Inflammatory Bowel Disease Unit, University of Calgary, Calgary, Alberta, Canada.
Division of Gastroenterology, Icahn School of Medicine Vanasek, Division of Gastroenterology and Hepatology, New York, New York, USA.
Gut. 2020 Apr;69(4):658-664. doi: 10.1136/gutjnl-2019-318256. Epub 2019 Jul 8.
To evaluate the cost-effectiveness of an inflammatory biomarker and clinical symptom directed tight control strategy (TC) compared with symptom-based clinical management (CM) in patients with Crohn's disease (CD) naïve to immunosuppressants and biologics using a UK public payer perspective.
A regression model estimated weekly CD Activity Index (CDAI)-based transition matrices (remission: CDAI <150, moderate: CDAI ≥150 to <300, severe: CDAI ≥300 to <450, very severe: CDAI ≥450) based on the Effect of Tight Control Management on Crohn's Disease (CALM) trial. A regression predicted hospitalisations. Health utilities and costs were applied to health states. Work productivity was monetised and included in sensitivity analyses. Remission rate, CD-related hospitalisations, adalimumab injections, other direct medical costs, quality-adjusted life-years (QALYs) and incremental cost-effectiveness ratio (ICER) were calculated.
Over 48 weeks, TC was associated with a higher clinical remission (CDAI <150) rate (58.2% vs 46.8%), fewer CD-related hospitalisations (0.124 vs 0.297 events per patient) and more injections of adalimumab (40 mg sc) (mean 31.0 vs 24.7) than CM. TC was associated with 0.032 higher QALYs and £593 higher total medical costs. The ICER was £18 656 per QALY. The ICER was cost-effective in 57.9% of simulations. TC became dominant, meaning less costly but more effective, when work productivity was included.
A TC strategy as used in the CALM trial is cost-effective compared with CM. Incorporating costs related to work productivity increases the economic value of TC. Cross-national inferences from this analysis should be made with caution given differences in healthcare systems.
NCT01235689; Results.
采用英国公共支付者视角，评估炎症生物标志物与临床症状指导的紧密控制策略（TC）与基于症状的临床管理（CM）相比，在未曾使用免疫抑制剂和生物制剂的克罗恩病（CD）患者中的成本效益。
回归模型根据 Effect of Tight Control Management on Crohn's Disease（CALM）试验估计了每周基于 CD 活动指数（CDAI）的转换矩阵（缓解：CDAI＜150、中度：CDAI≥150 至＜300、重度：CDAI≥300 至＜450、非常重度：CDAI≥450）。回归预测了住院治疗。健康效用和成本应用于健康状态。工作生产力被货币化并纳入敏感性分析。缓解率、CD 相关住院治疗、阿达木单抗注射、其他直接医疗费用、质量调整生命年（QALY）和增量成本效益比（ICER）计算。
在 48 周内，TC 与更高的临床缓解率（CDAI＜150）（58.2%比 46.8%）、更少的 CD 相关住院治疗（0.124 比 0.297 例/患者）和更多的阿达木单抗注射（40mg sc）（平均 31.0 比 24.7）有关，而 CM 则较低。TC 与 0.032 更高的 QALY 和 593 英镑更高的总医疗费用相关。ICER 为每 QALY 18656 英镑。在 57.9%的模拟中，TC 是具有成本效益的。当纳入工作生产力成本时，TC 成为主导策略，这意味着成本更低但效果更好。
与 CM 相比，CALM 试验中使用的 TC 策略具有成本效益。纳入与工作生产力相关的成本增加了 TC 的经济价值。鉴于医疗保健系统的差异，应谨慎从这项分析中进行跨国推断。
NCT01235689；结果。
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