Jasper M. Bos

Epidemiologic impact and cost-effectiveness of universal infant vaccination with a 7-valent conjugated pneumococcal vaccine in the Netherlands

BACKGROUND Streptococcus pneumoniae is one of the main causes of bacterial meningitis, bacteremia, pneumonia, and otitis media in the Netherlands. These diseases lead to substantial mortality, morbidity, and costs. The societal impact is especially severe because most cases occur in very young infants. OBJECTIVE The aim of this study was to estimate the epidemiological impact and cost-effectiveness of universal infant vaccination with a 7-valent conjugated pneumococcal vaccine in the Netherlands. METHODS Decision analysis was performed using epidemiological data and data on health care resource use from 1996 to 2001. A model was used to project the impact of pneumococcal vaccination on the incidence of pneumococcal infections in infants and children from birth to age 10 years. Costs, benefits, and health gains were estimated, and cost-effectiveness was calculated. All analyses were performed from a societal perspective. RESULTS On average, 339 cases per year of invasive pneumococcal infection occurred in infants and children from birth to age 10 years in the Netherlands from 1996 to 2001. The model predicted that introduction of the 7-valent conjugated pneumococcal vaccine would prevent 48 cases of bacterial meningitis and 88 cases of pneumococcal bacteremia per year, as well as 42,695 cases of pneumococcal otitis media and 3411 cases of invasive pneumococcal pneumonia. The model also predicted that vaccination would save 13 lives per year and prevent 31 cases of lifelong sequelae, rendering 382 discounted quality-adjusted life-years (QALYs) gained or 329 discounted life-years gained per year. Considering these health gains, vaccination would prevent Euro 9,453,600 of direct and indirect medical costs of meningococcal and pneumococcal infections in the Netherlands, including acute medical care, management of sequelae, and lost time at work. With a vaccine price of Euro 40 per dose, the base-case cost-effectiveness ratio would be Euro 71,250 per QALY. The model was sensitive to changes in incidence of infections, vaccine effectiveness, and vaccine price. CONCLUSIONS Our analytic model predicted that universal pneumococcal vaccination of infants in the Netherlands could prevent a large number of pneumococcal infections and considerably reduce related mortality and morbidity. However, the baseline cost-effectiveness ratio of such a vaccination program would be relatively unfavorable compared with other interventions implemented in the Netherlands.

Discounting Health Effects in Pharmacoeconomic Evaluations: Current Controversies

Currently, much debate still surrounds the discounting of health effects. Most general consensus statements have argued for the same discount rate for health and money; however, this practice has been questioned by several authors. The choice of discount rate can have varying effects on interventions, depending on the disease area. In this paper, we review two major current controversies around discounting: the use of similar or differential discount rates for health and money; and the validity of the underlying discounting model (time preference, constant discounting and the use of aggregated utilities for health effects). Various arguments justify a different rate of discounting for health effects than for money. Empirical evidence questions the validity of the constant discounting model, pointing out that time preference is not constant and should not be applied as such. Also, the validity of the aggregated utility model for health might be questioned, implying that a life cannot simply be cut into life years as single entities that are discounted back to the net present value. Such debates have led to varying methodologies being employed in economic evaluations, causing difficulties in their interpretation. Although there is sufficient evidence to question the use of similar discount rates for health and money, currently there is not enough information on the nature of the different processes that constitute discounting to reach a solid conclusion on the use of a different method. The lack of consensus on one of the most important topics in pharmacoeconomics makes the case for a more restricted use of cost-effectiveness or cost-utility ratios than as the most important singular outcome of pharmacoeconomic studies. Instead, results should be presented in a non-aggregated manner that enables policy makers to value health gains according to timing and to which subpopulation they are accrued in.

Economic Evaluation of Influenza Vaccination Assessment for The Netherlands

AbstractObjective: The objective of this study was to determine the costs associated with influenza and the cost effectiveness (net costs per life-year gained) of influenza vaccination in The Netherlands. Design and setting: The economic evaluation comprised a cost-of-illness assessment and a cost-effectiveness analysis, both of which were conducted from the healthcare perspective in The Netherlands. The modelling framework for the economic evaluation linked epidemiological aspects of influenza (e.g. incidence, mortality, years of life lost) to vaccination coverage and healthcare resource use. Healthcare resource use was specified for hospitalisations, general practitioner visits and drugs. Intervention: The intervention assessed in the cost-effectiveness analysis was influenza vaccination. Main outcome measures and results: The costs of influenza were estimated to be 31 million euros (EUR) for the influenza season 1995/96 in The Netherlands (EUR1 ≈

Discounting health effects in pharmacoeconomic evaluations

US1.1). For the extended programmein 1997/98, i.e. all elderly people, the cost-effectiveness ratio was estimated at EUR1820 per life-year gained. Subgroup analysis demonstrated that the programme had a more favourable cost effectiveness among the chronically ill elderly population (cost saving) than among the rest of the elderly population (EUR6900 per life-year gained). Conclusion: Influenza vaccination has a cost-effectiveness ratio that is better than or comparable to that of other implemented Dutch programmes in the prevention of infectious diseases.

Valuing prevention through economic evaluation: Some considerations regarding the choice of discount model for health effects with focus on infectious diseases

Currently, much debate still surrounds the discounting of health effects. Most general consensus statements have argued for the same discount rate for health and money; however, this practice has been questioned by several authors. The choice of discount rate can have varying effects on interventions, depending on the disease area. In this paper, we review two major current controversies around discounting: the use of similar or differential discount rates for health and money; and the validity of the underlying discounting model (time preference, constant discounting and the use of aggregated utilities for health effects).Various arguments justify a different rate of discounting for health effects than for money. Empirical evidence questions the validity of the constant discounting model, pointing out that time preference is not constant and should not be applied as such. Also, the validity of the aggregated utility model for health might be questioned, implying that a life cannot simply be cut into life years as single entities that are discounted back to the net present value. Such debates have led to varying methodologies being employed in economic evaluations, causing difficulties in their interpretation. Although there is sufficient evidence to question the use of similar discount rates for health and money, currently there is not enough information on the nature of the different processes that constitute discounting to reach a solid conclusion on the use of a different method.The lack of consensus on one of the most important topics in pharmacoeconomics makes the case for a more restricted use of cost-effectiveness or costutility ratios than as the most important singular outcome of pharmacoeconomic studies. Instead, results should be presented in a non-aggregated manner that enables policy makers to value health gains according to timing and to which subpopulation they are accrued in.

Health economics of a hexavalent meningococcal outer-membrane vesicle vaccine in children : potential impact of introduction in the Dutch vaccination program

In cost-effectiveness analysis, the valuing of costs and health effects over time remains a controversial issue. The debate mostly focuses on whether the discount rates for health and money should be equal and which discounting model and time preferences are most appropriate. In this paper we add to the debate by arguing that the assessment of effectiveness of a preventive intervention may influence the choice of the discounting procedure for health.Health effects in cost-effectiveness analysis are commonly expressed in life-years gained, QALYs gained or lives saved. These denominators are only indirect and partial measures of the effects of a preventive intervention. The actual effect of the intervention is a reduction of the risk of mortality and morbidity in a given period of time. This risk reduction will not always coincide with the moment at which the impact on (quality-adjusted) life-years gained is made (i.e. at risk exposure), for example when preventing chronic disease with an asymptomatic stage. In this paper we show that truly acknowledging the origin of health benefits could have implications for the discounting procedure. We present a discounting model that adequately focuses on the reduction of risk. This model recognises the potential interpretation of risk reduction for infection as an economic good to be acquired with associated mortality reductions as later indirect effects. This implies that our suggested discounting model focuses on the moment(s) of risk reduction. A numerical example illustrates our approach. We discuss the associated potential implications for public health policy and discuss how the effects of the intervention can be additionally corrected for societal preferences.

Towards a healthier discount procedure

The cost-effectiveness of universal vaccination of infants with a new hexavalent meningococcal B outer-membrane vesicle vaccine is projected for The Netherlands by applying decision analysis. The societal perspective is taken and direct and productivity costs (friction costs method) are considered. Future costs and effects are discounted at 4% (base year 1998). In this simulation model, vaccination would prevent 19 deaths and eight cases with severe long-term sequelae per year, rendering 526 additional quality adjusted life years (QALYs) per year. Yearly costs of acute phase of illness due to meningococcal infections in children are estimated at 1,426,634, while the future costs due to sequelae are estimated at 3,801,121 per year. Of all these costs, the vaccination program could prevent 3,334,052 per year. The program costs of meningococcal vaccination are estimated at 11,601,356, resulting in a cost-effectiveness ratio (CER) of 15,721 per QALY. These results are sensitive to the vaccine dose price (conservatively estimated at 10), efficacy, and coverage of meningococcal sero-subtypes.

Using pharmacoeconomics for policy making: Is rational decision making enhanced by applying thresholds for cost-effectiveness?

Most national guidelines for pharmacoeconomic research prescribe discounting, mostly of money and health against the same rate. There is much debate on whether this is adequate. Two theoretical arguments, the consistency argument of Weinstein and Stason, and the paralyzing paradox of Keeler and Cretin, are mostly responsible for the current standards. However, more recently, several authors have indicated that the basis to claim the necessity of using similar discount rates is rather weak, both practically and theoretically. In terms of finding a new theoretical basis on which to base discount rates for money and, in particular, health, Van Hout has made an important suggestion arguing that the discount rate for health could be based on the expected growth in life expectancy and the diminishing marginal utility related to such additional health. Similarly, Gravelle and Smith argue that if the value of health grows over time, discount rates that are used for costs cannot directly be applied to effects, but should be adjusted downwards.

Cost-effectiveness of HIV screening of patients attending clinics for sexually transmitted diseases in Amsterdam

© Future Drugs Ltd. All rights reserved. ISSN 1473-7167 247 Jasper M Bos, PhD Maarten J Postma†, PhD †Author for correspondence Groningen University Institute for Drug Exploration/University of Groningen Research Institute of Pharmacy, Groningen, The Netherlands Tel.: +31 503 632 607 Fax: +31 503 632 772 M.Postma@farm.rug.nl Using pharmacoeconomics for policy making: is rational decision making enhanced by applying thresholds for cost-effectiveness?

Combination Vaccine Against Invasive Meningococcal B and Pneumococcal Infections Potential Epidemiological and Economic Impact in The Netherlands

ObjectiveTo estimate the cost-effectiveness of universal HIV screening of patients attending a clinic for sexually transmitted diseases (STD) in Amsterdam. DesignCost effectiveness analysis. MethodsA Bernoulli model for the secondary transmission of HIV was linked with epidemiological data on infection with HIV and other STD in patients attending a STD clinic in Amsterdam from 1991 to 1997. This gave estimates of the number of secondary HIV infections caused by attenders of the STD clinic. Combined with data on the health and monetary benefits of averting HIV infection and costs of HIV screening, we assessed the cost-effectiveness of HIV-screening of attenders of the STD clinic. ResultsIncreased risk for HIV infection was found in STD clinic attendees infected with other STD. (odds ratio, 2.07). The risk differed for specific STD: the highest odds ratios were found for syphilis and gonorrhoea. Screening of all attendees was estimated at net costs of &U20AC;82 552 per secondary infection averted. The cost-effectiveness ranges between &U20AC;680 and &U20AC;9335 per life-year gained, depending on the value of key parameters used in the model. ConclusionCompared to other interventions in infectious diseases control in the Netherlands, screening of STD clinic attendees for HIV has an acceptable cost-effectiveness.