J.C. Mewes

Effectiveness of multidimensional cancer survivor rehabilitation and cost-effectiveness of cancer rehabilitation in general: a systematic review.

INTRODUCTION Many cancer survivors suffer from a combination of disease- and treatment-related morbidities and complaints after primary treatment. There is a growing evidence base for the effectiveness of monodimensional rehabilitation interventions; in practice, however, patients often participate in multidimensional programs. This study systematically reviews evidence regarding effectiveness of multidimensional rehabilitation programs for cancer survivors and cost-effectiveness of cancer rehabilitation in general. METHODS The published literature was systematically reviewed. Data were extracted using standardized forms and were summarized narratively. RESULTS Sixteen effectiveness and six cost-effectiveness studies were included. Multidimensional rehabilitation programs were found to be effective, but not more effective than monodimensional interventions, and not on all outcome measures. Effect sizes for quality of life were in the range of -0.12 (95% confidence interval [CI], -0.45-0.20) to 0.98 (95% CI, 0.69-1.29). Incremental cost-effectiveness ratios ranged from -€16,976, indicating cost savings, to €11,057 per quality-adjusted life year. CONCLUSIONS The evidence for multidimensional interventions and the economic impact of rehabilitation studies is scarce and dominated by breast cancer studies. Studies published so far report statistically significant benefits for multidimensional interventions over usual care, most notably for the outcomes fatigue and physical functioning. An additional benefit of multidimensional over monodimensional rehabilitation was not found, but this was also sparsely reported on. Available economic evaluations assessed very different rehabilitation interventions. Yet, despite low comparability, all showed favorable cost-effectiveness ratios. Future studies should focus their designs on the comparative effectiveness and cost-effectiveness of multidimensional programs.

Clinical outcome of patients with implantation of second‐generation drug‐eluting stents in the right coronary ostium: Insights from 2‐year follow‐up of the TWENTE trial

The aim of the present study was to assess the impact on clinical outcome of right coronary artery (RCA) ostial coverage with second‐generation drug‐eluting stents (DES).

PCN 149 - Early cost-effectiveness modeling for tumor infiltrating lymphocytes (TIL-)treatment versus ipilimumab in metastatic melanoma patients

Objectives: Metastatic melanoma has a poor prognosis with 10 year survival being 50% and expected survival rates of 25%-42% versus 45% (1yr) and 23,5% (2yr) for Ipilimumab. TIL is highly personalized, however complex and requests substantial upfront investments from the hospital in expensive lab-equipment, staff expertise and training, as well as extremely tight hospital logistics. Therefore, an early health economic modelling study, supporting a Coverage with Evidence Development (CED) program, was performed. Methods: We used a Markov decision model to estimate the expected costs and outcomes (quality adjusted life years; QALYs) for TIL versus Ipilimumab in metastatic melanoma patients from a societal perspective over a life long time horizon. Three mutually exclusive health states (stable disease, progressive disease and death) were modelled, divided in first and second line treatment. Technical failures and non-compliance were incorporated to reflect the dynamic nature of the technology. To inform further research prioritization, Value of Information (VOI) analysis was performed. Results: TIL is expected to yield more QALYs compared to Ipilimumab (0.99 vs 0.52 respectively) at lower total costs (€83,588 vs €87,834 respectively). Based on current information TIL has a probability of 88% for being cost effective at a cost/QALY threshold of €30,000. Expected Value of Perfect Information (EVPI) amounted to €1,2 million. Partial EVPI (EVPPI) was highest for survival data (€550,000). Expected Value of Sample information was estimated €355,000 for an optimal sample size of n=50. Conclusions: TIL is expected to improve QALYs compared to Ipilimumab at lower incremental cost and has the highest probability of being cost-effective. To reduce decision uncertainty, a future clinical trial to investigate survival seems most valuable, and should preferably be undertaken as part of a CED program.

A SYSTEMATIC APPROACH FOR ASSESSING, IN THE ABSENCE OF FULL EVIDENCE, WHETHER MULTICOMPONENT INTERVENTIONS CAN BE MORE COST-EFFECTIVE THAN SINGLE COMPONENT INTERVENTIONS

OBJECTIVES Multicomponent interventions (MCIs), consisting of at least two interventions, are common in rehabilitation and other healthcare fields. When the effectiveness of the MCI versus that of its single interventions is comparable or unknown, evidence of their expected incremental cost-effectiveness can be helpful in deciding which intervention to recommend. As such evidence often is unavailable this study proposes an approach to estimate what is more cost-effective; the MCI or the single intervention(s). METHODS We reviewed the literature for potential methods. Of those identified, headroom analysis was selected as the most suitable basis for developing the approach, based on the criteria of being able to estimate the cost-effectiveness of the single interventions versus that of the MCI (a) within a limited time frame, (b) in the absence of full data, and (c) taking into account carry-over and interaction effects. We illustrated the approach with an MCI for cancer survivors. RESULTS The approach starts with analyzing the costs of the MCI. Given a specific willingness-to-pay-value, it is analyzed how much effectiveness the MCI would need to generate to be considered cost-effective, and if this is likely to be attained. Finally, the cost-effectiveness of the single interventions relative to the potential of the MCI for being cost-effective can be compared. CONCLUSIONS A systematic approach using headroom analysis was developed for estimating whether an MCI is likely to be more cost effective than one (or more) of its single interventions.

Value Of Implementation Of Physical Exercise For Cancer Survivors.

Objectives: To evaluate which strategy for implementing exercise interventions for cancer survivors and increasing providers´ adherence to the exercise guidance has the highest expected value, using value-of-implementation analysis. Methods: The net-benefit framework underpinning health economic evaluations is used to conduct a value-of-implementation analysis considering seven implementation strategies (ISTs), including continuing medical education (CME), educational outreach visits (EOV), educational printed materials (EPM), local opinion leaders (LOPL), audit and feedback (AF), reminder systems (RS), and a multifaceted strategy (MF) consisting of CME and AF. The analysis consists of four steps; (1) analysing the expected value of perfect implementation (EVPIM) (2) assessing the estimated costs of the various ISTs, (3) comparing the ISTs´ costs to the EVPIM to decide which of these are considered cost-effective, and (4) assessing the total net benefit of the ISTs to identify which strategy has the greatest value. Results: The EVPIM for physical exercise in the Netherlands is €522m, which represents the maximum value that could be achieved if the guidance was implemented perfectly with a 100% adherence. The costs of the implementation strategies are lowest for PEM with €710,600 and highest for MF with €2,173,700. All ISTs´ costs are well below the EVPIM and thus all ISTs are cost-effective. The net-benefit of the ISTs ranges from €15,753,000 for PEM to €10,150,500 for RS. Conclusions: All evaluated implementation strategies are a cost-effective way of implementing physical exercise interventions for cancer survivors and increasing health professionals´ adherence to this guideline. However, all strategies contribute only marginally to achieving the highest possible value of implementation. This suggests that investing in more intensive implementation would be justified given the expected net-benefit.