Purpose: Despite India’s nationwide public sector tuberculosis (TB) control program, many patients seek and receive care in private sector clinics. Private sector care often includes inappropriate diagnostics and ineffective treatments of insufficient duration that can select for multidrug resistant (MDR) TB. Given current efforts to improve TB care and roll out new technologies, we evaluate likely impacts of these efforts if undertaken in the public and private sectors separately or in combination.

Method: We extend our previously developed, dynamic transmission microsimulation model of TB in India. The model follows India’s population stratified by age, sex, TB, drug resistance, and treatment status. We calibrate the model to Indian demographic, epidemiologic, and TB healthcare patterns in the public and private sectors. Control interventions include: 1) improving treatment effectiveness in the public sector only; 2) improving the accuracy and rapidity of TB diagnosis and drug sensitivity testing in the public and/or the private sector; 3) increasing referrals from the private sector to the public sector through public private mix (PPM); 4) reducing inappropriate medication use to prevent MDR generation in the private sector; 5) combinations of these efforts. Main outcomes are incidence and prevalence of active non-MDR and MDR TB in 2023 relative to 2013 levels.

Result: Without interventions, the model projects declines in non-MDR TB incidence (12%) and prevalence (12%) and increases in MDR incidence (15%) and prevalence (19%) between 2013 and 2023. For non-MDR TB, increasing referrals from the private to the public sector (through PPM) alone or in combination with improved diagnostics yields 15-17% lower incidence and 34-47% lower prevalence. Synergies provided by combined public and private sector interventions are evident for MDR outcomes. Exclusively private sector interventions result in MDR incidence and prevalence increases of 13-16%, whereas exclusively public sector interventions result in 2-7% declines. Combinations of PPM and increases in non-MDR TB treatment effectiveness to avoid generating MDR reduce incidence by 13-19%. Likewise, although MDR prevalence increases 14-18% with PPM alone, PPM combined with rapid, accurate diagnostics results in MDR prevalence declines of 55-58%.

Conclusion: Combining public and private sector interventions to improve and link TB care and rapid, accurate diagnostics is a promising approach for reducing non-MDR and MDR TB in India.

Purpose: Recessions are characterized by increased morbidity and mortality, reduced access to private health insurance and strain on public health insurers.  This study sought to evaluate the effect of unemployment on health outcomes, Medicare and overall healthcare spending, and the US healthcare industry.

Method: Data were collected for 50 states and DC from 1999-2009.  Unemployment, healthcare facility and occupational employment data were obtained from the Bureau of Labor Statistics.  Mortality and morbidity data were collected from the Center for Disease Control and Prevention.  Healthcare spending data were derived from the Centers for Medicare and Medicaid Services.  State fixed effects regressions were performed to examine the relationship between unemployment, Medicare and overall healthcare spending, and health outcomes (i.e. morbidity and mortality).  Regressions were also performed to model the association between Medicare and overall healthcare spending and healthcare facility and occupational employment.  Medicare models controlled for each state’s elderly population rate.  All statistical tests used a two-sided α significance level of p<.05.  Statistical analyses were performed with STATA.

Result: Unemployment was associated with declining self-reported health status and increased mortality rates for males (p<.01) and females (p<.001) aged 16-64 years old.  Further, as the economy contracts, Medicare’s share of state overall healthcare spending increased (p<.001) while all other state healthcare spending declined (p<.001).  An increase in Medicare’s share of state overall healthcare spending would positively affect statewide employment at general medical and surgical hospitals, outpatient physician offices and home health agencies (p<.001). Further, an increase in Medicare’s share of state overall healthcare spending would also increase statewide employment of registered nurses, home health aides, pharmacy techs, and physician assistants per 100,000 (p<.001), while it would negatively affect employment of internists and surgeons (p<.01).  To the contrary, as all other state healthcare spending increased, statewide employment of registered nurses, home health aides, and pharmacy techs decreased (p<.001), while employment of primary care physicians, internists, and surgeons increased (p<.05).

Conclusion: Unemployment is associated with increased morbidity and mortality.  Recessions are also associated with increased Medicare spending as a share of state overall healthcare spending, with statistically significant impacts on statewide healthcare facility and occupational employment.  During economic contractions, imbalanced numbers of healthcare providers might also lead to increasing morbidity and mortality rates for working age individuals.

Purpose: Increasingly, countries have introduced vaccination against human papillomavirus (HPV), causally linked to several cancers and genital warts, targeted to young girls, but few have recommended routine vaccination of boys. Declining vaccine prices and the growing evidence of vaccine impact on reducing HPV-related conditions in both women and men prompts countries, such as Norway, to decide whether HPV vaccination of boys is warranted.

Method: A previously-published dynamic model of HPV transmission was updated to integrate recent evidence of gender- and type-specific natural history of HPV infections and empirically calibrated to observed HPV prevalence and cervical cancer incidence in Norway. Reductions in the incidence of HPV, which include both the direct and indirect benefits of vaccination, were applied to a microsimulation model of the natural history of cervical cancer in the presence of status quo screening, and to incidence-based models for other non-cervical HPV-related diseases among both men and women. We adopted a societal perspective and compared the incremental costs and benefits (discounted 4% annually) of a scenario reflecting the current 3-dose coverage level of pre-adolescent girls (75%) with and without similar coverage in boys in a school-based delivery program. Multiple good-fitting parameter sets from the dynamic model were used to explore the impact of parameter uncertainty on reductions in HPV incidence. Sensitivity analyses were conducted on vaccine cost and properties, and differential uptake among boys.

Result: Assuming 75% vaccine coverage, high, lifelong vaccine efficacy, and the current market price of the vaccine (plus administration and supplies), we found that expanding the vaccination program to include boys generally exceeded the commonly cited willingness-to-pay threshold in Norway (i.e., $83,000/QALY), compared with vaccination of 12-year-old girls alone, even when including vaccine benefits to all HPV-related conditions. However, the current tender price is estimated at half the market price (not-publicly available); under this assumption, vaccinating both girls and boys exceeded $100,000/QALY when only cervical cancer endpoints were considered but fell below Norway’s willingness-to-pay threshold when including all HPV-related conditions. Results remained stable when male uptake was 50%.

Conclusion: At Norway’s current market price, expanding the HPV vaccination program to boys is unlikely to be cost effective; however, at the assumed tender price, vaccinating boys becomes more attractive and may warrant a change in the current female-only vaccination policy.

Purpose: Childhood cancer survivors face elevated risks for cardiac mortality, with congestive heart failure (CHF) responsible for up to half of all cases. Follow-up guidelines for survivors recommend routine cardiac assessment every 1 to 5 years, depending on original cancer diagnosis age and treatment, and angiotensin converting enzyme inhibitors (ACEI) may reduce CHF risk. We sought to estimate the clinical benefits and cost-effectiveness of routine cardiac assessment to detect asymptomatic left-ventricular dysfunction (ALVD) and ACEI treatment to reduce CHF incidence and improve overall survival.

Methods: Using a decision-analytic approach, we synthesized the best available data to model the clinical course of CHF in a cohort of patients similar to those in the Childhood Cancer Survivors Study (CCSS). We used a simulation model to project lifetime CHF risk, life expectancy (LE), lifetime costs and incremental cost-effectiveness ratios (ICERs) associated with interval-based cardiac assessment. Compared to no assessment, we estimated the incremental benefit of an echocardiogram every 1, 2, 5 or 10 years. Test performance (sensitivity=0.53, specificity=0.86) and absolute excess risk (AER) for CHF incidence were based on CCSS estimates, while a broader range of data were used to establish baseline assumptions, including: 1) ALVD progresses to CHF after a median interval of 5.9 years and 2) ACEI treatment for ALVD reduces CHF risk (RR=0.67). Screening and treatment costs were based on Medicare reimbursement rates.

Results: For a cohort of 5-year childhood cancer survivors (diagnosis age=10), the expected CHF-related mortality was 18.8%. Routine echocardiogram reduced lifetime CHF risk by 4.9% (every 10 years) to 11.9% (every 1 year). Compared to no assessment, the ICER for assessment every 10 years was $188,900 per LE gained. ICERs for all other strategies exceeded $200,000 per LE gained. Results were most sensitive to AER for CHF among CCSS, ACEI treatment effectiveness and echocardiogram specificity. Prevalence of individuals with false positive test results varied by strategy, ranging from 13% (every 10 years) to 91% (every 1 year) at 45 years of age. Based on probabilistic sensitivity analysis, the probability that assessment every 10 years was optimal given a cost-effectiveness threshold of $150,000 per QALY was only 2%.

Conclusions: Recommended follow-up guidelines for cardiac assessment may improve overall survival for childhood cancer survivors, but less frequent screening than currently recommended is likely optimal.

  Purpose:

Use of new oral anticoagulants (apixaban, dabigatran and rivaroxaban) for atrial fibrillation is increasing rapidly. The objective of this analysis was to investigate whether or not elimination of decision uncertainty related to the new oral anticoagulants for atrial fibrillation would be cost-effective.

  Method:

We developed a decision analytic model, designed as a probabilistic Markov model containing more than 200 different probability distributions and eight health states. Epidemiological input data was gathered from registries. Data on Health Related Quality of Life were based on published EQ-5D data and costs were based on national tariffs.

Efficacy data included the three major randomized controlled trials comparing each of the new oral anticoagulants (apixaban, dabigatran and rivaroxaban) with warfarin. Current efficacy estimates indicate that the new anticoagulants are efficacious on some, but not all, outcomes compared to warfarin. However, no direct evidence comparing any of these new anticoagulants with each other is yet available. To explore the value of reducing decision uncertainty, we conducted expected value of perfect information on parameters (EVPPI) for parameters and groups of parameters. We focused particularly on efficacy, in order to investigate whether new RCT’s with direct comparison on the new oral anticoagulants is worth conducting.

  Result:

Expected value of perfect information analyses on groups of parameters (EVPPI) for the group of efficacy parameters was not higher than EVPPI for the other groups of parameters (QALYs, costs, epidemiological data). EVPPI for efficacy data was $ 7 (medium risk patients) and $ 1,300 (high risk patients) per patient, given an assumed threshold value of $100,000 per QALY gained.

  Conclusion:

There is added value in conducting more research on the efficacy of new oral anticoagulants for high risk patients. Hence, new randomized controlled trial(s) comparing all of the new oral anticoagulants would probably decrease decision uncertainty, at least for high risk patients. However, better data on QALYs and epidemiological data would have even higher potential for reducing decision uncertainty.