Cost-utility analysis of biologic disease-modifying antirheumatic drugs (bDMARDs), targeted synthetic DMARDs (tsDMARDs) and biosimilar DMARDs (bsDMARDs) combined with methotrexate for Thai rheumatoid arthritis patients with high disease activity.

BACKGROUND: New biologic disease-modifying antirheumatic drugs (bDMARDs), targeted synthetic DMARDs (tsDMARDs) and biosimilar DMARDs (bsDMARDs) all showed greater clinical benefits in the treatment of patients with rheumatoid arthritis (RA) with high disease activity, but imposed higher costs than standard treatment. This study evaluated the cost-effectiveness of 11 alternative treatment strategies for RA patients with high disease activity whose treatment with three conventional synthetic DMARDs (csDMARDs) failed. METHODS: A Markov model was constructed using a societal perspective to estimate relevant costs and health outcomes in terms of quality-adjusted life years (QALYs) for a lifetime horizon (100 years), given a 3% annual discount. Alternative treatment strategies including five bDMARDs, two tsDMARDs, and four bsDMARDs in combination with methotrexate (MTX) were compared with the standard of care (SoC), i.e., cyclosporine and azathioprine. Direct and non-medical care costs were estimated by identifying the resources used, then multiplied by the standard costing menu in the year 2022. Utility and transitional probabilities were collected in three advanced tertiary hospitals. A network meta-analysis was used to estimate the efficacy of each treatment. Lifetime cost, QALYs and an incremental cost-effectiveness ratio were calculated and compared to the cost-effectiveness threshold of 160,000 THB per QALY gained (US $4,634, where 1 USD = 34.53 THB in 2022). Probabilistic and one-way sensitivity analyses were performed to estimate parameter uncertainties. RESULTS: The bDMARDs, tsDMARDs or bsDMARDs combined with MTX provided 0.09 to 0.33 QALYs gained with additional costs of 550,986 to 2,096,744 THB (US $15,957 to $60,722) compared to the SoC. The ICER ranged from 2.3 to 8.1 million THB per QALY (US $65,935 to $234,996) compared to the SoC. None of these combinations was cost-effective in the Thai context. The results were sensitive to the mortality hazard ratio of patients with high disease activity. CONCLUSIONS: Combinations of MTX with either bDMARDs, tsDMARDs or bsDMARDs were not economically attractive compared to the standard practice. However, they reduced disease activity and improved patient quality of life. The price negotiation process for these treatments must be conducted to ensure their financial value and affordability before they are included in the pharmaceutical reimbursement list.

Assessing the cost-effectiveness of COVID-19 vaccines in a low incidence and low mortality setting: the case of Thailand at start of the pandemic.

OBJECTIVE: This study aimed to assess the cost-effectiveness of COVID-19 vaccines, preferred COVID-19 vaccine profiles, and the preferred vaccination strategies in Thailand. METHODS: An age-structured transmission dynamic model was developed based on key local data to evaluate economic consequences, including cost and health outcome in terms of life-years (LYs) saved. We considered COVID-19 vaccines with different profiles and different vaccination strategies such as vaccinating elderly age groups (over 65s) or high-incidence groups, i.e. adults between 20 and 39 years old who have contributed to more than 60% of total COVID-19 cases in the country thus far. Analyses employed a societal perspective in a 1-year time horizon using a cost-effectiveness threshold of 160,000 THB per LY saved. Deterministic and probabilistic sensitivity analyses were performed to identify and characterize uncertainty in the model. RESULTS: COVID-19 vaccines that block infection combined with social distancing were cost-saving regardless of the target population compared to social distancing alone (with no vaccination). For vaccines that block infection, the preferred (cost-effective) strategy was to vaccinate the high incidence group. Meanwhile, COVID-19 vaccines that reduces severity (including hospitalization and mortality) were cost-effective when the elderly were vaccinated, while vaccinating the high-incidence group was not cost-effective with this vaccine type. Regardless of vaccine type, higher vaccination coverage, higher efficacy, and longer protection duration were always preferred. More so, vaccination with social distancing measures was always preferred to strategies without social distancing. Quarantine-related costs were a major cost component affecting the cost-effectiveness of COVID-19 vaccines. CONCLUSION: COVID-19 vaccines are good value for money even in a relatively low-incidence and low-mortality setting such as Thailand, if the appropriate groups are vaccinated. The preferred vaccination strategies depend on the type of vaccine efficacy. Social distancing measures should accompany a vaccination strategy.

A Data-Driven Analysis of the Economic Cost of Non-Pharmaceutical Interventions: A Cross-Country Comparison of Kenya, Singapore, and Thailand.

Objective: To estimate the economic impact of border closure and social distancing by estimating the decline of gross domestic product (GDP) in Kenya, Singapore and Thailand. Methods: We analysed secondary data retrospectively. To calculate impact of NPIs on GDP, the relationship between GDP and stock market index was examined using ordinary least squares (OLS). Then, autoregressive and moving averages (ARMA) model was used to examine the impact of NPI on stock market index. The change in GDP due to NPIs was derived by multiplying coefficients of OLS and ARMA models. Results: An increase in stock market index correlated with an increase in GDP, while both social distancing and border closure negatively correlated with stock market index. Implementation of NPIs correlated with the decline in GDP. Thai border closure had a greater decline in GDP than social distancing; Kenya exhibited the same trends; Singapore had the opposite trend. Conclusion: We quantified the magnitude of economic impact of NPIs in terms of GDP decline by linking stock market index and GDP. This approach may be applicable in other settings.

Binding and neutralizing antibody levels and vaccine efficacy/effectiveness compared between heterologous and homologous primary series COVID-19 vaccination: A systematic review and meta-analysis.

BACKGROUND: The data on the immunogenicity and efficacy of heterologous primary series COVID-19 vaccination are still limited. OBJECTIVE: To investigate the immunogenicity and vaccine efficacy/effectiveness compared between heterologous and homologous primary series COVID-19 vaccination. METHODS: We conducted a multi-source search for randomized controlled trials, prospective cohort, and case-control studies that investigated the immunogenicity or vaccine efficacy/effectiveness (VE) of heterologous primary series vaccination. Six online databases were searched from inception to June 2022. The primary outcome was the levels of binding antibodies and neutralizing antibodies (NAbs), and the secondary outcomes were VE against COVID-19 infection, hospitalization, and death. RESULTS: Among the 28 included studies, 21 and 7 were included to investigate immunogenicity and VE outcome, respectively. Heterologous CoronaVac (CV)/ChAdOx1 (ChAd) induced higher anti-RBD IgG and NAbs against wild type and delta variants compared to homologous CV or ChAd. However, risk of documented infection of CV/ChAd was similar to homologous CV, but higher than homologous ChAd (odds ratio: 2.56, 95% CI: 1.02-6.37). Heterologous ChAd/BNT162b2 (BNT) elicited a higher anti-spike level than homologous ChAd or BNT, and induced a higher NAbs level against delta variants compared to homologous ChAd. The VE of ChAd/BNT and homologous ChAd or BNT against hospitalization were similar. CONCLUSIONS: Heterologous CV/ChAd induced higher binding and neutralizing antibody levels than homologous CV or ChAd; and, ChAd/BNT induced higher binding and neutralizing antibody levels than homologous ChAd. However, CV/ChAd demonstrated increased risk of infection compared to homologous ChAd. Therefore, immunogenicity findings and real-world vaccine efficacy/effectiveness should be integrated in clinical practice.

Avoiding Trouble Ahead: Lessons Learned and Suggestions for Economic Evaluations of COVID-19 Vaccines.

With vaccines for coronavirus disease 2019 (COVID-19) being introduced in countries across the world, policy makers are facing many practical considerations about how best to implement a vaccination programme. The supply of vaccines is insufficient for the global population, so decisions must be made as to which groups are prioritised for any vaccination and when. Furthermore, the aims of vaccination programmes will differ between countries, with some prioritising economic benefits that could stem from the relaxation of non-pharmaceutical interventions and others seeking simply to reduce the number of COVID-19 cases or deaths. This paper aims to share the experiences and lessons learned from conducting economic evaluations in Singapore and Thailand on hypothetical COVID-19 vaccines to provide a basis for other countries to develop their own contextualised economic evaluations, with particular focus on the key uncertainties, technical challenges, and characteristics that modellers should consider in partnership with key stakeholders. Which vaccines, vaccination strategies, and policy responses are most economically beneficial remains uncertain. It is therefore important for all governments to conduct their own analyses to inform local policy responses to COVID-19, including the implementation of COVID-19 vaccines in both the short and the long run. It is essential that such studies are designed, and ideally conducted, before vaccines are introduced so that policy decisions and implementation procedures are not delayed.

Cost-effectiveness analysis of HLA-B*58: 01 genetic testing before initiation of allopurinol therapy to prevent allopurinol-induced Stevens-Johnson syndrome/toxic epidermal necrolysis in a Malaysian population.

OBJECTIVE: Studies found a strong association between allopurinol-induced Stevens-Johnson syndrome (SJS)/toxic epidermal necrolysis (TEN) and the HLA-B*58:01 allele. HLA-B*58:01 screening-guided therapy may mitigate the risk of allopurinol-induced SJS/TEN. This study aimed to evaluate the cost-effectiveness of HLA-B*58:01 screening before allopurinol therapy initiation compared with the current practice of no screening for Malaysian patients with chronic gout in whom a hypouricemic agent is indicated. METHODS: This cost-effectiveness analysis adopted a societal perspective with a lifetime horizon. A decision tree model coupled with Markov models were developed to estimate the costs and outcomes, represented by quality-adjusted life years (QALYs) gained, of three treatment strategies: (a) current practice (allopurinol initiation without HLA-B*58:01 screening); (b) HLA-B*58:01 screening before allopurinol initiation; and (c) alternative treatment (probenecid) without HLA-B*58:01 screening. The model was populated with data from literature review, meta-analysis, and published government documents. Cost values were adjusted for the year 2016, with costs and health outcomes discounted at 3% per annum. A series of sensitivity analysis including probabilistic sensitivity analysis were carried out to determine the robustness of the findings. RESULTS: Both HLA-B*58:01 screening and probenecid prescribing were dominated by current practice. Compared with current practice, HLA-B*58:01 screening resulted in 0.252 QALYs loss per patient at an additional cost of USD 322, whereas probenecid prescribing resulted in 1.928 QALYs loss per patient at an additional cost of USD 2203. One SJS/TEN case would be avoided for every 556 patients screened. At the cost-effectiveness threshold of USD 8695 per QALY, the probability of current practice being the best choice is 99.9%, in contrast with 0.1 and 0% in HLA-B*58:01 screening and probenecid prescribing, respectively. This is because of the low incidence of allopurinol-induced SJS/TEN in Malaysia and the lower efficacy of probenecid compared with allopurinol in gout control. CONCLUSION: This analysis showed that HLA-B*58:01 genetic testing before allopurinol initiation is unlikely to be a cost-effective intervention in Malaysia.