Dhalla Irfan A, Smith Monique A, Choudhry Niteesh K, Denburg Avram E
Keenan Research Centre, Li Ka Shing Knowledge Institute, St. Michael's Hospital, Departments of Medicine and Health Policy, Management and Evaluation, University of Toronto, Toronto, ON.
Healthc Policy. 2009 Nov;5(2):68-86.
Although combination pharmacotherapy after myocardial infarction dramatically reduces morbidity and mortality, the full benefits of secondary prevention medications remain unrealized owing to medication non-adherence. Because financial barriers are a major determinant of non-adherence, we examined the costs and benefits of providing free medications to myocardial infarction patients who do not have private insurance and are ineligible for substantial public coverage.
An economic evaluation combining decision analysis and Markov modelling was conducted to compare full public coverage of secondary prevention medications with the status quo. Costs and benefits were estimated using Canadian data wherever possible. The main outcome was the incremental cost-effectiveness ratio measured in cost per quality-adjusted life-year (QALY) gained.
From the perspective of the publicly funded healthcare system, full coverage resulted in greater quality-adjusted survival than the status quo (7.02 vs. 6.13 QALYs) but at increased cost ($20,423 vs. $17,173). The incremental cost-effectiveness ratio (ICER) for full coverage compared to the status quo was $3,663/QALY. This result was robust to a wide range of sensitivity analyses. In a secondary analysis from the perspective of government, the ICER for full coverage compared to the status quo was $12,350/QALY. In this analysis, the ICER was sensitive to changes in price elasticity, but remained below $50,000/QALY as long as the elasticity remained below -0.035.
Public payers in Canada should consider providing secondary prevention medications to myocardial infarction patients without private insurance free of charge. Full public coverage is cost-effective compared to the status quo.
尽管心肌梗死后联合药物治疗可显著降低发病率和死亡率，但由于药物治疗依从性不佳，二级预防药物的全部益处尚未实现。由于经济障碍是导致治疗依从性不佳的主要因素，我们研究了为没有私人保险且不符合大量公共保险资格的心肌梗死患者提供免费药物的成本和收益。
进行了一项结合决策分析和马尔可夫模型的经济评估，以比较二级预防药物的全面公共保险与现状。尽可能使用加拿大数据估算成本和收益。主要结果是以每获得一个质量调整生命年（QALY）的成本衡量的增量成本效益比。
从公共资助的医疗保健系统的角度来看，全面保险导致质量调整后的生存率高于现状（7.02个QALY对6.13个QALY），但成本增加（20,423美元对17,173美元）。与现状相比，全面保险的增量成本效益比（ICER）为3,663美元/QALY。这一结果在广泛的敏感性分析中是稳健的。从政府角度进行的二次分析中，与现状相比，全面保险的ICER为12,350美元/QALY。在此分析中，ICER对价格弹性的变化敏感，但只要弹性保持在-0.035以下，ICER就仍低于50,000美元/QALY。
加拿大的公共支付方应考虑为没有私人保险的心肌梗死患者免费提供二级预防药物。与现状相比，全面公共保险具有成本效益。
