Screening for abdominal aortic aneurysms in men: a Canadian perspective using Monte Carlo-based estimates. Predicting the cost-effectiveness of total hip and knee replacement: a health economic analysis. Cost-utility analysis of cataract surgery in the second eye. 3L, 5L, What the L? A NICE Conundrum Cost-effectiveness analysis: comparing single-level cervical disc replacement and single-level anterior cervical discectomy and fusion: clinical article. Cost-effectiveness of multilevel hemilaminectomy for lumbar stenosis-associated radiculopathy. A value-based medicine analysis of ranibizumab for the treatment of subfoveal neovascular macular degeneration. Incremental cost-effectiveness of initial cataract surgery. Therapy conversion to insulin detemir among patients with type 2 diabetes treated with oral agents: A modeling study of cost-effectiveness in the United States Fibromyalgia: Moderate and substantial pain intensity reduction predicts improvement in other outcomes and substantial quality of life gain Cost-utility analysis in schizophrenia. Understanding the value of minimally invasive procedures for the treatment of lumbar spinal stenosis: the case of interspinous spacer devices. Rescaling quality of life values from discrete choice experiments for use as QALYs: a cautionary tale The impact of preoperative patient characteristics on the cost-effectiveness of total hip replacement: a cohort study Cost-effectiveness of nivolumab in patients with advanced renal cell carcinoma treated in the United States Cost-effectiveness of a nurse-led telemonitoring intervention based on peak expiratory flow measurements in asthmatics: results of a randomised controlled trial Population based cost utility study of interferon beta-1b in secondary progressive multiple sclerosis Cost-effectiveness analysis of anastrozole vs tamoxifen in adjuvant therapy for early stage breast cancer in the United Kingdom: the 5-year completed treatment analysis of the ATAC (‘Arimidex', Tamoxifen alone or in combination) trial Evaluating the cost-effectiveness of fall prevention programs that reduce fall-related hip fractures in older adults. Economic Evaluation of Aquatic Exercise for Persons With Osteoarthritis Cost-effectiveness analysis of mechanical thrombectomy in acute ischemic stroke. Cost-Effectiveness of Thrombolysis With Recombinant Tissue Plasminogen Activator for Acute Ischemic Stroke Assessed by a Model Based on UK NHS Costs If you try to stop smoking, should we pay for it? The cost-utility of reimbursing smoking cessation support in the Netherlands.
OBJECTIVE Recently generated r and omized screening trial data have provided good evidence in favour of routine screening for abdominal aortic aneurysm ( AAA ) to reduce AAA-related deaths in men aged 65 years and older . We developed an economic model that assessed the incremental cost-utility of AAA screening to help decision makers judge the relevance of a national screening program in Canada . METHODS We constructed a 14 health state Markov model comparing 2 cohorts of 65-year-old men , where the first cohort was invited to attend screening for AAA using ultrasonography ( US )  and the second cohort followed the current practice of opportunistic detection . Lifetime outcomes included the life-years gained , AAA rupture avoided , AAA-related mortality , quality -adjusted life years ( QALYs ) and costs . Transition probabilities were derived from a systematic review of the literature , and a probabilistic sensitivity analysis was carried out to examine the effect of joint uncertainty in the variables of our analysis . The perspective adopted was that of the health care provider . RESULTS Invitations to attend screening produced an undiscounted gain in life expectancy of 0.049 years and a gain in discounted QALY of 0.019 for an estimated incremental lifetime cost of CAN$118 . The estimated incremental cost-utility ratio was CAN$6194 per QALY gained ( 95 % confidence interval [ CI ] 1892 - 10 837 ) . The numbers needed to invite to attend screening , and the numbers needed to screen to prevent 1 AAA-related death were 187 ( 95 % CI 130 - 292 ) and 137 ( 95 % CI 85 - 213 ) , respectively . The acceptability curve showed a greater than 95 % probability of the program 's being cost-effective , and the model was robust to changes in the values of key parameters within plausible ranges . CONCLUSION Our results support the economic viability of a national screening program for men reaching 65 years of age in Canada . More clinical studies are needed to define the role of screening in subgroups at high risk , especially in the female population The aim of this study was to perform a cost-utility analysis of  total hip ( THR ) and knee replacement ( TKR ) .  Arthritis is a disabling condition that leads to long-term deterioration in quality of life . Total joint replacement , despite being one of the greatest advances in medicine of the modern era , has recently come under scrutiny . The National Health Service ( NHS ) has competing dem and s , and re source allocation is challenging in times of economic restraint . Patients who underwent THR ( n = 348 ) or TKR ( n = 323 ) between January and July 2010 in one Scottish region were entered into a prospect i ve arthroplasty data base . A health-utility score was derived from the EuroQol ( EQ-5D ) score pre-operatively and at one year , and was combined with individual life expectancy to derive the quality -adjusted life years ( QALYs ) gained . Two-way analysis of variance was used to compare QALYs gained between procedures , while controlling for baseline differences . The number of QALYs gained was higher after THR than after TKR ( 6.5 vs 4.0 years , p < 0.001 ) . The cost per QALY for THR was £ 1372 compared with £ 2101 for TKR . The predictors of an increase in QALYs gained were poorer health before surgery ( p < 0.001 ) and younger age ( p < 0.001 ) . General health ( EQ-5D VAS ) showed greater improvement after THR than after TKR ( p < 0.001 ) . This study provides up-to- date cost-effectiveness data for total joint replacement . THR and TKR are extremely effective both clinical ly and in terms of cost effectiveness , with costs that compare favourably to those of other medical interventions OBJECTIVE To perform a reference case cost-utility analysis of  second-eye cataract surgery  by using the current literature on cataract outcomes and complications . DESIGN Computer-based econometric modeling . METHODS Visual acuity data of patients treated and observed over a 4-month postoperative period were obtained from the U.S. National Cataract Patient Outcomes Research Team report . The results from this prospect i ve study were combined with those of other studies that investigated the complication rates of cataract surgery to complete the cohort of patients and outcomes . These synthesized data were incorporated with time trade-off utility values , which accounted for prior successful cataract surgery in the fellow eye . Cost-utility determinations were made with decision analysis , and present value modeling was used to account for the time value of money and health state consequences . MAIN OUTCOME MEASURES The number of quality -adjusted life-years ( QALYs ) gained was calculated for the study group undergoing second-eye cataract surgery  , assuming that the postoperative vision in the second eye was equivalent to the vision in the first eye after surgery ( 20/27 ) . This was divided into the cost of the procedure to find the number of year 2001 nominal U.S. dollars spent per QALY gained . RESULTS Second-eye cataract surgery , as compared with unilateral pseudophakia , result ed in a mean gain of 1.31 undiscounted QALYs per patient treated . A 3 % annual discount rate , dependent on the duration of benefit , was used , yielding 0.92 discounted QALYs gained over a 12-year life expectancy . The mean discounted cost of treatment for each patient totaled 2509 US dollars . The cost divided by the QALYs gained ( benefit ) result ed in 2727 US dollars per QALY gained for this procedure . Sensitivity analysis varying costs and utility values revealed a range from 2045 US dollars to 3649 US dollars per QALY gained . CONCLUSIONS Second-eye cataract surgery is an extremely cost-effective procedure when compared with other interventions across medical specialties . The cost-effectiveness of second-eye surgery diminishes only slightly from the 2023 US dollars per QALY gained from first-eye cataract surgery . This suggests that patients with good vision in one eye and visual loss from cataract in the fellow eye derive substantial benefit from cataract extraction For many years , the National Institute for Health and Care Excellence ( NICE ) has recommended use of the EQ-5D-3L ( 3L ) [ 1 ] and its value set for the UK [ 2 ] . Since 2011 , an exp and ed-level instrument , the EQ-5D-5L ( 5L ) , has been available [ 3 ] and value sets now exist to support its use , including a value set for Engl and [ 4 , 5 ] . This poses a challenge for NICE . Should it recommend the 5L rather than the 3L ? This is neither a trivial nor merely academic matter : the choice of whether to use the 5L ( and English value set ) or the 3L ( and UK value set ) is likely to impact estimates of quality -adjusted life-years ( QALYs ) and incremental cost-effectiveness ratios ( ICERs ) . The size and direction of that impact will depend on the disease and the nature of the health problems . In general , where technologies improve self-reported health , estimates of QALY gains will often be smaller with the 5L [ 6 ] . In contrast , where technologies extend the length of life , estimates of QALY gains will be higher ( to varying degrees ) : each year of additional life is assigned a higher utility . The ultimate impact on health technology assessment ( HTA ) will depend on whether the differences between the 3L and 5L push ICERs from one side of the cost-effectiveness threshold to the other . Given the implication s for NICE ’s technology appraisal process , and other decisions informed by EQ-5D data , the Department of Health for Engl and has called for an independent validation of the 5L value set , given its relevance to policy [ 7 ] . In 2017 , NICE released a ‘ position statement ’ [ 8 ] stating that : The 3L value set continues to be used for reference-case analyses . Where 5L data have been collected , reference-case analyses should calculate utilities by mapping the 5L descriptive system data onto the 3L value set , using the van Hout et al. [ 9 ] mapping function . NICE supports sponsors of prospect i ve clinical studies continuing to use the 5L to collect data on quality of life . A further position statement is planned for August 2018 , to be informed by evidence from various studies underway . These include studies commissioned by the English Department of Health to investigate the implication s for past NICE technology appraisal s had the 5L been used , and to collect 3L and 5L data in parallel to further improve functions for mapping from one to the other . Other studies , funded by the EuroQol Group , are also underway , investigating various aspects of the relationship between the 3L and 5L across disease areas . The 3L and its UK value set has occupied a special place in NICE ’s technology appraisal process since its inception , therefore any transition will inevitably pose challenges ; for example , reconciling potential inconsistencies between past and future decisions . Given that evidence will continue to be su bmi tted using both the 3L and 5L for years to come , if both value sets are able to be used , there is a risk of inconsistency between decisions being made in the future . HTA in other countries may also face similar issues . Given the difficulties with any transition away from the 3L , is there a case for NICE to adopt the 5L as its preferred instrument ? Papers in this issue of Pharmacoeconomics , which are cited in this commentary , address that question by investigating comparative performance of the 3L and 5L OBJECT In recent years , there has been increased interest in the use of  cervical disc replacement ( CDR ) as an alternative to  anterior cervical discectomy and fusion (  ACDF ) . While ACDF is a proven intervention for patients with myelopathy or radiculopathy , it does have inherent limitations . Cervical disc replacement was design ed to preserve motion , avoid the limitations of fusion , and theoretically allow for a quicker return to activity . A number of recently published systematic review s and r and omized controlled trials have demonstrated positive clinical results for CDR , but no studies have revealed which of the 2 treatment strategies is more cost-effective . The purpose of this study was to evaluate the cost-effectiveness of CDR and ACDF by using the power of decision analysis . Additionally , the authors aim ed to identify the most critical factors affecting procedural cost and effectiveness and to define thresholds for durability and function to focus and guide future research . METHODS The authors created a surgical decision model for the treatment of single-level cervical disc disease with associated radiculopathy . The literature was review ed to identify possible outcomes and their likelihood following CDR and ACDF .  Health state utility factors were determined from the literature and assigned to each possible outcome , and procedural effectiveness was expressed in units of quality -adjusted life years ( QALYs ) . Using ICD-9 procedure codes and data from the Nationwide Inpatient Sample , the authors calculated the median cost of hospitalization by multiplying hospital charges by the hospital-specific cost-to-charge ratio . Gross physician costs were determined from the mean Medicare reimbursement for each current procedural terminology ( CPT ) code . Uncertainty as regards both cost and effectiveness numbers was assessed using sensitivity analysis . RESULTS In the reference case , the model assumed a 20-year duration for the CDR prosthesis . Cervical disc replacement led to higher average QALYs gained at a lower cost to society if both strategies survived for 20 years ( $ 3042/QALY for CDR vs $ 8760/QALY for ACDF ) . Sensitivity analysis revealed that CDR needed to survive at least 9.75 years to be considered a more cost-effective strategy than ACDF . Cervical disc replacement becomes an acceptable societal strategy as the prosthesis survival time approaches 11 years and the $ 50,000/QALY gained willingness-to-pay threshold is crossed . Sensitivity analysis also indicated that CDR must provide a utility state of at least 0.796 to be cost-effective . CONCLUSIONS Both CDR and ACDF were shown to be cost-effective procedures in the reference case . Results of the sensitivity analysis indicated that CDR must remain functional for at least 14 years to establish greater cost-effectiveness than ACDF . Since the current literature has yet to demonstrate with certainty the actual durability and long-term functionality of CDR , future long-term studies are required to vali date the present analysis BACKGROUND CONTEXT Laminectomy for lumbar stenosis-associated radiculopathy is associated with improvement in pain , disability , and quality of life . However , given rising health-care costs , attention has been turned to question the cost-effectiveness of lumbar decompressive procedures . The cost-effectiveness of multilevel hemilaminectomy for radiculopathy remains unclear . PURPOSE To assess the comprehensive medical and societal costs of multilevel hemilaminectomy at our institution and determine its cost-effectiveness in the treatment of degenerative lumbar stenosis . STUDY DESIGN Prospect i ve single cohort study . PATIENT SAMPLE Fifty-four consecutive patients undergoing multilevel hemilaminectomy for lumbar stenosis-associated radiculopathy after at least 6 months of failed conservative therapy were included . OUTCOME MEASURES Self-reported measures were assessed using an outcomes question naire that incorporated total back-related medical re source utilization , missed work , and improvement in leg pain ( visual analog scale for leg pain [ VAS-LP ] ) , disability ( Oswestry Disability Index [ ODI ] ) , quality of life ( Short Form-12 [ SF-12 ] ) , and health state values ( quality -adjusted life years [ QALYs ] , calculated from EuroQuol 5D [ EQ-5D ] with US valuation ) . METHODS Over a 2-year period , total back-related medical re source utilization , missed work , and improvement in leg pain ( VAS-LP ) , disability ( ODI ) , quality of life ( SF-12 ) , and health state values ( QALYs , calculated from EQ-5D with US valuation ) were assessed . Two-year re source use was multiplied by unit costs based on Medicare national allowable payment amounts ( direct cost ) , and patient and caregiver workday losses were multiplied by the self-reported gross-of-tax wage rate ( indirect cost ) . Mean total 2-year cost per QALY gained after multilevel hemilaminectomy was assessed . RESULTS Compared with preoperative health states reported after at least 6 months of medical management , a significant improvement in VAS-LP , ODI , and SF-12 ( physical and mental components ) was observed 2 years after multilevel hemilaminectomy , with a mean 2-year gain of 0.72 QALYs . Mean±st and ard deviation total 2-year  cost of multilevel hemilaminectomy was $ 24,264±10,319 ( surgery cost , $ 10,220±80.57 ; outpatient re source utilization cost , $ 3,592±3,243 ; and indirect cost , $ 10,452±9,364 ) . Multilevel hemilaminectomy was associated with a mean 2-year cost per QALY gained of $ 33,700 . CONCLUSIONS Multilevel hemilaminectomy  improved pain , disability , and quality of life in patients with lumbar stenosis-associated radiculopathy . Total cost per QALY gained for multilevel hemilaminectomy was $ 33,700 when evaluated 2 years after surgery with Medicare fees , suggesting that multilevel hemilaminectomy is a cost-effective treatment of lumbar radiculopathy OBJECTIVE To assess the conferred value and average cost-utility ( cost-effectiveness ) for intravitreal ranibizumab used to treat occult/minimally classic subfoveal choroidal neovascularization associated with age-related macular degeneration ( AMD ) . DESIGN Value-based medicine cost-utility analysis . PARTICIPANTS MARINA ( Minimally Classic/Occult Trial of the Anti-Vascular Endothelial Growth Factor Antibody Ranibizumab in the Treatment of Neovascular AMD ) Study patients utilizing published primary data . METHODS Reference case , third-party insurer perspective , cost-utility analysis using 2006 United States dollars . MAIN OUTCOME MEASURES Conferred value in the forms of ( 1 ) quality -adjusted life-years ( QALYs ) and ( 2 ) percent improvement in health-related quality of life . Cost-utility is expressed in terms of dollars expended per QALY gained . All outcomes are discounted at a 3 % annual rate , as recommended by the Panel on Cost-effectiveness in Health and Medicine . Data are presented for the second-eye model , first-eye model , and combined model . RESULTS Twenty-two intravitreal injections of 0.5 mg of ranibizumab administered over a 2-year period confer 1.039 QALYs , or a 15.8 % improvement in quality of life for the 12-year period of the second-eye model reference case of occult/minimally classic age-related subfoveal choroidal neovascularization . The reference case treatment cost is $ 52652 , and the cost-utility for the second-eye model is $ 50691/QALY . The quality -of-life gain from the first-eye model is 6.4 % and the cost-utility is $ 123887 , whereas the most clinical ly simulating combined model yields a quality -of-life gain of 10.4 % and cost-utility of $ 74169 . CONCLUSIONS By conventional st and ards and the most commonly used second-eye and combined models , intravitreal ranibizumab administered for occult/minimally classic subfoveal choroidal neovascularization is a cost-effective therapy . Ranibizumab treatment confers considerably greater value than other neovascular macular degeneration pharmaceutical therapies that have been studied in r and omized clinical trials PURPOSE The purpose of this study was to perform a reference case , cost-utility analysis of initial  cataract surgery using the current literature on cataract outcomes and complications . DESIGN Computer-based econometric modeling . METHODS Visual acuity data of patients treated and observed over a 4-month postoperative period was obtained from the US National Cataract Patient Outcomes Research Team ( PORT ) . The results from this prospect i ve study were combined with other studies that investigated the complication rates of cataract surgery to complete the cohort of patients and outcomes . These synthesized data were incorporated with time-tradeoff utility values , decision analysis , and econometric modeling to account for the time value of money . MAIN OUTCOME MEASURES The number of quality -adjusted life-years ( QALYs ) gained was calculated for the study group undergoing cataract extraction in the first eye when the vision was the same in both eyes . This was divided into the cost of the procedure to find the year 2000 nominal US dollars spent per quality -adjusted life-year ( $ /QALY ) gained . RESULTS Initial cataract surgery , compared with observation , result ed in a mean gain of 1.776 QALYs per patient treated . A 3 % annual discount rate was used to account for the benefit over time , yielding 1.25 QALYs gained . The mean cost of treatment ( also discounted at a 3 % annual rate ) of each patient totaled 2525 US dollars . The cost divided by the discounted benefit result ed in $ 2020/QALY gained for this procedure . CONCLUSIONS Initial cataract surgery seems to be highly cost-effective compared with procedures across multiple medical specialties . This information , incorporating patient preferences into evidence d-based medicine , will play an increasingly important role in the evaluation of health care in the future The aim of this study was to gain a preliminary indication of the long-term clinical and economic implication s of converting treatment for patients with type 2 diabetes to insulin detemir±oral hypoglycemic agents ( OHAs )  in a routine clinical practice setting in the United States . With the use of outcome data and patient characteristics reported from an ongoing prospect i ve observational trial , a vali date d computer simulation model of diabetes was used to project the clinical and cost outcomes associated with therapy conversion to insulin detemir over a 35-y period from ( 1 ) OHA only , ( 2 ) neutral protamine Hagedorn insulin (NPH)±OHA , and ( 3 ) insulin glargine±OHA .  Cost-effectiveness was assessed from a third-party healthcare payer perspective for the year 2005 . Costs and clinical outcomes were discounted at a rate of 3 % . Treatment with insulin detemir±OHA was associated with increases in quality -adjusted life expectancy of 0.309 , 0.350 , and 0.333 quality -adjusted life-years ( QALYs ) versus treatment with OHA alone , NPH±OHA , and insulin glargine±OHA , respectively . Increases in pharmacy costs were partially offset by reduced complications , particularly renal complications and neuropathy . Projected incremental cost-effectiveness ratios were well within the range considered to represent good value in the United States , at $ 7412 , $ 6269 , and $ 3951 per QALY gained for treatment with Idet+-OHA versus OHA alone , NPH±OHA , and Iglarg±OHA , respectively . On the basis of preliminary evidence of short-term improvements in glycemic control and reduced hypoglycemia , therapy conversion to insulin detemir±OHA from OHA alone , NPH±OHA , or insulin glargine±OHA was projected to increase quality -adjusted life expectancy and to represent a cost-effective treatment option in the United States & NA ; Chronic pain is associated with a range of other problems , including disturbed sleep , depression , anxiety , fatigue , reduced quality of life , and an inability to work or socialise . We investigated whether good symptom control of pain ( using definitions of moderate and substantial benefit ) is associated with improvement in other symptoms . Individual patient data from four r and omised trials in fibromyalgia ( 2575 patients ) lasting 8–14 weeks were used to calculate  percentage  pain reduction  for each completing patient ( 1858 ) , divided into one of five groups according to pain reduction , irrespective of treatment : substantial benefit – ≥50 % pain reduction ; moderate – 30 % to < 50 % ; minimal – 15 % to < 30 % ; marginal – 0 % to < 15 % ; worse – < 0 % ( increased pain intensity ) . We then calculated change from baseline to end of trial for measures of fatigue , function , sleep , depression , anxiety , ability to work , general health status , and quality ‐adjusted life year ( QALY ) gain over a 12‐month period . Substantial and moderate pain intensity reductions were associated with statistically significant reduction from baseline by end of trial in all measures , with values by trial end at or approaching normative values . Substantial pain intensity reduction result ed in 0.11 QALYs gained , and moderate pain intensity reduction in 0.07 QALYs gained over a 12‐month period . Substantial and moderate pain intensity reduction predicts broad beneficial outcomes and improved quality of life that do not occur without pain relief . Pain intensity reduction is a simple and effective predictor of which patients should continue treatment , and which should discontinue and try an alternative therapy Estimation of quality of life is important to the study of the pharmacoeconomics of schizophrenia . The subject has gained popularity among policymakers , clinicians , and patients and their families , since the advent of new antipsychotic medications that are more expensive than older drugs yet have been shown to cause fewer side effects . Quantifying quality of life has been difficult , since studies often inconsistently define the concept or use rating scales that are inappropriate for the patient population . Utility analysis is a procedure that calculates subjects ' preferences regarding living with various health states , given such options as trading more years of life at a lowered health state for dying sooner but having a strong health state during the last years of life . The feasibility of performing utility analysis among patients with schizophrenia was recently examined in a study carried out by the authors . This article reflects initial observations from that study of utility analysis and includes a discussion of problems still facing the study of quality of life and utility analysis BACKGROUND CONTEXT Minimally invasive lumbar spinal stenosis procedures have uncertain long-term value . PURPOSE This study sought to characterize factors affecting the long-term cost-effectiveness of such procedures using interspinous spacer devices ( " spacers " ) relative to decompression surgery as a case study . STUDY DESIGN Model-based cost-effectiveness analysis . PATIENT SAMPLE The Medicare Provider Analysis and Review data base for the years 2005 - 2009 was used to model a group of 65-year-old patients with spinal stenosis who had no previous spine surgery and no contraindications to decompression surgery .  OUTCOME MEASURES Costs , quality -adjusted life years ( QALYs ) , and cost per QALY gained were the outcome measures . METHODS A Markov model tracked health utility and costs over 10 years for a 65-year-old cohort under three care strategies : conservative care , spacer surgery , and decompression surgery .  Incremental cost-effectiveness ratios ( ICER ) reported as cost per QALY gained included direct medical costsfor surgery . Medicare cl aims data were used to estimate complication rates , reoperation , and related costs within 3 years . Utilities and long-term reoperation rates for decompression were derived frompublished studies . Spacer failure requiring reoperation beyond 3 years and post-spacer health utilities are uncertain and were evaluated through sensitivity analyses . In the base-case , the spacer failure rate was held constant for years 4 - 10 ( cumulative failure : 47 % ) . In a " worst-case " analysis , the 10-year cumulative reoperation rate was increased steeply ( to 90 % ) . Threshold analyses were performed to determine the impact of failure and post-spacer health utility on the cost-effectiveness of spacer surgery . RESULTS The spacer strategy had an ICER of $ 89,500/QALY gained under base-case assumptions , and remained under $ 100,000 as long as the 10-year cumulative probability of reoperation did not exceed 54 % . Under worst-case assumptions , the spacer ICER was $ 482,000/QALY and fell below $ 100,000 only if post-spacer utility was 0.01 greater than post-decompression utility or the cost of  spacer surgery was $ 1,600 less than the cost of decompression surgery . CONCLUSIONS Spacers may provide a reasonably cost-effective initial treatment option for patients with lumbar spinal stenosis . Their value is expected to improve if procedure costs are lower in outpatient setting s where these procedures are increasingly being performed . Decision analysis is useful for characterizing the long-term cost-effectiveness potential for minimally invasive spinal stenosis treatments and highlights the importance of complication rates and prospect i ve health utility assessment Background Research ers are increasingly investigating the potential for ordinal tasks such as ranking and discrete choice experiments to estimate QALY health state values . However , the assumptions of r and om utility theory , which underpin the statistical models used to provide these estimates , have received insufficient attention . In particular , the assumptions made about the decisions between living states and the death state are not satisfied , at least for some people . Estimated values are likely to be incorrectly anchored with respect to death ( zero ) in such circumstances . Methods Data from the Investigating Choice Experiments for the preferences of older people CAPability instrument ( ICECAP ) valuation exercise were analysed . The values ( previously anchored to the worst possible state ) were rescaled using an ordinal model proposed previously to estimate QALY-like values . Bootstrapping was conducted to vary artificially the proportion of people who conformed to the conventional r and om utility model underpinning the analyses . Results Only 26 % of respondents conformed unequivocally to the assumptions of conventional r and om utility theory . At least 14 % of respondents unequivocally violated the assumptions . Varying the relative proportions of conforming respondents in sensitivity analyses led to large changes in the estimated QALY values , particularly for lower-valued states . As a result these values could be either positive ( considered to be better than death ) or negative ( considered to be worse than death ) . Conclusion Use of a statistical model such as conditional ( multinomial ) regression to anchor quality of life values from ordinal data to death is inappropriate in the presence of respondents who do not conform to the assumptions of conventional r and om utility theory . This is clearest when estimating values for that group of respondents observed in valuation sample s who refuse to consider any living state to be worse than death : in such circumstances the model can not be estimated . Only a valuation task requiring respondents to make choices in which both length and quality of life vary can produce estimates that properly reflect the preferences of all respondents Background To facilitate the discussion on the increasing number of total hip replacements ( THR ) and their effectiveness , we apply a joint evaluation of hospital case costs and health outcomes at the patient level to enable comparative effectiveness research ( CER ) based on the preoperative health state . Methods In 2012 , 292 patients from a German orthopedic hospital participated in health state evaluation before and 6 months after THR , where health-related quality of life ( HRQoL ) and disease specific pain and dysfunction were analyzed using EQ-5D and WOMAC scores . Costs were measured with a patient-based DRG costing scheme in a prospect i ve observation of a cohort . Costs per quality -adjusted life year ( QALY ) were calculated based on the preoperative WOMAC score , as preoperative health states were found to be the best predictors of QALY gains in multivariate linear regressions . Results Mean inpatient costs of THR were 6,310 Euros for primary replacement and 7,730 Euros for inpatient lifetime costs including revisions . QALYs gained using the U.K. population preference-weighted index were 5.95 . Lifetime costs per QALY were 1,300 Euros . Conclusions The WOMAC score and the EQ-5D score before operation were the most important predictors of QALY gains . The poorer the WOMAC score or the EQ-5D score before operation , the higher the patient benefit . Costs per QALY were far below common thresholds in all preoperative utility score groups and with all underlying calculation method ologies Background We evaluated the cost-effectiveness of nivolumab versus everolimus in patients with advanced renal cell carcinoma ( RCC ) from a US payer perspective . Methods A partitioned survival model consisting of three health states , progression-free survival ( PFS ) , progressive disease , and death , was developed to evaluate the cost-effectiveness of intravenous nivolumab versus oral everolimus over a lifetime . The proportion of patients in each state was calculated based on parametric distributions fitted to PFS and overall survival ( OS ) data from CheckMate 025 ( N = 821 ) , a large r and omized phase 3 trial of nivolumab versus everolimus for advanced RCC . Health state utility data were derived from CheckMate 025 EQ-5D data . Scenario analyses and deterministic and probabilistic sensitivity analyses assessed the impact of uncertainty in model inputs on outcomes . Results Over a 25-year lifetime horizon , treatment with nivolumab result ed in a gain of 0.64 quality -adjusted life-years ( QALYs ) versus everolimus . Nivolumab had greater total costs versus everolimus ( $ US197,089 vs. $ US163,902 ) , mainly due to higher acquisition costs . The incremental cost-utility ratio ( ICUR ) , a measure of incremental costs divided by incremental QALYs , was $ US51,714 per QALY gained for nivolumab versus everolimus , and an incremental cost-effectiveness ratio was $ US44,576 per life-year gained for nivolumab versus everolimus . In sensitivity analyses , average body weight had the greatest impact on the ICUR for nivolumab versus everolimus ( base case $ US51,714 ; range $ US8863–$US94,566 ) . At a $ US150,000 willingness-to-pay ( WTP ) threshold , nivolumab had a 91.7 % probability of being cost-effective versus everolimus . Conclusions In the United States , at a WTP threshold of $ US150,000 per QALY , nivolumab was found to be cost-effective . Key drivers of cost-effectiveness were survival inputs for OS and the average weight of patients ; the latter directly affects nivolumab drug acquisition cost Background Asthma is a chronic lung disease in which recurrent asthma symptoms create a substantial burden to individuals and their families . At the same time the economic burden associated with asthma is considerable . Methods The cost-effectiveness study was part of a single centre prospect i ve r and omised controlled trial comparing a nurse-led telemonitoring programme to usual care in a population of asthmatic out patients . The study included 109 asthmatic out patients ( 56 children ; 53 adults ) . The duration of follow-up was 12 months , and measurements were performed at baseline , 4 , 8 , and 12 months . Patients were asked to transfer their monitor data at least twice daily and by judging the received data and following a stepwise intervention protocol a nurse was able to act as the main caregiver in the intervention group . In both groups the EQ-5D and the SF-6D were used to obtain estimates of health state utilities . One year health care costs , patient and family costs , and productivity losses were calculated . The mean incremental costs were weighted against the mean incremental effect in terms of QALY . Results The study population generally represented mild to moderate asthmatics . No significant differences were found between the groups with regard to the generic quality of life . Overall , the mean health care costs per patient were higher in the intervention group than in the control group . The intervention costs mainly caused the cost difference between the groups . The intervention costs the society € 31,035/QALY gained with regard to adults and with regard to children € 59,071/QALY gained . Conclusion If the outcome is measured by generic quality of life the nurse-led telemonitoring programme is of limited cost-effectiveness in the study population . From the societal perspective the probability of the programme being cost-effective compared to regular care was 85 % at a ceiling ratio of € 80,000/QALY gained among the adults and 68 % among the children . A decrease in the price of the asthma monitor will substantial increase the probability of the programme to be cost-effective . Trial registration Number : Abstract Objective : To evaluate the cost utility of interferon beta-1b in secondary progressive multiple sclerosis . Design : Population based cost utility model ( healthcare perspective ) . Data on use of health services were obtained from case records and routine morbidity data and utility values from a EuroQol survey . Local and published costs were used . Effectiveness was modelled using data on relative risk reductions from a r and omised trial of interferon beta-1b . Setting : Tayside region , 1993 - 5 . Subjects : 132 ambulatory people with secondary progressive multiple sclerosis . Main outcome measures : Cost per quality adjusted life year ( QALY ) gained . Rate of relapse and proportion becoming wheelchair dependent over three years . Results : The number needed to treat for 30 months to delay time to wheelchair dependence in one person by nine months was 18 ( 95 % confidence interval 5 to 26 ) . For every 18 people treated for 30 months , six relapses would be prevented , gaining 0.397 discounted QALYs . The cost per QALY gained was £ 1 024 667 ( £ 276 466 to £ 1 485 499 ) . If treatment was restricted to patients attending neurology services , the number needed to treat was 14 ( cost per QALY gained £ 833 514 ( £ 161 358 to ∞ ) ) . The cost per QALY gained was not sensitive to changes in cost which took account of a societal perspective . Conclusions : The cost per QALY gained from interferon beta is high because of the high drug cost and modest clinical effect . Re sources could be used more efficiently elsewhere . Key messages Secondary progressive multiple sclerosis is a potentially disabling disorder associated with low health related quality of life Interferon beta-1b may reduce rate of relapse The benefits of interferon beta-1b treatment are very low relative to its cost Cost utility analysis estimated a cost of over £ 1 m per QALY gained Cost per QALY was not affected by taking into account the costs of care Money would be better spent on other ways of improving quality of life than on interferon Results from the completed treatment analysis of the ATAC ( Arimidex , Tamoxifen alone or in combination ) trial indicated that anastrozole was significantly superior to tamoxifen in terms of efficacy and safety in the adjuvant treatment of postmenopausal women with hormone receptor-positive ( HR+ ) early breast cancer . On the basis of these results , this study estimated the cost-effectiveness of anastrozole vs tamoxifen , from the perspective of the UK National Health Service ( NHS ) . A Markov model was developed using the 5-year completed treatment analysis from the ATAC trial ( IS RCT N18233230 ) , as well as data obtained from published literature and expert opinion . Re source utilisation data and associated costs ( 2003–4 UK£ ) were compiled from st and ard sources and expert opinion . Utility scores for a number of health states were obtained from a cross-sectional study of 26 representative patients using the st and ard gamble technique . The utility scores were then inserted into the model to obtain cost per quality adjusted life-year ( QALY ) gained . Costs and benefits were discounted at recommended annual rates of the UK Treasury ( 3.5 % ) . Modelled for 25 years , anastrozole , relative to generic tamoxifen , was estimated to result in 0.244 QALYs gained per patient at an additional cost of £ 4315 per patient ) . The estimated incremental cost-effectiveness of anastrozole compared with tamoxifen was £ 17 656 per QALY gained . There was a greater than 90 % probability that the cost-effectiveness of anastrozole was below £ 30 000 per QALY gained and of the order of 65 % that it was below £ 20 000 per QALY gained . The results were robust to all parameters tested in sensitivity analysis . Compared with commonly accepted thresholds , anastrozole is a cost-effective alternative to generic tamoxifen in adjuvant treatment of postmenopausal women with HR+ early breast cancer from the UK NHS perspective OBJECTIVES To model the incremental cost-utility of seven interventions reported as effective for preventing falls in older adults . DESIGN Mathematical epidemiological model populated by data based on direct clinical experience and a critical review of the literature . SETTING Model represents population level interventions . PARTICIPANTS No human subjects were involved in the study . MEASUREMENS : The last Cochrane data base review and meta-analyses of r and omized controlled trials categorized effective fall-prevention interventions into seven groups : medical management ( withdrawal ) of psychotropics , group tai chi , vitamin D supplementation , muscle and balance exercises , home modifications , multifactorial individualized programs for all elderly people , and multifactorial individualized treatments for high-risk frail elderly people . Fall-related hip fracture incidence was obtained from the literature . Salary figures for health professionals were based on Bureau of Labor Statistics data . Using an integrated healthcare system perspective , healthcare costs were estimated based on practice and studies on falls in older adults . Base case incremental cost utility ratios were calculated , and probabilistic sensitivity analyses were conducted . RESULTS Medical management of psychotropics and group tai chi were the least-costly , most-effective options , but they were also the least studied . Excluding these interventions , the least-expensive , most-effective options are  vitamin D supplementation and home modifications . Vitamin D supplementation costs less than home modifications , but home modifications cost only $ 14,794/ quality -adjusted life year ( QALY ) gained more than vitamin D. In probabilistic sensitivity analyses excluding management of psychotropics and tai chi , home modification is most likely to have the highest economic benefit when QALYs are valued at $ 50,000 or $ 100,000 . CONCLUSION Of single interventions studied , management of psychotropics and tai chi reduces costs the most . Of more-studied interventions , home modifications provide the best value . These results must be interpreted in the context of the multifactorial nature of falls Objectives .To estimate cost and outcomes of the Arthritis Foundation aquatic exercise classes from the societal perspective . Design .R and omized trial of 20-week aquatic classes .  Cost per quality -adjusted life year ( QALY ) gained was estimated using trial data . Sample size was based on 80 % power to reject the null hypothesis that the cost/QALY gained would not exceed $ 50,000 . Subjects and Methods . Recruited 249 adults from Washington State aged 55 to 75 with a doctor-confirmed diagnosis of osteoarthritis to participate in aquatic classes .  The Quality of Well-Being Scale ( QWB ) and Current Health Desirability Rating ( CHDR ) were used for economic evaluation , supplemented by the arthritis-specific Health Assessment Question naire ( HAQ ) , Center for Epidemiologic Studies -Depression Scale ( CES-D ) , and Perceived Quality of Life Scale ( PQOL ) collected at baseline and postclass . Outcome results applied to life expectancy tables were used to estimate QALYs . Use of health care facilities was assessed from diaries/ question naires and Medicare reimbursement rates used to estimate costs . Nonparametric bootstrap sampling of costs/QALY ratios established the 95 % CI around the estimates . Results .Aquatic exercisers reported equal ( QWB ) or better ( CHDR , HAQ , PQOL ) health-related quality of life compared with controls . Outcomes improved with regular class attendance . Costs/QALY gained discounted at 3 % were $ 205,186 using the QWB and $ 32,643 using the CHRD . Conclusion .Aquatic exercise exceeded $ 50,000 per QALY gained using the community-weighted outcome but fell below this arbitrary budget constraint when using the participant-weighted measure . Confidence intervals around these ratios suggested wide variability of cost effectiveness of aquatic exercise OBJECT Mechanical thrombectomy is increasingly being used for the treatment of large-vessel ischemic stroke in patients who arrive outside of the 3-hour tissue plasminogen activator time window . In this study , the authors evaluated the cost and effectiveness of mechanical thrombectomy compared with st and ard medical therapy in patients who are ineligible to receive tissue plasminogen activator . METHODS Clinical outcomes of an open-label study of mechanical thrombectomy were compared with a hypothetical control group with a lower recanalization rate ( 18 vs 60 % ) and a lower rate of symptomatic intracranial hemorrhage ( 0.6 vs 7.8 % ) than the active treatment group . A Markov cost-effectiveness model was built to compare the health benefits and costs associated with mechanical thrombectomy compared with st and ard medical therapy . All probabilities , quality -of-life factors , and costs were estimated from the published literature . Univariate sensitivity analyses were performed to assess how variations in model parameters affect health and economic outcomes . RESULTS Treatment of acute ischemic stroke with mechanical thrombectomy increased survival time by 0.54 quality -adjusted life years ( QALYs ) , compared with st and ard medical therapy ( 2.37 vs 1.83 QALYs ) , at an increased cost of $ 6600 . This yielded an incremental cost-effectiveness ratio ( ICER ) of $ 12,120 per QALY gained , a value generally considered cost-effective . Sensitivity analysis showed that mechanical thrombectomy remained cost-effective ( ICER < $ 50,000 per QALY gained ) for all model inputs varied over a reasonable range , except for age at stroke treatment . For patients older than 82 years of age , the treatment was only borderline cost-effective ( ICER of $ 50,000 - 100,000 per QALY gained ) . CONCLUSIONS The treatment of large-vessel ischemic stroke with mechanical thrombectomy appears to be costeffective . These results require validation when data from a r and omized , controlled trial of mechanical thrombectomy become available Background and Purpose — Thrombolytic therapy is licensed for use in highly selected patients with acute ischemic stroke . We aim ed to model the health economic impact of limited use of thrombolytic therapy and to assess whether it was likely to be cost-effective when used more widely in the UK National Health Service ( NHS ) . Methods — The authors formed a discussion panel to develop the decision- analysis model of acute stroke care . It consisted of Markov state-transition processes , with probabilities of different health states determined by certain key variables . The range of estimates of efficacy of recombinant tissue plasminogen activator ( rt-PA ) was taken from an up date to a Cochrane systematic review of r and omized trials of thrombolysis . Data on outcome after stroke were taken from our hospital-based stroke register , supplemented by data derived from relevant literature sources . Results — The model suggested that compared with st and ard care , if eligible patients were treated with rt-PA up to 6 hours , there was a 78 % probability of a gain in quality -adjusted survival during the first year , at a cost of £ 13 581 per quality -adjusted life-year ( QALY ) gained . Over a lifetime , rt-PA was associated with cost-savings of £ 96 565 per QALY . However , the estimates were imprecise and highly susceptible to the assumptions used in the economic model ; under several plausible assumptions , rt-PA was much less cost-effective than st and ard care , and under others , a great deal more cost-effective . Conclusions — The estimates of effectiveness and cost-effectiveness were imprecise . Although the benefits appeared promising , the data did not support the widespread use of thrombolytic therapy outside the terms of the current restricted license in routine clinical practice in the NHS . There is a case for new large-scale r and omized trials comparing thrombolytic therapy with control up to 6 hours to determine more precisely the effects of rt-PA on short-term and long-term survival and its cost-effectiveness when used in a wider range of patients BACKGROUND Smoking cessation can be encouraged by reimbursing the costs of smoking cessation support ( SCS ) . The short-term efficiency of reimbursement has been evaluated previously . However , a thorough estimate of the long-term cost-utility is lacking . OBJECTIVES To evaluate long-term effects of reimbursement of SCS . METHODS Results from a r and omized controlled trial were extrapolated to long-term outcomes in terms of health care costs and ( quality adjusted ) life years ( QALY ) gained , using the Chronic Disease Model . Our first scenario was no reimbursement . In a second scenario , the short-term cessation rates from the trial were extrapolated directly . Sensitivity analyses were based on the trial 's confidence intervals . In the third scenario the additional use of SCS as found in the trial was combined with cessation rates from international meta-analyses . RESULTS Intervention costs per QALY gained compared to the reference scenario were approximately euro1200 extrapolating the trial effects directly , and euro4200 when combining the trial 's use of SCS with the cessation rates from the literature . Taking all health care effects into account , even costs in life years gained , result ed in an estimated incremental cost-utility of euro4500 and euro7400 , respectively . In both scenarios costs per QALY remained below euro16 000 in sensitivity analyses using a life-time horizon . CONCLUSIONS Extrapolating the higher use of SCS due to reimbursement led to more successful quitters and a gain in life years and QALYs . Accounting for overheads , administration costs and the costs of SCS , these health gains could be obtained at relatively low cost , even when including costs in life years gained . Hence , reimbursement of SCS seems to be cost-effective from a health care perspective
It was found that individual preferences over health are influenced by the duration of health states and their sequence .
However , although there is much variation across individual respondents , the assumptions tend to hold much better when valuations are aggregated across respondents , which is encouraging for economic evaluations that rely on using average ( mean or median ) values
The numbers of quality -adjusted life years ( QALYs ) gained are increasingly being used to represent the gains in individual utility from treatment .
This requires that the value of a health improvement to an individual is a simple product of gains in quality of life and length of life .
The article reports on a systematic review of the literature on 2 issues : whether the value of a state is affected by how long the state lasts , and by states that come before or after it .