Ranolazine is used to treat stable angina pectoris, the most common symptom of ischemic heart disease. Appropriate management of chronic stable angina pectoris is essential from both a clinical and ...an economic view point.
This systematic review and meta-analysis adhered to Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. We included cost-utility analyses, which compared ranolazine with other standard treatments for treating stable angina pectoris. The search was conducted in PubMed, EMBASE, and Scopus databases. A random-effects model based on the DerSimonian and Laird method was used to pool the incremental net benefit reported in purchasing power parity adjusted US dollars. The modified economic evaluation checklist was used to assess the risk of bias.
The pooled results from 7 selected studies with a time horizon of 1 year show that add-on ranolazine was significantly cost-effective compared with standard treatment, with a pooled incremental net benefit of US$1335 (95% CI, 500 to 2169) but with substantial heterogeneity (I2 = 79.46%). On subgroup analysis, ranolazine was cost-effective from the payers’ perspective (US$1975; 95% CI, 1042 to 2908; I2 = 69.23) but not from a societal perspective (US$297; 95% CI, –241 to 715; I2 = 0%). There was limited evidence from lower economies.
Pooled evidence suggests that add-on ranolazine therapy is cost-effective for chronic stable angina pectoris up to a 1-year time horizon. There is a lacuna of evidence from low- and middle-income countries and on long-term cost-effectiveness. The current evidence synthesis may provide a macroeconomic point of view for policy makers regarding the direction of ranolazine's cost-effectiveness for evidence-informed policy-making. PROSPERO identifier: CRD42022332454.
Introduction
Proprotein convertase subtilisin/kexin 9 inhibitors (PCSK9i) are monoclonal antibodies that lower lipid levels. Although several cardiovascular outcome trials reported the effectiveness ...of PCSK9i, the evidence on cost-effectiveness is mixed. We systematically reviewed the evidence and synthesized incremental net benefit (INB) to quantify pooled cost-effectiveness.
Methods
We systematically searched for full economic evaluation studies reporting outcomes of PCSK9i compared with other lipid-lowering pharmacotherapies. We searched PubMed, Embase, Scopus, and Tufts Registry for eligible studies up to August 2021, adhering to preferred reporting items for systematic reviews and meta-analyses guidelines. We pooled INB in US$ with a 95% confidence interval using a random-effects model. We assessed heterogeneity using the Cochran
Q
test and
I
2
statistics. We used the modified economic evaluations bias (ECOBIAS) checklist to evaluate the quality of selected studies.
Results
Twenty-three studies were eligible, mainly from high-income countries (HIC). The pooled INB (INBp) of PCSK9i versus other lipid-lowering pharmacotherapies were estimated from
n
= 24 comparisons, with high heterogeneity (
I
2
= 99.99). The INBp (95% CI) was $ − 78,207 (− 120,422; − 35,993) or € − 52,526 (− 80,879; − 24,174) (conversion factor 1 US$ = 0.67€) which shows that PCSK9i was not significantly cost-effective when compared to other standard therapies. On subgroup analysis PCSK9i was significantly not cost-effective $ − 23,672 (− 24,061; − 23,282) compared to other lipid-lowering pharmacotherapies in HICs, upper-middle-income countries $ − 158,412 (− 241,738; − 75,086) or when the target population was CVD $ − 109,343 (− 158,968; − 59,717); and for treatment subgroup: against placebo or no treatment $ − 79,018 (− 79,649; − 78,388 PCSK9) and standard statin therapies $ − 131,833 (− 173,449; − 90,216). The sensitivity analysis revealed that the findings are not robust for HICs and the treatment subgroups.
Conclusion
PCSK9 inhibitors are not cost-effective compared to other lipid-lowering pharmacotherapies in HICs. Further, current pieces of evidence are predominantly from HICs with largely lacking evidence from other economies.
Prospero registration
ID CRD42020206043.
Chronic Pb exposure associated systemic illness are partly posited to involve calcium homeostasis. Present systematic review aims to comprehensively evaluate the association between chronic lead ...exposure and markers of calcium homeostasis. Observational studies documenting the changes in calcium homeostasis markers (i.e. serum calcium, parathyroid hormone, vitamin D & calcitonin) between occupationally Pb exposed group and control group were systematically searched from pubmed-Medline, Scopus, and Embase digital databases since inception to September 24, 2021. The protocol was earlier registered at PROSPERO (ID: CRD42020199503) and executed adhering to PRISMA 2020 guidelines. Mean differences of calcium homeostasis markers between the groups were analysed using random-effects model. Conventional I
statistics was employed to assess heterogeneity, while the risk for various biases were assessed using Newcastle Ottawa Scale. Sub-group, sensitivity and meta-regression analyses were performed where data permitted. Eleven studies including 837 Pb exposed and 739 controls were part of the present study. Pb exposed group exhibited higher mean blood lead level i.e. 36.13 (with 95% CI 25.88-46.38) µg/dl significantly lower serum calcium (i.e. - 0.72 mg/dl with 95% CI - 0.36 to - 1.07) and trend of higher parathyroid levels and lower vitamin D levels than controls. Heterogeneity was high (I
> 90%) among the studies. Considering the cardinal role of calcium in multiple biological functions, present observations emphasis the need for periodic evaluation of calcium levels and its markers among those with known cumulative Pb exposure.
Purpose
To investigate the role of DHA supplementation in preventing age-related cognitive decline (ARCD) in individual cognitive domains by conducting systematic review and meta-analysis.
Methods
...Relevant clinical trials were systematically searched at Medline, PubMed, Scopus, Cochrane, ProQuest, and Embase databases since inception to June 2018. The PRISMA guidelines were adhered for data abstraction, quality assessment, and validation of included studies. Study details such as participant characteristics, DHA supplementation, and cognitive function outcome measures, i.e., memory, attention, working memory, and executive function, were extracted to perform meta-analysis according to the Cochrane guidelines. Additional meta-regression and subgroup analyses were performed to detect confounding variables and sensitivity of results, respectively.
Results
Ten studies including 2327 elderly individuals were part of the final results. Study exhibited minimal or no pooled incremental effects on memory (0.22, 95%CI = − 0.17 to 0.61,
I
2
= 94.36%), attention (0.1, 95%CI = − 0.04 to 0.25,
I
2
= 32.25%), working memory (0.01, 95%CI = − 0.10 to 0.12,
I
2
= 0%), and executive function (0.03, 95%CI = − 0.05 to 0.11,
I
2
= 78.48%) among the DHA-supplemented group. The results from standard mean difference between the groups, on memory (0.08, 95%CI = − 0.12 to 0.28,
I
2
= 76.82%), attention (0.04, 95%CI = − 0.09 to 0.23,
I
2
= 42.63%), working memory (− 0.08, 95%CI = − 0.26 to 0.10,
I
2
= 37.57%), and executive function (0.17, 95%CI = − 0.01 to 0.36,
I
2
= 78.48%) were similar to the results of pooled incremental analysis. Lastly, results remained unaffected by sensitivity and sub-group analyses.
Conclusions
Current pieces of evidence do not support the role of DHA supplementation, in preventing/retarding ARCD of memory, executive function, attention, and working memory.
Protocol registered at PROSPERO (ID: PROSPERO 2018 CRD42018099401).
This systematic review aimed to comprehensively synthesize cost-effectiveness evidences of bariatric surgery by pooling incremental net monetary benefits (INB). Twenty-eight full economic evaluation ...studies comparing bariatric surgery with usual care were identified from five databases. In high-income countries (HICs), bariatric surgery was cost-effective among mixed obesity group (i.e., obesity with/without diabetes) over a 10-year time horizon (pooled INB = $53,063.69; 95% CI $42,647.96, $63,479.43) and lifetime horizon (pooled INB = $101,897.96; 95% CI $79,390.93, $124,404.99). All studies conducted among obese with diabetes reported that bariatric surgery was cost-effective. Also, the pooled INB for obesity with diabetes group over lifetime horizon in HICs was $80,826.28 (95% CI $32,500.75, $129,151.81). Nevertheless, no evidence is available in low- and middle-income countries.
Graphical abstract
In the context of ever-growing health expenditure and limited resources, economic evaluations aid in making evidence-informed policy decisions. Cost-utility analysis (CUA) is often used, and CUA data ...synthesis is also desirable, but methodological issues are challenged. Hence, we aim to provide a step-by-step process to prepare the CUA data for meta-analysis.
Data harmonisation methods were constructed specifically considering CUA methodology, including inconsistent reports, economic parameters, heterogeneity (i.e., country's income, time horizon, perspective, modelling approaches, currency, willingness to pay). An incremental net benefit (INB) and its variance were estimated and pooled across studies using a basic meta-analysis by COMER.
Five scenarios show how to obtain INB and variance with various reported data: Study reports the mean and variance (Scenario 1) or 95% confidence interval (Scenario 2) of ΔC, ΔE, and ICER for INB/variance calculations. Scenario 3: ΔC, ΔE, and variances are available, but not for the ICER; a Monte Carlo was used to simulate ΔC and ΔE data, variance and covariance can be then estimated leading INB calculation. Scenario-4: Only the CE plane was available, ΔC and ΔE data can be extracted; means of ΔC, ΔE, and variance/covariance can be estimated accordingly, leading to INB/variance estimates. Scenario-5: Only mean cost/outcomes and ICER are available but not for variance and the CE-plane. A variance INB can be borrowed from other studies which are similar characteristics, including country income, ICERs, intervention-comparator, time period, country region, and model type and inputs (i.e., discounting, time horizon).
Out data harmonisation and meta-analytic methods should be useful for researchers for the synthesis of economic evidence to aid policymakers in decision making.
Several hepatitis A outbreaks have recently been reported in Kerala state, India. To inform coverage decision of hepatitis A vaccine in Kerala, this study aimed to examine the cost-effectiveness of ...1) hepatitis A vaccination among children aged 1 year and individuals aged 15 years, and 2) serological screening of individuals aged 15 years and vaccination of susceptible as compared to no vaccination or vaccination without serological screening. Both live attenuated hepatitis A vaccine and inactivated hepatitis A vaccine were considered in the analysis. A combination of decision tree and Markov models with a cycle length of one year was employed to estimate costs and benefits of different vaccination strategies. Analysis were based on both societal and payer perspectives. The lifetime costs and outcomes were discounted by 3%. Our findings indicated that all strategies were cost-saving for both societal and payer perspectives. Moreover, budget impact analysis revealed that vaccination without screening among individuals aged 15 years could save the government’s budget by reducing treatment cost of hepatitis A. Our cost-effectiveness evidence supports the inclusion of hepatitis A vaccination into the vaccination program for children aged 1 year and individuals aged 15 years in Kerala state, India.
Rheumatoid arthritis (RA) not only has a physical and emotional toll but also has a substantial economic impact. This study aims to estimate the burden of catastrophic health expenditure (CHE) on ...households due to RA in Tamil Nadu, India. We conducted cross-sectional descriptive hospital-based single-centre study at a tertiary care private multispecialty hospital in Tamil Nadu, India. The study comprised 320 RA patients who visited the outpatient clinic from April to October 2022. Demographic and baseline descriptive characteristics were reported. Multivariable logistic regression analyses were performed to identify major determinants associated with CHE. We also examined the inequality in household annual income and CHE. Most study participants were females (88.1%) with a mean age (SD) of 55.57 ± 12.29 years. About 93% of RA patients were from urban areas, and 89.4% were literate. Only 8.1% of respondents reported having health insurance. Households experiencing CHE owing to RA were 51.4% (n = 162). The mean (95% CI) annual health expenditure for treating RA is ₹44,700 (₹41,710 to 47,690) with a median (IQR) of ₹39,210 (₹25,500) $476 ($310). The corresponding mean (95% CI) and median (IQR) Out of pocket expenditure among RA patients per household were ₹40,698 (₹38,249 to 43,148) $494 ($464 to $524) and ₹36,450 (23,070) $442 ($280) respectively. Nearly half of the households with RA patients had a financial catastrophe due to healthcare costs being paid out-of-pocket and limited health insurance coverage. The results underscore the need for comprehensive approaches to strengthening public health policies along with financial risk protection and quality care in India.
Introduction
Region‐specific health‐related quality of life (HRQoL) scores or utility values are representative and pivotal for economic evaluations as they are influenced by the value judgment of ...the local population. This study systematically reviewed and pooled EuroQoL‐5 Dimension (EQ‐5D) utility scores of rheumatoid arthritis (RA) across primary studies from Asia.
Methods
Studies reporting EQ‐5D utility scores among adult RA patients from Asian countries were systematically searched in PubMed‐Medline, Scopus and Embase since inception through February 2020. Selected studies were systematically reviewed and study quality assessment was performed. Meta‐analysis was performed using a random‐effect model with subgroup and meta‐regression analysis to explore heterogeneity.
Results
Among 1391 searched articles, 37 studies with 31 983 participants were systematically reviewed and meta‐analysis was conducted among 31 studies. The pooled EQ‐5D scores and EQ‐5D visual analog score were 0.66 (95% CI 0.63‐0.69, I2 = 99.65%) and 61.21 (50.73‐71.69, I2 = 99.56%) respectively with high heterogeneity. For RA patients with no, low, moderate and high disease activity based on Disease Activity Score (DAS)‐28, the pooled EQ‐5D scores were 0.78 (0.65‐0.90), 0.73 (0.65‐0.80), 0.53 (0.32‐ 0.74), and 0.47 (0.32‐0.62), respectively. On meta‐regression, age of patients (P < .05) was positively associated and use of glucocorticoids (P < .05) was inversely associated with utility values.
Conclusion
Lower EQ‐5D scores were associated with severe disease activity, increasing age and female gender among RA patients. The study provides pooled EQ‐5D scores for RA patients that are useful inputs for cost‐utility studies in Asia.
In addition to statin therapy, Ezetimibe, a non-statin lipid-modifying agent, is increasingly used to reduce low-density lipoprotein cholesterol and atherosclerotic cardiovascular disease risk. ...Literature suggests the clinical effectiveness of Ezetimibe plus statin (EPS) therapy; however, primary evidence on its economic effectiveness is inconsistent. Hence, we pooled incremental net benefit to synthesise the cost-effectiveness of EPS therapy. We identified economic evaluation studies reporting outcomes of EPS therapy compared with other lipid-lowering therapeutic agents or placebo by searching PubMed, Embase, Scopus, and Tufts Cost-Effective Analysis registry. Using random-effects meta-analysis, we pooled Incremental Net Benefit (INB) in the US $ with a 95% confidence interval (CI). We used the modified economic evaluations bias checklist and GRADE quality assessment for quality appraisal. The pooled INB from twenty-one eligible studies showed that EPS therapy was significantly cost-effective compared to other lipid-lowering therapeutic agents or placebo. The pooled INB (95% CI) was $4,274 (621 to 7,927), but there was considerable heterogeneity (I2 = 84.21). On subgroup analysis EPS therapy is significantly cost-effective in high-income countries $4,356 (621 to 8,092), for primary prevention $4,814 (2,523 to 7,106), and for payers' perspective $3,255 (571 to 5,939), and from lifetime horizon $4,571 (746 to 8,395). EPS therapy is cost-effective compared to other lipid-lowering therapeutic agents or placebo in high-income countries and for primary prevention. However, there is a dearth of evidence from lower-middle-income countries and the societal perspective.
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