Cost-utility Analysis of Screening for Diabetic Retinopathy in Japan: A Probabilistic Markov Modeling Study

ABSTRACT

Purpose: To evaluate the cost-effectiveness for a screening interval longer than 1 year detecting diabetic retinopathy (DR) through the estimation of incremental costs per quality-adjusted life year (QALY) based on the best available clinical data in Japan.

Methods: A Markov model with a probabilistic cohort analysis was framed to calculate incremental costs per QALY gained by implementing a screening program detecting DR in Japan. A 1-year cycle length and population size of 50,000 with a 50-year time horizon (age 40–90 years) was used. Best available clinical data from publications and national surveillance data was used, and a model was designed including current diagnosis and management of DR with corresponding visual outcomes. One-way and probabilistic sensitivity analyses were performed considering uncertainties in the parameters.

Results: In the base-case analysis, the strategy with a screening program resulted in an incremental cost of 5,147 Japanese yen (¥; US$64.6) and incremental effectiveness of 0.0054 QALYs per person screened. The incremental cost-effectiveness ratio was ¥944,981 (US$11,857) per QALY. The simulation suggested that screening would result in a significant reduction in blindness in people aged 40 years or over (?16%). Sensitivity analyses suggested that in order to achieve both reductions in blindness and cost-effectiveness in Japan, the screening program should screen those aged 53–84 years, at intervals of 3 years or less.

Conclusions: An eye screening program in Japan would be cost-effective in detecting DR and preventing blindness from DR, even allowing for the uncertainties in estimates of costs, utility, and current management of DR.     

Cost-effectiveness of stent-retriever thrombectomy in large vessel occlusion strokes of the anterior circulation: Analysis from the French societal perspective

ObjectivesTo determine the cost-effectiveness of stent retriever thrombectomy (SRT) added to standard of care (SOC) in large vessel occlusion (LVO) strokes, adopting the French societal perspective given the lack of published studies with such perspective.MethodsWe developed an hybrid model (decision tree until one year post-stroke followed by a Markov model from one year onward). The time horizon was 20 years. We calculated transition probabilities across the modified Rankin Scale (mRS) based on a published meta-analysis. The main outcome measure was quality adjusted life-years (QALYs) gained. Resources and input costs were derived from a literature search. We calculated the incremental cost-effectiveness ratio (ICER) expressed as cost/QALY. We used 1-way deterministic and probabilistic sensitivity analysis (PSA) to evaluate the model uncertainty.ResultsIn the base-case, adding SRT to SOC resulted in increased effectiveness of 0.73 QALY while total costs were reduced by 3,874€ (ICER of −5,400€/QALY). In the scenario analysis adopting the French healthcare system perspective, the ICER was 4,901€/QALY. Parameters the most influential were the relative risks of SRT over SOC for 90-days mortality and for 90-days mRS 0–2, and the time horizon. PSA showed the 95% confidence interval of the ICER was −21,324 to 4,591€/QALY, with SRT having 85.5% chance to be dominant and 100% to be cost-effective at a threshold of 50,000€/QALY.ConclusionSRT was dominant from a French societal perspective, from 9 years post-stroke onwards. Cost-effectiveness of SRT added to SOC becomes undisputable with evidences from payer and societal viewpoints.     

A cost-utility analysis of once daily solifenacin compared to tolterodine in the treatment of overactive bladder syndrome

ABSTRACT

Objective: To evaluate the cost-utility of solifenacin, a new generation antimuscarinic, compared with tolterodine in the treatment of overactive bladder syndrome (OAB), from the perspective of the UK National Health Service (NHS).

Research design and methods: A 1-year Markov model was constructed using data from a 12-week, randomised, double-blind study that compared flexible dosing with solifenacin (5?mg and 10?mg) with tolterodine (IR 2?mg bd/ER 4?mg) in adults with OAB. The model incorporated five discrete health states that were based on disease severity (micturitions/day and incontinence episodes/day). A ‘drop out’ state was also used in the model to account for patients that discontinued treatment in the first year. UK-specific costs for drug treatment and pad use as well as utilities were assigned to each health state.

Results: Solifenacin was a less costly and more effective treatment strategy compared with tolterodine. During the course of 1 year, the estimated cost per patient was £509 for patients treated with solifenacin and £526 for those given tolterodine, a cost saving of £17 per patient. Treatment with solifenacin was also associated with a small incremental gain of 0.004 quality-adjusted-life-years (QALYs) over tolterodine. Sensitivity analysis suggests that the incremental cost effectiveness of solifenacin relative to tolterodine does not appear to exceed £30?000/QALY with even large variations in key model parameters.

Conclusion: Flexible dosing with solifenacin is likely to be cost-effective versus tolterodine in the treatment of OAB. Further studies are needed to confirm these results.     

Developing an Algorithm to Convert Routine Measures of Vision into Utility Values for Glaucoma

Purpose: Measures of quality of life called utility values (UVs) are needed to deliver the most cost-effective health care for glaucoma patients. UVs are rarely measured in clinical research and practice whereas clinical outcomes such as visual field are routinely collected. The aim of this study was to develop an algorithm that calculates UVs directly from combinations of routine measures of binocular visual field, visual acuity, and contrast sensitivity.

Methods: A total of 132 outpatients with primary open angle glaucoma were recruited. The Time Trade-off (TTO) question was administered during face-to-face interviews. Binocular ETDRS logMAR visual acuity (VA_B), binocular Pelli-Robson contrast sensitivity (CS_B), and Humphrey 24-2 monocular visual field tests were performed on the same day. Integrated (binocular) visual field (IVF) scores were derived. Tobit regression analyses were used to model utility values based on combinations of IVF, VA_B, CS_B and other controlling factors.

Results: UVs recorded for 123 cases correlated significantly with both clinical measures of binocular visual function (r?=??0.47, IVF; r?=??0.48, VA_B; r?=?0.50, CS_B; P <0.0001) and measures of vision-specific quality of life (r?=?0.54–0.6, P <0.0001). Two final models incorporate terms for IVF and VA_B, with or without living arrangements, and explain 22% and 31% of variation in utilities. CS_B was not included in either model due to co-linearity between CS_B and VA_B confounding the models.

Conclusion: The models provide preliminary algorithms for predicting the expected UVs for glaucoma populations directly from clinical outcomes collected routinely in clinical practice.     

Depression and pain: An appraisal of cost effectiveness and cost utility of antidepressants

BackgroundAlthough depression and chronic pain frequently co-occur, there is a lack of clarity in the literature regarding the cost-effectiveness and cost-utility of antidepressants in the presence of these two conditions. From the perspective of healthcare provider, the current study aims to compare the cost-effectiveness and cost-utility of antidepressants in a national cohort of depressed patients with and without comorbid pain conditions.MethodsAdult patients prescribed with antidepressants for depression were identified from the National Health Insurance Research Database in Taiwan (n = 96,501). By using remission as effectiveness measure and quality-adjusted life years (QALYs) as utility measure, the cost-effectiveness and cost-utility were compared across selective serotonin reuptake inhibitors (SSRIs), serotonin norepinephrine reuptake inhibitors (SNRIs), and tricyclic antidepressants (TCAs), as well as by the presence of comorbid painful physical symptoms (PPS).ResultsSSRIs dominated SNRIs in both the cost-effectiveness and cost-utility regardless of comorbid PPS. In comparison with TCAs, SSRIs were likely to be the cost-effective option for patients without PPS. In patients with PPS, the cost-utility advantage for SSRIs over TCAs varied with threshold willingness-to-pay levels. Comorbid PPS may be considered an effect modifier of the cost-utility comparisons between SSRIs and TCAs.ConclusionsFor depressed patients without PPS, SSRIs are likely to be cost-effective in improving remission rates and QALYs compared to TCAs and SNRIs. However, to improve cost-utility in those with comorbid PPS, people need to choose between SSRIs and TCAs according to threshold willingness-to-pay levels. Future research is warranted to clarify the impacts of different pain conditions on the economic evaluations of pharmacological treatments in patients with depression.     

De novo cost-utility analysis of oral paliperidone in the treatment of schizoaffective disorder

ObjectivesThe aim of this analysis is to compare costs and effectiveness of paliperidone ER vs. placebo in the treatment of schizoaffective disorder (SAD) in the Czech Republic based on pooled clinical trial data.MethodsA de novo micro-simulation model was developed to assess the cost-utility analysis of paliperidone vs. placebo as there is lack of clinical data comparing paliperidone to other interventions. There are no studies primarily evaluating the efficacy of treatment of SAD with other antipsychotics. The model estimated effectiveness and costs of patients with SAD every week during 24-week time horizon. The effectiveness was defined as improvement of a patient's PANSS score where utilities were assigned to each modelled PANSS score. Based on the patient level data a linear mixed-effects model was used to estimate the regression equations of percentage decrease of PANSS score from the baseline. Utilities were computed using a regression function of patients' age, sex and PANSS score, which was adapted from a clinical study of patients with schizophrenia as there are no QoL data on SAD patients. Among relevant costs, reflecting the payer's perspective, costs of pharmacotherapy, concomitant medications and outpatient care were considered.ResultsThe average ICER of paliperidone compared to placebo reached 28,935 EUR/QALY. The probability of paliperidone being cost-effective compared to placebo was 99.5%.ConclusionsTreatment of SAD with paliperidone results in acceptable ICER and high probability of being cost-effective compared to placebo. Thus, it can be considered as a cost-effective treatment of patients with SAD in the Czech Republic.     

肺移植与肺减容术治疗终末期肺气肿的疗效分析

目的探讨肺移植和肺减容手术(LVRS)治疗终末期肺气肿患者的临床疗效及卫生经济学指标,为临床选择治疗方案提供参考。方法回顾性分析自2002年9月至2008年8月无锡市人民医院61例终末期肺气肿患者行LVRS和肺移植术治疗的临床资料,根据手术方式不同将61例患者分为3组,LVRS组:39例,行单侧肺减容术;单肺移植术(SLTx)组:14例,行SLTx;双肺移植术(BLTx)组:8例,行BLTx。于围术期、术后6个月、1年和3年住院复查肺功能、血气分析指标、6 min步行距离(6-MWD)的改变,观察1年、3年生存率。并通过成本-效用分析进行卫生经济学评价。结果术后6个月、1年和3年LVRS组、SLTx组和BLTx组FEV1.0较术前分别改善75%、83%和49%,176%、162%和100%,260%、280%和198%;LVRS组、SLTx组和BLTx组FVC分别较术前改善21%、41%和40%,68%、73%和55%,82%、79%和89%;LVRS组、SLTx组和BLTx组6-MWD分别较术前增加75%、136%和111%,513%、677%和608%,762%、880%和741%。LVRS组、SLTx组和BLTx组患者1年、3年生存率分别为74.40%和58.90%,85.80%和64.30%,62.50%和50.00%。SLTx组随访3年的成本-效用比高于BLTx组(1 668.00 vs.1 168.55,P<0.05)和LVRS组(1 668.00 vs.549.46,P<0.05)。结论 SLTx、BLTx组术后各项功能指标较LVRS组明显改善。3年内成本-效用分析结果表明,LVRS组更经济、实惠。随着医疗技术的进步、移植医疗费用的降低、免疫抑制剂的国产化价格降低,肺移植总费用也随之降低,肺移植术将成为终末期肺气肿患者首选的外科治疗方法。