We compared the cost-effectiveness of a free nicotine replacement therapy (NRT) program with a statewide smoke-free workplace policy in Minnesota. We conducted 1-year simulations of costs and benefits. The number of individuals who quit smoking and the quality-adjusted life years (QALYs) were the measures of benefits. After 1 year, a NRT program generated 18,500 quitters at a cost of 7020 dollars per quitter (4440 dollars per QALY), and a smoke-free workplace policy generated 10,400 quitters at a cost of 799 dollars per quitter (506 dollars per QALY). Smoke-free work-place policies are about 9 times more cost-effective per new nonsmoker than free NRT programs are. Smoke-free workplace policies should be a public health funding priority, even when the primary goal is to promote individual smoking cessation.

In recent years, hepatitis B has taken a backseat to hepatitis C because of the increased prevalence of hepatitis C in the United States and western Europe. However, hepatitis B has reclaimed the attention of gastroenterologists and other health care professionals because of 3 developments: the introduction of polymerase chain reaction (PCR)-based hepatitis B virus (HBV) DNA testing; the improved understanding of the nature of HBV-related disease; and the introduction of potent, orally administered new antiviral agents. In our editorial, we discuss the treatment of HBV, which has evolved rapidly, and then comment on the cost-effectiveness of HBV therapies.

Background: Weaponized Bacillus anthracis is one of the few biological agents that can cause death and disease in sufficient numbers to devastate an urban setting.

Objective: To evaluate the cost-effectiveness of strategies for prophylaxis and treatment of an aerosolized B. anthracis bioterror attack.

Design: Decision analytic model.

Data Sources: We derived probabilities of anthrax exposure, vaccine and treatment characteristics, and their costs and associated clinical outcomes from the medical literature and bioterrorism-preparedness experts.

Target Population: Persons living and working in a large metropolitan U.S. city.

Time Horizon: Patient lifetime.

Perspective: Societal.

Intervention: We evaluated 4 postattack strategies: no prophylaxis, vaccination alone, antibiotic prophylaxis alone, or vaccination and antibiotic prophylaxis, as well as preattack vaccination versus no vaccination.

Outcome Measures: Costs, quality-adjusted life-years, life-years, and incremental cost-effectiveness.

Results of Base-Case Analysis: If an aerosolized B. anthracis bioweapon attack occurs, postexposure prophylactic vaccination and antibiotic therapy for those potentially exposed is the most effective (0.33 life-year gained per person) and least costly ($355 saved per person) strategy, as compared with vaccination alone. At low baseline probabilities of attack and exposure, mass previous vaccination of a metropolitan population is more costly ($815 million for a city of 5 million people) and not more effective than no vaccination.

Results of Sensitivity Analysis: If prophylactic antibiotics cannot be promptly distributed after exposure, previous vaccination may become cost-effective.

Limitations: The probability of exposure and disease critically depends on the probability and mechanism of bioweapon release.

Conclusions: In the event of an aerosolized B. anthracis bioweapon attack over an unvaccinated metropolitan U.S. population, postattack prophylactic vaccination and antibiotic therapy is the most effective and least expensive strategy.

Background: Although the Centers for Disease Control and Prevention (CDC) recommend routine HIV counseling, testing, and referral (HIVCTR) in settings with at least a 1 percent prevalence of HIV, roughly 280,000 Americans are unaware of their human immunodeficiency virus (HIV) infection. The effect of expanded screening for HIV is unknown in the era of effective antiretroviral therapy.

Methods: We developed a computer simulation model of HIV screening and treatment to compare routine, voluntary HIVCTR with current practice in three target populations: "high-risk" (3.0 percent prevalence of undiagnosed HIV infection; 1.2 percent annual incidence); "CDC threshold" (1.0 percent and 0.12 percent, respectively); and "U.S. general" (0.1 percent and 0.01 percent). Input data were derived from clinical trials and observational cohorts. Outcomes included quality-adjusted survival, cost, and cost-effectiveness.

Results: In the high-risk population, the addition of one-time screening for HIV antibodies with an enzyme-linked immunosorbent assay (ELISA) to current practice was associated with earlier diagnosis of HIV (mean CD4 cell count at diagnosis, 210 vs. 154 per cubic millimeter). One-time screening also improved average survival time among HIV-infected patients (quality-adjusted survival, 220.7 months vs. 219.8 months). The incremental cost-effectiveness was $36,000 per quality-adjusted life-year gained. Testing every five years cost $50,000 per quality-adjusted life-year gained, and testing every three years cost $63,000 per quality-adjusted life-year gained. In the CDC threshold population, the cost-effectiveness ratio for one-time screening with ELISA was $38,000 per quality-adjusted life-year gained, whereas testing every five years cost $71,000 per quality-adjusted life-year gained, and testing every three years cost $85,000 per quality-adjusted life-year gained. In the U.S. general population, one-time screening cost $113,000 per quality-adjusted life-year gained.

Conclusions: In all but the lowest-risk populations, routine, voluntary screening for HIV once every three to five years is justified on both clinical and cost-effectiveness grounds. One-time screening in the general population may also be cost-effective.

Background:

The costs, benefits, and cost-effectiveness of screening for human immunodeficiency virus (HIV) in health care settings during the era of highly active antiretroviral therapy (HAART) have not been determined.

Methods:

We developed a Markov model of costs, quality of life, and survival associated with an HIV-screening program as compared with current practice. In both strategies, symptomatic patients were identified through symptom-based case finding. Identified patients started treatment when their CD4 count dropped to 350 cells per cubic millimeter. Disease progression was defined on the basis of CD4 levels and viral load. The likelihood of sexual transmission was based on viral load, knowledge of HIV status, and efficacy of counseling.

Results:

Given a 1 percent prevalence of unidentified HIV infection, screening increased life expectancy by 5.48 days, or 4.70 quality-adjusted days, at an estimated cost of $194 per screened patient, for a cost-effectiveness ratio of $15,078 per quality-adjusted life-year. Screening cost less than $50,000 per quality-adjusted life-year if the prevalence of unidentified HIV infection exceeded 0.05 percent. Excluding HIV transmission, the cost-effectiveness of screening was $41,736 per quality-adjusted life-year. Screening every five years, as compared with a one-time screening program, cost $57,138 per quality-adjusted life-year, but was more attractive in settings with a high incidence of infection. Our results were sensitive to the efficacy of behavior modification, the benefit of early identification and therapy, and the prevalence and incidence of HIV infection.

Conclusions:

The cost-effectiveness of routine HIV screening in health care settings, even in relatively low-prevalence populations, is similar to that of commonly accepted interventions, and such programs should be expanded.

PURPOSE:

The cost-effectiveness of cardiopulmonary resuscitation (CPR) and defibrillation training for laypersons unselected for risk of encountering cases of cardiac arrest is not known. We compared the costs and health benefits of alternative resuscitation training strategies for adults without professional first-responder duties who are at average risk of encountering cases of out-of-hospital cardiac arrest.

METHODS:

We constructed a cost-effectiveness analytic model. Data on cardiac arrest epidemiology and the effectiveness of CPR/defibrillation training were obtained from the medical literature. Instructional costs were determined from a survey of training programs. Downstream cardiac arrest survivor quality-adjusted life expectancy and long-term health care costs were derived from prior studies. We compared three strategies for training unselected laypersons: CPR/defibrillation training alone, training combined with home defibrillator purchase, and no training. The main outcome measures were total instructional costs for trainees combined with health care costs for additional cardiac arrest survivors, and quality-adjusted survival for additional patients resuscitated by trainees.

RESULTS:

CPR/defibrillation training yielded 2.7 quality-adjusted hours of life at a cost of 62 US dollars per trainee (202,400 US dollars per quality-adjusted life-year [QALY] gained). Training laypersons in CPR/defibrillation with subsequent defibrillator purchase cost 2,489,700 US dollars per QALY. In contrast, CPR/defibrillation training cost less than 75,000 US dollars per QALY if trainees lived with persons older than 75 years or with persons who had cardiac disease, or if total training costs were less than 10 US dollars.

CONCLUSION:

Training unselected laypersons in CPR/defibrillation is costly compared with other public health initiatives. Conversely, training laypersons selected by occupation, low training costs, or having high-risk household companions is substantially more efficient.

Behavioral health interventions are often gauged with a dichotomous outcome, "success" or "failure." Hidden by this dichotomy is a series of behavior changes that can be followed with the Transtheoretical Model (stages of change). There has been little consideration, however, about whether this information can and should be used in cost-effectiveness analysis. We review the stages of change model and its applications to behavioral health interventions. We then discuss analytical methods for including stages of change, or similar behavior change models, in cost-effectiveness analysis (CEA). This is typically not done but it may be critical for study design and for interpreting CEA results.

BACKGROUND:

Photodynamic therapy appears to be effective in ablating high-grade dysplasia in Barrett's esophagus. Our aim was to identify the most effective and cost-effective strategy for managing high-grade dysplasia in Barrett's esophagus without associated endoscopically visible abnormalities.

METHODS:

By using decision analysis, the lifetime costs and benefits of 4 strategies for which long-term data exist were estimated by us: esophagectomy, endoscopic surveillance, photodynamic therapy, followed by esophagectomy for residual high-grade dysplasia; and photodynamic therapy followed by endoscopic surveillance for residual high-grade dysplasia. It was assumed by us that there was a 30% prevalence of cancer in high-grade dysplasia patients and a 77% efficacy of photodynamic therapy for high-grade dysplasia and early cancer.

RESULTS:

Esophagectomy cost 24,045 dollars, with life expectancy of 11.82 quality-adjusted life years. In comparison, photodynamic therapy followed by surveillance for residual high-grade dysplasia was the most effective strategy, with a quality-adjusted life expectancy of 12.31 quality-adjusted life years, but it also incurred the greatest lifetime cost (47,310 dollars) for an incremental cost-effectiveness of 47,410 dollars/quality-adjusted life years. The results were sensitive to post-surgical quality of life and survival, and to cancer prevalence if photodynamic therapy efficacy for cancer was less than 50%.

CONCLUSIONS:

Photodynamic therapy followed by endoscopic surveillance for residual high-grade dysplasia appears to be cost effective compared with esophagectomy for patients diagnosed with high-grade dysplasia in Barrett's esophagus. Clinical trials directly comparing these strategies are warranted.

Human papillomavirus (HPV) has been implicated as the primary etiologic agent of cervical cancer. Potential vaccines against high-risk HPV types are in clinical trials. We evaluated vaccination programs with a vaccine against HPV-16 and HPV-18. We developed disease transmission models that estimated HPV prevalence and infection rates for the population overall, by age group, by level of sexual activity within each age group, and by sex. Data were based on clinical trials and published and unpublished sources. An HPV-16/18 vaccine for 12-year-old girls would reduce cohort cervical cancer cases by 61.8%, with a cost-effectiveness ratio of $14,583 per quality-adjusted life year (QALY). Including male participants in a vaccine rollout would further reduce cervical cancer cases by 2.2% at an incremental cost-effectiveness ratio of $442,039/QALY compared to female-only vaccination. Vaccination against HPV-16 and HPV-18 can be cost-effective, although including male participants in a vaccination program is generally not cost-effective, compared to female-only vaccination.