Ross Eric L, Soeteman Djøra I
Department of Psychiatry, McLean Hospital, Belmont, Massachusetts (Ross); Department of Psychiatry, Massachusetts General Hospital (Ross), Department of Psychiatry, Harvard Medical School (Ross), and Center for Health Decision Science, Harvard T. H. Chan School of Public Health, all in Boston (Soeteman).
Psychiatr Serv. 2020 Oct 1;71(10):988-997. doi: 10.1176/appi.ps.201900625. Epub 2020 Jul 7.
This study aimed to estimate the cost-effectiveness of esketamine, a novel intranasally dosed antidepressant, for patients in the United States with treatment-resistant depression.
A decision-analytic model parameterized with efficacy data from phase 3 randomized trials of esketamine was used to simulate the effects of treatment with esketamine versus oral antidepressants over a 5-year horizon, from both societal and health care sector perspectives. Outcomes included remission and response of depression, quality-adjusted life-years (QALYs), costs, and incremental cost-effectiveness ratios (ICERs) for esketamine. Value-based prices were calculated, defined as the per-dose price at which esketamine would become cost-effective given cost-effectiveness thresholds of $50,000/QALY, $100,000/QALY, and $150,000/QALY. Uncertainty in these outcomes was assessed with probabilistic sensitivity analyses. Key model parameters included the efficacy of esketamine versus oral antidepressants (relative risk of 1.39 for remission; 1.32 for response) and the monthly cost of esketamine ($5,572 for month 1; $1,699-$2,244 thereafter).
Over 5 years, esketamine was projected to increase time in remission from 25.3% to 31.1% of life-years, resulting in a gain of 0.07 QALYs. Esketamine increased societal costs by $16,617 and health care sector costs by $16,995. Base case ICERs were $237,111/QALY (societal) and $242,496/QALY (health care sector). Probabilistic sensitivity analysis showed a greater than 95% likelihood that esketamine's ICER would be above $150,000/QALY. At a cost-effectiveness threshold of $150,000/QALY, esketamine's value-based price was approximately $140/dose (versus a current price of $240/dose).
Esketamine is unlikely to be cost-effective for management of treatment-resistant depression in the United States unless its price falls by more than 40%.
本研究旨在评估艾氯胺酮（一种新型鼻腔给药的抗抑郁药）对美国难治性抑郁症患者的成本效益。
采用一个决策分析模型，该模型用艾氯胺酮3期随机试验的疗效数据进行参数化，从社会和医疗保健部门的角度，模拟5年内艾氯胺酮与口服抗抑郁药治疗的效果。结果包括抑郁症的缓解和反应、质量调整生命年（QALY）、成本以及艾氯胺酮的增量成本效益比（ICER）。计算了基于价值的价格，定义为在成本效益阈值为每QALY 50,000美元、100,000美元和150,000美元的情况下，艾氯胺酮具有成本效益的每剂价格。通过概率敏感性分析评估这些结果的不确定性。关键模型参数包括艾氯胺酮与口服抗抑郁药的疗效（缓解的相对风险为1.39；反应的相对风险为1.32）以及艾氯胺酮的每月成本（第1个月为5,572美元；此后为1,699 - 2,244美元）。
在5年期间，预计艾氯胺酮可将缓解时间占生命年的比例从25.3%提高到31.1%，从而使QALY增加0.07。艾氯胺酮使社会成本增加了16,617美元，医疗保健部门成本增加了16,995美元。基础病例ICER为每QALY 237,111美元（社会）和每QALY 242,496美元（医疗保健部门）。概率敏感性分析表明，艾氯胺酮的ICER高于每QALY 150,000美元的可能性大于95%。在成本效益阈值为每QALY 150,000美元时，艾氯胺酮基于价值的价格约为每剂140美元（而当前价格为每剂240美元）。
在美国，艾氯胺酮用于难治性抑郁症的管理不太可能具有成本效益，除非其价格下降超过40%。
