Marian Shanahan

Buprenorphine versus methadone maintenance: a cost-effectiveness analysis.

This article presents the cost-effectiveness results of a randomised controlled trial conducted in two Australian cities. The trial was designed to assess the safety, efficacy and cost-effectiveness of buprenorphine versus methadone in the management of opioid dependence. The trial utilised a flexible dosing regime that was tailored to the clinical need of the patients, with high maximum doses, using the marketed formulation, under double-blind conditions. A total of 405 subjects were randomised to a treatment at one of three specialist outpatient drug treatment centres in Adelaide and Sydney, Australia. The perspective of the cost-effectiveness analysis was that of the service provider and included costs relevant to the provision of treatment. The primary outcome measure used in the economic analysis was change in heroin-free days from baseline to the sixth month of treatment. Treatment with methadone was found to be both less expensive and more effective than treatment with buprenorphine, which suggests methadone dominates buprenorphine. However, statistical testing found that the observed difference between the cost-effectiveness of methadone and buprenorphine treatments was not statistically significant. The results of this study provide useful policy information on the costs and outcomes associated with the use of methadone and buprenorphine and indicate that buprenorphine provides a viable alternative to methadone in the treatment of opioid dependence.

Cost effectiveness analysis of smoking cessation interventions

Objective: To identify which smoking cessation interventions provide the most efficient use of health care resources at a population level.

Clinical, psychosocial, and economic effects of antenatal day care for three medical complications of pregnancy: A randomised controlled trial of 395 women

BACKGROUND Day care is increasingly being used for complications of pregnancy, but there is little published evidence on its efficacy. We assessed the clinical, psychosocial, and economic effects of day care for three pregnancy complications in a randomised trial of day care versus standard care on an antenatal ward. METHODS 395 women were randomly assigned day (263) or ward (132) care in a ratio of two to one, stratified for major diagnostic categories (non-proteinuric hypertension, proteinuric hypertension, and preterm premature rupture of membranes). The research hypothesis was that for these disorders, as an alternative to admission, antenatal day care will reduce specified interventions and investigations, result in no differences in clinical outcome, lead to greater satisfaction and psychological wellbeing, and be more cost-effective. Data were collected through case-note review, self-report questionnaires (response rates 81.0% or higher) and via the hospitals financial system. Analysis was by intention to treat. FINDINGS All participants were included in the analyses. There were no differences between the groups in antenatal tests or investigations or intrapartum interventions. The total duration of antenatal care episodes was shorter in the day-care group than in the ward group (median 17 [IQR 5-9] vs 57 [35-123] h; p=0.001). Overall stay was also significantly shorter in the day-care group (mean 7.22 [SE 0.31] vs 8.53 [0.44]; p=0.014). The median number of care episodes was three (range one to 14) in the day-care group and two (one to nine) in the ward group (p=0.01). There were no statistically or clinically significant differences in maternal or perinatal outcomes. The day-care group reported greater satisfaction, with no evidence of unintended psychosocial sequelae. There was no significant difference in either average cost per patient or average cost per day of care. INTERPRETATION Since clinical outcomes and costs are similar, adoption by maternity services of a policy providing specified women with the choice between admission and day-unit care seems appropriate.

Using stated preference discrete choice modelling to inform health care decision-making: a pilot study of breast screening participation

This study was an important start to explore the feasibility of applying stated preference discrete choice modelling (SPDCM) for use in developing breast screening participation enhancement strategies. It needs to be followed by further research to establish model validity and authoritative results. In the meantime a random effects binary probit choice model was estimated using a main effects with selected 2-way interaction design and a convenience sample of Australian breast cancer screening participants. A response rate of 48% was obtained. Clear preferences for different service configurations were revealed and used to demonstrate how potential strategies to enhance future participation rates of women placed on routine recall could be identified. As anticipated accuracy of screening was the most important attribute of the service to influence the probability of uptake but others were screening time, travel time, information about screening benefits and the desire for privacy lending support to the view that benefit assessment goes beyond health factors. In summary, the SPDCM approach can be regarded as a judicious approach for helping decision-makers improve screening participation.

Cost-Effectiveness Analysis of the New South Wales Adult Drug Court Program.

In New South Wales, Australia, a cost-effectiveness evaluation was conducted of an adult drug court (ADC) program as an alternative to jail for criminal offenders addicted to illicit drugs. This article describes the program, the cost-effectiveness analysis, and the results. The results of this study reveal that, for the 23-month period of the evaluation, the ADC was as cost-effective as were conventional sanctions in delaying the time to the first offense and more cost-effective in reducing the frequency of offending for those outcome measures selected. Although the evaluation was conducted using the traditional steps of a cost-effectiveness analysis, because of the complexity of the program and data limitations it was not always possible to adhere to textbook procedures. As such, each step involved in undertaking the cost-effectiveness analysis is discussed, highlighting the key issues faced in the evaluation.

Hepatitis B Immunization in a Low-incidence Province of Canada Comparing Alternative Strategies

This study provides a comparative cost-effectiveness analysis of three universal im munization programs for hepatitis B virus (HBV). Using three theoretical cohorts of infants, 10-year-olds, and 12-year-olds, a universal immunization program was com pared with a prenatal screening/newborn immunization program involving testing of prepartum women and immunization of newborns of HBsAg-positive mothers. A Mar kov long-term outcome model used Manitoba data to estimate costs and health out comes across the lifespan. The model was based on an HBV incidence rate of 19/ 100,000 and a discount rate of 5% and incorporated the most recent treatment ad vances (interferon therapy). Cost-effectiveness was calculated as the ratio of dollars spent per year of life saved, with costs determined from the perspective of a third- party payer. The universal infant-immunization program, although not cost-saving, was associated with a low, economically attractive cost-effectiveness ratio of

Cost Benefit Analysis of Two Policy Options for Cannabis: Status Quo and Legalisation

15,900 (Ca nadian) per year of life saved, a figure substantially lower than the ratios of

Is in vitro fertilisation more effective than stimulated intrauterine insemination as a first-line therapy for subfertility? A cohort analysis

97,600 and

A comparative study of the costliness of Manitoba hospitals.

184,800 (Canadian) associated with the universal programs for 10- and 12-year- olds, respectively. Cost-effectiveness ratios were found to be sensitive to changes in immunization costs, HBV incidence rates, and the rate at which protective antibody levels are lost over time: If these variables move in the directions suggested by current trends, the authors anticipate an increasing economic appeal of universal programs well into the future. A universal program of HBV immunization for infants appears to be economically practical in regions where HBV infection rates are low and stable. Key words: hepatitis B; cost-effectiveness; immunization. (Med Decis Making 1997; 17:472-482)

Using Discrete Choice Modelling to Investigate Breast Screening Participation

Aims To date there has been limited analysis of the economic costs and benefits associated with cannabis legalisation. This study redresses this gap. A cost benefit analysis of two cannabis policy options the status quo (where cannabis use is illegal) and a legalised–regulated option was conducted. Method A cost benefit analysis was used to value the costs and benefits of the two policies in monetary terms. Costs and benefits of each policy option were classified into five categories (direct intervention costs, costs or cost savings to other agencies, benefits or lost benefits to the individual or the family, other impacts on third parties, and adverse or spill over events). The results are expressed as a net social benefit (NSB). Findings The mean NSB per annum from Monte Carlo simulations (with the 5 and 95 percentiles) for the status quo was