The impact of waiting for intervention on costs and effectiveness: the case of transcatheter aortic valve replacement

OBJECTIVES

The economic crisis in Europe might have limited access to some innovative technologies implying an increase of waiting time. The purpose of the study is to evaluate the impact of waiting time on the costs and benefits of transcatheter aortic valve replacement (TAVR) for the treatment of severe aortic stenosis.

METHODS

This is a cost-utility analysis from the perspective of the Spanish National Health Service. Results of two prospective hospital registries (158 and 273 consecutive patients) were incorporated into a probabilistic Markov model to compare quality adjusted life years (QALYs) and costs for TAVR after waiting for 3-12 months, relative to immediate TAVR. We simulated a cohort of 1000 patients, male, and 80 years old; other patient profiles were assessed in sensitivity analyses.

RESULTS

As waiting time increased, costs decreased at the expense of lower survival and loss of QALYs, leading to incremental cost-effectiveness ratios for eliminating waiting lists of about 12,500 € per QALY. In subgroup analyses prioritization of patients for whom higher benefit was expected led to a smaller loss of QALYs. Concerning budget impact, long waiting lists reduced spending considerably and permanently.

CONCLUSIONS

A shorter waiting time is likely to be cost-effective (considering commonly accepted willingness-to-pay thresholds in Europe) relative to 3 months or longer waiting periods. If waiting lists are nevertheless seen as unavoidable due to severe but temporary budgetary restrictions, prioritizing patients for whom higher benefit is expected appears to be a way of postponing spending without utterly sacrificing patients' survival and quality of life.

Cost-effectiveness of Intrathecal Baclofen Therapy in severe refractory non-focal disabling spasticity: a Spanish hospital perspective

BACKGROUND

Current knowledge about long-term economic consequences of Intrathecal Baclofen Therapy (ITB Therapy®) is incomplete.

METHODS

A markov model was developed to estimate long-term clinical and economic outcomes with ITB Therapy® and conventional medical management of severe refractory non-focal disabling spasticity. Clinical and cost inputs were obtained through a non-interventional, prospective, observational study in a Spanish neurorehabilitation hospital.

RESULTS

ITB Therapy® increased remaining lifetime costs by €35,605 and resulted in a gain of 1.06 quality-adjusted life-years (QALYs), thus showing an incremental cost-effectiveness ratio (ICER) of €33,619/QALY gained. In alternative scenarios, reflecting other clinical settings and management options, considerably lower ICER values were obtained. In particular, opportunities were identified to improve efficiency by setting clinically and economically sound targets for post-operation length of stay.

CONCLUSION

In the Spanish setting, ITB Therapy® resulted in an ICER close to €30,000/QALY gained; potential ways to reduce costs and further enhance efficiency can be identified.

Cost-effectiveness of Sativex in multiple sclerosis spasticity: new data and application to Italy

Multiple sclerosis (MS) is a chronic progressive disease that carries a high socioeconomic burden. Spasticity (rigidity and spasms) is common in MS and contributes to MS-related disability. This study aims to evaluate the cost-effectiveness of Sativex(®) (9-delta-tetrahydrocannabinol plus cannabidiol oromucosal spray) when used as add-on therapy for management of resistant MS-related spasticity in the context of the Italian healthcare system. A previously published Markov model-based analysis for the German and Spanish context was replicated, adapting it to the Italian setting. Model parameters were updated to reflect recent findings about MS-related spasticity and use of Sativex in daily clinical practice. The base case incremental cost-effectiveness ratio for Sativex use in Italy over a 5-year period was estimated to be €4968 per quality-adjusted life-year gained (year of costing: 2013). Sativex remained an efficient option in the Italian healthcare context - below the commonly accepted incremental threshold of €30,000 per quality-adjusted life-year gained - when deterministic and probabilistic sensitivity analyses were conducted. Sativex can be regarded as a cost-effective treatment option for patients with MS-related spasticity in Italy.

Sativex® in multiple sclerosis spasticity: a cost-effectiveness model

BACKGROUND

Multiple sclerosis (MS) is a chronic, progressive disease that carries a high socioeconomic burden. Spasticity (rigidity and spasms) is common in MS and a key contributor to MS-related disability.

OBJECTIVES

This study evaluated the cost-effectiveness of Sativex®, a 9-d-tetrahydrocannabinol/cannabidiol-based oromucosal spray that acts as an endocannabinoid system modulator. Sativex was recently approved for the management of resistant MS spasticity as add-on medication.

METHODS

A Markov model-based analysis was performed over a 5-year horizon from a German and Spanish healthcare payer perspective. The incremental cost of Sativex was low compared with current spasticity treatments, and provided a quality-adjusted life-year gain over the current standard of care.

RESULTS

The base-case incremental cost-effectiveness ratio for Sativex was estimated at €11,214/quality-adjusted life-year in Germany, while the drug was the dominant option in Spain, providing savings of €3496/patient over a 5-year period (year of costing: 2010). This was seen because the lower severity of spasticity in patients who had improved led to reduced resource consumption (e.g., physiotherapy and medications).

CONCLUSION

Despite having a relatively high acquisition cost, Sativex was shown to be a cost-effective treatment option for patients with MS-related spasticity.

Cost-effectiveness analysis of early versus non-early intervention in acute migraine based on evidence from the 'Act when Mild' study

BACKGROUND

In spite of the important progress made in the abortive treatment of acute migraine episodes since the introduction of triptans, reduction of pain and associated symptoms is in many cases still not as effective nor as fast as would be desirable. Recent research pays more attention to the timing of the treatment, and taking triptans early in the course of an attack when pain is still mild has been found more efficacious than the usual strategy of waiting for the attack to develop to a higher pain intensity level.

OBJECTIVE

To investigate the cost effectiveness of early versus non-early intervention with almotriptan in acute migraine.

METHODS

An economic evaluation was conducted from the perspectives of French society and the French public health system based on patient-level data collected in the AwM (Act when Mild) study, a placebo-controlled trial that compared the response to early and non-early treatment of acute migraine with almotriptan. Incremental cost-effectiveness ratios (ICERs) were determined in terms of QALYs, migraine hours and productive time lost. Costs were expressed in Euros (year 2010 values). Bootstrapping was used to derive cost-effectiveness acceptability curves.

RESULTS

Early treatment has shown to lead to shorter attack duration, less productive time lost, better quality of life, and is, with 92% probability, overall cost saving from a societal point of view. In terms of drug costs only, however, non-early treatment is less expensive. From the public health system perspective, the (bootstrap) mean ICER of early treatment amounts to €0.38 per migraine hour avoided, €1.29 per hour of productive time lost avoided, and €14,296 per QALY gained. Considering willingness-to-pay values of approximately €1 to avoid an hour of migraine, €10 to avoid the loss of a productive hour, or €30,000 to gain one QALY, the approximate probability that early treatment is cost effective is 90%, 90% and 70%, respectively. These results remain robust in different scenarios for the major elements of the economic evaluation.

CONCLUSIONS

Compared with non-early treatment, a strategy of early treatment of acute migraine with almotriptan when pain is still mild is, with high probability, cost saving from the French societal perspective and can be considered cost effective from the public health system point of view.

[Almotriptan vs. ergotamine plus caffeine for acute migraine treatment. A cost-efficacy analysis]

INTRODUCTION

Almotriptan has proven to be more efficacious and tolerable than ergotamine plus caffeine but is more expensive, thus raising the question about its cost-efficacy.

METHODS

The course of migraine attacks during 24 hours treated with almotriptan and ergotamine plus caffeine was modelled with a decision tree, using efficacy data from a recent randomized, double-blind clinical trial comparing the two drugs. Costs were calculated from the social perspective (including indirect costs due to absenteeism and loss of productivity) and from the Spanish National Health System (NHS) perspective (only including drug costs). The impact on quality of life was estimated using utilities assigned in the literature to different health states of migraine patients.

RESULTS

Treatment response was 57.7% for patients treated with almotriptan vs. 44.5% with ergotamine plus caffeine. Sustained pain-free status was achieved by 20.3% vs. 11.5%. Working days lost due to absenteeism and reduced productivity amounted to 0.24 vs. 0.38 days. Quality of life during attacks was estimated at an average utility of 0.548 vs. 0.422. From the NHS perspective, incremental costs per attack treated with almotriptan vs. ergotamine plus caffeine was euro 5.05, rendering an incremental cost-efficacy ratio of euro38.26 per additional response, euro57.39 per additional complete response, and euro14,709 per quality- adjusted life-year gained. From the social perspective almotriptan saved euro7.50 vs. ergotamine plus caffeine.

CONCLUSIONS

Almotriptan can be considered cost-efficacious vs. ergotamine plus caffeine from the NHS perspective and is the dominant option (both more efficacious and more economical) from the social perspective.

[Cost-efficacy analysis of fixed combinations of prostaglandin/prostamide for treating glaucoma]

OBJECTIVE

To assess the cost-efficacy of three fixed-combination glaucoma treatments currently available in Spain [bimatoprost with timolol (BT)- Ganfort, latanoprost with timolol (LT)- Xalacom, and travoprost with timolol (TT)- DuoTrav].

METHODS

Because no studies are available that give a direct comparison of these drugs, a systematic review was carried out to assess their efficacy. Resource consumption and costs were estimated using a model of usual local practice. For each of the three drugs, average and incremental cost-efficacy ratios were determined in terms of euros per percentage point of reduction of intraocular pressure (IOP) over a three-month period.

RESULTS

BT reduced IOP by 35.1%, LT by 35.0% and TT by 34.7%. Average cost-efficacy was estimated to be euro 5.34 per percentage point of IOP reduction with BT, euro 5.40 with LT, and euro 5.45 with TT. Incremental cost-efficacy (incremental cost per incremental percentage point of IOP reduction) was estimated to be euro 94.65 for LT vs. TT, and was negative for BT vs. TT and BT vs. LT, since in both cases BT was more efficacious and less expensive.

CONCLUSIONS

Compared to travoprost/timolol and latanoprost/timolol, bimatoprost/timolol appears to be the most economic alternative, with equal or better efficacy and safety results.

[Management costs of chest and CNS-related adverse events associated with the treatment of acute migraine attacks with oral triptans]

INTRODUCTION

Although adverse events of triptans are usually not important from a clinical point of view, they can worry patients and lead them to consume healthcare resources.

METHODS

A decision analytic model was used to represent the behavior and management of patients who suffered adverse events after taking a triptan. Using data about the incidence of adverse events, the behavior and management of patients, and the unit cost of the healthcare resource consumed, the costs of treating adverse events were calculated, as was the iatrogenic cost factor of the triptans available in Spain.

RESULTS

10 % to 20 % of patients who suffer a chest or CNS-related adverse advent related to triptan use seek medical attention. The management cost of a chest-related event was estimated to be euros 66,43, euros 33,09, or euros 137,01, depending on whether the patient consulted a neurologist, a primary care physician, or a hospital emergency department. For CNS-related events the management cost was estimated to be euros 52,88, euros 16,89 or euros 102,17, respectively. Excluding the placebo effect, the resulting iatrogenic cost factor varied between 1 for almotriptan 12,5 mg and 1,21 for zolmitriptan 2,5 mg. In absolute values, the average cost per patient (above placebo) varied between 0 euros for almotriptan 12,5 mg and euros 1,17 for eletriptan 80 mg.

CONCLUSIONS

The management of adverse events can add substantial costs to a treatment with triptans. These costs vary considerably between triptans due to differences in the incidence of adverse events. Lowest costs were found for almotriptan 12,5 mg.