Vortragssitzung
Poster 4: Economic Evaluation
Vorträge
Cost-effectiveness of surgical treatment in patients with refractory epilepsy: a systematic review
Anne Kitschen, Department of Health, Long-Term Care and Pensions, SOCIUM Research Center on Inequality and Social Policy, University of Bremen, Germany and Department of Philosophy, Politics and Economics, Witten/Herdecke University, Witten, Germany
Einleitung / Introduction
Epilepsy ranks fifth on the global burden of neurological disorders. About 30% of epilepsy patients develop a refractory epilepsy, that is, seizures cannot be controlled with antiepileptic drugs. Refractory epilepsy is not only associated with high direct and indirect costs, but also with a reduced quality of life. Surgery has been evaluated as an effective form of treatment for these patients. However, from an economic point of view, surgery is a costly treatment option. The aim of this systematic review is to synthesize the available evidence on the cost-effectiveness of surgical treatment compared to non-surgical treatment for patients with refractory epilepsy.
Methode / Method
A systematic literature search was conducted in MEDLINE, PsycINFO, EMBASE, Cochrane Library, and NHS EED from inception until June 2021. Title, abstract, and full-text screening as well as forward and backward citation search were conducted with respect to previously defined inclusion criteria by two independent researchers. Study characteristics, effectiveness measures, costs, and incremental cost-effectiveness ratios (ICERs) were extracted. All costs were converted to 2019 purchasing power parity US dollars (PPP-USD). The methodological quality of the included economic evaluations was assessed by the 10-item Drummond checklist.
Ergebnisse / Results
The literature search identified 2,688 studies, 14 of which met the inclusion criteria. The studies varied greatly in their methodology and time horizon. Six studies included the measurement of the effectiveness by the probability of seizure freedom, three by seizure reduction, one by a seizure free year, and nine by quality adjusted life years (QALYs). Surgery was the more effective treatment strategy across all studies, but was found to be more expensive in most studies. Still, most studies evaluated surgery as cost-effective. The ICER per patient seizure free ranged from dominant to PPP-USD 61,281 and the ICER per 1% seizure reduction ranged from PPP-USD 265 to PPP-USD 364. The ICER per year without seizures was PPP-USD 3,870 and the ICER per QALY ranged from dominant to PPP-USD 90,913 per QALY. The quality of included studies was acceptable, however, only four studies included indirect costs.
Zusammenfassung / Conclusion
Surgery has been shown to be an effective treatment strategy for patients with refractory epilepsy. This study shows that surgical treatment is also cost-effective compared to non-surgical treatment, especially when a lifetime horizon is adopted. In this regard, it is especially important that all disease-specific costs are considered over a long time horizon when assessing the cost-effectiveness of epilepsy treatment. Moreover, from an economic perspective, efforts should be made to improve access to surgical treatments for patients with refractory epilepsy.
AutorInnen
Anne Kitschen, Department of Health, Long-Term Care and Pensions, SOCIUM Research Center on Inequality and Social Policy, University of Bremen, Germany and Department of Philosophy, Politics and Economics, Witten/Herdecke University, Witten, Germany
Milda Aleknonytė-Resch, Department of Neurology, Kiel University, Kiel, Germany and Institute of Medical Informatics and Statistics, Kiel University, Kiel, Germany
Gabija Šakalytė, Kiel University, Kiel, Germany
Freya Diederich, Department of Health, Long-Term Care and Pensions, SOCIUM Research Center on Inequality and Social Policy, University of Bremen, Germany
Health Economic Evaluation of the ‘HerzCheck’ project for detection of early heart failure using telemedicine in structurally wear regions
Hannah Kentenich, Institut für Gesundheitsökonomie und Klinische Epidemiologie (IGKE), Universitätsklinikum Köln (AöR)
Einleitung / Introduction
Heart failure is one of the most common chronic diseases in Germany with a considerable economic impact. Structural cardiac damage may occur before the onset of heart failure symptoms and remains often unrecognized, resulting in poor outcomes. Unfortunately, there are no screening measures yet, that would allow early management of asymptomatic heart failure. In recent years, the global longitudinal strain (GLS) has gained increased importance due to its possibility to identify even subtle structural damage and the corresponding superior prognostic value. However, this innovative diagnostic marker is not yet widely used to diagnose heart failure. The aim of this health economic analyis is the evaluation of the cost-effectiveness of the ‘HerzCheck’, a program which should apply magnetic resonance imaging (MRI)-Screening based on GLS for early detection and prevention of asymptomatic heart failure.
Methode / Method
The health economic evaluation will be conducted along a randomized controlled trial (RCT) of the ‘HerzCheck’-Program which investigates the effectiveness of MRI screening in 6,600 patients at increased risk for developing heart failure (e.g., age 40-69 with diagnosed diabetes mellitus type 2) and subsequent preventive measures in those with abnormal GLS (recommendations for lifestyle adjustment, telemedical advice for treating physicians). Taking the perspective of the German Statutory Health Insurance, a decision-analytic Markov model will be developed to determine the lifetime cost-effectiveness of MRI screening and subsequent prevention compared to standard care without screening. Depending on the data availability, effectiveness will be measured in patient-relevant outcomes (e.g. life years gained) or surrogates, which should be highly correlated to patient-relevant outcomes. Costs will be based on identified relevant resource consumption. Relating the incremental costs of the program to the incremental benefits will result in an incremental cost-effectiveness ratio. MRI-Screening will classify patients into severe (severely worsened GLS) or moderate to severe (moderately to severely worsened GLS) heart failure. Data on efficacy and costs will be taken from the RCT, routine data from the AOK Nordost and literature. Sensitivity analyses will be conducted to account for uncertainty and to analyze the robustness of results.
Zusammenfassung / Conclusion
The determination of the cost-effectiveness of the 'HerzCheck'-Program intends to provide a basis for decision-making on the implementation of an innovative screening method in patients at increased risk of developing heart failure. The introduction of this new form of care, especially in rural areas, is expected to improve the prognosis of affected patients and save therapy costs.
AutorInnen
Hannah Kentenich, Institut für Gesundheitsökonomie und Klinische Epidemiologie (IGKE), Universitätsklinikum Köln (AöR)
Stephanie Stock, Institut für Gesundheitsökonomie und Klinische Epidemiologie (IGKE), Universitätsklinikum Köln (AöR)
Dusan Simic, Institut für Gesundheitsökonomie und Klinische Epidemiologie (IGKE), Universitätsklinikum Köln (AöR)
Dirk Müller, Institut für Gesundheitsökonomie und Klinische Epidemiologie (IGKE), Universitätsklinikum Köln (AöR)
Improving the readiness and clinical quality of antenatal care – findings from a quasi-experimental evaluation of a performance-based financing scheme in Burkina Faso
Inke Appel, Universitätsklinikum Heidelberg
Einleitung / Introduction
One health reform approach that is more and more applied in low-income countries is Performance based financing (PBF). PBF links performance-based payments to healthcare services to increase performance on predefined service outputs and is expected to streamline quality, effectiveness, and efficiency of service provision by aligning health workers’ responsiveness and motivation with priority health service targets. The implementation of performance-based financing (PBF) schemes in Sub-Saharan Africa to improve primary healthcare provision commonly includes mechanisms targeting ANC service quality. While maternal mortality has declined globally, maternal health losses remain high in Sub Saharan Africa (SSA) with 534 deaths per 100.000 live births in 2017. High-quality antenatal care (ANC) has the potential to decrease pregnancy-related complications for mothers and newborns. Repeated ANC visits contribute to reducing maternal and neonatal mortality and morbidity. In this study, we examine changes in ANC provision and quality produced by the introduction of a PBF scheme in rural Burkina Faso.
Methode / Method
This study followed a quasi-experimental design with two data collection points to estimate the effect of PBF as a health reform approach on ANC service quality by comparing primary health facilities across intervention and control districts. Outcome variables were defined using data on structural and process quality of care reflecting key clinical aspects of ANC provision (service readiness, screening and prevention) for two different client groups (i.e. first ANC visits, follow-up visits). To estimate the effect of PBF on the different ANC quality outcomes, we used a difference-in-differences approach based on linear regression.
Ergebnisse / Results
We found a statistically significant increase of 10 percent-points directly attributable to the PBF intervention in facilities readiness to provide ANC services. Although clinical care provided to different ANC client groups was generally low, especially with respect to preventive care measures, we failed to observe any substantial changes in the clinical provision of ANC care attributable to the PBF.
Zusammenfassung / Conclusion
This study presents a comprehensive assessment of the impact of PBF on ANC quality outcomes by measuring ANC quality along three categories (i.e., service readiness, screening, and prevention). As describes above the overall effects were weak. The observed pattern seems to largely reflect the incentive structure implemented by the scheme. For instance, the relative weights attached to performance indicators related to ANC promoted a stronger focus on service readiness compared to the often more complex performance of key clinical content. In addition to design features, implementation challenges like delayed payments, lack of training and supervision might have undermined its potential effects on ANC provision at the client level after the observed three-year implementation period.
AutorInnen
Stephan Brenner, Universitätsklinikum Heidelberg
Manuela De Allegri, Universitätsklinikum Heidelberg
Julia Lohmann, Universitätsklinikum Heidelberg
Jean-Louis Koulidati, Universitätsklinikum Heidelberg
Jake Robyn, World Bank
A Time-driven Activity-based Costing approach of Magnetic Resonance-guided High Intensity Focused Ultrasound for Cancer-induced Bone Pain
Julia Simões Correa Galendi, Institut für Gesundheitsökonomie und Klinische Epidemiologie Uniklinik Köln, Universität zu Köln
Einleitung / Introduction
Cancer-induced bone pain (CIBP) is a condition associated with bone metastases or other musculoskeletal tumors that affects the quality of life and the functionality of patients. For patients with persistent CIBP despite the use of opioids, palliative loco regional external beam radiotherapy (EBRT) is the treatment of choice. Magnetic Resonance-guided High Intensity Focused Ultrasound (MR-HIFU) is an emerging non-invasive treatment modality that can be performed either as alternative or in addition to EBRT. MR-HIFU has shown promising results for the management of CIBP, alleviating pain within few days after treatment in 66% patients in a placebo-controlled trial. To promote the integration of innovative medical devices such as MR-HIFU into the DRG scheme, hospitals have to collect cost-accounting data, to adjust and update the DRG-tariffs, and therefore allow fair reimbursement. Defining resource consumption and the resulting costs is one of the critical first steps for adopting MR-HIFU. The objective of the present micro costing study was to estimate resource consumption and the total costs of MR-HIFU service provision for a patient with cancer-induced bone pain from a hospital perspective.
Methode / Method
We conducted a time-driven activity-based costing (TD-ABC) of MR-HIFU treatments for CIBP from a hospital perspective. An European care-pathway (including a macro-, meso- and micro-level) was designed to incorporate the care-delivery value chain. Time estimates were obtained from medical records and from prospective direct observations. To calculate the capacity cost rate, data from the controlling department of a German university hospital were allocated to the modules of the care pathway. Best- and worst-case scenarios were calculated by applying lower and upper bounds of time measurements.
Ergebnisse / Results
The macro-level care pathway consisted of eight modules (i.e., outpatient consultations, pre-treatment imaging, preparation, optimization, sonication, post-treatment, recovery, and anesthesia). The total cost of an MR-HIFU treatment amounted to € 5147 per patient. Best- and worst-case scenarios yielded a total cost of € 4092 and to € 5876. According to cost categories, costs due to equipment accounted for 41% of total costs, followed by costs with personnel (32%), overhead (16%) and materials (11%).
Zusammenfassung / Conclusion
By applying a TD-ABC approach, our results show that from the hospital perspective the provision of MR-HIFU for patients with bone tumors costs on average € 5146 per patient. A trend of cost reduction can be assumed due to increase in operational capacity and to learning curve. This results can support the adoption of MR-HIFU in the clinical practice and will serve as basis for a cost-effectiveness evaluation.
AutorInnen
Julia Simões Correa Galendi, Institut für Gesundheitsökonomie und Klinische Epidemiologie Uniklinik Köln, Universität zu Köln
Sin Yuin Yeo, University of Cologne, Faculty of Medicine and University Hospital of Cologne, Institute of Diagnostic and Interventional Radiology
Dusan Simic, Institut für Gesundheitsökonomie und Klinische Epidemiologie Uniklinik Köln, Universität zu Köln
Holger Grüll, University of Cologne, Faculty of Medicine and University Hospital of Cologne, Institute of Diagnostic and Interventional Radiology
Stephanie Stock, Institut für Gesundheitsökonomie und Klinische Epidemiologie Uniklinik Köln, Universität zu Köln
Dirk Müller, Institut für Gesundheitsökonomie und Klinische Epidemiologie Uniklinik Köln, Universität zu Köln
Long-term benefits, harms and cost-effectiveness of screening individuals younger than age 50 with familial colorectal cancer risk based on a decision analysis within the Farkor study.
Gaby Sroczynski, Department of Public Health, Health Services Research, and Health Technology Assessment, UMIT - University for Health Sciences, Medical Informatics and Technology
Einleitung / Introduction
In Germany, colorectal cancer (CRC) screening with colonoscopy or immunologic fecal blood testing (iFOBT) is recommended and reimbursed as of age 50. Individuals with familial CRC risk may benefit from early screening at younger age. Our aim was to systematically evaluate and compare the benefit-harm balance and cost effectiveness of different screening strategies for individuals in Germany younger than age 50 identified with familial CRC risk.
Methode / Method
We developed and validated a Markov-state-transition model simulating CRC progression and management for individuals in Germany identified with familial CRC risk. The model was applied to evaluate different screening strategies that differ by screening test including colonoscopy and iFOBT, screening age at start and end, interval, and follow-up algorithms for the German health care context. We used German clinical, epidemiological, and economic data (index year 2020) along with published international test accuracy data from meta-analyses. We adopted the perspective of the German statutory health insurance, applied a lifelong time horizon and discounted effects and costs at 3% annually. Evaluated outcomes were reduction in cancer cases and deaths, life years gained [LYG], adverse events associated with colonoscopy, incremental harm-benefit ratios (IHBR), and incremental cost-effectiveness ratios (ICER; in Euro per LYG), compared to the next non-dominated strategy. Comprehensive sensitivity analyses were performed to assess uncertainty.
Ergebnisse / Results
In the base-case analyses with 100% compliance, the IHBRs measured in additional severe complications per additional LYG (SC/LYG) for iFOBT screening were 0.0014 (biennial, age 35-65), 0.0032 (biennial, age 35-75) and 0.0082 (annual, age 35-54; biennial, age 55-65) SC/LYG. Corresponding IHBRs for 10-yearly colonoscopy were 0.0012 (age 45-65), 0.0058 (age 35-65) and 0.0116 (age 30-70) SC/LYG. Compared to standard care, biennial iFOBT age 35-75 was cost-saving. The next more effective iFOBT strategies yielded ICERs of 2,630 Euro/LYG (biennial, age 30-70), and 34,675 Euro/LYG (annual, age 30-54; biennial, age 55-75), respectively. Compared to standard care, 10-yearly colonoscopy age 45-65 was cost-saving. Moving to earlier start and later stop yielded ICERs of 2,962, 3,240 and 9,279 Euro/LYG for 10-yearly colonoscopy screening at age 40-70, 35-65, and 30-70, respectively.
Zusammenfassung / Conclusion
Based on our decision-analytic results, offering colonoscopy or iFOBT screening to individuals younger than 50 years identified with familial CRC risk may be beneficial and can be considered cost-effective in the German health care setting. Considering benefit-harm ratios suggests 10-yearly colonoscopy or alternatively biennial iFOBT from age 30 to 70 as acceptable.