A critical structured review of economic evaluations of interventions for the prevention and treatment of osteoporosis

Osteoporosis is a major cause of morbidity, mortality and resource cost amongst the elderly population. Hip fracture is the most serious of the osteoporotic fractures, with approximately 10-20% of patients dying within six months of sustaining a fracture. Furthermore, hip fractures are the most expensive manifestation of osteoporosis, incurring about 87% of the total costs of osteoporotic fractures. This public health and economic burden is likely to increase in developed nations due, in part, to ageing populations. In addition, there is strong evidence that the age-specific incidence of fracture is rising. There are a number of treatments which can be used to prevent fracture including hormone replacement therapy (HRT), bisphosphonates, vitamin D and calcium. These interventions have been used for primary prevention, secondary prevention and the treatment of established osteoporosis. This Discussion Paper details the results of a structured review, the purpose of which was to identify and critically appraise economic evaluations relating to interventions for osteoporosis. The focus of the work is a critical assessment of the methodology of those studies. A total of 16 economic evaluations was identified on the basis of a computerised search of three bibliographic databases. All studies were based on decision analytical models and all took the form of cost-effectiveness analysis. Seven studies were from the US and four from the UK. The majority of studies focused on either primary prevention alone (seven) or both primary and secondary prevention where high-risk women were identified on the basis of bone mineral density screening (seven). Most studies considered the cost-effectiveness of HRT. Most of the published studies conclude that treatment using HRT is relatively cost-effective among symptomatic women or women who have had a prior hysterectomy. In contrast, for asymptomatic women, the results are more equivocal. The most recent cost-effectiveness analysis was undertaken by the National Osteoporosis Foundation (NOF) which makes the explicit assumption that HRT is the treatment of choice. For women unwilling or unable to take HRT, the next recommended treatment was alendronate; should alendronate not be tolerated, calcitonin was recommended. Many of the models included in the review exhibit methodological weaknesses which suggest heir results should be treated with some caution. One of these concerns the dearth of formally elicited health state preference data from patients or members of the public: only two studies in the review derive preferences empirically rather than use the authors’ judgement. A second limitation of many studies is the inappropriate application of costeffectiveness decision rules with the frequent use of average cost-effectiveness ratios. Areas of methodological controversy, such as whether or not to include costs unrelated to osteoporosis in life-years added as a result of treatment, increase uncertainty regarding how to interpret the results of the studies.osteoporosis, HRT

Age, Health, and the Willingness to Pay for Mortality Risk Reductions: A Contingent Valuation Survey of Ontario Residents

Much of the justification for environmental rulemaking rests on estimates of the benefits to society of reduced mortality rates. This research aims to fill gaps in the literature that estimates the value of a statistical life (VSL) by designing and implementing a contingent valuation study for persons 40 to 75 years of age, and eliciting WTP for reductions in current and future risks of death. Targeting this age range also allows us to examine the impact of age on WTP and, by asking respondents to complete a detailed health questionnaire, to examine the impact of health status on WTP. This survey was self-administered by computer to 930 persons in Hamilton, Ontario, in 1999. The survey uses audio and visual aids to communicate baseline risks of death and risk changes and are tested for comprehension of probabilities before being asked WTP questions. We credit these efforts at risk communication with the fact that mean WTP of respondents faced with larger risk reductions exceeds mean WTP of respondents faced with smaller risk reductions; that is, our respondents pass the external scope test. Our mean WTP estimates for a contemporaneous risk reduction imply a VSL ranging approximately from $1.2 to$3.8 million (1999 C$), depending on the size of the risk change valued, which is at or below estimates commonly used in environmental cost-benefit analyses by the Canadian and the U.S. governments. Interestingly, we find that age has no effect on WTP until roughly age 70 and above (the VSL is about$0.6 million for this age group) and that physical health status, with the possible exception of having cancer, has no effect. We also find that being mentally healthy raises WTP substantially. In addition, compared with estimates of WTP for contemporaneous risk reductions, mean WTP estimates for risk reductions of the same magnitude but beginning at age 70 are more than 50% smaller.

Processes, contexts, and rationale for disinvestment: a protocol for a critical interpretive synthesis

Background: Practical solutions are needed to support the appropriate use of available health system resources as countries are continually pressured to ‘do more with less’ in health care. Increasingly, health systems and organizations are exploring the reassessment of possibly obsolete, inefficient, or ineffective health system resources and potentially redirecting funds to those that are more effective and efficient. Such processes are often referred to as ‘disinvestment’. Our objective is to gain further understanding about: 1) whether how and under what conditions health systems decide to pursue disinvestment; 2) how health systems have chosen to undertake disinvestment; and 3) how health systems have implemented their disinvestment approach. Methods/Design We will use a critical interpretive synthesis (CIS) approach, to develop a theoretical framework based on insights drawn from a range of relevant sources. We will conduct systematic searches of databases as well as purposive searches to identify literature to fill conceptual gaps that may emerge during our inductive process of synthesis and analysis. Two independent reviewers will assess search results for relevance and conceptually map included references. We will include all empirical and non-empirical articles that focus on disinvestment at a system level. We will then extract key findings from a purposive sample of articles using frameworks related to government agendas, policy development and implementation, and health system contextual factors and then synthesize and integrate the findings to develop a framework about our core areas of interest. Lastly, we will convene a stakeholder dialogue with Canadian and international policymakers and other stakeholders to solicit targeted feedback about the framework (e.g., by identifying any gaps in the literature that we may want to revisit before finalizing it) and deliberating about barriers for developing and implementing approaches to disinvestment, strategies to address these barriers and about next steps that could be taken by different constituencies. Discussion Disinvestment is an emerging field and there is a need for evidence to inform the prioritization, development, and implementation of strategies in different contexts. Our CIS and the framework developed through it will support the actions of those involved in the prioritization, development, and implementation of disinvestment initiatives. Systematic review registration PROSPERO CRD42014013204 Electronic supplementary material The online version of this article (doi:10.1186/2046-4053-3-143) contains supplementary material, which is available to authorized users

A review of health utilities across conditions common in paediatric and adult populations

<p>Abstract</p> <p>Background</p> <p>Cost-utility analyses are commonly used in economic evaluations of interventions or conditions that have an impact on health-related quality of life. However, evaluating utilities in children presents several challenges since young children may not have the cognitive ability to complete measurement tasks and thus utility values must be estimated by proxy assessors. Another solution is to use utilities derived from an adult population. To better inform the future conduct of cost-utility analyses in paediatric populations, we reviewed the published literature reporting utilities among children and adults across selected conditions common to paediatric and adult populations.</p> <p>Methods</p> <p>An electronic search of Ovid MEDLINE, EMBASE, and the Cochrane Library up to November 2008 was conducted to identify studies presenting utility values derived from the Health Utilities Index (HUI) or EuroQoL-5Dimensions (EQ-5D) questionnaires or using time trade off (TTO) or standard gamble (SG) techniques in children and/or adult populations from randomized controlled trials, comparative or non-comparative observational studies, or cross-sectional studies. The search was targeted to four chronic diseases/conditions common to both children and adults and known to have a negative impact on health-related quality of life (HRQoL).</p> <p>Results</p> <p>After screening 951 citations identified from the literature search, 77 unique studies included in our review evaluated utilities in patients with asthma (n = 25), cancer (n = 23), diabetes mellitus (n = 11), skin diseases (n = 19) or chronic diseases (n = 2), with some studies evaluating multiple conditions. Utility values were estimated using HUI (n = 33), EQ-5D (n = 26), TTO (n = 12), and SG (n = 14), with some studies applying more than one technique to estimate utility values. 21% of studies evaluated utilities in children, of those the majority being in the area of oncology. No utility values for children were reported in skin diseases. Although few studies provided comparative information on utility values between children and adults, results seem to indicate that utilities may be similar in adolescents and young adults with asthma and acne. Differences in results were observed depending on methods and proxies.</p> <p>Conclusions</p> <p>This review highlights the need to conduct future research regarding measurement of utilities in children.</p

Validation of the GSFQ, a Self-Administered Symptom Frequency Questionnaire for Patients with Gastroesophageal Reflux Disease

BACKGROUND: Although the diagnosis of gastroesophageal reflux disease (GERD) is based primarily on symptoms experienced by a patient, relatively little attention has been paid to the development and validation of self-administered questionnaires specific to GERD symptoms. The present article presents the validation of the short, self-administered GERD Symptom Frequency Questionnaire (GSFQ)

Cost-utility analysis of infliximab and adalimumab for refractory ulcerative colitis

<p>Abstract</p> <p>Objective</p> <p>To evaluate cost-utility of infliximab and adalimumab for the treatment of moderate-to-severe ulcerative colitis (UC) refractory to conventional therapies in Canada.</p> <p>Methods</p> <p>A Markov model was constructed to evaluate incremental cost-utility ratios (ICUR) of 5 mg/kg and 10 mg/kg infliximab and adalimumab therapies compared to 'usual care' in treating a hypothetical cohort of patients (aged 40 years and weighing 80 kg) over a five-year time horizon from the perspective of a publicly-funded health care system. Clinical parameters were derived from the Active Ulcerative Colitis Trials 1 and 2. Costs were obtained through provincial drug benefit plans. ICUR was the main outcome measure and both deterministic and probabilistic sensitivity analyses were conducted.</p> <p>Results</p> <p>Compared to the strategy A ('usual care') in the base case analysis, the ICURs were CA$358,088/QALY for the strategy B ('5 mg/kg infliximab + adalimumab') and CA$575,540/QALY for the strategy C ('5 mg/kg and 10 mg/kg infliximab + adalimumab'). The results were sensitive to: the remission rates maintained in responders to 'usual care' and to 5 mg/kg infliximab, the rate of remission induced by adalimumab in non-responders to 5 mg/kg infliximab, early surgery rate, and utility values. When the willingness to pay (WTP) was less than CA$150,000/QALY, the probability of 'usual care' being the optimal strategy was 1.0. The probability of strategy B being optimal was 0.5 when the WTP approximated CA$400,000/QALY.</p> <p>Conclusions</p> <p>The ICURs of anti-TNF-α drugs were not satisfactory in treating patients with moderate-to-severe refractory UC. Future research could be aimed at the long-term clinical benefits of these drugs, especially adalimumab for patients intolerant or unresponsive to infliximab treatment.</p

Photodynamic Therapy for Barrett’s Esophagus with High-Grade Dysplasia: A Cost-Effectiveness Analysis

OBJECTIVES: To assess the cost-effectiveness of photodynamic therapy (PDT) and esophagectomy (ESO) relative to surveillance (SURV) for patients with Barrett’s esophagus (BE) and high-grade dysplasia (HGD)

BEACON:A Summary Framework to Overcome Potential Reimbursement Hurdles

Objective To provide a framework for addressing payers' criteria during the development of pharmaceuticals.Methods A conceptual framework was presented to an international health economic expert panel for discussion. A structured literature search (from 2010 to May 2015), using the following databases in Ovid: Medline((R)) and Medline((R)) In-Process (PubMed), Embase (Ovid), EconLit (EBSCOhost) and the National Health Service Economic Evaluation Database (NHS EED), and a 'grey literature' search, were conducted to identify existing criteria from the payer perspective. The criteria assessed by existing frameworks and guidelines were collated; the most commonly reported criteria were considered for inclusion in the framework. A mnemonic was conceived as a memory aide to summarise these criteria.Results Overall, 41 publications were identified as potentially relevant to the objective. Following further screening, 26 were excluded upon full-text review on the basis of no framework presented (n = 13), redundancy (n = 11) or abstract only (n = 2). Frameworks that captured criteria developed for or utilised by the pharmaceutical industry (n = 5) and reimbursement guidance (n = 10) were reviewed. The most commonly identified criteria-unmet need/patient burden, safety, efficacy, quality-of-life outcomes, environment, evidence quality, budget impact and comparator-were incorporated into the summary framework. For ease of communication, the following mnemonic was developed: BEACON (Burden/target population, Environment, Affordability/value, Comparator, Outcomes, Number of studies/quality of evidence).Conclusions The BEACON framework aims to capture the 'essence' of payer requirements by addressing the most commonly described criteria requested by payers regarding the introduction of a new pharmaceutical.</p

Evaluation of health outcomes in osteoarthritis patients after total knee replacement: a two-year follow-up

10.1186/1477-7525-8-87Health and Quality of Life Outcomes8