horizon, we have shown that ignoring this possibility will tend to overestimate the new drug’s ICER. Although we believe that health economists should include this possibility at least as a sensitivity analysis within future economic evaluations, many factors may limit its inclusion.

### Efficacy of a blended low intensity internet delivered psychological programme in patients with multimorbidity in primary care: study protocol for a randomized controlled trial

ADA: diagnosis according to criteria of the American Diabetes Association; AES: Advanced Encryption Standard; CHEERS: Consolidated Health Economic Evaluation Reporting Standards; CSRI: Client Service Receipt Inventory; EQ-5D-3 L: EuroQol-5D-3 L; GPs: general practitioners; ICERs: incremental cost- effectiveness ratios; ICTs: information and communication technologies; ICURs: incremental cost-utility ratios; IDF: International Diabetes Federation; ISPOR: International Society for Pharmacoeconomics and Outcomes Research; iTAU: improved treatment-as-usual; MBCT: Mindfulness-Based Cognitive Therapy; MINI: Mini-International Neuropsychiatric Interview; NICE: National Institute of Clinical Excellence (UK); NNT: number needed to treat; PC: primary care; RCT: randomized controlled trial; WHO: The World Health Organization

### Cost-effectiveness of health-related lifestyle advice delivered by peer or lay advisors: synthesis of evidence from a systematic review

The disparate nature of the included studies precluded a meta-analysis of study findings. Instead, evidence on the effectiveness of HRLAs was assessed based on: i) the quality and nature of the studies; and ii) the target popu- lation. Where evidence existed on the cost-effectiveness of HRLA interventions we evaluated it. Generally this evidence was lacking and so we synthesised our own es- timate of cost-effectiveness. We first grouped interven- tions according to the behaviour targeted as this dictated the size of the potential health gain. Within groups we then considered whether the reported interventions used similar or different modes of delivery. Typical modes of delivery included: community activities and mailshots (considered low intensity); telephone and group coun- selling (low to medium intensity); and personalised counselling (high intensity). Where studies in the same target behaviour group used the same mode of delivery, we selected one study to inform estimates of costs and effectiveness based on rigor of study design and rele- vance of the study population. Where interventions used a different mode of delivery, we compared them as alternative strategies, either against no intervention, or against non-HRLA delivered alternatives where these would be readily available. We ranked interventions ac- cording to effectiveness and eliminated dominated and extendedly dominated options prior to calculating in- cremental cost-effectiveness ratios (ICERs) [17]. The perspective of included studies was rarely stated, but none documented costs arising outside of the health sector. Where we synthesized cost-effectiveness esti- mates we considered only health benefits and costs falling on the health sector.

### Simulation of the cost effectiveness of malaria vaccines

CEA is a method for evaluating the relative efficiency of alternative interventions and thus can provide important information for assessing the potential implications of the numerous malaria vaccine candidates. This study used stochastic simulations of P. falciparum malaria epidemiol- ogy, combined with a case management model, to simu- late the cost-effectiveness of potential malaria vaccines under various transmission settings and delivered via dif- ferent modalities. This is an extension of previous research on pre-erythrocytic vaccines delivered via the EPI[12]. The simulations presented suggest that the cost-effective- ness of candidate malaria vaccines is likely to differ sub- stantially according to the transmission intensity and to the delivery modality adopted. They also suggest that alternative vaccine delivery modalities to the EPI may sometimes, but not always, be more cost-effective than the EPI. In general, at moderate vaccine prices, most vac- cines and delivery modalities simulated are likely to present cost-effectiveness ratios, which compare favoura- bly with those of other malaria interventions [41-43], making them potential attractive malaria control strate- gies, from an economic perspective, in malaria endemic countries.

### Cost-utility analysis of immune tolerance induction therapy versus on-demand treatment with recombinant factor VII for hemophilia A with high titer inhibitors in Iran

Methods: This study was based on the study of Knight et al, which evaluated the cost- effectiveness ratios of different treatments for hemophilia A with high-responding inhibitors. To adapt Knight et al’s results to the Iranian context, a few clinical parameters were varied, and cost data were replaced with the corresponding Iranian estimates of resource use. The time horizon of the analysis was 10 years. One-way sensitivity analyses were performed, varying the cost of the clotting factor, the drug dose, and the administration frequency, to test the robustness of the analysis.

### Local anaesthetic wound infiltration in addition to standard anaesthetic regimen in total hip and knee replacement: long-term cost-effectiveness analyses alongside the APEX randomised controlled trials

Methods: Cost-effectiveness was assessed from the health and social care payer perspective in relation to quality adjusted life years (QALYs) and the primary clinical outcome, the WOMAC Pain score at 12-months follow-up. Resource use was collected from hospital records and patient-completed postal questionnaires, and valued using unit cost estimates from local NHS Trust finance department and national tariffs. Missing data were addressed using multiple imputation chained equations. Costs and outcomes were compared per trial arm and plotted in cost-effectiveness planes. If no arm was dominant (i.e., more effective and less expensive than the other), incremental cost-effectiveness ratios were estimated. The economic results were bootstrapped incremental net monetary benefit statistics (INMB) and cost-effectiveness acceptability curves. One-way deterministic sensitivity analyses explored any methodological uncertainty.

### Cost-effectiveness analysis of interventions for migraine in four low- and middle-income countries

In order to assess the inherent uncertainty around (point) estimates of total intervention costs and health effects, a subset of intervention strategies were entered into an analytical software package (MCLeague), which performs a probabilistic uncertainty analysis using Monte Carlo simulation (1,000 runs were made, using a truncated normal distribution). A subset was chosen for the sake of being able to visualise the results in cloud graph format. The seven selected interventions were ASA + consumer education and all other drug interventions that included consumer education and provider training (since the latter gave better cost-effectiveness ratios than intervention sce- narios without one or both of these additional compo- nents). We used a coefficient of variation of 0.2 for effects and 0.25 for costs. The graphical results presented in Figure 1 relate to China and demonstrate that, even after allowing for this variability, the average cost- effectiveness ratios of interventions for ASA + consumer education do not overlap appreciably with other interven- tions, confirming its clear superiority in cost-effectiveness terms. It also shows that after allowing for uncertainty, the stepped-care strategy using both specific and non-specific

### Cost-effectiveness of molar single-implant versus fixed dental prosthesis

According to the report from Naito et al., Japanese na- tional norm for GOHAI is 52.2 ± 7.8 (0.84 ± 0.16 when converted to 0 to 1) for 50–59-year-olds [23]. Compar- ing with this result, the results of the current study can be considered the same as Implants and FDP that per- form well over time. That is, lost Implants and removed FDP do not function as well as the national norms. In Japan, the medical care necessary to stay healthy and alive, such as for recovery from sickness and disability, delayed progress of sickness and disability, maintenance of physical and mental functions, is adapted from public medical care insurance according to the universal healthcare system. As a patient’s co-payment, patients aged 6–69 years pay 30% of medical care costs at recep- tion while infants aged 0–5 years pay 20% (separate pub- lic subsidies provided by local governments) and elderly persons aged 70 and above pay 10% (or 30% depending on income). Unrelated to this, medical care for proce- dures such as cosmetic surgery, orthodontics and sex re- assignment surgery are completely self-funded, and medical treatments are not covered by public insurance. IFDP in this study is adapted for public medical care insurance, whereas PFDP corresponds to self-funded Table 4 Incremental cost-effectiveness ratios of Implant versus IFDP

### The impact of incorporating Bayesian network meta-analysis in cost-effectiveness analysis - a case study of pharmacotherapies for moderate to severe COPD

Results: Efficacy estimates from the NMA and PMA were similar, but the NMA provided estimates with higher precision. This resulted in similar incremental cost-effectiveness ratios (ICER). Probabilities of being cost-effective at willingness-to-pay thresholds (WTPs) between \$25,000 and \$100,000 per quality adjusted life year (QALY) varied considerably between the PMA- and NMA-based approaches. The largest difference in the probabilities of being cost-effective was observed at a WTP of approximately \$40,000/QALY. At this threshold, with the PMA-based analysis, ICS, LAMA and placebo had a 43%, 30, and 18% probability of being the most cost-effective. By contrast, with the NMA based approach, ICS, LAMA, and placebo had a 56%, 19%, and 21% probability of being cost-effective. For larger WTP thresholds the probability of LAMA being the most cost-effective became higher than that of ICS. Under the PMA-based analyses the cross-over occurred at a WTP threshold between \$60,000/QALY-\$65,000/QALY, whereas under the NMA-based approach, the cross-over occurred between \$85,000/QALY-\$90,000/QALY.

### Vitamin D supplementation to prevent depression and poor physical function in older adults: Study protocol of the D-Vitaal study, a randomized placebo-controlled clinical trial

The economic evaluation will be performed from a so- cietal perspective with a time horizon of 12 months. The analysis will be done according to the intention-to-treat principle. Missing cost and effect data will be imputed using multiple imputation according to the MICE algo- rithm [65]. Bias-corrected and accelerated bootstrapping with 5000 replications will be used to calculate 95 % confidence intervals around the mean difference in total costs between the two groups. Incremental cost- effectiveness ratios (ICERs) will be calculated by divid- ing the difference in mean total costs by the difference in mean effects on the primary outcomes (depressive symp- toms, functional limitations and physical performance) be- tween the treatment groups. A cost-utility analysis will be performed estimating the incremental costs per QALY gained. Bootstrapping will be used to estimate the uncer- tainty surrounding the ICERs, which will be graphically presented on cost-effectiveness planes. Cost-effectiveness acceptability curves and net monetary benefits will also be calculated. Sensitivity analyses will be performed on the most important and uncertain cost parameters.

### Why Perspective Matters In Health Outcomes Research Analyses

However, the objective of cost-effectiveness analysis is to maximize the effectiveness of an intervention based on budget constraints. The effectiveness of interventions are measured in life-years gained and QALYs gained for cost-effectiveness and cost-utility analysis respectively. Mutually exclusive options rank interventions from the highest to the lowest effectiveness. Then, programs that have a higher cost and lower effectiveness are ruled out as a dominated alternative, so they should not be implemented. The remaining interventions have their incremental cost- effectiveness ratios calculated. Using a fixed budget approach, a price per effectiveness unit, such as cost per life- year gained and QALY gained can be used as a decision rule. That is, the program that has the incremental cost- effectiveness ratio greater or equal to the price per QALY should be implemented. Therefore, this decision rule maximizes the healthcare budget, assuming constant returns to scale; the scale of a healthcare intervention can be reduced without changing the incremental cost-effective ratios. Under the assumption of constant returns to scale, only healthcare costs are included in the cost-effectiveness analysis. As the empirical data shows, QALY’s do not include changes in income (Davidsson and Levin, 2008) or productivity effects (Jonsson, 2009).

### Randomised controlled trial to improve health and reduce substance use in established psychosis (IMPaCT): cost effectiveness of integrated psychosocial health promotion

The economic evaluation takes a decision-making approach which ignores statistical significance (of both the clinical and economic outcomes) and instead focusses on the probability of one intervention being cost-effective compared to another in light of the avail- able data. This is the approach recommended over trad- itional reliance on decision rules regarding statistical significance [30, 31]. Cost-effectiveness and cost-utility analyses were conducted at 15 months to focus on the more pertinent question of whether any effect lasted beyond the end of the intervention, but 12 month cost and outcome data are also reported for information. The economic evaluation examined 8 possible cost-outcome combinations (accounting for the two cost perspectives and four outcomes). Incremental cost-effectiveness ratios (ICERs) were calculated for any combination showing both higher costs and better outcomes in either the intervention group or control group (it is unneces- sary to calculate ICERs for any combinations where one group shows both lower costs and better outcomes as it is then considered to ‘ dominate ’ the other group).

### Randomised controlled trial to improve health and reduce substance use in established psychosis (IMPaCT): cost-effectiveness of integrated psychosocial health promotion

The economic evaluation takes a decision-making approach which ignores statistical significance (of both the clinical and economic outcomes) and instead focusses on the probability of one intervention being cost-effective compared to another in light of the avail- able data. This is the approach recommended over trad- itional reliance on decision rules regarding statistical significance [30, 31]. Cost-effectiveness and cost-utility analyses were conducted at 15 months to focus on the more pertinent question of whether any effect lasted beyond the end of the intervention, but 12 month cost and outcome data are also reported for information. The economic evaluation examined 8 possible cost-outcome combinations (accounting for the two cost perspectives and four outcomes). Incremental cost-effectiveness ratios (ICERs) were calculated for any combination showing both higher costs and better outcomes in either the intervention group or control group (it is unneces- sary to calculate ICERs for any combinations where one group shows both lower costs and better outcomes as it is then considered to ‘ dominate ’ the other group).

### Potential cost-effectiveness and benefit-cost ratios of adult pneumococcal vaccination in Germany

The T-cell dependent immune response of PCV13 induces antibody titres in elderly comparable to those induced in infants. [13] Vaccination studies have shown that antibody levels after PCV13 were at least similar or superior for most vaccine shared serotypes to that induced by PPV23. However, implementing a PCV13 vaccination scheme in adults will cause additional costs in the German health care system due to the higher price of the vaccine. Therefore, this analysis aims to evaluate the benefit-cost ratio and cost-effectiveness of an adult vaccination program in individuals older than 50 years compared to the existing PPV23 recommenda- tion for adults as well as to ‘no vaccination’.

### Are multifaceted interventions more effective than single-component interventions in changing health-care professionals' behaviours? An overview of systematic reviews

Existing evidence on the effectiveness of multifaceted interventions is limited and conflicting. Early system- atic reviews by Davis et al. [5] (on the effectiveness of continuing medical education) and Wensing and Grol [6] (on the effectiveness of multifaceted and single interventions in primary care) argue that multifaceted interventions are more effective than single-component interventions. However, the methods used in these studies are unclear, and there are common methodological is- sues in the primary studies included in the reviews such as unit of analysis errors. Additionally, synthesis in the reviews was through vote counting which comprises a weak form of indirect evidence for the effectiveness of multifaceted interventions [5,6]. More recent systematic reviews [7,8] that used robust statis- tical tests to investigate this topic are in opposition to these early findings. Grimshaw et al. [7] was the first review team to use robust statistical methods to ex- plore the effectiveness of multifaceted interventions in changing health-care professionals’ behaviours; they concluded that multifaceted are not necessarily more effective than single-component interventions.

### Evaluating an extended rehabilitation service for stroke patients (EXTRAS): study protocol for a randomised controlled trial

Stroke units and early supported discharge (ESD) ser- vices are effective ways to improve patient outcomes and the quality of care following stroke [3,4]. These services are referred to as ‘organised stroke care’, and their key features are multidisciplinary stroke specialist expertise and coordination of care [5,6]. In contrast, there is no clear evidence of the clinical and cost effectiveness of lon- ger term rehabilitation following stroke [7]. A Cochrane review of therapy-based rehabilitation services for patients living at home more than one year after stroke concluded that it was unclear whether rehabilitation provided after one year can improve recovery [8]. However, therapy- based rehabilitation services for stroke patients at home provided soon after discharge have been shown to be effective [9].