Cost-effectiveness of vaccination against pneumococcal pneumonia in The Netherlands Baltussen R M, Ament A J, Leidl R M, Van Furth R

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1 Cost-effectiveness of vaccination against pneumococcal pneumonia in The Netherlands Baltussen R M, Ament A J, Leidl R M, Van Furth R Record Status This is a critical abstract of an economic evaluation that meets the criteria for inclusion on NHS EED. Each abstract contains a brief summary of the methods, the results and conclusions followed by a detailed critical assessment on the reliability of the study and the conclusions drawn. Health technology Vaccination against pneumococcal pneumonia. Type of intervention Primary prevention. Economic study type Cost-effectiveness analysis. Study population A hypothetical group of elderly people. Setting Hospital. The study was carried out in the Netherlands. Dates to which data relate Effectiveness data were collected from studies previously published between 1964 and 1995 and Dutch databases ( ). Resource use and cost data were collected from studies previously published between 1982 and 1993 and from Academic Hospital of Maastricht sources. The price year was Source of effectiveness data Effectiveness data were derived from a literature review. Modelling A decision tree was used to model the cost-effectiveness of the vaccination strategies. Outcomes assessed in the review The review assessed the following outcomes: efficacy of polyvalent polysaccharide pneumococcal vaccine, annual incidence of pneumococcal pneumonia per 100,000 individuals, hospital admission rates for pneumococcal pneumonia, length of stay and mortality rates. Study designs and other criteria for inclusion in the review Efficacy estimates were based on both randomised controlled trials and observational non-randomised trials. Page: 1 / 5

2 Sources searched to identify primary studies Criteria used to ensure the validity of primary studies Methods used to judge relevance and validity, and for extracting data Summary statistics from each study. Number of primary studies included Approximately 27 studies were included in the review. Methods of combining primary studies Investigation of differences between primary studies Results of the review An efficacy rate of 60% for all subgroups of elderly people was assumed. A vaccine duration of 5 years was applied. An incidence of 8 complications requiring GP consultation per 1,000 vaccinated individuals was applied. The annual incidence of pneumococcal pneumonia was 25% (range: 15-40%). The hospital admission rate for pneumococcal pneumonia was 30% (range: 20-40%). The average length of stay for patients of years was 14.6 days. The mortality rates in general practice and at the hospital, for patients of years were 0.02% and 5.6%, respectively. Treatment of pneumonia by general practitioners was assumed to require 3-4 consultations. Measure of benefits used in the economic analysis The primary measure of benefits was life-years gained due to the prevention of pneumococcal pneumonia. Life expectancy of individuals with an underlying disease was calculated using the DEALE (declining exponential approximation of life expectancy) methodology. Life expectancy was obtained by combining disease-specific mortalities with the age-, sex-, and race-adjusted mortality rate of a healthy individual. The mortality rates for individuals with underlying diseases were assumed to be equal for all ages and were based on data from Japanese and UK insurance companies (chronic lung disease 0.026; diabetes mellitus 0.011; chronic heart disease 0.012). Life-years were discounted at an annual rate of 5%. Direct costs Direct costs were discounted at an annual rate of 5%. Quantities and costs were reported separately. Direct costs included expenditure for purchasing and administering the vaccine, the treatment costs of vaccine side-effects and the treatment costs saved by preventing the disease. A distinction was made between vaccination costs, general practice treatment costs and hospital treatment costs. The quantity/cost boundary adopted was that of the hospital. The estimation of quantities and costs was based on actual data. The estimate of treatment costs was based on 1994 cost profiles of patients treated at the Academic Hospital of Maastricht. The price year was Statistical analysis of costs Not applicable. Page: 2 / 5

3 Indirect Costs Not included. Currency European Currency Units (ECU) with 1 ECU = 2.07 Dutch guilders. Sensitivity analysis One-way sensitivity analyses were performed on all effectiveness and cost data. Multi-way sensitivity analyses were performed on those variables shown in the one-way sensitivity analysis to influence the results most strongly. Estimated benefits used in the economic analysis Estimated benefits for elderly individuals with no underlying disease varied between and life-years. Estimated benefits for elderly individuals with chronic lung disease varied between and life-years. Estimated benefits for elderly individuals with diabetes mellitus varied between and life-years. Estimated benefits for elderly individuals with chronic heart disease varied between and life-years. Cost results Total costs for elderly individuals with no underlying disease varied between ECU and ECU, and for those with chronic lung disease varied between ECU and ECU. Total costs for elderly individuals with diabetes mellitus varied between ECU and ECU and for those with chronic heart disease varied between ECU and 9.5 ECU. Synthesis of costs and benefits The cost-effectiveness of vaccinating all individuals increases with age: vaccinating individuals aged years yields a cost-effectiveness ration (CER) of 37,500 ECU per life-year saved, whereas vaccinating individuals aged 85 years and older produces a cost saving. Vaccinating all individuals over the age of 55 years yields a CER of 3,300 ECU and vaccinating all those over the age of 65 years gives a CER of 1,500 ECU per life-year saved. The cost-effectiveness of vaccinating individuals with a specific underlying disease also increases with age, regardless of the underlying disease. These results are sensitive to vaccine efficacy rate, duration of immunity, hospital admission rate, costs of vaccine administration and retail price. Authors' conclusions Vaccination of all individuals over the age of 65 years is comparable in terms of cost-effectiveness to many existing health care interventions. The vaccination of individuals over the age of 55 years with chronic lung disease or chronic heart disease is similarly attractive from an economic point of view, as is the vaccination of individuals over the age of 65 years with diabetes mellitus. CRD COMMENTARY - Selection of comparators The rationale for the choice of the comparator was clear. You, as a user of this database, should verify whether this health technology is relevant to your setting. Validity of estimate of measure of benefit The authors considered a relevant measure of benefits, although, alternatively, quality-adjusted life years could have been used. The analysis only focused on community-acquired pneumonia and did not consider hospital-acquired pneumonia. The vaccine's efficacy in preventing meningitis or other diseases was not included in the analysis. The belief that vaccinated individuals have a less severe course of disease if they do become infected was not considered. The analysis did not consider that other pathogens may replace S.pneumoniae in vaccinated people. The results were Page: 3 / 5

4 sensitive to vaccine efficacy and duration of immunity, estimates of which were derived from case-control studies. More details about the method of identifying (from the literature) and combining the effectiveness results could, usefully, have been provided. Validity of estimate of costs Only direct costs were included. Vaccine dispensing costs and indirect costs such as costs associated with productivity loss were not considered (although for the population aged over 65 this would be a reasonable omission). Cost estimates were derived from local sources and are unlikely to be generalisable. Other issues The generalisability of the results to other countries or settings was discussed. A number of future trends such as the joint provision of pneumococcal and influenza vaccination may substantially alter these results. Implications of the study This modelled analysis suggests that vaccination against pneumococcal pneumonia is cost-effective according to the caveats listed in the authors' conclusions above. Source of funding Financial support from Pasteur Merieux MSD. Bibliographic details Baltussen R M, Ament A J, Leidl R M, Van Furth R. Cost-effectiveness of vaccination against pneumococcal pneumonia in The Netherlands. European Journal of Public Health 1997; 7(2): Original Paper URL 07/Issue_ 02/ sgm.abs.html Other publications of related interest 1. Cost-effectiveness and cost-utility of a pneumococcal immunization program in Quebec - systematic review. (Coutefficacite et cout-utilite d'un programme d'immunisation contre le pneumocoque au Quebec). Conseil d'evaluation des Technologies de la Sante du Quebec Montreal: Conseil d'evaluation des Technologies de la Sante du Quebec, Beutels P. A critical summary of economic evaluations of pneumococcal vaccination. Presse Medicale 1998;27(Suppl 1): Congress of the United States, Office of Technology Assessment. A review of selected Federal vaccine and immunisation policies: based on case studies of pneumococcal vaccine. Washington DC: Office of Technology Assessment, 1979: Sisk J E, Riegelman R K. Cost effectiveness of vaccination against pneumococcal pneumonia: an update. Annals of Internal Medicine 1986; 104: Indexing Status Subject indexing assigned by CRD MeSH Adult; Bacterial Vaccines /economics /immunology /administration & dosage; Cost-Benefit Analysis; Decision Support Techniques; Humans; Netherlands; Pneumococcal Infections /prevention & control; Pneumonia, Pneumococcal; Quality of Life; Vaccination /economics Page: 4 / 5

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