Cost‐effectiveness of endobronchial valve treatment in patients with severe emphysema compared to standard medical care

Background and objective

Bronchoscopic lung volume reduction using endobronchial valves (EBV) is an effective new treatment option for severe emphysema patients without interlobar collateral ventilation. The objective of this study was to perform an economic evaluation including the costs and cost‐effectiveness of EBV treatment compared with standard medical care (SoC) from the hospital perspective in the short term and long term.

Methods

For the short‐term evaluation, incremental cost‐effectiveness ratios (ICER) were calculated based on the 6‐month end point data from the STELVIO randomized trial. For the long‐term evaluation, a Markov simulation model was constructed based on STELVIO and literature. The clinical outcome data were quality‐adjusted life‐years (QALY) based on the EuroQol5‐Dimensions (EQ5D) questionnaire, the 6‐min walking distance (6MWD) and the St George’s Respiratory Questionnaire (SGRQ).

Results

The mean difference between the EBV group and controls was €16 721/patient. In the short‐term (6 months), costs per additional QALY was €205 129, the ICER for 6MWD was €160 and for SGRQ was €1241. In the long term, the resulting cost‐effectiveness ratios indicate additional costs of €39 000 per QALY gained with a 5‐year time horizon and €21 500 per QALY gained at 10 years. In comparison, historical costs per additional QALY 1 year after the coil treatment are €738 400, 5 years after lung volume reduction surgery are €48 415 and 15 years after double‐lung transplantation are €29 410.

Conclusion

The positive clinical effects of EBV treatment are associated with increased costs compared with SoC. Our results suggest that the EBV treatment has a favourable cost‐effectiveness profile, also when compared with other treatment modalities for this patient group.

     

Cost‐effectiveness analysis of ledipasvir/sofosbuvir in patients with chronic hepatitis C: Treatment of patients with absence or mild fibrosis compared to patients with advanced fibrosis

To evaluate the cost‐effectiveness of ledipasvir/sofosbuvir (LDV/SOF) in treatment‐naïve patients with chronic hepatitis C (CHC) genotype 1 (GT1) in the absence or mild fibrosis (F0‐F1) versus advanced fibrosis (F2‐F4), from the perspective of the Spanish Health System. A Markov model was developed to simulate disease progression, estimating costs and outcomes [life years gained (LYG) and quality‐adjusted life years (QALY)] derived from starting with LDV/SOF in patients with F0‐F1 compared with F2‐F4. Therapy duration was 8 weeks in noncirrhotic patients with viral load <6 million IU/mL and 12 weeks in the remaining patients. Sustained virologic response rates were obtained from real‐world cohort studies. Transition probabilities, utilities and direct costs were obtained from the literature. A 3% annual discount rate was applied to costs and outcomes. Sensitivity analyses were performed. LDV/SOF in F0‐F1 patients was a dominant strategy, being more effective (19.85 LYG and 19.80 QALY) than beginning treatment in F2‐F4 patients (18.63 LYG and 16.25 QALY), generating savings of €9228 per patient (€3661 due to disease management and monitoring). In a cohort of 1000 patients, LDV/SOF in F0‐F1 patients decreased the number of cases of decompensated cirrhosis (93%), hepatocellular carcinoma (97%) and liver‐related deaths (95%) and prevented 6 liver transplants compared to initiating LDV/SOF in F2‐F4 patients. In CHC treatment‐naïve GT1 patients, starting treatment with LDV/SOF in patients with F0‐F1 compared to those with F2‐F4 increases effectiveness by 1.22 LYG and 3.55 QALY gained and reduces disease burden and it is associated with cost savings.     

Cost‐effectiveness of sofosbuvir in the treatment of patients with hepatitis C

In France, 190 306 patients were suffering from chronic hepatitis C in 2012. These patients have a decreased life expectancy and are susceptible to complications associated with chronic hepatitis. Current treatments are poorly tolerated and their effectiveness varies depending on the genotype of the virus. Sofosbuvir, a new class of treatment, has demonstrated in five phase III trials sustained viral response (SVR) rates of over 90% across genotypes, higher than current treatments and has a tolerance profile similar to placebo. The objective was to determine the cost‐effectiveness of using sofosbuvir in the treatment of chronic HCV infection. A Markov model was used to compare treatment strategies with and without sofosbuvir. The model simulated the natural history of HCV infection. SVR rates were based on data from clinical trials. Utilities associated with different stages of disease were based on data from the literature. French direct medical costs were used. Price for sofosbuvir was the price used in the early access program for severe fibrosis stages. The incremental cost–effectiveness ratio for sofosbuvir versus current reference treatments was € 16 278/QALY and varied from 40 000 €/QALY for F0 stages to 12 080 €/QALY for F4 stages. The sensitivity analyses carried out confirmed the robustness of this result. Sofosbuvir is a cost‐effective treatment option for patients with hepatitis C.     

Cost‐effectiveness of elbasvir/grazoprevir use in treatment‐naive and treatment‐experienced patients with hepatitis C virus genotype 1 infection and chronic kidney disease in the United States

Among patients with chronic kidney disease (CKD) in the United States, HCV infection causes significant morbidity and mortality and results in substantial healthcare costs. A once‐daily oral regimen of elbasvir/grazoprevir (EBR/GZR) for 12 weeks was found to be a safe and efficacious treatment for HCV in patients with CKD. We evaluated the cost‐effectiveness of EBR/GZR in treatment‐naïve and treatment‐experienced CKD patients compared with no treatment (NoTx) and pegylated interferon plus ribavirin (peg‐IFN/RBV) using a computer‐based model of the natural history of chronic HCV genotype 1 infection, CKD and liver disease. Data on baseline characteristics of the simulated patients were obtained from NHANES, 2000–2010. Model inputs were estimated from published studies. Cost of treatment with EBR/GZR and peg‐INF/RBV were based on wholesale acquisition cost. All costs were from a third‐party payer perspective and were expressed in 2015 U.S. dollars. We estimated lifetime incidence of liver‐related complications, liver transplantation, kidney transplantation, end‐stage live disease mortality and end‐stage renal disease mortality; lifetime quality‐adjusted life years (QALY); and incremental cost‐utility ratios (ICUR). The model predicted that EBR/GZR will significantly reduce the incidence of liver‐related complications and prolong life in patients with chronic HCV genotype 1 infection and CKD compared with NoTx or use of peg‐IFN/RBV. EBR/GZR‐based regimens resulted in higher average remaining QALYs and higher costs (11.5716, $191 242) compared with NoTx (8.9199, $156 236) or peg‐INF/RBV (10.2857, $186 701). Peg‐IFN/RBV is not cost‐effective, and the ICUR of EBR/GZR compared with NoTx was $13 200/QALY. Treatment of a patient on haemodialysis with EBR/GZR resulted in a higher ICUR ($217 000/QALY). Assuming a threshold of $100 000 per QALY gained for cost‐effectiveness, use of elbasvir/grazoprevir to treat an average patient with CKD can be considered cost‐effective in the United States.     

Cost‐Utility Analysis of High Molecular Weight Hyaluronic Acid for Knee Osteoarthritis in Everyday Clinical Care in Patients at a Working Age: An Economic Evaluation of a Randomized Clinical Trial

Objective

Knee osteoarthritis (OA) is associated with high medical costs and especially with high productivity costs, in particular in patients in their working years. High molecular weight (HMW) hyaluronic acid (HA) is an alternative treatment for nonsteroidal antiinflammatory drugs, which are known for their serious side‐effects. The cost‐utility of intraarticular HMW‐HA treatment in these patients is unknown, however, and was assessed in this study.

Methods

Secondary care patients ages 18–65 years with knee OA were randomized to usual care plus HMW‐HA (intervention group) or to usual care only (control group). A cost‐utility analysis over 52 weeks from the societal and health care perspective was performed. Uncertainty for costs, effects, and cost‐utility ratio was analyzed by nonparametric bootstrapping. Baseline imbalance adjustment was done by inverse probability of treatment weighting.

Results

In total, 156 subjects were included (intervention group n = 77, control group n = 79). The total of productivity and medical costs was €475 higher in the intervention group at €7,754 (95% confidence interval [95% CI] 5,426, 10,436) versus €7,270 (95% CI 5,453, 9,262). The amount of quality‐adjusted life years (QALYs) gained during followup was also higher in the intervention group (0.779 versus 0.727). This variation resulted in an incremental cost‐effectiveness ratio of €9,100/QALY from a societal perspective and €8,700/QALY from a health care perspective. When the maximum willingness to pay for conditions similar to knee OA is considered, the probability on cost‐effectiveness is 64% and 86%, respectively.

Conclusion

Intraarticular HMW‐HA added to usual care for knee OA is probably cost‐effective in the treatment of knee OA.     

The cost‐effectiveness of immediate treatment or watch and wait with deferred chemotherapy for advanced asymptomatic follicular lymphoma

Recent evidence has shown that immediate treatment with rituximab induction, with and without maintenance, substantially reduces the need for further treatment in patients with advanced asymptomatic follicular lymphoma. This analysis estimates the cost‐effectiveness of immediate treatment approaches in comparison to a watch and wait approach from the perspective of the UK National Health Service. A Markov decision model was developed to estimate the cost‐effectiveness of treatment strategies in patients with asymptomatic follicular lymphoma. The model was populated using effectiveness data from a systematic literature review with the key clinical data sourced from a randomised trial, in which the treatment strategies were compared. Costs were estimated using UK national sources. In comparison to watchful waiting, both rituximab strategies were found to be more effective and cost saving. In comparison to rituximab induction, the addition of rituximab maintenance marginally increased effectiveness but substantially increased costs, resulting in an incremental cost‐effectiveness ratio (ICER) of £69 406 per quality‐adjusted life year (QALY). In probabilistic sensitivity analysis, rituximab induction was found to have a 68% probability of being cost‐effective at a threshold of £20 000 per QALY. In conclusion, active treatment with rituximab induction is a cost‐effective strategy to adopt in patients with asymptomatic follicular lymphoma.     

Cost‐effectiveness of personal tailored risk information and taster sessions to increase the uptake of the NHS stop smoking services: the Start2quit randomized controlled trial

Aims

To assess the cost‐effectiveness of a two‐component intervention designed to increase attendance at the NHS Stop Smoking Services (SSSs) in England.

Design

Cost‐effectiveness analysis alongside a randomized controlled trial (Start2quit).

Setting

NHS SSS and general practices in England.

Participants

The study comprised 4384 smokers aged 16 years or more identified from medical records in 99 participating practices, who were motivated to quit and had not attended the SSS in the previous 12 months.

Intervention and comparator

Intervention was a personalized and tailored letter sent from the general practitioner (GP) and a personal invitation and appointment to attend a taster session providing information about SSS. Control was a standard generic letter from the GP advertising SSS and asking smokers to contact the service to make an appointment.

Measurements

Costs measured from an NHS/personal social services perspective, estimated health gains in quality‐adjusted life‐years (QALYs) measured with EQ‐5D and incremental cost per QALY gained during both 6 months and a life‐time horizon.

Findings

During the trial period, the adjusted mean difference in costs was £92 [95% confidence interval (CI) = –£32 to –£216) and the adjusted mean difference in QALY gains was 0.002 (95% CI = –0.001 to 0.004). This generates an incremental cost per QALY gained of £59 401. The probability that the tailored letter and taster session is more cost‐effective than the generic letter at 6 months is never above 50%. In contrast, the discounted life‐time health‐care cost was lower in the intervention group, while the life‐time QALY gains were significantly higher. The probability that the intervention is more cost‐effective is more than 83% using a £20 000–30 000 per QALY‐gained decision‐making threshold.

Conclusions

An intervention designed to increase attendance at the NHS Stop Smoking Services (tailored letter and taster session in the services) appears less likely to be cost‐effective than a generic letter in the short term, but is likely to become more cost‐effective than the generic letter during the long term.     

Cost‐utility and cost‐effectiveness analyses of a long‐term,high‐intensity exercise program compared with conventional physical therapy in patients with rheumatoid arthritis

Objective

To estimate the cost utility and cost effectiveness of long‐term, high‐intensity exercise classes compared with usual care in rheumatoid arthritis (RA) patients.

Methods

RA patients (n = 300) were randomly assigned to either exercise classes or UC; followup lasted for 2 years. Outcome measures were quality‐adjusted life years (QALYs) according to the EuroQol (EQ‐5D), Short Form 6D (SF‐6D), and a transformed visual analog scale (VAS) rating personal health; functional ability according to the Health Assessment Questionnaire (HAQ) and McMaster Toronto Arthritis Patient Preference Interview (MACTAR); and societal costs.

Results

QALYs in both randomization groups were similar according to the EQ‐5D and SF‐6D, but were in favor of usual care according to the VAS (annual difference 0.037 QALY; 95% confidence interval [95% CI] 0.002, 0.069). Functional ability was similar according to the HAQ, but in favor of the exercise classes according to the MACTAR (annual difference 2.9 QALY; 95% CI 0.9, 4.9). Annual medical costs of the exercise program were estimated at €780 per participating patient (€1 ≈ $1.05). The increase per patient in total medical costs of physical therapy was estimated at €430 (95% CI €318, 577), and the increase in total societal costs at €602 (95% CI €?490, 1,664). For societal willingness‐to‐pay equal to €50,000 per QALY, usual care had better cost utility than exercise classes, and significantly so according to the VAS.

Conclusion

From a societal perspective and without taking possible preventive health effects into account, long‐term, high‐intensity exercise classes provide insufficient improvement in the valuation of health to justify the additional costs.

     

Effectiveness and cost‐effectiveness of interventions targeting harm reduction and chronic hepatitis C cascade of care in people who inject drugs: The case of France

Direct‐acting antivirals (DAAs) represent an opportunity to improve hepatitis C virus (HCV) care cascade. This combined with improved harm reduction interventions may lead to HCV elimination especially in people who inject drugs (PWID). We assessed the effectiveness/cost‐effectiveness of improvements in harm reduction and chronic hepatitis C (CHC) care cascade in PWID in France. We used a dynamic model of HCV transmission and CHC natural history and evaluated the following: improved needle/syringe programmes‐opioid substitution therapies, faster diagnosis/linkage to care, earlier treatment initiation, alone and in combination among active PWID (mean age = 36). Outcomes were as follows: life expectancy in discounted quality‐adjusted life years (QALYs); direct lifetime discounted costs; incremental cost‐effectiveness ratio (ICER); number of infections/reinfections. Under the current practice, life expectancy was 15.846 QALYs, for a mean lifetime cost of €20 762. Treatment initiation at F0 fibrosis stage alone was less effective and more costly than faster diagnosis/linkage to care combined with treatment initiation at F0, which increased life expectancy to 16.694 QALYs, decreased new infections by 37%, with a ICER = €5300/QALY. Combining these interventions with harm reduction improvements was the most effective scenario (life expectancy = 16.701 QALYs, 41% decrease in new infections) but was not cost‐effective (ICER = €105 600/QALY); it became cost‐effective with higher initial HCV incidence rates and lower harm reduction coverage than in our base‐case scenario. This study illustrated the high effectiveness, and cost‐effectiveness, of a faster diagnosis/linkage to care together with treatment from F0 with DAAs. This “Test and treat” strategy should play a central role both in improving the life expectancies of HCV‐infected patients, and in reducing HCV transmission.     

Cost‐effectiveness of recombinant activated factor VII vs. plasma‐derived activated prothrombin complex concentrate in the treatment of mild‐to‐moderate bleeding episodes in patients with severe haemophilia A and inhibitors in Spain

Several analyses have shown that recombinant activated factor VII (rFVIIa) is a cost‐effective intervention compared with plasma‐derived activated prothrombin complex concentrate (pd‐aPCC) for the on‐demand treatment of mild‐to‐moderate bleeds in haemophilia patients with inhibitors. The aim of the study was to assess the cost‐effectiveness of rFVIIa vs. pd‐aPCC in the treatment of bleeding episodes in severe haemophilia A patients with inhibitors in Spain. A decision analytic model was designed to evaluate the costs and clinical outcomes of using rFVIIa or pd‐aPCC to treat mild‐to‐moderate joint bleeds in children (≤14 years old) and adults with inhibitors. Data were obtained from a published meta‐analysis and a panel of haemophilia experts. The analysis was conducted from the perspective of the Spanish National Healthcare System. One‐way sensitivity analyses were performed to assess the impact of model assumptions on study results. In the Treur meta‐analysis, rFVIIa resulted in cumulative joint bleed resolution of 88% and 95% after 24 and 36 h, respectively, compared with 62% and 76%, respectively, with pd‐aPCC (Treur et al. Haemophilia 2009; 15 : 420–36). Here, the mean cost per bleed was estimated at €8473 and €15 579 in children and adults treated with rFVIIa, vs. €8627 and €15 677 in children and adults treated with pd‐aPCC. rFVIIa treatment was found to be the dominating option (cheaper and more effective). The one‐way sensitivity analysis also confirmed that rFVIIa was less costly than pd‐aPCC. The model suggests that rFVIIa is a cost‐effective option compared with pd‐aPCC for the treatment of mild‐to‐moderate bleeding episodes in a Spanish setting.     

Análisis coste-efectividad de dos estrategias de tratamiento para la hepatitis C crónica: antes y después del acceso a los agentes antivirales de acción directa en España

Objective

To evaluate the cost-effectiveness of a strategy based on direct-acting antivirals (DAAs) following the marketing of simeprevir and sofosbuvir (post-DAA) versus a pre-direct-acting antiviral strategy (pre-DAA) in patients with chronic hepatitis C, from the perspective of the Spanish National Health System.

Cost effectiveness of combined spa–exercise therapy in ankylosing spondylitis: A randomized controlled trial

Objective

To evaluate the cost effectiveness and cost utility of a 3‐week course of combined spa therapy and exercise therapy in addition to standard treatment consisting of antiinflammatory drugs and weekly group physical therapy in ankylosing spondylitis (AS) patients.

Methods

A total of 120 Dutch outpatients with AS were randomly allocated into 3 groups of 40 patients each. Group 1 was treated in a spa resort in Bad Hofgastein, Austria; group 2 in a spa resort in Arcen, The Netherlands. The control group stayed at home and continued their usual activities and standard treatment during the intervention weeks. After the intervention, all patients followed weekly group physical therapy. The total study period was 40 weeks. Effectiveness of the intervention was assessed by functional ability using the Bath Ankylosing Spondylitis Function Index (BASFI). Utilities were measured with the EuroQoL (EQ‐5D_utility). A time‐integrated summary score defined the clinical effects (BASFI‐area under the curve [AUC]) and utilities (EQ‐5D_utility‐AUC) over time. Both direct (health care and non‐health care) and indirect costs were included. Resource utilization and absence from work were registered weekly by the patients in a diary. All costs were calculated from a societal perspective.

Results

A total of 111 patients completed the diary. The between‐group difference for the BASFI‐AUC was 1.0 (95% confidence interval [95% CI] 0.4–1.6; P = 0.001) for group 1 versus controls, and 0.6 (95% CI 0.1–1.1; P = 0.020) for group 2 versus controls. The between‐group difference for EQ‐5D_utility‐AUC was 0.17 (95% CI 0.09–0.25; P < 0.001) for group 1 versus controls, and 0.08 (95% CI 0.00–0.15; P = 0.04) for group 2 versus controls. The mean total costs per patient (including costs for spa therapy) in Euros (€) during the study period were €3,023 for group 1, €3,240 for group 2, and €1,754 for the control group. The incremental cost‐effectiveness ratio per unit effect gained in functional ability (0–10 scale) was €1,269 (95% CI 497–3,316) for group 1, and €2,477 (95% CI 601–12,098) for group 2. The costs per quality‐adjusted life year gained were €7,465 (95% CI 3,294–14,686) for group 1, and €18,575 (95% CI 3,678–114,257) for group 2.

Conclusion

Combined spa–exercise therapy besides standard treatment with drugs and weekly group physical therapy is more effective and shows favorable cost‐effectiveness and cost‐utility ratios compared with standard treatment alone in patients with AS.

     

The management of type 2 diabetes with fixed‐ratio combination insulin degludec/liraglutide (IDegLira) versus basal‐bolus therapy (insulin glargine U100 plus insulin aspart): A short‐term cost‐effectiveness analysis in the UK setting

Aim

To evaluate the cost‐effectiveness of IDegLira versus basal‐bolus therapy (BBT) with insulin glargine U100 plus up to 4 times daily insulin aspart for the management of type 2 diabetes in the UK.

Methods

A Microsoft Excel model was used to evaluate the cost‐utility of IDegLira versus BBT over a 1‐year time horizon. Clinical input data were taken from the treat‐to‐target DUAL VII trial, conducted in patients unable to achieve adequate glycaemic control (HbA1c <7.0%) with basal insulin, with IDegLira associated with lower rates of hypoglycaemia and reduced body mass index (BMI) in comparison with BBT, with similar HbA1c reductions. Costs (expressed in GBP) and event‐related disutilities were taken from published sources. Extensive sensitivity analyses were performed.

Results

IDegLira was associated with an improvement of 0.05 quality‐adjusted life years (QALYs) versus BBT, due to reductions in non‐severe hypoglycaemic episodes and BMI with IDegLira. Costs were higher with IDegLira by GBP 303 per patient, leading to an incremental cost‐effectiveness ratio (ICER) of GBP 5924 per QALY gained for IDegLira versus BBT. ICERs remained below GBP 20 000 per QALY gained across a range of sensitivity analyses.

Conclusions

IDegLira is a cost‐effective alternative to BBT with insulin glargine U100 plus insulin aspart, providing equivalent glycaemic control with a simpler treatment regimen for patients with type 2 diabetes inadequately controlled on basal insulin in the UK.     

Cost-effectiveness and cost-utility analyses of a web-based computer-tailored intervention for prevention of binge drinking among Spanish adolescents

Background

Binge drinking (BD) among adolescents is a public health concern worldwide. This study assessed the cost-effectiveness and cost-utility of a web-based computer-tailored intervention to prevent BD in adolescence.

Methods

The sample was drawn from a study evaluating the Alerta Alcohol program. The population consisted of adolescents 15 to 19 years of age. Data were recorded at baseline (January to February 2016) and after 4 months (May to June 2017) and were used to estimate costs and health outcomes, as measured by the number of BD occasions and quality-adjusted life years (QALYs). Incremental cost-effectiveness and cost-utility ratios were calculated from National Health Service (NHS) and societal perspectives and for a time horizon of 4 months. A multivariate deterministic sensitivity analysis of best/worst scenarios by subgroups was used to account for uncertainty.

Results

The cost of reducing BD occasions by one per month was €16.63 from the NHS perspective, which from the societal perspective resulted in savings of €7986.37. From the societal perspective, the intervention resulted in an incremental cost of €71.05 per QALY gained from the NHS perspective and this was dominant, resulting in savings of €34,126.64 per QALY gained in comparison with the control group. Subgroup analyses showed that the intervention was dominant for girls from both the perspectives and for individuals 17 years or older from the NHS perspective.

Conclusions

Computer-tailored feedback is a cost-effective way to reduce BD and increase QALYs among adolescents. However, long-term follow-up is needed to evaluate more fully changes in both BD and health-related quality of life.     

An economic evaluation of pregabalin versus usual care in the management of community-treated patients with refractory painful diabetic peripheral neuropathy in primary care settings

ObjectiveTo estimate the cost-effectiveness of pregabalin versus usual care (UC) in the management of community-treated patients with refractory painful diabetic peripheral neuropathy (pDPN) in primary care settings (PCS) in Spain.MethodsData was extracted from a 12-week registry study assessing costs of neuropathic pain in Spain. Pregabalin-naïve outpatients treated with UC or newly prescribed pregabalin were selected for inclusion in the cost-effectiveness analysis. Effectiveness was expressed as quality-adjusted life years (QALY) gain. Perspectives of the Spanish National Health System (NHS) and society (2006) were applied for cost calculations. Results were expressed as incremental cost-effectiveness ratio (ICER). Bootstrapping techniques (10,000 re-samples) were used to obtain the probabilistic ICER and the cost-effectiveness acceptability curve.ResultsA total of 189 patients were included in the economic analysis. Compared with UC, pregabalin was associated with higher QALY gain in a period of 12-weeks; 0.0406 ± 0.0343 versus 0.0285 ± 0.0350 (p = 0.167). Overall total costs (€1368 ± 1229 vs. €1258 ± 1474; p = 0.587) and healthcare costs (€628 ± 590 vs. €469 ± 420; p = 0.134) were similar for both pregabalin and UC, respectively. ICERs for pregabalin varied from €5302 (95% CI: dominant; €144,105) for total costs to €14,381 (dominant; €115,648) for healthcare costs. Probabilistic sensitivity analyses showed that 79–84% of ICERs were below the threshold of €30,000/QALY.ConclusionThis study suggests that pregabalin may be cost-effective in the management of community-treated refractory outpatients, with pDPN when compared with usual care in the primary care setting in Spain. These findings may help policy makers when making health decision in the management of diabetes in the community.     

Cost‐utility analysis of treatment strategies in patients with recent‐onset rheumatoid arthritis

Objective

To evaluate societal costs and quality‐adjusted life years (QALYs) of treatment strategies for patients with recent‐onset active rheumatoid arthritis (RA).

Methods

Patients (n = 508) were randomly allocated to 1 of 4 treatment strategy groups: sequential monotherapy, step‐up combination therapy, initial combination therapy with prednisone, or initial combination therapy with infliximab. For 2 years, patients reported cost and utility measures.

Results

Average QALYs (ideally 2.00) for groups 1–4 were 1.29, 1.31, 1.32, and 1.41, respectively, for the British EuroQol (P ≤ 0.05 for group 4 versus groups 1–3); 1.41, 1.43, 1.44, and 1.52, respectively, for the Dutch EuroQol (P ≤ 0.05 for group 4 versus groups 1–3); and 1.38, 1.38, 1.39, and 1.44, respectively, for the Short Form 6D (P ≤ 0.05 for group 4 versus groups 1–3). The Time Trade‐Off showed no significant differences. In the primary analysis, using the friction cost method to value productivity, the cost‐utility ratio for group 4 against the next best alternative was estimated at €130,000 (95% confidence interval €27,000, €3,000,000) per QALY. Using the human capital method, the value of sustained productivity in group 4 largely compensated for the extra medication costs.

Conclusion

Initial combination therapy with infliximab for patients with recent‐onset active RA resulted in significantly better quality of life than other strategies. Using the friction cost method, costs to achieve this improvement are generally considered too high, and initial combination therapy with prednisone should be preferred. However, depending on the extent to which productivity is valued, infliximab costs could be largely compensated for by savings on productivity. Since patterns of infliximab use had not yet stabilized after 2 years, longer followup may change the economic conclusions.     

Cost‐Effectiveness of Maintenance Hemodialysis in Japan

The cost‐effectiveness according to primary disease or dialysis duration has never been analyzed with respect to maintenance hemodialysis (MHD). Study candidates were > 20 years of age and had received hemodialysis for at least 6 months. Hemodialysis patients were prospectively observed for 36 months, and patient utility was assessed based on the Euro‐QOL 5‐dimensions (EQ‐5D), from which the quality adjusted life years (QALYs) were estimated. Medical costs were calculated based on medical service fees. The cost‐effectiveness defined as the incremental cost utility ratio (ICUR) was analyzed from a social perspective. A total of 29 patients (mean age; 59.9 ± 13.1 years) undergoing 437 dialysis sessions were analyzed. Utility based upon the EQ‐5D score was 0.75 ± 0.21, and the estimated total medical cost for one year of MHD treatment was 4.52 ± 0.88 US$10 000. ICUR was 6.88 ± 4.47 US$10 000/QALY on average, and when comparing ICUR based on the causes of kidney failure, the value for diabetic nephropathy was found to be higher than that for glomerulonephritis (8.17 ± 6.28 vs. 6.82 ± 4.07). ICUR after 36 months observation increased mainly in the patients below 65 years of age (All; P < 0.05, <65; P < 0.01, 65≤; not significant). MHD is a treatment that could improve the socioeconomic state of elderly patients with end‐stage kidney disease (ESKD), but the ICUR for diabetic nephropathy was higher than that for glomerulonephritis.     

¿El uso de edoxabán sería coste-efectivo para la prevención del ictus y la embolia sistémica en pacientes con fibrilación auricular no valvular en España?

Introduction and objectives

To assess the cost-effectiveness of edoxaban vs acenocoumarol in the prevention of stroke and systemic embolism in patients with nonvalvular atrial fibrillation (NVAF) in Spain.

Cost‐effectiveness and budget impact of interferon‐free direct‐acting antiviral‐based regimens for hepatitis C treatment: the French case

We evaluated the cost‐effectiveness and the budget impact of new DAA‐based regimen use in France. A Markov model simulated chronic hepatitis C (CHC) treatment interventions with IFN‐based and IFN‐free regimens at stage of fibrosis ≥F3, ≥F2 or regardless of fibrosis stage, and treatment either with the least or the most expensive combination. It estimated quality‐adjusted life years (QALYs) and incremental cost‐effectiveness ratios (ICERs). It also assessed the budget impact over 5 years of treating all CHC‐screened patients, regardless of fibrosis, assuming ≤20 000 patients treated/year and priority to ≥F3. Sensitivity analyses were also conducted. For genotypes (G) 1–4, the initiation of IFN‐free regardless of fibrosis was a cost‐effective strategy compared to prior standard of care (SOC) initiated at stage F2: €40 400–88 300/QALY gained in G1; similar results were obtained for patients infected with G4. Considering G2–3, the most cost‐effective strategy was IFN‐based regimens regardless of fibrosis compared to prior SOC initiated at stage F2: €21 300 and €19 400/QALY gained, respectively; the strategy with IFN‐free regimens being more effective but not cost‐effective at current costs. The budget impact of treating all CHC‐screened patients over 5 years would range between 3.5 and 7.2 billion €, depending on whether one considers the least or the most expensive combination of new DAAs and whether one treats G2–3 with IFN‐based or IFN‐free new DAAs. In France, treatment initiation with new DDAs regardless of fibrosis stage is cost‐effective, but would add 3.5–7.2 billion € to an already overburdened medical care system.     

Cost‐effectiveness analyses of anti‐hepatitis C virus treatments using quality of life scoring among patients with chronic liver disease in Hiroshima prefecture,Japan

Aim

We estimated the cost‐effectiveness of direct‐acting antiviral treatment (DAA) compared to triple therapy (simeprevir, pegylated interferon‐α [Peg‐IFN], and ribavirin [RBV]) (scenario 1), Peg‐IFN + RBV (scenario 2), and non‐antiviral therapy (scenario 3).

Methods

Cost‐effectiveness was evaluated as incremental cost‐effectiveness ratios (ICERs) using direct costs and indirect costs, which included loss of wages during the patient's lifetime due to early death caused by viral hepatitis infection. Quality of life (QOL) scores were determined by EQ‐5D‐3L questionnaire survey on 200 HCV patients in Hiroshima.

Results

The QOL scores for chronic hepatitis, liver cirrhosis, and hepatocellular carcinoma were estimated as 0.871, 0.774, and 0.780, respectively. The follow‐up period that the ICER of scenario 1 becomes shortest (cost <¥6 million) was 25 years after treatment in men and women who started treatment at the age of 20–60. In contrast, those of scenarios 2 and 3 was 10 years after treatment in patients who started treatment at age <80 years. Based on the sensitivity analysis in scenario 1, the most significant factor affecting the value of ICER is the QOL score after sustained virologic response (SVR), followed by the SVR rate of DAA or follow‐up period.

Conclusions

Direct‐acting antiviral treatment was estimated to be cost‐effective from 10 to 25 years after treatment, depending on the SVR rate of the drugs and the age of onset of treatment. In order to increase the cost‐effectiveness of DAA treatment, measures or effort to improve the QOL score of patients after SVR are necessary.