Manns Braden, Klarenbach Scott, Lee Helen, Culleton Bruce, Shrive Fiona, Tonelli Marcello
Department of Community Health Sciences, University of Alberta, Edmonton, Alberta T6B 2b7 Canada.
Nephrol Dial Transplant. 2007 Oct;22(10):2867-78. doi: 10.1093/ndt/gfm367. Epub 2007 Jun 25.
There is uncertainty about the most cost-effective way to treat hyperphosphataemia in patients with end-stage renal disease. Methods. We performed an economic analysis which compared the use of sevelamer with calcium carbonate in a simulated cohort of North American dialysis patients, using the perspective of the health care purchaser and a lifetime horizon. Outcomes considered were quality-adjusted life years (QALYs) gained and health care costs. To account for uncertainty, we considered four separate modelling strategies, obtaining data on the relative effectiveness of sevelamer from the recent Dialysis Clinical Outcomes Revisited study.
In the base analysis, the use of sevelamer was associated with a cost per QALY gained of CAN$157,00, compared with calcium carbonate. Assuming no survival or hospitalization advantage for sevelamer, use of sevelamer resulted in an incremental cost of CAN$17,00 per patient. In alternate models which assumed sevelamer to be more effective than calcium-based phosphate binders, the use of sevelamer was associated with a cost per QALY gained ranging from CAN$127,00-$278,00. Assuming that sevelamer resulted in a differential reduction in mortality in patients > or = 65 years of age, use of sevelamer in this subgroup was associated with a cost per QALY of CAN$105,500. Results were similar in groups defined by age > or = 55 or by > or = 45 years. Since dialysis is expensive, interventions for dialysis patients that improve survival without reducing the need for dialysis will be associated with a cost-utility ratio at least as great as that of dialysis itself. As such, we repeated the primary analysis excluding the costs of dialysis and transplantation and found that the cost per QALY gained for sevelamer was $77,600.
The cost per QALY gained for treating all dialysis patients with sevelamer exceeds what would usually be considered good value for the money. While the high cost per QALY was in part due to the inclusion of the costs of dialysis and transplant in the analysis, the cost per QALY gained remained relatively unattractive even when these costs were excluded. Although a lower cost per QALY gained is realized when only patients older than 65 years are treated, this strategy remains economically unattractive, particularly given the uncertainty of clinical benefit in this group.
对于终末期肾病患者高磷血症最具成本效益的治疗方法尚无定论。方法：我们进行了一项经济学分析，从医疗保健购买者的角度并在终身范围内，比较了司维拉姆与碳酸钙在北美透析患者模拟队列中的使用情况。所考虑的结果是获得的质量调整生命年（QALY）和医疗保健成本。为了考虑不确定性，我们采用了四种不同的建模策略，从最近的“透析临床结果再探讨”研究中获取司维拉姆相对有效性的数据。
在基础分析中，与碳酸钙相比，使用司维拉姆获得每QALY的成本为15700加元。假设司维拉姆在生存或住院方面无优势，使用司维拉姆导致每位患者的增量成本为1700加元。在假设司维拉姆比钙基磷结合剂更有效的替代模型中，使用司维拉姆获得每QALY的成本在12700 - 27800加元之间。假设司维拉姆能使65岁及以上患者的死亡率有差异地降低，在该亚组中使用司维拉姆获得每QALY的成本为105500加元。在年龄≥55岁或≥45岁定义的组中结果相似。由于透析费用高昂，对于透析患者而言，在不减少透析需求的情况下提高生存率的干预措施，其成本效益比至少与透析本身一样高。因此，我们重复了主要分析，排除了透析和移植的成本，发现司维拉姆获得每QALY的成本为77600美元。
用司维拉姆治疗所有透析患者获得每QALY的成本超过了通常认为的性价比良好的范围。虽然每QALY的高成本部分归因于分析中纳入了透析和移植的成本，但即使排除这些成本，获得每QALY的成本仍然相对缺乏吸引力。尽管仅治疗65岁以上患者时获得每QALY的成本较低，但该策略在经济上仍然缺乏吸引力，特别是考虑到该组临床获益的不确定性。
