Monday, October 20, 2014: 1:00 PM - 2:30 PM

* Finalists for the Lee B. Lusted Student Prize

1:00 PM

Jeremy D. Goldhaber-Fiebert, PhD, Sze-chuan Suen, MS and Kimberly Babiarz, MA, PhD, Stanford University, Stanford, CA
Purpose: As lower income countries like India experience rapid economic development, resources available for health interventions increase. Cost-effectiveness analysis (CEA) is critical for leveraging these newly acquired resources most efficiently. When interventions differentially extend life expectancy, CEA best practices require accounting for background medical spending that varies by age and sex. This practice is common in the US and Europe but less so for developing countries where data on background medical spending are sparse. We developed an approach to estimate time-varying age- and sex-specific medical spending from household consumption expenditure surveys and applied them to a policy-relevant example in India.

Method: We analyzed nationally representative household expenditure data (871,702 households) collected in 15 cross-sectional waves (1995 to 2010) by India’s National Sample Survey Organization. The main outcome was real household medical expenditure. We quantified the average expenditure attributable to household members by age and sex for the overall population and for urban and rural subpopulations for each wave using regression analysis to decompose household expenditure. We characterized time-trends with inverse-variance-weighted, local polynomial smoothing. We inflation adjusted expenditures to 2012 Rupees and accounted for complex survey sampling designs to achieve nationally representative estimates.

Result: Real per-capita average monthly medical expenditure rose nearly 60% (from 50 to 80 Rupees) between 1995 and 2010, with urban expenditure rising faster and higher than rural expenditure. Expenditure on drugs in outpatient settings accounted for 78% of total medical expenditure, lower in urban areas (74%) than in rural areas (79%). Monthly expenditure for males aged 0-19 years averaged 10 Rupees from 2005-2010 and increased with age to 225 Rupees for males aged 60+. For females aged 0-19 years during this period, expenditure averaged 8 Rupees, rose rapidly during childbearing years (150 Rupees), and were lower than men for those aged 60+ (200 Rupees). The largest growth in spending over 1995-2010 has been for urban men aged 50+ and women aged 30-59, particularly in urban areas.

Conclusion: In India, higher medical expenditure has become increasingly concentrated in urban areas particularly in older males and for outpatient drug purchases. More generally, the methods we used demonstrate that it is possible to estimate individual-level background medical expenditure from household consumption expenditure surveys for many developing countries for the purpose of conducting best-practice CEAs.

1:15 PM

Dagna Constenla, PhD1, Nelson Alvis-Guzmán, PhD, MPH, MD2, Brigina Kemp, MD3, Marisol Concha-Barrientos, MD4, Nelson Alvis-Zakzuk, BA5, Maria Carrasquilla-Sotomayo, BA5, Ana Carvalho, MBA6 and Ciro de Quadros, MD6, (1)Johns Hopkins University, Baltimore, MD, (2)Universidad de Cartagena., Colombia, Colombia, (3)Secretaria Municipal de Saúde, Campinas, Brazil, (4)Asociación Chilena de Seguridad, Santiago, Chile, (5)Universidad de Cartagena, Cartagena, Colombia, (6)Sabin Vaccine Institute, Washington DC, DC

Neisseria meningitidis (NM) is a leading cause of bacterial meningitis and septicemia in infants, young children and adolescents, with considerable morbidity and mortality and outbreaks every two years in certain parts of the world. Public health costs associated with meningococcal outbreaks are not well known in Latin America. The aim of the study is to provide estimates of the economic burden of meningococcal outbreaks in two endemic countries of the region. 


We developed an economic model to estimate the cost associated with meningococcal outbreaks in Brazil (Campinas, Sao Paulo) and Colombia (Cartagena and Sincelejo, Cartagena de Indias) from a societal perspective. Structured interviews were conducted by local health authorities to estimate the cost of the outbreaks. The interviews captured information about the use of resources, expenses allocated to case management (e.g. chemoprophylaxis), immunization campaigns and response activities during the outbreak and disease surveillance after the outbreak. Resource utilization and cost data associated with control of the outbreak (response phase) and monitoring of disease (disease surveillance phase) were collected retrospectively. 


Costs associated with outbreaks of meningococcal disease were reported from two recent outbreaks: one in Brazil (Vila Brandina in 2011), and one in Colombia (Cartagena de Indias in 2012). The first outbreak that occurred in Vila Brandina, São Paulo, reported 3 cases that were associated with a total investigation and outbreak management cost of US$34,425 (US$11,475 per notified case), compared to US$735.10 (US$122.52 per notified case) for the 2012 outbreak, which reported 6 cases in Cartagena de Indias. These costs correspond to the disease response phase. For the disease surveillance phase, the costs ranged from US$3,935 (Cartagena outbreak) to US$6,667 (outbreak in Vila Brandina). The difference in cost between the two outbreaks was due to the number of cases of an outbreak, the size of the population, the area of exposure, and management practices.


Findings of this study underscore the importance of meningococcal disease in the region. Current study findings will be used to inform national health authorities about the economic burden of meningococcal outbreaks in endemic countries of the region.

1:30 PM

Rachel A. Elliott, PhD, MRPharmS1, Lukasz Tanajewski, BSc MSc PhD2, Georgios Gkountouras, BSc MSc2, Matthew J Boyd, BPharm (Hons) PhD MRPharmS2, Rajnikant Mehta, BSc MSc2, Nick Barber, BPharm MRPharmS MSc PhD3, Anthony Avery, BMedSci MB ChB DGM DCH MRCGP DM FRCGP4, Justin Waring, BA MA PhD5, Antony Chuter, BA6, Nde-Eshimuni Salema, MRPharmS PhD4 and Christopher Craig, BA2, (1)School of Pharmacy, Nottingham, United Kingdom, (2)University of Nottingham, Nottingham, United Kingdom, (3)The Health Foundation, London, United Kingdom, (4)Nottingham School of Medicine, Nottingham, United Kingdom, (5)Nottingham Business School, Nottingham, United Kingdom, (6)Copyhold Lane, West Sussex, United Kingdom

We aimed to estimate cost-effectiveness of a community-pharmacy service to improve adherence to new medicines for long-term-conditions, compared with current practice, by combining effectiveness in adherence improvement and intervention costs from an RCT with modelled effects of adherence on patient outcomes and healthcare costs, to estimate the effect on costs and quality-adjusted-life-years (QALYs).


The New Medicine Service (NMS) is offered by community-pharmacists in England to people starting a new medicine for asthma/ chronic obstructive pulmonary disease (COPD), type 2 diabetes (T2D), hypertension or antiplatelet/anticoagulant treatment to help improve medicines adherence. We conducted a robust, pragmatic patient-level RCT, the primary outcome was adherence at 10 weeks (defined as Morisky Medication Adherence Score, MMAS-8 ≥ 6). We undertook the economic analysis from the perspective of NHS England with a lifetime time-horizon.

We developed Markov models for each therapeutic area, using the most commonly prescribed drug in each to inform model design. Clinical event probability, treatment pathway, resource-use and costs were extracted from literature and English costing tariffs. Lifetime cost and QALYs were derived from each medicine-specific model, for adherent and non-adherent patients. A composite probabilistic model combined patient-level adherence models with adherence rates and intervention costs from the trial. Cost per extra QALY and cost-effectiveness acceptability curves were generated.


504 patients (253 current practice; 251 NMS intervention) were recruited from 46 pharmacies. 249 (49.4%) had hypertension, 117 (23.2%) asthma/COPD; 95 (18.8%) T2D; 43 (8.5%) antiplatelet/anticoagulant treatment. At Week 10 there was a significant adherence improvement in NMS arm, compared to current practice, with adjusted odds ratio 1.81 (95%CI: 1.07-3.05, p=0.03).

Mean (median, range) NHS cost at 10 weeks for patients in current practice and NMS are £260 (121, 0-1668), and £215 (110,0-1458), respectively, suggesting NMS service costs were countered by reduced NHS contact costs.

NMS generated a mean of 0.06 (95%CI: 0.00-0.16) more QALYs per patient, at a mean reduced cost of £-190 (-929-87). The NMS service dominates current practice, with an ICER (95% credibility range) of -£3,005 (-17,212-4,542). Probabilistic analysis suggests the probability that NMS dominates current practice is 0.81. NMS has a high probability (0.97) of cost-effectiveness at a willingness-to-pay of £20,000/QALY.


NMS increased health gain at a cost per QALY well below most accepted UK thresholds for technology implementation, £20,000-£30,000.

1:45 PM

Shahriar Shams, MA1, Lusine Abrahamyan, MD MPH PhD2, Gabrielle van der Velde, DC, PhD2 and Nicholas Mitsakakis, MSc PhD2, (1)Dalla Lana School of Public Health, University of Toronto, Toronto, ON, Canada, (2)Toronto Health Economics and Technology Assessment (THETA) Collaborative, University of Toronto, Toronto, ON, Canada
Purpose:   Whiplash injury following a traffic collision may lead to whiplash-associated disorder (WAD). The present study gives a detailed description of the health care utilization among patients with whiplash injury.  It evaluates the association between patients’ expected recovery at baseline and their health care costs one year after the accident. 

Method: We re-analyzed data from a previously conducted randomized clinical trial containing one year healthcare costs of 340 patients with whiplash injury following a motor vehicle accident. Detailed descriptive statistics were generated for health care utilization and cost. A two-part Zero Adjusted Gamma (ZAGA) regression model was used to investigate the association between cost and expected recovery, adjusting for important confounders. This model was selected primarily because it addressed issues with the cost data such as high skewness and presence of zeros. Model fitting was assessed with the use of diagnostics, while Bootstrap resampling was employed for model validation.

Result: The median cost of those who expected to “never get better” (N=74) was $7,354.  This cost was three times larger that those who expected to “get better slowly” (N=101) and more than five times larger than those who expected to “get better soon” (N=165). The association between expected recovery and cost was demonstrated by the covariate adjusted two-part model, where patients expecting to “never get better” had on average 2.66 times higher costs than those who expected to “get better soon” (p-value < 0.0001). Additional covariates with significant association with cost were Whiplash Disability Questionnaire (WDQ) score (p-value < 0.0001), Center for Epidemiologic Studies Depression score (CESD) (p-value = 0.0022) and Physical Component score (PCS) (p-value < 0.0001). The model was validated and seemed to fit the data well.

Conclusion: The ZAGA model was shown to perform well for the analysis of health care cost data. Expected recovery and other modifiable factors were found to have a significant effect on health care utilization and cost. These findings could have a significant impact on policy making by informing evidence-based guidelines for managing minor traffic injuries in Ontario.

2:00 PM

Emanuel Krebs, M.A., Thomas Kerr, Ph.D., Julio Montaner, MD, Evan Wood, MD, Ph.D. and Bohdan Nosyk, Ph.D., BC Centre for Excellence in HIV/AIDS, Vancouver, BC, Canada

   Purpose: Research into crime-related costs associated with methadone maintenance treatment's (MMT) known longitudinal pattern of continued drug use, treatment and full abstention is sparse. Our objective was to characterize crime-related costs associated with this chronic cyclical pattern among opioid dependent individuals.

   Methods: We considered individuals enrolled in a prospective study between December 2011 and May 2013 in Vancouver, Canada. Monthly crime-related costs (2013 CAD) were derived from self-reported criminal activity. On the basis of MMT receipt and illicit opioid use, individuals were classified in mutually exclusive health states: (i) MMT with high effectiveness; (ii) MMT with low effectiveness; (iii) opioid abstinence; or (iv) relapse. MMT was defined as with high effectiveness if no concurrent illicit opioid use was reported, and as with low effectiveness otherwise. We stratified individuals as daily, non-daily or non-stimulant users and controlled for individual demographic and socio-economic characteristics. A two-part multiple regression model, estimated using generalized linear modeling, was constructed to account for excess zeroes and skewness in cost data. The first part modeled the probability of having a non-zero cost using a logit model specification, while the second estimated the level of non-zero costs, using a Gamma distribution and log link. Crime-related costs were estimated for each health state and stratified by stimulant use intensity.

   Results: Our study included 982 individuals (median age 47, 38% female) for a total of 2,232 observations. Compared to periods of relapse, MMT with high effectiveness was associated with lower monthly costs of criminality ($6,298 reduction; 95% C.I. ($1,578,$11,017)), as were episodes of opioid abstinence ($6,563 ($1,564,$11,561)). Also compared to periods of relapse, estimated cost reductions for daily stimulant users were greater than for non-daily users, both for periods of MMT with high effectiveness ($12,203 [$2,541,$21,866] vs.$3,832 [$938,$6,725]) and periods of opioid abstinence ($12,704 [$2,453,$22,954] vs.$3,998 [$1,024,$8,061]).

   Conclusions: Using longitudinal data on individuals with a history of MMT utilization, we found that MMT with high effectiveness was associated with lower costs of criminality. When compared to periods of relapse, cost reductions were highest among daily stimulant users during periods of MMT with high effectiveness or during periods of opioid abstinence, whereas periods of MMT with low effectiveness compared to periods of relapse were not associated with any statistical difference in costs.