An economic evaluation of restorative justice post-sentence in England and Wales.

Introduction: Participation in restorative justice interventions post-sentence has been shown to reduce reoffending and mitigate harm to victims. Investment in, and access to, restorative justice remains limited in England and Wales. An economic model was developed to synthesize the available evidence in order to develop contemporary and robust estimates of the economic impact of investment in restorative justice interventions. Methods: This research focused on direct and indirect restorative justice interventions for victims and offenders post-sentence in England and Wales. Included offences were those with an identifiable victim. A model was developed to estimate the social benefit-cost ratio of restorative justice, as well as the direct financial return to the criminal justice system. The modeled benefits of restorative justice included reductions in reoffending and direct wellbeing benefits for victims. It was not possible to incorporate direct wellbeing benefits for offenders due to evidence gaps. Results: In the model, 8% of referrals to restorative justice resulted in direct restorative justice interventions and 19% resulted in indirect Restorative justice interventions. The modeled cost of the restorative justice pathway per direct intervention was £3,394. The base case estimate for the social benefit-cost ratio of restorative justice was £14 per £1 invested, with a direct return to the criminal justice system of £4 as a result of substantial reductions in reoffending. Scenario analysis suggested a plausible range of £7 to £20 social benefit per £1 invested. Hypothetically, increasing the proportion of eligible cases referred for a restorative justice intervention from 15 to 40% could be associated with an increase in investment of £5 m, and benefits to the criminal justice system totaling £22 m, implying a net saving of £17 m. Conclusion: The research suggests that Restorative justice has the potential to yield a substantial social return on investment (SROI) and direct return on investment to the criminal justice system. The economic case for investment in restorative justice centers on identifying offenders with a high risk of offending and enabling them to participate in an intervention that has been repeatedly demonstrated to help them to change their behavior.

Cost-effectiveness of an insertable cardiac monitor in a high-risk population in the US.

BACKGROUND: Insertable cardiac monitors (ICMs) are a clinically effective means of detecting atrial fibrillation (AF) in high-risk patients, and guiding the initiation of non-vitamin K oral anticoagulants (NOACs). Their cost-effectiveness from a US clinical payer perspective is not yet known. The objective of this study was to evaluate the cost-effectiveness of ICMs compared to standard of care (SoC) for detecting AF in patients at high risk of stroke (CHADS2 ≥ 2), in the US. METHODS: Using patient data from the REVEAL AF trial (n = 393, average CHADS2 score = 2.9), a Markov model estimated the lifetime costs and benefits of detecting AF with an ICM or with SoC (specifically intermittent use of electrocardiograms and 24-h Holter monitors). Ischemic and hemorrhagic strokes, intra- and extra-cranial hemorrhages, and minor bleeds were modelled. Diagnostic and device costs, costs of treating stroke and bleeding events and medical therapy-specifically costs of NOACs were included. Costs and health outcomes, measured as quality-adjusted life years (QALYs), were discounted at 3% per annum, in line with standard practice in the US setting. One-way deterministic and probabilistic sensitivity analyses (PSA) were undertaken. RESULTS: Lifetime per-patient cost for ICM was $31,116 versus $25,330 for SoC. ICMs generated a total of 7.75 QALYs versus 7.59 for SoC, with 34 fewer strokes projected per 1000 patients. The model estimates a number needed to treat of 29 per stroke avoided. The incremental cost-effectiveness ratio was $35,528 per QALY gained. ICMs were cost-effective in 75% of PSA simulations, using a $50,000 per QALY threshold, and a 100% probability of being cost-effective at a WTP threshold of $150,000 per QALY. CONCLUSIONS: The use of ICMs to identify AF in a high-risk population is likely to be cost-effective in the US healthcare setting.

The Challenges of Outcomes-Based Contract Implementation for Medicines in Europe.

OBJECTIVES: The aim was to outline the challenges of implementing outcomes-based contracts (OBCs) in Europe. METHODS: A scoping review was conducted, building on the searches of a previous systematic review and updating them for December 2017 until May 2021. The combined results were screened, based on inclusion and exclusion criteria. All identified studies published in the English language that described specific OBC schemes for medicines in European countries were included. Insights into the challenges of OBCs were extracted and analysed to develop a conceptual framework. RESULTS: Ten articles from the previous systematic review matched our inclusion criteria, along with 14 articles from electronic searches. Analysis of these 24 articles and classification of the challenges revealed that there are multiple barriers that must be overcome if OBCs that benefit all stakeholders are going to be adopted widely across Europe. These challenges were grouped according to five key themes: negotiation framework; outcomes; data; administration and implementation; and laws and regulation. CONCLUSIONS: If the promise of OBCs is to be fully realised in Europe, there remain major challenges that need to be overcome by all stakeholders working in partnership. The overlapping and interconnected nature of these challenges highlights the complexity of OBC arrangements.

Cost-effectiveness of an insertable cardiac monitor to detect atrial fibrillation in patients with cryptogenic stroke.

Background: We assessed cost-effectiveness of insertable cardiac monitors (ICMs) in a US cryptogenic stroke population. Materials & methods: We modelled lifetime costs and quality-adjusted life years for three monitoring strategies post cryptogenic stroke: ICM starting immediately, ICM starting after Holter monitoring (delayed ICM) and standard of care involving intermittent ECG and Holter monitoring. Patient characteristics and detection efficacy were based on the CRYSTAL-AF trial. AF detection altered the modelled anticoagulation therapy and subsequent stroke and bleed risks. Results & conclusion: Immediate ICM was found to be cost-effective versus standard of care and cost-saving versus delayed ICM. Results were robust to sensitivity analyses. ICMs are a cost-effective diagnostic tool for the prevention of recurrent stroke in a US cryptogenic stroke population.