Natalia Olchanski

Cost-Utility Analyses in Orthopaedic Surgery

BACKGROUND The rising cost of health care has increased the need for the orthopaedic community to understand and apply economic evaluations. We critically reviewed the literature on orthopaedic cost-utility analysis to determine which subspecialty areas are represented, the cost-utility ratios that have been utilized, and the quality of the present literature. METHODS We searched the English-language medical literature published between 1976 and 2001 for orthopaedic-related cost-utility analyses in which outcomes were reported as cost per quality-adjusted life year. Two trained reviewers independently audited each article to abstract data on the methods and reporting practices used in the study as well as the cost-utility ratios derived by the analysis. RESULTS Our search yielded thirty-seven studies, in which 116 cost-utility ratios were presented. Eleven of the studies were investigations of treatment strategies in total joint arthroplasty. Study methods varied substantially, with only five studies (14%) including four key criteria recommended by the United States Panel on Cost-Effectiveness in Health and Medicine. According to a reader-assigned measure of study quality, cost-utility analyses in orthopaedics were of lower quality than those in other areas of medicine (p = 0.04). While the number of orthopaedic studies has increased in the last decade, the quality did not improve over time and did not differ according to subspecialty area or journal type. For the majority of the interventions that were studied, the cost-utility ratio was below the commonly used threshold of

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

50,000 per quality-adjusted life year for acceptable cost-effectiveness. CONCLUSIONS Because of limitations in methodology, the current body of literature on orthopaedic cost-utility analyses has a limited ability to guide policy, but it can be useful for setting priorities and guiding research. Future research with clear and transparent reporting is needed in all subspecialty areas of orthopaedic practice.

Quality of Abstracts of Papers Reporting Original Cost-Effectiveness Analyses:

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.

A synthesis of cost-utility analysis literature in infectious disease.

Background . Although many peer-reviewed journals have adopted standards for reporting cost-effectiveness analyses (CEAs), guidelines do not exist for the accompanying abstracts. Abstracts are the most easily accessed portion of journal articles, yet little is known about their quality. The authors examined the extent to which abstracts of published CEAs include key data elements (intervention, comparator, target population, study perspective) and assessed the effect of journal characteristics on reporting quality. Methods .Systematic review of the English-language medical literature from 1998 through 2001. The authors searched MEDLINE for original CEAs reported in costs per quality-adjusted life years(i.e., cost-utility analyses). Two independent readers abstracted data elements and met to resolve discrepancies. Results . Among the 303 abstracts reviewed, a clear description of the intervention was present in 94%, comparator in 71%, target population in 85%, and study perspective in 28%. All 4 data elements were reported in 20% of abstracts, 3 elements in 49%, 2 in 22%, and 0 or 1 in 9%. In journals with CEA-specific abstract reporting requirements, structured abstract requirements, or impact factors ≥ 10, significantly more data were included in abstracts than in journals without these features (P < 0.01 for all comparisons). Conclusions . Abstracts of published CEAs frequently omit data elements critical to proper study interpretation. An explicit core set of reporting standards is needed, based on the standards by the US Public Health Service’s Panel on Cost-Effectiveness for reporting of CEAs, but specific to the accompanying abstracts.

The peculiar economics of life-extending therapies: a review of costing methods in health economic evaluations in oncology.

The purpose of this review is to understand infectious disease-related cost-utility analyses by describing published analyses, examining growth and quality trends over time, examining factors related to quality, and summarising standardised results. 122 cost-utility analyses and 352 cost-utility ratios were identified. Pharmaceutical interventions were most common (47.5%); three author groups accounted for 42.8% of pharmaceutical ratios. High-volume journals (three or more published cost-utility analyses) published higher quality analyses than low-volume journals (p<0.001). Use of probabilistic sensitivity analysis and discounting at 3% were more frequently found in the years after the US Public Health Service Panel on Cost-Effectiveness in Health and Medicine recommendations (p<0.01). Median ratios varied from US13,500 dollars/quality-adjusted life year (QALY) for immunisations to US810,000 dollars/QALY for blood safety. Publication of infectious disease cost-utility analyses is increasing. The results of cost-utility analyses have important implications for the development of clinical guidelines and resource allocation decisions. More trained investigators and better peer-review processes are needed.

A role for research: an observation on preventive services for women.

Published literature lacks consensus, and most guidelines lack definitive recommendations as to whether cost-effectiveness analyses (CEAs) should include all “future” costs or distinguish between related and unrelated medical costs. This systematic review of oncology CEAs evaluated cost methods used and the impact on the cost-effectiveness of incorporating different cost categories, including costs due to study intervention, related medical costs of the treated condition, and unrelated medical costs. Of the 59 studies reviewed, none included medical costs unrelated to the treated condition and 14 studies (32%) excluded direct medical costs related to the condition but not the evaluated intervention. Recomputing ICERs using different cost categories altered overall cost-effectiveness conclusions. The authors propose conventional CEA methods may implicitly penalize therapies that add “expensive” life years for chronically ill patients. Presenting ICERs computed with and without disease-attributable costs can help better convey how much the treatment itself contributes to overall costs.

Stress CMR myocardial perfusion imaging (CMR-MPI) is cost-effective compared to nuclear SPECT: a retrospective cost-effectiveness analysis

BACKGROUND The Patient Protection and Affordable Care Act of 2010 (ACA) added preventive services for women, recommended by the IOM, to healthcare coverage requirements beginning in August 2011. PURPOSE The current review provides evidence on the economic impact of services that will be covered under the ACA, focusing on IOM-recommended measures that address womens health. METHODS This review analyzed the cost-effectiveness literature related to these services using the Tufts Medical Center Cost-Effectiveness Analysis Registry (www.cearegistry.org), which catalogs detailed information on cost-effectiveness studies published in English in the peer-reviewed literature. In order to keep the review relevant to current clinical practice, the analysis was restricted to studies published in 2000-2010. The data search and analysis were performed in 2011. RESULTS Cost-effectiveness studies have evaluated a limited subset of the preventive measures available for women. Further, few cost-effectiveness studies have evaluated the recommended counseling and screening services for women. Of 16 relevant studies found, eight focused on HIV screening, with results varying substantially depending on the specific groups screened and the screening frequency. CONCLUSIONS The current review underscores the finding that there is a substantial gap in the health economic literature on preventive care, especially with respect to screening and counseling of women in the primary care setting. There is some evidence that better access to preventive services can be maintained at a reasonable cost to the healthcare system, and that certain services may even lower healthcare costs.

Palivizumab Prophylaxis for Respiratory Syncytial Virus: Examining the Evidence Around Value

Background Stress CMR myocardial perfusion is a strong risk-stratifying tool increasingly used for patient management. However, the cost-effectiveness of this technique in patients with suspected ischemia, has never been studied against nuclear SPECT. Methods From 2003-2011, 707 patients underwent CMR-MPI for ischemia assessment in our center. Estimated pre-test cardiac risk derived from a combined Framingham Heart Study and Diamond Forrester risk percentage was used to match CMR patients against 39,876 patients who underwent pharmacologic stress SPECT in another tertiary-care center during the same time period. Framingham scoring system for the prediction of cardiovascular risk was also stratified by presence or absence of prior evidence of CAD. A validated computer algorithm was used to perform 1:1 patient risk-matching. For all patients, cardiac events (acute MI/death), angiographically-significant CAD, percutaneous coronary intervention and bypass grafting, repeat stress testing/imaging within 2 years, and cost estimates for these events from national average were collected for cost-effectiveness analysis. One-to-one risk-profile matching between CMR-MPI and SPECT was successful in 704 patients (99.6%). Ischemia by SPECT was positive, negative, and equivocal in 8%, 74%, and 18%, which compared with 22%, 75%, and 3%, respectively by CMR-MPI. A negative SPECT was associated with a 2-year cardiac event rate of 4.6% compared to 1.3% by CMR-MPI (p=0.002). Other items relevant to cost-effectiveness analysis using imaging for “gate-keeping” stratification are shown in Table 1. Conclusions In patients with an intermediate risk of ischemic heart disease, stress CMR myocardial perfusion is cost-effective when compared to pharmacologic stress SPECT. A negative stress CMR perfusion study is associated with a lower 2 year event rate and lower downstream costs.

Patient Variability Seldom Assessed in Cost-effectiveness Studies:

Abstract Respiratory syncytial virus (RSV) infection is the most common cause of lower respiratory tract infection and the leading cause of hospitalization among young children, incurring high annual costs among US children under the age of 5 years. Palivizumab has been found to be effective in reducing hospitalization and preventing serious lower respiratory tract infections in high-risk infants. This paper presents a systematic review of the cost-effectiveness studies of palivizumab and describes the main highlights of a round table discussion with clinical, payer, economic, research method, and other experts. The objectives of the discussion were to (1) review the current state of clinical, epidemiology, and economic data related to severe RSV disease; (2) review new cost-effectiveness estimates of RSV immunoprophylaxis in US preterm infants, including a review of the field’s areas of agreement and disagreement; and (3) identify needs for further research.

Cost comparison across heart failure patients with reduced and preserved ejection fractions: Analyses of inpatient decompensated heart failure admissions

Background. Cost-effectiveness analysis (CEA) estimates can vary substantially across patient subgroups when patient characteristics influence preferences, outcome risks, treatment effectiveness, life expectancy, or associated costs. However, no systematic review has reported the frequency of subgroup analysis in CEA, what type of heterogeneity they address, and how often heterogeneity influences whether cost-effectiveness ratios exceed or fall below conventional thresholds. Methods. We reviewed the CEA literature cataloged in the Tufts Medical Center CEA Registry, a repository describing cost-utility analyses published through 2016. After randomly selecting 200 of 642 articles published in 2014, we ascertained whether each study reported subgroup results and collected data on the defining characteristics of these subgroups. We identified whether any of the CEA subgroup results crossed conventional cost-effectiveness benchmarks (e.g.,