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Introduction A randomized trial has demonstrated that lung cancer screening reduces mortality. Identifying participant and program characteristics that influence the cost-effectiveness of screening will help translate trial results into benefits at the population level. Methods Six U.S. cohorts (males and females aged 50, 60, or 70) were simulated in an existing patient-level lung cancer model. Smoking histories reflected observed U.S. patterns. We simulated lifetime histories of 500,000 identical individuals per cohort in each scenario. Costs per quality-adjusted life-year gained ($/QALY) were estimated for each program: CT screening; stand-alone smoking cessation therapies (4–30% 1-year abstinence); and combined programs. Results Annual screening of current and former smokers aged 50–74 cost between $126,000–$169,000/QALY (minimum 20 pack-years of smoking) or $110,000–$166,000/QALY (40 pack-year minimum), compared to no screening and assuming background quit rates. Screening was beneficial but had a higher cost per QALY when the model included radiation-induced lung cancers. If screen participation doubled background quit rates, the cost of annual screening (at age 50, 20 pack-year minimum) was below $75,000/QALY. If screen participation halved background quit rates, benefits from screening were nearly erased. If screening had no effect on quit rates, annual screening cost more but provided fewer QALYs than annual cessation therapies. Annual combined screening/cessation therapy programs at age 50 cost $130,500–$159,700/QALY, compared to annual stand-alone cessation. Conclusions The cost-effectiveness of CT screening will likely be strongly linked to achievable smoking cessation rates. Trials and further modeling should explore the consequences of relationships between smoking behaviors and screen participation.

Background Chronic hepatitis C (HCV) is a difficult to treat disease affecting over 3 million Americans. Protease inhibitors increase the effectiveness of standard therapy but are costly. A genetic assay may identify patients most likely to benefit from this treatment advance. Objective Cost-effectiveness assessment of new protease inhibitors and an Interleukin-28B (IL- 28B) genotyping assay for treating chronic HCV Design Decision-analytic Markov model Data Sources Published literature and expert opinion Target Population Treatment-naïve patients with chronic, genotype 1 HCV mono-infection Time Horizon Lifetime Perspective Societal Interventions Strategies are defined by the use of IL-28B genotyping and type of treatment (standard therapy: pegylated interferon with ribavirin; triple therapy: standard therapy and a protease inhibitor). IL-28B guided triple therapy stratifies CC genotype patients to standard therapy and non-CC types to triple therapy. Outcome Measures Discounted costs (2010 U.S. dollars) and quality-adjusted life years (QALYs); incremental cost effectiveness ratios Results of Base-Case Analysis For patients with mild and advanced fibrosis, universal triple therapy reduces life-time risk of hepatocellular-carcinoma by 39% and 29% and increases quality-adjusted life expectancy by 3% and 8% compared to standard therapy. Gains from IL- 28B guided triple therapy are smaller. If the protease inhibitor costs $1,100 per week, universal triple therapy costs $102,600 per QALY (mild fibrosis) or $51,500 per QALY (advanced fibrosis) compared to IL-28B guided triple therapy and $70,100 per QALY and $36,300 per QALY compared to standard therapy. Results of Sensitivity Analysis Results are sensitive to the cost of protease inhibitors and treatment adherence rates. Limitations Lack of long-term comparative effectiveness data on the new protease inhibitors Conclusions Both universal triple therapy and IL-28B guided triple therapy are cost-effective with the least expensive protease inhibitor for patients with advanced fibrosis. Primary Funding Source Stanford Graduate Fellowship

Patients with mixed pathologies have nearly twice the incremental risk of dementia compared with patients with only Alzheimer-type lesions. Consequently, many cases of dementia could be prevented or delayed by targeting the vascular component.

Objectives The objective of this analysis was to estimate costs for lung cancer care and evaluate trends in the share of costs that are the responsibility of Medicare beneficiaries. Methods SEER-Medicare data from 1991–2003 on n=60,231 lung cancer patients were used to estimate monthly and patient-liability costs for clinical phases of lung cancer care (pre-diagnosis, staging, initial, continuing, and terminal), stratified by treatment, stage, and non- vs. small cell lung cancer. Lung cancer-attributable costs were estimated by subtracting each patient's own pre-diagnosis costs. Costs were estimated as the sum of Medicare reimbursements (payments from Medicare to the service provider), co-insurance reimbursements, and patient-liability costs (deductibles and `co-pays' that are the patient's responsibility). Costs and patient-liability costs were fit with regression models to compare trends by calendar year, adjusting for age at diagnosis. Results For a 72-year old diagnosed with lung cancer in 2000, monthly costs in the first 6 months of care ranged from $2,687 (no active treatment) to $9,360 (chemo-radiotherapy), and varied by stage at diagnosis and histologic type. Patient-liability costs represented up to 21.6% of care costs and increased over the period 1992–2003 for most stage and treatment categories, even when care costs decreased or remained unchanged. The greatest monthly patient liability was incurred by chemo-radiotherapy patients ranging across stages from $1,617 to $2,004 per month. Conclusions Costs for lung cancer care are substantial and Medicare beneficiaries are responsible for an increasing share of the cost.

Aims: To compare the early impact of COVID-19 infections and mortality from February to July 2020 across the Nordic nations of Sweden, Norway, Denmark, and Finland through available public data sources and conduct a descriptive analysis of the potential factors that drove different epidemiological outcomes, with a focus on Sweden’s response. Methods: COVID-19 cases, deaths, tests, case age distribution, and the difference between 2020 all-cause mortality and the average mortality of the previous 5 years were compared across nations. Patterns in cell phone mobility data, testing strategies, and seniors’ care home deaths were also compared. Data for each nation were based on publicly available sources as of July 31, 2020. Results: Compared with its Nordic peers, Sweden had a higher incidence rate across all ages, a higher COVID-19-related death rate only partially explained by population demographics, a higher death rate in seniors’ care, and higher all-cause mortality. Sweden had approximately half as much mobility change as its Nordic neighbours until April and followed similar rates as its neighbours from April to July. Denmark led its Nordic peers in testing rates, while Sweden had the highest cumulative test-positivity rate continuously from mid-March. Conclusions: COVID-19 pushed Sweden’s health system to its capacity, exposed systemic weaknesses in the seniors’ care system, and revealed challenges with implementing effective contact tracing and testing strategies while experiencing a high case burden. Looser government restrictions at the beginning of the outbreak are likely to have played a role in the impact of COVID-19 in Sweden. In an effort to improve epidemic control, Sweden has increased testing rates, implemented more restrictive prevention measures, and increased their intensive care unit bed capacity.

ObjectiveTo estimate the cost, effectiveness, and cost effectiveness of HIV and HCV screening of injection drug users (IDUs) in opioid replacement therapy (ORT).DesignDynamic compartmental model of HIV and HCV in a population of IDUs and non-IDUs for a representative U.S. urban center with 2.5 million adults (age 15–59).MethodsWe considered strategies of screening individuals in ORT for HIV, HCV, or both infections by antibody or antibody and viral RNA testing. We evaluated one-time and repeat screening at intervals from annually to once every 3 months. We calculated the number of HIV and HCV infections, quality-adjusted life years (QALYs), costs, and incremental cost-effectiveness ratios (ICERs).ResultsAdding HIV and HCV viral RNA testing to antibody testing averts 14.8–30.3 HIV and 3.7–7.7 HCV infections in a screened population of 26,100 IDUs entering ORT over 20 years, depending on screening frequency. Screening for HIV antibodies every 6 months costs $30,700/QALY gained. Screening for HIV antibodies and viral RNA every 6 months has an ICER of $65,900/QALY gained. Strategies including HCV testing have ICERs exceeding $100,000/QALY gained unless awareness of HCV-infection status results in a substantial reduction in needle-sharing behavior.DiscussionAlthough annual screening for antibodies to HIV and HCV is modestly cost effective compared to no screening, more frequent screening for HIV provides additional benefit at less cost. Screening individuals in ORT every 3–6 months for HIV infection using both antibody and viral RNA technologies and initiating ART for acute HIV infection appears cost effective.

BackgroundNo consensus exists on screening to detect the estimated 2 million Americans unaware of their chronic hepatitis C infections. Advisory groups differ, recommending birth-cohort screening for baby boomers, screening only high-risk individuals, or no screening. We assessed one-time risk assessment and screening to identify previously undiagnosed 40–74 year-olds given newly available hepatitis C treatments.Methods and FindingsA Markov model evaluated alternative risk-factor guided and birth-cohort screening and treatment strategies. Risk factors included drug use history, blood transfusion before 1992, and multiple sexual partners. Analyses of the National Health and Nutrition Examination Survey provided sex-, race-, age-, and risk-factor-specific hepatitis C prevalence and mortality rates. Nine strategies combined screening (no screening, risk-factor guided screening, or birth-cohort screening) and treatment (standard therapy–peginterferon alfa and ribavirin, Interleukin-28B-guided (IL28B) triple-therapy–standard therapy plus a protease inhibitor, or universal triple therapy). Response-guided treatment depended on HCV genotype. Outcomes include discounted lifetime costs (2010 dollars) and quality adjusted life-years (QALYs).Compared to no screening, risk-factor guided and birth-cohort screening for 50 year-olds gained 0.7 to 3.5 quality adjusted life-days and cost $168 to $568 per person. Birth-cohort screening provided more benefit per dollar than risk-factor guided screening and cost $65,749 per QALY if followed by universal triple therapy compared to screening followed by IL28B-guided triple therapy. If only 10% of screen-detected, eligible patients initiate treatment at each opportunity, birth-cohort screening with universal triple therapy costs $241,100 per QALY. Assuming treatment with triple therapy, screening all individuals aged 40–64 years costs less than $100,000 per QALY.ConclusionsThe cost-effectiveness of one-time birth-cohort hepatitis C screening for 40–64 year olds is comparable to other screening programs, provided that the healthcare system has sufficient capacity to deliver prompt treatment and appropriate follow-on care to many newly screen-detected individuals.