Patricia Harrington

Cost-effectiveness of a national public access defibrillation programme

AIM Proposed Irish legislation aimed at increasing survival from out-of-hospital-cardiac-arrest (OHCA) mandates the provision of automated external defibrillators (AEDs) in a comprehensive range of publicly accessible premises in urban and rural areas. This study estimated the clinical and cost effectiveness of the legislation, compared with alternative programme configurations involving more targeted AED placement. METHODS We used a cost-utility analysis to estimate the costs and consequences of public access defibrillation (PAD) programmes from a societal perspective, based on AED deployment by building type. Comparator programmes ranged from those that only included building types with the highest incidence of OHCA, to the comprehensive programme outline in the proposed legislation. Data on OHCA incidence and outcomes were obtained from the Irish Out-of-Hospital-Cardiac-Arrest Register (OHCAR). Costs were obtained from the Irish health service, device suppliers and training providers. RESULTS The incremental cost effectiveness ratio (ICER) for the most comprehensive PAD scheme was €928,450/QALY. The ICER for the most scaled-back programme involving AED placement in transport stations, medical practices, entertainment venues, schools (excluding primary) and fitness facilities was €95,640/QALY. A 40% increase in AED utilisation when OHCAs occur in a public area could potentially render this programme cost effective. CONCLUSION National PAD programmes involving widespread deployment of static AEDs are unlikely to be cost-effective. To improve cost-effectiveness any prospective programmes should target locations with the highest incidence of OHCA and be supported by efforts to increase AED utilisation, such as improving public awareness, increasing CPR and AED training, and establishing an EMS-linked AED register.

A systematic review of intermittent pneumatic compression for critical limb ischaemia

Intermittent pneumatic compression (IPC) is designed to aid wound healing and limb salvage for patients with critical limb ischaemia who are not candidates for revascularisation. We conducted a systematic review of the literature to identify and critically appraise the evidence supporting its use in this population. A search was conducted in Embase, MEDLINE and clinical trial registries up to the end of March 2013. No date or language restrictions were applied. Quality assessment was performed by two people independently. Quality was assessed using the Cochrane risk of bias tool and the NICE case-series assessment tool. Two controlled before-and-after (CBA) studies and six case series were identified. One retrospective CBA study involving compression of the calf reported improved limb salvage and wound healing (OR 7.00, 95% CI 1.82 to 26.89, p<0.01). One prospective CBA study involving sequential compression of the foot and calf reported statistically significant improvements in claudication distances and SF-36 quality of life scores. No difference in all-cause mortality was found. Complications included pain associated with compression, as well as skin abrasion and contact rash as a result of the cuff rubbing against the skin. All studies had a high risk of bias. In conclusion, the limited available results suggest that IPC may be associated with improved limb salvage, wound healing and pain management. However, in the absence of additional well-designed analytical studies examining the effect of IPC in critical limb ischaemia, this treatment remains unproven.

Cost-effectiveness of prion filtration of red blood cells to reduce the risk of transfusion-transmitted variant Creutzfeldt-Jakob disease in the Republic of Ireland

BACKGROUND: Variant Creutzfeldt‐Jakob disease (vCJD) is a rare, progressive fatal noninflammatory neurodegenerative disease. Ireland has the second highest rate of vCJD in the world with an ongoing risk of vCJD transmission through blood transfusion. Prion‐removing filters have been developed to reduce the risk of vCJD transmission. This study aimed to evaluate the cost‐effectiveness of implementing a policy of prion filtration of red blood cells (RBCs) in the Republic of Ireland.

Cost-Effectiveness of a National Opportunistic Screening Program for Atrial Fibrillation in Ireland.

OBJECTIVES To evaluate the cost-effectiveness of a national atrial fibrillation screening program in Ireland involving annual opportunistic pulse palpation of all those older than 65 years during general practitioner consultations, with an electrocardiogram being performed if an irregular pulse is detected. METHODS A probabilistic Markov model was used to simulate costs and clinical outcomes in a hypothetical cohort of men and women with and without screening over the course of 25 years, using a societal perspective. RESULTS Screening was associated with an incremental cost-effectiveness ratio of €23,004/quality-adjusted life-year compared with routine care. Nevertheless, if the relative risk of stroke and systematic embolism in screen-detected patients is more than 12% lower than that in patients with atrial fibrillation identified through routine practice, then screening would not be considered cost-effective at a willingness-to-pay threshold of €45,000/quality-adjusted life-year. An analysis comparing alternative combinations of start age and screening interval found that less frequent screening with a later start age may be more cost-effective than an annual screening from age 65 years. CONCLUSIONS Annual opportunistic screening of men and women aged 65 years and older in primary care in Ireland is likely to be cost-effective using conventional willingness-to-pay thresholds, assuming that those detected through screening have a comparable stroke risk profile as those detected through routine practice. Raising the start age of screening or increasing the screening interval may improve the cost-effectiveness of a prospective screening program.

Using prediction intervals from random-effects meta-analyses in an economic model.

OBJECTIVES When incorporating treatment effect estimates derived from a random-effect meta-analysis it is tempting to use the confidence bounds to determine the potential range of treatment effect. However, prediction intervals reflect the potential effect of a technology rather than the more narrowly defined average treatment effect. Using a case study of robot-assisted radical prostatectomy, this study investigates the impact on a cost-utility analysis of using clinical effectiveness derived from random-effects meta-analyses presented as confidence bounds and prediction intervals, respectively. METHODS To determine the cost-utility of robot-assisted prostatectomy, an economic model was developed. The clinical effectiveness of robot-assisted surgery compared with open and conventional laparoscopic surgery was estimated using meta-analysis of peer-reviewed publications. Assuming treatment effect would vary across studies due to both sampling variability and differences between surgical teams, random-effects meta-analysis was used to pool effect estimates. RESULTS Using the confidence bounds approach the mean and median ICER was €24,193 and €26,731/QALY (95%CI: €13,752 to €68,861/QALY), respectively. The prediction interval approach produced an equivalent mean and median ICER of €26,920 and €26,643/QALY (95%CI: -€135,244 to €239,166/QALY), respectively. Using prediction intervals, there is a probability of 0.042 that robot-assisted surgery will result in a net reduction in QALYs. CONCLUSIONS Using prediction intervals rather than confidence bounds does not affect the point estimate of the treatment effect. In meta-analyses with significant heterogeneity, the use of prediction intervals will produce wider ranges of treatment effect, and hence result in greater uncertainty, but a better reflection of the effect of the technology.

Clinical-effectiveness of self-management interventions in chronic obstructive pulmonary disease: An overview of reviews:

Self-management (SM) is defined as the provision of interventions to increase patients’ skills and confidence, empowering the individual to take an active part in their disease management. There is uncertainty regarding the optimal format and the short- and long-term benefits of chronic obstructive pulmonary disease (COPD) SM interventions in adults. Therefore, a high-quality overview of reviews was updated to examine their clinical effectiveness. Sixteen reviews were identified, interventions were broadly classified as education or action plans, complex interventions with an SM focus, pulmonary rehabilitation (PR), telehealth and outreach nursing. Systematic review and meta-analysis quality and the risk of bias of underlying primary studies were assessed. Strong evidence was found that PR is associated with significant improvements in health-related quality of life (HRQoL). Limited to moderate evidence for complex interventions (SM focus) with limited evidence for education, action plans, telehealth interventions and outreach nursing for HRQoL was found. There was strong evidence that education is associated with a significant reduction in COPD-related hospital admissions, moderate to strong evidence that telehealth interventions and moderate evidence that complex interventions (SM focus) are associated with reduced health care utilization. These findings from a large body of evidence suggesting that SM, through education or as a component of PR, confers significant health gains in people with COPD in terms of HRQoL. SM supported by telehealth confers significant reductions in healthcare utilization, including hospitalization and emergency department visits.

Response to McKinnell et al’s Original Article “Cost-Benefit Analysis From the Hospital Perspective of Universal Active Screening Followed by Contact Precautions for Methicillin-Resistant Staphylococcus aureus Carriers”

To the Editor—We read with interest the cost-benefit analysis by McKinnell et al who found that universal screening for methicillin-resistant Staphylococcus aureus (MRSA) may be relative costly for hospitals. We assessed the potential economic aspects of screening as part of a review of national MRSA control guidelines in Ireland. We found that MRSA screening is generally advocated as part of infection prevention and control measures, but an important consideration is the cost-effectiveness of the type of screening approach. For patients admitted to acute hospitals setting, 7 studies (United States, 4; Germany, 1; United Kingdom, 1; Ireland, 1) compared the cost of universal screening with targeted screening of at-risk patients. Costs were limited to direct medical costs and were evaluated from the perspective of the healthcare provider or hospital. Four studies were cost comparisons, 2 reported cost-effectiveness of the strategies compared with a base case of no screening and relative to each other, while 1 study provided a cost-benefit analysis of universal versus targeted screening. In hospitals where MRSA is endemic, screening (targeted or universal) reduced infection rates and was cost saving compared with a policy of no screening. Universal MRSA screening strategies were more effective but also more cost-intensive than targeted screening. In a retrospective review of a 3-year MRSA screening program that was implemented from 2006 to 2009 in the United Kingdom, only 7 extra MRSA cases were detected using universal screening compared with targeted screening, and in 1 month, universal screening generated 4,200 negative screens that incurred an additional €25,488 in laboratory costs. Similarly, a prospective study by Creamer et al found that extending screening to patients without risk factors (ie, universal screening) increased the number of screenings and the costs but did not result in the detection of a significant number of additional cases. In a 2011 US study, targeted screening was associated with lower costs and better outcomes than a policy of no screening, whereas universal screening was associated with an average cost-effectiveness ratio of €11,769 per MRSA infection. In a second cost-effectiveness analysis, targeted screening strategies were found to be more cost-effective than universal screening, with incremental cost-effectiveness ratios of €3,227 to €28,507, depending on the prevalence rate and testing used, compared with €103,169 to €183,269 per additional infection averted for universal screening. Finally, a US prospective study comparing the clinical effectiveness and cost benefit of universal versus targeted screening reported a benefit-to-cost ratio of 0.50, indicating that for every additional euro spent on universal versus targeted screening, only €0.40 could be recovered in avoided costs due to a reduction in MRSA healthcareassociated infection. The control of MRSA is a multidisciplinary task involving surveillance, patient screening, decolonization, isolation and/ or the cohorting of patients, environmental decontamination, antimicrobial stewardship, maintenance of adequate staffing levels, and hand hygiene. Although considerable coordination efforts may need to be invested in control, we demonstrate that the evidence strongly suggests that overall MRSA prevention and control strategies are associated with significant cost savings. The control measures have additional merits because they increase the awareness of the importance of all healthcareassociated infections and their implementation decreases other healthcare-associated infections. However, MRSA control measures encompass a wide range of interventions, the efficacy and cost of some of which are dependent on prevalence rates, local resistance patterns, the characteristics of the patient population, and the hospital facilities, all of which will vary from country to country. Because the MRSA prevalence rate in Ireland is higher than in the United Kingdom and in other Northern European countries, MRSA prevention and control is very relevant in the potential efficient use of resources. In conclusion, the evidence shows that screening, whether universal or targeted, is better than no screening, resulting in fewer MRSA infections. Although universal screening, as currently practiced in the United Kingdom, is the most costly but the most effective strategy, it is not as cost-effective as it is resource intensive. Universal screening detects few additional cases and results in a large number of additional negative screens. However, any evaluation of the effectiveness of screening methods should take account of healthcare costs, methods, the rapidity of test results, and the prevalence of colonization and infection.

CONTRIBUTION OF STAKEHOLDER ENGAGEMENT TO THE IMPACT OF A HEALTH TECHNOLOGY ASSESSMENT: AN IRISH CASE STUDY

OBJECTIVES The aim of this study was to illustrate the contribution of stakeholder engagement to the impact of health technology assessment (HTA) using an Irish HTA of a national public access defibrillation (PAD) program. BACKGROUND In response to draft legislation that proposed a PAD program, the Minister for Health requested that Health Information and Quality Authority undertake an HTA to inform the design and implementation of a national PAD program and the necessary underpinning legislation. The draft legislation outlined a program requiring widespread installation and maintenance of automatic external defibrillators in specified premises. METHODS Stakeholder engagement to optimize the impact of the HTA included one-to-one interviews with politicians, engagement with an Expert Advisory Group, public and targeted consultation, and positive media management. RESULTS The HTA quantified the clinical benefits of the proposed PAD program as modest, identified that substantial costs would fall on small/medium businesses at a time of economic recession, and that none of the programs modeled were cost-effective. The Senator who proposed the Bill actively publicized the HTA process and its findings and encouraged participation in the public consultation. Participation of key stakeholders was important for the quality and acceptability of the HTA findings and advice. Media management promoted public engagement and understanding. The Bill did not progress. CONCLUSIONS The HTA informed the decision not to progress with legislation for a national PAD program. Engagement was tailored to ensure that key stakeholders including politicians and the public were informed of the HTA process, the findings, and the advice, thereby maximizing acceptance. Appropriate stakeholder engagement optimizes the impact of HTA.

The HIQA’s Health Technology Assessment of Breast Screening: Highlighting Some of the Challenges Posed by Evaluations of Screening Programs

A review of the Health Information and Quality Authoritys (HIQA) assessment of breast cancer surveillance cancer criticized how the results were presented and interpreted. The health technology assessment (HTA) investigated surveillance options for women aged less than 50 years who were at elevated risk of breast cancer. Surveillance strategies using digital mammography, magnetic resonance imaging, or a combination of the two modalities were modeled on the basis of diagnostic test accuracy. The HTA faced a number of issues, including the use of diagnostic test accuracy as a surrogate for long-term outcomes; modeling interventions that were not considered acceptable to clinicians; and extrapolating for screening intervals and age ranges not directly supported by available evidence. The evaluation of screening programs gives rise to challenges in terms of balancing an adequate exploration of the possible options while also being cognizant of what is appropriately supported by evidence. In this article, the authors of the HIQA report discuss the challenges posed by this particular HTA.