Sorrel Wolowacz

Fracture liaison services for the evaluation and management of patients with osteoporotic fracture: a cost-effectiveness evaluation based on data collected over 8 years of service provision.

SummaryThe cost-effectiveness of Fracture Liaison Services (FLSs) for prevention of secondary fracture in osteoporosis patients in the United Kingdom (UK), and the cost associated with their widespread adoption, were evaluated. An estimated 18 fractures were prevented and £21,000 saved per 1,000 patients. Setup across the UK would cost an estimated £9.7 million.IntroductionOnly 11% to 28% of patients with a fragility fracture receive osteoporosis treatment in the UK. FLSs provide an efficient means to identify patients and are endorsed by the Department of Health but have not been widely adopted. The objective of this study was to evaluate the cost-effectiveness of FLSs in the UK and the cost associated with their widespread adoption.MethodsA cost-effectiveness and budget-impact model was developed, utilising detailed audit data collected by the West Glasgow FLS.ResultsFor a hypothetical cohort of 1,000 fragility-fracture patients (740 requiring treatment), 686 received treatment in the FLS compared with 193 in usual care. Assessments and osteoporosis treatments cost an additional £83,598 and £206,544, respectively, in the FLS; 18 fractures (including 11 hip fractures) were prevented, giving an overall saving of £21,000. Setup costs for widespread adoption of FLSs across the UK were estimated at £9.7 million.ConclusionsFLSs are cost-effective for the prevention of further fractures in fragility-fracture patients. The cost of widespread adoption of FLS across the UK is small in comparison with other service provision and would be expected to result in important benefits in fractures avoided and reduced hospital bed occupancy.

Methodologies used in cost-effectiveness models for evaluating treatments in major depressive disorder: A systematic review:

BackgroundDecision makers in many jurisdictions use cost-effectiveness estimates as an aid for selecting interventions with an appropriate balance between health benefits and costs. This systematic literature review aims to provide an overview of published cost-effectiveness models in major depressive disorder (MDD) with a focus on the methods employed. Key components of the identified models are discussed and any challenges in developing models are highlighted.MethodsA systematic literature search was performed to identify all primary model-based economic evaluations of MDD interventions indexed in MEDLINE, the Cochrane Library, EMBASE, EconLit, and PsycINFO between January 2000 and May 2010.ResultsA total of 37 studies were included in the review. These studies predominantly evaluated antidepressant medications. The analyses were performed across a broad set of countries. The majority of models were decision-trees; eight were Markov models. Most models had a time horizon of less than 1 year. The majority of analyses took a payer perspective. Clinical input data were obtained from pooled placebo-controlled comparative trials, single head-to-head trials, or meta-analyses. The majority of studies (24 of 37) used treatment success or symptom-free days as main outcomes, 14 studies incorporated health state utilities, and 2 used disability-adjusted life-years. A few models (14 of 37) incorporated probabilities and costs associated with suicide and/or suicide attempts. Two models examined the cost-effectiveness of second-line treatment in patients who had failed to respond to initial therapy. Resource use data used in the models were obtained mostly from expert opinion. All studies, with the exception of one, explored parameter uncertainty.ConclusionsThe review identified several model input data gaps, including utility values in partial responders, efficacy of second-line treatments, and resource utilisation estimates obtained from relevant, high-quality studies. It highlighted the differences in outcome measures among the trials of MDD interventions, which can lead to difficulty in performing indirect comparisons, and the inconsistencies in definitions of health states used in the clinical trials and those used in utility studies. Clinical outcomes contributed to the uncertainty in cost-effectiveness estimates to a greater degree than costs or utility weights.

Cost-effectiveness of venous thromboembolism prophylaxis in total hip and knee replacement surgery: the evolving application of health economic modelling over 20 years:

ABSTRACT Objectives: In the last two decades, there has been considerable evolution of methods for cost-effectiveness modelling. Some of the first models were developed in the area of venous thromboembolism (VTE) prophylaxis. Hence, this area can serve as an important example to illustrate evolving standards. Our objectives are to document evolving methodology by describing VTE models, assess their critical strengths and weaknesses, and inform future advances for models in this therapeutic area. Research design and methods: A systematic review of economic models of primary VTE prevention following hip and knee replacement surgery was undertaken. Electronic searches of PubMed, EMBASE, the Cochrane library, and grey literature were conducted (1985–2006). Reference lists of included articles and reviews were examined for relevant studies. Results: Twenty-nine cost-effectiveness models were identified. Nineteen other cost-effectiveness analyses were excluded because they were not model-based; 16 were simple cost calculations and three were analyses of resource use data collected alongside clinical trials. The majority of models (24) were constructed as decision trees, frequently utilising previously published model structures, with some adaptation for new comparators, and/or addition of relevant events omitted by earlier models (e.g., bleeding due to prophylactic treatment). Later models have included Markov processes to model potential long-term consequences of VTE (recurrent VTE and post-thrombotic syndrome) over longer time horizons. Systematic identification of clinical evidence and more sophisticated analysis methods (e.g., Bayesian mixed-treatment comparisons and probabilistic sensitivity analyses) have recently been introduced. Conclusions: Model structures have evolved substantially in this highly studied therapeutic area, with improvements made to the model structure, the comprehensiveness of clinical evidence included, and the underlying calculation methodology.

Cost Effectiveness of Pegaptanib for the Treatment of Age-Related Macular Degeneration in the UK

Background: Age-related macular degeneration (AMD) is the primary cause of vision loss in the elderly and results in significant economic and humanistic burden. The selective vascular endothelial growth factor inhibitor, pegaptanib (Macugen®) is indicated for patients with neovascular AMD. Guidance is needed regarding the cost effectiveness of treatment, any variation between sub-populations of differing clinical characteristics and the optimum duration of treatment. Objective: To estimate the cost effectiveness of pegaptanib versus best supportive care (BSC) for AMD from the perspective of the UK government, and to evaluate the impact of patient characteristics and differing treatment discontinuation scenarios.Methods: A cohort of 1000 patients aged >45 years with a best-corrected visual acuity (VA) in their better-seeing eye of ≤6/12 was modelled. Patients were either treated with pegaptanib (0.3mg every 6 weeks for a maximum of 2 years in their better-seeing eye only) or received BSC (no active treatment). Supportive services were provided for patients with a VA ≤6/60.A 10-year Markov model composed of 12 VA states (defined by individual Snellen lines) and a dead state was constructed.1 Time-dependent transition probabilities for the loss and gain of Snellen lines were derived from parametric survival curves fitted to patient-level data from the VISION trials. Survival curves were fitted with treatment and baseline Snellen scores as covariates; additional curves were fitted with the addition of age, gender, lesion type or lesion size as covariates. Mortality rates were adjusted for the age, gender and VA of the population. Cost effectiveness was expressed as the incremental cost (IC) per vision-year saved and IC/QALY. Uncertainty was explored by probabilistic and univariate sensitivity analysis. Costs (year 2005 values) and outcomes were discounted at 3.5% per anum.Results: In the base-case analysis, treatment was targeted to patients with a VA of 6/12 to 6/95 and discontinued after 2 years, or earlier if VA fell below 6/95 or by ≥6 lines. The IC/QALY was estimated as £8023 (upper 95% CI £20 641). Cost effectiveness varied by age (age <75 years = £2033/QALY; age >75 years = £11 657/QALY) and by pre-treatment VA (6/12–6/95 = £8023/QALY; 6/12–6/60 = £6664/QALY; 6/12s-6/24 = £1920/QALY). Gender and lesion type or size had little effect. Cost effectiveness was not sensitive to precise rules for treatment discontinuation, but was maximised if treatment was discontinued in patients no longer likely to benefit.Conclusions: The results suggest that pegaptanib treatment is likely to be cost effective across all groups studied, and marginally more cost effective in younger patients and those with better pre-treatment VA. Cost effectiveness appears to be optimised if treatment is discontinued after 1 year if individual patients’ VA has dropped by ≥6 lines from pre-treatment levels, or at any time if it drops below 6/95. However, strict application of discontinuation rules does not appear to be necessary for pegaptanib to be cost effective. Clinical judgement and patient preference should be an important determinant in decisions about stopping treatment.

Cost Effectiveness of Ofatumumab Plus Chlorambucil in First-Line Chronic Lymphocytic Leukaemia in Canada

AbstractObjectiveOur objective was to estimate the cost effectiveness of ofatumumab plus chlorambucil (OChl) versus chlorambucil in patients with chronic lymphocytic leukaemia for whom fludarabine-based therapies are considered inappropriate from the perspective of the publicly funded healthcare system in Canada.MethodsA semi-Markov model (3-month cycle length) used survival curves to govern progression-free survival (PFS) and overall survival (OS). Efficacy and safety data and health-state utility values were estimated from the COMPLEMENT-1 trial. Post-progression treatment patterns were based on clinical guidelines, Canadian treatment practices and published literature. Total and incremental expected lifetime costs (in Canadian dollars [

Pharmacoeconomics of dabigatran etexilate for prevention of thromboembolism after joint replacement surgery

Can], year 2013 values), life-years and quality-adjusted life-years (QALYs) were computed. Uncertainty was assessed via deterministic and probabilistic sensitivity analyses.ResultsThe discounted lifetime health and economic outcomes estimated by the model showed that, compared with chlorambucil, first-line treatment with OChl led to an increase in QALYs (0.41) and total costs (

Economic Evaluations of New Oral Anticoagulants for the Prevention of Venous Thromboembolism After Total Hip or Knee Replacement: A Systematic Review

Can27,866) and to an incremental cost-effectiveness ratio (ICER) of

Predictors of health-related quality of life in sufferers with restless legs syndrome: a multi-national study.

Can68,647 per QALY gained. In deterministic sensitivity nanalyses, the ICER was most sensitive to the modelling time horizon and to the extrapolation of OS treatment effects beyond the trial duration. In probabilistic sensitivity analysis, the probability of cost effectiveness at a willingness-to-pay threshold of

Comparative Efficacy and Safety Of Dabigatran Etexilate and Rivaroxaban For The Treatment Of Deep Vein Thrombosis and Pulmonary Embolism

Can100,000 per QALY gained was 59xa0%.ConclusionsBase-case results indicated that improved overall response and PFS for OChl compared with chlorambucil translated to improved quality-adjusted life expectancy. Sensitivity analysis suggested that OChl is likely to be cost effective subject to uncertainty associated with the presence of any long-term OS benefit and the model time horizon.

Cost/effectiveness model of dabigatran in the prevention of venous thromboembolism in major orthopedic surgery: Adaptation for Italy

Dabigatran etexilate (DE) is a novel oral anticoagulant indicated for the prevention of venous thromboembolism in patients undergoing total hip or total knee replacement surgery. The majority of these patients receive some kind of thromboprophylaxis, most commonly low-molecular-weight heparin (LMWH). However, the subcutaneous route of LMWH administration may act as a barrier to the continuation of effective anticoagulant prophylaxis after discharge from hospital. The oral route of DE administration may allow more patients to receive extended thromboprophylaxis and may reduce costs, such as those associated with nurse time for LMWH administrations, platelet monitoring, needlestick injuries and sharps disposal. This article presents an overview of the clinical evidence for DE and a systematic review of the economic evaluations of the drug.