Afschin Gandjour

Cost-Effectiveness of Different Strategies for Selecting and Treating Individuals at Increased Risk of Osteoporosis or Osteopenia: A Systematic Review

OBJECTIVESnTo compare cost-effectiveness modeling analyses of strategies to prevent osteoporotic and osteopenic fractures either based on fixed thresholds using bone mineral density or based on variable thresholds including bone mineral density and clinical risk factors.nnnMETHODSnA systematic review was performed by using the MEDLINE database and reference lists from previous reviews. On the basis of predefined inclusion/exclusion criteria, we identified relevant studies published since January 2006. Articles included for the review were assessed for their methodological quality and results.nnnRESULTSnThe literature search resulted in 24 analyses, 14 of them using a fixed-threshold approach and 10 using a variable-threshold approach. On average, 70% of the criteria for methodological quality were fulfilled, but almost half of the analyses did not include medication adherence in the base case. The results of variable-threshold strategies were more homogeneous and showed more favorable incremental cost-effectiveness ratios compared with those based on a fixed threshold with bone mineral density. For analyses with fixed thresholds, incremental cost-effectiveness ratios varied from €80,000 per quality-adjusted life-year in women aged 55 years to cost saving in women aged 80 years. For analyses with variable thresholds, the range was €47,000 to cost savings.nnnCONCLUSIONSnRisk assessment using variable thresholds appears to be more cost-effective than selecting high-risk individuals by fixed thresholds. Although the overall quality of the studies was fairly good, future economic analyses should further improve their methods, particularly in terms of including more fracture types, incorporating medication adherence, and including or discussing unrelated costs during added life-years.

Cost-effectiveness of angiotensin-converting enzyme inhibitors for the prevention of diabetic nephropathy in The Netherlands--a Markov model.

Objective Type 2 diabetes is the main cause of end-stage renal disease (ESRD) in Europe and the USA. Angiotensin-converting enzyme (ACE) inhibitors have a potential to slow down the progression of renal disease and therefore provide a renal-protective effect. The aim of our study was to assess the most cost-effective time to start an ACE inhibitor (or an angiotensin II receptor blocker [ARB] if coughing as a side effect occurs) in patients with newly diagnosed type 2 diabetes in The Netherlands. Methods A lifetime Markov decision model with simulated 50-year-old patients with newly diagnosed diabetes mellitus was developed using published data on costs and health outcomes and simulating the progression of renal disease. A health insurance perspective was adopted. Three strategies were compared: treating all patients at the time of diagnosing type 2 diabetes, screening for microalbuminuria, and screening for macroalbuminuria. Results In the base-case analysis, the treat-all strategy is associated with the lowest costs and highest benefit and therefore dominates screening both for macroalbuminuria and microalbuminuria. A multivariate sensitivity analysis shows that the probability of savings is 70%. Conclusions In The Netherlands for patients with type 2 diabetes prescription of an ACE inhibitor immediately after diagnosis should be considered if they do not have contraindications. An ARB should be considered for those patients developing a dry cough under ACE inhibitor therapy. The potential for cost savings would be even larger if the prevention of cardiovascular events were considered.

Presenting Germany’s drug pricing rule as a cost-per-QALY rule

In Germany, the Institute for Quality and Efficiency in Health Care (IQWiG) makes recommendations for ceiling prices of drugs based on an evaluation of the relationship between costs and effectiveness. To set ceiling prices, IQWiG uses the following decision rule: the incremental cost-effectiveness ratio of a new drug compared with the next effective intervention should not be higher than that of the next effective intervention compared to its comparator. The purpose of this paper is to show that IQWiG’s decision rule can be presented as a cost-per-QALY rule by using equity-weighted QALYs. This transformation shows where both rules share commonalities. Furthermore, it makes the underlying ethical implications of IQWiG’s decision rule transparent and open to debate.

The German method for setting ceiling prices for drugs: in some cases less data are required

The Institute for Quality and Efficiency in Health Care in Germany makes recommendations for ceiling prices of drugs based on an evaluation of the relationship between costs and effects in each therapeutic area. The analysis requires, when applicable, calculation of savings from avoided clinical events and increased future health expenditures from prolonging life (i.e., downstream costs). This article suggests that because of the specific requirements of the Institute for Quality and Efficiency in Health Care, in some cases calculation of downstream costs is not necessary when clinical outcomes are used as a measure of effectiveness. In this article, we identify these conditions. If they hold, it will reduce data requirements, the costs and time required to conduct evaluations, and the uncertainty in the analysis.

Cost-Effectiveness Analysis of High-Efficiency Hemodiafiltration Versus Low-Flux Hemodialysis Based on the Canadian Arm of the CONTRAST Study

AimThe aim of this study was to assess the cost effectiveness of high-efficiency on-line hemodiafiltration (OL-HDF) compared with low-flux hemodialysis (LF-HD) for patients with end-stage renal disease (ESRD) based on the Canadian (Centre Hospitalier de l’Université de Montréal) arm of a parallel-group randomized controlled trial (RCT), the CONvective TRAnsport STudy.MethodsAn economic evaluation was conducted for the period of the RCT (74xa0months). In addition, a Markov state transition model was constructed to simulate costs and health benefits over lifetime. The primary outcome was costs per quality-adjusted life-year (QALY) gained. The analysis had the perspective of the Quebec public healthcare system.ResultsA total of 130 patients were randomly allocated to OL-HDF (nxa0=xa067) and LF-HD (nxa0=xa063). The cost-utility ratio of OL-HDF versus LF-HD was Can

Budget impact analysis of drugs for ultra-orphan non-oncological diseases in Europe

53,270 per QALY gained over lifetime. This ratio was fairly robust in the sensitivity analysis. The cost-utility ratio was lower than that of LF-HD compared with no treatment (immediate death), which was Can

Cost–effectiveness of preventing weight gain and obesity: what we know and what we need to know

93,008 per QALY gained.ConclusionsHigh-efficiency OL-HDF can be considered a cost-effective treatment for ESRD in a Canadian setting. Further research is needed to assess cost effectiveness in other settings and healthcare systems.

Drug pricing and control of health expenditures: a comparison between a proportional decision rule and a cost-per-QALY rule

Background/aim: Ultra-orphan diseases (UODs) have been defined by a prevalence of less than 1 per 50,000 persons. However, little is known about budget impact of ultra-orphan drugs. Methods: For analysis, the budget impact analysis (BIA) had a time horizon of 10 years (2012–2021) and a pan-European payer’s perspective, based on prevalence data for UODs for which patented drugs are available and/or for which drugs are in clinical development. Results: A total of 18 drugs under patent protection or orphan drug designation for non-oncological UODs were identified. Furthermore, 29 ultra-orphan drugs for non-oncological diseases under development that have the potential of reaching the market by 2021 were found. Total budget impact over 10 years was estimated to be €15,660 and €4965 million for approved and pipeline ultra-orphan drugs, respectively (total: €20,625 million). Conclusion: The analysis does not support concerns regarding an uncontrolled growth in expenditures for drugs for UODs.

Determining the price for pharmaceuticals in Germany: comparing a shortcut for IQWiG's efficiency frontier method with the price set by the manufacturer for ticagrelor.

The objective of this study was to show gaps and inconsistencies in selected literature on the cost–effectiveness of preventing weight gain and obesity and to set an agenda for future research. A review and qualitative analysis of the literature was carried out on the cost–effectiveness of preventing weight gain and obesity, with a primary focus on programs that influence health outcomes and directly change individual behavior through physical activity promotion (i.e., energy expenditure increase). A literature search reveals that computer simulation models on the lifetime cost of obese versus normal-weight persons show conflicting results. Studies on programs to promote physical activity as a means to prevent obesity also show varying cost–effectiveness ratios, with a key variable from a societal perspective being the cost of time required to exercise. In particular, this review found a need for more parsimonious simulation models and more information on the comparative cost–effectiveness of programs to prevent weight gain/obesity.

Convergence of decision rules for value-based pricing of new innovative drugs

BACKGROUND AND AIMSnIn Germany, the Institute for Quality and Efficiency in Health Care (IQWiG) makes recommendations for reimbursement prices of drugs on the basis of a proportional relationship between costs and health benefits. This paper analyzed the potential of IQWiGs decision rule to control health expenditures and used a cost-per-quality-adjusted life year (QALY) rule as a comparison.nnnMETHODSnA literature search was conducted, and a theoretical model of health expenditure growth was built.nnnRESULTSnThe literature search shows that the median incremental cost-effectiveness ratio of German cost-effectiveness analyses was €7650 per QALY gained, thus yielding a much lower threshold cost-effectiveness ratio for IQWiGs rule than an absolute rule at €30u2009000 per QALY. The theoretical model shows that IQWiGs rule is able to contain the long-term growth of health expenditures under the conservative assumption that future health increases at a constant absolute rate and that the threshold incremental cost-effectiveness ratio increases at a smaller rate than health expenditures. In contrast, an absolute rule offers the potential for manufacturers to raise drug prices in response to the threshold, thus resulting in an initial spike in expenditures.nnnCONCLUSIONSnResults suggest that IQWiGs proportional rule will lead to lower drug prices and a slower growth of health expenditures than an absolute cost-effectiveness threshold at €30u2009000 per QALY. This finding is surprising as IQWiGs rule-in contrast to a cost-per-QALY rule-does not start from a fixed budget.