scholarly journals Pipeline embolization device versus coiling for the treatment of large and giant unruptured intracranial aneurysms: a cost-effectiveness analysis

2017 ◽  
Vol 42 (6) ◽  
pp. E6 ◽  
Author(s):  
Arvin R. Wali ◽  
Charlie C. Park ◽  
David R. Santiago-Dieppa ◽  
Florin Vaida ◽  
James D. Murphy ◽  
...  
Keyword(s):  
Cost Effectiveness ◽  
Intracranial Aneurysms ◽  
Cost Effective ◽  
Endovascular Coiling ◽  
Effective Strategy ◽  
Pipeline Embolization Device ◽  
Cost Effective Strategy ◽  
Effectiveness Analysis ◽  
Giant Intracranial Aneurysms ◽  
The Cost

OBJECTIVERupture of large or giant intracranial aneurysms leads to significant morbidity, mortality, and health care costs. Both coiling and the Pipeline embolization device (PED) have been shown to be safe and clinically effective for the treatment of unruptured large and giant intracranial aneurysms; however, the relative cost-to-outcome ratio is unknown. The authors present the first cost-effectiveness analysis to compare the economic impact of the PED compared with coiling or no treatment for the endovascular management of large or giant intracranial aneurysms.METHODSA Markov model was constructed to simulate a 60-year-old woman with a large or giant intracranial aneurysm considering a PED, endovascular coiling, or no treatment in terms of neurological outcome, angiographic outcome, retreatment rates, procedural and rehabilitation costs, and rupture rates. Transition probabilities were derived from prior literature reporting outcomes and costs of PED, coiling, and no treatment for the management of aneurysms. Cost-effectiveness was defined, with the incremental cost-effectiveness ratios (ICERs) defined as difference in costs divided by the difference in quality-adjusted life years (QALYs). The ICERs < $50,000/QALY gained were considered cost-effective. To study parameter uncertainty, 1-way, 2-way, and probabilistic sensitivity analyses were performed.RESULTSThe base-case model demonstrated lifetime QALYs of 12.72 for patients in the PED cohort, 12.89 for the endovascular coiling cohort, and 9.7 for patients in the no-treatment cohort. Lifetime rehabilitation and treatment costs were $59,837.52 for PED; $79,025.42 for endovascular coiling; and $193,531.29 in the no-treatment cohort. Patients who did not undergo elective treatment were subject to increased rates of aneurysm rupture and high treatment and rehabilitation costs. One-way sensitivity analysis demonstrated that the model was most sensitive to assumptions about the costs and mortality risks for PED and coiling. Probabilistic sampling demonstrated that PED was the cost-effective strategy in 58.4% of iterations, coiling was the cost-effective strategy in 41.4% of iterations, and the no-treatment option was the cost-effective strategy in only 0.2% of iterations.CONCLUSIONSThe authors’ cost-effective model demonstrated that elective endovascular techniques such as PED and endovascular coiling are cost-effective strategies for improving health outcomes and lifetime quality of life measures in patients with large or giant unruptured intracranial aneurysm.

scholarly journals Accurate diagnosis of latent tuberculosis in children, people who are immunocompromised or at risk from immunosuppression and recent arrivals from countries with a high incidence of tuberculosis: systematic review and economic evaluation

2016 ◽  
Vol 20 (38) ◽  
pp. 1-678 ◽  
Author(s):  
Peter Auguste ◽  
Alexander Tsertsvadze ◽  
Joshua Pink ◽  
Rachel Court ◽  
Farah Seedat ◽  
...  
Keyword(s):  
Cost Effectiveness ◽  
Latent Tuberculosis ◽  
Cost Effective ◽  
Skin Tests ◽  
Effective Strategy ◽  
Nice Guideline ◽  
Cost Effective Strategy ◽  
High Incidence ◽  
The Uk ◽  
The Cost

BackgroundTuberculosis (TB), caused byMycobacterium tuberculosis(MTB) [(Zopf 1883) Lehmann and Neumann 1896], is a major cause of morbidity and mortality. Nearly one-third of the world’s population is infected with MTB; TB has an annual incidence of 9 million new cases and each year causes 2 million deaths worldwide.ObjectivesTo investigate the clinical effectiveness and cost-effectiveness of screening tests [interferon-gamma release assays (IGRAs) and tuberculin skin tests (TSTs)] in latent tuberculosis infection (LTBI) diagnosis to support National Institute for Health and Care Excellence (NICE) guideline development for three population groups: children, immunocompromised people and those who have recently arrived in the UK from high-incidence countries. All of these groups are at higher risk of progression from LTBI to active TB.Data sourcesElectronic databases including MEDLINE, EMBASE, The Cochrane Library and Current Controlled Trials were searched from December 2009 up to December 2014.Review methodsEnglish-language studies evaluating the comparative effectiveness of commercially available tests used for identifying LTBI in children, immunocompromised people and recent arrivals to the UK were eligible. Interventions were IGRAs [QuantiFERON®-TB Gold (QFT-G), QuantiFERON®-TB Gold-In-Tube (QFT-GIT) (Cellestis/Qiagen, Carnegie, VA, Australia) and T-SPOT.TB(Oxford Immunotec, Abingdon, UK)]. The comparator was TST 5 mm or 10 mm alone or with an IGRA. Two independent reviewers screened all identified records and undertook a quality assessment and data synthesis. A de novo model, structured in two stages, was developed to compare the cost-effectiveness of diagnostic strategies.ResultsIn total, 6687 records were screened, of which 53 unique studies were included (a further 37 studies were identified from a previous NICE guideline). The majority of the included studies compared the strength of association for the QFT-GIT/G IGRA with the TST (5 mm or 10 mm) in relation to the incidence of active TB or previous TB exposure. Ten studies reported evidence on decision-analytic models to determine the cost-effectiveness of IGRAs compared with the TST for LTBI diagnosis. In children, TST (≥ 5 mm) negative followed by QFT-GIT was the most cost-effective strategy, with an incremental cost-effectiveness ratio (ICER) of £18,900 per quality-adjusted life-year (QALY) gained. In immunocompromised people, QFT-GIT negative followed by the TST (≥ 5 mm) was the most cost-effective strategy, with an ICER of approximately £18,700 per QALY gained. In those recently arrived from high TB incidence countries, the TST (≥ 5 mm) alone was less costly and more effective than TST (≥ 5 mm) positive followed by QFT-GIT or T-SPOT.TBor QFT-GIT alone.LimitationsThe limitations and scarcity of the evidence, variation in the exposure-based definitions of LTBI and heterogeneity in IGRA performance relative to TST limit the applicability of the review findings.ConclusionsGiven the current evidence, TST (≥ 5 mm) negative followed by QFT-GIT for children, QFT-GIT negative followed by TST (≥ 5 mm) for the immunocompromised population and TST (≥ 5 mm) for recent arrivals were the most cost-effective strategies for diagnosing LTBI that progresses to active TB. These results should be interpreted with caution given the limitations identified. The evidence available is limited and more high-quality research in this area is needed including studies on the inconsistent performance of tests in high-compared with low-incidence TB settings; the prospective assessment of progression to active TB for those at high risk; the relative benefits of two-compared with one-step testing with different tests; and improved classification of people at high and low risk for LTBI.Study registrationThis study is registered as PROSPERO CRD42014009033.FundingThe National Institute for Health Research Health Technology Assessment programme.

scholarly journals Treatment for Severe Lupus Nephritis: A Cost-Effectiveness Analysis in China

2021 ◽  
Vol 12 ◽  
Author(s):  
Zonglin Dai ◽  
Xi Zhang ◽  
Irene OL Wong ◽  
Eric HY Lau ◽  
Zhiming Lin
Keyword(s):  
Cost Effectiveness ◽  
Cost Effective ◽  
Gdp Per Capita ◽  
Effective Strategy ◽  
Lifetime Horizon ◽  
Clinical Prognosis ◽  
Cost Effective Strategy ◽  
Per Capita ◽  
The One ◽  
The Cost

Background: Lupus nephritis (LN) is the most common secondary glomerular diseases that will cause end-stage renal disease (ESRD) and renal-related death. The cost-effectiveness of various treatments for LN recommended by official guidelines has not been investigated in China. Our study is to evaluate clinical prognosis and cost-effectiveness of the current treatments for severe LN.Methods: A Markov model was simulated for 1,000 LN patients of 30 years old, over a 3-years and 30-years lifetime horizon respectively. We assessed the cost-effectiveness of six therapeutic strategies from a societal perspective, with cyclophosphamide (CYC) or mycophenolate mofetil (MMF) induction therapy followed by CYC, MMF or azathioprine (AZA) maintenance therapy. Main outcomes included quality-adjusted life years (QALYs), incremental cost-effectiveness ratio (ICER) and clinical prognosis. One and three times gross domestic product (GDP) per capita were used as the willingness-to-pay (WTP) thresholds. We also carried out sensitivity analysis under a lifetime horizon.Results: Compared with the baseline strategy of CYC induction and maintenance, for a 3-years horizon the most cost-effective strategy was CYC induction and AZA maintenance with $448 per QALY gained, followed by MMF induction and AZA maintenance which however was not cost-effective under the one times GDP per capita WTP threshold. For a lifetime horizon, CYC induction and AZA maintenance remained the most cost-effective strategy but MMF induction and maintenance became cost-effective under the one times GDP per capita WTP threshold and achieved a higher complete remission rate (57.2 versus 48.9%) and lower risks of ESRD (3.3 versus 5.8%) and all-cause mortality (36.0 versus 40.8%). The risk of developing ESRD during maintenance was the most influential parameter affecting ICER.Conclusions: The strategy of CYC induction followed by AZA maintenance was the most cost-effective strategy in China for short-term treatment, while the strategy of MMF in both induction and maintenance became cost-effective and yielded more desirable clinical outcomes for lifetime treatment. The uncertainty analysis supported the need for monitoring the progression to ESRD.

Bendamustine and Rituximab Versus Conventional Chemoimmunotherapy As a Frontline Treatment for Patients with Indolent B-Cell Lymphoma: A Cost-Effectiveness Analysis

Blood ◽  
2016 ◽  
Vol 128 (22) ◽  
pp. 1186-1186 ◽  
Author(s):  
Andrew Aw ◽  
Kathryn Coyle ◽  
Isabelle Bence-Bruckler ◽  
Christopher N. Bredeson ◽  
Doug Coyle
Keyword(s):  
Cost Effectiveness ◽  
Incremental Cost ◽  
Cost Effective ◽  
Effective Strategy ◽  
Health States ◽  
Cost Effective Strategy ◽  
Subgroup Analyses ◽  
Frontline Treatment ◽  
Cost Effectiveness Acceptability Curve ◽  
The Cost

Abstract Background: Indolent lymphomas are characterized by a chronic relapsing-remitting course. Bendamustine-Rituximab (BR) has been shown to improve overall response rate and progression free survival (PFS) in the upfront treatment of patients with indolent B-cell non-Hodgkin lymphoma (iNHL), as compared with conventional chemoimmunotherapy (Rummel et al., 2013; Flinn et al., 2014). The pan-Canadian Oncology Drug Review has recommended publicly funding BR, but concluded there is substantial uncertainty regarding the regimen's cost-effectiveness. The objective of our study was to assess the cost-effectiveness of BR as compared with Rituximab-Cyclophosphamide, Doxorubicin, Vincristine, Prednisone (RCHOP) as frontline treatment for patients with advanced iNHL from a Canadian perspective. Methods: A Markov model was developed to estimate the costs, life expectancy and quality-adjusted life-years (QALYs) associated with the two regimen options allowing determination of the incremental cost-utility ratio (ICUR). Model parameters were derived from peer-reviewed studies. Key health states included FT (frontline therapy), MR (2-year state of maintenance R), PF1 (1st progression-free state), PD1/2/3 (subsequent progressive disease states requiring salvage), PF2/3/4 (subsequent progression-free states post-salvage), palliation and death. To determine progression after FT, individual data elements were derived from the published literature, and transition probabilities were determined through parametric survival analysis. Age-related mortality was obtained from Statistics Canada. Cost data (in 2016 Canadian dollars) were obtained from current funding arrangements under the New Drug Funding Program of Cancer Care Ontario, the Ontario Health Insurance Plan Schedule of Benefits and Fees, and the published literature. Utility values for health states and utility decrements associated with treatment related adverse events (AEs) were derived from peer-reviewed studies. The analysis was performed from the health care provider perspective, with a lifetime time horizon (equivalent to 24 years) and cycle lengths of 6 months. Patients were treated with a maximum of 3 lines of salvage therapy (3rd salvage permitted in age-appropriate patients achieving at least 1 year remission from 2nd line salvage). In order to address uncertainty of model input variables, a probabilistic analysis in which model inputs were represented by probability distributions was utilized, permitting a Monte Carlo simulation with 5000 replications. Costs and utilities were discounted at a rate of 5% per annum. Subgroup analyses for the following iNHL histologies were performed using individualized parametric survival curves: follicular lymphoma (FL), mantle cell lymphoma (MCL), marginal zone lymphoma (MZL), lymphoplasmacytic lymphoma (LPL). Results: The average costs and QALYs for the two treatment strategies were as follows: $116,811 and 5.86 QALYs for RCHOP; $121,364 and 6.38 QALYs for BR. The incremental cost per QALY gained for using BR with respect to RCHOP was $8,812 (Figure 1). Subgroup analyses revealed robust ICUR results: $27,398 (FL), $8,924 (MCL), $10,012 (MZL), $6,565 (LPL). For the commonly accepted willingness to pay threshold (WTP) of $50,000 per QALY, BR was the more cost-effective strategy 92% of the time in the entire cohort (Figure 2). In the subgroup analyses, BR was the more cost-effective strategy 66%, 82%, 64%, 86% of the time in FL, MCL, MZL, LPL respectively. ICUR results were robust to sensitivity analyses of key variables including age at study entry, maximum allowable age for therapy, duration of AEs, probability of death from palliation state and discount rate. Conclusion: Our model suggests that BR is a cost-effective strategy for the frontline treatment of patients with iNHL as compared with RCHOP. The cost-effectiveness of BR may be driven by the upfront PFS advantage despite higher acquisition costs and is consistent in various iNHL histology subgroups. Our analysis supports the use of frontline BR for iNHL in the Canadian setting. Figure 1 Cost-effectiveness acceptability curve Figure 1. Cost-effectiveness acceptability curve Figure 2 Incremental cost-effectiveness of BR relative to RCHOP with WTP threshold of $50,000 per QALY Figure 2. Incremental cost-effectiveness of BR relative to RCHOP with WTP threshold of $50,000 per QALY Disclosures Bence-Bruckler: Lundbeck: Membership on an entity's Board of Directors or advisory committees.

scholarly journals Detecting Germline PTEN Mutations Among At-Risk Patients With Cancer: An Age- and Sex-Specific Cost-Effectiveness Analysis

2015 ◽  
Vol 33 (23) ◽  
pp. 2537-2544 ◽  
Author(s):  
Joanne Ngeow ◽  
Chang Liu ◽  
Ke Zhou ◽  
Kevin D. Frick ◽  
David B. Matchar ◽  
...  
Keyword(s):  
Cost Effectiveness ◽  
Cleveland Clinic ◽  
Cost Effective ◽  
Cancer Surveillance ◽  
Sensitivity Analyses ◽  
Base Case ◽  
Effective Strategy ◽  
Female Patients ◽  
Cost Effective Strategy ◽  
The Cost

Purpose Cowden syndrome (CS) is an autosomal dominant disorder characterized by benign and malignant tumors. One-quarter of patients who are diagnosed with CS have pathogenic germline PTEN mutations, which increase the risk of the development of breast, thyroid, uterine, renal, and other cancers. PTEN testing and regular, intensive cancer surveillance allow for early detection and treatment of these cancers for mutation-positive patients and their relatives. Individual CS-related features, however, occur commonly in the general population, making it challenging for clinicians to identify CS-like patients to offer PTEN testing. Patients and Methods We calculated the cost per mutation detected and analyzed the cost-effectiveness of performing selected PTEN testing among CS-like patients using a semi-quantitative score (the PTEN Cleveland Clinic [CC] score) compared with existing diagnostic criteria. In our model, first-degree relatives of the patients with detected PTEN mutations are offered PTEN testing. All individuals with detected PTEN mutations are offered cancer surveillance. Results CC score at a threshold of 15 (CC15) costs from $3,720 to $4,573 to detect one PTEN mutation, which is the most inexpensive among the different strategies. At base-case, CC10 is the most cost-effective strategy for female patients who are younger than 40 years, and CC15 is the most cost-effective strategy for female patients who are between 40 and 60 years of age and male patients of all ages. In sensitivity analyses, CC15 is robustly the most cost-effective strategy for probands who are younger than 60 years. Conclusion Use of the CC score as a clinical risk calculator is a cost-effective prescreening method to identify CS-like patients for PTEN germline testing.

Screening and Vaccination Against Measles and Varicella Among Health Care Workers: A Cost-effectiveness Analysis

2021 ◽  
pp. 101053952110264
Author(s):  
Ji-Suk Lee ◽  
Oh Jeong ◽  
Hyunju Yang
Keyword(s):  
Health Care ◽  
Cost Effectiveness ◽  
Health Care Workers ◽  
Cost Effective ◽  
Cost Effectiveness Analysis ◽  
Health Care Facilities ◽  
Effective Strategy ◽  
Cost Effective Strategy ◽  
Effectiveness Analysis ◽  
Care Workers

The aim of this study was to examine the most cost-effective strategy of screening and vaccinating measles- and varicella-susceptible health care workers (HCWs). A retrospective cost-effectiveness analysis was conducted at a tertiary hospital in Korea with 300 HCWs who were at high risk of infection. Self-reported histories of vaccinations, infectious diseases, and contact with such cases were collected. Serological tests for immunoglobulin G titers of measles and varicella were performed. Data were analyzed using analysis of variance, Kruskal-Wallis test, χ2 test, and Fisher exact test. Seropositivity rates were 96.3% for measles and 95.7% for varicella. Four different strategies (cases) for vaccination were investigated. Considering the progressive decline in antibody concentrations and the false-positive responses in self-reported histories, case 3, which involved administering 2-dose vaccinations to susceptible HCWs demonstrated by antibody screening tests for both measles and varicella, was the most cost-effective strategy. Health care facilities should establish mandatory immunization policies that reduce the risk of transmission of vaccine-preventable diseases.

scholarly journals Analysis of the cost-effectiveness of treatment strategies for CML with incorporation of treatment discontinuation

2019 ◽  
Vol 3 (21) ◽  
pp. 3266-3277 ◽  
Author(s):  
Chihiro Yamamoto ◽  
Hirotomo Nakashima ◽  
Takashi Ikeda ◽  
Shin-ichiro Kawaguchi ◽  
Yumiko Toda ◽  
...  
Keyword(s):  
Cost Effectiveness ◽  
Treatment Strategies ◽  
Cost Effective ◽  
Treatment Discontinuation ◽  
Effective Strategy ◽  
Cost Effective Strategy ◽  
Key Points ◽  
The Cost

Key Points The cost of TKI for treatment of CML can be substantially saved by treatment discontinuation in patients who achieved DMR. Starting treatment with imatinib is the most cost-effective strategy even after incorporation of treatment discontinuation.

scholarly journals Diagnostic yield of genetic tests in epilepsy

Neurology ◽  
2019 ◽  
Vol 92 (5) ◽  
pp. e418-e428 ◽  
Author(s):  
Iván Sánchez Fernández ◽  
Tobias Loddenkemper ◽  
Marina Gaínza-Lein ◽  
Beth Rosen Sheidley ◽  
Annapurna Poduri
Keyword(s):  
Genetic Testing ◽  
Cost Effectiveness ◽  
Publication Bias ◽  
Diagnostic Yield ◽  
Cost Effective ◽  
Effective Strategy ◽  
Genetic Tests ◽  
Cost Effective Strategy ◽  
Testing Strategies ◽  
The Cost

ObjectiveTo compare the cost-effectiveness of genetic testing strategies in patients with epilepsy of unknown etiology.MethodsThis meta-analysis and cost-effectiveness study compared strategies involving 3 genetic tests: chromosomal microarray (CMA), epilepsy panel (EP) with deletion/duplication testing, and whole-exome sequencing (WES) in a cost-effectiveness model, using “no genetic testing” as a point of comparison.ResultsTwenty studies provided information on the diagnostic yield of CMA (8 studies), EP (9 studies), and WES (6 studies). The diagnostic yield was highest for WES: 0.45 (95% confidence interval [CI]: 0.33–0.57) (0.32 [95% CI: 0.22–0.44] adjusting for potential publication bias), followed by EP: 0.23 (95% CI: 0.18–0.29), and CMA: 0.08 (95% CI: 0.06–0.12). The most cost-effective test was WES with an incremental cost-effectiveness ratio (ICER) of $15,000/diagnosis. However, after adjusting for potential publication bias, the most cost-effective test was EP (ICER: $15,848/diagnosis) followed by WES (ICER: $34,500/diagnosis). Among combination strategies, the most cost-effective strategy was WES, then if nondiagnostic, EP, then if nondiagnostic, CMA (ICER: $15,336/diagnosis), although adjusting for potential publication bias, the most cost-effective strategy was EP ± CMA ± WES (ICER: $18,385/diagnosis). While the cost-effectiveness of individual tests and testing strategies overlapped, CMA was consistently less cost-effective than WES and EP.ConclusionWES and EP are the most cost-effective genetic tests for epilepsy. Our analyses support, for a broad population of patients with unexplained epilepsy, starting with these tests. Although less expensive, CMA has lower yield, and its use as the first-tier test is thus not supported from a cost-effectiveness perspective.

scholarly journals Pharmaco Economics Analysis of COVID-19 Vaccines in Ukraine

2021 ◽  
pp. 140-147
Author(s):  
Tsekhmister Yaroslav Volodymyrovych ◽  
Stepanenko Viktor Ivanovich ◽  
Konovalova Tetiana ◽  
Tsekhmister Bogdan Yaroslavovych
Keyword(s):  
Cost Effectiveness ◽  
Cost Effective ◽  
The Elderly ◽  
Transmission Model ◽  
Sample Population ◽  
Group Model ◽  
Effective Strategy ◽  
Vaccine Strategy ◽  
Cost Effective Strategy ◽  
The Cost

Aims: To evaluate pharmacoeconomics for the vaccination of COVID-19 vaccine and analyze the cost-effectiveness for the vaccine in Ukraine. Study design:  we have analyzed using models for the economics of coronavirus vaccine. Place and duration of study: Sample: population of Ukraine, data used from the official website of Ministry of Health, Ukraine. April - May 2021 Methodology: We have used the transmission model to analyze the vaccine strategy. Data were collected from official sources. We structured an age group model for evaluating high transmitters. Four strategies were organized and analyzed for analyzing the cost-effective strategy vaccination for everyone, no vaccination, and vaccination for old age only, high transmitters’ vaccination. Results: we have analyzed country specific cost-effective strategy for Ukraine depends upon the pandemic and economics of the country. Vaccinating older people was found to be the economically effective for Ukraine. In these study influences of discount rate analysis on QALY in Ukraine was done. When we vaccinate, high transmitters’ ratio was found to be 8.8% higher than for the elderly. This analysis suggests that vaccinating first the elderly group would not be so cost-effective. While doubling the cost for the vaccine, if the vaccine is available early with the scenario of pre-existing immunity has shifted cost-effectiveness for high transmitters than for the elderly in Ukraine Conclusion: we conclude from our pharmacoeconomic research study that cost effective analysis depends on pandemic and vaccinating elderly would be effective economically.

Twin Vaginal Deliveries in Labor Rooms: A Cost-Effectiveness Analysis

2021 ◽  
Author(s):  
Jenny Y. Mei ◽  
Divya Mallampati ◽  
Ilina D. Pluym ◽  
Christina S. Han ◽  
Yalda Afshar
Keyword(s):  
Cost Effectiveness ◽  
Cost Effective ◽  
Cost Effectiveness Analysis ◽  
Sensitivity Analyses ◽  
Base Case ◽  
Decision Analysis Model ◽  
Effective Strategy ◽  
Cost Effective Strategy ◽  
Effectiveness Analysis ◽  
Vaginal Deliveries

Objective Twin vaginal deliveries (VDs) are often performed in the operating room (OR) given the theoretical risk of conversion to cesarean delivery (CD) for the aftercoming twin. We aim to evaluate the cost-effectiveness of performing VDs for twin gestations in the labor and delivery room (LDR) versus OR. Study Design We conducted a cost-effectiveness analysis using a decision-analysis model that compared the costs and effectiveness of two strategies of twin deliveries undergoing a trial of labor: (1) intended delivery in the LDR and 2) delivery in the OR. Sensitivity analyses were performed to assess strength and validity of the model. Primary outcome was incremental cost-effectiveness ratio (ICER) defined as cost needed to gain 1 quality-adjusted life year (QALY). Results In the base-case scenario, where 7% of deliveries resulted in conversion to CD for twin B, attempting to deliver twins in the LDR was the most cost-effective strategy. For every QALY gained by delivering in the OR, 243,335 USD would need to be spent (ICER). In univariate sensitivity analyses, the most cost-effective strategy shifted to delivering in the OR when the following was true: (1) probability of successful VD was less than 86%, (2) probability of neonatal morbidity after emergent CD exceeded 3.5%, (3) cost of VD in an LDR exceeded 10,500 USD, (4) cost of CD was less than 10,000 USD, or (5) probability of neonatal death from emergent CD exceeded 2.8%. Assuming a willingness to pay of 100,000 USD per neonatal QALY gained, attempted VD in the LDR was cost effective in 51% of simulations in the Monte Carlo analysis. Conclusion Twin VDs in the LDR are cost effective based on current neonatal outcome data, taking into account gestational age and associated morbidity. Further investigation is needed to elucidate impact of cost and outcomes on optimal utilization of resources. Key Points

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