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.
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
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 .