{"version":"sf-lyon-earlier-testosterone-cea-v1","reviewedAt":"2026-09-07","organization":"Lyon-Martin Community Health Services","program":"Earlier adult testosterone initiation","confidence":"very-low","denominator":"10 incremental QALYs","formula":"10 * costPerSupportedStart / (utilityDifference * waitAvoidedYears * onsetFactor * transferRetention * additionality)","scope":"Proposed acceleration of clinically eligible adults seeking masculinization; not all clinic services, minors, estrogen therapy or surgery.","scenarios":[{"name":"Favorable positive","costPerSupportedStart":250,"utilityDifference":0.14,"waitAvoidedYears":0.25,"onsetFactor":1,"transferRetention":1,"additionality":0.75},{"name":"Central analyst estimate","costPerSupportedStart":1000,"utilityDifference":0.07,"waitAvoidedYears":0.25,"onsetFactor":0.5,"transferRetention":0.5,"additionality":0.5},{"name":"Unfavorable positive","costPerSupportedStart":2000,"utilityDifference":0.01,"waitAvoidedYears":0.08333333333333333,"onsetFactor":0.5,"transferRetention":0.25,"additionality":0.25}],"judgments":[{"key":"costPerSupportedStart","label":"Cost per supported earlier start","basis":"Assumed nominal USD $1,000: three all-in clinical/lab/medication encounter bundles at $250 plus $250 navigation/coordination allocation including unsuccessful engagement. Neither unit price nor utilization is measured locally; no assumed reimbursement savings."},{"key":"utilityDifference","label":"Three-month utility difference","basis":"Nolan 2024 randomized secondary analysis: baseline-adjusted EQ-5D-5L difference 0.07, reported 95% CI −0.07 to 0.21; nonsignificant. UK tariff, short open-label trial. Positive scenario values are not confidence bounds. Preserve reported interval rather than reconstructing one from the inconsistent reported P value."},{"key":"waitAvoidedYears","label":"Wait avoided","basis":"Central three months matches the external trial window; local wait and number of accelerated starts unknown. Credit no benefit beyond three months; not a lifetime treatment estimate."},{"key":"onsetFactor","label":"Within-window benefit onset","basis":"50% assumes a linear ramp from zero to the measured month-three endpoint. Immediate full benefit in the favorable case is a stress assumption, not observed onset."},{"key":"transferRetention","label":"Local transfer retention","basis":"50% judgment for Australian-to-SF care setting and population differences; no local causal utility measurement."},{"key":"additionality","label":"Genuinely accelerated share","basis":"50% judgment for starts actually brought forward by the donor rather than existing insurance/funding or alternative access. Do not credit all scheduled appointments."}],"nullBoundary":"No shortened wait, no additional financing or no utility benefit means no finite positive-benefit price. The utility interval includes harm. Signed utility sensitivity is supported by the model; nonpositive health results are not presented as a positive cost-effectiveness price.","fundingRoom":{"verifiedUsd":null,"status":"unverified","nextEvidence":"A priced adult-testosterone access tranche: current waits, accelerated starts, clinician/pharmacy capacity, reimbursement and restricted-gift allocation."},"excluded":["Benefits beyond month three","Mortality inferred from suicidality scores","Additional depression/dysphoria credit already reflected in utility","Minors, estrogen therapy, surgery, psychotherapy and other primary care"],"sources":[{"publisher":"Lyon-Martin","title":"Healthcare services","url":"https://www.lyon-martin.org/healthcare-services","published":"Undated","retrieved":"2026-09-07","sourceType":"Local prescribing, monitoring and support identity; not marginal unit cost"},{"publisher":"Nolan et al., JAMA Network Open","title":"Testosterone and Quality of Life in Transgender and Gender-Diverse Adults Seeking Masculinization","url":"https://jamanetwork.com/journals/jamanetworkopen/fullarticle/2825347","published":"2024-10-25","retrieved":"2026-09-07","sourceType":"Primary randomized secondary analysis; preference-based utility endpoint, not local effect"},{"publisher":"San Francisco Human Rights Commission","title":"RFP 100 grant agreements for commission approval, p.12","url":"https://media.api.sf.gov/documents/HRC_RFP_100_Grant_Agreement_Commission_Approval_20260209.pdf","published":"2026-02-09","retrieved":"2026-09-07","sourceType":"Proposed mixed integrated-care funding, not a hormone-access budget"},{"publisher":"San Francisco DPH","title":"Contracted programs planning list, rows 292–293","url":"https://media.api.sf.gov/documents/DPH_Contracted_Programs_4-17-26.pdf","published":"2026-04-17","retrieved":"2026-09-07","sourceType":"Dated planning figures; not executed current cuts or private funding room"},{"publisher":"Lyon-Martin","title":"Save Lyon-Martin capital campaign","url":"https://www.savelyonmartin.com/","published":"Undated current campaign","retrieved":"2026-09-07","sourceType":"Prospective multi-service capacity and permanent home; not incremental hormone starts"}],"evaluatedScenarios":[{"name":"Favorable positive","costPerSupportedStart":250,"utilityDifference":0.14,"waitAvoidedYears":0.25,"onsetFactor":1,"transferRetention":1,"additionality":0.75,"qalysPerSupportedStart":0.026250000000000002,"costPerTenQalys":95238.09523809522,"additionalQalys":10.500000000000002},{"name":"Central analyst estimate","costPerSupportedStart":1000,"utilityDifference":0.07,"waitAvoidedYears":0.25,"onsetFactor":0.5,"transferRetention":0.5,"additionality":0.5,"qalysPerSupportedStart":0.0021875,"costPerTenQalys":4571428.571428571,"additionalQalys":0.21875000000000003},{"name":"Unfavorable positive","costPerSupportedStart":2000,"utilityDifference":0.01,"waitAvoidedYears":0.08333333333333333,"onsetFactor":0.5,"transferRetention":0.25,"additionality":0.25,"qalysPerSupportedStart":0.000026041666666666665,"costPerTenQalys":768000000,"additionalQalys":0.0013020833333333333}]}