Pillai Nadia, Dusheiko Mark, Burnand Bernard, Pittet Valérie
Institute of Social and Preventive Medicine (IUMSP), Lausanne University Hospital, Lausanne, Switzerland.
Centre for Health Economics, University of York, York, United Kingdom.
PLoS One. 2017 Oct 3;12(10):e0185500. doi: 10.1371/journal.pone.0185500. eCollection 2017.
Inflammatory bowel disease (IBD) is a chronic disease placing a large health and economic burden on health systems worldwide. The treatment landscape is complex with multiple strategies to induce and maintain remission while avoiding long-term complications. The extent to which rising treatment costs, due to expensive biologic agents, are offset by improved outcomes and fewer hospitalisations and surgeries needs to be evaluated. This systematic review aimed to assess the cost-effectiveness of treatment strategies for IBD.
A systematic literature search was performed in March 2017 to identify economic evaluations of pharmacological and surgical interventions, for adults diagnosed with Crohn's disease (CD) or ulcerative colitis (UC). Costs and incremental cost-effectiveness ratios (ICERs) were adjusted to reflect 2015 purchasing power parity (PPP). Risk of bias assessments and a narrative synthesis of individual study findings are presented.
Forty-nine articles were included; 24 on CD and 25 on UC. Infliximab and adalimumab induction and maintenance treatments were cost-effective compared to standard care in patients with moderate or severe CD; however, in patients with conventional-drug refractory CD, fistulising CD and for maintenance of surgically-induced remission ICERs were above acceptable cost-effectiveness thresholds. In mild UC, induction of remission using high dose mesalazine was dominant compared to standard dose. In UC refractory to conventional treatments, infliximab and adalimumab induction and maintenance treatment were not cost-effective compared to standard care; however, ICERs for treatment with vedolizumab and surgery were favourable.
We found that, in general, while biologic agents helped improve outcomes, they incurred high costs and therefore were not cost-effective, particularly for use as maintenance therapy. The cost-effectiveness of biologic agents may improve as market prices fall and with the introduction of biosimilars. Future research should identify optimal treatment strategies reflecting routine clinical practice, incorporate indirect costs and evaluate lifetime costs and benefits.
炎症性肠病（IBD）是一种慢性疾病，给全球卫生系统带来了巨大的健康和经济负担。治疗方案复杂，有多种诱导和维持缓解同时避免长期并发症的策略。昂贵的生物制剂导致治疗成本上升，而改善的治疗效果、减少的住院和手术次数能在多大程度上抵消这些成本，仍有待评估。本系统评价旨在评估IBD治疗策略的成本效益。
2017年3月进行了系统的文献检索，以确定针对诊断为克罗恩病（CD）或溃疡性结肠炎（UC）的成人患者的药物和手术干预的经济学评价。成本和增量成本效益比（ICER）经调整以反映2015年购买力平价（PPP）。呈现了偏倚风险评估和对各个研究结果的叙述性综合分析。
纳入49篇文章；24篇关于CD，25篇关于UC。在中度或重度CD患者中，英夫利昔单抗和阿达木单抗的诱导和维持治疗与标准治疗相比具有成本效益；然而，在传统药物难治性CD患者、瘘管性CD患者以及维持手术诱导缓解方面，ICER高于可接受的成本效益阈值。在轻度UC中，与标准剂量相比，使用高剂量美沙拉嗪诱导缓解占主导地位。在对传统治疗难治的UC中，与标准治疗相比，英夫利昔单抗和阿达木单抗的诱导和维持治疗不具有成本效益；然而，维多珠单抗治疗和手术的ICER是有利的。
我们发现，总体而言，虽然生物制剂有助于改善治疗效果，但它们成本高昂，因此不具有成本效益，特别是用作维持治疗时。随着市场价格下降和生物类似药的推出，生物制剂的成本效益可能会提高。未来的研究应确定反映常规临床实践的最佳治疗策略，纳入间接成本并评估终身成本和效益。
