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Cost-effectiveness of models for prevention of vertical HIV transmission – voluntary counseling and testing and choices of drug regimen
Yot Teerawattananon, Theo Vos, Viroj Tangcharoensathien, Miranda Mugford
Cost Effectiveness and Resource Allocation , 2005, DOI: 10.1186/1478-7547-3-7
Abstract: We examine a hypothetical cohort of 100,000 pregnancies as a decision model. Cost and outcome parameters are estimated as they would apply under Thai routine health service conditions. Effectiveness probabilities are based on best available evidence, from systematic reviews where possible. The main outcome is the number of cases of paediatric HIV averted.The combining administration of AZT and NVP is the most cost-effective drug option. One VCT session with AZT+NVP averts 337 cases of infection at 556 USD per case averted, while two VCT with the same drug regimen averts 16 additional cases at cost of 1,266 USD per infection averted. The incremental cost-effectiveness ratio of moving from 1VCT, AZT+NVP to 2VCT, AZT+NVP is 16,000 USD per additional averted case, which is much lower than the recommended threshold value for HIV infection averted in Thailand. Multivariate uncertainty analysis supports the findings, showing that at a threshold of 35,000 USD, 2VCT, AZT+NVP is preferable to other VCT and drug strategies.Interventions for preventing mother-to-child transmission of HIV are cost-effective. Further costs and negative effects of drug resistance, are unlikely to outweigh the social benefits of reduce transmission of HIV. This model suggests that the new drug regimen is a cost-effective option in the Thai health system at currently accepted thresholds for adopting health technologies.Thailand is one of the countries having most success fighting the epidemic of HIV/AIDS infection [1,2]. Two randomised clinical trials conducted in Thailand have provided substantial impact on prevention of mother to child transmission of HIV/AIDS (PMTCT). The first demonstrated in 1999 that a short course of twice daily oral Zidovudine (AZT) was safe, well-tolerated and, in the absence of breast-feeding, lessened the risk for mother to child HIV-1 transmission from 18.9% to 9.4% [3]. This prompted the Thai Government to provide universal access to a short course of AZT in 2000 [4,5].
Cost-effectiveness of HIV prevention interventions in Andhra Pradesh state of India
Lalit Dandona, SG Prem Kumar, G Anil Kumar, Rakhi Dandona
BMC Health Services Research , 2010, DOI: 10.1186/1472-6963-10-117
Abstract: Based on data from a representative sample of 128 public-funded HIV prevention programs of 14 types in Andhra Pradesh, we have recently reported the number of HIV infections averted by each type of HIV prevention intervention and their cost. Using estimates of the age of onset of HIV infection, we used standard methods to calculate the cost per Disability Adjusted Life Year (DALY) saved as a measure of cost-effectiveness of each type of HIV prevention intervention.The point estimates of the cost per DALY saved were less than US $50 for blood banks, men who have sex with men programmes, voluntary counselling and testing centres, prevention of parent to child transmission clinics, sexually transmitted infection clinics, and women sex worker programmes; between US $50 and 100 for truckers and migrant labourer programmes; more than US $100 and up to US $410 for composite, street children, condom promotion, prisoners and workplace programmes and mass media campaign for the general public. The uncertainty range around these estimates was very wide for several interventions, with the ratio of the high to the low estimates infinite for five interventions.The point estimates for the cost per DALY saved from the averted HIV infections for all interventions was much lower than the per capita gross domestic product in this Indian state. While these indicative cost-effectiveness estimates can inform HIV control planning currently, the wide uncertainty range around estimates for several interventions suggest the need for more firm data for estimating cost-effectiveness of HIV prevention interventions in India.India has had substantial resources allocated for HIV/AIDS control of which the major portion would be spent on HIV prevention [1,2]. Efficient use of these resources would take into account the gaps in coverage of HIV prevention interventions, the cost of interventions and their cost-effectiveness. The state of Andhra Pradesh in south India, with a population of over 80 mil
Management strategies and cost effectiveness in the prevention of cervical cancer
Smita R Prasad
ClinicoEconomics and Outcomes Research , 2009, DOI: http://dx.doi.org/10.2147/CEOR.S4226
Abstract: nagement strategies and cost effectiveness in the prevention of cervical cancer Review (4413) Total Article Views Authors: Smita R Prasad Published Date June 2009 Volume 2009:1 Pages 17 - 23 DOI: http://dx.doi.org/10.2147/CEOR.S4226 Smita R Prasad University of Kentucky, College of Public Health, Lexington, KY, USA Abstract: This paper introduces the burden of cervical cancer and the primary and secondary preventative interventions currently available, and provides an overview of the bivalent and quadrivalent human papillomavirus (HPV) vaccines. A brief account of the virology and the clinical efficacy of both is given. Examinations of the two main types of cost analyses, cost-effective and cost-benefit, as well as examples, are presented in addition to the possible impact these analyses and further economic models will have on budget and policy making decisions. In general, most cost analyses provide support for the implementation of primary prevention strategies, HPV immunization, in conjunction with cervical cancer screening programs. Vaccination against HPV, therefore, is a cost-effective cervical cancer prevention mechanism.
Seasonal Influenza Vaccination for Children in Thailand: A Cost-Effectiveness Analysis  [PDF]
Aronrag Meeyai?,Naiyana Praditsitthikorn?,Surachai Kotirum?,Wantanee Kulpeng?,Weerasak Putthasri?,Ben S. Cooper?,Yot Teerawattananon
PLOS Medicine , 2015, DOI: 10.1371/journal.pmed.1001829
Abstract: Background Seasonal influenza is a major cause of mortality worldwide. Routine immunization of children has the potential to reduce this mortality through both direct and indirect protection, but has not been adopted by any low- or middle-income countries. We developed a framework to evaluate the cost-effectiveness of influenza vaccination policies in developing countries and used it to consider annual vaccination of school- and preschool-aged children with either trivalent inactivated influenza vaccine (TIV) or trivalent live-attenuated influenza vaccine (LAIV) in Thailand. We also compared these approaches with a policy of expanding TIV coverage in the elderly. Methods and Findings We developed an age-structured model to evaluate the cost-effectiveness of eight vaccination policies parameterized using country-level data from Thailand. For policies using LAIV, we considered five different age groups of children to vaccinate. We adopted a Bayesian evidence-synthesis framework, expressing uncertainty in parameters through probability distributions derived by fitting the model to prospectively collected laboratory-confirmed influenza data from 2005-2009, by meta-analysis of clinical trial data, and by using prior probability distributions derived from literature review and elicitation of expert opinion. We performed sensitivity analyses using alternative assumptions about prior immunity, contact patterns between age groups, the proportion of infections that are symptomatic, cost per unit vaccine, and vaccine effectiveness. Vaccination of children with LAIV was found to be highly cost-effective, with incremental cost-effectiveness ratios between about 2,000 and 5,000 international dollars per disability-adjusted life year averted, and was consistently preferred to TIV-based policies. These findings were robust to extensive sensitivity analyses. The optimal age group to vaccinate with LAIV, however, was sensitive both to the willingness to pay for health benefits and to assumptions about contact patterns between age groups. Conclusions Vaccinating school-aged children with LAIV is likely to be cost-effective in Thailand in the short term, though the long-term consequences of such a policy cannot be reliably predicted given current knowledge of influenza epidemiology and immunology. Our work provides a coherent framework that can be used for similar analyses in other low- and middle-income countries.
Management strategies and cost effectiveness in the prevention of cervical cancer  [cached]
Smita R Prasad
ClinicoEconomics and Outcomes Research , 2009,
Abstract: Smita R PrasadUniversity of Kentucky, College of Public Health, Lexington, KY, USAAbstract: This paper introduces the burden of cervical cancer and the primary and secondary preventative interventions currently available, and provides an overview of the bivalent and quadrivalent human papillomavirus (HPV) vaccines. A brief account of the virology and the clinical efficacy of both is given. Examinations of the two main types of cost analyses, cost-effective and cost-benefit, as well as examples, are presented in addition to the possible impact these analyses and further economic models will have on budget and policy making decisions. In general, most cost analyses provide support for the implementation of primary prevention strategies, HPV immunization, in conjunction with cervical cancer screening programs. Vaccination against HPV, therefore, is a cost-effective cervical cancer prevention mechanism.Keywords: cervical cancer, human papillomavirus, HPV
Effectiveness and cost-effectiveness of behavioural strategies in the prevention of cigarette smoking  [cached]
Müller-Riemenschneider, Falk,Rasch, Andrej,Bockelbrink, Angelina,Vauth, Christoph
GMS Health Technology Assessment , 2008,
Abstract: Background: The hazardous health effects of smoking and second hand smoke have been confirmed in numerous studies. For Germany, the mortality attributable to smoking is estimated at 110,000 to 140,000 deaths per year, associated with annual smoking-related costs of 17 to 21 billion euro. Because the majority of smokers initiate this habit early in life, behavioural preventive strategies usually tried to prevent the uptake of smoking among children and youths. Objectives: The goal of this HTA is to summarise the current literature on behavioural strategies for smoking prevention and to evaluate their medical effectiveness/efficacy and cost-effectiveness as well as the ethical, social and legal implications of smoking prevention programs. In addition, this report aims to compare the effectiveness and efficacy of different intervention components and to evaluate the reliability of results in the German context. Methods: Relevant publications were identified by means of a structured search of databases accessed through the German Institute of Medical Documentation and Information (DIMDI). In addition a manual search of identified reference lists was conducted. The present report includes German and English literature published between August 2001 and August 2006 targeting youths up to 18 years old. The methodological quality of included studies was assessed according to pre-defined quality criteria, based on the criteria of evidence-based medicine. Results: Among 3,580 publications 37 medical studies met the inclusion criteria. Overall study quality was satisfactory but only half the studies reported smoking uptake as an outcome, while the remaining studies reported alternative outcome parameters. The follow-up duration varied between twelve and 120 months. Although overall effectiveness of prevention programs showed considerable heterogeneity, there was evidence for the long-term effectiveness of behavioural smoking prevention programs. However, the reduction in smoking rates was only moderate. Community and multisectorial interventions reported more conclusive evidence for reductions in smoking rates, while the evidence for school-based programs alone was inconclusive. Only one study from Germany fulfilled the methodological criteria and was included in this report. Three included economic studies focused on school-based interventions. Study results suggested, that the cost-effectiveness of school-based behavioural interventions is positive. Discussion: Behavioural preventive strategies were effective to delay or decrease uptake of smoking behaviour among
Using cost-effectiveness analyses to inform policy: the case of antiretroviral therapy in Thailand
Sripen Tantivess, Gill Walt
Cost Effectiveness and Resource Allocation , 2006, DOI: 10.1186/1478-7547-4-21
Abstract: This article reviews the development of the national ART programme in Thailand between 1992 and 2004. It examines the roles of cost-effectiveness information in treatment policy decisions. Qualitative approaches including document analysis and interview of key informants were employed.Two significant policy shifts have been observed in government-organised ART provision. In 1996, service-based therapy for a few was replaced by a research network to support clinical assessments of antiretroviral medication in public hospitals. This decision was taken after a domestic study illustrated the unaffordable fiscal burden and inefficient use of resources in provision of ART. The numbers of treatment recipients was maintained at 2,000 per year throughout the 1990s. It was not until 2001 that a new government pledged to extend the numbers receiving the service, as part of its commitment to universal coverage. Several elements played a role in this decision: new groups of dominant actors, drug price reductions, a pro-active civil society movement, lessons from experience on treatment benefits, and global treatment advocacy. Unlike previous policy discourse, human rights, ethics and equity notions were explicitly raised to support therapy extension.In the early decision, moving from a relatively limited ART service to a research network was clearly influenced by cost-effectiveness data. But in the 2001 decision to include ART in the universal coverage package, cost-effectiveness arguments were over-ruled by other considerations. Thai ART policy was shaped by many factors, and was not a simple rational process which relied on evidence.While human immune-deficiency virus (HIV) infection is incurable, use of antiretrovirals (ARVs) is the most effective intervention to prolong patients' lives. Combination antiretroviral therapy (ART), widely introduced in developed countries since the mid-1990s, has resulted in a dramatic decline in opportunistic diseases and therefore HIV-related
Statin cost effectiveness in primary prevention: A systematic review of the recent cost-effectiveness literature in the United States
Aaron P Mitchell, Ross J Simpson
BMC Research Notes , 2012, DOI: 10.1186/1756-0500-5-373
Abstract: We conducted a systematic review of the literature on statin cost-effectiveness. The four studies that met inclusion criteria reported varying conclusions about the cost-effectiveness of statin treatment, without a clear consensus as to whether statins are cost-effective for primary prevention. However, after accounting for each study’s assumptions about statin costs, we found substantial agreement among the studies. Studies that assumed statins to be more expensive found them to be less cost-effective, and vice-versa. Furthermore, treatment of low-risk groups became cost-effective as statins became less expensive.Drug price is the primary determinant of statin cost-effectiveness within a given risk group. As more statin drugs become generic, patients at low risk for coronary disease may be treated cost-effectively. Though many factors must be weighed in any medical decision, from a cost-effectiveness perspective, statins may now be considered an appropriate therapy for many patients at low risk for heart disease.The HMG-CoA reductase inhibitors, or “statins,” are proven in multiple randomized, controlled, clinical trials to lower cardiac morbidity and mortality [1]. Statins successfully lower LDL cholesterol in most patients, with substantial reductions in the risk of major coronary events, such as MI [2], and stroke [3,4]. Statins reduce mortality in patients with pre-existing coronary disease [1], but it is unclear if this mortality benefit holds for primary prevention [3,5]. Statins are generally well-tolerated and have a low rate of major side effects [6].Statin trials suggest that the relative risk reduction of cardiac disease is constant regardless of each patient’s overall risk [1,7,8]. Therefore, the number needed to treat is lower in higher-risk groups; more heart attacks will be prevented by treating 100 patients at high risk for disease than at low risk. Accordingly, statins are more cost-effective in higher-risk groups, since fewer patients must be trea
Cost-Effectiveness of Apixaban Compared with Warfarin for Stroke Prevention in Atrial Fibrillation  [PDF]
Soyon Lee, Rachel Mullin, Jon Blazawski, Craig I. Coleman
PLOS ONE , 2012, DOI: 10.1371/journal.pone.0047473
Abstract: Background Apixaban was shown to be superior to adjusted-dose warfarin in preventing stroke or systemic embolism in patients with atrial fibrillation (AF) and at least one additional risk factor for stroke, and associated with reduced rates of hemorrhage. We sought to determine the cost-effectiveness of using apixaban for stroke prevention. Methods Based on the results from the Apixaban Versus Warfarin in Patients with Atrial Fibrillation (ARISTOTLE) trial and other published studies, we constructed a Markov model to evaluate the cost-effectiveness of apixaban versus warfarin from the Medicare perspective. The base-case analysis assumed a cohort of 65-year-old patients with a CHADS2 score of 2.1 and no contraindication to oral anticoagulation. We utilized a 2-week cycle length and a lifetime time horizon. Outcome measures included costs in 2012 US$, quality-adjusted life-years (QALYs), life years saved and incremental cost-effectiveness ratios. Results Under base case conditions, quality adjusted life expectancy was 10.69 and 11.16 years for warfarin and apixaban, respectively. Total costs were $94,941 for warfarin and $86,007 for apixaban, demonstrating apixaban to be a dominant economic strategy. Upon one-way sensitivity analysis, these results were sensitive to variability in the drug cost of apixaban and various intracranial hemorrhage related variables. In Monte Carlo simulation, apixaban was a dominant strategy in 57% of 10,000 simulations and cost-effective in 98% at a willingness-to-pay threshold of $50,000 per QALY. Conclusions In patients with AF and at least one additional risk factor for stroke and a baseline risk of ICH risk of about 0.8%, treatment with apixaban may be a cost-effective alternative to warfarin.
Cost-effectiveness of human papillomavirus vaccination for prevention of cervical cancer in Taiwan
Pang-Hsiang Liu, Fu-Chang Hu, Ping-Ing Lee, Song-Nan Chow, Chao-Wan Huang, Jung-Der Wang
BMC Health Services Research , 2010, DOI: 10.1186/1472-6963-10-11
Abstract: We developed a Markov model to compare the health and economic outcomes of vaccinating preadolescent girls (at the age of 12 years) for the prevention of cervical cancer with current practice, including cervical cytological screening. Data were synthesized from published papers or reports, and whenever possible, those specific to Taiwan were used. Sensitivity analyses were performed to account for important uncertainties and different vaccination scenarios.Under the assumption that the HPV vaccine could provide lifelong protection, the massive vaccination among preadolescent girls in Taiwan would lead to reduction in 73.3% of the total incident cervical cancer cases and would result in a life expectancy gain of 4.9 days or 8.7 quality-adjusted life days at a cost of US$324 as compared to the current practice. The incremental cost-effectiveness ratio (ICER) was US$23,939 per life year gained or US$13,674 per quality-adjusted life year (QALY) gained given the discount rate of 3%. Sensitivity analyses showed that this ICER would remain below US$30,000 per QALY under most conditions, even when vaccine efficacy was suboptimal or when vaccine-induced immunity required booster shots every 13 years.Although gains in life expectancy may be modest at the individual level, the results indicate that prophylactic HPV vaccination of preadolescent girls in Taiwan would result in substantial population benefits with a favorable cost-effectiveness ratio. Nevertheless, we should not overlook the urgency to improve the compliance rate of cervical screening, particularly for older individuals.Cervical cancer is one of the most common female malignancies worldwide. The cervical cancer rate has declined in Taiwan over the last decade, an effect largely attributed to widespread screening for cervical cancer. Nonetheless, the compliance with cervical screening in Taiwan remains suboptimal that the annual screening rate was 28.6% for women aged over 30 years [1], and the incidence of cervic
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