Najafzadeh M, Marra C A, Sadatsafavi M, Aaron S D, Sullivan S D, Vandemheen K L, Jones P W, Fitzgerald J M
Faculty of Pharmaceutical Sciences, University of British Columbia, Vancouver, British Columbia, Canada.
Thorax. 2008 Nov;63(11):962-7. doi: 10.1136/thx.2007.089557. Epub 2008 Jul 11.
Little is known about the combination of different medications in chronic obstructive pulmonary disease (COPD). This study determined the cost effectiveness of adding salmeterol (S) or fluticasone/salmeterol (FS) to tiotropium (T) for COPD.
This concurrent, prospective, economic analysis was based on costs and health outcomes from a 52 week randomised study comparing: (1) T 18 microg once daily + placebo twice daily (TP group); (2) T 18 microg once daily + S 25 microg/puff, 2 puffs twice daily (TS group); and (3) T 18 microg once daily + FS 250/25 microg/puff, 2 puffs twice daily (TFS group). The incremental cost effectiveness ratios (ICERs) were defined as incremental cost per exacerbation avoided, and per additional quality adjusted life year (QALY) between treatments. A combination of imputation and bootstrapping was used to quantify uncertainty, and extensive sensitivity analyses were performed.
The average patient in the TP group generated CAN$2678 in direct medical costs compared with $2801 (TS group) and $4042 (TFS group). The TS strategy was dominated by TP and TFS. Compared with TP, the TFS strategy resulted in ICERs of $6510 per exacerbation avoided, and $243,180 per QALY gained. In those with severe COPD, TS resulted in equal exacerbation rates and slightly lower costs compared with TP.
TFS had significantly better quality of life and fewer hospitalisations than patients treated with TP but these improvements in health outcomes were associated with increased costs. Neither TFS nor TS are economically attractive alternatives compared with monotherapy with T.
关于慢性阻塞性肺疾病（COPD）中不同药物联合使用的情况，人们了解甚少。本研究确定了在COPD患者中，在噻托溴铵（T）基础上加用沙美特罗（S）或氟替卡松/沙美特罗（FS）的成本效益。
本同步、前瞻性经济分析基于一项为期52周的随机研究的成本和健康结局，该研究比较了：（1）每日一次18微克T+每日两次安慰剂（TP组）；（2）每日一次18微克T+每吸25微克S，每日两次，每次2吸（TS组）；（3）每日一次18微克T+每吸250/25微克FS，每日两次，每次2吸（TFS组）。增量成本效益比（ICER）定义为每次避免的加重事件的增量成本，以及各治疗组之间每增加一个质量调整生命年（QALY）的增量成本。采用插补法和自抽样法相结合来量化不确定性，并进行了广泛的敏感性分析。
TP组患者的平均直接医疗成本为2678加元，TS组为2801加元，TFS组为4042加元。TS策略被TP和TFS策略所主导。与TP相比，TFS策略的ICER为每次避免加重事件6510加元，每获得一个QALY为243,180加元。在重度COPD患者中，TS组与TP组的加重率相同，但成本略低。
与接受TP治疗的患者相比，TFS组患者的生活质量明显更好，住院次数更少，但这些健康结局的改善与成本增加相关。与T单药治疗相比，TFS和TS在经济上都不是有吸引力的替代方案。
