Elsisi Gihan H, Eldessouki Randa, Kalo Zoltan, Elmazar Mohamed M, Taha Ahmed S, Awad Basma F, El-Hamamsy Manal H
Pharmacoeconomic Unit, Central Administration for Pharmaceutical Affairs, Cairo, Egypt.
Scientific and Health Policy Initiatives, International Society for Pharmacoeconomics and Outcomes Research, NJ, USA; Faculty of Medicine, Fayoum University, Al Fayoum, Egypt.
Value Health Reg Issues. 2014 Sep;4:24-30. doi: 10.1016/j.vhri.2014.06.004. Epub 2014 Jul 8.
The combination of antiplatelet and anticoagulant therapy significantly reduces the rate of thromboembolic events in patients with heart valves compared with anticoagulant therapy alone. Cost-effectiveness of this therapy in Egypt, however, has not yet been established.
The aim of the present study was to evaluate the cost-effectiveness of the combined use of warfarin and low-dose aspirin (100 mg) versus warfarin alone in patients with mechanical aortic heart valve prostheses who began therapy at the age of 50 to 60 years over a 5-year period from the perspective of the medical providers.
A cohort Markov process model with five health states (recovery, reoperation, bleeding, thromboembolism, and death) based on Egyptian clinical practice was derived from published sources. The clinical parameters were derived from meta-analyses of randomized controlled trials of patients with mechanical valve prostheses. The quality of life of the health states was derived using the available published data. Direct medical costs were obtained from four top-rated governmental cardiology hospitals in Egypt. All costs and effects were discounted at 3.5% annually. All costs were converted using the purchasing power parity rate and are reported in US $ for the financial year of 2013.
The total quality-adjusted life-years (QALYs) were estimated to be 1.1616 and 1.1199 for the warfarin plus aspirin group and the warfarin group, respectively, which resulted in a difference of 0.0416 QALYs. The total costs for the warfarin plus aspirin group and the warfarin group were US $307.33 and US $315.25, respectively (the difference was US $7.92), which yielded an incremental cost-effectiveness ratio of -190.38 for the warfarin plus aspirin group. Thus, the combined therapy was dominant. Various one-way sensitivity analyses indicated that probabilities of reoperation and bleeding in the recovery state had the greatest effects on incremental costs. The model parameters that had the greatest effects on incremental QALYs were the relative risk reduction of death and the utility value in the recovery state.
The present study is the first cost-utility analysis to conclude that, from the perspective of Egyptian medical providers, combined therapy is more effective and less costly than warfarin alone for patients with mechanical aortic valve prostheses. For clinicians and patients who choose to focus on minimizing thromboembolic risk, these results suggest that combined therapy offers the best protection. This study helps to inform decisions about the allocation of health care system resources and to achieve better health in the Egyptian population.
与单独使用抗凝治疗相比，抗血小板和抗凝联合治疗可显著降低心脏瓣膜病患者的血栓栓塞事件发生率。然而，该治疗方法在埃及的成本效益尚未确定。
本研究旨在从医疗服务提供者的角度，评估华法林与低剂量阿司匹林（100毫克）联合使用与单独使用华法林，在年龄为50至60岁的机械主动脉心脏瓣膜置换术后患者中，进行为期5年治疗的成本效益。
基于埃及临床实践，从已发表的资料中得出一个具有五个健康状态（康复、再次手术、出血、血栓栓塞和死亡）的队列马尔可夫过程模型。临床参数来自机械瓣膜置换术患者随机对照试验的荟萃分析。健康状态的生活质量通过现有已发表数据得出。直接医疗成本来自埃及四家顶级政府心脏病医院。所有成本和效果均按每年3.5%进行贴现。所有成本均使用购买力平价汇率进行换算，并以2013财年的美元报告。
华法林加阿司匹林组和华法林组的总质量调整生命年（QALY）分别估计为1.1616和1.1199，相差0.0416个QALY。华法林加阿司匹林组和华法林组的总成本分别为307.33美元和315.25美元（相差7.92美元），华法林加阿司匹林组的增量成本效益比为 -190.38。因此，联合治疗占主导地位。各种单向敏感性分析表明，康复状态下再次手术和出血的概率对增量成本影响最大。对增量QALY影响最大的模型参数是死亡相对风险降低率和康复状态下的效用值。
本研究是首个成本效用分析，得出从埃及医疗服务提供者的角度来看，对于机械主动脉瓣膜置换术患者，联合治疗比单独使用华法林更有效且成本更低。对于选择专注于最小化血栓栓塞风险的临床医生和患者来说，这些结果表明联合治疗提供了最佳保护。本研究有助于为医疗保健系统资源分配决策提供信息，并在埃及人群中实现更好的健康状况。
