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Cost-effectiveness and Value of Further Research of Treatment Strategies for Cardiovascular Disease
Linköping University, Department of Medicine and Health Sciences, Health Technology Assessment and Health Economics. Linköping University, Faculty of Health Sciences.
2007 (English)Doctoral thesis, comprehensive summary (Other academic)
Abstract [en]

Economic evaluations provide a tool to estimate costs and health consequences of competing medical technologies, ultimately to aid decision makers when deciding which medical technologies should be funded from available resources. Such decisions inevitably need to be taken under uncertainty and it is not clear how to approach them in health care decision-making. Recent work in economic evaluation has proposed an analytic framework where two related, but conceptually different decisions need to be considered: (1) should a medical technology be adopted given existing evidence; and (2) whether more evidence should be acquired to support the adoption decision in the future. The proposed analytic framework requires a decision-analytic model appropriately representing the clinical decision problem under consideration, a probabilistic analysis of this model in order to determine cost-effectiveness and characterise current decision uncertainty, and estimating the value of additional information from research to reduce decision uncertainty. The main aim of this thesis is to apply the analytic framework on three case studies concerning treatment strategies for cardiovascular disease in order to establish whether the treatment strategies should be adopted given current available information and if more information should be acquired to support the adoption decisions in the future. The implications for policy and methodology of utilising the analytic framework employed in the case studies are also discussed in this thesis.

The results of the case studies show that a screening programme for abdominal aortic aneurysm in 65-year-old men is likely to be cost-effective in a Swedish setting and there appears to be little value in performing further research regarding this decision problem; an early interventional strategy in non-ST-elevation acute coronary syndrome is cost-effective for patients at intermediate to high risk of further cardiac events in a UK setting; endarterectomy in patients with an asymptomatic carotid artery stenosis is cost-effective for men around 73 years of age or younger in a Swedish setting and conducting further research regarding this decision problem is potentially worthwhile.

Comparing the results of the present analyses with current clinical practice shows a need for changing clinical practice in Sweden regarding screening for abdominal aortic aneurysm and endarterectomy in patients with asymptomatic carotid artery stenosis. Furthermore, employing the analytic framework applied in the case studies can improve treatment guidelines and recommendations for further research. In particular, treatment guidelines ought to consider in which particular subgroups of patients an intervention is cost-effective.

The case studies indicate that it is feasible to apply the analytic framework for economic evaluation of health care. Methodological development can improve the accuracy with which cost-effectiveness and value of information is estimated, but may also lead to comprehensive and complex evaluations. The nature of the decision problem should determine the level of comprehensiveness required for a particular evaluation.

Place, publisher, year, edition, pages
2007. , 131 p.
Series
Linköping University Medical Dissertations, ISSN 0345-0082 ; 1011
Keyword [en]
Economic evaluation, decision-analytic modelling, prioritising research, carotid endarterectomy, abdominal aortic aneurysm, screening, non-ST-elevation acute coronary syndrome, early intervention
National Category
Health Care Service and Management, Health Policy and Services and Health Economy
Identifiers
URN: urn:nbn:se:liu:diva-9788ISBN: 978-91-85831-20-3 (print)OAI: oai:DiVA.org:liu-9788DiVA: diva2:24162
Public defence
2007-09-27, Berzeliussalen, Campus US, Linköpings universitet, Linköping, 13:00 (English)
Opponent
Supervisors
Available from: 2007-09-24 Created: 2007-09-24 Last updated: 2009-08-22
List of papers
1. Decision-anaytical model with lifetime estimation of costs and health outcomes for one-time screening for abdominal aortic aneursm in 65-year-old men
Open this publication in new window or tab >>Decision-anaytical model with lifetime estimation of costs and health outcomes for one-time screening for abdominal aortic aneursm in 65-year-old men
2005 (English)In: British Journal of Surgery, ISSN 0007-1323, Vol. 92, no 8, 976-983 p.Article in journal (Refereed) Published
Abstract [en]

Background: Abdominal aortic aneurysm (AAA) causes about 2 per cent of all deaths in men over the age of 65 years. A major improvement in operative mortality would have little impact on total mortality, so screening for AAA has been recommended as a solution. The cost-effectiveness of a programme that invited 65-year-old men for ultrasonographic screening was compared with current clinical practice in a decision-analytical model.

Methods: In a probabilistic Markov model, costs and health outcomes of a screening programme and current clinical practice were simulated over a lifetime perspective. To populate the model with the best available evidence, data from published papers, vascular databases and primary research were used.

Results: The results of the base-case analysis showed that the incremental cost per gained life-year for a screening programme compared with current practice was €7760, and that for a quality-adjusted life-year was €9700. The probability of screening being cost-effective was high.

Conclusion: A financially and practically feasible screening programme for AAA, in which men are invited for ultrasonography in the year in which they turn 65, appears to yield positive health outcomes at a reasonable cost.

National Category
Medical and Health Sciences
Identifiers
urn:nbn:se:liu:diva-14658 (URN)10.1002/bjs.5122 (DOI)
Available from: 2007-09-24 Created: 2007-09-24 Last updated: 2009-05-18
2. Informing the efficient use of health care and health care research resources: the case of screening for abdominal aortic aneurysm in Sweden
Open this publication in new window or tab >>Informing the efficient use of health care and health care research resources: the case of screening for abdominal aortic aneurysm in Sweden
2006 (English)In: Health Economics, ISSN 1057-9230, Vol. 15, no 12, 1311-1322 p.Article in journal (Refereed) Published
Abstract [en]

Background: An analytical framework using Bayesian decision theory and value-of-information analysis has recently been advocated for the economic evaluation of health technologies. The purpose of this study was to apply this framework to screening for abdominal aortic aneurysm (AAA) in Sweden and to compare the conclusions from this study with the conclusions presented in an assessment performed by the Swedish Council of Technology Assessment (SBU).

Methods: A probabilistic decision-analytical model was developed to establish the cost-effectiveness of a screening programme for AAA relative to current clinical practice and to calculate the value-of-information.

Results: The cost per quality-adjusted life-year for screening was €9700. The expected value of perfect information for the assessment of overall cost-effectiveness was low, suggesting little benefit in conducting further research. Expected value of perfect partial information indicated that rupture probabilities were associated with the highest uncertainty. By contrast, the SBU report concluded there was limited evidence of cost-effectiveness and proposed further research.

Conclusion: The investigated screening programme for AAA is likely to be cost-effective and conducting another clinical trial is unlikely to add much valuable information to this decision problem. These recommendations contrast with the vaguer recommendations from SBU that more evidence is required of costs-effectiveness.

Keyword
cost-effectiveness, decision making, prioritising research, abdominal aortic aneurysm
National Category
Medical and Health Sciences
Identifiers
urn:nbn:se:liu:diva-14659 (URN)10.1002/hec.1130 (DOI)
Available from: 2007-09-24 Created: 2007-09-24
3. The cost-effectiveness of an early interventional strategy in non-ST-elevation acute coronary syndrome based on the RITA 3 trial
Open this publication in new window or tab >>The cost-effectiveness of an early interventional strategy in non-ST-elevation acute coronary syndrome based on the RITA 3 trial
Show others...
2008 (English)In: Heart, ISSN 1355-6037, E-ISSN 1468-201X, Vol. 94, 717-723 p.Article in journal (Refereed) Published
Abstract [en]

Background: Evidence suggests that an early interventional strategy for patients with non-ST-elevation acute coronary syndrome (NSTE-ACS) can improve health outcomes but also increase costs when compared with a conservative strategy.

Objective: The aim of this study was to assess the cost-effectiveness of an early interventional strategy in different risk groups from a UK health-service perspective.

Design: Decision-analytic model based on randomised clinical trial data.

Main outcome measures: Costs in UK Sterling at 2003/2004 prices and quality-adjusted life years (QALYs) combined into an incremental cost-effectiveness ratio.

Methods: Data from the third Randomised Intervention Trial of unstable Angina (RITA 3) was employed to estimate rates of cardiovascular death and myocardial infarction, costs and health-related quality of life. Cost-effectiveness was estimated over patients’ lifetimes within the decision-analytic model.

Results: The mean incremental cost per QALY gained for an early interventional strategy was approximately £55 000, £22 000 and £12 000 for patients at low, intermediate and high risk, respectively. The early interventional strategy is approximately 1%, 35% and 95% likely to be cost-effective for patients at low, intermediate and high risk, respectively, at a threshold of £20 000 per QALY. The cost-effectiveness of early intervention in low-risk patients is sensitive to assumptions about the duration of the treatment effect.

Conclusion: An early interventional strategy in patients presenting with NSTE-ACS is likely to be considered cost-effective for patients at high and intermediate risk, but this is less likely to be the case for patients at low risk.

National Category
Medical and Health Sciences
Identifiers
urn:nbn:se:liu:diva-14660 (URN)10.1136/hrt.2007.127340 (DOI)
Available from: 2007-09-24 Created: 2007-09-24 Last updated: 2017-12-13
4. Cost-effectiveness of endarterectomy in patients with asymptomatic carotid artery stenosis in Sweden
Open this publication in new window or tab >>Cost-effectiveness of endarterectomy in patients with asymptomatic carotid artery stenosis in Sweden
2008 (English)In: British Journal of Surgery, ISSN 0007-1323, E-ISSN 1365-2168, Vol. 95, no 6, 714-720 p.Article in journal (Refereed) Published
Abstract [en]

Background: Long-term health outcomes and costs are important when deciding whether a strategy of carotid endarterectomy in addition to best medical management should be recommended for patients with asymptomatic carotid artery stenosis. This study investigated the cost-effectiveness of such a strategy compared with a strategy of best medical management alone.

Methods: Based on data from the randomized Asymptomatic Carotid Surgery Trial (ACST), a national vascular database and other published sources, expected costs and health outcomes in terms of quality-adjusted life years (QALYs) of both treatment strategies were estimated using decision-analytical modelling. Cost-effectiveness was established for a Swedish setting from a societal perspective.

Results: Base-case analysis showed that the incremental cost per QALY of a strategy with carotid endarterectomy for 65- and 75-year-old men (women) was 34 557 (311 133) and 58 930 (779 776) respectively. Sensitivity analyses indicated that the duration of the treatment effect after 5 years of follow-up in the ACST was important for the cost-effectiveness results.

Conclusion: Carotid endarterectomy in addition to best medical management can be considered cost-effective in men aged 73 years or less but is less likely to be cost-effective in older men or in women.

Place, publisher, year, edition, pages
Chichester, West Sussex, United Kingdom: John Wiley & Sons, 2008
National Category
Medical and Health Sciences
Identifiers
urn:nbn:se:liu:diva-14661 (URN)10.1002/bjs.6157 (DOI)000258391500009 ()
Available from: 2007-09-24 Created: 2007-09-24 Last updated: 2017-12-13Bibliographically approved
5. The value of further research into the cost-effectiveness of endarterectomy in patients with asymptomatic carotid artery stenosis in Sweden
Open this publication in new window or tab >>The value of further research into the cost-effectiveness of endarterectomy in patients with asymptomatic carotid artery stenosis in Sweden
2007 (English)Article in journal (Refereed) Submitted
National Category
Medical and Health Sciences
Identifiers
urn:nbn:se:liu:diva-14662 (URN)
Available from: 2007-09-24 Created: 2007-09-24

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