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Health Economic Studies
Abstract
Study Design. Narrative overview. Objective. To provide clinicians with a basic understanding of economic studies, including cost-benefit, cost-effectiveness, and cost-utility analyses. Summary of Background Data. As decisions regarding public health policy, insurance reimbursement, and patient care incorporate factors other than traditional outcomes such as satisfaction or symptom resolution, health economic studies are increasingly prominent in the literature. This trend will likely continue, and it is therefore important for clinicians to have a fundamental understanding of the common types of economic studies and be able to read them critically. In this brief article, the basic concepts of economic studies and the differences between cost-benefit, cost-effectiveness, and cost-utility studies are discussed. Methods. An overview of the field of health economic analysis is presented. Results. Cost-benefit, cost-effectiveness, and cost-utility studies all integrate cost and outcome data into a decision analysis model. These different types of studies are distinguished mainly by the way in which outcomes are valued. Obtaining accurate cost data is often difficult and can limit the generalizability of a study. Conclusion. With a basic understanding of health economic analysis, clinicians can be informed consumers of these important studies.
... A QALY by itself is not the only way to estimate quality of care when assessing cost-effectiveness or cost-utility. There are several other study designs that can be used to quantify and compare cost-effectiveness of interventions 33,34) . Angevine et al. provided an overview of three economic analyses for evaluating healthcare interventions: i) costbenefit analysis, ii) cost-effectiveness analysis, and iii) costutility analysis ( Table 1). ...
... The main difference in these methodologies is the primary outcome measure used. Cost-benefit, costeffectiveness, and cost-utility analyses designs measure the following outcomes, respectively: monetary value (dollars gained or saved), specific health outcomes, and QALYs 34) . When undertaking a cost-utility analysis, a cost-effectiveness ratio can be calculated, which is defined as the "total costs (direct + indirect) of an intervention divided by the quality of life gained from, or utility of, the intervention." ...
... These metrics can be used to compare the cost-effectiveness of surgical versus medical management, or perhaps two different surgical options. Each of these methodologies provides a unique perspective to the overall value of a procedure, with specific advantages and disadvantages, particularly for spine surgery 34) . ...
Objective: To summarize the main findings from research on measuring the value in spine surgery.
Summary of Background Data: Determining the value of surgical interventions, which is defined by the quality and efficacy of care received divided by the cost to deliver healthcare, is inherently complex. The two most fundamental components of value-quality and total cost-are multifactorial and difficult to quantify.
Methods: A narrative review of all the relevant papers known to the author was conducted.
Results: It is straightforward to calculate the aggregate hospital cost following a surgical procedure, but it is not simple to estimate the total cost of a procedure-including the direct and indirect costs. These individual metrics can help providers make more educated decisions with regards to improving patient quality of life and minimizing unnecessary costs. A consensus of the appropriate cost-per-quality-adjusted life-year threshold of different spine surgeries needs to be established. As these metrics become more commonplace in spine surgery, the potential for personalized health care will continue to be developed.
Conclusions: As the healthcare system shifts toward value-based care, there is a substantial need for research assessing the value as defined by the quality and efficacy of care received divided by the cost to deliver healthcare of specific spine surgery procedures. Studies on different predictors-both patient-specific and surgical-that may influence outcomes, cost, and value are required.
... EE helps to maximize outcomes and minimize costs especially in conditions with limited resources in which taking decisions which way to go might be difficult. It will allow us to evaluate the return-oninvestment (ROI) (how much value we get from our spending) [13]. There are many ways for health economists to assess EE. ...
... countries or regions to attract more or fewer healthcare resources [13]. The MOH could use EE to evaluate the disease burden concerning others and use this information to prepare their budget. ...
... As discussed above, medical officials tend to avoid using the word rationing and sometimes use the word prioritizing assuming they are the same but they are not [8]. Some researchers argue that rationing healthcare is the action, and priority setting is the tool [13]. In particular, priority setting can be set through EE to ration healthcare [27]. ...
... 10,18 The QALY can either be used as an independent point of comparison among various procedures, or to value the outcome of a given intervention. 7,9 In keeping with the gold standard in economic analysis, an incremental cost-effectiveness ratio can be determined based on the ratio of the difference in cost and the difference in outcome of 1 intervention compared with another, aiding in enlightened decisions. 7 CUA is considered to be most useful in conditions requiring treatment aimed at optimizing quality of life, as would be the case for an invasive ameloblastoma. ...
... 7,9 In keeping with the gold standard in economic analysis, an incremental cost-effectiveness ratio can be determined based on the ratio of the difference in cost and the difference in outcome of 1 intervention compared with another, aiding in enlightened decisions. 7 CUA is considered to be most useful in conditions requiring treatment aimed at optimizing quality of life, as would be the case for an invasive ameloblastoma. 7,9 In view of the current paucity of literature on utility analysis in its surgical treatment and the persistent lack of consensus regarding optimal treatment, this study steered to most accurately obtain such utility values by directly measuring 3 distinct utility scores, thus minimizing the limitations of a single value. ...
... 7 CUA is considered to be most useful in conditions requiring treatment aimed at optimizing quality of life, as would be the case for an invasive ameloblastoma. 7,9 In view of the current paucity of literature on utility analysis in its surgical treatment and the persistent lack of consensus regarding optimal treatment, this study steered to most accurately obtain such utility values by directly measuring 3 distinct utility scores, thus minimizing the limitations of a single value. ...
Our objective was to determine the potential impact of the surgical treatment of ameloblastoma in children through validated health state utility outcome measures.
Methods:
A survey-based preference health utility assessment using the visual analog scale, time trade-off, and standard gamble methods was undertaken among a general population sample. Quality-adjusted life years were derived from these measures. A one-way ANOVA was used for statistical analysis, with a mean (P) value of 0.05 considered significant. Demographic parameters were individually assessed as possible predictors of each utility score.
Results:
In total, 86 participants took part in this study, with a mean age of 29.9 years. Greater utility scores were observed among participants reporting no religious beliefs (P = 0.025, t = 2.28). No other demographic parameters showed statistically significant prediction of utility score. From the mean utility scores (± SD) (visual analog scale = 0.60 ± 0.17; time trade-off = 0.65 ± 0.22; standard gamble = 0.64 ± 0.20), a gain of 30.0, 32.3, and 32.1 quality-adjusted life years may be derived, respectively. All utility outcome measures suggested that an ameloblastoma during childhood is perceived as more burdensome than several debilitating conditions, such as cleft lip and palate.
Conclusions:
To attain perfect health, participants would theoretically undergo surgical treatment of an ameloblastoma during childhood, with willingness to trade off 28.2 years of life and accepting a 35.7% risk of death. The objective assessment of the perceived burden of an ameloblastoma affliction during childhood may inspire cost-utility or cost-effectiveness analyses at broader societal levels.
... Meanwhile, the incremental effect (∆E) was defined as the difference in PPCs rates 14 days post-surgery and QALYs 12 months following surgery. The ICER was calculated by dividing incremental cost by incremental effects (ICER = ∆C/∆E) [32]. ...
Background
While prehabilitation (pre surgical exercise) effectively prevents postoperative pulmonary complications (PPCs), its cost-effectiveness in valve heart disease (VHD) remains unexplored. This study aims to evaluate the cost-effectiveness of a three-day prehabilitation program for reducing PPCs and improving quality adjusted life years (QALYs) in Chinese VHD patients.
Methods
A cost-effectiveness analysis was conducted alongside a randomized controlled trial featuring concealed allocation, blinded evaluators, and an intention-to-treat analysis. In total, 165 patients scheduled for elective heart valve surgery at West China Hospital were randomized into intervention and control groups. The intervention group participated in a three-day prehabilitation exercise program supervised by a physiotherapist while the control group received only standard preoperative education. Postoperative hospital costs were audited through the Hospital Information System, and the EuroQol five-dimensional questionnaire was used to provide a 12-month estimation of QALY. Cost and effect differences were calculated through the bootstrapping method, with results presented in cost-effectiveness planes, alongside the associated cost-effectiveness acceptability curve (CEAC). All costs were denominated in Chinese Yuan (CNY) at an average exchange rate of 6.73 CNY per US dollar in 2022.
Results
There were no statistically significant differences in postoperative hospital costs (8484 versus 9615 CNY, 95% CI –2403 to 140) or in the estimated QALYs (0.909 versus 0.898, 95% CI –0.013 to 0.034) between the intervention and control groups. However, costs for antibiotics (339 versus 667 CNY, 95% CI –605 to –51), nursing (1021 versus 1200 CNY, 95% CI –330 to –28), and electrocardiograph monitoring (685 versus 929 CNY, 95% CI –421 to –67) were significantly lower in the intervention group than in the control group. The CEAC indicated that the prehabilitation program has a 92.6% and 93% probability of being cost-effective in preventing PPCs and improving QALYs without incurring additional costs.
Conclusions
While the three-day prehabilitation program did not significantly improve health-related quality of life, it led to a reduction in postoperative hospital resource utilization. Furthermore, it showed a high probability of being cost-effective in both preventing PPCs and improving QALYs in Chinese patients undergoing valve surgery.
Clinical Registration Number
This trial is registered in the Chinese Clinical Trial Registry (URL: https://www.chictr.org.cn/) with the registration identifier ChiCTR2000039671.
... By analyzing the economic impact of genetic disorders, researchers can provide insights into the cost-effectiveness of genetic counseling, prevention, and healthcare strategies. This research informs healthcare policies and resource allocation to address the healthcare needs of populations with high levels of homozygosity [58]. ...
This comprehensive review explores the multifaceted relationship between increased homozygosity and human fertility, delving into the genetic, ethical, cultural, and public health dimensions of this complex phenomenon. Homozygosity, characterized by identical alleles at specific gene loci, can result from consanguineous marriages, genetic drift, and population isolation. The review highlights key findings, including the heightened risk of recessive genetic disorders, the implications for immune system diversity, and the influence on complex traits and diseases. It underscores the critical role of genetic counseling in addressing these consequences, considering the ethical implications, and respecting cultural practices. The delicate balance between genetic diversity and cultural norms is emphasized, calling for increased awareness and community engagement. Looking ahead, the review suggests emerging technologies, longitudinal studies, and interdisciplinary research as crucial avenues for further exploration, with the ultimate goal of informing effective public health policies and interventions that safeguard genetic diversity and cultural traditions for future generations.
... A cost is a resource that is sacrificed to accomplish an objective outcome [122]. There are various approaches to economically evaluate the healthcare-related industries, such as cost-utility, cost-effectiveness, and cost-benefit approaches [123]. Cost-benefit analysis weighs outcomes in relation to financial costs. ...
Coronavirus disease (COVID-19) emerged in China in December 2019. In March 2020, the WHO declared it as a pandemic leading to worldwide lockdowns and travel restrictions. By May, it infected 4,789,205 and killed 318,789. This led to severe shortages in the medical sector besides devastating socio-economic effects. Many technologies such as artificial intelligence (AI), virtual reality (VR), microfluidics, 3D printing and 3D scanning can step in to contain the virus and hinder its extensive spread. This article aims to explore the potentials of 3D printing and microfluidic in accelerating the diagnosis and monitoring of the disease and fulfilling the shortages of personal protective equipment (PPE) and medical equipment. It highlights the main applications of 3D printers and microfluidics in providing PPE (masks, respirators, face shields, goggles, isolation chambers/hoods), supportive care (respiratory equipment) and diagnostic supplies (sampling swabs & lab-on-chip) to ease the COVID-19 pressures. Also, the cost of such technology and regulations considerations are addressed. We conclude that 3D-printing provided reusable and low cost solutions to mitigate the shortages. However, safety, sterility and compatibility with environmental protection standards need to be guaranteed through standardization and assessment by regulatory bodies. Finally, lessons learned from this pandemic can also help the world prepare for upcoming outbreaks
... In this case-which includes multiple stages, with different costs and different probabilities of success at each stage-a decision tree would be a useful tool to model cost-effectiveness for the perspective of the organizational decision-maker [37]. By inputting the likely costs, outcomes, and probabilities of success into a visual, branching model, decision-makers would be better able to understand the trade-offs between the timing of costs and the likelihood that those costs will lead to the adoption of the program (see Appendix A for an example decision tree). ...
Background
Economic evaluations frequently are utilized to compare the value of different interventions in medicine and health in concrete terms. Implementation science also would benefit from the incorporation of economic evaluations, but such studies are rare in the literature. The National Cancer Institute has supported a special collection of articles focusing on economic evaluations in implementation science. Even when interventions are supported by substantial evidence, they are implemented infrequently in the field. Implementation costs are important determinants for whether organizational decision-makers choose to adopt an intervention and whether the implementation process is successful. Economic evaluations, such as cost-effectiveness analyses, can help organizational decision-makers choose between implementation approaches for evidence-based interventions by accounting for costs and succinctly presenting cost/benefit tradeoffs.
Main text
This manuscript presents a discussion of important considerations for incorporating economic evaluations into implementation science. First, the distinction between intervention and implementation costs is presented, along with an explanation of why the comprehensive representation of implementation costs is elusive. Then, the manuscript describes how economic evaluations in implementation science may differ from those in medicine and health intervention studies, especially in terms of determining the perspectives and outcomes of interest. Finally, referencing a scale-up trial of an evidence-based behavioral health intervention, concrete case examples of how cost data can be collected and used in economic evaluations targeting implementation, rather than clinical outcomes, are described.
Conclusions
By gaining a greater understanding of the costs and economic impact associated with different implementation approaches, organizational decision-makers will have better transparency for future replication and scale-up. The use of economic evaluations can help to advance this understanding and provide researchers, purveyors or third-party intermediaries, and organizational decision-makers with essential information to facilitate implementation.
... However, in a resource-limited setting, it is important to determine whether allocating resources to these interventions would yield good value for money. Costeffectiveness analysis (CEA) is the most common health economic evaluation tool used to compare at least two interventions, to identify the intervention that has a higher likelihood of producing the greatest health gains with the least resources [8]. Incremental costeffectiveness ratio (ICER) is used to compare and rank alternative interventions.. ...
Background
In sub-Saharan Africa, there is increasing mortality and morbidity of adolescents due to poor linkage, retention in HIV care and adherence to antiretroviral therapy (ART). This is a result of limited adolescent-centred service delivery interventions. This cost-effectiveness and feasibility study were piggybacked on a cluster-randomized trial that assessed the impact of an adolescent-centred service delivery intervention. The service delivery intervention examined the impact of an incentive scheme consisting of conditional economic incentives and motivational interviewing on the health outcomes of adolescents living with HIV in Nigeria.
Method
A cost-effectiveness analysis from the healthcare provider’s perspective was performed to assess the cost per additional patient achieving undetected viral load through the proposed intervention. The cost-effectiveness of the incentive scheme over routine care was estimated using the incremental cost-effectiveness ratio (ICER), expressed as cost/patient who achieved an undetectable viral load. We performed a univariate sensitivity analysis to examine the effect of key parameters on the ICER. An in-depth interview was conducted on the healthcare personnel in the intervention arm to explore the feasibility of implementing the service delivery intervention in HIV treatment hospitals in Nigeria.
Result
The ICER of the Incentive Scheme intervention compared to routine care was US1137 per quality-adjusted life-years suggested by Woods et al., 2016, the intervention was not cost-effective. The sensitivity test showed that the intervention will be cost-effective if the frequency of CD4 count and viral load tests are reduced from quarterly to triannually. Healthcare professionals reported that patients’ acceptance of the intervention was very high.
Conclusion
The conditional economic incentives and motivational interviewing was not cost-effective, but can become cost-effective if the frequency of HIV quality of life indicator tests are performed 1–3 times per annum. Patients’ acceptance of the intervention was very high. However, healthcare professionals believed that sustaining the intervention may be difficult unless factors such as government commitment and healthcare provider diligence are duly addressed.
Trial registration
This trial is registered in the WHO International Clinical Trials Registry through the WHO International Registry Network (PACTR201806003040425).
... Health economics might aim to model the cost-benefit, cost-effectiveness or cost-utility of an 4 intervention or process. 11 The cost-benefit of an intervention refers to its potential to save costs compared to the price of the intervention itself. For example, if dipping ten patients' breast implants in antimicrobial solution were to cost £200, but saved £10,000 by avoiding a revision surgery, this would represent a cost-benefit. ...
This editorial explores value in relation to plastic surgery and strategies that have been suggested to deliver value-based healthcare. We consider how value is measured, accounting for patient outcomes and experiences, costs and equity, and describe strategies that might improve value, such as outcome-based reimbursement, reporting transparency and high volume specialist centres.
... An analysis from the economic standpoint provides a useful method for assessing the value of an intervention by assessing the cost associated with a health outcome (eg, life years). 45 ...
Hip arthroscopy has emerged as a highly popular and minimally invasive treatment of femoroacetabular impingement syndrome and labral tears by correcting the femoral and acetabular morphology and addressing the chondrolabral pathology. It has been reported to lead to significant improvements of patient-reported outcomes with minimal complications at short-term, mid-term, and long-term follow-up in addition to having low rates of secondary surgeries. As a result, rates of hip arthroscopy have increased dramatically, both in the United States and worldwide. Albeit these favorable outcomes of hip arthroscopy have been well-established, its cost-effectiveness has not yet been as well defined. However, even in the scenario of limited resources of today’s health care, new data has shown that this procedure is truly cost-effective.
... Preference-based measures characterize health status by providing a single utility score from multiple domains of health. The utility score, based on valuations of different health states, is central to estimation of quality-adjusted life years (QALY), cost-utility analysis, cost-effectiveness of interventions, and quantitation of health outcomes [2,6]. ...
Spinal disorders and associated interventions are costly in the United States, putting them in the limelight of economic analyses. The Patient-Reported Outcomes Measurement Information System Global Health Survey (PROMIS-GHS) requires mapping to other surveys for economic investigation. Previous studies have proposed transformations of PROMIS-GHS to EuroQol 5-Dimension (EQ-5D) health index scores. These models require validation in adult spine patients. In our study, PROMIS-GHS and EQ-5D were randomly administered to 121 adult spine patients. The actual health index scores were calculated from the EQ-5D instrument and estimated scores were calculated from the PROMIS-GHS responses with six models. Goodness-of-fit for each model was determined using the coefficient of determination (R2), mean squared error (MSE), and mean absolute error (MAE). Among the models, the model treating the eight PROMIS-GHS items as categorical variables (CATReg) was the optimal model with the highest R2 (0.59) and lowest MSE (0.02) and MAE (0.11) in our spine sample population. Subgroup analysis showed good predictions of the mean EQ-5D by gender, age groups, education levels, etc. The transformation from PROMIS-GHS to EQ-5D had a high accuracy of mean estimate on a group level, but not at the individual level.
... a. Health economic analysis: To compare the costutility of the investigated treatments DA and DF [17]. b. ...
Background
Fusion in addition to decompression has become the standard treatment for lumbar spinal stenosis with degenerative spondylolisthesis (DS). The evidence for performing fusion among these patients is conflicting and there is a need for further investigation through studies of high quality. The present protocol describes an ongoing study with the primary aim of comparing the outcome between decompression alone and decompression with instrumented fusion. The secondary aim is to investigate whether predictors can be used to choose the best treatment for an individual. The trial, named the NORDSTEN-DS trial, is one of three studies in the Norwegian Degenerative Spinal Stenosis (NORDSTEN) study.
Methods
The NORDSTEN-DS trial is a block-randomized, controlled, multicenter, non-inferiority study with two parallel groups. The surgeons at the 15 participating hospitals decide whether a patient is eligible or not according to the inclusion and exclusion criteria. Participating patients are randomized to either a midline preserving decompression or a decompression followed by an instrumental fusion.
Primary endpoint is the percentage of patients with an improvement in Oswestry Disability Index version 2.0 of more than 30% from baseline to 2-year follow-up. Secondary outcome measurements are the Zürich Claudication Questionnaire, Numeric Rating Scale for back and leg pain, Euroqol 5 dimensions questionnaire, Global perceived effect scale, complications and several radiological parameters. Analysis and interpretation of results will also be conducted after 5 and 10 years.
Conclusion
The NORDSTEN/DS trial has the potential to provide Level 1 evidence of whether decompression alone should be advocated as the preferred method or not. Further on the study will investigate whether predictors exist and if they can be used to make the appropriate choice for surgical treatment for this patient group.
Trial registration
ClinicalTrials.gov Identifier: NCT02051374. First Posted: January 31, 2014. Last Update Posted: February 14, 2018.
... While all 3 typically measure cost in monetary units, cost-effectiveness and cost-utility analyses measure outcomes in disease-or condition-specific units of outcome and health status preference and QALYs, respectively. 17 Cost-effectiveness analyses use natural units such as change in hemoglobin A1C, improvement in systolic blood pressure, or improvement in scores on a pain questionnaire to assess outcomes. While this facilitates the analysis of the study by using data that are likely readily available, it hinders comparisons to other studies that use different outcome measures. ...
The complexity and heterogeneity of adult spinal deformity (ASD) creates significant difficulties in performing high-quality, complete economic analyses. For the same reasons, however, such studies are immensely valuable to clinicians and health policy experts. There has been a paradigm shift towards value-based healthcare provision and as such, there is an increasing focus on demonstrating not just the value ASD surgery, but the provision of care at large. Health-related quality of life measures are an important tool for assessing value of an intervention and its effect on a quality-adjusted life year (QALY). Currently, there are no definitive criteria in regard to assigning the appropriate value to a QALY. A general accepted threshold discussed in literature is $100 000 per QALY gained. However, this figure may be variable across populations, and may not necessarily be applicable in today's economy, or in all healthcare economies. Fundamentally, an effective treatment method may be associated with a high upfront cost, however, if durable, will be cost-effective over time.
The emphasis on carotid endarterectomy and CUA in the field of adult spine deformity is relatively recent; therefore, there is a limited amount of data on cost-effectiveness analyses. Continued efforts with emphasis on value-based outcomes are needed with long-term follow-up studies.
Predictive biomarkers (or moderators of treatment) are features, or more likely feature clusters, that discriminate individuals who are more likely to experience a favourable or unfavourable effect from a specific treatment. Utilization of validated predictive biomarkers for chronic low back pain (CLBP) treatments is a plausible strategy to guide patients more rapidly to effective treatments thereby reducing wastage of finite healthcare funds on treatments that are ineffective (or potentially harmful). Yet, few predictive biomarkers have been successfully validated in clinical studies. This paper summarizes work by the Phenotype/Precision Spine Focus Group of the International Society for the Study of the Lumbar Spine that addressed: (1) relevant definitions for terminology; (2) advantages and disadvantages of different research approaches for the specification of predictive biomarkers; (3) methods for assessment of clinical validity; (4) approaches for their implementation; (5) barriers to predictive biomarker identification; and (6) a prioritised list of recommendations for the development and refinement of predictive biomarkers for CLBP. Key recommendations include the harmonisation of data collection, data sharing, integration of theoretical models, development of new treatments, and health economic analyses to inform cost-benefit of assessments and the application of matched treatments. The complexity of CLBP demands large datasets to derive meaningful progress. This will require coordinated and substantive collaboration involving multiple disciplines and across the research spectrum from the basic sciences to clinical applications.
The aim of the study was to develop and compare utility value sets for the EORTC QLU-C10D, a cancer-specific utility instrument based on the EORTC QLQ-C30, using the preferences of the general public and cancer patients in Singapore, and to assess their measurement properties.
A total of 600 individuals from the general public were recruited using a multi-stage random sampling, along with 626 cancer patients with clinically confirmed diagnoses from outpatient clinics of the largest tertiary cancer hospital. Each participant valued 16 pairs of EORTC QLU-C10D health states using a discrete choice experiment (DCE). Conditional logit models were used to analyze the DCE responses of the general public and cancer patients separately. Utility values were assessed for known-group validity and responsiveness in the cancer patients by comparing mean values across subgroups of patients and calculating standardized response means using longitudinal EORTC QLQ-C30 data, respectively.
Physical functioning and pain had the most impact on utility for both cancer patients and general public groups. Worst health state utility values were −0.821 and −0.463 for the general public and cancer patients, respectively. Cancer patients’ values were lower for mild-to-moderate health states but higher for moderately-to-highly impaired states compared with the general public’s values. Both value sets discriminated between patients with differing characteristics and responded equally well to improved health status, but the cancer patients’ value set was slightly more responsive to deteriorated health.
EORTC QLU-C10D value sets based on the preferences of the Singaporean general public and cancer patients exhibited differences in values but similar psychometric properties.
Background
Syphilis is a sexually transmitted infection causing significant global morbidity and mortality. To inform policymaking and economic evaluation studies for syphilis, we summarised utility and disability weights for health states associated with syphilis.
Methods
We conducted a systematic review, searching six databases for economic evaluations and primary valuation studies related to syphilis from January 2000 to February 2022. We extracted health state utility values or disability weights, including identification of how these were derived. The study was registered in the international prospective register of systematic reviews (PROSPERO, CRD42021230035).
Findings
Of 3401 studies screened, 22 economic evaluations, two primary studies providing condition-specific measures, and 13 burden of disease studies were included. Fifteen economic evaluations reported outcomes as disability-adjusted life years (DALYs) and seven reported quality-adjusted life years (QALYs). Fourteen of 15 economic evaluations that used DALYS based their values on the original Global Burden of Disease (GBD) study from 1990 (published in 1996). For the seven QALY-related economic evaluations, the methodology varied between studies, with some studies using assumptions and others creating utility weights or converting them from disability weights.
Interpretation
We found a limited evidence base for the valuation of health states for syphilis, a lack of transparency for the development of existing health state utility values, and inconsistencies in the application of these values to estimate DALYs and QALYs. Further research is required to expand the evidence base so that policymakers can access accurate and well-informed economic evaluations to allocate resources to address syphilis and implement syphilis programs that are cost-effective.
The number of arthroplasty procedures has been rising at a significant rate, contributing to a notable portion of the nation's health care spending. This growth has contributed to an increase in the number of health care economic studies in the field of adult reconstruction surgery. Although these articles are filled with important information, they can be difficult to understand without a background in business or economics. The goal of this review is to define the common terminology used in health care economic studies, assess their value and benefit in the context of total joint arthroplasty, and highlight shortcomings in the current literature. [Orthopedics. 202x;45(x):xx-xx.].
Objectives
The health-related quality of life (HRQoL) and utilities of patients with chronic hepatitis B (CHB) virus infection, including compensated cirrhosis (CC), decompensated cirrhosis (DC) and different stages of hepatocellular carcinoma (HCC), have not been well described in China. This study aimed to evaluate HRQoL and utilities and provide parameters for the economic evaluation of CHB-related diseases.
Methods
We conducted a multicentre cross-sectional and study to measure the HRQoL of patients with CHB, CC, DC and HCC using the Chinese short form (SF) 36 health survey V.2. The utilities were extracted based on the SF-six dimension scoring model. Multivariable regression analyses identified the effects on HRQoL.
Results
A total of 1071 patients (639 with CHB, 125 with CC, 85 with DC and 222 with HCC) were invited to complete the questionnaire. Physical HRQoL was not impaired in the CHB stage, while mental HRQoL was significantly impaired. Physical composite summary scores have a more significant decrease than mental composite summary scores at the advanced stages (CC, DC and HCC). The utility scores of CHB only, CC, DC and HCC were 0.773, 0.750, 0.683 and 0.640, respectively. The utility scores in the early, middle and terminal stages of HCC were 0.656, 0.635 and 0.615, respectively.
Conclusion
Slowing the progress of CHB-related diseases and providing psychological support early are the key points to improving the quality of life with the diseases. The utility values estimated in this study can provide a vital instrument for cost-effectiveness studies on CHB-related diseases.
Background
Hip arthroscopy has frequently been shown to produce successful outcomes as a treatment for femoroacetabular impingement (FAI) and labral tears. However, there is less literature on whether the favorable results of hip arthroscopy can justify the costs, especially when compared with a nonoperative treatment.
Purpose
To systematically review the cost-effectiveness of hip arthroscopy for treating FAI and labral tears.
Study Design
Systematic review; Level of evidence, 3.
Methods
PubMed/MEDLINE, Embase, and Cochrane Library databases, and the Tufts University Cost-Effectiveness Analysis Registry were searched to identify articles that reported the cost per quality-adjusted life-year (QALY) generated by hip arthroscopy. The key terms used were “hip arthroscopy,” “cost,” “utility,” and “economic evaluation.” The threshold for cost-effectiveness was set at $50,000/QALY. The Methodological Index for Non-Randomized Studies instrument and Quality of Health Economic Studies (QHES) score were used to determine the quality of the studies. This study was prospectively registered on PROSPERO (CRD42020172991).
Results
Six studies that reported the cost-effectiveness of hip arthroscopy were identified, and 5 of these studies compared hip arthroscopy to a nonoperative comparator. These studies were found to have a mean QHES score of 85.2 and a mean cohort age that ranged from 33-37 years. From both a health care system perspective and a societal perspective, 4 studies reported that hip arthroscopy was more costly but resulted in far greater gains than did nonoperative treatment. The preferred treatment strategy was most sensitive to duration of benefit, preoperative osteoarthritis, cost of the arthroscopy, and the improvement in QALYs with hip arthroscopy.
Conclusion
In the majority of the studies, hip arthroscopy had a higher initial cost but provided greater gain in QALYs than did a nonoperative treatment. In certain cases, hip arthroscopy can be cost-effective given a long enough duration of benefit and appropriate patient selection. However, there is further need for literature to analyze willingness-to-pay thresholds.
We read with interest the study by Cohen and colleagues addressing the role of lymph node core biopsy (LNCB) for the diagnosis of lymphoproliferative disorders (LPDs) (1). Although we agree that LNCB provides diagnostic clues in most instances, we think that it should not be adopted routinely. We believe, instead, that incisional/excisional biopsies should be performed in all suitable cases. This view is supported by everyday clinical practice and literature data.
The advent of biologic therapies has transformed care for severe atopic disorders but their high cost poses new challenges with regard to long‐term sustainability and fair allocation of resources. This article covers the basic concepts of cost‐utility analyses and reviews the available literature on cost utility of biologic drugs in atopic disorders. When used within their limits as part of a multi‐dimensional assessment, economic analyses can be extremely useful to guide decision‐making and prioritization of care. Despite the good quality of most cost‐utility analyses conducted for the use of biologics in asthma and other atopic diseases, their conclusions regarding cost‐effectiveness are extremely variable. This is mainly due to the use of inconsistent estimates of health utility benefit with therapy. Development of reliable and validated instruments to measure disutility in atopic disorders and measure of indirect costs in atopic disease are identified as a priority for future research.
Background: A recent meta-analysis affirmed the benefit of medicinal cannabis for chronic neuropathic pain, a disabling and difficult-to-treat condition. As medicinal cannabis use is becoming increasingly prevalent among Americans, an exploration of its economic feasibility is warranted. We present this cost-effectiveness analysis of adjunctive cannabis pharmacotherapy for chronic peripheral neuropathy.
Materials and Methods: A published Markov model comparing conventional therapies for painful diabetic neuropathy was modified to include arms for augmenting first-line, second-line (if first-line failed), or third-line (if first- and second-line failed) therapies with smoked cannabis. Microsimulation of 1,000,000 patients compared the cost (2017 U.S. dollars) and effectiveness (quality-adjusted life years [QALYs]) of usual care with and without adjunctive cannabis using a composite of third-party and out-of-pocket costs. Model efficacy inputs for cannabis were adapted from clinical trial data. Adverse event rates were derived from a prospective study of cannabis for chronic noncancer pain and applied to probability inputs for conventional therapies. Cannabis cost was derived from retail market pricing. Parameter uncertainty was addressed with one-way and probabilistic sensitivity analysis.
Results: Adding cannabis to first-line therapy was incrementally less effective and costlier than adding cannabis to second-line and third-line therapies. Third-line adjunctive cannabis was subject to extended dominance, that is, the second-line strategy was more effective with a more favorable incremental cost-effectiveness ratio of 100,000/QALY gained, second-line adjunctive cannabis was the strategy most likely to be cost-effective.
Conclusion: As recently proposed willingness-to-pay thresholds for the United States health marketplace range from 300,000 per QALY, cannabis appears cost-effective when augmenting second-line treatment for painful neuropathy. Further research is warranted to explore the long-term benefit of smoked cannabis and standardization of its dosing for chronic neuropathic pain.
Rapid advancement of medical and surgical therapies, coupled with the recent preoccupation with limiting healthcare costs, makes a collision of the 2 objectives imminent. This article explains the value of cost-effectiveness analysis (CEA) in reconciling the 2 competing goals, and provides a brief introduction to evidence-based CEA techniques. The historical role of CEA in determining whether new neurosurgical strategies provide value for cost is summarized briefly, as are the limitations of the technique. Finally, the unique ability of the neurosurgical community to provide input to the CEA process is emphasized, as are the potential risks of leaving these important decisions in the hands of others.
Background:
Fluid samples obtained from an affected joint still play a central role in the diagnosis of periprosthetic joint infection (PJI). It is the only preoperative test able to discover the causative microbiological agent. In the hip, fluid aspiration can be performed through fluoroscopy, ultrasound, or, less commonly, computed tomography. However, there is still a lack of consensus on which method is preferable in terms of efficacy and costbenefit.
Purposes:
We, therefore, asked whether (1) the benefits in terms of sensitivity and specificity and (2) the costs were comparable between fluoroscopy- and ultrasound-guided joint aspirations in a suspicious of hip PJI.
Methods:
Between 2013 and 2016, 52 hip aspirations were performed on 49 patients with clinical, radiological, or serological suspicion of PJI, waiting for a revision surgery. The patients were divided in two groups: fluoroscopy- (n = 26) vs ultrasound-guided hip aspiration group (n = 26). These groups were also divided in control and infected patients. The criteria of MusculoSkeletal Infection Society (MSIS) were used, as gold standard, to define PJI.
Results:
(1) Ultrasound-guided aspiration revealed valid sensitivity (89% vs 60%) and specificity (94% vs 81%) in comparison with fluoroscopic-guided aspiration. (2) The cost analysis was also in favor of ultrasound-guided aspiration (125.30€) than fluoroscopic-guided aspiration (343.58€).
Conclusions:
We concluded that ultrasound-guided hip aspiration could represent a valid, safe, and less expensive diagnostic alternative to fluoroscopic-guided aspiration in hip PJI.
Background:
Outcomes of nonsurgical management of acute Achilles tendon rupture have been demonstrated to be noninferior to those of surgical management. We performed a cost-minimization analysis of surgical and nonsurgical management of acute Achilles tendon rupture.
Methods:
We used a claims database to identify patients who underwent surgical (n = 1,979) and nonsurgical (n = 3,065) management of acute Achilles tendon rupture and compared overall costs of treatment (surgical procedure, follow-up care, physical therapy, and management of complications). Complication rates were also calculated. Patients were followed for 1 year after injury.
Results:
Average treatment costs in the year after initial diagnosis were higher for patients who underwent initial surgical treatment than for patients who underwent nonsurgical treatment (2,432 for nonsurgical treatment; P < 0.001). However, surgical treatment required fewer office visits (4.52 versus 10.98; P < 0.001) and less spending on physical therapy (928; P < 0.001). Rates of rerupture requiring subsequent treatment (2.1% versus 2.4%; P = 0.34) and additional costs (2,515; P = 0.34) were not significantly different regardless whether initial treatment was surgical or nonsurgical. In both cohorts, management of complications contributed to approximately 5% of the total cost.
Conclusion:
From the payer's perspective, the overall costs of nonsurgical management of acute Achilles tendon rupture were significantly lower than the overall costs of surgical management.
Level of evidence:
III, Economic Decision Analysis.
Please confirm the identified heading levels are okay.
This chapter discusses key concepts for understanding how to assess the value of health care interventions. Value has been defined as a comparison of the outcomes achieved to the costs incurred related to an intervention [1]. Evidence-based medicine has emerged as a field designed to satisfy increasing needs to balance benefits of treatment with health care interventions to rising health care costs. A gradual shift toward a value-driven rather than resource utilization-based health care system has occurred. There have been increased demands to contain costs with greater focus on outcomes (rather than process), which require the application of appropriate methods of economic evaluation. Cost-effectiveness analysis is increasingly used by health care decision makers to allocate scarce resources in an increasingly value-maximizing, patient-centered health care system that considers outcomes (effectiveness) in relation to resources (cost). This chapter introduces several basic concepts regarding the economic measurement of health benefits, costs, and cost-effectiveness methods applicable to spine care.
Previous chapters have focused on cardiovascular safety in drug development and therapeutic use. In this final chapter, we provide a flavor of safety considerations in other aspects of integrated biopharmaceutical medicine, a discipline that encompasses drug development, commercial-scale manufacture, prescription by physicians, dispensing by pharmacists, and the administration of medicines (both by patients themselves and by caretakers, hospital staff, and residential care staff).
Background
The American Shoulder and Elbow Surgeons (ASES) questionnaire was developed to provide a standardized method for evaluating shoulder function. Previous studies have determined the clinical responsiveness of this outcome measure for heterogenous populations or patients with nonoperatively treated rotator cuff disease. Currently, to our knowledge, no studies exist that establish the clinically relevant change in the ASES score after shoulder arthroplasty.
Questions/purposes
We asked: (1) What are the minimal clinically important difference (MCID) and substantial clinical benefit (SCB) for the ASES score after primary and reverse shoulder arthroplasties? (2) Are the MCID and SCB for the ASES score different between primary and reverse shoulder arthroplasties? (3) What patient-related factors are associated with achieving the MCID and SCB after total shoulder arthroplasty and reverse shoulder arthroplasty?
Methods
A longitudinally maintained institutional shoulder arthroplasty registry was retrospectively queried for patients who underwent primary shoulder arthroplasty, including anatomic or reverse total shoulder arthroplasty from 2007 to 2013, with a minimum 2-year followup. Seven hundred ninety-four patients were identified and eligible; 304 of these patients did not have 2 years of followup or complete datasets, resulting in a study cohort of 490 patients (62% of the 794 potentially eligible). The MCID and SCB of the ASES score for these patients was calculated using an anchor-based method, using four different anchors measuring satisfaction with work, activities, overall, and activity from the SF-36. The MCID (anchored to somewhat satisfied) and SCB (very satisfied) of the ASES score were calculated for the entire cohort and stratified by arthroplasty type. Multivariate logistic regression of patient-related factors that influence the MCID and SCB achievement was performed.
Results
The MCID for all patients combined ranged from 6.3 to 13.5; for the overall satisfaction anchor, the MCID was 13.5 ± 4.5 (95% CI, 4.8–22.3). The SCB for the overall cohort ranged from 12.0 to 36.6; for the overall satisfaction anchor, the SCB was 36.6 ± 3.8 (95% CI, 29.1–44.1). There were no differences in the MCID of the ASES score between anatomic and reverse shoulder arthroplasty for any of the anchors (p = 0.159–0.992) or the SCB for any of the anchors (p = 0.467–0.977). Combining anatomic and reverse shoulder arthroplasty in one group, higher preoperative ASES score (odds ratio [OR], 0.96; 95% CI, 0.94–0.98; p < 0.001), having a reverse shoulder arthroplasty (OR, 0.36; 95% CI, 0.16–0.85; p = 0.016), and having rheumatoid arthritis were independent predictors of not achieving an MCID for the ASES 2 years after surgery. Higher preoperative ASES score (OR, 0.91; 95% CI, 0.89–0.92; p < 0.001), a diagnosis of rotator cuff tear arthropathy (OR, 0.14; 95% CI, 0.07–0.30; p < 0.001), a diagnosis of back pain (OR, 0.42; 95% CI, 0.24–0.71); p = 0.002), and living alone (OR, 0.36; 95% CI, 0.19–0.69; p = 0.002) were all independent predictors of not achieving SCB after shoulder arthroplasty.
Conclusions
Patients with glenohumeral arthritis or rotator cuff tear arthropathy who undergo primary conventional total or reverse shoulder arthroplasty and have at least a nine-point improvement in their ASES score experience a clinically important change, whereas those who have at least a 23-point improvement in their ASES score experience a substantial clinical benefit. High preoperative function was associated with a decreased likelihood of achieving clinically important change after total shoulder arthroplasty.
Level of Evidence
Level III, therapeutic study.
Health economic evaluations potentially provide valuable information to clinicians, health care administrators, and policy makers regarding the financial implications of decisions about the care of patients. The highest quality research should be used to inform decisions that have direct impact on the access to care and the outcome of treatment. However, economic analyses are often complex and use research methods which are relatively unfamiliar to clinicians. Furthermore, health economic data have substantial national, regional, and institutional variability, which can limit the external validity of the results of a study. Therefore, minimum guidelines that aim to standardise the quality and transparency of reporting health economic research have been developed, and instruments are available to assist in the assessment of its quality and the interpretation of results.
The purpose of this editorial is to discuss the principal types of health economic studies, to review the most common instruments for judging the quality of these studies and to describe current reporting guidelines. Recommendations for the submission of these types of studies to The Bone & Joint Journal are provided.
Cite this article: Bone Joint J 2016;98-B:147–51.
Purpose
The aim of this study was to compare the clinical results between open and arthroscopic Latarjet and perform a cost analysis of the two techniques.
Materials and methods
A systematic review of articles present in PubMed and MEDLINE was performed in accordance with PRISMA guidelines. Studies concerning post-operative outcomes following Latarjet procedures for chronic anterior shoulder instability were selected for analysis. The clinical and radiographic results as well as the costs of the open and arthroscopic techniques were evaluated.
Results
Twenty-three articles, describing a total of 1317 shoulders, met the inclusion criteria: 17 studies were related to open Latarjet, and 6 to the arthroscopic technique. Despite the heterogeneity of the evaluation scales, the clinical results seemed very satisfactory for both techniques. We detected a statistically significant difference in the percentage of bone graft healing in favour of the open technique (88.6 vs 77.6 %). Recurrent dislocation was more frequent following open surgery (3.3 % after open surgery vs 0.3 % after arthroscopy), but this finding was biased by the large difference in follow-up duration between the two techniques. The direct costs of the arthroscopic procedure were double in comparison to open surgery (€2335 vs €1040). A lack of data prevented evaluation of indirect costs and, therefore, a cost-effectiveness analysis.
Conclusions
The open and arthroscopic Latarjet techniques showed excellent and comparable clinical results. However, the much higher direct costs of the arthroscopic procedure do not seem, at present, to be justified by a benefit to the patient.
Level of evidence
III.
Raymond Roy-Camille was the first to describe pedicle screw fixation of the spine.[1][1] In the mid-1960s, this was considered a radical deviation from normal spinal surgical practice. It took three decades for the notion of segmental fixation of the spine utilising the pedicles as an anchor point
In recent years, there has been an increase in the number of decision analysis studies in the spine literature. While there are several published reviews on the different types of decision analysis (cost-effectiveness, cost-benefit, cost-utility), there is limited information in the spine literature regarding the mathematical models used in these studies (decison tree, Markov modeling, Monte Carlo simulation).
The purpose of this review is to provide an overview of the types of decision analytic models used in spine surgery. A secondary aim is to provide a systematic overview of the most cited studies in the spine literature.
This is a systematic review of the available information from all sources regarding decision analytics and economic modeling in spine surgery.
A systematic search of Pubmed, Embase, and Cochrane review was performed to identify the most relevant peer-reviewed literature of decision analysis/cost-effectiveness analysis (CEA) models including decisions trees, Markov models and Monte Carlo simulations. Additionally, CEA models based on Investigational Drug Exemption studies (IDE) were reviewed in particular detail, as these studies are prime candidates for economic modeling.
The initial review of the literature resulted in 712 abstracts. After two-reviewer assessment of abstract relevance and methodological quality, 19 studies were selected: 12 with decision tree constructs and 7 with Markov models. Each study was assessed for methodological quality as well as a review of the overall results of the model. A generalized overview of the mathematical construction and methodology of each type of model was also performed. Limitations, strengths and potential applications to spine research were further explored.
Decision analytic modeling represents a powerful tool both in the assessment of competing treatment options and potentially in the formulation of policy and reimbursement. Our review provides a generalized overview and a conceptual framework to help spine physicians with the construction of these models.
Copyright © 2015 Elsevier Inc. All rights reserved.
Cost-effectiveness research is an increasingly used tool in evaluating treatments in orthopaedic surgery. Without high-quality primary-source data, the results of a cost-effectiveness study are either unreliable or heavily dependent on sensitivity analyses of the findings from the source studies. However, to our knowledge, the strength of recommendations provided by these studies in orthopaedics has not been studied.
We asked: (1) What are the strengths of recommendations in recent orthopaedic cost-effectiveness studies? (2) What are the reasons authors cite for weak recommendations? (3) What are the methodologic reporting practices used by these studies?
The titles of all articles published in six different orthopaedic journals from January 1, 2004, through April 1, 2014, were scanned for original health economics studies comparing two different types of treatment or intervention. The full texts of included studies were reviewed to determine the strength of recommendations determined subjectively by our study team, with studies providing equivocal conclusions stemming from a lack or uncertainty surrounding key primary data classified as weak and those with definitive conclusions not lacking in high-quality primary data classified as strong. The reasons underlying a weak designation were noted, and methodologic practices reported in each of the studies were examined using a validated instrument. A total of 79 articles met our prespecified inclusion criteria and were evaluated in depth.
Of the articles included, 50 (63%) provided strong recommendations, whereas 29 (37%) provided weak recommendations. Of the 29 studies, clinical outcomes data were cited in 26 references as being insufficient to provide definitive conclusions, whereas cost and utility data were cited in 13 and seven articles, respectively. Methodologic reporting practices varied greatly, with mixed adherence to framing, costs, and results reporting. The framing variables included clearly defined intervention, adequate description of a comparator, study perspective clearly stated, and reported discount rate for future costs and quality-adjusted life years. Reporting costs variables included economic data collected alongside a clinical trial or another primary source and clear statement of the year of monetary units. Finally, results reporting included whether a sensitivity analysis was performed.
Given that a considerable portion of orthopaedic cost-effectiveness studies provide weak recommendations and that methodologic reporting practices varied greatly among strong and weak studies, we believe that clinicians should exercise great caution when considering the conclusions of cost-effectiveness studies. Future research could assess the effect of such cost-effectiveness studies in clinical practice, and whether the strength of recommendations of a study's conclusions has any effect on practice patterns.
Given the increasing use of cost-effectiveness studies in orthopaedic surgery, understanding the quality of these studies and the reasons that limit the ability of studies to provide more definitive recommendations is critical. Highlighting the heterogeneity of methodologic reporting practices will aid clinicians in interpreting the conclusions of cost-effectiveness studies and improve future research efforts.
Objectives:
Mathematical modeling is used widely in economic evaluations of pharmaceuticals and other health-care technologies. Users of models in government and the private sector need to be able to evaluate the quality of models according to scientific criteria of good practice. This report describes the consensus of a task force convened to provide modelers with guidelines for conducting and reporting modeling studies.
Methods:
The task force was appointed with the advice and consent of the Board of Directors of ISPOR. Members were experienced developers or users of models, worked in academia and industry, and came from several countries in North America and Europe. The task force met on three occasions, conducted frequent correspondence and exchanges of drafts by electronic mail, and solicited comments on three drafts from a core group of external reviewers and more broadly from the membership of ISPOR.
Results:
Criteria for assessing the quality of models fell into three areas: model structure, data used as inputs to models, and model validation. Several major themes cut across these areas. Models and their results should be represented as aids to decision making, not as statements of scientific fact; therefore, it is inappropriate to demand that models be validated prospectively before use. However, model assumptions regarding causal structure and parameter estimates should be continually assessed against data, and models should be revised accordingly. Structural assumptions and parameter estimates should be reported clearly and explicitly, and opportunities for users to appreciate the conditional relationship between inputs and outputs should be provided through sensitivity analyses.
Conclusions:
Model-based evaluations are a valuable resource for health-care decision makers. It is the responsibility of model developers to conduct modeling studies according to the best practicable standards of quality and to communicate results with adequate disclosure of assumptions and with the caveat that conclusions are conditional upon the assumptions and data on which the model is built.
The cost-effectiveness acceptability curve (CEAC) is a method for summarizing the uncertainty in estimates of cost-effectiveness. The CEAC, derived from the joint distribution of costs and effects, illustrates the (Bayesian) probability that the data are consistent with a true cost-effectiveness ratio falling below a specified ceiling ratio. The objective of the paper is to illustrate how to construct and interpret a CEAC.
A retrospective cost-effectiveness analysis of the Atrial Fibrillation Follow-up Investigation of Rhythm Management (AFFIRM) randomized controlled trial with 4060 patients followed for 3.5 years. The target population was patients with atrial fibrillation who were 65 years of age or had other risk factors for stroke or death similar to those enrolled in AFFIRM. The intervention involved the management of patients with atrial fibrillation with antiarrhythmic drugs (rhythm-control) compared with drugs that control heart rate (rate-control). Measurements of mean survival, mean costs and incremental cost-effectiveness were made. The uncertainty surrounding the estimates of cost-effectiveness was illustrated through a cost-effectiveness acceptability curve.
The base case point estimate for the difference in effects and costs between rate and rhythm-control is 0.08 years (95% CI: -0.1 years to 0.24 years) and -US1,100 to -$11,006). The CEAC shows that the decision uncertainty surrounding the adoption of rate-control strategies is less than 1.7% regardless of the maximum acceptable ceiling ratio. Thus, there is very little uncertainty surrounding the decision to adopt rate-control compared to rhythm-control for patients with atrial fibrillation from a resource point of view.
The CEAC is straightforward to calculate, construct and interpret. The CEAC is useful to a decision maker faced with the choice of whether or not to adopt a technology because it provides a measure of the decision uncertainty surrounding the choice.
Spine Patient Outcomes Research Trial observational and randomized cohort participants with a confirmed diagnosis of intervertebral disc herniation (IDH) who received either usual nonoperative care and/or standard open discectomy were followed from baseline at 6 weeks, 3, 6, 12, and 24 months at 13 spine clinics in 11 US states.
To evaluate the cost-effectiveness of surgery relative to nonoperative care among patients with a confirmed diagnosis of lumbar IDH.
The cost-effectiveness of surgery as a treatment for conditions associated with low back and leg symptoms remains poorly understood.
Incremental cost-effectiveness ratio, reported as discounted cost per quality adjusted life year (QALY) gained in 2004 US dollars based on EuroQol EQ-5D health state values with US scoring, and information on resource utilization and time away from work.
Among 775 patients who underwent surgery and 416 who were treated nonoperatively, the mean difference in QALYs over 2 years was 0.21 (95% CI: 0.16-0.25) in favor of surgery. Surgery was more costly than nonoperative care; the mean difference in total cost was 11,737-16,770). The cost per QALY gained for surgery relative to nonoperative care was 49,523-94,999) using general adult surgery costs and 20,419-52,512) using Medicare population surgery costs.
Surgery for IDH was moderately cost-effective when evaluated over 2 years. The estimated economic value of surgery varied considerably according to the method used for assigning surgical costs.
Limits on health-care resources mandate that resource-allocation decisions be guided by considerations of cost in relation to expected benefits. In cost-effectiveness analysis, the ratio of net health-care costs to net health benefits provides an index by which priorities may be set. Quality-of-life concerns, including both adverse and beneficial effects of therapy, may be incorporated in the calculation of health benefits as adjustments to life expectancy. The timing of future benefits and costs may be accounted for by the appropriate use of discounting. Current decisions must inevitably be based on imperfect information, but sensitivity analysis can increase the level of confidence in some decisions while suggesting areas where further research may be valuable in guiding others. Analyses should be adaptable to the needs of various health-care decision makers, including planners, administrators and providers.
Health status measurement for use in economic appraisal of health care programmes is reviewed in this paper, with particular emphasis on utility measurement. A framework for economic appraisal is presented displaying the various components that must be measured, and showing how the three forms of analysis (cost-effectiveness analysis, cost-benefit analysis and cost-utility analysis) relate to the framework and to each other. One of the components in the framework is health status; it can be measured using ad hoc numeric scales, willingness to pay/receive or health state utilities. The determination of health state utilities is reviewed covering the following issues: alternative sources of utilities, health state descriptions, multi-attribute utility approach, determination of appropriate subjects, utility aggregation, and accuracy. Three measurement techniques for health state utilities are described in detail: rating scale, standard gamble, and time trade-off. The use of these methods is described for both chronic and temporary health states and for both health states considered better than death and those considered worse than death.
A cost-effectiveness study was performed from the societal and health care perspectives.
To evaluate the costs-effectiveness of lumbar fusion for chronic low back pain (CLBP) during a 2-year follow-up.
A full economic evaluation comparing costs related to treatment effects in patients with CLBP is lacking.
A total of 284 of 294 patients with CLBP for at least 2 years were randomized to either lumbar fusion or a nonsurgical control group. Costs for the health care sector (direct costs), and costs associated with production losses (indirect costs) were calculated. Societal total costs were identified as the sum of direct and indirect costs. Treatment effects were measured using patient global assessment of improvement, back pain (VAS), functional disability (Owestry), and return to work.
The societal total cost per patient (standard deviations) in the surgical group was significantly higher than in the nonsurgical group: Swedish kroner (SEK) 704,000 (254,000) vs. SEK 636,000 (208,000). The cost per patient for the health care sector was significantly higher for the surgical group, SEK 123,000 (60,100) vs. 65,200 (38,400) for the control group. All treatment effects were significantly better after surgery. The incremental cost-effectiveness ratio (ICER), illustrating the extra cost per extra effect unit gained by using fusion instead of nonsurgical treatment, were for improvement: SEK 2,600 (600-5,900), for back pain: SEK 5,200 (1,100-11,500), for Oswestry: SEK 11,300 (1,200-48,000), and for return to work: SEK 4,100 (100-21,400).
For both the society and the health care sectors, the 2-year costs for lumbar fusion was significantly higher compared with nonsurgical treatment but all treatment effects were significantly in favor of surgery. The probability of lumbar fusion being cost-effective increased with the value put on extra effect units gained by using surgery.