Publications by authors named "Zanfina Ademi"

110 Publications

Markov modelling of treatment response in a 30-year cohort study of newly diagnosed epilepsy.

Brain 2021 Oct 25. Epub 2021 Oct 25.

Department of Neurology, Alfred Hospital, Melbourne VIC 3004, Australia.

People with epilepsy have variable and dynamic trajectories in response to antiseizure medications. Accurately modelling long-term treatment response will aid prognostication at the individual level and health resource planning at the societal level. Unfortunately, a robust model is lacking. We aimed to develop a Markov model to predict the probability of future seizure-freedom based on current seizure state and number of antiseizure medication regimens trialled. We included 1,795 people with newly diagnosed epilepsy who attended a specialist clinic in Glasgow, Scotland, between July 1982 and October 2012. They were followed up until October 2014 or death. We developed a simple Markov model, based on current seizure state only, and a more detailed model, based on both current seizure state and number of antiseizure medication regimens trialled. Sensitivity analyses were performed for the regimen-based states model to examine the effect of regimen changes due to adverse effects. The model was externally validated in a separate cohort of 455 newly diagnosis epilepsy patients seen in Perth, Australia, between May 1999 and May 2016. Our models suggested that once seizure-freedom was achieved, it was likely to persist, regardless of the number of antiseizure medications trialled to reach that point. The likelihood of achieving long-term seizure-freedom was highest with the first antiseizure medication regimen, at approximately 50%. The chance of achieving seizure-freedom fell with subsequent regimens. Fluctuations between seizure-free and not seizure-free states were highest earlier on, but decreased with chronicity of epilepsy. Seizure-freedom/recurrence risk tables were constructed with these probability data, similar to cardiovascular risk tables. Sensitivity analyses showed that the general trends and conclusions from the base model were maintained despite perturbing the model and input data with regimen changes due to adverse effects. Quantitative comparison with the external validation cohort showed excellent consistency at year 1, good at year 3 and moderate at year 5. Quantitative models, as used in this study, can provide pertinent clinical insights that are not apparent from simple statistical analysis alone. Attaining seizure freedom at any time in a patient's epilepsy journey will confer durable benefit. Seizure-freedom risk tables may be used to individualise the prediction of future seizure control trajectory.
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http://dx.doi.org/10.1093/brain/awab401DOI Listing
October 2021

The Impact of Diabetes on Productivity in India.

Diabetes Care 2021 Oct 21. Epub 2021 Oct 21.

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

Objective: Diabetes increases the risk of premature mortality and considerably impacts on work productivity. We sought to examine the impact of diabetes in India, in terms of excess premature mortality, years of life lost (YLL), productivity-adjusted life years (PALYs) lost, and its associated economic impact.

Research Design And Methods: A life table model was constructed to examine the productivity of the Indian working-age population currently aged 20-59 years with diabetes, followed until death or retirement age (60 years). The same cohort was resimulated, hypothetically assuming that they did not have diabetes. The total difference between the two cohorts, in terms of excess deaths, YLL and PALYs lost reflected the impact of diabetes. Data regarding the prevalence of diabetes, mortality, labor force dropouts, and productivity loss attributable to diabetes were derived from published sources.

Results: In 2017, an estimated 54.4 million (7.6%) people of working-age in India had diabetes. With simulated follow-up until death or retirement age, diabetes was predicted to cause 8.5 million excess deaths (62.7% of all deaths), 42.7 million YLL (7.4% of total estimated years of life lived), and 89.0 million PALYs lost (23.3% of total estimated PALYs), equating to an estimated Indian rupee 176.6 trillion (U.S. dollars 2.6 trillion; purchasing power parity 9.8 trillion) in lost gross domestic product.

Conclusions: Our study demonstrates the impact of diabetes on productivity loss and highlights the importance of health strategies aimed at the prevention of diabetes.
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http://dx.doi.org/10.2337/dc21-0922DOI Listing
October 2021

Economic Evaluations of Child Nutrition Interventions in Low- and Middle-Income Countries: Systematic Review and Quality Appraisal.

Adv Nutr 2021 Sep 12. Epub 2021 Sep 12.

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

Economic evaluation is crucial for cost-effective resource allocation to improve child nutrition in low and middle-income countries (LMICs). However, the quality of published economic evaluations in these settings is not well understood. This systematic review aimed to assess the quality of existing economic evaluations of child nutrition interventions in LMICs and synthesize the study characteristics and economic evidence. We searched 9 electronic databases, including MEDLINE, with the following concepts: economic evaluation, children, nutrition, and LMICs. All types of interventions addressing malnutrition, including stunting, wasting, micronutrient deficiency, and overweight, were identified. We included economic evaluations that examined both costs and effects published in English peer-reviewed journals and used the Drummond checklist for quality appraisal. We present findings through a narrative synthesis. Sixty-nine studies with diverse settings, perspectives, time horizons, and outcome measures were included. Most studies used data from sub-Saharan Africa and South Asia and addressed undernutrition. The mortality rate, intervention effect, intervention coverage, cost, and discount rate were reported as predictors among studies that performed sensitivity analyses. Despite the heterogeneity of included studies and the possibility of publication bias, 81% of included studies concluded that nutrition interventions were cost-effective or cost-beneficial, mostly based on a country's cost-effectiveness thresholds. Regarding quality assessment, the studies published after 2016 met more criteria than studies published before 2016. Most studies had well-stated research questions, forms of economic evaluation, interventions, and conclusions. However, reporting the perspective of the analyses, justification of discount rates, and describing the role of funders and ethics approval were identified as areas needing improvement. The gaps in the quality of reporting could be improved by consolidated guidance on the publication of economic evaluations and the use of appropriate quality appraisal checklists. Strengthening the evidence base for child malnutrition across different regions is necessary to inform cost-effective investment in LMICs. Trial registration: PROSPERO CRD42020194445.
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http://dx.doi.org/10.1093/advances/nmab097DOI Listing
September 2021

Productivity burden of hypertension in Japan.

Hypertens Res 2021 Aug 26. Epub 2021 Aug 26.

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

In the present study, we aimed to estimate the impact of hypertension in the working-age Japanese population. We developed life table models to estimate total deaths, years of life lived, and productivity-adjusted life years lived (a newly developed metric for quantifying the burden of acute and chronic health conditions on work productivity) among Japanese individuals with hypertension aged 20-64 years, with simulated follow-up until age 65 years. Data inputs were drawn from local population statistics and published sources. Gross domestic product per person employed, a measure of labor productivity, was used to assign an economic value to each productivity-adjusted life year lived. Outcomes and costs were discounted by 2% annually. In 2017, 26.3 million Japanese individuals aged 20-64 years (37.5%) had hypertension. Of these people, 23.7% were treated and had controlled blood pressure, 23.2% were treated but had uncontrolled blood pressure, and 53.1% were untreated. During the simulated follow-up until age 65 years, 335,342 deaths (28.0% of total deaths), 1.6 million years of life (0.8% of total), 3.1 million productivity-adjusted life years (1.9% of total), and US$242.9 billion or 28.3 trillion Japanese yen of gross domestic product were lost to hypertension. Our findings highlight the considerable economic burden of hypertension in Japan, as well as the importance of effective strategies for hypertension prevention and management, which are likely to deliver a significant return on investment.
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http://dx.doi.org/10.1038/s41440-021-00731-0DOI Listing
August 2021

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

Eur J Prev Cardiol 2021 Aug;28(9):975-982

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
August 2021

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

Eur J Prev Cardiol 2021 Aug;28(9):966-972

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
August 2021

Cost-Effectiveness of Empagliflozin and Metformin Combination Versus Standard Care as First-Line Therapy in Patients with Type 2 Diabetes Mellitus.

Endocr Pract 2021 Aug 10. Epub 2021 Aug 10.

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

Objective: Sodium-glucose cotransporter 2 (SGLT2) inhibitors have been shown to reduce cardiovascular events, but are currently not used as first-line therapy. This study was conducted to evaluate the cost-effectiveness of first-line empagliflozin plus metformin versus metformin monotherapy among Australians with type 2 diabetes mellitus (T2DM) and existing cardiovascular disease (CVD).

Methods: A Markov model with one-year cycles and a five-year time horizon was constructed to simulate the occurrence of recurrent cardiovascular events among Australians aged 50 to 84 years with T2DM and CVD. Efficacy results were derived from the EMPA-REG OUTCOME trial. Costs and utilities were drawn from published sources. The evaluation adopted both healthcare and societal perspectives, with the latter ascribing the Australian Government's 'value of statistical life year' (VoSLY, AUD 213,000) to each year lived by a person. Future outcomes were discounted at 5% annually. Sensitivity analyses were conducted to enhance robustness of conclusions.

Results: Compared to metformin monotherapy, first-line empagliflozin plus metformin reduced overall cardiovascular events by 0.82% and overall deaths by 7.72% over five years. There were 0.2 years of life saved (YoLS) per person and 0.16 quality-adjusted life years (QALYs) gained, at a net healthcare cost of AUD 4,408. These equated to incremental cost-effectiveness ratios of AUD 22,076 per YoLS and AUD 28,244 per QALY gained. The gains in VoSLY equated to AUD 42,530 per person, meaning that from a societal perspective, the intervention was cost saving.

Conclusion: First-line empagliflozin plus metformin may represent a cost-effective strategy for the management of T2DM and CVD in Australia.
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http://dx.doi.org/10.1016/j.eprac.2021.07.018DOI Listing
August 2021

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

Eur J Prev Cardiol 2021 Jul;28(8):897-904

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
July 2021

The Health and Productivity Burden of Depression in South Korea.

Appl Health Econ Health Policy 2021 Nov 25;19(6):941-951. 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
November 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

Chronic Kidney Disease and Cerebrovascular Disease: Consensus and Guidance From a KDIGO Controversies Conference.

Stroke 2021 Jul 3;52(7):e328-e346. Epub 2021 Jun 3.

Ottawa Hospital Research Institute, Department of Medicine, The Ottawa Hospital, Civic Campus, ON, Canada (M.M.S.).

The global health burden of chronic kidney disease is rapidly rising, and chronic kidney disease is an important risk factor for cerebrovascular disease. Proposed underlying mechanisms for this relationship include shared traditional risk factors such as hypertension and diabetes, uremia-related nontraditional risk factors, such as oxidative stress and abnormal calcium-phosphorus metabolism, and dialysis-specific factors such as cerebral hypoperfusion and changes in cardiac structure. Chronic kidney disease frequently complicates routine stroke risk prediction, diagnosis, management, and prevention. It is also associated with worse stroke severity, outcomes and a high burden of silent cerebrovascular disease, and vascular cognitive impairment. Here, we present a summary of the epidemiology, pathophysiology, diagnosis, and treatment of cerebrovascular disease in chronic kidney disease from the Kidney Disease: Improving Global Outcomes Controversies Conference on central and peripheral arterial disease with a focus on knowledge gaps, areas of controversy, and priorities for research.
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http://dx.doi.org/10.1161/STROKEAHA.120.029680DOI Listing
July 2021

First-line Treatment with Empagliflozin and Metformin Combination Versus Standard Care for Patients with Type 2 Diabetes Mellitus and Cardiovascular Disease in Qatar. A Cost-Effectiveness Analysis.

Curr Probl Cardiol 2021 Apr 6:100852. Epub 2021 Apr 6.

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

Sodium-glucose cotransporter 2 (SGLT2) inhibitors have shown to reduce cardiovascular events and mortality in patients with type 2 diabetes mellitus (T2DM), but they are currently not used as first-line therapy in clinical practice. This study sought to evaluate the cost-effectiveness of first-line empagliflozin plus standard care for patients with newly diagnosed T2DM and existing cardiovascular disease (CVD). A decision-analytic Markov model with one-year cycles and a lifetime time horizon was developed from the perspective of the Qatari healthcare system to compare first-line empagliflozin combined with metformin versus metformin monotherapy for patients aged 50 to 79 years with T2DM and existing CVD. Two health states were considered: 'Alive with CVD and T2DM' and 'Dead'. Patients could experience non-fatal myocardial infarction, non-fatal stroke, hospitalization for heart failure, hospitalization for unstable angina, and cardiovascular or non-cardiovascular death. Model inputs were ascertained from published and publicly available sources in Qatar. Costs and outcomes were discounted at 3% per annum. Sensitivity analyses were conducted to evaluate parameter uncertainty. The model predicted that adding empagliflozin to current standard care led to additional 1.9 years of life saved (YoLS) and 1.5 quality-adjusted life year (QALYs) per person, and an incremental cost of QAR 56,869 (USD 15,619), which equated to an incremental cost-effectiveness ratio of QAR 30,675 (USD 8,425) per YoLS and QAR 39,245 (USD 10,779) per QALY. Sensitivity analyses showed the findings to be robust. First-line empagliflozin combined with metformin appears to be a cost-effective therapeutic option for patients with T2DM and CVD.
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http://dx.doi.org/10.1016/j.cpcardiol.2021.100852DOI Listing
April 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

Economic evaluation methods used in home-visiting interventions: A systematic search and review.

Health Soc Care Community 2021 Nov 24;29(6):1650-1667. Epub 2021 Mar 24.

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

Home-visiting interventions are used to improve outcomes for families experiencing disadvantage. As scarce resources must be allocated carefully, appropriate methods are required to provide accurate information on the effect of these programmes. We aimed to investigate: economic evaluation/analysis methods used in home-visiting programmes for children, young people and families, study designs and methods suitable in situations where randomised-controlled-trials are not feasible, and type of costs included in analyses, including any implementation costs stated. A systematic search and review was conducted of existing full economic evaluation/analysis methods in home-visiting programmes for children, young people and/or families. We included studies published in English between January 2000 and mid-November 2020. Of the 4,742 papers sourced, 60 were retained for full-text review, and 21 included. Economic-analysis methods found in the included studies were: within trial economic evaluation, economic evaluation using decision analytic modelling (i.e. cost-utility, cost-benefit analysis), cost comparison and cost-consequence. Studies incorporating return on investment and budget impact analysis were also found. Study designs suitable when randomisation was not feasible included parallel cluster randomised trials and using pre-post intervention data. Costs depended mainly on study context and only one study reported implementation costs. We hope this information will help guide future economic evaluations of home-visiting interventions.
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http://dx.doi.org/10.1111/hsc.13349DOI Listing
November 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 05;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

Burden of disease and productivity impact of Streptococcus suis infection in Thailand.

PLoS Negl Trop Dis 2021 01 22;15(1):e0008985. Epub 2021 Jan 22.

Novel Bacteria and Drug Discovery Research Group (NBDD), Microbiome and Bioresource Research Strength, Jeffrey Cheah School of Medicine and Health Sciences, Monash University Malaysia, Bandar Sunway, Malaysia.

Background: Streptoccocus suis (S.suis) infection is a neglected zoonosis disease in humans mainly affects men of working age. We estimated the health and economic burden of S.suis infection in Thailand in terms of years of life lost, quality-adjusted life years (QALYs) lost, and productivity-adjusted life years (PALYs) lost which is a novel measure that adjusts years of life lived for productivity loss attributable to disease.

Methods: A decision-analytic Markov model was developed to simulate the impact of S. suis infection and its major complications: death, meningitis and infective endocarditis among Thai people in 2019 with starting age of 51 years. Transition probabilities, and inputs pertaining to costs, utilities and productivity impairment associated with long-term complications were derived from published sources. A lifetime time horizon with follow-up until death or age 100 years was adopted. The simulation was repeated assuming that the cohort had not been infected with S.suis. The differences between the two set of model outputs in years of life, QALYs, and PALYs lived reflected the impact of S.suis infection. An annual discount rate of 3% was applied to both costs and outcomes. One-way sensitivity analyses and Monte Carlo simulation modeling technique using 10,000 iterations were performed to assess the impact of uncertainty in the model.

Key Results: This cohort incurred 769 (95% uncertainty interval [UI]: 695 to 841) years of life lost (14% of predicted years of life lived if infection had not occurred), 826 (95% UI: 588 to 1,098) QALYs lost (21%) and 793 (95%UI: 717 to 867) PALYs (15%) lost. These equated to an average of 2.46 years of life, 2.64 QALYs and 2.54 PALYs lost per person. The loss in PALYs was associated with a loss of 346 (95% UI: 240 to 461) million Thai baht (US$11.3 million) in GDP, which equated to 1.1 million Thai baht (US$ 36,033) lost per person.

Conclusions: S.suis infection imposes a significant economic burden both in terms of health and productivity. Further research to investigate the effectiveness of public health awareness programs and disease control interventions should be mandated to provide a clearer picture for decision making in public health strategies and resource allocations.
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http://dx.doi.org/10.1371/journal.pntd.0008985DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7857555PMC
January 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 03 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 clinical utility of exome sequencing and extended bioinformatic analyses in adolescents and adults with a broad range of neurological phenotypes: an Australian perspective.

J Neurol Sci 2021 01 3;420:117260. Epub 2020 Dec 3.

Health Economics Unit, Centre for Health Policy, Melbourne School of Population and Global Health, University of Melbourne, Melbourne, Australia; Australian Genomics Health Alliance, Melbourne, Australia.

Currently there is no secured ongoing funding in Australia for next generation sequencing (NGS) such as exome sequencing (ES) for adult neurological disorders. Studies have focused on paediatric populations in research or highly specialised settings, utilised standard NGS pipelines focusing only on small insertions, deletions and single nucleotide variants, and not explored impacts on management in detail. This prospective multi-site study performed ES and an extended bioinformatics repeat expansion analysis pipeline, on patients with broad phenotypes (ataxia, dementia, dystonia, spastic paraparesis, motor neuron disease, Parkinson's disease and complex/not-otherwise-specified), with symptom onset between 2 and 60 years. Genomic data analysis was phenotype-driven, using virtual gene panels, reported according to American College of Medical Genetics and Genomics guidelines. One-hundred-and-sixty patients (51% female) were included, median age 52 years (range 14-79) and median 9 years of symptoms. 34/160 (21%) patients received a genetic diagnosis. Highest diagnostic rates were in spastic paraparesis (10/25, 40%), complex/not-otherwise-specified (10/38, 26%) and ataxia (7/28, 25%) groups. Findings were considered 'possible/uncertain' in 21/160 patients. Repeat expansion detection identified an unexpected diagnosis of Huntington disease in an ataxic patient with negative ES. Impacts on management, such as more precise and tailored care, were seen in most diagnosed patients (23/34, 68%). ES and a novel bioinformatics analysis pipepline had a substantial diagnostic yield (21%) and management impacts for most diagnosed patients, in heterogeneous, complex, mainly adult-onset neurological disorders in real-world settings in Australia, providing evidence for NGS and complementary multiple, new technologies as valuable diagnostic tools.
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http://dx.doi.org/10.1016/j.jns.2020.117260DOI Listing
January 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
August 2021

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 2021

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

Real-world adherence, persistence, and in-class switching during use of dipeptidyl peptidase-4 inhibitors: a systematic review and meta-analysis involving 594,138 patients with type 2 diabetes.

Acta Diabetol 2021 Jan 18;58(1):39-46. Epub 2020 Aug 18.

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

Aims: Medication adherence and persistence are important determinants of treatment success in type 2 diabetes mellitus (T2DM). This systematic review and meta-analysis evaluated the real-world adherence, persistence, and in-class switching among patients with T2DM prescribed dipeptidyl peptidase-4 (DPP4) inhibitors.

Methods: MEDLINE, EMBASE, Cochrane Library, PsychINFO, and CINAHL were searched for relevant observational studies published in the English language up to 20 December 2019. This was supplemented by manual screening of the references of included papers. Random-effects meta-analysis was performed.

Results: Thirty-four cohort studies involving 594,138 patients with T2DM prescribed DPP4 inhibitors from ten countries were included. The pooled proportion adherent (proportion of days covered (PDC) or medication possession ratio (MPR) ≥ 0.80) was 56.9% (95% confidence interval [CI] 49.3-64.4) at one year and 44.2% (95% CI 36.4-52.1) at two years. The proportion persistent with treatment decreased from 75.6% (95% CI 71.5-79.5) at six months to 52.8% (95% CI 51.6-59.8) at two years. No significant differences in adherence and persistence were observed between individual DPP4 inhibitors. At one year, just 3.2% (95% CI 3.1-3.3) of patients switched from one DPP4 inhibitor to another. Switching from saxagliptin and alogliptin to others was commonest.

Conclusions: Adherence to and persistence with DPP4 inhibitors is suboptimal but similar across all medications within the class. While in-class switching is uncommon, saxagliptin and alogliptin are the DPP4 inhibitors most commonly switched. Interventions to improve treatment adherence and persistence among patients with T2DM prescribed DPP4 inhibitors may be warranted.
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http://dx.doi.org/10.1007/s00592-020-01590-wDOI Listing
January 2021
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