Revicki D A, Brown R E, Palmer W, Bakish D, Rosser W W, Anton S F, Feeny D
MEDTAP International, Arlington, VA 22201, USA.
Pharmacoeconomics. 1995 Dec;8(6):524-40. doi: 10.2165/00019053-199508060-00007.
The aim of this study was to estimate the cost effectiveness of nefazodone compared with imipramine or fluoxetine in treating women with major depressive disorder. Clinical decision analysis and a Markov state-transition model were used to estimate the lifetime health outcomes and medical costs of 3 antidepressant treatments. The model, which represents ideal primary care practice, compares treatment with nefazodone to treatment with either imipramine or fluoxetine. The economic analysis was based on the healthcare system of the Canadian province of Ontario, and considered only direct medical costs. Health outcomes were expressed as quality-adjusted life years (QALYs) and costs were in 1993 Canadian dollars ($Can; $Can1 = $US0.75, September 1995). Incremental cost-utility ratios were calculated comparing the relative lifetime discounted medical costs and QALYs associated with nefazodone with those of imipramine or fluoxetine. Data for constructing the model and estimating necessary parameters were derived from the medical literature, clinical trial data, and physician judgement. Data included information on: Ontario primary care physicians' clinical management of major depression; medical resource use and costs; probabilities of recurrence of depression; suicide rates; compliance rates; and health utilities. Estimates of utilities for depression-related hypothetical health states were obtained from patients with major depression (n = 70). Medical costs and QALYs were discounted to present value using a 5% rate. Sensitivity analyses tested the assumptions of the model by varying the discount rate, depression recurrence rates, compliance rates, and the duration of the model. The base case analysis found that nefazodone treatment costs $Can1447 less per patient than imipramine treatment (discounted lifetime medical costs were $Can50,664 vs $Can52,111) and increases the number of QALYs by 0.72 (13.90 vs 13.18). Nefazodone treatment costs $Can14 less than fluoxetine treatment (estimated discounted lifetime medical costs were $Can50,664 vs $Can50,678) and produces slightly more QALYs (13.90 vs 13.79). In the sensitivity analyses, the cost-effectiveness ratios comparing nefazodone with imipramine ranged from cost saving to $Can17,326 per QALY gained. The cost-effectiveness ratios comparing nefazodone with fluoxetine ranged from cost saving to $Can7327 per QALY gained. The model was most sensitive to assumptions about treatment compliance rates and recurrence rates. The findings suggest that nefazodone may be a cost-effective treatment for major depression compared with imipramine or fluoxetine. The basic findings and conclusions do not change even after modifying model parameters within reasonable ranges.
本研究的目的是评估与丙咪嗪或氟西汀相比，奈法唑酮治疗重度抑郁症女性的成本效益。采用临床决策分析和马尔可夫状态转换模型来估计三种抗抑郁治疗的终身健康结局和医疗成本。该模型代表理想的初级保健实践，将奈法唑酮治疗与丙咪嗪或氟西汀治疗进行比较。经济分析基于加拿大安大略省的医疗保健系统，仅考虑直接医疗成本。健康结局以质量调整生命年（QALYs）表示，成本以1993年加拿大元计（1加元 = 0.75美元，1995年9月）。计算增量成本效用比，比较与奈法唑酮相关的相对终身贴现医疗成本和QALYs与丙咪嗪或氟西汀的情况。构建模型和估计必要参数的数据来自医学文献、临床试验数据和医生判断。数据包括以下信息：安大略省初级保健医生对重度抑郁症的临床管理；医疗资源使用和成本；抑郁症复发概率；自杀率；依从率；以及健康效用。从重度抑郁症患者（n = 70）中获得与抑郁症相关的假设健康状态的效用估计值。使用5%的贴现率将医疗成本和QALYs贴现至现值。敏感性分析通过改变贴现率、抑郁症复发率、依从率和模型持续时间来检验模型的假设。基础病例分析发现，奈法唑酮治疗每位患者的成本比丙咪嗪治疗少1447加元（贴现终身医疗成本分别为50,664加元和52,111加元），QALYs增加0.72（分别为13.90和13.18）。奈法唑酮治疗成本比氟西汀治疗少14加元（估计贴现终身医疗成本分别为50,664加元和50,678加元），产生的QALYs略多（分别为13.90和13.79）。在敏感性分析中，比较奈法唑酮与丙咪嗪的成本效益比范围从节省成本到每获得一个QALY花费17,326加元。比较奈法唑酮与氟西汀的成本效益比范围从节省成本到每获得一个QALY花费7327加元。该模型对治疗依从率和复发率的假设最为敏感。研究结果表明，与丙咪嗪或氟西汀相比，奈法唑酮可能是治疗重度抑郁症的一种具有成本效益的疗法。即使在合理范围内修改模型参数后，基本发现和结论也不会改变。
