A Preface to the Economic Analysis of Disease Transmission

Infectious diseases are transmitted from person to person or from vectors such as mosquitos to people. The uninfected take precautions against these diseases and the infected try to mitigate their symptoms and to get cured. In doing so, people may weigh the costs of illness, prevention and therapy. They may also (altruistically) weigh the costs of people whom their own behavior puts at risk, for instance their sexual partners, or they may act entirely selfishly. Some of these behaviours may therefore lead to externalities and a corresponding rationale for government interventions. A recent literature uses economics to investigate the implications of rational choice by individuals about their response to infectious diseases. It analyzes decisions about prevention, vaccination, testing, therapies and government intervention. This paper reviews this literature with an emphasis on examples from the HIV/AIDS epidemic.     

Pharmacoeconomic aspects of poor adherence: can better adherence reduce healthcare costs?

Abstract

Background:

Poor adherence to medical treatment is one of the main reasons why patients do not achieve the full benefits of their therapy. It also has a substantial financial weight in terms of money wasted for unused medication and increased healthcare costs including hospitalization due to clinical complications.

Objective:

To provide an overview and examples of the financial and economic consequences of poor adherence to treatment, techniques and devices for monitoring adherence and interventions for improvement of treatment adherence.

Results:

New electronic devices with monitoring features may help to objectively monitor patients’ adherence to a treatment regimen that can help a healthcare professional determine how to intervene to improve adherence and subsequent clinical outcome. Interventions that aim to enhance adherence may confer cost-effectiveness benefits in some indications and settings. The nature of the intervention(s) used depends on a range of factors, including patient preference, therapy area and cost of the intervention. However, there is a pressing need for rigorous trials, as current studies often have major flaws in the economic methodology, especially in terms of incremental analysis and sensitivity analysis.

Limitations:

This review has focused on a limited number of therapeutic areas as coverage of a more extensive range of diseases may be beyond the scope of such a summary. Nevertheless, the examples are representative of the challenges encountered in many other diseases.

Conclusions:

The clinical and economic consequences of non-adherence and interventions to improve compliance reflect the nature and severity of non-adherence, as well as the pathophysiology and severity of the disease. Interventions that aim to enhance adherence may confer cost-effectiveness benefits in some indications and settings, and good adherence can help payers and providers contain costs by extracting maximum value from their investment in therapies.     

Cost-effectiveness of desirudin in the prevention of the thromboembolic complications of surgery

Summary

New therapies reduce the risk of deep-vein thrombosis (DVT) following orthopaedic surgery, but may be more costly than low-molecular-weight heparin, the current standard treatment. Decision analysis and life-table methods were used to model the incremental cost-effectiveness of Revasc® (desirudin) compared with low-molecular-weight heparin (enoxaparin) in DVT prophylaxis following total hip replacement. A health-service perspective (payer, prescriber) was adopted and the principal endpoint was cost/life-year saved over 15 years. Costs were updated from published Swedish data to reflect 1998/9 UK prices and practices.

Prophylactic treatment with desirudin rather than enoxaparin for the prevention of thromboembolic complications of hip surgery should lead to an increase of 4.69 life-years/100 patients over 15 years, at an increased cost of £12,026/100 patients: the cost per life-year saved is therefore £2,566. This compares favourably with a range of commonly used alternative interventions. Desirudin is therefore a cost-effective method of preventing postoperative DVT in patients undergoing total hip replacement surgery.     

中国残疾预防的转折机会和预期分析

残疾社会负担迅速增加是推动我国尽快开展残疾预防工作的重要原因,而现代医学科技的发展使绝大部分残疾可防可控是开展残疾预防的必要条件。系统回顾了近30年来我国主要的残疾预防政策行动,总结了取得的成效和存在的问题,分析了我国残疾预防工作面临的新形势以及新的政策动向,提出了下一步残疾预防工作的四个重点,即提高认识、完善政策、加强行动、强化支持。     

Cost-effectiveness of combination chemotherapy (oxaliplatin or irinotecan in combination with 5-FU/FA) compared with 5-FU/FA alone

SUMMARY

Combination therapies of oxaliplatin with 5-fluorouracil (5-FU) and folinic acid (FA) and irinotecan with 5-FU/FA have been shown to offer comparable clinical improvements in advanced colorectal cancer and are becoming part of routine clinical practice in the UK. Using published key Phase III trials of these two combination therapies (oxaliplatin trial, 620 patients; irinotecan trial, 387 patients) we calculated incremental cost-effectiveness ratios for progression-free survival and response rates compared with each regimen's control arm. Average drug-acquisition costs were used.

The incremental cost to achieve an additional progression-free year is £26,665 for oxaliplatin in combination therapy and £30,171 for irinotecan in combination therapy. In terms of response rates, the costs incurred per year to achieve an additional responding patient are £31,065 for oxaliplatin in combination therapy and £46,343 for irinotecan combination therapy.

These analyses indicate that the two combination therapies offer comparable benefits in terms of efficacy and cost-effectiveness compared with 5-FU/FA alone. The two treatments differ in terms of their toxicity.     

Real-world incidence and burden of adverse events among non-metastatic prostate cancer patients treated with secondary hormonal therapies following androgen deprivation therapy

Abstract

Aims: To describe the incidence and identify prognostic factors of central nervous system (CNS) adverse events (AEs) and any AEs (CNS, skin rash, or fracture) and evaluate the healthcare resource utilization (HCRU), direct medical costs, and therapy discontinuation associated with these AEs among non-metastatic prostate cancer (nmPC) patients who received secondary hormone therapies.

Methods and results: nmPC patients who had initiated secondary hormonal therapy with enzalutamide, bicalutamide, or abiraterone ≥1?year after androgen deprivation therapy (ADT) were identified in the MarketScan database. Survival analyses were used to describe the incidence of CNS or any AEs. Annual HCRU and costs were compared across patient groups (CNS AE vs no CNS AE; any AE vs no AE) using propensity score weighted generalized linear models. Multivariate Cox proportional hazards models were used to identify AE predictors and compare risks of discontinuation.

Results: The analysis included 532 patients who initiated secondary hormonal therapies, among whom 201 (38%) and 244 (46%) experienced a CNS AE and any AE, respectively. Median times to CNS AE and any AE from therapy initiation were 17.90 and 11.00?months, respectively. Predictors of any AE were any AE in the baseline period (≤6?months before starting therapy), Charlson Comorbidity Index (CCI) score (1 vs 0), surgical castration, and older age. Predictors of CNS AEs were CNS AE in the baseline period and CCI score (1 vs 0). CNS and any AEs were associated with significantly higher HCRU. CNS AEs were associated with significantly higher incremental total medical costs ($18,522). CNS AEs and any AEs significantly increased therapy discontinuation risk by 48% and 38%, respectively.

Conclusions: AEs increase the economic burden and therapy discontinuation among nmPC patients receiving secondary hormonal therapies subsequent to ADTs. These patients should be carefully evaluated for AEs to reduce therapy discontinuation, HCRU, and direct medical costs.     

我国卫生防疫体系制度变迁中的政府责任分析

卫生防疫所涉及内容的利益外溢性和单个人的无力作为决定了卫生防疫这一产品的纯公共品性质。我国政府作为卫生防疫管制者的身份在不断地加强，而作为生产者的身份则一直在弱化。这样一种状况造成在卫生防疫中政府责任的缺失，其直接后果就是各种解放后几近绝迹的传染病的死灰复燃和各种突发性公共卫生事件的频发。因此，强调政府特别是中央政府在卫生防疫中的财政责任和管制责任就显得较为迫切。     

160例老年高血压患者药物治疗的调查分析

目的了解高校社区老年高血压患者的病情与药物治疗情况,探讨药师参与定期回访指导患者合理用药,对提高老年高血压治疗控制率的意义。方法通过对学校健康管理中心北校区社区160例确诊的老年高血压患者随访调查,按照《中国高血压防治指南》2010年修订版进行治疗达标评估分析。结果 160例老年高血压中约71.9%患有心脑血管疾病、糖尿病等并发症;药物治疗率为83.1%;血压控制率为70.6%。结论该社区老年高血压药物治疗率、控制率均较高,但在合理使用药物治疗方面还存在一些误区,医生和药师应指导老年高血压患者合理使用降压药物,从而提高其药物治疗效果。     

Economic evaluation of a pharmacogenomic multi-gene panel test to optimize anti-hypertension therapy: simulation study

Abstract

Aims: Hypertension is the strongest modifiable risk factor for cardiovascular disease, affecting 80 million individuals in the US and responsible for ～360,000 deaths, at total annual costs of $93.5 billion. Antihypertension therapies guided by single genotypes are clinically more effective and may avert more adverse events than the standard of care of layering anti-hypertensive drug therapies, thus potentially decreasing costs. This study aimed to determine the economic benefits of the implementation of multi-gene panel guided therapies for hypertension from the payer perspective within a 3-year time horizon.

Materials and methods: A simulation analysis was conducted for a panel of 10 million insured patients categorized clinically as untreated, treated but uncontrolled, and treated and controlled over a 3-year treatment period. Inputs included research data; empirical data from a 11-gene panel with known functional, heart, blood vessel, and kidney genotypes; and therapy efficacy and safety estimates from literature. Cost estimates were categorized as related to genetic testing, evaluation and management, medication, or adverse events.

Results: Multi-gene panel guided therapy yielding savings of $6,256,607,500 for evaluation and management, $908,160,000 for medications, and $37,467,508,716 for adverse events, after accounting for incremental genetic testing costs of $2,355,540,000. This represents total 3-year savings of $42,276,736,216, or a 47% reduction, and 3-year savings of $4,228 and annual savings of $1,409 per covered patient.

Conclusions: A precision medicine approach to genetically guided therapy for hypertension patients using a multi-gene panel reduced total 3-year costs by 47%, yielding savings exceeding $42.3 billion in an insured panel of 10 million patients. Importantly, 89% of these savings are generated by averting specific adverse events and, thus, optimizing choice of therapy in function of both safety and efficacy.     

The application of economics concepts to stratified medicine—use of health economics data to support market access for stratified medicine interventions

Stratified medicine (SM), as opposed to empirical medicine, is the practice of using biomarkers or diagnostic tests to guide the choice of therapeutic treatments. The link between the diagnostic test and the therapy provides new opportunities for value creation and may strengthen the value proposition to pricing and reimbursement authorities. However, SM provides new challenges for the value assessment process, in particular health technology assessment (HTA) and pricing and reimbursement (P&R) decisions. Although health economics (HE) should be relevant for all stakeholders, not all stakeholders are comfortable with analysis/interpretation of economic data relevant to SM interventions as this approach is still in an early/emergent stage in most markets. This article addresses how different stakeholders are using health economic data in the overall value of information analysis to inform prioritization and reimbursement of SM interventions. Findings of an expert discussion outlines key challenges affecting various stakeholders when applying health economic data in the healthcare decision-making process for SM interventions.     

Ethics and economics

The author suggests that one way to better manage the burgeoning costs in acute care settings and improve patient care is by the earlier use of ethics case consultations and end-of-life support from ethics teams. This study determined that, in several very diverse clinical scenarios, timely facilitation of meaningful communication and decision making between patients, families, and health care providers can result in the more appropriate use of health care resources. While few of the patients in this study had recorded advanced directives in place, and there was initially a lack of family consensus in some cases, compliance with the ethics team recommendations led to a more appropriate clinical unit placement; and improved family support helped manage the costs of care and focus on the patients' quality of life. The decrease in the use of medical interventions and therapies after ethics consultations was consistent in all cases presented here.     

Treatment patterns among patients with psoriasis using a large national payer database in the United States: a retrospective study

Aim: To characterize treatment patterns of psoriasis patients in a large US managed care database.

Materials and methods: Adults with newly-diagnosed psoriasis were identified from July 3, 2006–August 31, 2014. Patients had continuous enrollment with medical and pharmacy benefits for ≥6 months prior to and ≥1 year following the index date. The index date was the point at which any of the following inclusion criteria were satisfied: first psoriasis diagnosis by a dermatologist, ≥ 2 psoriasis diagnoses ≥30 days apart, or a diagnosis of psoriasis followed by a claim for psoriasis therapy. Of primary interest was to measure and describe the following psoriasis treatment patterns: utilization rates, time to treatment discontinuation, and lines of therapy for various therapeutic classes of pharmacologic therapies.

Results: From the 128,308 patients identified, 53% were female, mean?±?SD age was 50?±?16 years, with median 3 years follow-up. Topicals were received by 86% of patients, non-biologic systemics by 13%, biologics by 6%, phototherapy by 5%, and 13% received no psoriasis-related medication. Median time from index to first treatment was 0 days for topical, 6 months for non-biologic systemic, and 6 months for biologic. Of those treated, first-line therapies included topical (95%), non-biologic systemic (4%), and biologic (2%). For those with second-line treatment, non-biologic systemic (71%) and biologic (30%) therapies were more common. The most common treatment pattern was topicals only (83%), while all other patterns comprised <5% of the treatment patterns observed.

Limitations: Like other observational studies, limitations to consider when interpreting results include the 6-month pre-index period of no psoriasis or the psoriasis medication claim may not perfectly select only incident user of psoriasis medications, claims-based algorithms may not accurately represent true treatment patterns, absence of over-the-counter medications data, and having no trend analyses over time or between groups.

Conclusions: While the majority of patients with psoriasis initiated a pharmacological therapy, a significant portion did not have a claim for any psoriasis medication. Topical treatments are the most commonly used treatments for psoriasis. Non-biologic systemic and biologic therapies were rarely used first line, but became more common in later lines of treatment.     

The future of drug discovery and development: Shifting emphasis towards personalized medicine

The drug discovery sector is being revolutionized by the current rate of advances in the public and private human genome projects and by the development of new technologies for biomarker testing. In effect, as the genetic roots of disease, disease progression and treatment effectiveness are uncovered, the demand for sophisticated prognostic, diagnostic and monitoring tests will be increasing. Already this has led to the development of innovative diagnostics products meeting the criteria of improved efficacy and safety as well as better cost-benefits. In order to achieve the ultimate goal of a more predictive and personalized medicine requires the drug discovery industry to implement more synergies between the two worlds of clinical research and diagnostics. The therapeutics that are enabled by that strategy are often called “theranostics” — highly specific tests that allow for the diagnosis of the disease, but to administer the most appropriate treatment regimen, and to monitor a patient's response to therapy. Biomarkers will constitute a critical component of the health care delivery system in order to detect, diagnose and monitor diseases and other medical conditions as well as to evaluate treatment options and effectiveness. While diagnostic breakthroughs typically precede therapeutic advances, the presence of new therapies can stimulate the demand for testing. The main question that remains to be answered is how will the biomarker paradigm alters these companies' innovation and commercialization strategies. Whereas developing drug targets may offer greater long-term value, initial commercial opportunities often arise in diagnostics.     

Re-treatment with varenicline is a cost-effective aid for smoking cessation

Objective: One quit attempt with varenicline has been found to be a cost-effective smoking cessation intervention. The purpose of this study was to analyze varenicline’s cost-effectiveness in patients who relapse during or after the first treatment. A comparison was made between re-treatment schema with varenicline and re-treatment schema with bupropion, NRT and unaided cessation, and treatment once with varenicline in a Finnish context.

Methods: The two-quit version of BENESCO Markov model was used to follow a cohort of smokers making up to two quit attempts over a lifetime. The abstinence rates of the interventions were derived from a Cochrane review. Gender- and age-specific data on the incidence and prevalence of five smoking-related diseases were included in the model. Quality-adjusted life-years, total expected costs, and the lifetime cumulative incidence of smoking-related morbidities and mortality were the primary outcomes evaluated.

Results: The study cohort comprised 116,533 smokers who were willing to make a quit attempt. In the lifetime simulation, re-treatment with varenicline yielded 6,150–20,250 extra quitters, depending on the comparator. Among these quitters it was possible to prevent 899–2,972 additional cases of smoking-related diseases, and 395–1,307 deaths attributable to smoking. Re-treatment with varenicline resulted in cost savings of up to 54.9 million Euros. Re-treatment with varenicline dominated all the other smoking cessation interventions used in the analysis. Sensitivity analysis supported the robustness of the base case results.

Limitations: The analysis did not consider adverse events, and included only five major smoking-related diseases, which is a conservative approach, and probably leads to under-estimation of cost-effectiveness of cessation interventions. Furthermore, assumptions of constant relative risks for smoking-related diseases for each smoking status and the proxy values used as efficacy estimates of second quit attempts for other interventions than varenicline are limitations.

Conclusions: A second quitting effort with varenicline is economically justifiable.     

乌梅丸抑木扶土辨治厥阴证诸病

"乌梅丸"出自汉代张仲景《伤寒论》,是抑木扶土之经方之一,乌梅丸多用于"久利",历代医家在谨守原方配伍和功用特点的基础上,对本方进行了深入研究,辨证施治,随证化裁,并将其广泛应用于内、妇、儿科等多种疾病,现对乌梅丸基于抑木扶土之辨治诸病思路进行总结,为抑木扶土角度论乌梅丸辨治厥阴病提供思路.     

维格列汀与二甲双胍合用治疗糖尿病的药物经济学研究

目的比较维格列汀、吡格列酮、格列美脲分别与二甲双胍合用治疗2型糖尿病时的效果、成本及成本-效果。方法运用Markov模型对三种治疗方案的终身治疗成本及效用（期望寿命、质量调整寿命年）进行经济学评价,通过文献资料和专家问卷咨询获得临床、生命质量、并发症年治疗成本等数据,进行敏感度分析。结果维格列汀、吡格列酮、格列美脲分别与二甲双胍合用治疗2型糖尿病分别延长11.02、10.96、10.90个质量调整生命年,而生命周期中三种治疗方案的治疗费用分别为124892元、134135元、126010元。敏感度分析证明了结果的可靠性。结论与吡格列酮、格列美脲合并二甲双胍质量相比,维格列汀合并二甲双胍治疗获得的健康效果更好,而治疗成本更低。     

Economic evaluations in migraine: systematic literature review and a novel approach

Abstract

Background: For novel migraine therapies, economic evaluations will be required to understand the trade-offs between additional health benefit and additional cost. The purpose of this study was to conduct a systematic literature review (SLR) to identify previous economic evaluations in migraine from the United Kingdom or Irish perspective to critically appraise these evaluations and to propose, if necessary, a novel modelling approach that can be used for future economic evaluations of migraine therapies.

Methods: An SLR was conducted to identify previous economic evaluations of preventive migraine treatments. Key opinion leaders were consulted to determine the criteria for a robust migraine economic evaluation. Economic evaluations identified in the SLR were appraised against these criteria, and a novel cost-effectiveness model structure was then proposed.

Results: Eight records reporting on published economic evaluations were identified and critically appraised for general quality. Expert consultation provided 6 recommendations on the ideal model structure for migraine that is both clinically and economically meaningful. A decision-tree plus Markov structure was then developed as a cost-effectiveness model for migraine therapies where each health state is associated with a patient distribution across monthly migraine day (MMD) frequencies.

Conclusions: Future migraine economic evaluations should allow for assessments across the full spectrum of migraine, a response-based stopping rule, and the estimation of benefits and resource costs based on MMD frequency. The approach proposed in this paper captures all of the desired elements for an economic evaluation of migraine therapy and is suitable to assess new migraine therapies.     

Assessing the economic merits of managing cytomegalovirus infection in organ and stem cell transplantation

Abstract

Two preventative approaches exist to manage cytomegalovirus (CMV), a common infection in recipients of organ and stem cell transplants: prophylaxis – the prevention of viraemia – and pre-emptive therapy – the prevention of manifestation of disease in patients who have viraemia. Economic evaluation may provide a helpful framework to inform the choice between these two approaches. However, several issues arise. Direct comparisons of prophylaxis and pre-emptive therapy are rare and there are few epidemiological data that depict the full natural history of CMV infection and disease. There is a need for large, prospective randomised trials that directly compare these two strategies and are of sufficient duration to assess their overall impact on direct and indirect effects of CMV as well as patient quality of life. These methodological issues are relevant to the economic evaluation of preventative measures in other clinical settings and highlight the need for a rigorous evaluative framework to best inform decision making about the optimal strategy for patients.     

MNT: an innovative employee-friendly benefit that saves

In an effort to address the rising cost of health care within employee and retiree populations, many large employers are turning to an innovative health care solution: the registered dietitian and medical nutrition therapy and prevention. Research and case histories show the effectiveness of this approach.