Optimal allocation of scarce PCR tests during the COVID-19 pandemic.

BACKGROUND/AIM: During the coronavirus disease (COVID-19) pandemic, Germany and various other countries experienced a shortage of polymerase chain reaction (PCR) laboratory tests due to the highly transmissible SARS-CoV-2 Omicron variant that drove an unprecedented surge of infections. This study developed a mathematical model that optimizes diagnostic capacity with lab-based PCR testing. METHODS: A mathematical model was constructed to determine the value of PCR testing in relation to the pre-test probability of COVID-19. Furthermore, the model derives the lower and upper bounds for the threshold pre-test probability of the designated priority group. The model was applied in a German setting using the PCR test-positivity rate at the beginning of February 2022. RESULTS: The value function of PCR testing is bell-shaped with respect to the pre-test probability, reaching a maximum at a pre-test probability of 0.5. Based on a PCR test-positivity rate of 0.3 and assuming that at least two thirds of the tested population have a pre-test probability below, lower and higher pre-test probability thresholds are ≥ 0.1 and 0.7, respectively. Therefore, individuals who have a 25% likelihood of testing positive because they exhibit symptoms should be a higher priority for PCR testing. Furthermore, a positive rapid antigen test in asymptomatic individuals with no known exposure to COVID-19 should be confirmed using PCR. Yet, symptomatic individuals with a positive RAT should be excluded from PCR testing. CONCLUSION: A mathematical model that allows for the optimal allocation of scarce PCR tests during the COVID-19 pandemic was developed.

New development: Increasing vaccination uptake in repeated Covid 19 vaccination mandates

IMPACTSome countries are still struggling to vaccinate residents against Covid 19 despite the wide availability of vaccines. This situation becomes more complex when considering the possible need for regular booster shots. Repeated vaccine mandates that impose fines on vaccine refusers may increase vaccination uptake. However, the uptake may not be sufficient to lift all Covid 19 restrictions. This article recommends that policy-makers consider an alternative financial incentive system that relies on rewards in addition to fines. Theoretical and empirical evidence suggests that a combination can yield a stronger response than using rewards or fines alone.

Cost-effectiveness of future lockdown policies against the COVID-19 pandemic.

AIM: While the European Union (EU) has approved several COVID-19 vaccines, new variants of concern may be able to escape immunity. The purpose of this study is to project the cost-effectiveness of future lockdown policies in conjunction with a variant-adapted vaccine booster. The exemplary scenario foresees a 25% decline in the vaccine protection against severe disease. METHODS: A decision model was constructed using, for example, information on age-specific fatality rates, intensive care unit (ICU) costs and outcomes, and herd protection threshold. The costs and benefits of a future lockdown strategy were determined from a societal viewpoint under three future scenarios-a booster shot's efficacy of 0%, 50%, and 95%. RESULTS: The cost-effectiveness ratio of a lockdown policy in conjunction with a booster dose with 95% efficacy is €44,214 per life year gained. A lockdown is cost-effective when the probability of approving a booster dose with 95% efficacy is at least 48% (76% when considering uncertainty in input factors). CONCLUSION: In this exemplary scenario, a future lockdown policy appears to be cost-effective if the probability of approving a variant-adapted vaccine booster with an efficacy of 95% is at least 48%.

COVID-19 and the forgone health benefits of elective operations.

BACKGROUND AND AIM: The first SARS-CoV-2 pandemic wave in Germany involved a tradeoff between saving the lives of COVID-19 patients by providing sufficient intensive care unit (ICU) capacity and foregoing the health benefits of elective procedures. This study aims to quantify this tradeoff. METHODS: The analysis is conducted at both the individual and population levels. The analysis calculates quality-adjusted life years (QALYs) to facilitate a comparison between the health gains from saving the lives of COVID-19 patients in the ICU and the health losses associated with postponing operative procedures. The QALYs gained from saving the lives of COVID-19 patients are calculated based on both the real-world ICU admissions and deaths averted from flattening the first wave. Scenario analysis was used to account for variation in input factors. RESULTS: At the individual level, the resource-adjusted QALY gain of saving one COVID-19 life is predicted to be 3 to 15 times larger than the QALY loss of deferring one operation (the average multiplier is 9). The real-world QALY gain at the population level is estimated to fall within the range of the QALY loss due to delayed procedures. The modeled QALY gain by flattening the first wave is 3 to 31 times larger than the QALY loss due to delayed procedures (the average multiplier is 17). CONCLUSION: During the first wave of the pandemic, the resource-adjusted health gain from treating one COVID-19 patient in the ICU was found to be much larger than the health loss from deferring one operation. At the population level, flattening the first wave led to a much larger health gain than the health loss from delaying operative procedures.

Was EU's COVID-19 vaccine procurement strategy irrational? A re-analysis based on cost-effectiveness considerations.

AIM: The European Union (EU) has received criticism for being slow to secure coronavirus disease (COVID-19) vaccine contracts in 2020 before the approval of the first COVID-19 vaccine. This study aimed to retrospectively analyze the EU's COVID-19 vaccine procurement strategy. To this end, the study retrospectively determined the minimum vaccine efficacy that made vaccination cost-effective from a societal perspective in Germany before clinical trial announcements in late 2020. The results were compared with the expected vaccine efficacy before the announcements. METHODS: Two strategies were analyzed: vaccination followed by the complete lifting of mitigation measures and a long-term mitigation strategy. A decision model was constructed using, for example, information on age-specific fatality rates, intensive care unit costs and outcomes, and herd protection thresholds. The base-case time horizon was 5 years. Cost-effectiveness of vaccination was determined in terms of the costs per life-year gained. The value of an additional life-year was borrowed from new, innovative oncological drugs, as cancer is a condition with a perceived threat similar to that of COVID-19. RESULTS: A vaccine with 50% efficacy against death due to COVID-19 was not clearly cost-effective compared with a long-term mitigation strategy if mitigation measures were planned to be lifted after vaccine rollout. The minimum vaccine efficacy required to achieve cost-effectiveness was 40% in the base case. The sensitivity analysis showed considerable variation around the minimum vaccine efficacy, extending above 50% for some of the input variables. CONCLUSIONS: This study showed that vaccine efficacy levels expected before clinical trial announcements did not clearly justify lifting mitigation measures from a cost-effectiveness standpoint. Hence, the EU's sluggish procurement strategy still appeared to be rational at the time of decision making.

Value-based pricing of a COVID-19 vaccine.

AIM: The purpose of this study is to determine the value-based price of a COVID-19 vaccine from a societal perspective in Germany. METHODS: A decision model was constructed using, e.g., information on age-specific fatality rates, intensive care unit (ICU) costs and outcomes, and the full vaccination rate. Three strategies were analysed: vaccination (with 95 % and 50 % efficacy against death), a mitigation strategy, and no intervention. The base-case time horizon was 5 years. The value of a vaccine includes savings from avoiding COVID-19 mitigation measures and productivity loss, as well as health benefits from preventing COVID-19 related mortality. The value of an additional life year was borrowed from new, innovative oncological drugs, as cancer reflects a condition with a similar morbidity and mortality burden in the general population in the short term as COVID-19. RESULTS: A vaccine with a 95 % efficacy dominates the mitigation strategy strictly. The value-based price (€6,431) is thus determined by the comparison between vaccination and no intervention. The price is particularly sensitive to the full vaccination rate and the duration of vaccine protection. In contrast, the value of a vaccine with 50 % efficacy is more ambiguous. CONCLUSION: This study yields a value-based price for a COVID-19 vaccine with 95 % efficacy, which is considerably greater than the purchasing price.

How Many Intensive Care Beds are Justifiable for Hospital Pandemic Preparedness? A Cost-effectiveness Analysis for COVID-19 in Germany.

INTRODUCTION: Germany is experiencing the second COVID-19 pandemic wave. The intensive care unit (ICU) bed capacity is an important consideration in the response to the pandemic. The purpose of this study was to determine the costs and benefits of maintaining or expanding a staffed ICU bed reserve capacity in Germany. METHODS: This study compared the provision of additional capacity to no intervention from a societal perspective. A decision model was developed using, e.g. information on age-specific fatality rates, ICU costs and outcomes, and the herd protection threshold. The net monetary benefit (NMB) was calculated based upon the willingness to pay for new medicines for the treatment of cancer, a condition with a similar disease burden in the near term. RESULTS: The marginal cost-effectiveness ratio (MCER) of the last bed added to the existing ICU capacity is €21,958 per life-year gained assuming full bed utilization. The NMB decreases with an additional expansion but remains positive for utilization rates as low as 2%. In a sensitivity analysis, the variables with the highest impact on the MCER were the mortality rates in the ICU and after discharge. CONCLUSIONS: This article demonstrates the applicability of cost-effectiveness analysis to policies of hospital pandemic preparedness and response capacity strengthening. In Germany, the provision of a staffed ICU bed reserve capacity appears to be cost-effective even for a low probability of bed utilization.

The clinical and economic value of a successful shutdown during the SARS-CoV-2 pandemic in Germany.

Background and aim: A shutdown of businesses enacted during the SARS-CoV-2 pandemic can serve different goals, e.g., preventing the intensive care unit (ICU) capacity from being overwhelmed ('flattening the curve') or keeping the reproduction number substantially below one ('squashing the curve'). The aim of this study was to determine the clinical and economic value of a shutdown that is successful in 'flattening' or 'squashing the curve' in Germany. Methods: In the base case, the study compared a successful shutdown to a worst-case scenario with no ICU capacity left to treat COVID-19 patients. To this end, a decision model was developed using, e.g., information on age-specific fatality rates, ICU outcomes, and the herd protection threshold. The value of an additional life year was borrowed from new, innovative oncological drugs, as cancer reflects a condition with a similar morbidity and mortality burden in the general population in the short term as COVID-19. Results: A shutdown that is successful in 'flattening the curve' is projected to yield an average health gain between 0.01 and 0.05 life years (0.1 to 0.6 months) per capita in the German population. The corresponding economic value ranges between €616 and €4797 per capita or, extrapolated to the total population, 1%-12% of the gross domestic product (GDP) in 2019. A shutdown that is successful in 'squashing the curve' is expected to yield a minimum health gain of 0.08 life years (1 month) per capita, corresponding to 19 % of the GDP in 2019. Results are particularly sensitive to mortality data and the prevalence of undetected cases. Conclusion: A successful shutdown is forecasted to yield a considerable gain in life years in the German population. Nevertheless, questions around the affordability and underfunding of other parts of the healthcare system emerge.