- Advanced Decision Science Methods and Modeling in Health
HRP 263, MED 263 (Spr)
- Analysis of Costs, Risks, and Benefits of Health Care
BIOMEDIN 432, HRP 392 (Aut)
- Analysis of Costs, Risks, and Benefits of Health Care
MGTECON 332 (Aut)
Independent Studies (9)
- Directed Reading in Health Research and Policy
HRP 299 (Spr)
- Directed Reading in Medicine
MED 299 (Aut, Win, Spr, Sum)
- Early Clinical Experience in Medicine
MED 280 (Aut, Win, Spr, Sum)
- Graduate Research
HRP 399 (Aut, Win, Spr, Sum)
- Graduate Research
MED 399 (Aut, Win, Spr, Sum)
- Medical Scholars Research
HRP 370 (Spr)
- Medical Scholars Research
MED 370 (Aut, Win, Spr, Sum)
- Undergraduate Research
HRP 199 (Spr)
- Undergraduate Research
MED 199 (Aut, Win, Spr)
- Directed Reading in Health Research and Policy
Prior Year Courses
- Advanced Decision Science Methods and Modeling in Health
HRP 263, MED 263 (Spr)
- Advanced Decision Science Methods and Modeling in Health
HRP 263, MED 263 (Spr)
- Measuring Global Health
HRP 241, HUMBIO 129M, MED 231 (Spr)
- Advanced Decision Science Methods and Modeling in Health
HRP 263, MED 263 (Spr)
- Rethinking Global Health
HRP 240, MED 230 (Spr)
- Advanced Decision Science Methods and Modeling in Health
Cost-Effectiveness of Treatment of Diabetic Macular Edema
ANNALS OF INTERNAL MEDICINE
2014; 160 (1): 18-?
View details for Web of Science ID 000330249700003
Disease Control Implications of India's Changing Multi-Drug Resistant Tuberculosis Epidemic.
2014; 9 (3)
Multi-drug resistant tuberculosis (MDR TB) is a major health challenge in India that is gaining increasing public attention, but the implications of India's evolving MDR TB epidemic are poorly understood. As India's MDR TB epidemic is transitioning from a treatment-generated to transmission-generated epidemic, we sought to evaluate the potential effectiveness of the following two disease control strategies on reducing the prevalence of MDR TB: a) improving treatment of non-MDR TB; b) shortening the infectious period between the activation of MDR TB and initiation of effective MDR treatment.We developed a dynamic transmission microsimulation model of TB in India. The model followed individuals by age, sex, TB status, drug resistance status, and treatment status and was calibrated to Indian demographic and epidemiologic TB time trends. The main effectiveness measure was reduction in the average prevalence reduction of MDR TB over the ten years after control strategy implementation. We find that improving non-MDR cure rates to avoid generating new MDR cases will provide substantial non-MDR TB benefits but will become less effective in reducing MDR TB prevalence over time because more cases will occur from direct transmission - by 2015, the model estimates 42% of new MDR cases are transmission-generated and this proportion continues to rise over time, assuming equal transmissibility of MDR and drug-susceptible TB. Strategies that disrupt MDR transmission by shortening the time between MDR activation and treatment are projected to provide greater reductions in MDR prevalence compared with improving non-MDR treatment quality: implementing MDR diagnostic improvements in 2017 is expected to reduce MDR prevalence by 39%, compared with 11% reduction from improving non-MDR treatment quality.As transmission-generated MDR TB becomes a larger driver of the MDR TB epidemic in India, rapid and accurate MDR TB diagnosis and treatment will become increasingly effective in reducing MDR TB cases compared to non-MDR TB treatment improvements.
View details for DOI 10.1371/journal.pone.0089822
View details for PubMedID 24608234
Cost-effectiveness of preoperative imaging for appendicitis after indeterminate ultrasonography in the second or third trimester of pregnancy.
Obstetrics and gynecology
2013; 122 (4): 821-829
To assess the cost-effectiveness of diagnostic laparoscopy, computed tomography (CT), and magnetic resonance imaging (MRI) after indeterminate ultrasonography in pregnant women with suspected appendicitis.A decision-analytic model was developed to simulate appendicitis during pregnancy taking into consideration the health outcomes for both the pregnant women and developing fetuses. Strategies included diagnostic laparoscopy, CT, and MRI. Outcomes included positive appendectomy, negative appendectomy, maternal perioperative complications, preterm delivery, fetal loss, childhood cancer, lifetime costs, discounted life expectancy, and incremental cost-effectiveness ratios.Magnetic resonance imaging is the most cost-effective strategy, costing $6,767 per quality-adjusted life-year gained relative to CT, well below the generally accepted $50,000 per quality-adjusted life-year threshold. In a setting where MRI is unavailable, CT is cost-effective even when considering the increased risk of radiation-associated childhood cancer ($560 per quality-adjusted life-year gained relative to diagnostic laparoscopy). Unless the negative appendectomy rate is less than 1%, imaging of any type is more cost-effective than proceeding directly to diagnostic laparoscopy.Depending on imaging costs and resource availability, both CT and MRI are potentially cost-effective. The risk of radiation-associated childhood cancer from CT has little effect on population-level outcomes or cost-effectiveness but is a concern for individual patients. For pregnant women with suspected appendicitis, an extremely high level of clinical diagnostic certainty must be reached before proceeding to operation without preoperative imaging.
View details for DOI 10.1097/AOG.0b013e3182a4a085
View details for PubMedID 24084540
Cost-effectiveness of helicopter versus ground emergency medical services for trauma scene transport in the United States.
Annals of emergency medicine
2013; 62 (4): 351-364 e19
STUDY OBJECTIVE: We determine the minimum mortality reduction that helicopter emergency medical services (EMS) should provide relative to ground EMS for the scene transport of trauma victims to offset higher costs, inherent transport risks, and inevitable overtriage of patients with minor injury. METHODS: We developed a decision-analytic model to compare the costs and outcomes of helicopter versus ground EMS transport to a trauma center from a societal perspective during a patient's lifetime. We determined the mortality reduction needed to make helicopter transport cost less than $100,000 and $50,000 per quality-adjusted life-year gained compared with ground EMS. Model inputs were derived from the National Study on the Costs and Outcomes of Trauma, National Trauma Data Bank, Medicare reimbursements, and literature. We assessed robustness with probabilistic sensitivity analyses. RESULTS: Helicopter EMS must provide a minimum of a 17% relative risk reduction in mortality (1.6 lives saved/100 patients with the mean characteristics of the National Study on the Costs and Outcomes of Trauma cohort) to cost less than $100,000 per quality-adjusted life-year gained and a reduction of at least 33% (3.7 lives saved/100 patients) to cost less than $50,000 per quality-adjusted life-year. Helicopter EMS becomes more cost-effective with significant reductions in patients with minor injury who are triaged to air transport or if long-term disability outcomes are improved. CONCLUSION: Helicopter EMS needs to provide at least a 17% mortality reduction or a measurable improvement in long-term disability to compare favorably with other interventions considered cost-effective. Given current evidence, it is not clear that helicopter EMS achieves this mortality or disability reduction. Reducing overtriage of patients with minor injury to helicopter EMS would improve its cost-effectiveness.
View details for DOI 10.1016/j.annemergmed.2013.02.025
View details for PubMedID 23582619
Cost-effectiveness of tolvaptan in autosomal dominant polycystic kidney disease.
Annals of internal medicine
2013; 159 (6): 382-389
Chinese translationIn the TEMPO (Tolvaptan Efficacy and Safety in Management of Autosomal Dominant Polycystic Kidney Disease and Its Outcomes) trial, tolvaptan significantly reduced expansion of kidney volume and loss of kidney function.To determine how the benefits of tolvaptan seen in TEMPO may relate to longer-term health outcomes, such as progression to end-stage renal disease (ESRD) and death, and cost-effectiveness.A decision-analytic model.Published literature from 1993 to 2012.Persons with early autosomal dominant polycystic kidney disease.Lifetime.Societal.Patients received tolvaptan therapy until death, development of ESRD, or liver complications or no tolvaptan therapy.Median age at ESRD onset, life expectancy, discounted quality-adjusted life-years and lifetime costs (in 2010 U.S. dollars), and incremental cost-effectiveness ratios.Tolvaptan prolonged the median age at ESRD onset by 6.5 years and increased life expectancy by 2.6 years. At $5760 per month, tolvaptan cost $744 100 per quality-adjusted life-year gained compared with standard care.For patients with autosomal dominant polycystic kidney disease that progressed more slowly, the cost per quality-adjusted life-year gained was even greater for tolvaptan.Although TEMPO followed patients for 3 years, the main analysis assumed that clinical benefits persisted over patients' lifetimes.Assuming that the benefits of tolvaptan persist in the longer term, the drug may slow progression to ESRD and reduce mortality rates. However, barring an approximately 95% reduction in price, cost-effectiveness does not compare favorably with many other commonly accepted medical interventions.National Institutes of Health and Agency for Healthcare Research and Quality.
View details for DOI 10.7326/0003-4819-159-6-201309170-00004
View details for PubMedID 24042366
- Analyzing Screening Policies for Childhood Obesity MANAGEMENT SCIENCE 2013; 59 (4): 782-795
Cost-Effectiveness of Statins for Primary Cardiovascular Prevention in Chronic Kidney Disease
JOURNAL OF THE AMERICAN COLLEGE OF CARDIOLOGY
2013; 61 (12): 1250-1258
The authors sought to evaluate the cost-effectiveness of statins for primary prevention of myocardial infarction (MI) and stroke in patients with chronic kidney disease (CKD).Patients with CKD have an elevated risk of MI and stroke. Although HMG Co-A reductase inhibitors (?statins?) may prevent cardiovascular events in patients with non?dialysis-requiring CKD, adverse drug effects and competing risks could materially influence net effects and clinical decision-making.We developed a decision-analytic model of CKD and cardiovascular disease (CVD) to determine the cost-effectiveness of low-cost generic statins for primary CVD prevention in men and women with hypertension and mild-to-moderate CKD. Outcomes included MI and stroke rates, discounted quality-adjusted life years (QALYs) and lifetime costs (2010 USD), and incremental cost-effectiveness ratios.For 65-year-old men with moderate hypertension and mild-to-moderate CKD, statins reduced the combined rate of MI and stroke, yielded 0.10 QALYs, and increased costs by $1,800 ($18,000 per QALY gained). For patients with lower baseline cardiovascular risks, health and economic benefits were smaller; for 65-year-old women, statins yielded 0.06 QALYs and increased costs by $1,900 ($33,400 per QALY gained). Results were sensitive to rates of rhabdomyolysis and drug costs. Statins are less cost-effective when obtained at average retail prices, particularly in patients at lower CVD risk.Although statins reduce absolute CVD risk in patients with CKD, the increased risk of rhabdomyolysis, and competing risks associated with progressive CKD, partly offset these gains. Low-cost generic statins appear cost-effective for primary prevention of CVD in patients with mild-to-moderate CKD and hypertension.
View details for DOI 10.1016/j.jacc.2012.12.034
View details for Web of Science ID 000316751100006
View details for PubMedID 23500327
Cost-Effectiveness Analysis of Risk-Factor Guided and Birth-Cohort Screening for Chronic Hepatitis C Infection in the United States
2013; 8 (3)
No consensus exists on screening to detect the estimated 2 million Americans unaware of their chronic hepatitis C infections. Advisory groups differ, recommending birth-cohort screening for baby boomers, screening only high-risk individuals, or no screening. We assessed one-time risk assessment and screening to identify previously undiagnosed 40-74 year-olds given newly available hepatitis C treatments.A Markov model evaluated alternative risk-factor guided and birth-cohort screening and treatment strategies. Risk factors included drug use history, blood transfusion before 1992, and multiple sexual partners. Analyses of the National Health and Nutrition Examination Survey provided sex-, race-, age-, and risk-factor-specific hepatitis C prevalence and mortality rates. Nine strategies combined screening (no screening, risk-factor guided screening, or birth-cohort screening) and treatment (standard therapy-peginterferon alfa and ribavirin, Interleukin-28B-guided (IL28B) triple-therapy-standard therapy plus a protease inhibitor, or universal triple therapy). Response-guided treatment depended on HCV genotype. Outcomes include discounted lifetime costs (2010 dollars) and quality adjusted life-years (QALYs). Compared to no screening, risk-factor guided and birth-cohort screening for 50 year-olds gained 0.7 to 3.5 quality adjusted life-days and cost $168 to $568 per person. Birth-cohort screening provided more benefit per dollar than risk-factor guided screening and cost $65,749 per QALY if followed by universal triple therapy compared to screening followed by IL28B-guided triple therapy. If only 10% of screen-detected, eligible patients initiate treatment at each opportunity, birth-cohort screening with universal triple therapy costs $241,100 per QALY. Assuming treatment with triple therapy, screening all individuals aged 40-64 years costs less than $100,000 per QALY.The cost-effectiveness of one-time birth-cohort hepatitis C screening for 40-64 year olds is comparable to other screening programs, provided that the healthcare system has sufficient capacity to deliver prompt treatment and appropriate follow-on care to many newly screen-detected individuals.
View details for DOI 10.1371/journal.pone.0058975
View details for Web of Science ID 000316549400032
View details for PubMedID 23533595
The Utility of Childhood and Adolescent Obesity Assessment in Relation to Adult
MEDICAL DECISION MAKING
2013; 33 (2): 163-175
High childhood obesity prevalence has raised concerns about future adult health, generating calls for obesity screening of young children.To estimate how well childhood obesity predicts adult obesity and to forecast obesity-related health of future US adults.Longitudinal statistical analyses; microsimulations combining multiple data sets.National Longitudinal Survey of Youth, Population Study of Income Dynamics, and National Health and Nutrition Evaluation Surveys.The authors estimated test characteristics and predictive values of childhood body mass index to identify 2-, 5-, 10-, and 15 year-olds who will become obese adults. The authors constructed models relating childhood body mass index to obesity-related diseases through middle age stratified by sex and race.Twelve percent of 18-year-olds were obese. While screening at age 5 would miss 50% of those who become obese adults, screening at age 15 would miss 9%. The predictive value of obesity screening below age 10 was low even when maternal obesity was included as a predictor. Obesity at age 5 was a substantially worse predictor of health in middle age than was obesity at age 15. For example, the relative risk of developing diabetes as adults for obese white male 15-year-olds was 4.5 versus otherwise similar nonobese 15-year-olds. For obese 5-year-olds, the relative risk was 1.6.Main results do not include Hispanics due to sample size. Past relationships between childhood and adult obesity and health may change in the future.Early childhood obesity assessment adds limited information to later childhood assessment. Targeted later childhood approaches or universal strategies to prevent unhealthy weight gain should be considered.
View details for DOI 10.1177/0272989X12447240
View details for Web of Science ID 000316684200006
View details for PubMedID 22647830
Palm oil taxes and cardiovascular disease mortality in India: economic-epidemiologic model.
BMJ (Clinical research ed.)
2013; 347: f6048-?
To examine the potential effect of a tax on palm oil on hyperlipidemia and on mortality due to cardiovascular disease in India.Economic-epidemiologic model.A microsimulation model of mortality due to myocardial infarction and stroke among Indian populations was constructed, incorporating nationally representative data on systolic blood pressure, total cholesterol, tobacco smoking, diabetes, and cardiovascular event history, and stratified by age, sex, and urban/rural residence. Household expenditure data were used to estimate the change in consumption of palm oil following changes in oil price and the potential substitution of alternative oils that might occur after imposition of a tax. A 20% excise tax on palm oil purchases was simulated over the period 2014-23.The model was used to project future mortality due to myocardial infarction and stroke, as well as the potential effect of a tax on food insecurity, accounting for the effect of increased food prices.A 20% tax on palm oil purchases would be expected to avert approximately 363?000 (95% confidence interval 247?000 to 479?000) deaths from myocardial infarctions and strokes over the period 2014-23 in India (1.3% reduction in cardiovascular deaths) if people do not substitute other oils for reduced palm oil consumption. Given estimates of substitution of palm oil with other oils following a 20% price increase for palm oil, the beneficial effects of increased polyunsaturated fat consumption would be expected to enhance the projected reduction in deaths to as much as 421?000 (256?000 to 586?000). The tax would be expected to benefit men more than women and urban populations more than rural populations, given differential consumption and cardiovascular risk. In a scenario incorporating the effect of taxation on overall food expenditures, the tax may increase food insecurity by <1%, resulting in 16?000 (95% confidence interval 12?000 to 22?000) deaths.Curtailing palm oil intake through taxation may modestly reduce hyperlipidemia and cardiovascular mortality, but with potential distributional consequences differentially benefiting male and urban populations, as well as affecting food security.
View details for DOI 10.1136/bmj.f6048
View details for PubMedID 24149818
- Analyzing Screening Policies for Childhood Obesity Management Science 2013; 59 (April): 782-795
Performance of serum biomarkers for the early detection of invasive aspergillosis in febrile, neutropenic patients: a multi-state model.
2013; 8 (6)
The performance of serum biomarkers for the early detection of invasive aspergillosis expectedly depends on the timing of test results relative to the empirical administration of antifungal therapy during neutropenia, although a dynamic evaluation framework is lacking.We developed a multi-state model describing simultaneously the likelihood of empirical antifungal therapy and the risk of invasive aspergillosis during neutropenia. We evaluated whether the first positive test result with a biomarker is an independent predictor of invasive aspergillosis when both diagnostic information used to treat and risk factors of developing invasive aspergillosis are taken into account over time. We applied the multi-state model to a homogeneous cohort of 185 high-risk patients with acute myeloid leukemia. Patients were prospectively screened for galactomannan antigenemia twice a week for immediate treatment decision; 2,214 serum samples were collected on the same days and blindly assessed for (1->3)- ?-D-glucan antigenemia and a quantitative PCR assay targeting a mitochondrial locus.The usual evaluation framework of biomarker performance was unable to distinguish clinical benefits of ?-glucan or PCR assays. The multi-state model evidenced that the risk of invasive aspergillosis is a complex time function of neutropenia duration and risk management. The quantitative PCR assay accelerated the early detection of invasive aspergillosis (P?=?.010), independently of other diagnostic information used to treat, while ?-glucan assay did not (P?=?.53).The performance of serum biomarkers for the early detection of invasive aspergillosis is better apprehended by the evaluation of time-varying predictors in a multi-state model. Our results provide strong rationale for prospective studies testing a preemptive antifungal therapy, guided by clinical, radiological, and bi-weekly blood screening with galactomannan antigenemia and a standardized quantitative PCR assay.
View details for DOI 10.1371/journal.pone.0065776
View details for PubMedID 23799048
Mental Health Services Use by Children Investigated by Child Welfare Agencies
2012; 130 (5): 861-869
To examine the rates and predictors of mental health services use for a nationally representative cohort of youths who had been investigated for alleged maltreatment.Data came from caregiver and caseworker baseline and 18-month interviews in the second National Survey of Child and Adolescent Well-being. These interviews took place from March 2008 to September 2008 and September 2010 to March 2011. Data on family and child characteristics and service use were gathered and examined by using weighted univariate and multivariate analyses.Children had numerous challenges: 61.8% had a previous report of maltreatment, 46.3% had poor socialization skills, and 23.9% had a mental health problem measured by the Child Behavior Checklist (CBCL). At baseline, 33.3% received some mental health service and this varied by age, with younger children receiving fewer services. This percentage decreased to 30.9% at the 18-month follow-up, although the youngest children had increases in services use. For younger children, race/ethnicity, out-of-home placement, chronic physical health problems, low adaptive behaviors, and CBCL scores in the clinical range were related to use. For children ? 11, out-of-home placement, high CBCL scores, and family risk factors predicted services use at 18 months.Mental health services utilization increases as young children come into contact with schools and medical providers or have more intensive involvement with child welfare. Minority children receive fewer services adjusting for need. Over the 18-month follow-up, there was a decrease in service use that may be a result of the tremendous financial challenges taking place in the United States.
View details for DOI 10.1542/peds.2012-1330
View details for Web of Science ID 000310505900055
View details for PubMedID 23045565
Screening and Rapid Molecular Diagnosis of Tuberculosis in Prisons in Russia and Eastern Europe: A Cost-Effectiveness Analysis
2012; 9 (11)
Prisons of the former Soviet Union (FSU) have high rates of multidrug-resistant tuberculosis (MDR-TB) and are thought to drive general population tuberculosis (TB) epidemics. Effective prison case detection, though employing more expensive technologies, may reduce long-term treatment costs and slow MDR-TB transmission.We developed a dynamic transmission model of TB and drug resistance matched to the epidemiology and costs in FSU prisons. We evaluated eight strategies for TB screening and diagnosis involving, alone or in combination, self-referral, symptom screening, mass miniature radiography (MMR), and sputum PCR with probes for rifampin resistance (Xpert MTB/RIF). Over a 10-y horizon, we projected costs, quality-adjusted life years (QALYs), and TB and MDR-TB prevalence. Using sputum PCR as an annual primary screening tool among the general prison population most effectively reduced overall TB prevalence (from 2.78% to 2.31%) and MDR-TB prevalence (from 0.74% to 0.63%), and cost US$543/QALY for additional QALYs gained compared to MMR screening with sputum PCR reserved for rapid detection of MDR-TB. Adding sputum PCR to the currently used strategy of annual MMR screening was cost-saving over 10 y compared to MMR screening alone, but produced only a modest reduction in MDR-TB prevalence (from 0.74% to 0.69%) and had minimal effect on overall TB prevalence (from 2.78% to 2.74%). Strategies based on symptom screening alone were less effective and more expensive than MMR-based strategies. Study limitations included scarce primary TB time-series data in FSU prisons and uncertainties regarding screening test characteristics.In prisons of the FSU, annual screening of the general inmate population with sputum PCR most effectively reduces TB and MDR-TB prevalence, doing so cost-effectively. If this approach is not feasible, the current strategy of annual MMR is both more effective and less expensive than strategies using self-referral or symptom screening alone, and the addition of sputum PCR for rapid MDR-TB detection may be cost-saving over time.
View details for DOI 10.1371/journal.pmed.1001348
View details for Web of Science ID 000311888800014
View details for PubMedID 23209384
Evaluating Child Welfare Policies with Decision-Analytic Simulation Models
ADMINISTRATION AND POLICY IN MENTAL HEALTH AND MENTAL HEALTH SERVICES RESEARCH
2012; 39 (6): 466-477
The objective was to demonstrate decision-analytic modeling in support of Child Welfare policymakers considering implementing evidence-based interventions. Outcomes included permanency (e.g., adoptions) and stability (e.g., foster placement changes). Analyses of a randomized trial of KEEP-a foster parenting intervention-and NSCAW-1 estimated placement change rates and KEEP's effects. A microsimulation model generalized these findings to other Child Welfare systems. The model projected that KEEP could increase permanency and stability, identifying strategies targeting higher-risk children and geographical regions that achieve benefits efficiently. Decision-analytic models enable planners to gauge the value of potential implementations.
View details for DOI 10.1007/s10488-011-0370-z
View details for Web of Science ID 000309862900006
View details for PubMedID 21861204
Assessing Screening Policies for Childhood Obesity
2012; 20 (7): 1437-1443
To address growing concerns over childhood obesity, the United States Preventive Services Task Force (USPSTF) recently recommended that children undergo obesity screening beginning at age 6. An Expert Committee recommends starting at age 2. Analysis is needed to assess these recommendations and investigate whether there are better alternatives. We model the age- and sex-specific population-wide distribution of BMI through age 18 using National Longitudinal Survey of Youth (NLSY) data. The impact of treatment on BMI is estimated using the targeted systematic review performed to aid the USPSTF. The prevalence of hypertension and diabetes at age 40 are estimated from the Panel Study of Income Dynamics (PSID). We fix the screening interval at 2 years, and derive the age- and sex-dependent BMI thresholds that minimize adult disease prevalence, subject to referring a specified percentage of children for treatment yearly. We compare this optimal biennial policy to biennial versions of the USPSTF and Expert Committee recommendations. Compared to the USPSTF recommendation, the optimal policy reduces adult disease prevalence by 3% in relative terms (the absolute reductions are <1%) at the same treatment referral rate, or achieves the same disease prevalence at a 28% reduction in treatment referral rate. If compared to the Expert Committee recommendation, the reductions change to 6 and 40%, respectively. The optimal policy treats mostly 16-year olds and few children under age 14. Our results suggest that adult disease is minimized by focusing childhood obesity screening and treatment on older adolescents.
View details for DOI 10.1038/oby.2011.373
View details for Web of Science ID 000305840200015
View details for PubMedID 22240724
- Accounting for Biases When Linking Empirical Studies and Simulation Models MEDICAL DECISION MAKING 2012; 32 (3): 397-399
New Protease Inhibitors for the Treatment of Chronic Hepatitis C A Cost-Effectiveness Analysis
ANNALS OF INTERNAL MEDICINE
2012; 156 (4): 279-U68
Chronic hepatitis C virus is difficult to treat and affects approximately 3 million Americans. Protease inhibitors increase the effectiveness of standard therapy, but they are costly. A genetic assay may identify patients most likely to benefit from this treatment advance.To assess the cost-effectiveness of new protease inhibitors and an interleukin (IL)-28B genotyping assay for treating chronic hepatitis C virus.Decision-analytic Markov model.Published literature and expert opinion.Treatment-naive patients with chronic, genotype 1 hepatitis C virus monoinfection.Lifetime.Societal.Strategies are defined by the use of IL-28B genotyping and type of treatment (standard therapy [pegylated interferon with ribavirin]; triple therapy [standard therapy and a protease inhibitor]). Interleukin-28B-guided triple therapy stratifies patients with CC genotypes to standard therapy and those with non-CC types to triple therapy.Discounted costs (in 2010 U.S. dollars) and quality-adjusted life-years (QALYs); incremental cost-effectiveness ratios.For patients with mild and advanced fibrosis, universal triple therapy reduced the lifetime risk for hepatocellular carcinoma by 38% and 28%, respectively, and increased quality-adjusted life expectancy by 3% and 8%, respectively, compared with standard therapy. Gains from IL-28B-guided triple therapy were smaller. If the protease inhibitor costs $1100 per week, universal triple therapy costs $102,600 per QALY (mild fibrosis) or $51,500 per QALY (advanced fibrosis) compared with IL-28B-guided triple therapy and $70,100 per QALY (mild fibrosis) and $36,300 per QALY (advanced fibrosis) compared with standard therapy.Results were sensitive to the cost of protease inhibitors and treatment adherence rates.Data on the long-term comparative effectiveness of the new protease inhibitors are lacking.Both universal triple therapy and IL-28B-guided triple therapy are cost-effective when the least-expensive protease inhibitor are used for patients with advanced fibrosis.Stanford University.
View details for Web of Science ID 000300607600005
View details for PubMedID 22351713
Diabetes, Its Treatment, and Catastrophic Medical Spending in 35 Developing Countries
2012; 35 (2): 319-326
To assess the individual financial impact of having diabetes in developing countries, whether diabetic individuals possess appropriate medications, and the extent to which health insurance may protect diabetic individuals by increasing medication possession or decreasing the risk of catastrophic spending.Using 2002-2003 World Health Survey data (n = 121,051 individuals; 35 low- and middle-income countries), we examined possession of medications to treat diabetes and estimated the relationship between out-of-pocket medical spending (2005 international dollars), catastrophic medical spending, and diabetes. We assessed whether health insurance modified these relationships.Diabetic individuals experience differentially higher out-of-pocket medical spending, particularly among individuals with high levels of spending (excess spending of $157 per year [95% CI 130-184] at the 95th percentile), and a greater chance of incurring catastrophic medical spending (17.8 vs. 13.9%; difference 3.9% [95% CI 0.2-7.7]) compared with otherwise similar individuals without diabetes. Diabetic individuals with insurance do not have significantly lower risks of catastrophic medical spending (18.6 vs. 17.7%; difference not significant), nor were they significantly more likely to possess diabetes medications (22.8 vs. 20.6%; difference not significant) than those who were otherwise similar but without insurance. These effects were more pronounced and significant in lower-income countries.In low-income countries, despite insurance, diabetic individuals are more likely to experience catastrophic medical spending and often do not possess appropriate medications to treat diabetes. Research into why policies in these countries may not adequately protect people from catastrophic spending or enhance possession of critical medications is urgently needed.
View details for DOI 10.2337/dc11-1770
View details for Web of Science ID 000299856000024
View details for PubMedID 22238276
Multi-Country Analysis of Palm Oil Consumption and Cardiovascular Disease Mortality for Countries at Different Stages of Economic Development: 1980-1997
GLOBALIZATION AND HEALTH
Cardiovascular diseases represent an increasing share of the global disease burden. There is concern that increased consumption of palm oil could exacerbate mortality from ischemic heart disease (IHD) and stroke, particularly in developing countries where it represents a major nutritional source of saturated fat.The study analyzed country-level data from 1980-1997 derived from the World Health Organization's Mortality Database, U.S. Department of Agriculture international estimates, and the World Bank (234 annual observations; 23 countries). Outcomes included mortality from IHD and stroke for adults aged 50 and older. Predictors included per-capita consumption of palm oil and cigarettes and per-capita Gross Domestic Product as well as time trends and an interaction between palm oil consumption and country economic development level. Analyses examined changes in country-level outcomes over time employing linear panel regressions with country-level fixed effects, population weighting, and robust standard errors clustered by country. Sensitivity analyses included further adjustment for other major dietary sources of saturated fat.In developing countries, for every additional kilogram of palm oil consumed per-capita annually, IHD mortality rates increased by 68 deaths per 100,000 (95% CI [21-115]), whereas, in similar settings, stroke mortality rates increased by 19 deaths per 100,000 (95% CI [-12-49]) but were not significant. For historically high-income countries, changes in IHD and stroke mortality rates from palm oil consumption were smaller (IHD: 17 deaths per 100,000 (95% CI [5.3-29]); stroke: 5.1 deaths per 100,000 (95% CI [-1.2-11.0])). Inclusion of other major saturated fat sources including beef, pork, chicken, coconut oil, milk cheese, and butter did not substantially change the differentially higher relationship between palm oil and IHD mortality in developing countries.Increased palm oil consumption is related to higher IHD mortality rates in developing countries. Palm oil consumption represents a saturated fat source relevant for policies aimed at reducing cardiovascular disease burdens.
View details for DOI 10.1186/1744-8603-7-45
View details for Web of Science ID 000300306700001
View details for PubMedID 22177258
Cost Effectiveness of Fibrosis Assessment Prior to Treatment for Chronic Hepatitis C Patients
2011; 6 (12)
Chronic hepatitis C (HCV) is a liver disease affecting over 3 million Americans. Liver biopsy is the gold standard for assessing liver fibrosis and is used as a benchmark for initiating treatment, though it is expensive and carries risks of complications. FibroTest is a non-invasive biomarker assay for fibrosis, proposed as a screening alternative to biopsy.We assessed the cost-effectiveness of FibroTest and liver biopsy used alone or sequentially for six strategies followed by treatment of eligible U.S. patients: FibroTest only; FibroTest with liver biopsy for ambiguous results; FibroTest followed by biopsy to rule in; or to rule out significant fibrosis; biopsy only (recommended practice); and treatment without screening. We developed a Markov model of chronic HCV that tracks fibrosis progression. Outcomes were expressed as expected lifetime costs (2009 USD), quality-adjusted life-years (QALYs), and incremental cost-effectiveness ratios (ICER).Treatment of chronic HCV without fibrosis screening is preferred for both men and women. For genotype 1 patients treated with pegylated interferon and ribavirin, the ICERs are $5,400/QALY (men) and $6,300/QALY (women) compared to FibroTest only; the ICERs increase to $27,200/QALY (men) and $30,000/QALY (women) with the addition of telaprevir. For genotypes 2 and 3, treatment is more effective and less costly than all alternatives. In clinical settings where testing is required prior to treatment, FibroTest only is more effective and less costly than liver biopsy. These results are robust to multi-way and probabilistic sensitivity analyses.Early treatment of chronic HCV is superior to the other fibrosis screening strategies. In clinical settings where testing is required, FibroTest screening is a cost-effective alternative to liver biopsy.
View details for DOI 10.1371/journal.pone.0026783
View details for Web of Science ID 000298171400004
View details for PubMedID 22164204
Economic evaluation research in the context of Child Welfare policy: A structured literature review and recommendations
CHILD ABUSE & NEGLECT
2011; 35 (9): 722-740
With over 1 million children served by the US Child Welfare system at a cost of $20 billion annually, this study examines the economic evaluation literature on interventions to improve outcomes for children at risk for and currently involved with the system, identifies areas where additional research is needed, and discusses the use of decision-analytic modeling to advance Child Welfare policy and practice.The review included 19 repositories of peer-reviewed and non-peer-reviewed "gray" literatures, including items in English published before November, 2009. Original research articles were included if they evaluated interventions based on costs and outcomes. Review articles were included to assess the relevance of these techniques over time and to highlight the increasing discussion of methods needed to undertake such research. Items were categorized by their focus on: interventions for the US Child Welfare system; primary prevention of entry into the system; and use of models to make long-term projections of costs and outcomes.Searches identified 2,640 articles, with 49 ultimately included (19 reviews and 30 original research articles). Between 1988 and 2009, reviews consistently advocated economic evaluation and increasingly provided methodological guidance. 21 of the original research articles focused on Child Welfare, while 9 focused on child mental health. Of the 21 Child Welfare articles, 81% (17) focused on the US system. 47% (8/17) focused exclusively on primary prevention, though 83% of the US system, peer-reviewed articles focused exclusively on prevention (5/6). 9 of the 17 articles included empirical follow-up (mean sample size: 264 individuals; mean follow-up: 3.8 years). 10 of the 17 articles used modeling to project longer-term outcomes, but 80% of the articles using modeling were not peer-reviewed. Although 60% of modeling studies included interventions for children in the system, all peer-reviewed modeling articles focused on prevention.Methodological guidance for economic evaluations in Child Welfare is increasingly available. Such analyses are feasible given the availability of nationally representative data on children involved with Child Welfare and evidence-based interventions.Policy analyses considering the long-term costs and effects of interventions to improve Child Welfare outcomes are scarce, feasible, and urgently needed.
View details for DOI 10.1016/j.chiabu.2011.05.012
View details for Web of Science ID 000295946000007
View details for PubMedID 21944552
The Business Case for Quality Improvement Oral Anticoagulation for Atrial Fibrillation
CIRCULATION-CARDIOVASCULAR QUALITY AND OUTCOMES
2011; 4 (4): 416-424
The potential to save money within a short time frame provides a more compelling "business case" for quality improvement than merely demonstrating cost-effectiveness. Our objective was to demonstrate the potential for cost savings from improved control in patients anticoagulated for atrial fibrillation.Our population consisted of 67 077 Veterans Health Administration patients anticoagulated for atrial fibrillation between October 1, 2006, and September 30, 2008. We simulated the number of adverse events and their associated costs and utilities, both before and after various degrees of improvement in percent time in therapeutic range (TTR). The simulation had a 2-year time horizon, and costs were calculated from the perspective of the payer. In the base-case analysis, improving TTR by 5% prevented 1114 adverse events, including 662 deaths; it gained 863 quality-adjusted life-years and saved $15.9 million compared with the status quo, not accounting for the cost of the quality improvement program. Improving TTR by 10% prevented 2087 events, gained 1606 quality-adjusted life-years, and saved $29.7 million. In sensitivity analyses, costs were most sensitive to the estimated risk of stroke and the expected stroke reduction from improved TTR. Utilities were most sensitive to the estimated risk of death and the expected mortality benefit from improved TTR.A quality improvement program to improve anticoagulation control probably would be cost-saving for the payer, even if it were only modestly effective in improving control and even without considering the value of improved health. This study demonstrates how to make a business case for a quality improvement initiative.
View details for DOI 10.1161/CIRCOUTCOMES.111.960591
View details for Web of Science ID 000292872500008
View details for PubMedID 21712521
Diabetes mellitus and tuberculosis in countries with high tuberculosis burdens: individual risks and social determinants
INTERNATIONAL JOURNAL OF EPIDEMIOLOGY
2011; 40 (2): 417-428
A growing body of evidence supports the role of type 2 diabetes as an individual-level risk factor for tuberculosis (TB), though evidence from developing countries with the highest TB burdens is lacking. In developing countries, TB is most common among the poor, in whom diabetes may be less common. We assessed the relationship between individual-level risk, social determinants and population health in these settings.We performed individual-level analyses using the World Health Survey (n = 124,607; 46 countries). We estimated the relationship between TB and diabetes, adjusting for gender, age, body mass index, education, housing quality, crowding and health insurance. We also performed a longitudinal country-level analysis using data on per-capita gross domestic product and TB prevalence and incidence and diabetes prevalence for 1990-95 and 2003-04 (163 countries) to estimate the relationship between increasing diabetes prevalence and TB, identifying countries at risk for disease interactions.In lower income countries, individuals with diabetes are more likely than non-diabetics to have TB [univariable odds ratio (OR): 2.39; 95% confidence interval (CI): 1.84-3.10; multivariable OR: 1.81; 95% CI: 1.37-2.39]. Increases in TB prevalence and incidence over time were more likely to occur when diabetes prevalence also increased (OR: 4.7; 95% CI: 1.0-22.5; OR: 8.6; 95% CI: 1.9-40.4). Large populations, prevalent TB and projected increases in diabetes make countries like India, Peru and the Russia Federation areas of particular concern.Given the association between diabetes and TB and projected increases in diabetes worldwide, multi-disease health policies should be considered.
View details for DOI 10.1093/ije/dyq238
View details for Web of Science ID 000289165800020
View details for PubMedID 21252210
Screening with OGTT alone or in combination with the Indian diabetes risk score or genotyping of TCF7L2 to detect undiagnosed type 2 diabetes in Asian Indians
INDIAN JOURNAL OF MEDICAL RESEARCH
2011; 133 (3): 294-299
With increasing number of people with diabetes worldwide, particularly in India, it is necessary to search for low cost screening methods. We compared the effectiveness and costs of screening for undiagnosed type 2 diabetes mellitus (T2DM), using oral glucose tolerance testing (OGTT) alone, or following a positive result from the Indian Diabetes Risk Score (IDRS) or following a positive result from genotyping of the TCF7L2 polymorphisms in Asian Indians.In subjects without known diabetes (n=961) recruited from the Chennai Urban Rural Epidemiology Study (CURES), OGTT, IDRS, and genotyping of rs12255372 (G/T) and rs7903146(C/T) of TCF7L2 polymorphisms were done. IDRS includes four parameters: age, abdominal obesity, family history of T2DM and physical activity.OGTT identified 72 subjects with newly diagnosed diabetes (NDD), according to the World Health Organization criteria of fasting plasma glucose ? 126 mg/dl or a plasma glucose ? 200 mg/dl, 2 h after 75 g oral glucose load. IDRS screening (cut-off ? 60) yielded 413 positive subjects, which included 54 (75%) of the 72 NDD subjects identified by OGTT. Genotyping yielded 493 positive subjects which only included 36 (50%) of the 72 NDD subjects showing less discriminatory power. Screening with both SNPs missed 27 (37.5%) NDD subjects identified by IDRS. In contrast, IDRS missed only 9 (12.5%) of the NDD subjects identified by genotyping. Total screening cost for OGTT alone, or with IDRS were rs 384,400 and 182,810 respectively. Comparing OGTT alone to IDRS followed by OGTT, the incremental cost per additional NDD subject detected by doing OGTT on everyone was rs 11,199 (rs 201,590 for detecting additional 18 NDD subjects).For screening a population of subjects without diagnosed diabetes in India, a simple diabetes risk score is more effective and less expensive than genotyping or doing OGTT on the whole population.
View details for Web of Science ID 000289322400010
View details for PubMedID 21441683
Quantifying Child Mortality Reductions Related to Measles Vaccination
2010; 5 (11)
This study characterizes the historical relationship between coverage of measles containing vaccines (MCV) and mortality in children under 5 years, with a view toward ongoing global efforts to reduce child mortality.Using country-level, longitudinal panel data, from 44 countries over the period 1960-2005, we analyzed the relationship between MCV coverage and measles mortality with (1) logistic regressions for no measles deaths in a country-year, and (2) linear regressions for the logarithm of the measles death rate. All regressions allowed a flexible, non-linear relationship between coverage and mortality. Covariates included birth rate, death rates from other causes, percent living in urban areas, population density, per-capita GDP, use of the two-dose MCV, year, and mortality coding system. Regressions used lagged covariates, country fixed effects, and robust standard errors clustered by country. The likelihood of no measles deaths increased nonlinearly with higher MCV coverage (ORs: 13.8 [1.6-122.7] for 80-89% to 40.7 [3.2-517.6] for ?95%), compared to pre-vaccination risk levels. Measles death rates declined nonlinearly with higher MCV coverage, with benefits accruing more slowly above 90% coverage. Compared to no coverage, predicted average reductions in death rates were -79% at 70% coverage, -93% at 90%, and -95% at 95%.40 years of experience with MCV vaccination suggests that extremely high levels of vaccination coverage are needed to produce sharp reductions in measles deaths. Achieving sustainable benefits likely requires a combination of extended vaccine programs and supplementary vaccine efforts.
View details for DOI 10.1371/journal.pone.0013842
View details for Web of Science ID 000283838600016
View details for PubMedID 21079809
Empirically Evaluating Decision-Analytic Models
VALUE IN HEALTH
2010; 13 (5): 667-674
Model-based cost-effectiveness analyses support decision-making. To augment model credibility, evaluation via comparison to independent, empirical studies is recommended.We developed a structured reporting format for model evaluation and conducted a structured literature review to characterize current model evaluation recommendations and practices. As an illustration, we applied the reporting format to evaluate a microsimulation of human papillomavirus and cervical cancer. The model's outputs and uncertainty ranges were compared with multiple outcomes from a study of long-term progression from high-grade precancer (cervical intraepithelial neoplasia [CIN]) to cancer. Outcomes included 5 to 30-year cumulative cancer risk among women with and without appropriate CIN treatment. Consistency was measured by model ranges overlapping study confidence intervals.The structured reporting format included: matching baseline characteristics and follow-up, reporting model and study uncertainty, and stating metrics of consistency for model and study results. Structured searches yielded 2963 articles with 67 meeting inclusion criteria and found variation in how current model evaluations are reported. Evaluation of the cervical cancer microsimulation, reported using the proposed format, showed a modeled cumulative risk of invasive cancer for inadequately treated women of 39.6% (30.9-49.7) at 30 years, compared with the study: 37.5% (28.4-48.3). For appropriately treated women, modeled risks were 1.0% (0.7-1.3) at 30 years, study: 1.5% (0.4-3.3).To support external and projective validity, cost-effectiveness models should be iteratively evaluated as new studies become available, with reporting standardized to facilitate assessment. Such evaluations are particularly relevant for models used to conduct comparative effectiveness analyses.
View details for DOI 10.1111/j.1524-4733.2010.00698.x
View details for Web of Science ID 000280674200021
View details for PubMedID 20230547
Inpatient treatment of diabetic patients in Asia: evidence from India, China, Thailand and Malaysia
2010; 27 (1): 101-108
The prevalence of Type 2 diabetes mellitus (DM) has grown rapidly, but little is known about the drivers of inpatient spending in low- and middle-income countries. This study aims to compare the clinical presentation and expenditure on hospital admission for inpatients with a primary diagnosis of Type 2 DM in India, China, Thailand and Malaysia.We analysed data on adult, Type 2 DM patients admitted between 2005 and 2008 to five tertiary hospitals in the four countries, reporting expenditures relative to income per capita in 2007.Hospital admission spending for diabetic inpatients with no complications ranged from 11 to 75% of per-capita income. Spending for patients with complications ranged from 6% to over 300% more than spending for patients without complications treated at the same hospital. Glycated haemoglobin was significantly higher for the uninsured patients, compared with insured patients, in India (8.6 vs. 8.1%), Hangzhou, China (9.0 vs. 8.1%), and Shandong, China (10.9 vs. 9.9%). When the hospital admission expenditures of the insured and uninsured patients were statistically different in India and China, the uninsured always spent less than the insured patients.With the rising prevalence of DM, households and health systems in these countries will face greater economic burdens. The returns to investment in preventing diabetic complications appear substantial. Countries with large out-of-pocket financing burdens such as India and China are associated with the widest gaps in resource use between insured and uninsured patients. This probably reflects both overuse by the insured and underuse by the uninsured.
View details for DOI 10.1111/j.1464-5491.2009.02874.x
View details for Web of Science ID 000273451900015
View details for PubMedID 20121896
Program Spending to Increase Adherence: South African Cervical Cancer Screening
2009; 4 (5)
Adherence is crucial for public health program effectiveness, though the benefits of increasing adherence must ultimately be weighed against the associated costs. We sought to determine the relationship between investment in community health worker (CHW) home visits and increased attendance at cervical cancer screening appointments in Cape Town, South Africa.We conducted an observational study of 5,258 CHW home visits made in 2003-4 as part of a community-based screening program. We estimated the functional relationship between spending on these visits and increased appointment attendance (adherence). Increased adherence was noted after each subsequent CHW visit. The costs of making the CHW visits was based on resource use including both personnel time and vehicle-related expenses valued in 2004 Rand. The CHW program cost R194,018, with 1,576 additional appointments attended. Adherence increased from 74% to 90%; 55% to 87%; 48% to 77%; and 56% to 80% for 6-, 12-, 24-, and 36-month appointments. Average per-woman costs increased by R14-R47. The majority of this increase occurred with the first 2 CHW visits (90%, 83%, 74%, and 77%; additional cost: R12-R26).We found that study data can be used for program planning, identifying spending levels that achieve adherence targets given budgetary constraints. The results, derived from a single disease program, are retrospective, and should be prospectively replicated.
View details for DOI 10.1371/journal.pone.0005691
View details for Web of Science ID 000266415100005
View details for PubMedID 19492097
Knowledge-based errors in anesthesia: a paired, controlled trial of learning and retention
CANADIAN JOURNAL OF ANAESTHESIA-JOURNAL CANADIEN D ANESTHESIE
2009; 56 (1): 35-45
Optimizing patient safety by improving the training of physicians is a major challenge of medical education. In this pilot study, we hypothesized that a brief lecture, targeted to rare but potentially dangerous situations, could improve anesthesia practitioners' knowledge levels with significant retention of learning at six months.In this paired controlled trial, anesthesia residents and attending physicians at Massachusetts General Hospital took the same 14-question multiple choice examination three times: at baseline, immediately after a brief lecture, and six months later. The lecture covered material on seven "intervention" questions; the remaining seven were "control" questions. The authors measured immediate knowledge acquisition, defined as the change in percentage of correct answers on intervention questions between baseline and post-lecture, and measured learning retention as the difference between baseline and six months. Both measurements were corrected for change in performance on control questions.Fifty of the 89 subjects completed all three examinations. The post-lecture increase in percentage of questions answered correctly, adjusted for control, was 22.2% [95% confidence interval (CI) 16.0-28.4%; P < 0.01], while the adjusted increase at six months was 7.9% (95% CI 1.1-14.7%; P = 0.024).A brief lecture improved knowledge, and the subjects retained a significant amount of this learning at six months. Exposing residents or other practitioners to this type of inexpensive teaching intervention may help them to avoid preventable uncommon errors that are rooted in unfamiliarity with the situation or the equipment. The methods used for this study may also be applied to compare the effect of various other teaching modalities while, at the same time, preserving participant anonymity and making adjustments for ongoing learning.
View details for DOI 10.1007/s12630-008-9002-9
View details for Web of Science ID 000263012800006
View details for PubMedID 19247776
Trade-offs in cervical cancer prevention - Balancing benefits and risks
ARCHIVES OF INTERNAL MEDICINE
2008; 168 (17): 1881-1889
New screening and vaccination technologies will provide women with more options for cervical cancer prevention. Because the risk of cervical cancer diminishes with effective routine screening, women may wish to consider additional attributes, such as the likelihood of false-positive results and diagnostic procedures for mild abnormalities likely to resolve without intervention in their screening choices.We used an empirically calibrated simulation model of cervical cancer in the United States to assess the benefits and potential risks associated with prevention strategies differing by primary screening test, triage test for abnormal results (cytologic testing, human papillomavirus [HPV] DNA test), and screening frequency. Outcomes included colposcopy referrals, cervical intraepithelial neoplasia (CIN) types 1 and 2 or 3, lifetime cancer risk, and quality-adjusted life expectancy.Across strategies, colposcopy referrals and diagnostic workups varied 3-fold, although diagnostic rates of CIN 2 or 3 were similar and 95% of positive screening test results were for mild abnormalities likely to resolve on their own. For a representative group of a thousand 20-year-old women undergoing triennial screening for 10 years, we expect 1038 colposcopy referrals (7 CIN 2 or 3 diagnoses) from combined cytologic and HPV DNA testing and fewer than 200 referrals (6-7 CIN 2 or 3 diagnoses) for strategies that use triage testing. Similarly, for a thousand 40-year-old women, combined cytologic and HPV DNA testing led to 489 referrals (9 CIN 2 or 3), whereas alternative strategies resulted in fewer than 150 referrals (7-8 CIN 2 or 3). Using cytologic testing followed by triage testing in younger women minimizes both diagnostic workups and positive HPV test results, whereas in older women diagnostic workups are minimized with HPV DNA testing followed by cytologic triage testing.Clinically relevant information highlighting trade-offs among cervical cancer prevention strategies allows for inclusion of personal preferences into women's decision making about screening and provides additional dimensions to the construction of clinical guidelines.
View details for Web of Science ID 000259393000007
View details for PubMedID 18809815
Cost-effectiveness of cervical cancer screening with human papillomavirus DNA testing and HPV-16,18 vaccination
JOURNAL OF THE NATIONAL CANCER INSTITUTE
2008; 100 (5): 308-320
The availability of human papillomavirus (HPV) DNA testing and vaccination against HPV types 16 and 18 (HPV-16,18) motivates questions about the cost-effectiveness of cervical cancer prevention in the United States for unvaccinated older women and for girls eligible for vaccination.An empirically calibrated model was used to assess the quality-adjusted life years (QALYs), lifetime costs, and incremental cost-effectiveness ratios (2004 US dollars per QALY) of screening, vaccination of preadolescent girls, and vaccination combined with screening. Screening varied by initiation age (18, 21, or 25 years), interval (every 1, 2, 3, or 5 years), and test (HPV DNA testing of cervical specimens or cytologic evaluation of cervical cells with a Pap test). Testing strategies included: 1) cytology followed by HPV DNA testing for equivocal cytologic results (cytology with HPV test triage); 2) HPV DNA testing followed by cytology for positive HPV DNA results (HPV test with cytology triage); and 3) combined HPV DNA testing and cytology. Strategies were permitted to switch once at age 25, 30, or 35 years.For unvaccinated women, triennial cytology with HPV test triage, beginning by age 21 years and switching to HPV testing with cytology triage at age 30 years, cost $78,000 per QALY compared with the next best strategy. For girls vaccinated before age 12 years, this same strategy, beginning at age 25 years and switching at age 35 years, cost $41,000 per QALY with screening every 5 years and $188,000 per QALY screening triennially, each compared with the next best strategy. These strategies were more effective and cost-effective than screening women of all ages with cytology alone or cytology with HPV triage annually or biennially.For both vaccinated and unvaccinated women, age-based screening by use of HPV DNA testing as a triage test for equivocal results in younger women and as a primary screening test in older women is expected to be more cost-effective than current screening recommendations.
View details for DOI 10.1093/jnci/djn019
View details for Web of Science ID 000253796800008
View details for PubMedID 18314477
Cost-effectiveness of HPV 16, 18 vaccination in Brazil
2007; 25 (33): 6257-6270
We use an empirically calibrated model to estimate the cost-effectiveness of cervical cancer prevention in Brazil, a country with a high cervical cancer burden. Assuming 70% coverage, HPV 16, 18 vaccination of adolescent girls is expected to reduce the lifetime risk of cancer by approximately 42.7% (range, 33.2-53.5%); screening three times per lifetime is expected to reduce risk by 21.9-30.7% depending on the screening test, and a combined approach of vaccination and screening is expected to reduce cancer risk by a mean of 60.8% (range, 52.8-70.1%). In Brazil; provided the cost per vaccinated woman is less than I$ 25, implying a per dose cost of approximately I$ 5, vaccination before age 12, followed by screening three times per lifetime between ages 35 and 45, would be considered very cost-effective using the country's per capita gross domestic product as a cost-effectiveness threshold. Assuming a coverage rate of 70%, this strategy would be expected to prevent approximately 100,000 cases of invasive cervical cancer over a 5-year period. Vaccination strategies identified as cost-effective may be unaffordable in countries with similar socioeconomic profiles as Brazil without assistance; these results can provide guidance to the global community by identifying health investments of highest priority and with the greatest promise.
View details for DOI 10.1016/j.vaccine.2007.05.058
View details for Web of Science ID 000248905900014
View details for PubMedID 17606315
Modeling human papillomavirus and cervical cancer in the United States for analyses of screening and vaccination.
Population health metrics
2007; 5: 11-?
To provide quantitative insight into current U.S. policy choices for cervical cancer prevention, we developed a model of human papillomavirus (HPV) and cervical cancer, explicitly incorporating uncertainty about the natural history of disease.We developed a stochastic microsimulation of cervical cancer that distinguishes different HPV types by their incidence, clearance, persistence, and progression. Input parameter sets were sampled randomly from uniform distributions, and simulations undertaken with each set. Through systematic reviews and formal data synthesis, we established multiple epidemiologic targets for model calibration, including age-specific prevalence of HPV by type, age-specific prevalence of cervical intraepithelial neoplasia (CIN), HPV type distribution within CIN and cancer, and age-specific cancer incidence. For each set of sampled input parameters, likelihood-based goodness-of-fit (GOF) scores were computed based on comparisons between model-predicted outcomes and calibration targets. Using 50 randomly resampled, good-fitting parameter sets, we assessed the external consistency and face validity of the model, comparing predicted screening outcomes to independent data. To illustrate the advantage of this approach in reflecting parameter uncertainty, we used the 50 sets to project the distribution of health outcomes in U.S. women under different cervical cancer prevention strategies.Approximately 200 good-fitting parameter sets were identified from 1,000,000 simulated sets. Modeled screening outcomes were externally consistent with results from multiple independent data sources. Based on 50 good-fitting parameter sets, the expected reductions in lifetime risk of cancer with annual or biennial screening were 76% (range across 50 sets: 69-82%) and 69% (60-77%), respectively. The reduction from vaccination alone was 75%, although it ranged from 60% to 88%, reflecting considerable parameter uncertainty about the natural history of type-specific HPV infection. The uncertainty surrounding the model-predicted reduction in cervical cancer incidence narrowed substantially when vaccination was combined with every-5-year screening, with a mean reduction of 89% and range of 83% to 95%.We demonstrate an approach to parameterization, calibration and performance evaluation for a U.S. cervical cancer microsimulation model intended to provide qualitative and quantitative inputs into decisions that must be taken before long-term data on vaccination outcomes become available. This approach allows for a rigorous and comprehensive description of policy-relevant uncertainty about health outcomes under alternative cancer prevention strategies. The model provides a tool that can accommodate new information, and can be modified as needed, to iteratively assess the expected benefits, costs, and cost-effectiveness of different policies in the U.S.
View details for PubMedID 17967185
- Public health policy for cervical cancer prevention: The role of decision science, economic evaluation, and mathematical modeling VACCINE 2006; 24: 155-163
Chapter 18: Public health policy for cervical cancer prevention: the role of decision science, economic evaluation, and mathematical modeling.
2006; 24: S3 155-63
Several factors are changing the landscape of cervical cancer control, including a better understanding of the natural history of human papillomavirus (HPV), reliable assays for detecting high-risk HPV infections, and a soon to be available HPV-16/18 vaccine. There are important differences in the relevant policy questions for different settings. By synthesizing and integrating the best available data, the use of modeling in a decision analytic framework can identify those factors most likely to influence outcomes, can guide the design of future clinical studies and operational research, can provide insight into the cost-effectiveness of different strategies, and can assist in early decision-making when considered with criteria such as equity, public preferences, and political and cultural constraints.
View details for PubMedID 16950003
Estimating the cost of cervical cancer screening in five developing countries.
Cost effectiveness and resource allocation : C/E
2006; 4: 13-?
Cost-effectiveness analyses (CEAs) can provide useful information to policymakers concerned with the broad allocation of resources as well as to local decision makers choosing between different options for reducing the burden from a single disease. For the latter, it is important to use country-specific data when possible and to represent cost differences between countries that might make one strategy more or less attractive than another strategy locally. As part of a CEA of cervical cancer screening in five developing countries, we supplemented limited primary cost data by developing other estimation techniques for direct medical and non-medical costs associated with alternative screening approaches using one of three initial screening tests: simple visual screening, HPV DNA testing, and cervical cytology. Here, we report estimation methods and results for three cost areas in which data were lacking.To supplement direct medical costs, including staff, supplies, and equipment depreciation using country-specific data, we used alternative techniques to quantify cervical cytology and HPV DNA laboratory sample processing costs. We used a detailed quantity and price approach whose face validity was compared to an adaptation of a US laboratory estimation methodology. This methodology was also used to project annual sample processing capacities for each laboratory type. The cost of sample transport from the clinic to the laboratory was estimated using spatial models. A plausible range of the cost of patient time spent seeking and receiving screening was estimated using only formal sector employment and wages as well as using both formal and informal sector participation and country-specific minimum wages. Data sources included primary data from country-specific studies, international databases, international prices, and expert opinion. Costs were standardized to year 2000 international dollars using inflation adjustment and purchasing power parity.Cervical cytology laboratory processing costs were I$1.57-3.37 using the quantity and price method compared to I$1.58-3.02 from the face validation method. HPV DNA processing costs were I$6.07-6.59. Rural laboratory transport costs for cytology were I$0.12-0.64 and I$0.14-0.74 for HPV DNA laboratories. Under assumptions of lower resource efficiency, these estimates increased to I$0.42-0.83 and I$0.54-1.06. Estimates of the value of an hour of patient time using only formal sector participation were I$0.07-4.16, increasing to I$0.30-4.80 when informal and unpaid labor was also included. The value of patient time for traveling, waiting, and attending a screening visit was I$0.68-17.74. With the total cost of screening for cytology and HPV DNA testing ranging from I$4.85-40.54 and I$11.30-48.77 respectively, the cost of the laboratory transport, processing, and patient time accounted for 26-66% and 33-65% of the total costs. From a payer perspective, laboratory transport and processing accounted for 18-48% and 25-60% of total direct medical costs of I$4.11-19.96 and I$10.57-28.18 respectively.Cost estimates of laboratory processing, sample transport, and patient time account for a significant proportion of total cervical cancer screening costs in five developing countries and provide important inputs for CEAs of alternative screening modalities.
View details for PubMedID 16887041
Cost-effectiveness of cervical-cancer screening in five developing countries
NEW ENGLAND JOURNAL OF MEDICINE
2005; 353 (20): 2158-2168
Cervical-cancer screening strategies that involve the use of conventional cytology and require multiple visits have been impractical in developing countries.We used computer-based models to assess the cost-effectiveness of a variety of cervical-cancer screening strategies in India, Kenya, Peru, South Africa, and Thailand. Primary data were combined with data from the literature to estimate age-specific incidence and mortality rates for cancer and the effectiveness of screening for and treatment of precancerous lesions. We assessed the direct medical, time, and program-related costs of strategies that differed according to screening test, targeted age and frequency, and number of clinic visits required. Single-visit strategies involved the assumption that screening and treatment could be provided in the same day. Outcomes included the lifetime risk of cancer, years of life saved, lifetime costs, and cost-effectiveness ratios (cost per year of life saved).The most cost-effective strategies were those that required the fewest visits, resulting in improved follow-up testing and treatment. Screening women once in their lifetime, at the age of 35 years, with a one-visit or two-visit screening strategy involving visual inspection of the cervix with acetic acid or DNA testing for human papillomavirus (HPV) in cervical cell samples, reduced the lifetime risk of cancer by approximately 25 to 36 percent, and cost less than 500 dollars per year of life saved. Relative cancer risk declined by an additional 40 percent with two screenings (at 35 and 40 years of age), resulting in a cost per year of life saved that was less than each country's per capita gross domestic product--a very cost-effective result, according to the Commission on Macroeconomics and Health.Cervical-cancer screening strategies incorporating visual inspection of the cervix with acetic acid or DNA testing for HPV in one or two clinical visits are cost-effective alternatives to conventional three-visit cytology-based screening programs in resource-poor settings.
View details for Web of Science ID 000233288600008
View details for PubMedID 16291985
The costs of reducing loss to follow-up in South African cervical cancer screening.
Cost effectiveness and resource allocation : C/E
2005; 3: 11-?
This study was designed to quantify the resources used in reestablishing contact with women who missed their scheduled cervical cancer screening visits and to assess the success of this effort in reducing loss to follow-up in a developing country setting.Women were enrolled in this Cape Town, South Africa-based screening study between 2000 and 2003, and all had scheduled follow-up visits in 2003. Community health worker (CHW) time, vehicle use, maintenance, and depreciation were estimated from weekly logs and cost accounting systems. The percentage of women who attended their scheduled visit, those who attended after CHW contact(s), and those who never returned despite attempted contact(s) were determined. The number of CHW visits per woman was also estimated.3,711 visits were scheduled in 2003. Of these, 2,321 (62.5%) occurred without CHW contact, 918 (24.8%) occurred after contact(s), and 472 (12.7%) did not occur despite contact(s). Loss to follow-up was reduced from 21% to 6%, 39% to 10%, and 50% to 24% for 6, 12, and 24-month visits. CHWs attempted 3,200 contacts in 530 trips. On average, 3 CHWs attempted to contact 6 participants over each 111 minute trip. The per-person cost (2003 Rand) for these activities was 12.75, 24.92, and 40.50 for 6, 12, and 24-month visits.CHW contact with women who missed scheduled visits increased their return rate. Cost-effectiveness analyses aimed at policy decisions about cervical cancer screening in developing countries should incorporate these findings.
View details for PubMedID 16288646
- Papanicolaou screening in developing countries AMERICAN JOURNAL OF CLINICAL PATHOLOGY 2005; 124 (2): 314-315
Male involvement in cardiovascular preventive healthcare in two rural Costa Rican communities
2005; 40 (6): 690-695
Gender differences in health system usage can lead to differences in the incidence of morbidity and mortality. We conducted a pilot screening targeted towards men to evaluate gender differences in cardiovascular disease risk factor detection and time since last clinic visit.Three evening sessions in two communities screened 148 people, mean age 47.7 years. Height, weight, body mass index, blood pressure, blood glucose, and total cholesterol were measured. A questionnaire on past medical history was administered. Participants with elevated measurements were referred to appropriate care.Men accounted for 60.1% of those screened; 65.5% of the group was overweight, and 22.3% was obese with 42.6% hypertension, 39.2% hypercholesterolemia, and 2.7% high blood glucose. Among men aged 35 to 65, 65.2% were overweight, 20.3% obese, 46.4% hypertensive, 42.0% hypercholesterolemic, and 1.5% with high blood glucose. Within the last 2 years, 53.3% of men and 9.1% of women aged 35 to 65 had not visited a doctor (P = 0.004).A significant portion of those screened had elevated cardiovascular disease risk factors. Given that men visited doctors significantly less frequently, efforts to involve men in prevention of cardiovascular disease within these communities are warranted.
View details for DOI 10.1016/j.ypmed.2004.09.009
View details for Web of Science ID 000229006700011
View details for PubMedID 15850866
Randomized controlled community-based nutrition and exercise intervention improves glycemia and cardiovascular risk factors in type 2 diabetic patients in rural Costa Rica
2003; 26 (1): 24-29
The prevalence of type 2 diabetes, especially in developing countries, has grown over the past decades. We performed a controlled clinical study to determine whether a community-based, group-centered public health intervention addressing nutrition and exercise can ameliorate glycemic control and associated cardiovascular risk factors in type 2 diabetic patients in rural Costa Rica.A total of 75 adults with type 2 diabetes, mean age 59 years, were randomly assigned to the intervention group or the control group. All participants received basic diabetes education. The subjects in the intervention group participated in 11 weekly nutrition classes (90 min each session). Subjects for whom exercise was deemed safe also participated in triweekly walking groups (60 min each session). Glycosylated hemoglobin, fasting plasma glucose, total cholesterol, triglycerides, HDL and LDL cholesterol, height, weight, BMI, and blood pressure were measured at baseline and the end of the study (after 12 weeks).The intervention group lost 1.0 +/- 2.2 kg compared with a weight gain in the control group of 0.4 +/- 2.3 kg (P = 0.028). Fasting plasma glucose decreased 19 +/- 55 mg/dl in the intervention group and increased 16 +/- 78 mg/dl in the control group (P = 0.048). Glycosylated hemoglobin decreased 1.8 +/- 2.3% in the intervention group and 0.4 +/- 2.3% in the control group (P = 0.028).Glycemic control of type 2 diabetic patients can be improved through community-based, group-centered public health interventions addressing nutrition and exercise. This pilot study provides an economically feasible model for programs that aim to improve the health status of people with type 2 diabetes.
View details for Web of Science ID 000185504900004
View details for PubMedID 12502654