Chronic Kidney Disease (CKD) is a risk factor for cardiovascular disease, early mortality, and kidney failure. There is a substantial burden of CKD in Manitoba’s rural and remote First Nations. Early detection and treatment of CKD in this population may be cost-effective. We constructed a Markov model comparing screening for CKD, by both estimated glomerular filtration rate and albuminuria, to usual care using the perspective of the health care payer. Patients were classified into initial risk groups based on results from the First Nations Community Based Screening to Improve Kidney Health and Prevent Dialysis initiative. Screening in Manitoba’s rural and remote First Nations was associated with a $33,500/QALY incremental cost-effectiveness ratio in comparison to usual care. Restricting to communities accessible primarily by air travel, this ratio fell to $16,180/QALY. In conclusion, at a willingness-to-pay threshold of $50,000/QALY, screening for CKD in Manitoba’s rural and remote First Nations is likely cost-effective.

ACE inhibitors have been widely used in the treatment of certain diseases of the cardiovascular system, the major use being hypertension, since all ACE inhibitors are prescribed for its treatment. ACE inhibitors is also used in the treatment of congestive heart failure. The angiotensin-converting enzyme (ACE) converts angiotensin 1 into angiotensin I1 and also stimulates the production of aldosterone (a hormone produced in the adrenal glands that influences salt and water retention by the kidneys, increasing blood volume and blood pressure). The cost benefit, cost-effectiveness and cost utility of ACE inhibitors have not been established. The objective of the study was to review and analyse the cost of ACE inhibitors by using a medical aid claims database. Data for the study population consisted of all prescriptions containing one or more ACE inhibitor combinations and were extracted from the central database of Interpharm datasystems for a period of one year, from 1 January 2001 to 31 December 2001. A total of 1 475 532 prescriptions containing a total of 2 953 244 ACE inhibitor items represented the study population. Through the analysis of the general medicine utilisation patterns that were obtained from the medicine claims database, it became evident that ACE inhibitor utilisation contributes considerably to the total prevalence and cost of all the medicine items available on the database. It constituted a total prevalence of 4,62% (n =1 475 532) of all the prescriptions and a total prevalence of 2,31% (n =2 953 244) for all the medicine items in the prescriptions with a cost of 3,65% (n =R379 91 1 472,OO). It was concluded that in the analysis of ACE inhibitors according to the innovator/generic classification, the majority of ACE inhibitors prescribed during the twelve-month period were for the innovator product, with a prevalence of 82,56% (n =68 162) and a cost of 89,11% (n =R13 863 080, 90). The utilisation of the generic ACE inhibitors, with a prevalence of 17,44% (n =68 162) and at a cost of 10,89% (n =R13 863 080, 90), was under-utilised. If the total number of prescriptions containing innovator ACE inhibitors could be generically substituted, (37,54%) R5 204 392,68 in cost expenditure could be saved over a twelve-month period. However, the fact that not all the innovator ACE inhibitors have generic equivalents available must be taken into account. If only the prescriptions containing ACE inhibitor items that have generic equivalents were to be substituted with their generic equivalents, R899 751.29(6.5%) would be saved. This was found by adding all the costs saved by substituting innovator drugs with their generics. Consequently, it can be concluded that the extensive use of the innovator ACE inhibitors could mean an exceptional increase in the cost expenditure associated with ACE inhibitor therapy. In completion of the study, recommendations were formulated as an aim to optimise the utilisation of ACE inhibitor generic equivalents. / Thesis (M. Pharm.)--North-West University, Potchefstroom Campus, 2004.

It is important to account for all sources of uncertainty when evaluating the clinical or cost-effectiveness of health care technologies. Therefore, this thesis takes as its basis a cost-effectiveness study in liver transplantation and identifies two previously unexplored issues that can arise in clinical and cost-effectiveness studies. A literature review of studies evaluating the effectiveness, costs or cost-effectiveness of solid organ transplantation confirmed that these issues were important and relevant to other transplantation studies. The first issue concerns the selection of an appropriate method for estimating mean study costs in the presence of incomplete (censored) data. Twelve techniques were identified and their accuracy was compared across artificially created mechanisms and levels of censoring. Lin's method with known cost histories and short interval lengths is recommended for accurately estimating mean costs and their uncertainty. It is assumed that these findings are generalisable to any solid organ transplant study where censoring is an issue. The second issue explored in this thesis relates to methods for measuring uncertainty around survival, HRQL and cost estimates derived from prognostic models in the absence of observed data. Probabilistic sensitivity analysis is recommended for measuring prognostic model parameter uncertainty and estimating individual patient outcomes and their uncertainties, as it is able to incorporate the additional uncertainty from using prognostic models to estimate control group outcomes. This thesis shows the quantitative importance of these issues and the methodological guidance offered should enable decision makers to have more confidence in clinical and cost-effectiveness estimates. Providing decision makers with a fuller estimate of the uncertainty around clinical and cost effectiveness estimates will aid them in decisions about the necessity of conducting further research in to the clinical or cost-effectiveness of health care technologies.

Objectives: The objectives of the research were to determine which intravenous (IV) antibiotics were cost-effective in Diabetic Foot Infections (DFIs) and to assess the impact of MRSA prevalence on clinical outcome. Methods: A Cost-effectiveness analysis (CEA) was performed on IV antibiotics used to treat moderate to severe DFIs in hospitalized patients. MRSA prevalence was taken into account by calculating an ‘Adjusted cure rate’ and re-analysing the CEA. Results: In the original CEA, imipenem/cilastatin was the cost-effective agent. When MRSA prevalence was taken into account imipenem/cilastatin, moxifloxacin, cefoxitin and ertapenem were cost-effective antibiotics. Conclusion: MRSA prevalence adjustments changed the results of the CEA and included classes of IV antibiotics that are seen being using in practice, such as fluoroquinolones and cephalosporins. These methods could potentially have an impact on the evaluation of clinical cure rates and resistance when evaluating the literature.

Background: Androgen deprivation therapy (ADT) has known adverse effects (AEs). Intermittent (INT) ADT may reduce AEs, improve quality of life, and lower costs compared to continuous (CONT) treatment. Objective: To evaluate the cost-effectiveness of INT vs CONT ADT in men with advanced prostate cancer. Methods: A lifetime Markov individual simulation model was developed to evaluate the incremental cost per quality adjusted life month (QALM) of INT vs CONT ADT. Results: INT dominated CONT ADT (mean total costs $94,460 vs $109,431; mean total QALMs 47.0 vs 46.4). INT ADT resulted in less time on therapy (22.4 vs 56.8 months), fewer hip fractures (0.080 vs 0.093 per patient), and fewer total cases of sexual dysfunction (72.5% vs 87.0% of patients) and cardiovascular disease (38.7% vs 44.6% of patients). Conclusions: These results suggest INT ADT is cost-effective compared to CONT ADT however, differences were small. Additional research is required to confirm these findings.

Objectives: The objectives of the research were to determine which intravenous (IV) antibiotics were cost-effective in Diabetic Foot Infections (DFIs) and to assess the impact of MRSA prevalence on clinical outcome. Methods: A Cost-effectiveness analysis (CEA) was performed on IV antibiotics used to treat moderate to severe DFIs in hospitalized patients. MRSA prevalence was taken into account by calculating an ‘Adjusted cure rate’ and re-analysing the CEA. Results: In the original CEA, imipenem/cilastatin was the cost-effective agent. When MRSA prevalence was taken into account imipenem/cilastatin, moxifloxacin, cefoxitin and ertapenem were cost-effective antibiotics. Conclusion: MRSA prevalence adjustments changed the results of the CEA and included classes of IV antibiotics that are seen being using in practice, such as fluoroquinolones and cephalosporins. These methods could potentially have an impact on the evaluation of clinical cure rates and resistance when evaluating the literature.

Background: Androgen deprivation therapy (ADT) has known adverse effects (AEs). Intermittent (INT) ADT may reduce AEs, improve quality of life, and lower costs compared to continuous (CONT) treatment. Objective: To evaluate the cost-effectiveness of INT vs CONT ADT in men with advanced prostate cancer. Methods: A lifetime Markov individual simulation model was developed to evaluate the incremental cost per quality adjusted life month (QALM) of INT vs CONT ADT. Results: INT dominated CONT ADT (mean total costs $94,460 vs $109,431; mean total QALMs 47.0 vs 46.4). INT ADT resulted in less time on therapy (22.4 vs 56.8 months), fewer hip fractures (0.080 vs 0.093 per patient), and fewer total cases of sexual dysfunction (72.5% vs 87.0% of patients) and cardiovascular disease (38.7% vs 44.6% of patients). Conclusions: These results suggest INT ADT is cost-effective compared to CONT ADT however, differences were small. Additional research is required to confirm these findings.

Typescript. / Thesis (Ph. D.)--University of Hawaii at Manoa, 1985. / Bibliography: leaves 326-337. / Photocopy. / xviii, 337 leaves, bound ill. 29 cm

Background The costs of healthcare are on the rise. With an ageing population, growing demand for health services and expensive new technologies, Australia’s annual health care bill has more than doubled in the last ten years, and is projected to increase a further 127% by 2033. As third-party provider of health care, the Government must make difficult decisions about how best to allocate limited resources to the many new and existing drugs, technologies and health services available for prevention and treatment of disease. Cost-effectiveness analysis of interventions can help identify those that should be given funding priority in order to maximise population health, but its use in allocating resources to prevention has been limited. There have been few cost-effectiveness analyses of preventive interventions, particularly for the potentially more effective strategies targeting the whole population, such as taxation, regulation and community campaigns. Current methods are poorly designed for capturing the change in population distribution of risk that can occur with these types of interventions. Use of cost-effectiveness analysis has also been limited by the use of many different (and often simplistic) modelling methods and assumptions that prevent league table comparison of results to help identify most cost-effective strategies. This thesis presents new methods for evaluating cost-effectiveness of preventive interventions, with application to interventions promoting physical activity, preventing alcohol misuse, reducing body mass, promoting fruits and vegetables and reducing dietary salt intake, from an Australian health sector perspective. Methods Proportional multi-state life table models were developed for each risk factor and for risk factor combinations, using population impact fraction (PIF) functions to quantify the potential intervention impact of a change in individual or population risk factor exposure on disease and injury. The models were used to simulate population health in disability-adjusted life years (DALYs) and costs of disease treatment, over the lifetime of the Australian population in 2003, for a range of individual- and populationtargeted interventions using intervention costs and effects derived from Australian cost data and published evaluation studies. Monte-Carlo analysis was used to derive uncertainty around all outcome measures, and sensitivity of results to key modelling choices and assumptions was also evaluated. Cost-effectiveness of six physical activity interventions, ten alcohol interventions, two body mass interventions, 23 fruit and vegetable interventions and four dietary salt interventions was evaluated in comparison to current Australian practice. In addition, where multiple mutually-exclusive interventions were evaluated, a partial null (‘no current practice intervention’) scenario was calculated and cost-effectiveness of incrementally adding each intervention to a package was evaluated, to determine the optimal intervention mix and to compare optimal outcomes with the current practice. Findings For physical activity, a package of six individual- and population-targeted interventions is cost-effective and could avert a third of disease burden attributable to physical inactivity. For reducing alcohol misuse, a package of eight individual- and population-targeted interventions could avert a third of disease burden attributable to hazardous and heavy levels of drinking. Although the current practice of random breath testing is cost-effective, if the expenditure on random breath testing had been distributed to more cost-effective interventions, around ten times the improvement in population health could have been achieved. The individually-targeted interventions for body mass, fruits and vegetables and salt intake are not cost-effective. Providing incentives for food industry to reduce salt in processed foods, on the other hand, is far more effective in improving population health and can lead to cost-saving for the health sector in the long term. if (moderate) reductions in salt were made mandatory for food manufacturers, around 20 times the health gains achieved by the current voluntary program could be achieved. Overall, eight interventions are potentially cost-saving for the health sector: voluntary and mandatory limits on salt in processed foods; mass media- and pedometer-based community campaigns to promote physical activity; a community program to promote fruits and vegetables; and volumetric taxation, advertising bans and an increase of the minimum legal drinking age to 21 years to address alcohol misuse. A further 12 interventions for reducing alcohol misuse, and promoting physical activity and fruit and vegetable consumption, are under a $50,000 per DALY threshold of costeffectiveness, and are also recommended for health sector investment. Implications The integration of a proportional multi-state life table model with PIF function in this research has proved to have a number of advantages over previous modelling methods. The PIF function enables better simulation of the true continuous distribution of risk in the population, and facilitates analysis of population-targeted interventions that shift the whole distribution of risk. It also substantially simplifies the integration of multiple risk factors into the one model, which was previously constrained by the need to create separate states for every risk factor category (e.g. active and inactive) and risk factor categories in combination (e.g. obese and active, obese and inactive, etc.). This not only makes for easier and more accurate analyses of interventions targeting multiple risk factors, but enables evaluation of packages of many different risk factor interventions. Further investment in preventive interventions is highly recommended. The population-targeted approaches hold most promise for improving population health. Although there is potential for opposition from industry stakeholders and public concern around Government paternalism, these interventions have most potential to generate cost-savings for the health sector in the long-term. Given the weaker evidence around effectiveness of these interventions, however, it is recommended that programs are implemented with sufficient funding for monitoring and evaluation of outcomes.

Thesis (M. Med. Sc.)--University of Hong Kong, 2005. / Also available in print.