Table A14:

Assessment of the Limitations of Canada-Based Studies Evaluating the Cost-Effectiveness of rTMS

Author, Year, Country	Does the model structure adequately reflect the nature of the health condition under evaluation?	Is the time horizon sufficiently long to reflect all important differences in costs and outcomes?	Are all important and relevant health outcomes included?	Are the clinical inputsa obtained from the best available sources?	Do the clinical inputsa match the estimates contained in the clinical sources?	Are all important and relevant (direct) costs included in the analysis?	Are the estimates of resource use obtained from the best available sources?	Are the unit costs of resources obtained from the best available sources?	Is an appropriate incremental analysis presented, or can it be calculated from the reported data?	Are all important and uncertain parameters subjected to appropriate sensitivity analysis?	Is there a potential conflict of interest?	Overall Judgmentb
Fitzgibbon et al, 2019,143 Canada (Ontario)	Yes (6-mo cycle for total of 164 cycles of a lifetime model. Main clinical states (acute treatment, remission, relapse, maintenance, and death were included	Yes. Lifetime horizon was applied	Yes	Yes (didn't use relative effects, but all efficacy inputs were obtained from meta-analysis of RCTs)	Yes	Yes	Yes (used Ontario sources)	Yes	Yes	Yes	No	Minor limitations
Health Quality Ontario, 2014 (published 2016),13 Canadad	Yes (12 monthly cycles due to unavailability of valid long-term clinical data, main clinical states (e.g., acute treatment with adverse events, remission, relapse, and death)	No. Time horizon is 1 y due to unavailability of long-term clinical data. No long-term costs and outcomes were captured	Yes	Yes (didn't use relative effects, but all efficacy inputs were obtained from meta-analysis of RCTs)	Yes	Yes	Yes (used Ontario sources)	Yes	Yes	Yes	No	Minor limitations
University of Calgary, 201434 (Alberta), Canada	Yes (3- to 6- week time horizon and, given unavailability of valid long-term data on effectiveness, only response and remission data were included)	No. Time horizon is 3–6 weeks (longest duration of follow-up reported in RCTs assessing clinical effectiveness). No long-term costs and outcomes were captured	Yes	Yes (relative effects of rTMS were obtained from meta-analysis of RCTs)	Yes	Yes	Yes (used Alberta sources)	Yes	Yes	Yes	No	Minor limitations

Abbreviations: RCT, randomized controlled trial; rTMS, repetitive transcranial magnetic stimulation.

Note: Response options for all items were “yes,” “partially,” “no,” “unclear,” and “NA” (not applicable).

^aClinical inputs include relative treatment effects, natural history, and utilities.

^bOverall judgment could be “minor limitations,” “potentially serious limitations,” or “very serious limitations.”