Publications by authors named "Ella Zomer"

75 Publications

The Health and Productivity Burden of Depression in South Korea.

Appl Health Econ Health Policy 2021 Jun 25. Epub 2021 Jun 25.

School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia.

Objectives: Major depression in South Korea, which remains under-diagnosed and under-treated, increases the risk of premature death, and reduces quality of life and work productivity. The aim of this study was to quantify the depression-related health and productivity loss in South Korea in terms of life-years lost and productivity-adjusted life-years (PALYs) lost.

Method: Age and sex-specific life table models simulated follow-up of South Koreans with depression aged 15 to 54 years, until 55 years. Depression was defined as major depression. Inputs were drawn from national datasets and published sources. Models were constructed for the cohort with depression and repeated assuming they had no depression. Differences in total deaths, years of life, and PALYs represented the impact of depression. PALYs were ascribed a financial value equivalent to total gross domestic product (GDP) divided by the number of equivalent full-time workers (KRW81,507,146 or USD74,748). All outcomes were discounted by 3% per annum.

Results: In 2019, there were more than 500,000 people aged 15-54 years with major depression in South Korea. We predicted that until this cohort reached age 55 years, and assuming 22.2% of people with depression are treated, depression led to 12,000 excess deaths, more than 55,000 discounted years of life lost and 1.6 million discounted PALYs lost, equating to KRW133 trillion (USD122 billion) in lost GDP. Applying treatment-related response and remission rates of 11.8% and 42.1%, respectively, and a non-response/non-remission rate of 46.1%, increased the total number of PALYs lost by almost 6.0%.

Conclusions: Our study highlights the considerable productivity loss attributable to depression among South Koreans over their working lifetime. Better prevention and treatment of depression is needed for long-term economic gains.
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http://dx.doi.org/10.1007/s40258-021-00649-1DOI Listing
June 2021

Cost Burden and Cost-Effective Analysis of the Nationwide Implementation of the Quality in Acute Stroke Care Protocol in Australia.

J Stroke Cerebrovasc Dis 2021 Aug 19;30(8):105931. Epub 2021 Jun 19.

School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia. Electronic address:

Objectives: The Quality in Acute Stroke Care (QASC) protocol is a multidisciplinary approach to implement evidence-based treatment after acute stroke that reduces death and disability. This study sought to evaluate the cost-effectiveness of implementing the QASC protocol across Australia, from a healthcare and a societal perspective.

Materials And Methods: A decision-analytic model was constructed to reflect one-year outcomes post-stroke, aligned with the stroke severity categories of the modified Rankin scale (mRS). Decision analysis compared outcomes following implementation of the QASC protocol versus no implementation. Population data were extracted from Australian databases and data inputs regarding stroke incidence, costs, and utilities were drawn from published sources. The analysis assumed a progressive uptake and efficacy of the QASC protocol over five years. Health benefits and costs were discounted by 5% annually. The cost of each year lived by an Australian, from a societal perspective, was based on the Australian Government's 'value of statistical life year' (AUD 213,000).

Results: Over five years, the model predicted 263,722 strokes among the Australian population. The implementation of the QASC protocol was predicted to prevent 1,154 deaths and yield a gain of 876 years of life (0.003 per stroke), and 3,180 quality-adjusted life years (QALYs) (0.012 per stroke). There was an estimated net saving of AUD 65.2 million in healthcare costs (AUD 247 per stroke) and AUD 251.7 million in societal costs (AUD 955 per stroke).

Conclusions: Implementation of the QASC protocol in Australia represents both a dominant (cost-saving) strategy, from a healthcare and a societal perspective.
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http://dx.doi.org/10.1016/j.jstrokecerebrovasdis.2021.105931DOI Listing
August 2021

Trends in the Utilization of Lipid-Lowering Medications in Australia: An Analysis of National Pharmacy Claims Data.

Curr Probl Cardiol 2021 May 8:100880. Epub 2021 May 8.

School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia.

Lipid-lowering medications comprise standard of care in the prevention of cardiovascular disease. This study examined the trends in the utilization of statin and non-statin medications in the Australian general population between 2013 and 2019. Pharmacoepidemiological analyses were performed using pharmacy dispensing data from Australian Pharmaceutical Benefits Scheme. One-year prevalence and incidence of statin and non-statin prescribing patterns were reported, and relative variations in prescribing examined via Poisson regression modelling. The one-year prevalence of statins' prescriptions decreased between 2013-2019 by 5.5% (from 25.0%-19.5%). Females were less likely than males to be prescribed statins (rate ratio [RR]=0.90, 95% confidence interval [CI] 0.89-0.91). The one-year prevalence of ezetimibe alone, and in combination with statins, increased consistently from 2013-2019 from 1.5%-3.6% (P<0.01) and 0.1%-1.1% (P<0.01), respectively. The prevalence was higher among those aged 61-80 years (RR=1.20, 95%CI 1.10-1.21) and those aged older than 80 years (RR=1.34, 95%CI 1.22-1.47), when compared to people aged <60 years. The incidence of ezetimibe prescriptions was highest in people aged 61-80 years (RR=1.36, 95%CI 1.31-1.41) compared to those aged <60 years. The one-year prevalence of proprotein convertase subtilisin/kexin type 9 inhibitor prescriptions was highest among those aged 46-60 years (RR=1.24, 95%CI 0.97-4.97) compared to people aged <46 and >60 years. Females were less likely than males to be prescribed a proprotein convertase subtilisin/kexin type 9 inhibitor (RR=0.87, 95%CI 0.75-0.98). Statins remain the most prevalent lipid-lowering medication prescribed in Australia. The prescribing of non-statin medications remains low, but is increasing.
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http://dx.doi.org/10.1016/j.cpcardiol.2021.100880DOI Listing
May 2021

Switching, Persistence and Adherence to Statin Therapy: a Retrospective Cohort Study Using the Australian National Pharmacy Data.

Cardiovasc Drugs Ther 2021 Jun 7. Epub 2021 Jun 7.

School of Public Health and Preventive Medicine, Monash University, 553 St Kilda Rd, Melbourne, 3004, Australia.

Background: Statins are widely prescribed for the primary and secondary prevention of cardiovascular disease (CVD), but their effectiveness is dependent on the level of adherence and persistence.

Objectives: This study aimed to explore the patterns of switching, adherence and persistence among the Australian general population with newly dispensed statins.

Methods: A retrospective cohort study was conducted using a random sample of data from the Australian national prescription claims data. Switching, adherence to and persistence with statins were assessed for people starting statins from 1 January 2015 to 31 December 2019. Switching was defined as either switching to another intensity of statin, to another statin or to a non-statin agent. Non-persistence to treatment was defined as discontinuation (i.e. ≥90 days with no statin) of coverage. Adherence was measured using proportion of days covered (PDC), and patients with PDC < 0.80 were considered non-adherent. Cox proportional hazard models were used to compare discontinuation, switching and reinitiation between different statins.

Results: A cohort of 141,062 people dispensed statins and followed over a median duration of 2.5 years were included. Of the cohort, 29.3% switched statin intensity, 28.4% switched statin type, 3.7% switched to ezetimibe and in 2.7%, ezetimibe was added as combination therapy during the study period. Overall, 58.8% discontinued statins based on the 90-day gap criteria, of whom 55.2% restarted. The proportion of people non-adherent was 24.0% at 6 months to 49.0% at 5 years. People on low and moderate intensity statins were more likely to discontinue compared to those on high-intensity statins (hazard ratio [HR] 1.20, 95% confidence interval [CI] 1.09-1.31), (HR 1.28, 95%CI 1.14-1.42), respectively. Compared to maintaining same statin type and intensity, switching statins, which includes up-titration (HR 0.77, 95%CI 0.70 to 0.86) was associated with less likelihood of discontinuation after reinitiation.

Conclusions: Long-term persistence and adherence to statins remains generally poor among Australians, which limits the effectiveness of these medicines and the consequent health impact they may provide for individuals (and by extension, the population impact when poor persistence and adherence is considered in the statin-taking population). Switching between statins is prevalent in one third of statin users, although any clinical benefit of the observed switching trend is unknown. This, combined with the high volume of statin prescriptions, highlights the need for better strategies to address poor persistence and adherence.
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http://dx.doi.org/10.1007/s10557-021-07199-7DOI Listing
June 2021

Estimating the Productivity Impact of Acute Myeloid Leukemia in Australia Between 2020 and 2029, Using a Novel Work Utility Measure: The Productivity-Adjusted Life Year (PALY).

JCO Oncol Pract 2021 May 12:OP2000904. Epub 2021 May 12.

Monash University, School of Public Health and Preventive Medicine, Melbourne, Australia.

Purpose: Acute myeloid leukemia (AML) is a rare hematologic malignancy accounting for 0.8% of new cancer diagnoses in Australia. High mortality and morbidity affect work productivity through workforce dropout and premature death. This study sought to estimate the productivity loss attributable to AML in the Australian population over 10 years and to estimate the costs of this productivity loss. Productivity was measured using productivity-adjusted life years (PALYs), a similar concept to quality-adjusted life years, but adjusts for the productivity loss attributable to disease, rather than impaired health.

Materials And Methods: Dynamic life tables modeled the Australian working population (age 15-65 years) between 2020 and 2029. The model population had two cohorts: those with and without AML. Differences in life years, PALYs, and costs represented the health and productivity impact of AML. Secondary analyses evaluated the impact of different scenarios.

Results: Over the next 10 years, there will be 7,600 years of life lost and 7,337 PALYs lost because of AML, amounting to Australian dollars (AU$) 1.43 billion in lost gross domestic product ($971 million in US dollars). Secondary analyses highlight potential savings of approximately AU$52 million if survival rates were improved by 20% and almost AU$118 million in savings if the return-to-work rates increased by 20% on the current estimates.

Conclusion: Our study demonstrates that even in low-incidence cancer, high mortality and morbidity translate to profound impacts on years of life, productivity, and the broader economy. Better treatment strategies are likely to result in significant economic gains. This highlights the value of investing in research for improved therapies.
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http://dx.doi.org/10.1200/OP.20.00904DOI Listing
May 2021

Characterising experiences with acute myeloid leukaemia using an Instagram content analysis.

PLoS One 2021 3;16(5):e0250641. Epub 2021 May 3.

School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia.

Instagram has more than one billion monthly users, which presents a unique research opportunity particularly in rare diseases or hard to reach populations. This study focuses on acute myeloid leukaemia, a rare haematological malignancy and aims to characterise who posts acute myeloid leukaemia-related content and the type of content created. The findings can provide information and a method for future studies, particularly those focused on online or social media based interventions. Acute myeloid leukaemia-related Instagram posts were identified by searching specific and relevant hashtags (#). A content analysis systematically classified themes in the data. A convenience sample of 100 posts (138 photos) were manually extracted and coded. Data are described using descriptive statistics and demonstrated by qualitative examples. The most frequent users in our sample were patients (66%), patient support networks (24%) and professional organisations (10%). Patients who were communicating their health update (31%) were the most frequently posted content and 25% of these posts described a symptom experience. Our findings demonstrate that patients and their support networks are frequenting Instagram and therefore may be able to receive and benefit from tailored intervention, however there is an identified gap in health-organisations participating in this virtual online community.
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http://journals.plos.org/plosone/article?id=10.1371/journal.pone.0250641PLOS
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8092772PMC
May 2021

The Preventable Productivity Burden of Kidney Disease in Australia.

J Am Soc Nephrol 2021 Mar 9. Epub 2021 Mar 9.

School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia

Background: Kidney disease is associated with impaired work productivity. However, the collective effect of missed work days, reduced output at work, and early withdrawal from the workforce is rarely considered in health-economic evaluations.

Methods: To determine the effect on work productivity of preventing incident cases of kidney disease, using the novel measure "productivity-adjusted life year" (PALY), we constructed a dynamic life table model for the Australian working-age population (aged 15-69 years) over 10 years (2020-2029), stratified by kidney-disease status. Input data, including productivity estimates, were sourced from the literature. We ascribed a financial value to the PALY metric in terms of gross domestic product (GDP) per equivalent full-time worker and assessed the total number of years lived, total PALYs, and broader economic costs (GDP per PALY). We repeated the model simulation, assuming a reduced kidney-disease incidence; the differences reflected the effects of preventing new kidney-disease cases. Outcomes were discounted by 5% annually.

Results: Our projections indicate that, from 2020 to 2029, the estimated number of new kidney-disease cases will exceed 161,000. Preventing 10% of new cases of kidney disease during this period would result in >300 premature deaths averted and approximately 550 years of life and 7600 PALYs saved-equivalent to a savings of US$1.1 billion in GDP or US$67,000 per new case avoided.

Conclusions: Pursuing a relatively modest target for preventing kidney disease in Australia may prolong years of life lived and increase productive life years, resulting in substantial economic benefit. Our findings highlight the need for investment in preventive measures to reduce future cases of kidney disease.
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http://dx.doi.org/10.1681/ASN.2020081148DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8017534PMC
March 2021

Future burden of cardiovascular disease in Australia: impact on health and economic outcomes between 2020 and 2029.

Eur J Prev Cardiol 2021 Mar 4. Epub 2021 Mar 4.

School of Public Health and Preventive Medicine, Monash University, 553 St Kilda Rd, Melbourne 3004, Australia.

Aims: To estimate the health and economic burden of new and established cardiovascular disease from 2020 to 2029 in Australia.

Methods And Results: A two-stage multistate dynamic model was developed to predict the burden of the incident and prevalent cardiovascular disease, for Australians 40-90 years old from 2020 to 2029. The model captured morbidity, mortality, years of life lived, quality-adjusted life years, healthcare costs, and productivity losses. Cardiovascular risk for the primary prevention population was derived using Australian demographic data and the Pooled Cohort Equation. Risk for the secondary prevention population was derived from the REACH registry. Input data for costs and utilities were extracted from published sources. All outcomes were annually discounted by 5%. A number of sensitivity analyses were undertaken to test the robustness of the study. Between 2020 and 2029, the model estimates 377 754 fatal and 991 375 non-fatal cardiovascular events. By 2029, 1 061 756 Australians will have prevalent cardiovascular disease (CVD). The population accrued 8 815 271 [95% uncertainty interval (UI) 8 805 083-8 841 432] years of life lived with CVD and 5 876 975 (5 551 484-6 226 045) QALYs. The total healthcare costs of CVD were projected to exceed Australian dollars (AUD) 61.89 (61.79-88.66) billion, and productivity losses will account for AUD 78.75 (49.40-295.25) billion, driving the total cost to surpass AUD 140.65 (123.13-370.23) billion.

Conclusion: Cardiovascular disease in Australia has substantial impacts in terms of morbidity, mortality, and lost revenue to the healthcare system and the society. Our modelling provides important information for decision making in relation to the future burden of cardiovascular disease.
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http://dx.doi.org/10.1093/eurjpc/zwab001DOI Listing
March 2021

The impact of coronary heart disease prevention on work productivity: a 10-year analysis.

Eur J Prev Cardiol 2021 May;28(4):418-425

School of Public Health and Preventive Medicine, Monash University, 553 St Kilda Rd, Melbourne, VIC 3004, Australia.

Aims: To determine the impact of preventing new (incident) cases of coronary heart disease (CHD) on years of life and productivity, using the novel measure 'productivity-adjusted life year' (PALY), over the next 10 years.

Methods And Results: A dynamic life table model was constructed for the total Australian working-age population (15-69 years) over 10 years (2020-2029), separated by CHD status. Productivity estimates were sourced from the literature. The PALY was ascribed a financial value in terms of gross domestic product (GDP) per equivalent full-time worker. The total number of years lived, PALYs, and economic burden (in terms of GDP per PALY) were estimated. The model simulation was repeated assuming incidence was reduced, and the differences represented the impact of CHD prevention. All outcomes were discounted by 5% per annum. Over 10 years, the total projected years lived and PALYs in the Australian working-age population (with and without CHD) were 133 million and 83 million, respectively, amounting to A$17.2 trillion in GDP. We predicted more than 290 000 new (incident) CHD cases over the next 10 years. If all new cases of CHD could be prevented during this period, a total of 4 000 deaths could be averted, resulting in more than 8 000 years of life saved and 104 000 PALYs gained, equivalent to a gain of nearly A$21.8 billion (US$14.8 billion) in GDP.

Conclusion: Prevention of CHD will prolong years of life lived and productive life years, resulting in substantial economic benefit. Policy makers and employers are encouraged to engage in preventive measures addressing CHD.
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http://dx.doi.org/10.1093/eurjpc/zwaa037DOI Listing
May 2021

Assessing the impact of smoking on the health and productivity of the working-age Indonesian population using modelling.

BMJ Open 2020 11 19;10(11):e041832. Epub 2020 Nov 19.

School of Public Health and Preventive Medicine, Monash University Faculty of Medicine Nursing and Health Sciences, Melbourne, Victoria, Australia

Objectives: To estimate the impact of smoking in the working-age Indonesian population in terms of costs, years of life, quality-adjusted life years (QALYs) and productivity-adjusted life years (PALYs) lost.

Methods: Life table modelling of Indonesian smokers aged 15-54 years, followed up until 55 years (retirement age). Contemporary data on demographics, all-cause mortality, population attributable fractions and prevalence of smoking were derived from the Institute for Health Metrics and Evaluation. The quality of life and reduction in productivity due to smoking were derived from published sources. The analysis was repeated but with the assumption that the cohorts were non-smokers. The differences in results represented the losses incurred due to smoking. Gross domestic product (GDP) per equivalent full-time worker (US$11 765) was used for estimation of the cost of each PALY, and an annual discount rate of 3.0% was applied to all costs and outcomes.

Results: The prevalences of smoking among Indonesian working-age men and women were 67.2% and 2.16%, respectively. This study estimated that smoking caused 846 123 excess deaths, 2.9 million years of life lost (0.40%), 41.6 million QALYs lost (5.9%) and 15.6 million PALYs lost (2.3%). The total cost of productivity loss due to smoking amounted to US$183.7 billion among the working-age population followed up until retirement. Healthcare cost was predicted to be US$1.8 trillion. Over a 1-year time horizon, US$10.2 billion was lost in GDP and 117 billion was lost in healthcare costs.

Conclusion: Smoking imposes significant health and economic burden in Indonesia. The findings stress the importance of developing effective tobacco control strategies at the macro and micro levels, which would benefit the country both in terms of health and wealth.
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http://dx.doi.org/10.1136/bmjopen-2020-041832DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7678342PMC
November 2020

Productivity-Adjusted Life-Years: A New Metric for Quantifying Disease Burden.

Pharmacoeconomics 2021 03 11;39(3):271-273. Epub 2021 Jan 11.

School of Public Health and Preventive Medicine, Monash University, 553 St Kilda Road, Melbourne, VIC, 3004, Australia.

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http://dx.doi.org/10.1007/s40273-020-00999-zDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7797495PMC
March 2021

Productivity Benefits of Preventing Type 2 Diabetes in Australia: A 10-Year Analysis.

Diabetes Care 2021 Mar 8;44(3):715-721. Epub 2021 Jan 8.

School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia

Objective: Diabetes imposes a heavy burden on both health and productivity. In this study, we sought to estimate the potential productivity gains associated with the prevention of type 2 diabetes over the next 10 years in Australia.

Research Design And Methods: Dynamic life table models were constructed to estimate years of life lived and productivity-adjusted life-years (PALYs) lived by Australians aged 20-69 years over the period from 2020 to 2029. The models distinguished people with and without type 2 diabetes. PALYs were ascribed a financial value equivalent to gross domestic product (GDP) per full-time worker in Australia (∼200,000 Australian dollars [AUD]). The model simulation was first undertaken assuming currently expected trends in the incidence of type 2 diabetes and then repeated assuming hypothetically that the incidence was reduced. The difference between the modeled outputs reflected the impact of new cases of type 2 diabetes on productivity as well as the potential benefits of prevention. An annual 5% discount rate was applied to all outcomes.

Results: Over the next decade, 140 million years of life and 87 million PALYs will be lived by Australians of working age, contributing AUD 18.0 trillion to the country's GDP. A 10% reduction in the incidence of type 2 diabetes would result in a gain of 2,510 PALYs and AUD 532 million in GDP.

Conclusions: This study illustrates the health and economic impact of type 2 diabetes and the gains that could be potentially achieved from the implementation of effective prevention strategies. However, cost-effectiveness evaluations of these prevention strategies are needed.
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http://dx.doi.org/10.2337/dc20-1429DOI Listing
March 2021

The Health and Productivity Burden of Migraines in Australia.

Headache 2020 Nov 7;60(10):2291-2303. Epub 2020 Oct 7.

School of Public Health and Preventive Medicine, Monash University, Melbourne, Vic., Australia.

Objective: This study aimed to quantify the health and productivity burden of migraines in Australia, measured by quality-adjusted life years (QALYs), productivity-adjusted life years (PALYs, a novel measure of productivity), and associated health-care and broader economic costs.

Methods: A Markov state-transition model was constructed to simulate follow-up of Australians aged 20-64 years over the next 10 years. The model was first run using current prevalence estimates of migraine. It was then rerun assuming that people with migraine hypothetically did not have the condition. Differences in outcomes between the 2 model simulations represented the health and productivity burden attributable to migraine. All data inputs were obtained from published sources. Gross domestic product (GDP) per equivalent full-time worker in Australia was used to reflect the cost of each PALY (AU$177,092). Future costs and outcomes were discounted by 5% annually.

Results: Currently, 1,274,319 million (8.5%) Australians aged 20-64 years have migraine. Over the next 10 years, migraine was predicted to lead to a loss of 2,577,783 (95% confidence interval [CI] 2,054,980 to 3,000,784) QALYs among this cohort (2.02 per person and 2.43% of total QALYs), and AU$1.67 (95% CI $1.16 to $2.37) billion in health-care costs (AU$1313 per person, 95% CI $914 to $1862). There would also be 384,740 (95% CI 299,102 to 479,803) PALYs lost (0.30 per person and 0.53% of total PALYs), resulting in AU$68.13 (95% CI $44.42 to $98.25) billion of lost GDP (AU$53,467 per person, 95% CI $34,855 to $77,102).

Conclusion: Migraines impose a substantial health and economic burden on Australians of working age. Funding interventions that reduce the prevalence of migraines and/or its effects are likely to provide sound return on investment.
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http://dx.doi.org/10.1111/head.13969DOI Listing
November 2020

Bempedoic acid for high-risk patients with CVD as adjunct lipid-lowering therapy: A cost-effectiveness analysis.

J Clin Lipidol 2020 Nov - Dec;14(6):772-783. Epub 2020 Sep 4.

School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia. Electronic address:

Background: Bempedoic acid is a novel adenosine triphosphate citrate lyase inhibitor shown to reduce low density lipoprotein cholesterol when used as an adjunct lipid-lowering therapy in patients with high cardiovascular disease (CVD) risk.

Objective: Our analysis aimed to determine the price at which bempedoic acid would be cost-effective from the Australian health care perspective.

Methods: A Markov model was designed using data from the Cholesterol Lowering via Bempedoic Acid, an ACL-Inhibiting Regimen (CLEAR) Harmony trial, to model the clinical outcomes and costs of 1000 patients treated with bempedoic acid over a lifetime horizon. Relevant health states were "Alive with CVD," "Alive with recurrent CVD," and "Dead." With annual cycles, patients were at risk of a nonfatal myocardial infarction, coronary revascularization, and death from CVD or non-CVD causes. Costs and utilities were obtained from published sources. Outcomes of interest were the incremental cost-effectiveness ratios in terms of cost per quality-adjusted life year (QALY) gained and cost per year of life saved. Outcomes were discounted at 5% per annum.

Results: Among 1000 individuals, bempedoic acid in addition to statin therapy was estimated to save 122 (discounted) years of life and 103 (discounted) QALYs compared with statin therapy alone. At an acquisition cost of AU$584.40 per year (USD$397.01), bempedoic acid would be considered cost-effective within the Australian setting, with an incremental cost-effectiveness ratio of AU$49,890 per QALY gained (USD$33,893) and AU$42,433 per year of life saved (USD$28,827).

Conclusions: Bempedoic acid may be cost-effective within the Australian health care setting at an annual acquisition price less than $600.
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http://dx.doi.org/10.1016/j.jacl.2020.08.013DOI Listing
September 2020

The costs of epilepsy in Australia: A productivity-based analysis.

Neurology 2020 12 15;95(24):e3221-e3231. Epub 2020 Sep 15.

From the Department of Neuroscience, Central Clinical School (E.F., Z.C., M.R., T.J.O., P.K.), and School of Public Health and Preventive Medicine (Z.C., E.Z., D.L., P.K., Z.A.), Monash University, Melbourne; Department of Neurology (E.F., M.R., T.J.O., P.K.), The Royal Melbourne Hospital, Parkville; Department of Neurology (E.F., M.R., T.J.O., P.K.), Alfred Health, Melbourne; Department of Medicine (Z.C., M.R., T.J.O., D.L., G.D.J., P.K.), The University of Melbourne, Parkville; Department of Medicine (P.C.), Monash University; Eastern Health (P.C.), Florey Institute of Neuroscience and Mental Health (P.C., G.D.J.), Melbourne; and Department of Neurology (G.D.J.), Austin Hospital, Heidelberg, Australia.

Objective: To determine the health economic burden of epilepsy for Australians of working age by using life table modeling and to model whether improved seizure control may result in substantial health economic benefits.

Methods: Life table modeling was used for working age Australians aged 15-69 years with epilepsy and the cohort was followed until age 70 years. Published 2017 population and epilepsy-related data regarding epilepsy prevalence, mortality, and productivity were used. This model was then re-simulated, assuming the cohort no longer had epilepsy. Differences in outcomes between these cohorts were attributed to epilepsy. Scenarios were also simulated in which the proportion of seizure-free patients increased from baseline 70% up to 75% and 80%.

Results: In 2017, Australians of working age with epilepsy followed until age 70 years were predicted to experience over 14,000 excess deaths, more than 78,000 years of life lost, and over 146,000 productivity-adjusted life years lost due to epilepsy. This resulted in lost gross domestic product (GDP) of US $22.1 billion. Increasing seizure freedom by 5% and 10% would reduce health care costs, save years of life, and translate to US $2.6 billion and US $5.3 billion GDP retained for seizure freedom rates of 75% and 80%, respectively.

Conclusions: Our study highlights the considerable societal and economic burden of epilepsy. Relatively modest improvements in overall seizure control could bring substantial economic benefits.
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http://dx.doi.org/10.1212/WNL.0000000000010862DOI Listing
December 2020

The economic impact of familial hypercholesterolemia on productivity.

J Clin Lipidol 2020 Nov - Dec;14(6):799-806.e3. Epub 2020 Aug 17.

School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia.

Background: Familial hypercholesterolemia (FH) is a common inherited cause for premature coronary artery disease that increases suffering and disability in affected people. However, the extent to which FH impacts work productivity at a population level is unclear.

Objective: We aimed to quantify the burden of heterozygous FH (HeFH) in terms of productivity-adjusted life years (PALYs) lost to HeFH in Australia.

Methods: A life-table model was constructed to quantify years of life and PALYs lived by Australians with HeFH (prevalence 1 in 300) and of working age (aged 20-69 years). Follow-up was simulated until age 70 years. The model was then resimulated, but assuming the cohort did not have HeFH. Increased cardiovascular mortality and reduction in productivity attributable to HeFH were sourced from published data. Differences in total years of life, quality-adjusted life years, and PALYs lived by the "HeFH cohort" and the same cohort without HeFH ("non-HeFH cohort") reflected the quality-adjusted life years and PALYs lost due to HeFH. All future costs and outcomes were discounted by 5% annually.

Results: In 2017, an estimated 51,587 people of working age in Australia (0.33%) had HeFH. Over their working lifetime, we predicted that 2950 excess cardiovascular deaths occurred in the current Australian population of working age individuals with HeFH, resulting in a loss of 24,727 years of life. In terms of productivity, HeFH led to the loss of 24,954 PALYs over the working lifetime. Based on gross domestic product (GDP) per full-time equivalent worker, this equated to a total of AUD 5.23 billion in lost GDP over the working lifetime, with an average of AUD 101,366 lost per person. A relative reduction of 20% in cardiovascular deaths (as can be achieved with adequate cholesterol control) would lead to 1113 PALYs and AUD 233 million in GDP saved in the HeFH cohort.

Conclusion: The impact of HeFH on work productivity is significant. Screening and prevention strategies tailored early in life are likely to exert not only a positive impact on health but also the economy.
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http://dx.doi.org/10.1016/j.jacl.2020.08.004DOI Listing
August 2020

Health and productivity burden of coronary heart disease in the working Indonesian population using life-table modelling.

BMJ Open 2020 09 9;10(9):e039221. Epub 2020 Sep 9.

Department of Epidemiology and Preventive Medicine, Monash University School of Public Health and Preventive Medicine, Melbourne, Victoria, Australia

Objectives: The impact of coronary heart disease (CHD) and its effect on work productivity at a population level remains unknown in Indonesia. This study estimates the health and productivity lost to CHD in terms of years of life, quality-adjusted life years (QALYs) and productivity-adjusted life years (PALYs).

Setting And Participants: A life-table model was constructed to simulate the experiences of Indonesians currently aged 15-54 years (working age) with CHD, followed-up to 55 years (retirement age). The life-table analysis was then repeated assuming that the cohort did not have CHD. Differences in the results reflected the impact of CHD. Demographical, prevalence and mortality data were based on the 2017 Global Burden of Disease study and 2018 Indonesian National Health Survey. Costs, productivity indices and utilities were derived from published sources. The cost of each PALY was assumed to be equivalent to gross domestic product per equivalent full-time worker (US$11 765). Future costs and outcomes were discounted by 3% annually.

Primary And Secondary Outcome Measures: Differences in total deaths, years of life and PALYs represented the impact of CHD.

Results: At present, 1 954 543 (1.45%) Indonesians of working-age have CHD. By retirement age, it was estimated that CHD resulted in 32 492 (36.6%) excess deaths, 128 132 (0.5%) years of life lost, 2 331 495 (10.5%) QALYs lost and 1 589 490 (6.9%) PALYs lost. The economic impact of lost productivity amounted to US$33.3 billion, and healthcare costs to US$139 billion.

Conclusion: The health and economic burden of CHD in Indonesia looms large. This highlights the importance of its prevention and control, strategies for which, if effective, will deliver financial return.
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http://dx.doi.org/10.1136/bmjopen-2020-039221DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7482464PMC
September 2020

Inclisiran as Adjunct Lipid-Lowering Therapy for Patients with Cardiovascular Disease: A Cost-Effectiveness Analysis.

Pharmacoeconomics 2020 09;38(9):1007-1020

School of Public Health and Preventive Medicine, Monash University, Level 4, 553 St Kilda Road, Melbourne, VIC, 3004, Australia.

Background: Inclisiran inhibits hepatic synthesis of proprotein convertase subtilisin-kexin type 9 (PCSK9). The comparison of inclisiran with statin versus statin alone in the ORION-10 trial demonstrated significant reductions in low-density lipoprotein cholesterol (LDL-C). Our study explored whether the use of inclisiran with statin versus statin alone for secondary prevention of cardiovascular events is cost effective from the Australian healthcare perspective, based on the price of currently available PCSK9 inhibitors.

Methods: A Markov model was developed based on the ORION-10 trial to model outcomes and costs incurred by patients over a lifetime analysis. The three health states were 'alive with cardiovascular disease (CVD)', 'alive with recurrent CVD', and 'dead'. Cost and utilities were estimated from published sources. The cost of inclisiran was estimated from the annual cost of evolocumab, a PCSK9 inhibitor currently available in Australia (AU$6334, based on 2020 data). Outcomes of interest were incremental cost-effectiveness ratios (ICERs) in terms of cost per quality-adjusted life-year (QALY) and cost per year of life saved (YoLS). All costs, QALYs and YoLS were discounted at 5% per annum in line with Australian standards.

Results: Among 1000 subjects followed-up over a lifetime analysis, inclisiran with statin compared with statin alone prevented 235 non-fatal myocardial infarctions (NFMIs; 151 NFMI and 84 repeat NFMI cases) and 114 coronary revascularisation cases, and increased years of life by 0.549 (discounted) and QALYs by 0.468 (discounted). At an annual price of AU$6334, the net marginal cost was AU$58,965 per person. The above values equated to ICERs of AU$107,402 per YoLS and AU$125,732 per QALY gained. Assuming a willingness-to-pay threshold of AU$50,000, inclisiran would have to be priced 60% lower than other available PCSK9 inhibitors to be considered cost effective.

Conclusions: As an adjunct therapy to statin treatment in those who have persistently elevated LDL-C despite optimal statin therapy, inclisiran is effective in reducing cardiovascular events in patients with atherosclerotic CVD. Inclisiran is not cost effective from the Australian healthcare perspective, assuming acquisition costs of current PCSK9 inhibitors. The cost of inclisiran would have to be 60% lower than that of evolocumab.
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http://dx.doi.org/10.1007/s40273-020-00948-wDOI Listing
September 2020

Cost-effectiveness of health technologies in adults with type 1 diabetes: a systematic review and narrative synthesis.

Syst Rev 2020 08 3;9(1):171. Epub 2020 Aug 3.

School of Public Health and Preventive Medicine, Monash University, 553 St Kilda Road, Melbourne, Victoria, 3004, Australia.

Background: With the rapid development of technologies for type 1 diabetes, economic evaluations are integral in guiding cost-effective clinical and policy decisions. We therefore aimed to review and synthesise the current economic literature for available diabetes management technologies and outline key determinants of cost-effectiveness.

Methods: A systematic search was conducted in April 2019 that focused on modelling or trial based economic evaluations. Searched databases included Medline, Medline in-process and other non-indexed citations, EMBASE, PubMed, All Evidenced Based Medicine Reviews, EconLit, Cost-effectiveness analysis Registry, Research Papers in Economics, Web of Science, PsycInfo, CINAHL, and PROSPERO from inception. We assessed quality of included studies with the Questionnaire to Assess Relevance and Credibility of Modeling Studies for Informing Health Care Decision Making an ISPOR-AMCP-NPC good practice task force report. Screening of abstracts and full-texts, appraisal, and extraction were performed by two independent researches.

Results: We identified 16,772 publications, of which 35 were analysed and included 11 health technologies. Despite a lack of consensus, most studies reported that insulin pumps (56%) or interstitial glucose sensors (62%) were cost-effective, although incremental cost-effectiveness ratios ranged widely ($14,266-$2,997,832 USD). Cost-effectiveness for combined insulin pumps and glucose sensors was less clear. Determinants of cost-effectiveness included treatment effects on glycosylated haemoglobin and hypoglycaemia, costing of technologies and complications, and measures of utility.

Conclusions: Insulin pumps or glucose sensors appeared cost-effective, particularly in populations with higher HbA1c levels and rates of hypoglycaemia. However, cost-effectiveness for combined insulin pumps and glucose sensors was less clear.

Registration: The study was registered with PROSPERO, number CRD42017077221.
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http://dx.doi.org/10.1186/s13643-020-01373-yDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7401226PMC
August 2020

Cost-effectiveness of dapagliflozin in chronic heart failure: an analysis from the Australian healthcare perspective.

Eur J Prev Cardiol 2020 Jul 14:2047487320938272. Epub 2020 Jul 14.

School of Public Health and Preventive Medicine, Monash University, Australia.

Aim: To assess the cost-effectiveness of dapagliflozin in addition to standard care versus standard care alone in patients with chronic heart failure and reduced ejection fraction.

Methods: A Markov model was constructed based on the Dapagliflozin and Prevention of Adverse Outcomes in Heart Failure trial to assess the clinical outcomes and costs of 1000 hypothetical subjects with established heart failure and reduced ejection fraction. The model consisted of three health states: 'alive and event-free', 'alive after non-fatal hospitalisation for heart failure' and 'dead'. Costs and utilities were estimated from published sources. The main outcome was the incremental cost-effectiveness ratio per quality-adjusted life-year gained. An Australian public healthcare perspective was employed. All outcomes and costs were discounted at a rate of 5% annually.

Results: Over a lifetime horizon, the addition of dapagliflozin to standard care in patients with heart failure and reduced ejection fraction prevented 88 acute heart failure hospitalisations (including readmissions) and yielded an additional 416 years of life and 288 quality-adjusted life-years (discounted) at an additional cost of A$3,692,440 (discounted). This equated to an incremental cost-effectiveness ratio of A$12,482 per quality-adjusted life-year gained, well below the Australian willingness-to-pay threshold of A$50,000 per quality-adjusted life-year gained. Subanalyses in subjects with and without diabetes resulted in similar incremental cost-effectiveness ratios of A$13,234 and A$12,386 per quality-adjusted life-year gained, respectively.

Conclusion: Dapagliflozin is likely to be cost-effective when used as an adjunct therapy to standard care compared with standard care alone for the treatment of chronic heart failure and reduced ejection fraction.
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http://dx.doi.org/10.1177/2047487320938272DOI Listing
July 2020

Novel Treatment Strategies for Secondary Prevention of Cardiovascular Disease: A Systematic Review of Cost-Effectiveness.

Pharmacoeconomics 2020 10;38(10):1095-1113

School of Public Health and Preventive Medicine, Monash University, 553 St Kilda Rd, Melbourne, VIC, 3004, Australia.

Background: New pharmacological therapies for the treatment of cardiovascular disease (CVD) have emerged in recent years. The high rates of CVD and the need for long-term treatment to decrease risk factors makes cost-effectiveness crucial for their successful long-term implementation.

Objective: This study assessed cost-effectiveness studies of novel pharmacological treatments (ezetimibe, proprotein convertase subtilisin/kexin type 9 [PCSK9] inhibitors, omega-3 polyunsaturated fatty acids [n-3 PUFAs], and the cardiovascular polypill) compared with standard care for the secondary prevention of CVD.

Methods: We searched seven databases and the reference list of selected literature reviews for eligible cost-effective analyses (CEA) published between January 2009 and January 2020 that evaluated the above novel treatments versus standard care. Two independent reviewers performed the screening and evaluation in accordance with the Consolidated Health Economic Evaluation Reporting Standards statement. Cost results were adapted to 2018 US dollars (US$) to facilitate comparisons between studies. Consideration of cost-effectiveness was based on the original study criteria.

Results: Thirty-two studies were included in this review, most of them adopting a healthcare perspective. Studies evaluating ezetimibe, PCSK9 inhibitors and n-3 PUFAs assessed their addition to standard care compared with standard care alone, while studies analysing the polypill evaluated the replacement of multiple monotherapies for a fixed-dose combination. Ten studies reported on ezetimibe, fifteen evaluated PCSK9 inhibitors, five focused on n-3 PUFAs and seven on the polypill. From a healthcare perspective, ezetimibe was cost effective in 62.5% of the studies (incremental cost-effectiveness ratios [ICERs] ranged from US$27,195 to US$204,140), n-3 PUFAs in 60% (ICERs from US$57,128 to US$139,082) and the cardiovascular polypill in 100% (ICERs from dominant to US$30,731) compared with standard care. Conversely, only 10% of the studies considered PCSK9 inhibitors cost effective compared with standard care from a healthcare perspective (ICERs ranged from US$231,119 to US$1,223,831). Additionally, ezetimibe was cost effective in 50% of the studies, PCSK9 inhibitors in 33% and the polypill in 50% of the studies adopting a societal perspective. The key model-related parameters predicting cost-effectiveness included drug cost, time horizon, and the baseline risk of cardiovascular events.

Conclusions: Based on current pricing and willingness-to-pay thresholds, most CEA studies considered ezetimibe, n-3 PUFAs and the polypill to be cost effective compared with standard care but not PCSK9 inhibitors for secondary prevention of CVD.
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http://dx.doi.org/10.1007/s40273-020-00936-0DOI Listing
October 2020

The impact of diabetes on the productivity and economy of Bangladesh.

BMJ Glob Health 2020 06;5(6)

Department of Epidemiology and Preventive Medicine, Monash University School of Public Health and Preventive Medicine, Melbourne, Victoria, Australia.

Aims: To estimate the impact of type 2 diabetes in terms of mortality, years of life lost (YLL) and productivity-adjusted life years (PALY) lost in Bangladesh.

Methods: A life table model was constructed to estimate the productivity of the Bangladeshi population of current working age (20-59 years) with diabetes. Follow-up to 60 years (retirement age) was simulated. The life table analysis was then repeated assuming that the cohort did not have diabetes, with subsequent improvement in productivity. Differences in the results of the two analyses reflected the impact of diabetes on health and productivity. Demographic and the prevalence of diabetes data were sourced from the International Diabetes Foundation estimates for 2017 and mortality data were based on the 2017 Global Burden of Disease study. Relative risk and productivity indices were based on an Indian and Bangladeshi study, respectively. The cost of each PALY was assumed to be equivalent to gross domestic product (GDP) per equivalent full-time worker (US$8763). Future costs and years of life, and PALYs lived were discounted at an annual rate of 3%.

Results: Assuming a follow-up of this population (aged 20-59 years) until age 60 years or death, an estimated 813 807 excess deaths, loss of 4.0 million life years (5.5%) and 9.2 million PALYs (20.4%) were attributable to having diabetes. This was equivalent to 0.7 YLL, and 1.6 PALYs lost per person. The loss in PALYs equated to a total of US$97.4 billion lost (US$16 987 per person) in GDP. The results of the scenario analysis showed that the estimation was robust.

Conclusion: In Bangladesh, the impact of diabetes on productivity loss and the broader economy looms large, and poses a substantial risk to the country's future prosperity. This highlights the critical importance of health strategies aimed at the control of diabetes.
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http://dx.doi.org/10.1136/bmjgh-2020-002420DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7295429PMC
June 2020

An economic evaluation of the All New Zealand Acute Coronary Syndrome Quality Improvement Registry programme-subanalyses for Māori (ANZACS-QI 42).

N Z Med J 2020 05 8;133(1514):16-32. Epub 2020 May 8.

Co-Director of the Centre of Cardiovascular Research and Education (CCRE), Monash University, Melbourne, Victoria, Australia.

Aims: To evaluate the clinical and cost impacts of the All New Zealand Acute Coronary Syndrome Quality Improvement programme (ANZACS-QI) specifically for Māori with acute coronary syndrome (ACS).

Methods: Decision analytic Markov models were used to estimate the effectiveness and costs of the ANZACS-QI programme over four years of full coverage (2013 to 2016), against a hypothetical scenario in which the registry did not exist. The estimated return on investment (ROI) and incremental cost-effectiveness ratios (ICERs) are reported.

Results: The ROI ratio for the ANZACS-QI programme for Māori over the four-year period of full coverage was 1.51; that is, every dollar spent on the programme resulted in a return of NZD $1.51. The estimated ICER was NZD $114,786 per year of life saved (YoLS) over a one-year time horizon, but extending the benefits accrued to five years reduced the ICER to NZD $20,173 per YoLS.

Conclusions: The ANZACS-QI programme represents a sound investment for improving outcomes in the setting of ACS for Māori in New Zealand. Using highly conservative assumptions, the programme would be cost-saving based on an annual ROI ratio of 1.5.
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May 2020

Cost-Effectiveness Analysis of a Hybrid Closed-Loop System Versus Multiple Daily Injections and Capillary Glucose Testing for Adults with Type 1 Diabetes.

Diabetes Technol Ther 2020 11 19;22(11):812-821. Epub 2020 Oct 19.

School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia.

Hybrid closed-loop systems may offer improved HbA1c levels, more time-in-range, and less hypoglycemia than alternative treatment strategies. However, it is unclear if glycemic improvements offset this technology's higher acquisition costs. Among adults with type 1 diabetes in Australia, we sought to evaluate the cost-effectiveness of a hybrid closed-loop system in comparison with the current standard of care, comprising insulin injections and capillary glucose testing. Cost-effectiveness analysis was performed using decision analysis in combination with a Markov model to simulate disease progression in a cohort of adults with type 1 diabetes and compare the downstream health and economic consequences of hybrid closed-loop therapy versus current standard of care. Transition probabilities and utilities were sourced from published studies. Costs were considered from the perspective of the Australian health care system. A lifetime horizon was considered, with annual discount rates of 5% applied to future costs and outcomes. Uncertainty was assessed with probabilistic and deterministic sensitivity analyses. Use of a hybrid closed-loop system resulted in an incremental cost-effectiveness ratio of Australian dollars (AUD) 37,767 per quality-adjusted life year (QALY) gained. This is below the traditionally cited willingness to pay a threshold of $50,000 per QALY gained in the Australian setting. Sensitivity analyses that varied baseline glycemic control, treatment effects, technology costs, age, discount rates, and time horizon indicated the results to be robust. For adults with type 1 diabetes, hybrid closed-loop therapy is likely to be cost-effective compared with multiple daily injections and capillary glucose testing in Australia.
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http://dx.doi.org/10.1089/dia.2020.0064DOI Listing
November 2020

Cost-Effectiveness of Switching Patients With Heart Failure and Reduced Ejection Fraction to Sacubitril/Valsartan: The Australian Perspective.

Heart Lung Circ 2020 Sep 2;29(9):1310-1317. Epub 2019 Apr 2.

CCRE Therapeutics, Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, Vic, Australia. Electronic address:

Background: The cost-effectiveness, from the Australian health care perspective, of switching patients with heart failure and reduced ejection fraction (HFREF) stable on angiotensin converting enzyme (ACE) inhibitors/angiotensin II receptor blockers (ARBs) to the angiotensin receptor neprilysin inhibitor (ARNi) sacubitril/valsartan is unclear. We sought to assess the cost-effectiveness of sacubitril/valsartan versus enalapril in patients with HFREF in the contemporary Australian setting.

Methods: We developed a Markov model with two health states ('Alive' and 'Dead') to assess the cost-effectiveness of sacubitril/valsartan versus enalapril in patients with HFREF. Model subjects were 63 years of age at entry and had simulated follow-up over 20 years. Transition probabilities were derived from the Prospective comparison of ARNI with ACEI to Determine Impact on Global Mortality and morbidity in Heart Failure (PARADIGM-HF) study. Costs and utility data were derived from published sources. All costs and effects were discounted at an annual rate of 5% and are presented in Australian dollars. Sensitivity analyses were undertaken to test variability in key data inputs.

Results: In the base-case analysis, sacubitril/valsartan was found to reduce non-fatal heart failure hospitalisations and cardiovascular deaths, with numbers-needed-to-treat over a 20-year period of 40 and 27, respectively. The use of sacubitril/valsartan led to an additional 6 months of life gained per patient, translating to A$27,954 per years of life saved (YoLS) and A$40,513 per quality-adjusted-life-years (QALY) gained. The results of the sensitivity analyses indicated that the results were robust.

Conclusions: Our analysis supports switching HFREF patients on ACE inhibitor or ARB to sacubitril/valsartan.
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http://dx.doi.org/10.1016/j.hlc.2019.03.007DOI Listing
September 2020

The cost-effectiveness of icosapent ethyl in combination with statin therapy compared with statin alone for cardiovascular risk reduction.

Eur J Prev Cardiol 2020 Jan 10:2047487319896648. Epub 2020 Jan 10.

School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia.

Aims: The aim of this study was to estimate the cost-effectiveness, from the perspective of the Australian public healthcare system, of icosapent ethyl in combination with statin therapy compared with statin alone for the prevention of cardiovascular disease.

Methods And Results: A Markov model populated with data from the Reduction of Cardiovascular Events with Icosapent Ethyl-Intervention Trial was designed to predict the effectiveness and costs of icosapent ethyl in combination with statins compared with statins alone over a 20-year time horizon. Data inputs for costs and utilities were sourced from published sources. The annual costs of icosapent ethyl were assumed to be AUD1637 (USD2907) per person. All future costs and outcomes were discounted annually by 5%. The main outcome of interest was incremental cost-effectiveness ratios in terms of cost per quality adjusted life year (QALY) gained and per year of life saved (YoLS). Over a 20-year time horizon, compared with statin alone, icosapent ethyl in combination with statin was estimated to cost an additional AUD$13,022 per person, but led to 0.338 YoLS and 0.289 QALYs gained (all discounted). These equated to incremental cost-effectiveness ratios of AUD45,036 per QALY gained and AUD38,480 per YoLS. Sub-analyses for primary and secondary prevention were AUD96,136 and AUD35,935 per QALY gained, respectively. The results were sensitive to time-horizon, age related trends and the acquisition price of icosapent ethyl.

Conclusion: Compared with statin alone, icosapent ethyl in combination with statin therapy is likely to be cost-effective in the prevention of cardiovascular disease assuming a willingness-to-pay threshold of AUD50,000 per QALY gained, especially in the secondary preventive setting.
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http://dx.doi.org/10.1177/2047487319896648DOI Listing
January 2020

Economic evaluation of clinical quality registries: a systematic review.

BMJ Open 2019 12 15;9(12):e030984. Epub 2019 Dec 15.

School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia

Objectives: The objective of this systematic review was to examine the existing evidence base for the cost-effectiveness or cost-benefit of clinical quality registries (CQRs).

Design: Systematic review and narrative synthesis.

Data Sources: Nine electronic bibliographic databases, including MEDLINE, EMBASE and CENTRAL, in the period from January 2000 to August 2019.

Eligibility Criteria: Any peer-reviewed published study or grey literature in English which had reported on an economic evaluation of one or more CQRs.

Data Extraction And Synthesis: Data were screened, extracted and appraised by two independent reviewers. A narrative synthesis was performed around key attributes of each CQR and on key patient outcomes or changes to healthcare processes or utilisation. A narrative synthesis of the cost-effectiveness associated with CQRs was also conducted. The primary outcome was cost-effectiveness, in terms of the estimated incremental cost-effectiveness ratio (ICER), cost savings or return-on-investment (ROI) attributed to CQR implementation.

Results: Three studies and one government report met the inclusion criteria for the review. A study of the National Surgical Quality Improvement Programme (NSQIP) in the USA found that the cost-effectiveness of this registry improved over time, based on an ICER of US$8312 per postoperative event avoided. A separate study in Canada estimated the ROI to be US$3.43 per US$1.00 invested in the NSQIP. An evaluation of a post-splenectomy CQR in Australia estimated that registry cost-effectiveness improved from US$234 329 to US$18 358 per life year gained when considering the benefits accrued over the lifetime of the population. The government report evaluating five Australian CQRs estimated an overall return of 1.6-5.5 times the cost of investment.

Conclusions: Available data indicate that CQRs can be cost-effective and can lead to significant returns on investment. It is clear that further studies that evaluate the economic and clinical impacts of CQRs are necessary.

Prospero Registration Number: CRD42018116807.
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http://dx.doi.org/10.1136/bmjopen-2019-030984DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6924778PMC
December 2019

Dynamics of switching, adherence, and persistence of dipeptidyl peptidase-4 inhibitors use: A nationwide cohort study.

Diabetes Res Clin Pract 2019 Dec 4;158:107909. Epub 2019 Nov 4.

Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, Victoria, Australia. Electronic address:

Aims: To characterise the patterns of switching, adherence, and persistence among adults aged ≥18 years with diabetes prescribed dipeptidyl peptidase-4 inhibitors (DPP-4is) in Australia.

Methods: The analysis included 15,915 adults newly prescribed DPP-4is (sitagliptin = 9576; vildagliptin = 1130; saxagliptin = 1126; linagliptin = 3560; and alogliptin = 523). Multivariable logistic regression model was used to compare the non-adherence (proportion of days covered [PDC] <0.80) rates whereas Cox proportional hazards regression models were used to compare switching and non-persistence (≥90-day gap) among different DPP4-is over 12-months.

Results: Overall, 36.0% (5722/15,915) of DPP-4i users were non-adherent and 30.0% (4775/15,915) were non-persistent at 12-months. Compared to sitagliptin, vildagliptin, linagliptin, and alogliptin were not associated with higher non-adherence and non-persistence. However, saxagliptin was associated with a higher likelihood of being non-adherent (odds ratio 1.41, 95% confidence interval [CI] 1.23-1.60) or non-persistent (hazard ratio 1.27, 95% CI 1.15-1.42) compared to sitagliptin. Just 3.2% of people switched between different DPP-4is. Compared to sitagliptin, people initiated on vildagliptin, saxagliptin, alogliptin, and linagliptin were more likely to switch.

Conclusions: We found no significant differences in the adherence and persistence rates between alogliptin, vildagliptin or linagliptin and sitagliptin. However, saxagliptin was associated with higher non-adherence and non-persistence compared to sitagliptin. Switching was lowest amongst users of sitagliptin.
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http://dx.doi.org/10.1016/j.diabres.2019.107909DOI Listing
December 2019

Sacubitril-valsartan versus enalapril for acute decompensated heart failure: a cost-effectiveness analysis.

Eur J Prev Cardiol 2019 Oct 4:2047487319878953. Epub 2019 Oct 4.

School of Public Health and Preventive Medicine, Monash University, Australia.

Background: The Comparison of Sacubitril-Valsartan versus Enalapril on Effect on NT-proBNP in Patients Stabilised from an Acute Heart Failure Episode (PIONEER-HF) trial demonstrated significant reductions in N-terminal pro-B-type natriuretic peptide. Our study explored the cost-effectiveness of the use of sacubitril-valsartan versus enalapril in acute decompensated heart failure from the Australian healthcare perspective.

Methods: A Markov model was designed using data from the PIONEER-HF trial to model the clinical progress and costs of patients over a lifetime time horizon. The model consisted of three health states: 'alive and event-free', 'alive after non-fatal hospitalisation for acute decompensated heart failure' or 'dead'. Costs and utilities were estimated from published sources. The cost of sacubitril-valsartan (per the Australian pharmaceutical benefits schedule) was AU$7.08/day. Outcomes of interest were the incremental cost-effectiveness ratios in terms of cost per quality-adjusted life year gained and cost per year of life saved. Cost and benefits were discounted at 5.0% per annum.

Results: Compared to enalapril, sacubitril-valsartan was estimated to cost an additional AU$7464 (discounted) per person, but lead to 0.127 years of life saved (discounted) and 0.096 quality-adjusted life years gained (discounted) over a lifetime analysis. These equated to incremental cost-effectiveness ratios of AU$58,629/year of life saved (US$41,795, EU€58,629, GBP£32,001) and AU$77,889/quality-adjusted life year gained (US$55,526, EU€49,202, GBP£42,504). We have assumed a threshold of AU$50,000/quality-adjusted life year gained to suggest cost-effectiveness.

Conclusions: At its current acquisition price, sacubitril-valsartan in comparison to enalapril is not likely to be cost-effective in the management of acute decompensated heart failure in Australia. A price reduction of more than 25% would confer cost-effectiveness.
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http://dx.doi.org/10.1177/2047487319878953DOI Listing
October 2019

An Economic Evaluation of the All New Zealand Acute Coronary Syndrome Quality Improvement Registry Program (ANZACS-QI 28).

Heart Lung Circ 2020 Jul 9;29(7):1046-1053. Epub 2019 Sep 9.

Centre of Cardiovascular Research and Education in Therapeutics, School of Public Health and Preventive Medicine, Monash University, Melbourne, Vic, Australia. Electronic address:

Background: The All New Zealand Acute Coronary Syndrome Quality Improvement (ANZACS-QI) program comprises a clinical quality registry of acute coronary syndrome patients admitted to hospitals across New Zealand. Its primary purpose is to improve quality of care by promoting evidence- and guidelines-based practice, and benchmarking against performance targets. Few studies have examined the cost-effectiveness attributed to clinical quality registries. We aimed to evaluate the clinical and cost impacts of the ANZACS-QI program in New Zealand from both a societal and health care system perspective.

Methods: Using decision analytic Markov models, we estimated the effectiveness and costs of the ANZACS-QI program in each year over 4 years (2013-2016), against a hypothetical scenario where the registry did not exist. We assumed that the ANZACS-QI contributed to 15% of the temporal changes to patient mortality and hospital readmissions for myocardial infarction observed in the study period. Marginal costs of the registry and years of life saved were estimated.

Results: Over a one-year period, the return on investment (ROI) ratio for the ANZACS-QI program was 1.53; thus, every dollar spent on the program resulted in a return of NZD $1.53. (All dollars are in 2017 New Zealand dollars [NZD] unless otherwise stated). The estimated incremental cost-effectiveness ratio (ICER) was $113,327 per year of life saved (YoLS). Extending the time horizon to 5 years, reduced the ICER to $19,684 per YoLS.

Conclusions: The ANZACS-QI program represents a sound investment for New Zealand. Even based on highly conservative assumptions, the program is cost saving for society, at a ROI ratio of about 1.5 each year.
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http://dx.doi.org/10.1016/j.hlc.2019.08.012DOI Listing
July 2020