Assessing cost-effectiveness in healthcare: history of the $50,000 per QALY threshold.
ABSTRACT Cost-effectiveness analyses, particularly in the USA, commonly use a figure of $50,000 per life-year or quality-adjusted life-year gained as a threshold for assessing the cost-effectiveness of an intervention. The history of this practice is ill defined, although it has been linked to the end-stage renal disease kidney dialysis cost-effectiveness literature from the 1980s. The use of $50,000 as a benchmark for assessing the cost-effectiveness of an intervention first emerged in 1992 and became widely used after 1996. The appeal of the $50,000 figure appears to lie in the convenience of a round number rather than in the value of renal dialysis. Rather than arbitrary thresholds, estimates of willingness to pay and the opportunity cost of healthcare resources are needed.
SourceAvailable from: Giorgio Lorenzo Colombo[Show abstract] [Hide abstract]
ABSTRACT: Costs may play a role in deciding how and when to start highly active antiretroviral therapy (HAART) in a naïve patient. The aim of the present study was to assess the cost- effectiveness of treatment with HAART in a large clinical cohort of naïve adults to determine the potential role of single-tablet regimens in the management of patients with human immunodeficiency virus (HIV). An incremental cost-effectiveness ratio analysis was performed, including a quality-adjusted life year approach. In total, 741 patients (females comprising 25.5%) were retrospectively included. The mean age was 39 years, the mean CD4 cell count was 266 cells/μL, and the mean viral load was 192,821 copies/mL. The most commonly used backbone was tenofovir + emtricitabine (77.6%); zidovudine + lamivudine was used in 10%, lamivudine + abacavir in 3%, and other nucleoside reverse transcriptase inhibitor (NRTI) or NRTI-free regimens in 9.4% of patients. NNRTIs were used in 52.8% of cases, boosted protease inhibitors in 44.1%, and unboosted protease inhibitors and integrase inhibitors in 0.7% and 2.4%, respectively. Starting therapy at CD4 >500 cells/μL and CD4 351-500 cells/μL rather than at <201 cells/μL was the more cost-effective approach. The same consideration was not true comparing current indications with the possibility to start HAART at any CD4 value (eg, >500 cells per μL); in this case, the incremental cost-effectiveness ratio value was €199,130 per quality-adjusted life year gained, a higher value than the one suggested in guidelines. The single-tablet regimen (STR) invariably dominated any other therapeutic approach. Sensitivity analysis was performed, and starting right away with an STR was cost-effective even when compared with therapeutic strategies contemplating STR as simplification. By integrating clinical data with economic variables, our study offers an estimate of the cost-effectiveness of the various first-line treatment strategies for patients infected with HIV and provides significant evidence to be used in future prospective pharmacoeconomic evaluations.Patient Related Outcome Measures 01/2015; 6:53-60. DOI:10.2147/PROM.S63586
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ABSTRACT: Abstract Objective. Early, high-quality, minimally interrupted bystander cardio-pulmonary resuscitation (BCPR) is essential for out-of-hospital cardiac arrest survival. However, rates of bystander intervention remain low in many geographic areas. Community CPR programs have been initiated to combat these low numbers by teaching compression-only CPR to laypersons. This study examined bystander CPR and the cost-effectiveness of a countywide CPR program to improve out-of-hospital cardiac arrest survival. Methods. A 2-year retrospective review of emergency medical services (EMS) run reports for adult nontraumatic cardiac arrests was performed using existing prehospital EMS quality assurance data. The incidence and success of bystander CPR to produce prehospital return of spontaneous circulation and favorable neurologic outcomes at hospital discharge were analyzed. The outcomes were paired with cost data for the jurisdiction's community CPR program to develop a cost-effectiveness model. Results. During the 23-month study period, a total of 371 nontraumatic adult out-of-hospital cardiac arrests occurred, with a 33.4% incidence of bystander CPR. Incremental cost-effectiveness analysis for the community CPR program demonstrated a total cost of $22,539 per quality-adjusted life-year (QALY). A significantly increased proportion of those who received BCPR also had an automated external defibrillator (AED) applied. There was no correlation between witnessed arrest and performance of BCPR. A significantly increased proportion of those who received BCPR were found to be in a shockable rhythm when the initial ECG was performed. In the home setting, the chances of receiving BCPR were significantly smaller, whereas in the public setting a nearly equal number of people received and did not receive BCPR. Witnessed arrest, AED application, public location, and shockable rhythm on initial ECG were all significantly associated with positive ROSC and neurologic outcomes. A home arrest was significantly associated with worse neurologic outcome. Conclusions. Cost-effectiveness analysis demonstrates that a community CPR outreach program is a cost-effective means for saving lives when compared to other healthcare-related interventions. Bystander CPR showed a clear trend toward improving the neurologic outcome of survivors. The findings of this study indicate a need for additional research into the economic effects of bystander CPR. Key words: CPR; EMS; cost effectiveness.Prehospital Emergency Care 02/2015; DOI:10.3109/10903127.2014.995844 · 1.81 Impact Factor
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ABSTRACT: Recent pertussis outbreaks have prompted re-examination of post-exposure prophylaxis (PEP) strategies, when immunization is not immediately protective. Chemoprophylaxis is recommended to household contacts; however there are concerns of clinical failure and significant adverse events, especially with erythromycin among infants who have the highest disease burden. Newer macrolides offer fewer side effects at higher drug costs. We sought to determine the cost-effectiveness of PEP strategies from the health care payer perspective. A Markov model was constructed to examine 4 mutually exclusive strategies: erythromycin, azithromycin, clarithromycin, or no intervention, stratified by age group of contacts ("infant", "child", and "adult"). Transition probabilities, costs and quality-adjusted life years (QALYs) were derived from the literature. Chronic neurologic sequelae were modeled over a lifetime, with costs and QALYs discounted at 5%. Associated health outcomes and costs were compared, and incremental cost-effectiveness ratios (ICER) were calculated in 2012 Canadian dollars. Deterministic and probabilistic sensitivity analyses were performed to evaluate the degree of uncertainty in the results. Azithromycin offered the highest QALYs in all scenarios. While this was the dominant strategy among infants, it produced an ICER of $16,963 per QALY among children and $2,415 per QALY among adults. Total QALYs with azithromycin were 19.7 for a 5-kg infant, 19.4 for a 10-year-old child, and 18.8 for a 30-year-old adult. The costs of azithromycin PEP among infants, children and adults were $1,976, $132 and $90, respectively. While results were sensitive to changes in PEP effectiveness (11% to 87%), disease transmission (variable among age groups) and hospitalization costs ($379 to $59,644), the choice of strategy remained unchanged. Pertussis PEP is a cost-effective strategy compared with no intervention and plays an important role in contact management, potentially in outbreak situations. From a healthcare payer perspective, azithromycin is the optimal strategy among all contact groups.PLoS ONE 01/2015; 10(3):e0119271. DOI:10.1371/journal.pone.0119271 · 3.53 Impact Factor