Joanna E. Siegel

Cost-effectiveness in health and medicine

1. Cost-Effectiveness Analysis as a Guide to Resource Allocation in Health: Roles and Limitations 2. Theoretical Foundations of Cost-Effectiveness Analysis 3. Framing and Designing the Cost-Effectiveness Analysis 4. Identifying and Valuing Outcomes 5. Assessing the Effectiveness of Health Interventions 6. Estimating Costs in Cost-Effectiveness Analysis 7. Time Preference 8. Reflecting Uncertainty in Cost-Effectiveness Analysis 9. Reporting Cost-Effectiveness Studies and Results Appendix A: Summary of Recommendations for the Reference Case Appendix B: Cost-Effectiveness of Strategies to Prevent Neural Tube Defects Appendix C: The Cost-Effectiveness of Dietary and Pharmacologic Therapy for Cholesterol Reduction in Adults

Guidelines for Pharmacoeconomic Studies

SummaryThis article reports the recommendations of the Panel on Cost Effectiveness in Health and Medicine, sponsored by the US Public Health Service, on standardised methods for conducting cost-effectiveness analyses. Although not expressly directed at analyses of pharmaceutical agents, the Panel’s recommendations are relevant to pharmacoeconomic studies.The Panel outlines a ‘Reference Case’ set of methodological practices to improve quality and comparability of analyses. Designed for studies that inform resource-allocation decisions, the Reference Case includes recommendations for study framing and scope, components of the numerator and denominator of cost-effectiveness ratios, discounting, handling uncertainty and reporting.The Reference Case analysis is conducted from the societal perspective, and includes all effects of interventions on resource use and health. Resource use includes ‘time’ resources, such as for caregiving or undergoing an intervention. The quality-adjusted life-year (QALY) is the common measure of health effect across Reference Case studies. Although the Panel does not endorse a measure for obtaining quality-of-life weights, several recommendations address the QALY. The Panel recommends a 3% discount rate for costs and health effects.Pharmacoeconomic studies have burgeoned in recent years. The Reference Case analysis will improve study quality and usability, and permit comparison of pharmaceuticals with other health interventions.

Cost Utility of Maintenance Treatment of Recurrent Depression with Sertraline Versus Episodic Treatment with Dothiepin

SummaryThe objective of this study was to model, for patients at risk of recurrent depression, the cost-utility of maintenance therapy with sertraline compared with treatment of acute episodes with dothiepin (‘episodic treatment’). Using clinical decision analysis techniques, a Markov state-transition model was constructed to estimate the lifetime costs and quality-adjusted life-years (QALYs) of the 2 therapeutic strategies. The model follows 2 cohorts of 35-year-old women at high risk for recurrent depression over their lifetimes. Model construction and relevant data (probabilities) for performing the analysis were based on existing clinical knowledge. Two physician panels were used to obtain estimates of recurrence probabilities not available in the literature, health utilities, and resource consumption. Costs were obtained from published sources. The baseline analysis showed that it costs £2172 (

Bleach programs for preventing AIDS among i.v. drug users: modeling the impact of HIV prevalence.

US3692, 1991 currency) to save an additional QALY with sertraline maintenance treatment. Sensitivity analysis showed that the incremental cost-utility ratio ranged from £557 to £5260 per QALY. Overall, the resulting ratios are considered to be well within the range of cost-utility ratios that support the adoption and appropriate utilisation of a technology. Based on the study assumptions, long term maintenance treatment with sertraline appears to be clinically and economically justified choice for patients at high risk of recurrent depression.

Oregon's Medicaid Ranking and Cost- Effectiveness Is There Any Relationship?

BACKGROUND The growing importance of drug use as a mode of HIV transmission has led to increased attention to AIDS prevention among intravenous drug users (IVDUs). This analysis examines the effectiveness of bleach distribution, a program to prevent HIV transmission via shared needles. METHODS We used a Markov model to assess the role of the initial HIV prevalence among drug users in determining the effectiveness of bleach programs. The model incorporates survey data on risk behaviors and published information describing HIV incubation and mortality. It predicts life expectancy for cohorts of IVDUs with and without a bleach program to estimate program effectiveness. RESULTS We found that bleach programs can produce the greatest life-year savings in areas of low HIV prevalence. In the lowest prevalence scenario (0.02 initial prevalence), initiation of the program resulted in a projected savings of 2.3 life years per HIV-negative drug user, compared with 1.7 and 1.3 years under medium (0.25) and high (0.60) prevalence, respectively. CONCLUSIONS While bleach programs are beneficial in all groups of IVDUs, these results highlight the advantages of introducing bleach programs early, when prevalence is still comparatively low in a drug-user population.

Can We Better Prioritize Resources for Cost-Utility Research?:

The authors examine whether Oregons 1990, 1991, 1992, and 1993 prioritized lists were ranked in a manner consistent with cost-effectiveness. Two sets of cost-ef fectiveness data are used: data from economic analyses and Oregons own cost- effectiveness data. Comparing the ranks of Oregons lists with the ranks of cost- effectiveness estimates from the literature reveals Spearman correlations of -0.08 for the 1990 list, +0.39 for the 1991 list, +0.25 for the 1992 list, and +0.24 for the 1993 list. Comparing Oregons lists with Oregons own cost-effectiveness data reveals rank correlations of +0.99 for the 1990 list, +0.06 for the 1991 list, -0.05 for the 1992 list, and -0.03 for the 1993 list. Thus, there appear to be essentially no relationship be tween the 1990 list and cost-effectiveness estimates from the economic literature and modest positive relationships between the 1991-93 lists and the literature. In addition, there is virtually no relationship between the 1991-93 lists and Oregons own cost- effectiveness data. Further, the correlations are very different from +1.0, suggesting that other factors are at play. For example, the 1993 list that is currently being imple mented was ranked primarily by improvement in five-year survival and human judg ment, not cost-effectiveness. Key words: Oregon; Medicaid; cost-effectiveness; ra tioning ; resource allocation. (Med Decis Making 1996;16:99-107)

Economic evaluation of HIV testing among intravenous drug users : An analytic framework and its application to Italy

Purpose. We examined 512 published cost-utility analyses (CUAs) in the U.S. and other developed countries from 1976 through 2001 to determine: 1) the types of interventions studied; 2) whether they cover diseases and conditions with the highest burden; and, 3) to what extent they have covered leading health concerns defined by the Healthy People 2010 report. Data and Methods. We compared rankings of the most common diseases covered by the CUAs to rankings of U.S. disease burden. We also examined the extent to which CUAs covered key Healthy People 2010 priorites. Results. CUAs have focused mostly on pharmaceuticals (40%) and surgical procedures (16%). When compared to leading causes of DALYs, the data show overrepresentation of CUAs in cerebrovascular disease, diabetes, breast cancer, and HIV/AIDS, and underrepresentation in depression and bipolar disorder, injuries, and substance abuse disorders. Few CUAs have targeted Healthy People 2010 areas, such as physical activity. Conclusions. Published CUAs are associated with burden measures, but have not covered certain important health problems. These discrepancies do not alone indicate that society has been targeting resources for research inefficiently, but they do suggest the need to formalize the question of where each CUA research dollar might do the most good.

Whose Blood Is Safer?: The Effect of the Stage of the Epidemic on Screening for HIV

We performed an economic evaluation of HIV testing among intravenous drug users (IVDUs) in Italy using the analytical framework of cost-effectiveness analysis. A semi-Markov model was developed to calculate costs and life expectancy of a cohort of IVDUs with and without an annual HIV testing program. We also investigated the incremental cost-effectiveness of a hypothetical early treatment to prolong the life expectancy of HIV-infected asymptomatic subjects by 1 year. The testing program is cost saving in the low prevalence scenario (0.05), and costs L 14,000,000 (US

Deliberation: Obtaining Informed Input from a Diverse Public

8,400) and L 55,800,000 (US

Introduction to SMLTREE

33,500) per year of life saved in areas of medium (0.3) and high (0.6) prevalence, respectively. The incremental cost-effectiveness of the hypothetical early treatment may compare favorably with other health care interventions. The program may be considered a cost-effective procedure in low and medium prevalence areas. Where prevalence is high, more evidence about the magnitude of the behavior change is needed. In these areas, the availability of an effective early treatment may become the economic rationale for implementing such a program.