Trenaman Logan, Sadatsafavi Mohsen, Almeida Fernanda, Ayas Najib, Lynd Larry, Marra Carlo, Stacey Dawn, Bansback Nick
School of Population and Public Health, University of British Columbia, Vancouver, Canada (LT,NB)
Center for Clinical Epidemiology and Evaluation, Vancouver Coastal Health Research Institute, Vancouver, Canada (LT, MS, NA, NB)
Med Decis Making. 2015 Jul;35(5):671-82. doi: 10.1177/0272989X14556676. Epub 2014 Oct 24.
There is increasing evidence highlighting the effectiveness of patient decision aids (PtDAs), but evidence supporting their cost-effectiveness is lacking. We consider patients with obstructive sleep apnea (OSA), in whom a PtDA may decrease nonadherence to treatment by empowering patients to receive the option that is most congruent with their own values.
To determine the potential costs and benefits of delivering a PtDA to patients with moderate OSA.
A Markov cohort decision-analytic model was developed for patients with moderate OSA, comparing a PtDA to usual care over 5 years from a societal perspective. Data for patient preference for treatment options was taken from a recent randomized crossover trial, event data (cardiovascular, motor vehicle accidents) came from national databases and published literature. Potential improvements in adherence are unknown, so we considered a realistic range of values. Outcome measures were 5-year costs (in 2010 Canadian dollars), quality-adjusted life years (QALYs), and the incremental cost-effectiveness ratio (ICER).
When adherence to treatment was unchanged, the PtDA strategy was dominated by incurring lower QALYs and higher costs. When nonadherence was decreased by 20% in the PtDA arm (corresponding to an increase in adherence from 63% to 70% for continuous positive airway pressure and from 77% to 82% for mandibular advancement splints in year 1), the ICER fell to $62,414/QALY. Costs associated with the treatment devices and delivering the PtDA had the greatest effect on cost-effectiveness.
The model relies on surrogate measures and opinions for key parameters.
The cost-effectiveness of PtDAs will depend on contextual factors, but a framework is described for properly considering their long-term cost-effectiveness. A number of important questions around the appropriateness of benefit measurement for PtDA trials are highlighted.
越来越多的证据表明患者决策辅助工具（PtDAs）具有有效性，但支持其成本效益的证据却很缺乏。我们考虑阻塞性睡眠呼吸暂停（OSA）患者，PtDAs 可能通过使患者能够选择与其自身价值观最相符的治疗方案来减少治疗不依从性。
确定为中度 OSA 患者提供 PtDAs 的潜在成本和收益。
为中度 OSA 患者建立了一个马尔可夫队列决策分析模型，从社会角度比较了 PtDAs 与常规护理在 5 年期间的情况。患者对治疗方案偏好的数据取自最近的一项随机交叉试验，事件数据（心血管疾病、机动车事故）来自国家数据库和已发表的文献。依从性的潜在改善情况未知，因此我们考虑了一系列现实的取值范围。结果指标为 5 年成本（以 2010 年加拿大元计）、质量调整生命年（QALYs）以及增量成本效益比（ICER）。
当治疗依从性不变时，PtDAs 策略的 QALYs 较低且成本较高，处于劣势。当 PtDAs 组的不依从性降低 20%（相当于持续气道正压通气治疗的依从性从第 1 年的 63%提高到 70%，下颌前移矫治器的依从性从 77%提高到 82%）时，ICER 降至 62,414 美元/QALY。与治疗设备和提供 PtDAs 相关的成本对成本效益影响最大。
该模型依赖于关键参数的替代指标和观点。
PtDAs 的成本效益将取决于具体情况，但描述了一个用于恰当考虑其长期成本效益的框架。强调了围绕 PtDA 试验效益测量适当性的一些重要问题。
