An economic evaluation based on a randomized placebo-controlled trial of varenicline in smokers with cardiovascular disease: results for Belgium, Spain, Portugal, and Italy

Motivational support intervention to reduce smoking and increase physical activity in smokers not ready to quit: the TARS RCT

Background

Physical activity can support smoking cessation for smokers wanting to quit, but there have been no studies on supporting smokers wanting only to reduce. More broadly, the effect of motivational support for such smokers is unclear.

Objectives

The objectives were to determine if motivational support to increase physical activity and reduce smoking for smokers not wanting to immediately quit helps reduce smoking and increase abstinence and physical activity, and to determine if this intervention is cost-effective.

Design

This was a multicentred, two-arm, parallel-group, randomised (1 : 1) controlled superiority trial with accompanying trial-based and model-based economic evaluations, and a process evaluation.

Setting and participants

Participants from health and other community settings in four English cities received either the intervention (n = 457) or usual support (n = 458).

Intervention

The intervention consisted of up to eight face-to-face or telephone behavioural support sessions to reduce smoking and increase physical activity.

Main outcome measures

The main outcome measures were carbon monoxide-verified 6- and 12-month floating prolonged abstinence (primary outcome), self-reported number of cigarettes smoked per day, number of quit attempts and carbon monoxide-verified abstinence at 3 and 9 months. Furthermore, self-reported (3 and 9 months) and accelerometer-recorded (3 months) physical activity data were gathered. Process items, intervention costs and cost-effectiveness were also assessed.

Results

The average age of the sample was 49.8 years, and participants were predominantly from areas with socioeconomic deprivation and were moderately heavy smokers. The intervention was delivered with good fidelity. Few participants achieved carbon monoxide-verified 6-month prolonged abstinence [nine (2.0%) in the intervention group and four (0.9%) in the control group; adjusted odds ratio 2.30 (95% confidence interval 0.70 to 7.56)] or 12-month prolonged abstinence [six (1.3%) in the intervention group and one (0.2%) in the control group; adjusted odds ratio 6.33 (95% confidence interval 0.76 to 53.10)]. At 3 months, the intervention participants smoked fewer cigarettes than the control participants (21.1 vs. 26.8 per day). Intervention participants were more likely to reduce cigarettes by ≥ 50% by 3 months [18.9% vs. 10.5%; adjusted odds ratio 1.98 (95% confidence interval 1.35 to 2.90] and 9 months [14.4% vs. 10.0%; adjusted odds ratio 1.52 (95% confidence interval 1.01 to 2.29)], and reported more moderate-to-vigorous physical activity at 3 months [adjusted weekly mean difference of 81.61 minutes (95% confidence interval 28.75 to 134.47 minutes)], but not at 9 months. Increased physical activity did not mediate intervention effects on smoking. The intervention positively influenced most smoking and physical activity beliefs, with some intervention effects mediating changes in smoking and physical activity outcomes. The average intervention cost was estimated to be £239.18 per person, with an overall additional cost of £173.50 (95% confidence interval -£353.82 to £513.77) when considering intervention and health-care costs. The 1.1% absolute between-group difference in carbon monoxide-verified 6-month prolonged abstinence provided a small gain in lifetime quality-adjusted life-years (0.006), and a minimal saving in lifetime health-care costs (net saving £236).

Conclusions

There was no evidence that behavioural support for smoking reduction and increased physical activity led to meaningful increases in prolonged abstinence among smokers with no immediate plans to quit smoking. The intervention is not cost-effective.

Limitations

Prolonged abstinence rates were much lower than expected, meaning that the trial was underpowered to provide confidence that the intervention doubled prolonged abstinence.

Future work

Further research should explore the effects of the present intervention to support smokers who want to reduce prior to quitting, and/or extend the support available for prolonged reduction and abstinence.

Trial registration

This trial is registered as ISRCTN47776579.

Funding

This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 27, No. 4. See the NIHR Journals Library website for further project information.

Cost-effectiveness analysis of bariatric surgery for morbid obesity in Belgium

AIMS

This study presents the cost-effectiveness analysis of bariatric surgery in Belgium from a third-party payer perspective for a lifetime and 10-year horizon.

MATERIALS AND METHODS

A decision analytic model incorporating Markov process was developed to compare the cost-effectiveness of gastric bypass, sleeve gastrectomy, and adjustable gastric banding against conventional medical management (CMM). In the model, patients could undergo surgery, or experience post-surgery complications, type 2 diabetes, cardiovascular diseases, or die. Transition probabilities, costs, and utilities were derived from the literature. The impact of different surgical methods on body mass index (BMI) level in the base-case analysis was informed by the Scandinavian Obesity Surgery Registry and the Swedish Obese Subject (SOS) study. Healthcare resource use and costs were obtained from Belgian sources. A base-case analysis was performed for the population, the characteristics of which were obtained from surgery candidates in Belgium.

RESULTS

In the base-case analysis over a 10-year time horizon, the increment in quality-adjusted life-years (QALYs) gained from bariatric surgery vs CMM was 1.4 per patient, whereas the incremental cost was €3,788, leading to an incremental cost-effectiveness ratio (ICER) of €2,809 per QALY. Over a lifetime, bariatric surgery produced savings of €9,332, an additional 1.1 life years and 5.0 QALYs. Bariatric surgery was cost-effective at 10 years post-surgery and dominant over conventional management over a lifetime horizon.

LIMITATIONS

The model did not include the whole scope of obesity-related complications, and also did not account for variation in surgery outcomes for different populations of diabetic patients. Also, the data about management of patients after surgery was based on assumptions and the opinion of a clinical expert.

CONCLUSIONS

It was demonstrated that a current mix of bariatric surgery methods was cost-effective at 10 years post-surgery and cost-saving over the lifetime of the Belgian patient cohort considered in this analysis.

Modelling a budgetary impact analysis for funding drug-based smoking cessation therapies for patients with major depressive disorder in Spain

BACKGROUND

Smoking is associated with high healthcare resource utilisation and cost to society. Patients with major depressive disorder (MDD) exhibit high susceptibility to nicotine dependence. Varenicline, bupropion and nicotine replacement therapy are all indicated for smoking cessation; however funding by the Spanish national health system (SNHS) is limited. We modelled a budgetary impact analysis (BIA) to estimate the impact of the SNHS funding drug-based therapies for smoking cessation in smokers with MDD.

METHODS

The BIA compared the current unfunded scenario versus a funded scenario (varenicline, bupropion, nicotine replacement therapy combined with medical follow-up and counselling) using the Spanish SNHS and societal perspectives. The BIA design was a hybrid model using a decision tree algorithm (population size: smokers with MDD) and Markov chains (smoking cessation attempts) over a 5-year horizon. Smoking cessation drug efficacy was derived from clinical trials, and smoking cessation costs avoided were taken from an analysis of the Spanish National Health Survey. Results were shown as incremental cost savings. Scenarios and threshold univariate sensitivity analyses tested model robustness.

RESULTS

The funded scenario resulted in an increase of 43,478 cessation attempts and 8930 fewer smokers after 5 years compared to the unfunded scenario. The cost of funding was €25.3 million and costs avoided were €26.5 million. There was a cumulative 5-year incremental cost saving of €1.2 million to Spanish society. Results were robust using alternative scenarios.

CONCLUSIONS

Funding smoking cessation drugs in patients with MDD is of economic benefit to Spain and could produce net savings from the third year of implementation.

Advocacy for outpatient cardiac rehabilitation globally

BACKGROUND

Cardiovascular diseases (CVD) are the leading cause of death globally. Cardiac rehabilitation (CR) is an evidence-based intervention recommended for patients with CVD, to prevent recurrent events and to improve quality of life. However, despite the proven benefits, only a small percentage of those would benefit from CR actually receive it worldwide. This paper by the International Council of Cardiovascular Prevention and Rehabilitation forwards the groundwork for successful CR advocacy to achieve broader reimbursement, and hence implementation.

METHODS

First, the results of the International Council's survey on national CR reimbursement policies by government and insurance companies are summarized. Second, a multi-faceted approach to CR advocacy is forwarded. Finally, as per the advocacy recommendations, the economic impact of CVD and the corresponding benefits of CR and its cost-effectiveness are summarized. This provides the case for CR reimbursement advocacy.

RESULTS

Thirty-one responses were received, from 25 different countries: 18 (58.1 %) were from high-income countries, 10 (32.4 %) from upper middle-income, and 3 (9.9 %) from lower middle-income countries. When asked who reimburses at least some portion of CR services in their country, 19 (61.3 %) reported the government, 17 (54.8 %) reported patients pay out-of-pocket, 16 (51.6 %) reported insurance companies, 12 (38.7 %) reported that it is shared between the patient and another source, and 7 (22.6 %) reported another source.

CONCLUSIONS

Many patients pay out-of-pocket for CR. CR reimbursement around the world is inconsistent and insufficient. Advocacy campaigns forwarding the CR cause, supported by the relevant literature, enlisting sources of support in a unified manner with an organized plan, are needed, and must be pursued persistently.

Mathematical Modeling in Tobacco Control Research: Initial Results From a Systematic Review

OBJECTIVES

The US Food and Drug Administration has expressed interest in using mathematical models to evaluate potential tobacco policies. The goal of this systematic review was to synthesize data from tobacco control studies that employ mathematical models.

METHODS

We searched five electronic databases on July 1, 2013 to identify published studies that used a mathematical model to project a tobacco-related outcome and developed a data extraction form based on the ISPOR-SMDM Modeling Good Research Practices. We developed an organizational framework to categorize these studies and identify models employed across multiple papers. We synthesized results qualitatively, providing a descriptive synthesis of included studies.

RESULTS

The 263 studies in this review were heterogeneous with regard to their methodologies and aims. We used the organizational framework to categorize each study according to its objective and map the objective to a model outcome. We identified two types of study objectives (trend and policy/intervention) and three types of model outcomes (change in tobacco use behavior, change in tobacco-related morbidity or mortality, and economic impact). Eighteen models were used across 118 studies.

CONCLUSIONS

This paper extends conventional systematic review methods to characterize a body of literature on mathematical modeling in tobacco control. The findings of this synthesis can inform the development of new models and the improvement of existing models, strengthening the ability of researchers to accurately project future tobacco-related trends and evaluate potential tobacco control policies and interventions. These findings can also help decision-makers to identify and become oriented with models relevant to their work.

Cost-effectiveness of retreatment with varenicline after failure with or relapse after initial treatment for smoking cessation

OBJECTIVES

A recent trial showed the clinical benefit of retreatment with varenicline in subjects failing on the initial treatment, or relapsing after initial success. The objective of this study was to evaluate the cost-effectiveness of retreatment with varenicline compared with other smoking cessation interventions.

METHODS

A published Markov model was adapted to compare one quit attempt of varenicline followed by retreatment to treatment/retreatment with nicotine replacement therapy (NRT), bupropion or placebo, and with only 1 quit attempt of varenicline. Efficacy was obtained from clinical trials. Incidence of smoking-related diseases was based on published data. Cost of therapies and complications was obtained from databases and literature.

RESULTS

For 1000 smokers willing to quit, varenicline retreatment saves 275,000€, 118,000€, 316,000€ and 237,000€ compared to NRT, bupropion, placebo, or one single varenicline quit attempt respectively at lifetime and from the healthcare payer perspective. The number of quality adjusted life years gained is 74, 63, 193 and 111 respectively. Sensitivity analyses showed the robustness of these findings.

CONCLUSION

This analysis suggests that in the long term, varenicline retreatment is a dominant intervention, meaning both greater health gains and greater costs saved, over other possible interventions and therefore should be considered as a standard option.

Cost-effectiveness analysis of coronary artery disease screening in HIV-infected men

BACKGROUND

HIV-infected patients are at increased risk of coronary artery disease (CAD). We evaluated the cost-effectiveness of cardiac screening for HIV-positive men at intermediate or greater CAD risk.

DESIGN

We developed a lifetime microsimulation model of CAD incidence and progression in HIV-infected men.

METHODS

Input parameters were derived from two HIV cohort studies and the literature. We compared no CAD screening with stress testing and coronary computed tomography angiography (CCTA)-based strategies. Patients with test results indicating 3-vessel/left main CAD underwent invasive coronary angiography (ICA) and received coronary artery bypass graft surgery. In the stress testing + medication and CCTA + medication strategies, patients with 1-2-vessel CAD results received lifetime medical treatment without further diagnostics whereas in the stress testing + intervention and CCTA + intervention strategies, patients with these results underwent ICA and received percutaneous coronary intervention.

RESULTS

Compared to no screening, the stress testing + medication, stress testing + intervention, CCTA + medication, and CCTA + intervention strategies resulted in 14, 11, 19, and 14 quality-adjusted life days per patient and incremental cost-effectiveness ratios of 49,261, 57,817, 34,887 and 56,518 Euros per quality-adjusted life year (QALY), respectively. Screening only at higher CAD risk thresholds was more cost-effective. Repeated screening was clinically beneficial compared to one-time screening, but only stress testing + medication every 5 years remained cost-effective. At a willingness-to-pay threshold of 83,000 €/QALY (∼ 100,000 US$/QALY), implementing any CAD screening was cost-effective with a probability of 75-95%.

CONCLUSIONS

Screening HIV-positive men for CAD would be clinically beneficial and comes at a cost-effectiveness ratio comparable to other accepted interventions in HIV care.