Economic Evaluation of Decennial Pertussis Vaccination with Tetanus, Diphtheria and Acellular Pertussis (TDAP) Vaccine in Adult Populations with Asthma or Chronic Obstructive Pulmonary Disease (COPD) in Brazil

Objectives: Pertussis, a highly contagious respiratory disease caused by Bordetella pertussis, is endemic in Brazil, but is underdiagnosed in adults due to atypical symptomatology and limited diagnosis time window. Brazil's Ministry of Health recommends decennial boosters in adults against diphtheria and tetanus, but not pertussis. After the COVID-19 pandemic, infectious diseases surged worldwide due to lack of natural exposure and reduced immunization coverage. Asthma and COPD populations are at increased risk of pertussis infection. This study assessed the cost-utility of decennial pertussis vaccination with Tdap vaccine versus no pertussis vaccination in Brazil's adult asthma and COPD populations in a high-incidence context. Method(s): A static cross-sectional population-based cost-utility model of decennial Tdap boosters in asthma patients >=50 years and COPD patients >=40 years was developed from the payer's perspective. Pertussis incidence from Sao Paulo's state surveillance system in the peak year 2014 was adjusted for underdiagnosis and relative risk of pertussis in asthma and COPD populations. Vaccine efficacy and coverage, and costs and outcomes discounted at 5%, were obtained from the literature and public databases. Deterministic and probabilistic sensitivity analyses, and scenario analyses were run, including alternative annual incidence. Result(s): In the asthma population, Tdap boosters would incur 7,065,788 Brazilian reais (BRL) direct costs and save 32.85 Life Years (LYs) and 262.13 Quality-Adjusted LYs (QALYs). In the COPD population, Tdap boosters would incur 41,102,844 BRL direct costs and save 157.47 LYs and 1,078.26 QALYs. Discounted incremental cost-utility ratios were 26,956 and 38,120 BRL/QALY in asthma and COPD populations, respectively. At a cost-effectiveness threshold of 1 Gross Domestic Product (GDP)/capita, 85.8% and 49.7% of simulations were cost-effective in asthma and COPD populations, respectively, while all simulations were cost-effective at a threshold of 3 GDP/capita. Conclusion(s): Implementing decennial Tdap boosters for adult asthma and COPD patients should be considered, given the favorable cost-utility profile in peak-incidence years.Copyright © 2023

Cost-effectiveness analysis of vaccination against COVID-19 in China.

Introduction: Since September 2020, Chinese populations aged > 3 years have been encouraged to receive a two-dose inoculation with vaccines against coronavirus disease 2019 (COVID-19). This study aims to evaluate the cost-effectiveness of the current vaccination strategy amongst the general population in mainland China from a societal perspective. Methods: In this study, we construct a decision tree with Markov models to compare the economic and health consequences of the current vaccination strategy versus a no-vaccination scenario, over a time horizon of one year and an annual discount rate of 5%. Transition probabilities, health utilities, healthcare costs, and productivity losses are estimated from literature. Outcome measures include infection rates, death rates, quality-adjusted life years (QALYs), and costs. The incremental cost-effectiveness ratio (ICER) is then calculated to evaluate the cost-effectiveness of the current vaccination strategy, and both one-way deterministic sensitivity analysis and probabilistic sensitivity analysis (PSA) are applied to assess the impact of uncertainties on results. Results: Our simulation indicates that compared with a no-vaccination scenario, vaccination amongst the general population in mainland China would reduce the infection rate from 100% to 45.3% and decrease the death rate from 6.8% to 3.1%. Consequently, the strategy will lead to a saving of 37,664.77 CNY (US$5,256.70) and a gain of 0.50 QALYs per person per year on average (lifetime QALY and productivity loss due to immature death are included). The cost-saving for each QALY gain is 74,895.69 CNY (US$10,452.85). Result of the PSA indicates that vaccination is the dominating strategy with a probability of 97.9%, and the strategy is cost-effective with a probability of 98.5% when the willingness-to-pay (WTP) is 72,000 CNY (US$10,048.71) per QALY. Conclusion: Compared with a no-vaccination scenario, vaccination among the general population in mainland China is the dominating strategy from a societal perspective. The conclusion is considered robust in the sensitivity analyses.

Economic evaluations of antivirals for pandemic influenza viruses

Background: The coronavirus, COVID-19, has caused a global pandemic of an unprecedented scale. The efficacy of antivirals and other drugs, considered for repurposing, is assessed in clinical trials. It is not clear, however, whether these treatments, when available, will be cost effective. Purpose(s): To systematically review published economic evaluations of antivirals for the management of pandemic influenza. Method(s): The following databases were searched from inception to 26 March 2020: Medline (EBSCO HOST), EMBASE (OVID), EconLit (OVID), NHS EED (OVID) and HTA (OVID). Citation tracking and reference checking were also used. Only full economic evaluations published in the last ten years were included. Studies were quality assessed using NICE economic evaluation checklist. Data were extracted into standard data extraction tables and narratively summarised. Result(s): Of 709 records identified, 14 studies were included. These were mostly conducted in high income countries. They were seven (50.0%) cost-utility analyses, four (28.6%) cost-effectiveness analyses, two (14.3%) cost-consequences analyses, and one (7.1%) cost-benefit analysis. Antiviral treatment-containing strategies were found to be either cost saving or cost effective. Empirical treatment was more cost effective than test-guided treatment for young adults but less for older adults. Infection rate, prevalence, antiviral efficacy and costs were the key drivers of cost effectiveness Conclusion(s): Antiviral treatment for managing pandemic influenza viruses that have high case fatality rate, similar to the COVID-19 pandemic, has shown to be cost effective, either as standalone intervention or part of a multifaceted strategy.

Assessing health-related quality-of-life in Australian Multiple Sclerosis Longitudinal Study participants using six multi-attribute utility instruments: implications for healthcare decision-making

Background: Despite important discoveries/advances in treating multiple sclerosis (MS), people with MS (pwMS) can experience delays in accessing new treatments if decision-makers lack robust health economic evidence including health-related quality-of-life (HRQoL) benefits of the intervention. Health state utilities (HSU) are a HRQoL input for cost-utility analysis. Objective(s): Several multi-attribute utility instruments (MAUIs) are available from which HSUs can be derived, but the most appropriate MAUI for use in MS has not been identified. We aimed to determine the preferentially sensitive MAUI(s) that capture the full impact of MS on HRQoL. Method(s): Participants in this study came from a comprehensive HRQoL survey (mid-2020) of the Australian MS Longitudinal Study. The survey included six MAUIs (EQ-5D-5L/ EQ-5D5LPsychosocial, SF-6D versions 1 and 2, AQoL-8D and PropR), and sociodemographic, Covid19-related and subjective wellbeing data. HSUs were generated from Australian value sets. Ceiling and floor effects were investigated. Bland-Altman plots and Shannon's Indices were examined. Minimal important differences and population norms were sourced from the literature. Result(s): N=1,683 pwMS completed the survey (67% response). HSUs were derived for >97% of respondents. Mean age 58.6 years, 80% female, 19% reported severe disease and 63% had relapsing-remitting MS. Mean (SD) HSUs ranged from 0.45+/-0.29 (SF-6Dv1) to 0.63+/-0.22 (AQoL-8D). EQ-5D-5L revealed the highest ceiling (HSU=1.0;n=157,10%) and floor (HSU<=0;n=113,7%) effects. PwMS with EQ-5D-5L HSU<=0/HSU=1 reported mean HSUs of 0.37/0.91, 0.35/0.90, and 0.08/0.85 for the AQoL-8D, EQ-5D5LPsychosocial and SF-6D, respectively. Conclusion(s): While the EQ-5D is the most commonly cited MAUI (in 85% of health technology assessment guidelines), our preliminary comparison results suggest the EQ-5D-5L is not preferentially sensitive in assessing the complex HRQoL domains for pwMS.

Cost Utility Of Vaccination Against COVID-19 In Brazil Ricardo Fernandes, Marisa Santos

Introduction. The severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), which causes coronavirus disease 2019 (COVID-19), is a single-strand ribonucleic acid virus that was first identified in January 2020 in patients with viral pneumonia in Wuhan, China. The virus has since spread rapidly around the world, leading the World Health Organization to declare it a pandemic on 11 March 2020. In Brazil there have been 21.8 million cases of SARS-CoV-2 infection and 608,500 deaths. The objective of this study was to evaluate the cost utility of the Oxford, CoronaVac, and Janssen vaccines from the perspective of the Brazilian public health system. Methods. Three microsimulation models were constructed using individual data. The simulations contained seven transition states related to the natural history of COVID-19. The model with a daily cycle had a time horizon of one year and used data from 289 days of the pandemic. The analysis considered direct medical costs from the Brazilian health system perspective. Outpatient, hospital, and mortality databases were used for the model inputs and patient data were stratified by age. Effective vaccines reduced the likelihood of patients becoming ill. Information on the quality of life of patients receiving treatment in the outpatient or hospital setting and disease sequelae were extracted from the published literature. The main outcome of the analysis was quality-adjusted life-years (QALYs). Results. The vaccines had incremental cost-utility ratios ranging from USD 4,121 (Oxford) to USD 3,160 per QALY (CoronaVac). The older the population, the lower the incremental cost-utility ratio. Given a willingness-to-pay threshold of BRL 3,129 per QALY, all the vaccines were considered cost effective in the probabilistic sensitivity analysis. The incremental cost-effectiveness ratio stratified by age ranged from USD 6,327 per QALY in patients older than 75 years (Janssen) to USD 20,993 per QALY in patients younger than 59 years (CoronaVac). Conclusions. The results of this analysis, stratified by patient age, can help in the preparation of a vaccination prioritization plan.

Intensive care unit resources and patient-centred outcomes in severe COVID-19: a prospective single-centre economic evaluation.

During the COVID-19 pandemic, ICU bed shortages sparked a discussion about resource allocation. We aimed to analyse the value of ICU treatment of COVID-19 from a patient-centred health economic perspective. We prospectively included 49 patients with severe COVID-19 and calculated direct medical treatment costs. Quality of life was converted into aggregated quality-adjusted life years using the statistical remaining life expectancy. Costs for non-treatment as the comparator were estimated using the value of statistical life year approach. We used multivariable linear or logistic regression to identify predictors of treatment costs, quality of life and survival. Mean (SD) direct medical treatment costs were higher in patients in ICU with COVID-19 compared with those without (£60,866 (£42,533) vs. £8282 (£14,870), respectively; p < 0.001). This was not solely attributable to prolonged ICU length of stay, as costs per day were also higher (£3115 (£1374) vs. £1490 (£713), respectively; p < 0.001), independent of overall disease severity. We observed a beneficial cost-utility value of £7511 per quality-adjusted life-year gained, even with a more pessimistic assumption towards the remaining life expectancy. Extracorporeal membrane oxygenation therapy provided no additional quality-adjusted life-year benefit. Compared with non-treatment (costs per lost life year, £106,085), ICU treatment (costs per quality-adjusted life-year, £7511) was economically preferable, even with a pessimistic interpretation of patient preferences for survival (sensitivity analysis of the value of statistical life year, £48,848). Length of ICU stay was a positive and extracorporeal membrane oxygenation a negative predictor for quality of life, whereas costs per day were a positive predictor for mortality. These data suggest that despite high costs, ICU treatment for severe COVID-19 may be cost-effective for quality-adjusted life-years gained.

Economic evaluation for mass vaccination against COVID-19.

BACKGROUND: Vaccine is supposed to be the most effective means to prevent COVID-19 as it may not only save lives but also reduce productivity loss due to resuming pre-pandemic activities. Providing the results of economic evaluation for mass vaccination is of paramount importance for all stakeholders worldwide. METHODS: We developed a Markov decision tree for the economic evaluation of mass vaccination against COVID-19. The effectiveness of reducing outcomes after the administration of three COVID-19 vaccines (BNT162b2 (Pfizer-BioNTech), mRNA-1273 (Moderna), and AZD1222 (Oxford-AstraZeneca)) were modelled with empirical parameters obtained from literatures. The direct cost of vaccine and COVID-19 related medical cost, the indirect cost of productivity loss due to vaccine jabs and hospitalization, and the productivity loss were accumulated given different vaccination scenarios. We reported the incremental cost-utility ratio and benefit/cost (B/C) ratio of three vaccines compared to no vaccination with a probabilistic approach. RESULTS: Moderna and Pfizer vaccines won the greatest effectiveness among the three vaccines under consideration. After taking both direct and indirect costs into account, all of the three vaccines dominated no vaccination strategy. The results of B/C ratio show that one dollar invested in vaccine would have USD $13, USD $23, and USD $28 in return for Moderna, Pfizer, and AstraZeneca, respectively when health and education loss are considered. The corresponding figures taking value of the statistical life into account were USD $176, USD $300, and USD $443. CONCLUSION: Mass vaccination against COVID-19 with three current available vaccines is cost-saving for gaining more lives and less cost incurred.

Cost Utility of Vaccination Against COVID-19 in Brazil.

OBJECTIVES: The objective of this study was to evaluate the cost-utility of the Oxford, CoronaVac, and Janssen COVID-19 vaccines from the perspective of the Brazilian public health system. METHODS: A total of 3 microsimulation models were constructed with individual data to evaluate the 3 vaccines. The simulation contains 7 transition states that are related to the natural history of the disease. The model with a daily cycle has a time horizon of 1 year and uses data from 289 days of the pandemic. The analysis was conducted from the perspective of the Brazilian public health system considering direct medical costs. For the model inputs, outpatient and hospital databases were used with information on treated patients stratified by age. Information on mortality was also stratified based on patients' age in the mortality database (SIM). The efficacy of vaccines to reduce the likelihood of patients becoming ill was evaluated independently for each vaccine. Information on the quality of life of patients in outpatient or hospital treatment and the sequelae resulting from the disease were extracted from the literature. The main outcome of the analysis was quality-adjusted life-years (QALYs). RESULTS: The vaccines showed incremental cost-utility ratios ranging from R$-23 161.3/QALY (Oxford) to R$17 757.85/QALY (CoronaVac). The older the population, the lower was the incremental cost-utility ratio. Given a willingness-to-pay threshold of R$17 586/QALY, all the vaccines were considered cost-effective in the probabilistic sensitivity analysis. CONCLUSIONS: The results of the analysis by age group can help in the preparation of a vaccination prioritization plan.

Economic Evaluation of the Protecting Teeth @ 3 Randomized Controlled Trial.

INTRODUCTION: An economic evaluation (EE) was conducted alongside a randomized controlled trial (the Protecting Teeth @ 3 Study [PT@3]), exploring the additional preventive value of fluoride varnish (FV) application at 6-monthly intervals in nursery schools compared to treatment as usual (TAU) in the same nurseries. TAU represented a multicomponent national child oral health improvement intervention, the Childsmile program, apart from nursery FV. METHODS: The EE was a within-trial cost-utility analysis (CUA) comparing the FV and TAU groups. The CUA was conducted from a National Health Service perspective and followed relevant methods guidance. Within-trial costs included intervention costs and health care resource use costs. Health outcomes were expressed in quality-adjusted life years (QALYs) accrued over the 2-y follow-up period. The Child Health Utility 9 Dimensions questionnaire was used to obtain utility scores. National reference costs were used, a discount rate of 1.5% for public health interventions was adopted, multiple imputation methods for missing data were employed, sensitivity analyses were conducted, and incremental cost-utility ratios were calculated. RESULTS: Data from 534 participants from the 2014-2015 PT@3 intake were used in the EE analyses, n = 265 (50%) in the FV arm and n = 269 (50%) in the TAU arm. Mean incremental cost per child in the FV arm was £68.37 (P = 0.382; 95% confidence interval [CI], -£18.04 to £143.82). Mean incremental QALY was -0.004 (P = 0.636; 95% CI, -0.016 to 0.007). The probability that the FV intervention was cost-effective at the UK £20,000 threshold was 11.3%. CONCLUSION: The results indicate that applying FV in nurseries in addition to TAU (all other components of Childsmile, apart from nursery FV) would not be deemed cost-effective given current UK thresholds. In view of previously proven clinical effectiveness and economic worthiness of the universal nursery toothbrushing component of Childsmile, continuation of the additional, targeted nursery FV component in its pre-COVID-19 form should be reviewed given its low probability of cost-effectiveness. KNOWLEDGE TRANSFER STATEMENT: The results of this study can be used by child oral health policy makers and dental public health professionals. They can form part of the evidence to inform the Scottish, UK, and international guidance on community-based child oral health promotion programs.

POSC74 Considerations for Mental Health Effects in Health Economic Analyses

Background: COVID-19 illuminated the fragility and importance of mental wellbeing. While health economic analyses often exclusively focus on direct health impacts and costs specific to the disease being assessed, these analyses commonly neglect downstream mental health impacts and costs of poor prognosis, debilitating adverse events, ineffective therapy, or limited remaining interventional options. Therefore, economic analyses may not capture the full picture when comparing interventions. Aim: This work aims to consider the psychological consequences applicable to all diseases and to outline key areas in economic analyses where such considerations could be effectively captured. The two overarching areas where mental health consequences can be included are: (1) quality of life (QoL), measured as utility in cost-utility analyses;and (2) monetary costs. Health state-specific utility values likely capture the mental health aspects of the included disease states (e.g., progressive or progression-free disease), and adverse event- and administration-related disutilities capture the negative mental health effects of treatment side-effects and administration, respectively. However, other factors can have substantial consequences on a patient’s mental health and, as a result, will impact their QoL (e.g., patients who have exhausted all available treatment/intervention options may have a lower utility than patients who have not). Moreover, monetary costs included in economic analyses typically focus on direct healthcare requirements of the disease and indirect costs relating to caregiving, lost wages and/or lost productivity (depending on the perspective taken). Evaluations rarely consider the potentially significant accompanying monetary costs of psychotherapy or lost working time due to mental health detriment. Conclusions: Most health economic analyses solely include costs and outcomes directly related to the specific indication being assessed, but downstream mental health costs/consequences can have a significant impact on a patient’s QoL and costs incurred. Accounting for mental health in economic analyses can substantially impact findings and may provide more complete view.

Evaluation of the cost-utility of a prescription digital therapeutic for the treatment of opioid use disorder.

Background: The opioid epidemic continues to generate a significant mental and physical health burden on patients, and claims the life of almost 150 Americans daily. Making matters worse, an increase in relapses and/or opioid-related deaths has been reported in more than 40 U.S. states since the start of the COVID-19 pandemic. Opioid use disorder (OUD) is one of the single most expensive disorders in the United States, generating average medical costs of $60B from just 2 million Americans diagnosed with the disorder. In commercial use since 2019, reSET-O is a non-drug, prescription digital therapeutic (PDT) that delivers evidence-based neurobehavioral treatment for OUD and helps overcome the barriers associated with access to care, stigma, and social distancing. Although shown to be cost effective and efficacious in clinical trials and real-world evidence studies, respectively, information on its value for money from a health utilities and cost per quality-adjusted life-year is needed to inform policy discussions.Objectives: To evaluate the impact of reSET-O on health utilities and assess its overall cost per quality-adjusted life year (QALY) gained vs. treatment-as-usual (TAU).Methods: Decision analytic model comparing reSET-O plus TAU to TAU alone (i.e. buprenorphine, face-to-face counseling, and contingency management) over 12 weeks. Clinical effectiveness data (abstinence and health utility) were obtained from a clinical trial, and resource utilization and cost data were adapted from a recent claims data analysis to reflect less frequent face-to-face counseling with the therapeutic.Results: The addition of reSET-O to TAU decreases total health care costs by -$131 and resulted in post-treatment utility values within population norms, with a corresponding gain of 0.003 QALYs. reSET-O when used adjunctively to TAU was economically dominant (less costly, more effective) vs. TAU alone.Conclusion: reSET-O is an economically-dominant adjunctive treatment for OUD and is associated with an overall reduction in total incremental cost vs TAU.