Thyroid nodules are a common incidental imaging finding and prone to overdiagnosis. Several risk stratification systems have been developed to reduce unnecessary work-up, with two of the most ...utilized including the American Thyroid Association 2015 (ATA2015) and the newer American College of Radiology Thyroid Imaging, Reporting and Data System (TIRADS) guidelines. The purpose of this study is to evaluate the cost-effectiveness of the ATA2015 versus the TIRADS guidelines in the management of incidental thyroid nodules.
A cost-utility analysis was conducted using decision tree modeling, evaluating adult patients with incidental thyroid nodules < 4 cm. Model inputs were populated using published literature, observational data, and expert opinion. Single-payer perspective, Canadian dollar currency, five-year time horizon, willingness to pay (WTP) threshold of $50,000, and discount rate of 1.5% per annum were utilized. Scenario, deterministic and probabilistic sensitivity analyses were performed. The primary outcome was the incremental cost-effectiveness ratio (ICER) expressed as incremental cost per quality-adjusted life year (QALY) gained.
For the base case scenario, TIRADS dominated the ATA2015 strategy by a slim margin, producing 0.005 more QALYs at $25 less cost. Results were sensitive to the malignancy rate of biopsy and the utilities of a patient with a benign nodule/subclinical malignancy or under surveillance. Probabilistic sensitivity analysis showed that TIRADS was the more cost-effective option 79.7% of the time.
The TIRADS guidelines may be the more cost-effective strategy by a small margin compared to ATA2015 in most scenarios when used to risk stratify incidental thyroid nodules.
Background
To inform the development of the European Academy of Allergy and Clinical Immunology's (EAACI) Guidelines on Allergen Immunotherapy (AIT) for allergic asthma, we assessed the evidence on ...the effectiveness, cost‐effectiveness and safety of AIT.
Methods
We performed a systematic review, which involved searching nine databases. Studies were screened against predefined eligibility criteria and critically appraised using established instruments. Data were synthesized using random‐effects meta‐analyses.
Results
98 studies satisfied the inclusion criteria. Short‐term symptom scores were reduced with a standardized mean difference (SMD) of −1.11 (95% CI −1.66, −0.56). This was robust to a prespecified sensitivity analyses, but there was evidence suggestive of publication bias. Short‐term medication scores were reduced SMD −1.21 (95% CI −1.87, −0.54), again with evidence of potential publication bias. There was no reduction in short‐term combined medication and symptom scores SMD 0.17 (95% CI −0.23, 0.58), but one study showed a beneficial long‐term effect.
For secondary outcomes, subcutaneous immunotherapy (SCIT) improved quality of life and decreased allergen‐specific airway hyperreactivity (AHR), but this was not the case for sublingual immunotherapy (SLIT). There were no consistent effects on asthma control, exacerbations, lung function, and nonspecific AHR.
AIT resulted in a modest increased risk of adverse events (AEs). Although relatively uncommon, systemic AEs were more frequent with SCIT; however no fatalities were reported.
The limited evidence on cost‐effectiveness was mainly available for sublingual immunotherapy (SLIT) and this suggested that SLIT is likely to be cost‐effective.
Conclusions
AIT can achieve substantial reductions in short‐term symptom and medication scores in allergic asthma. It was however associated with a modest increased risk of systemic and local AEs. More data are needed in relation to secondary outcomes, longer‐term effectiveness and cost‐effectiveness.
Many countries use the cost-effectiveness thresholds recommended by the World Health Organization's Choosing Interventions that are Cost-Effective project (WHO-CHOICE) when evaluating health ...interventions. This project sets the threshold for cost-effectiveness as the cost of the intervention per disability-adjusted life-year (DALY) averted less than three times the country's annual gross domestic product (GDP) per capita. Highly cost-effective interventions are defined as meeting a threshold per DALY averted of once the annual GDP per capita. We argue that reliance on these thresholds reduces the value of cost-effectiveness analyses and makes such analyses too blunt to be useful for most decision-making in the field of public health. Use of these thresholds has little theoretical justification, skirts the difficult but necessary ranking of the relative values of locally-applicable interventions and omits any consideration of what is truly affordable. The WHO-CHOICE thresholds set such a low bar for cost-effectiveness that very few interventions with evidence of efficacy can be ruled out. The thresholds have little value in assessing the trade-offs that decision-makers must confront. We present alternative approaches for applying cost-effectiveness criteria to choices in the allocation of health-care resources.
Objective
To provide guidance on selecting the most appropriate price index for adjusting health expenditures or costs for inflation.
Data Sources
Major price index series produced by federal ...statistical agencies.
Study Design
We compare the key characteristics of each index and develop suggestions on specific indexes to use in many common situations and general guidance in others.
Data Collection/Extraction Methods
Price series and methodological documentation were downloaded from federal websites and supplemented with literature scans.
Principal Findings
The gross domestic product implicit price deflator or the overall Personal Consumption Expenditures (PCE) index is preferable to the Consumer Price Index (CPI‐U) to adjust for general inflation, in most cases. The Personal Health Care (PHC) index or the PCE health‐by‐function index is generally preferred to adjust total medical expenditures for inflation. The CPI medical care index is preferred for the adjustment of consumer out‐of‐pocket expenditures for inflation. A new, experimental disease‐specific Medical Care Expenditure Index is now available to adjust payments for disease treatment episodes.
Conclusions
There is no single gold standard for adjusting health expenditures for inflation. Our discussion of best practices can help researchers select the index best suited to their study.
Abstract
Cost-effectiveness thresholds are important decision rules that determine whether health interventions represent good value for money. In low- and middle-income countries, the World Health ...Organization (WHO) one to three times per capita gross domestic product (GDP) per disability-adjusted life years (DALYs) averted has been the most widely used threshold for informing resource allocation decisions. However, in 2016, the WHO withdrew recommendations for using this threshold, creating a significant vacuum in South Africa and many countries that rely on results of cost-effectiveness analyses for making resource allocation decisions. This study estimates a cost-effectiveness threshold that reflects the health opportunity cost of health spending in South Africa using a three-step approach. First, marginal returns to health spending was estimated as health spending elasticity for crude death rates using a fixed effect estimation approach. Second, the opportunity cost of health spending was estimated as DALYs averted. Finally, a cost per DALY averted threshold was estimated as the inverse of the marginal product of health spending. We show that 1% of total health spending in 2015 (equivalent to approximately ZAR 1.54 billion/USD 120.7 million) averted 1050 deaths, 34 180 years of life lost, 5880 years lived with disability and 40 055 DALYs. The cost-effectiveness threshold was estimated at approximately ZAR 38 500 (USD 3015) per DALY averted, ∼53% of South Africa’s per capita GDP in 2015 (ZAR 72 700/USD 5700) and lower than the previously recommended one to three times per capita GDP. As South Africa moves towards implementing universal health coverage reforms through National Health Insurance by 2025, the adoption of a threshold that reflects health opportunity costs will be crucial for ensuring efficiency in the allocation of scarce resources. This study provides useful insight into the magnitude of the health opportunity cost of health spending in South Africa and highlights the need for further research.
Objective
To determine the cost‐effectiveness of surveillance imaging with PET/CT scan among patients with human papillomavirus‐positive oropharyngeal squamous cell carcinoma.
Study Design
...Cost‐effectiveness analysis.
Setting
Oncologic care centers in the United States with head and neck oncologic surgeons and physicians.
Methods
We compared the cost‐effectiveness of 2 posttreatment surveillance strategies: clinical surveillance with the addition of PET/CT scan versus clinical surveillance alone in human papillomavirus‐positive oropharyngeal squamous cell carcinoma patients. We constructed a Markov decision model which was analyzed from a third‐party payer's perspective using 1‐year Markov cycles and a 30‐year time horizon. Values for transition probabilities, costs, health care utilities, and their studied ranges were derived from the literature.
Results
The incremental cost‐effectiveness ratio for PET/CT with clinical surveillance versus clinical surveillance alone was $89,850 per quality‐adjusted life year gained. Flexible fiberoptic scope exams during clinical surveillance would have to be over 51% sensitive or PET/CT scan cost would have to exceed $1678 for clinical surveillance alone to be more cost‐effective. The willingness‐to‐pay threshold at which imaging surveillance was equally cost‐effective to clinical surveillance was approximately $80,000/QALY.
Conclusion
Despite lower recurrence rates of human papillomavirus‐positive oropharyngeal cancer, a single PET/CT scan within 6 months after primary treatment remains a cost‐effective tool for routine surveillance when its cost does not exceed $1678. The cost‐effectiveness of this strategy is also dependent on the clinical surveillance sensitivity (flexible fiberoptic pharyngoscopy), and willingness‐to‐pay thresholds which vary by country.
The results of a recent single-arm trial (ZUMA-5) of axicabtagene ciloleucel (axi-cel) for relapsed/refractory (r/r) follicular lymphoma (FL) demonstrated high rates of durable response and tolerable ...toxicity among treated patients. To quantify the value of axi-cel compared with standard of care (SOC) to manage r/r FL patients who have had at least 2 prior lines of systemic therapy (3L+), a cost-effectiveness model was developed from a US third-party payer perspective.
A 3-state partitioned-survival cost-effectiveness model was developed with a lifetime horizon. Patient-level analyses of the 36-month ZUMA-5 (axi-cel) and SCHOLAR-5 (SOC) studies were used to extrapolate progression-free and overall survivals. After 5 years of survival, an estimated 40% of the modeled population was assumed to experience long-term remission based on literature. Results include the incremental cost-effectiveness ratio (ICER) measured as incremental cost per quality-adjusted life year (QALY) gained. One-way sensitivity analysis, probabilistic sensitivity analysis, and scenario analyses were performed. All outcomes were discounted 3% per year.
Axi-cel led to an increase of 4.28 life-years, 3.64 QALYs, and a total cost increase of $321 192 relative to SOC, resulting in an ICER of $88 300 per QALY. Across all parameters varied in the one-way sensitivity analysis, the ICER varied between $133 030 and $67 277. In the probabilistic sensitivity analysis, axi-cel had a 99% probability of being cost-effective across 5000 iterations using a $150 000 willingness-to-pay threshold.
Given the robustness of the model results and sensitivity analyses, axi-cel is expected to be a cost-effective treatment in 3L+ r/r FL.
•Relapse, recurrence, and disease burden remain common in follicular lymphoma; 19% of patients relapse within 2 years of treatment, and treatment toxicity and follow-up substantially impair quality of life. Given the high rates of relapse and recurrence in this patient population and the availability of novel treatments that confer proven clinical benefit, contextualizing the value of these novel treatments is of great importance.•The value of axicabtagene ciloleucel (axi-cel) compared with the standard of care (SOC) was assessed using a 3-state partitioned-survival cost-effectiveness model with a lifetime horizon. Patient-level analyses of the 36-month ZUMA-5 (axi-cel) and SCHOLAR-5 (SOC) studies were used to extrapolate progression-free and overall survivals. Axi-cel led to an increase of 4.28 life-years, 3.64 quality-adjusted life years (QALYs), and a total cost increase of $321 192 relative to SOC, resulting in an incremental cost-effectiveness ratio of $88 300 per QALY.•Given the incremental cost-effectiveness ratio under the commonly accepted willingness-to-pay thresholds of $100 000 to $150 000/QALY in the United States, axi-cel is expected to be a cost-effective treatment in relapsed and recurrent follicular lymphoma patients who have failed 2 prior lines of systemic therapy.
Background
The combination of tislelizumab and gemcitabine plus cisplatin (GP) in the first‐line treatment of patients with recurrent or metastatic nasopharyngeal carcinoma (R/M NPC) has yielded ...significant results. However, it is not clear whether this treatment option is cost‐effective in China. The purpose of this study is to evaluate the cost‐effectiveness of tislelizumab plus GP for the first‐line treatment of R/M NPC from the perspective of the Chinese healthcare system.
Methods
A partitioned survival model with three discrete health states was constructed to evaluate the cost‐effectiveness of tislelizumab plus GP versus GP in patients with R/M NPC. The target population enrolled in the RATIONALE‐309 trial had previously not treated for R/M NPC. Drug costs were obtained from relevant databases, and the remaining cost and health utility data were collected from the literature. The main outcomes include the expected life years, quality‐adjusted life years (QALYs), total cost, and incremental cost–benefit ratio (ICER).
Results
The tislelizumab plus GP regimen produced an additional cost ($18392.76) and additional 1.57 QALYs compared with GP used alone. The ICER was $18392.75/QALYs. Sensitivity analysis showed that the analysis was robust and the utility of PD status was most sensitive to the model results. The possibility of tislelizumab plus GP being cost‐effective at the willingness‐to‐pay (WTP) threshold of $37 653/QALY was 99.8%. Subgroup analysis showed that high PD‐L1 expression had little impact on the ICER of this regimen.
Conclusion
In patients with R/M NPC, the regimen of tislelizumab plus GP, as the first‐line treatment, is more cost‐effective than the GP regimen in China.
Background
Compared with the conventional work‐up (CWU) including computed tomography (CT) of the chest and abdomen, MRI of the head and neck, and skeletal scintigraphy, positron emission tomography ...(PET)/MRI might improve diagnostic accuracy, shorten the work‐up time, and reduce false‐positive (FP) findings in patients with nasopharyngeal carcinoma (NPC). However, evidence of cost‐effectiveness is needed for the adoption of PET/MRI for the initial staging in NPC.
Purpose
To evaluate the cost‐effectiveness and clinical value of PET/MRI as an initial staging procedure for NPC.
Study Type
Retrospective cohort cost effectiveness study.
Subjects
Three hundred forty‐three patients with a median age of 51 (13–81) years underwent PET/MRI before treatment (the PET/MRI group) and the remaining 677 patients with a median age of 55 (15–95) years only underwent CWU (the CWU group). There were 80 (23.3%) females and 193 (28.5%) females in the PET/MRI and CWU groups, respectively.
Field Strength/Sequence
3‐T integrated PET/MRI system, diffusion‐weighted echo‐planar imaging (b = 0 and 1000 s/mm2) and 18F fluorodeoxyglucose PET.
Assessment
The primary end point was the FP rate. Costs were determined as issued in 2021 by the Medical Insurance Administration Bureau of Zhejiang, China.
Statistical Tests
Incremental cost effectiveness ratio (ICER) measured cost of using PET/MRI per percent of patients who avoided a FP. A P‐value <0.05 was considered statistically significant.
Results
For the whole group, the de novo metastatic disease rate was 5.2% (53/1020). A total of 187 patients with FP results were observed. Significantly more patients with FP results were observed in the CWU group compared to the PET/MRI group (25.6% vs. 4.1%). The ICER was $54 for each percent of patients avoiding a FP finding.
Data Conclusion
Compared with CWU, PET/MRI may reduce the FP risk. Furthermore, PET/MRI may be cost‐effective as an initial staging procedure for NPC.
Evidence Level
3
Technical Efficacy
Stage 6
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