Shih Ya-Chen Tina, Mauskopf Josephine, Borker Rohit
Section of Health Services Research, Department of Biostatistics, Division of Quantitative Sciences, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA.
Pharmacoeconomics. 2007;25(7):577-90. doi: 10.2165/00019053-200725070-00004.
Asthma is one of the most common chronic diseases in the US, and its prevalence continues to increase. Despite the availability of effective asthma controller medications, many patients with asthma are still not meeting therapeutic goals because of poor disease management. The high disease prevalence combined with the high costs associated with the poor management of asthma, make patients with asthma a costly group to treat for managed care organisations (MCOs) and this motivates decision makers in MCOs to consider both the clinical and economic value of asthma therapies.
To compare the cost effectiveness of first-line controller asthma therapies in patients with mild-to-moderate persistent asthma from an MCO payer perspective.
A decision-analysis model was developed to evaluate the cost effectiveness of fluticasone propionate and salmeterol administered in a single inhaler (salmeterol/fluticasone propionate 50/100microg), compared with fluticasone propionate inhaled corticosteroids (FPIC), non-fluticasone propionate inhaled corticosteroids (nFPIC) and leukotriene modifiers. The model estimated costs ($US, year 2005 values) and health outcomes over a 1-year period. Costs and outcomes data were obtained from published clinical trials and observational studies, and model assumptions on the relationship between adherence and effectiveness were evaluated by a panel of experts. Effectiveness measures included symptom-free days and rescue medication-free days. The cost effectiveness of first-line asthma therapies was compared using a step-wise approach, with FPIC as the reference case. Both one-way and probabilistic sensitivity analyses were performed to assess the robustness of results over a range of assumptions.
The step-wise comparison found that the additional costs for achieving an incremental effectiveness unit (incremental cost-effectiveness ratio) using single-inhaler salmeterol/fluticasone propionate compared with FPIC was $US9.55 per symptom-free day and $US8.93 per rescue medication-free day. Sensitivity analyses indicated that the model was robust to changes in base-case assumptions. A probabilistic sensitivity analysis showed that, corresponding to a benchmark value of $US14.8 per symptom-free day, the probabilities that single-inhaler salmeterol/fluticasone propionate, n-FPIC and leukotriene modifiers were more cost effective than FPIC were 98%, 30.7% and 2.1%, respectively.
Based on our decision analysis, the additional costs for achieving incremental effectiveness with single-inhaler salmeterol/fluticasone propionate treatment compared with FPIC and nFPIC may be lower than the commonly accepted benchmark value for cost effectiveness, based on published estimates of the utility losses associated with asthma symptoms. Single-inhaler salmeterol/fluticasone propionate may also be more cost effective than leukotriene modifiers.
哮喘是美国最常见的慢性疾病之一，其患病率持续上升。尽管有有效的哮喘控制药物，但由于疾病管理不善，许多哮喘患者仍未达到治疗目标。哮喘的高患病率以及与管理不善相关的高成本，使得哮喘患者成为管理式医疗组织（MCO）治疗成本高昂的群体，这促使MCO的决策者考虑哮喘治疗的临床和经济价值。
从MCO支付方的角度比较一线控制哮喘疗法在轻度至中度持续性哮喘患者中的成本效益。
开发了一个决策分析模型，以评估与丙酸氟替卡松吸入性糖皮质激素（FPIC）、非丙酸氟替卡松吸入性糖皮质激素（nFPIC）和白三烯调节剂相比，使用单一吸入器（沙美特罗/丙酸氟替卡松50/100微克）给药的丙酸氟替卡松和沙美特罗的成本效益。该模型估计了1年内的成本（2005年美元价值）和健康结果。成本和结果数据来自已发表的临床试验和观察性研究，专家小组评估了关于依从性与有效性之间关系的模型假设。有效性指标包括无症状天数和无需使用急救药物的天数。采用逐步方法比较一线哮喘疗法的成本效益，以FPIC作为参考案例。进行了单向和概率敏感性分析，以评估一系列假设下结果的稳健性。
逐步比较发现，与FPIC相比，使用单一吸入器沙美特罗/丙酸氟替卡松实现一个增量有效性单位（增量成本效益比）的额外成本为每无症状天9.55美元，每无需使用急救药物天8.93美元。敏感性分析表明，该模型对基础案例假设的变化具有稳健性。概率敏感性分析表明，对应于每无症状天14.8美元的基准值，单一吸入器沙美特罗/丙酸氟替卡松、n-FPIC和白三烯调节剂比FPIC更具成本效益的概率分别为98%、30.7%和2.1%。
基于我们的决策分析，与FPIC和nFPIC相比，使用单一吸入器沙美特罗/丙酸氟替卡松治疗实现增量有效性的额外成本可能低于基于已发表的与哮喘症状相关的效用损失估计的普遍接受的成本效益基准值。单一吸入器沙美特罗/丙酸氟替卡松也可能比白三烯调节剂更具成本效益。
