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Ademi Z, Norman R, Pang J, Sijbrands E, Watts GF, Hutten BA, Wiegman A. Cost-effectiveness and Return on Investment of a Nationwide Case-Finding Program for Familial Hypercholesterolemia in Children in the Netherlands. JAMA Pediatr 2023; 177:625-632. [PMID: 37126315 PMCID: PMC10152372 DOI: 10.1001/jamapediatrics.2023.0763] [Citation(s) in RCA: 11] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/14/2022] [Accepted: 02/02/2023] [Indexed: 05/02/2023]
Abstract
Importance The Netherlands is one of the few countries that has a long-term history of active screening for familial hypercholesterolemia (FH), enabling health-economic analyses. Objective To investigate cost-effectiveness and the return on investment (ROI) of a nationwide cascade case-finding and preventive treatment program starting with identification of FH in children and treatment, from both a societal and health care perspective. Design, Setting, and Participants Cascade case-finding and early preventive treatment were modeled to simulate the progression of disease and costs of 10-year-olds suspected of having heterozygous FH over a lifetime. The model consisted of 3 health states: alive without coronary heart disease (CHD), alive with CHD, and deceased. Mendelian randomization analysis was used to quantify the risk of a first CHD event as a function of age and total lifetime exposure to low-density lipoprotein cholesterol. Cost-effectiveness was defined as €20 000 ($21 800) per QALYs (quality-adjusted life-years) gained, using incremental cost-effectiveness ratios (ICERs). All future benefits and costs were discounted annually by 1.5% and 4%, respectively. Interventions The study compared 2 strategies: (1) cascade screening and initiation of treatment with statins in children (mean age, 10 years) and (2) no screening, later detection, and treatment. Main Outcomes and Measures Outcome of interest included cost, detection, and successful treatment of FH in terms of life-years gained and QALYs. The clinical and cost outputs for each model in the 2 scenarios (early detection and treatment and later detection and treatment) were totaled to determine the overall cost-effectiveness and ROI attributed to implementation of the Dutch FH program. Results In this model constructed to simulate the progression of FH in 1000 hypothetical 10-year-olds, from a health care perspective, the program would gain 2.53 QALYs per person, at an additional cost of €23 365 ($25 468) (both discounted). These equated to an ICER of €9220 ($10 050) per QALY gained. From the societal perspective, the detection and treatment program were cost saving over a lifetime compared with no cascade screening for FH. The ROI for the detection and treatment program for FH in children was €8.37 ($9.12). Conclusions and Relevance The findings of this study suggest that the early detection and treatment program for FH in children may offer a good value for investment, being both health and cost saving. The findings and interpretations are conditional on assumptions inherent in the health economic model.
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Affiliation(s)
- Zanfina Ademi
- Centre for Medicine Use and Safety, Faculty of Pharmacy and Pharmaceutical Sciences, Monash University, Melbourne, Victoria, Australia
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
| | - Richard Norman
- School of Population Health, Curtin University, Perth, Western Australia, Australia
| | - Jing Pang
- School of Medicine, University of Western Australia, Crawley, Western Australia, Australia
| | | | - Gerald F. Watts
- School of Medicine, University of Western Australia, Crawley, Western Australia, Australia
- Departments of Cardiology and Internal Medicine, Royal Perth Hospital, Perth, Western Australia, Australia
| | - Barbara A. Hutten
- Department of Epidemiology and Data Science, Amsterdam Cardiovascular Sciences, Amsterdam UMC location AMC, University of Amsterdam, Amsterdam, the Netherlands
| | - Albert Wiegman
- Department of Paediatrics, Amsterdam UMC location University of Amsterdam, Amsterdam, the Netherlands
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Serné EH, Roze S, Buompensiere MI, Valentine WJ, De Portu S, de Valk HW. Cost-Effectiveness of Hybrid Closed Loop Insulin Pumps Versus Multiple Daily Injections Plus Intermittently Scanned Glucose Monitoring in People With Type 1 Diabetes in The Netherlands. Adv Ther 2022; 39:1844-1856. [PMID: 35226346 DOI: 10.1007/s12325-022-02058-9] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2021] [Accepted: 01/24/2022] [Indexed: 12/26/2022]
Abstract
INTRODUCTION Hybrid closed loop (HCL) insulin pump systems and intermittently scanned continuous glucose monitoring (IS-CGM) are increasingly used by individuals with type 1 diabetes (T1D). The aim of the analysis was to compare the long-term cost-effectiveness of the MiniMed 670G HCL system versus IS-CGM plus multiple daily injections of insulin (MDI) or continuous subcutaneous insulin infusion (CSII) in adults with T1D in the Netherlands. METHODS The analysis was performed using the IQVIA CORE Diabetes Model with clinical input data sourced from observational studies. Simulated patients were assumed to have a baseline HbA1c of 7.8%. Use of the MiniMed 670G system was assumed to reduce HbA1c by 0.4% and confer a quality-of-life (QoL) benefit through reduced fear of hypoglycemia (FoH). The analysis was performed from a societal perspective over a lifetime time horizon; future costs and clinical outcomes pertaining to the Netherlands were used and discounted at 4% and 1.5% per annum, respectively. RESULTS Use of the MiniMed 670G HCL system was projected to improve mean quality-adjusted life expectancy by 2.231 quality-adjusted life years (QALYs) versus IS-CGM. Total mean lifetime costs were EUR 13,683 higher with the MiniMed 670G system resulting in an ICER of EUR 6133 per QALY gained. Sensitivity analyses revealed findings to be sensitive to changes in assumptions around severe hypoglycemic event rates and the (QoL) benefit associated with reduced FoH. CONCLUSIONS Over patient lifetimes, for adults with long-standing T1D in the Netherlands, use of the MiniMed 670G system is projected to be cost-effective versus IS-CGM plus MDI or CSII.
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Affiliation(s)
| | | | | | - William J Valentine
- Ossian Health Economics and Communications GmbH, Bäumleingasse 20, 4051, Basel, Switzerland.
| | - Simona De Portu
- Medtronic International Trading Sàrl, Tolochenaz, Switzerland
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Siegel KR, Ali MK, Zhou X, Ng BP, Jawanda S, Proia K, Zhang X, Gregg EW, Albright AL, Zhang P. Cost-effectiveness of Interventions to Manage Diabetes: Has the Evidence Changed Since 2008? Diabetes Care 2020; 43:1557-1592. [PMID: 33534729 DOI: 10.2337/dci20-0017] [Citation(s) in RCA: 92] [Impact Index Per Article: 23.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/23/2020] [Accepted: 04/03/2020] [Indexed: 02/03/2023]
Abstract
OBJECTIVE To synthesize updated evidence on the cost-effectiveness (CE) of interventions to manage diabetes, its complications, and comorbidities. RESEARCH DESIGN AND METHODS We conducted a systematic literature review of studies from high-income countries evaluating the CE of diabetes management interventions recommended by the American Diabetes Association (ADA) and published in English between June 2008 and July 2017. We also incorporated studies from a previous CE review from the period 1985-2008. We classified the interventions based on their strength of evidence (strong, supportive, or uncertain) and levels of CE: cost-saving (more health benefit at a lower cost), very cost-effective (≤$25,000 per life year gained [LYG] or quality-adjusted life year [QALY]), cost-effective ($25,001-$50,000 per LYG or QALY), marginally cost-effective ($50,001-$100,000 per LYG or QALY), or not cost-effective (>$100,000 per LYG or QALY). Costs were measured in 2017 U.S. dollars. RESULTS Seventy-three new studies met our inclusion criteria. These were combined with 49 studies from the previous review to yield 122 studies over the period 1985-2017. A large majority of the ADA-recommended interventions remain cost-effective. Specifically, we found strong evidence that the following ADA-recommended interventions are cost-saving or very cost-effective: In the cost-saving category are 1) ACE inhibitor (ACEI)/angiotensin receptor blocker (ARB) therapy for intensive hypertension management compared with standard hypertension management, 2) ACEI/ARB therapy to prevent chronic kidney disease and/or end-stage renal disease in people with albuminuria compared with no ACEI/ARB therapy, 3) comprehensive foot care and patient education to prevent and treat foot ulcers among those at moderate/high risk of developing foot ulcers, 4) telemedicine for diabetic retinopathy screening compared with office screening, and 5) bariatric surgery compared with no surgery for individuals with type 2 diabetes (T2D) and obesity (BMI ≥30 kg/m2). In the very cost-effective category are 1) intensive glycemic management (targeting A1C <7%) compared with conventional glycemic management (targeting an A1C level of 8-10%) for individuals with newly diagnosed T2D, 2) multicomponent interventions (involving behavior change/education and pharmacological therapy targeting hyperglycemia, hypertension, dyslipidemia, microalbuminuria, nephropathy/retinopathy, secondary prevention of cardiovascular disease with aspirin) compared with usual care, 3) statin therapy compared with no statin therapy for individuals with T2D and history of cardiovascular disease, 4) diabetes self-management education and support compared with usual care, 5) T2D screening every 3 years starting at age 45 years compared with no screening, 6) integrated, patient-centered care compared with usual care, 7) smoking cessation compared with no smoking cessation, 8) daily aspirin use as primary prevention for cardiovascular complications compared with usual care, 9) self-monitoring of blood glucose three times per day compared with once per day among those using insulin, 10) intensive glycemic management compared with conventional insulin therapy for T2D among adults aged ≥50 years, and 11) collaborative care for depression compared with usual care. CONCLUSIONS Complementing professional treatment recommendations, our systematic review provides an updated understanding of the potential value of interventions to manage diabetes and its complications and can assist clinicians and payers in prioritizing interventions and health care resources.
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Affiliation(s)
- Karen R Siegel
- Division of Diabetes Translation, Centers for Disease Control and Prevention, Atlanta, GA
| | - Mohammed K Ali
- Division of Diabetes Translation, Centers for Disease Control and Prevention, Atlanta, GA.,Hubert Department of Global Health and Department of Family and Preventive Medicine, Emory University, Atlanta, GA
| | - Xilin Zhou
- Division of Diabetes Translation, Centers for Disease Control and Prevention, Atlanta, GA
| | - Boon Peng Ng
- Division of Diabetes Translation, Centers for Disease Control and Prevention, Atlanta, GA.,College of Nursing and Disability, Aging and Technology Cluster, University of Central Florida, Orlando, FL
| | - Shawn Jawanda
- Division of Diabetes Translation, Centers for Disease Control and Prevention, Atlanta, GA
| | - Krista Proia
- Division of Diabetes Translation, Centers for Disease Control and Prevention, Atlanta, GA
| | - Xuanping Zhang
- Division of Diabetes Translation, Centers for Disease Control and Prevention, Atlanta, GA
| | - Edward W Gregg
- Division of Diabetes Translation, Centers for Disease Control and Prevention, Atlanta, GA
| | - Ann L Albright
- Division of Diabetes Translation, Centers for Disease Control and Prevention, Atlanta, GA
| | - Ping Zhang
- Division of Diabetes Translation, Centers for Disease Control and Prevention, Atlanta, GA
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van Schoonhoven AV, Gout-Zwart JJ, de Vries MJS, van Asselt ADI, Dvortsin E, Vemer P, van Boven JFM, Postma MJ. Costs of clinical events in type 2 diabetes mellitus patients in the Netherlands: A systematic review. PLoS One 2019; 14:e0221856. [PMID: 31490989 PMCID: PMC6730996 DOI: 10.1371/journal.pone.0221856] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2018] [Accepted: 08/18/2019] [Indexed: 01/14/2023] Open
Abstract
BACKGROUND Type 2 diabetes mellitus (T2DM) is an established risk factor for cardiovascular and nephropathic events. In the Netherlands, prevalence of T2DM is expected to be as high as 8% by 2025. This will result in significant clinical and economic impact, highlighting the need for well-informed reimbursement decisions for new treatments. However, availability and consistent use of costing methodologies is limited. OBJECTIVE We aimed to systematically review recent costing data for T2DM-related cardiovascular and nephropathic events in the Netherlands. METHODS A systematic literature review in PubMed and Embase was conducted to identify available Dutch cost data for T2DM-related events, published in the last decade. Information extracted included costs, source, study population, and costing perspective. Finally, papers were evaluated using the Consolidated Health Economic Evaluation Reporting Standards (CHEERS). RESULTS Out of initially 570 papers, 36 agreed with the inclusion criteria. From these studies, 150 cost estimates for T2DM-related clinical events were identified. In total, 29 cost estimates were reported for myocardial infarction (range: €196-€27,038), 61 for stroke (€495-€54,678), fifteen for heart failure (€325-€16,561), 24 for renal failure (€2,438-€91,503), and seventeen for revascularisation (€3,000-€37,071). Only four estimates for transient ischaemic attack were available, ranging from €587 to €2,470. Adherence to CHEERS was generally high. CONCLUSIONS The most expensive clinical events were related to renal failure, while TIA was the least expensive event. Generally, there was substantial variation in reported cost estimates for T2DM-related events. Costing of clinical events should be improved and preferably standardised, as accurate and consistent results in economic models are desired.
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Affiliation(s)
- Alexander V. van Schoonhoven
- Unit of PharmacoTherapy, Epidemiology & Economics (PTE2), Department of Pharmacy, University of Groningen, Groningen, the Netherlands
| | - Judith J. Gout-Zwart
- Asc Academics, Groningen, the Netherlands
- Department of Nephrology, University of Groningen, University Medical Centre Groningen (UMCG), Groningen, the Netherlands
| | - Marijke J. S. de Vries
- Unit of PharmacoTherapy, Epidemiology & Economics (PTE2), Department of Pharmacy, University of Groningen, Groningen, the Netherlands
| | - Antoinette D. I. van Asselt
- Department of Epidemiology, University Medical Centre Groningen, Groningen, the Netherlands
- Department of Health Sciences, University of Groningen, University Medical Centre Groningen (UMCG), Groningen, the Netherlands
| | | | - Pepijn Vemer
- Unit of PharmacoTherapy, Epidemiology & Economics (PTE2), Department of Pharmacy, University of Groningen, Groningen, the Netherlands
- Department of Epidemiology, University Medical Centre Groningen, Groningen, the Netherlands
| | - Job F. M. van Boven
- Department of General Practice & Elderly Care, University of Groningen, University Medical Center Groningen (UMCG), Groningen, the Netherlands
- Department of Clinical Pharmacy & Pharmacology, University of Groningen, University Medical Centre Groningen (UMCG), Groningen, the Netherlands
| | - Maarten J. Postma
- Unit of PharmacoTherapy, Epidemiology & Economics (PTE2), Department of Pharmacy, University of Groningen, Groningen, the Netherlands
- Department of Health Sciences, University of Groningen, University Medical Centre Groningen (UMCG), Groningen, the Netherlands
- Department of Economics, Econometrics & Finance, University of Groningen, Faculty of Economics & Business, Groningen, The Netherlands
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Roze S, Smith-Palmer J, de Portu S, Delbaere A, de Brouwer B, de Valk HW. Cost-effectiveness of sensor-augmented insulin pump therapy vs continuous subcutaneous insulin infusion in patients with type 1 diabetes in the Netherlands. CLINICOECONOMICS AND OUTCOMES RESEARCH 2019; 11:73-82. [PMID: 30679914 PMCID: PMC6336135 DOI: 10.2147/ceor.s186298] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Aim The aim of this study was to perform a cost-effectiveness analysis to establish the cost-effectiveness of sensor-augmented pump therapy (SAP) with automated insulin suspension vs continuous subcutaneous insulin infusion (CSII) alone in patients with type 1 diabetes in the Netherlands. Patients and methods The analysis was performed using the IQVIA CORE Diabetes Model (CDM) in two different patient cohorts: one with suboptimal glycemic control at baseline (mean age 27 years, mean baseline HbA1c 8.0% [64 mmol/mol]) and the other at increased risk of hypoglycemic events (mean age 18.6 years, mean baseline HbA1c 7.5% [58 mmol/mol]). Clinical input data were sourced from published literature, and the analysis was performed from the societal perspective. Results In patients with suboptimal baseline glycemic control, SAP improved quality-adjusted life expectancy by 1.77 quality-adjusted life years (QALYs) vs CSII (15.54 QALYs vs 13.77 QALYs) with higher lifetime costs (EUR 189,855 vs EUR 150,366), resulting in an incremental cost-effectiveness ratio (ICER) of EUR 22,325 per QALY gained. In this cohort, sensitivity analyses showed that the influence of SAP on fear of hypoglycemia (FoH) and baseline HbA1c were key drivers of results. In patients at increased risk of hypoglycemia, the gain in quality-adjusted life expectancy with SAP vs CSII was 2.16 QALYs (16.70 QALYs vs 14.53 QALYs) with higher lifetime costs (EUR 204,013 vs EUR 171,032) leading to an ICER of EUR 15,243 per QALY gained. In this patient group, findings were most sensitive to changes in assumptions relating to the incidence of severe hypoglycemic events in the CSII arm. Conclusion For type 1 diabetes patients in the Netherlands who do not achieve target HbA1c levels or who experience frequent severe hypoglycemic events on CSII, switching to SAP is likely to be cost-effective.
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Affiliation(s)
| | | | - Simona de Portu
- Medtronic International Trading Sàrl, Tolochenaz, Switzerland
| | - Alexis Delbaere
- Medtronic International Trading Sàrl, Tolochenaz, Switzerland
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Cost-Effectiveness of Primary Prevention with Statin Treatment for Chinese Patients with Type 2 Diabetes. Adv Ther 2018; 35:2214-2223. [PMID: 30390239 DOI: 10.1007/s12325-018-0823-9] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2018] [Indexed: 12/25/2022]
Abstract
INTRODUCTION Statins can reduce the risk of cardiovascular events in patients with diabetes. The objective of this analysis was to evaluate whether primary prevention with statin treatment is cost-effective for newly diagnosed type 2 diabetes mellitus (T2DM) patients in the Chinese context. METHODS An economic analysis of primary prevention with statin treatment was conducted using the Chinese Outcomes Model for T2DM with a time horizon of a lifetime, which was developed and validated based on the Chinese population. Clinical costs and utility inputs were gathered from published sources. Lifetime discounted quality-adjusted life-years (QALYs), costs, and the incremental cost-effectiveness ratio (ICER) were measured. The uncertainty was evaluated by one-way and probabilistic sensitivity analyses. RESULTS Statin treatment with atorvastatin 10 mg could add 0.08 QALYs with an additional $1676 compared with that of no statin management (control strategy) over a lifetime horizon, which led to an ICER of $21,924 per QALY gained. At a willingness-to-pay threshold of $27,351 per QALY gained, there was an approximately 80% probability of statin treatment being cost-effective compared with the control strategy. The model outcomes were most sensitive to the length of the expected life and age at the T2DM diagnosis. CONCLUSIONS Statin treatment with atorvastatin is most likely cost-effective for primary prevention in Chinese patients newly diagnosed with type 2 diabetes. FUNDING Partially funded by Pfizer Inc.
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Karlsson SA, Franzén S, Svensson AM, Miftaraj M, Eliasson B, Andersson Sundell K. Prescription of lipid-lowering medications for patients with type 2 diabetes mellitus and risk-associated LDL cholesterol: a nationwide study of guideline adherence from the Swedish National Diabetes Register. BMC Health Serv Res 2018; 18:900. [PMID: 30486824 PMCID: PMC6260691 DOI: 10.1186/s12913-018-3707-4] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2018] [Accepted: 11/12/2018] [Indexed: 12/02/2022] Open
Abstract
BACKGROUND Management of type 2 diabetes mellitus (T2DM) encompasses intensive glycaemic control, along with treatment of comorbidities and complications to handle the increased risk of cardiovascular disease (CVD). Improved control of LDL-cholesterol (LDL-C) with lipid-lowering medications is associated with reduced CVD risk in T2DM patients. Thus, treatment guidelines recommend lipid-lowering medications for T2DM patients with LDL-C above risk-associated thresholds. This study aimed to assess healthcare provider adherence to guidelines regarding lipid-lowering medication prescription among T2DM patients and to analyse factors associated with lipid-lowering medication prescription. METHODS Observations in 2007 - 2014 for T2DM patients age ≥ 18 were collected from the Swedish National Diabetes Register. Observations were excluded if they lacked information about LDL-C, lipid-lowering medication prescription or CVD. Observations with established CVD were attributed to secondary prevention; remaining observations were attributed to primary prevention. The analyses included primary and secondary prevention observations with LDL-C above risk-associated thresholds (LDL-C ≥ 2.5 mmol/l and LDL-C ≥ 1.8 mmol/l respectively). Guideline adherence was analysed as the probability of prescribing lipid-lowering medications using mixed-effect model regression adjusted for potential confounders. Factors associated with prescribing lipid-lowering medications were analysed for patient and healthcare provider characteristics using mixed-effect model regression and odds ratio. RESULTS A total of 1,204,376 observations from 322,046 patients reported by 1352 healthcare providers were included. Primary prevention accounted for 63%; 52% were men, mean age was 64 and mean LDL-C was 3.4 mmol/l. For secondary prevention, 60% were men, mean age was 72 and mean LDL-C was 2.7 mmol/l. During 2007-2014, guideline adherence ranged from 36 to 47% for primary prevention and 59 to 69% for secondary prevention. In general, concomitant prescription of diabetes medications, antiplatelets and antihypertensives along with smoking and specialised care were associated with higher prescription of lipid-lowering medications. Patients age ≥ 80 were associated with lower prescription of lipid-lowering medications. Higher prescription was associated with longer diabetes duration in primary prevention and men in secondary prevention. CONCLUSIONS Adherence to treatment guidelines levelled off after an initial increase in both prevention groups. Lipid-lowering medication prescription was based on individualised CVD risk.
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Affiliation(s)
- Sofia Axia Karlsson
- Department of Public Health and Community Medicine, Sahlgrenska Academy, University of Gothenburg, BOX 453, SE-405 30 Gothenburg, Sweden
| | - Stefan Franzén
- National Diabetes Register, Centre of Registers, Gothenburg, Sweden
| | | | - Mervete Miftaraj
- National Diabetes Register, Centre of Registers, Gothenburg, Sweden
| | - Björn Eliasson
- Department of Molecular and Clinical Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Karolina Andersson Sundell
- Department of Public Health and Community Medicine, Sahlgrenska Academy, University of Gothenburg, BOX 453, SE-405 30 Gothenburg, Sweden
- AstraZeneca AB, Medical Evidence and Observational Research, Mölndal, Sweden
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Ortendahl JD, Harmon AL, Bentley TGK, Broder MS. A systematic literature review of methods of incorporating mortality in cost-effectiveness analyses of lipid-lowering therapies. J Med Econ 2017; 20:767-775. [PMID: 28562126 DOI: 10.1080/13696998.2017.1336449] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
AIMS Cost effectiveness analysis (CEA) is a useful tool for estimating the value of an intervention in relation to alternatives. In cardiovascular disease (CVD), CEA is especially important, given the high economic and clinical burden. One key driver of value is CVD mortality prevention. However, data used to inform CEA parameters can be limited, given the difficulty in demonstrating statistically significant mortality benefit in randomized clinical trials (RCTs), due in part to the frequency of fatal events and limited trial durations. This systematic review identifies and summarizes whether published CVD-related CEAs have incorporated mortality benefits, and the methodology among those that did. MATERIALS AND METHODS A systematic literature review was conducted of CEAs of lipid-lowering therapies published between 2000-2017. Health technology assessments (HTA) and full-length manuscripts were included, and sources of mortality data and methods of applying mortality benefits were extracted. Results were summarized as proportions of articles to articulate common practices in CEAs of CVD. RESULTS This review identified 100 studies for inclusion, comprising 93 full-length manuscripts and seven HTA reviews. Among these, 99% assumed a mortality benefit in the model. However, 87 of these studies that incorporated mortality differences did so despite the trials used to inform model parameters not demonstrating statistically significant differences in mortality. None of the 12 studies that used statistically significant findings from an individual RCT were based on active control studies. In a sub-group analysis considering the 60 CEAs that incorporated a direct mortality benefit, 48 (80%) did not have RCT evidence for statistically significant benefit in CVD mortality. LIMITATIONS AND CONCLUSIONS The finding that few CEA models included mortality inputs from individual RCTs of lipid-lowering therapy may be surprising, as one might expect that treatment efficacy should be based on robust clinical evidence. However, regulatory requirements in CVD-related RCTs often lead to insufficient sample sizes and observation periods for detecting a difference in CVD mortality, which results in the use of intermediate outcomes, composite end-points, or meta-analysis to extrapolate long-term mortality benefit in a lifetime CEA.
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Affiliation(s)
- Jesse D Ortendahl
- a Partnership for Health Analytic Research , Beverly Hills , CA , USA
| | - Amanda L Harmon
- a Partnership for Health Analytic Research , Beverly Hills , CA , USA
| | - Tanya G K Bentley
- a Partnership for Health Analytic Research , Beverly Hills , CA , USA
| | - Michael S Broder
- a Partnership for Health Analytic Research , Beverly Hills , CA , USA
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Roze S, Duteil E, Smith-Palmer J, de Portu S, Valentine W, de Brouwer BFE, Reznik Y, de Valk HW. Cost-effectiveness of continuous subcutaneous insulin infusion in people with type 2 diabetes in the Netherlands. J Med Econ 2016; 19:742-9. [PMID: 26985982 DOI: 10.3111/13696998.2016.1167695] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
AIMS Up to 30% of insulin-treated type 2 diabetes patients are unable to achieve HbA1c targets despite optimization of insulin multiple daily injections (MDI). For these patients the use of continuous subcutaneous insulin infusion (CSII) represents a useful but under-utilized alternative. The aim of the present analysis was to examine the cost-effectiveness of initiating CSII in type 2 diabetes patients failing to achieve good glycemic control on MDI in the Netherlands. METHODS Long-term projections were made using the IMS CORE Diabetes Model. Clinical input data were sourced from the OpT2mise trial. The analysis was performed over a lifetime time horizon. The discount rates applied to future costs and clinical outcomes were 4% and 1.5% per annum, respectively. RESULTS CSII was associated with improved quality-adjusted life expectancy compared with MDI (9.38 quality-adjusted life years [QALYs] vs 8.95 QALYs, respectively). The breakdown of costs indicated that ∼50% of costs were attributable to diabetes-related complications. Higher acquisition costs of CSII vs MDI were partially offset by the reduction in complications. The ICER was estimated at EUR 62,895 per QALY gained and EUR 60,474 per QALY gained when indirect costs were included. CONCLUSIONS In the Netherlands, CSII represents a cost-effective option in patients with type 2 diabetes who continue to have poorly-controlled HbA1c despite optimization of MDI. Since the ICER falls below the willingness-to-pay threshold of EUR 80,000 per QALY gained, CSII is likely to represent good-value for money in the treatment of poorly-controlled T2D patients compared with MDI.
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Affiliation(s)
- S Roze
- a HEVA HEOR , Lyon , France
| | | | - J Smith-Palmer
- b Ossian Health Economics and Communications , Basel , Switzerland
| | - S de Portu
- c Medtronic International Sàrl , Tolochenaz , Switzerland
| | - W Valentine
- b Ossian Health Economics and Communications , Basel , Switzerland
| | | | - Y Reznik
- e University of Caen Côte de Nacre Regional Hospital Center , Caen , France
| | - H W de Valk
- f University Medical Centre Heidelberglaan , Utrecht , The Netherlands
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de Vries FM, Denig P, Vegter S, Bos HJ, Postma MJ, Hak E. Does a cardiovascular event change adherence to statin treatment in patients with type 2 diabetes? A matched cohort design. Curr Med Res Opin 2015; 31:595-602. [PMID: 25629791 DOI: 10.1185/03007995.2015.1011780] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
OBJECTIVE To be effective, adherence to statin treatment is essential. We assessed the effect of an apparent first cardiovascular event on statin adherence rates in type 2 diabetes patients. RESEARCH DESIGN AND METHODS A matched cohort study was conducted among type 2 diabetes patients initiating statin treatment for primary prevention in the Groningen University IADB.nl pharmacy database. Patients who had a drug-treated cardiovascular event (index date) after statin initiation were matched to a reference patient without such an event with similar gender, age at statin initiation, initiation date, follow-up period and adherence level before the event. Adherence rates were measured as percentages of days covered (PDC), and shifts in adherence levels (non-adherent/partially adherent/fully adherent) and rates around the event were evaluated. RESULTS We could match 375 of the 855 eligible index patients to a reference patient. Index patients had on average a PDC of 81% after the index date; reference patients had a PDC of 71% (p < 0.001) while both had a PDC of 79% before the index date. Index patients were 4.5 times more likely than reference patients to shift from non-adherent to fully adherent (95% CI 1.1-18.8) and 1.8 times more likely to shift from partially adherent to fully adherent (95% CI 1.2-2.6). In the index group, 26% of patients became more adherent after the first cardiovascular event. In contrast, 20% of patients became less adherent. LIMITATIONS Medication proxies were used, which could have caused misclassification. Furthermore, a substantial group of index patients could not be matched to a reference patient due to small ranges in matching criteria. CONCLUSIONS The occurrence of a drug-treated cardiovascular event appeared to avert the declining statin adherence rate observed in diabetes patients without such an event. On the other hand, one in five patients became less adherent after the event, indicating that there are still important benefits to achieve.
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Affiliation(s)
- F M de Vries
- University Groningen, Department of Pharmacy, Unit of PharmacoEpidemiology & PharmacoEconomics (PE2) , Groningen , The Netherlands
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Aarnio E, Korhonen MJ, Huupponen R, Martikainen J. Cost-effectiveness of statin treatment for primary prevention in conditions of real-world adherence--estimates from the Finnish prescription register. Atherosclerosis 2015; 239:240-7. [PMID: 25618032 DOI: 10.1016/j.atherosclerosis.2014.12.059] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/14/2014] [Revised: 12/18/2014] [Accepted: 12/24/2014] [Indexed: 11/28/2022]
Abstract
OBJECTIVE To estimate the cost-effectiveness of statin therapy for primary prevention of coronary heart disease (CHD) events under real-world adherence. METHODS A cost-effectiveness model was applied to estimate the expected 10-year costs and health outcomes (in terms of quality-adjusted life-years, QALYs) associated with and without statin treatment (at defined adherence levels) among hypothetical cohorts of Finnish men and women who were initially without established CHD. Treatment efficacy, cost, and quality of life estimates were obtained from published sources. Long-term treatment adherence was measured based on data from the national prescription register. RESULTS At an assumed willingness-to-pay threshold of €20,000 per QALY gained, statin treatment with real-world adherence was cost-effective among the older patient groups when the patients' 10-year CHD risk was as high as 20% and did not seem cost-effective in the youngest age groups. Conversely, statin treatment with full adherence was cost-effective for almost all patient groups with a 10-year CHD risk of at least 15%. CONCLUSIONS Even though generic statins are now low-cost drugs, treatment adherence seems to have a major impact on the cost-effectiveness of statin treatment in primary prevention. This finding stresses the importance of making a concerted effort for improving adherence among patients on statin therapy to obtain full benefit of the investment in statins. Therefore, novel cost-effective approaches to improve treatment adherence are warranted.
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Affiliation(s)
- Emma Aarnio
- Department of Clinical Pharmacology, Tykslab, Turku University Hospital, Turku, Finland; Pharmacoeconomics and Outcomes Research Unit (PHORU), School of Pharmacy, University of Eastern Finland, Kuopio, Finland.
| | - Maarit J Korhonen
- Department of Pharmacology, Drug Development and Therapeutics, University of Turku, Turku, Finland.
| | - Risto Huupponen
- Department of Clinical Pharmacology, Tykslab, Turku University Hospital, Turku, Finland; Department of Pharmacology, Drug Development and Therapeutics, University of Turku, Turku, Finland.
| | - Janne Martikainen
- Pharmacoeconomics and Outcomes Research Unit (PHORU), School of Pharmacy, University of Eastern Finland, Kuopio, Finland.
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