Springer Science and Business Media LLC

Chronic obstructive pulmonary disease (COPD) has high morbidity and mortality rates. COPD impairs body functioning, reduces quality of life, and creates a great economic burden for society. Pulmonary rehabilitation (PR) has become an important nonpharmacological treatment for COPD. This paper systematically reviews economic evaluations of PR in COPD patients in different settings. We aimed to understand the cost-effectiveness of PR in different settings for COPD to provide economic evidence for decision-makers. We searched eight databases from their inception to 23 November 2019. The results were presented in terms of an incremental cost-effectiveness ratio (ICER), and the decision uncertainty was expressed by cost-effectiveness acceptability curves (CEACs). We used the Consensus on Health Economic Criteria to assess study quality. This review included ten studies that matched the selection criteria. Five studies compared PR with usual care in primary healthcare or outpatient departments. Two studies compared community-based PR with hospital PR or usual care. In the other studies, PR was mainly carried out at home. Compared with usual care, PR was cost-effective in primary healthcare institutions or outpatient departments. According to CEACs, community-based PR had a 50% probability of cost-effectiveness at £30,000/quality-adjusted life year (QALY) compared with hospital PR in the UK. Based on the ICER, community-based PR was “moderately” cost-effective, with a ratio of €32,425/QALY compared with usual care in the Netherlands. Home-based PR was dominant compared with usual care, and tele-rehabilitation was dominant compared with traditional home PR. PR conducted in different settings can potentially be cost-effective, as measured using QALY or the Chronic Respiratory Questionnaire (CRQ).

In the UK, the standard of care for patients with multiple myeloma who received ≥2 prior treatments is lenalidomide plus dexamethasone (LEN + DEX) and pomalidomide plus DEX (POM + DEX) (in Wales only). Recently, panobinostat plus bortezomib and DEX (PAN + BTZ + DEX) was licensed in this setting. The current study assessed the progression-free survival (PFS) and overall survival (OS) outcomes with PAN + BTZ + DEX versus LEN + DEX (primary comparator) and POM + DEX (exploratory comparator). Since an anchor-based indirect treatment comparison was not feasible, the matching-adjusted indirect treatment comparison approach was used. To compare the survival outcomes, patient-level data were generated for the comparators utilizing published Kaplan–Meier survival estimates. The use of approximated patient-level data and matched data for PAN + BTZ + DEX allowed the use of Cox proportional hazards models and the assessment of the proportional hazards assumption. In cases where there was evidence that the proportional hazards assumption was violated, time-dependent hazard ratios (HRs) were estimated. Median and mean values for PFS and OS were predicted. For both PFS and OS, the proportional hazards assumption was not satisfied, therefore time-dependent HRs were estimated. Using time-dependent HRs, the mean PFS was estimated to be 11.83 months for PAN + BTZ + DEX and 10.96 months for LEN + DEX. The corresponding mean OS estimates were 30.73 and 27.76 months, respectively. Comparisons with POM + DEX were affected by large uncertainty and did not allow making robust inferences. To our knowledge, this is the first study that combined matching-adjusted indirect treatment comparison with time-dependent HRs to address changing patterns in the HR. The results suggest that treatment with PAN + BTZ + DEX and LEN + DEX are associated with similar mean PFS and OS in the third-line treatment setting of multiple myeloma.

The Peristeen transanal irrigation system is intended to allow people with bowel dysfunction to flush out the lower part of the bowel as part of their bowel management strategy. Peristeen was the subject of an evaluation by the National Institute for Health and Care Excellence, through its Medical Technologies Evaluation Programme, for the management of bowel dysfunction. The company, Coloplast, submitted a case for adoption of the technology, claiming that the technology improves the severity of chronic constipation or faecal incontinence and improves quality of life for people with bowel dysfunction. Other claimed benefits included reduced frequency of UTIs, stoma surgery and hospitalisation rates, as well as reduced costs. The submission was critiqued by Cedar. The clinical evidence assessed included one randomised controlled trial, and 12 observational studies for adults and 11 studies for children. Although there are limitations in the evidence, the assessed studies show some improvement in outcomes for patients who choose to continue using Peristeen. The committee heard from patient experts that Peristeen had improved their lives and allowed them increased independence. The submitted economic evidence had numerous flaws, however following Cedar’s changes to the model, and additional sensitivity analysis, the use of Peristeen was judged unlikely to be cost incurring compared with standard bowel care. The Peristeen transanal irrigation system received a positive recommendation in Medical Technologies Guidance 36.

Due to its nature, extent and consequences, torture is considered a major public health problem and a serious violation of human rights. Our study aims to set the foundation for a theoretical framework of the costs related to torture. It examines existing challenges and proposes some solutions. Our proposed framework targets policy makers, human rights activists, professionals working in programmes, centres and rehabilitation projects, judges and lawyers, survivors of torture and their families and anyone involved in the prevention and fight against this practice and its consequences. We adopted a methodology previously used in studies investigating the challenges in measuring and valuing productivity costs in health disorders. We identify and discuss conceptual, methodological, political and ethical challenges that studies on the economic and social costs of torture pose and propose alternatives in terms of possible solutions to these challenges. The economic dimension of torture is rarely debated and integrated in research, policies and programmes. Several challenges such as epistemological, methodological, ethical or political ones have often been presented as obstacles to cost studies of torture and as an excuse for not investigating this dimension. In identifying, analysing and proposing solutions to these challenges, we intend to stimulate the integration of the economic dimension in research and prevention of torture strategies.

Automated medication systems have been found to reduce errors in the medication process, but little is known about the cost-effectiveness of such systems. The objective of this study was to perform a model-based indirect cost-effectiveness comparison of three different, real-world automated medication systems compared with current standard practice. The considered automated medication systems were a patient-specific automated medication system (psAMS), a non-patient-specific automated medication system (npsAMS), and a complex automated medication system (cAMS). The economic evaluation used original effect and cost data from prospective, controlled, before-and-after studies of medication systems implemented at a Danish hematological ward and an acute medical unit. Effectiveness was described as the proportion of clinical and procedural error opportunities that were associated with one or more errors. An error was defined as a deviation from the electronic prescription, from standard hospital policy, or from written procedures. The cost assessment was based on 6-month standardization of observed cost data. The model-based comparative cost-effectiveness analyses were conducted with system-specific assumptions of the effect size and costs in scenarios with consumptions of 15,000, 30,000, and 45,000 doses per 6-month period. With 30,000 doses the cost-effectiveness model showed that the cost-effectiveness ratio expressed as the cost per avoided clinical error was €24 for the psAMS, €26 for the npsAMS, and €386 for the cAMS. Comparison of the cost-effectiveness of the three systems in relation to different valuations of an avoided error showed that the psAMS was the most cost-effective system regardless of error type or valuation. The model-based indirect comparison against the conventional practice showed that psAMS and npsAMS were more cost-effective than the cAMS alternative, and that psAMS was more cost-effective than npsAMS.

Oncology drugs are often approved for multiple indications, for which their clinical benefit varies. Aligning a single price to this differing value remains a challenge. This study examines the clinical and economic value, price, and reimbursement of multi-indication cancer drugs across seven countries, representing different approaches to value assessment, pricing, and coverage decisions: the USA, Germany, France, England, Canada, Australia, and Scotland. Twenty-five multi-indication cancer drugs across 100 indications were identified with US Food and Drug Administration (FDA) approval between 2009 and 2019. For each indication data on Health Technology Assessment (HTA) recommendations, disease prevalence, and drug prices were obtained. Quality-adjusted life years (QALYs) gained, disease prevalence, list prices, and HTA outcomes were then compared across indications and regions. First approved indications provide a higher clinical benefit whilst targeting a smaller patient group than indication extensions. Quality-adjusted life year gains were higher for first (0.99, 95% CI 0.05–3.25) compared to second (0.51, 95% CI 0.02–1.63, p < 0.001) and third (0.58, 95% CI 0.05–2.07, p < 0.01) approved indications. Disease prevalence per 100,000 inhabitants was 20.7 (95% CI 0.2–63.3) for first compared to 27.1 (95% CI 1.5–109.6, p = 0.907) for second and 128.3 (95% CI 3.1–720.1, p < 0.001) for third approved indications. With each approved indication drug prices declined in Germany and France, remained constant in the UK, Canada, and Australia, whilst they increased in the USA. Negative HTA outcomes, clinical restrictions, and managed entry agreements (MEAs) were more frequently observed for indication extensions. Results suggest that indication development is prioritised according to clinical value and disease prevalence. Countries employ different mechanisms to account for each indication’s differential benefit, e.g., weighted-average prices (Germany, France, Australia), differential discounts (England, Scotland), clinical restrictions, and MEAs (England, Scotland, Australia, Canada). Value-based indication-specific pricing can help to align the benefit and price for multi-indication cancer drugs.

Several low- and middle-income countries are interested in extending their existing health insurance for specific groups to eventually cover their entire populations. For those countries interested in such an extension, it is important to understand what characterises a well performing social health insurance scheme. This article provides a simple framework to analyse key performance issues related to the functions of health financing within the context of social health insurance. The framework first illustrates how performance in the health financing functions of revenue collection, pooling and purchasing affects the realisation of health financing targets of resource generation, optimal resource use and financial accessibility of health services for all. Then, within each health financing function, key performance issues and associated measurable indicators are developed. The set of performance indicators provided in this article should help policy makers to monitor the development of social health insurance schemes and identify areas for improvement. In doing so, policy makers can come closer to achieving universal coverage — access to appropriate healthcare for all at an affordable cost — the ultimate goal of social health insurance.

According to a new German guideline, decisions about bisphosphonate treatment for post-menopausal women should be based on 10-year fracture risk, and bone density should be measured by dual x-ray absorptiometry (DXA). Recently, there has been growing interest in quantitative ultrasound (QUS) as a less expensive screening alternative. To determine the cost effectiveness of osteoporosis screening with QUS as a pre-test for DXA and treatment with alendronate compared with (i) immediate access to DXA and (ii) no screening in women of the general population aged 50-90 years in Germany. A cost-utility analysis and a budget impact analysis were performed from the perspective of the statutory health insurance (SHI). A Markov model with a 1-year cycle length was used to simulate costs and benefits (QALYs), discounted at 3% per annum, over a lifetime. The number of women correctly diagnosed by QUS and DXA as being above a 10-year risk of ≥30% was estimated for different age groups (50–60, 60–70, 70–80 and 80–90 years, respectively). The robustness of the results was tested by a probabilistic Monte Carlo simulation. Compared with no screening, the cost effectiveness of QUS plus DXA was found to be €3529, €9983, €4382 and €1987 per QALY for 50-, 60-, 70- and 80-year-old women, respectively (year 2006 values). This screening strategy results in annual costs of €96 million or 0.07% of the SHI’s annual budget. The cost effectiveness of DXA alone compared with DXA plus QUS is €5331, €60 804, €14943 and €3654 per QALY for 50-, 60-, 70- and 80-year-old women, respectively. DXA alone results in a higher number of QALYs in all age groups. The results were robust in the sensitivity analysis. Compared with no screening, the cost effectiveness of QUS and DXA in sequence is very favourable in all age groups. However, direct access to DXA is also a cost-effective option, as it increases the number of QALYs at an acceptable cost compared with pre-testing by QUS (except for women aged 60–70 years). Therefore, QUS as a pre-test for DXA can be clearly recommended only in women aged 60–70 years. For the other age groups, the cost effectiveness of QUS as a pre-test depends on the global budget constraint and the accessibility of DXA.