Section of Gastroenterology and Hepatology, Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire.
Section of Gastroenterology and Hepatology, Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire; Department of Psychiatry, Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire.
Clin Gastroenterol Hepatol. 2022 Jan;20(1):136-144.e31. doi: 10.1016/j.cgh.2020.09.043. Epub 2020 Oct 1.
Irritable bowel syndrome (IBS) is one of the most expensive gastroenterological conditions and is an ideal target for developing a value-based care model. We assessed the comparative cost-benefit of treatments for IBS with diarrhea (IBS-D), the most common IBS subtype from insurer and patient perspectives.
We constructed a decision analytic model assessing trade-offs among guideline-recommended and recently FDA-approved drugs, supplements, low FODMAP diet, cognitive behavioral therapy (CBT). Outcomes and costs were derived from systematic reviews of clinical trials and national databases. Health-gains were represented using quality-adjusted life years (QALY).
From an insurer perspective, on-label prescription drugs (rifaximin, eluxadoline, alosetron) were significantly more expensive than off-label treatments, low FODMAP, or CBT. Insurer treatment preferences were driven by average wholesale prescription drug prices and were not affected by health gains in sensitivity analysis within standard willingness-to-pay ranges up to $150,000/QALY-gained. From a patient perspective, prescription drug therapies and neuromodulators appeared preferable due to a reduction in lost wages due to IBS with effective therapy, and also considering out-of-pocket costs of low FODMAP food and out-of-pocket costs to attend CBT appointments. Comparative health outcomes exerted influence on treatment preferences from a patient perspective in cost-benefit analysis depending on a patients' willingness-to-pay threshold for additional health-gains, but health outcomes were less important than out-of-pocket costs at lower willingness-to-pay thresholds.
Costs are critical determinants of IBS treatment value to patients and insurers, but different costs drive patient and insurer treatment preferences. Divergent cost drivers appear to explain misalignment between patient and insurer IBS treatment preferences in practice.
肠易激综合征（IBS）是最昂贵的肠胃病之一，是开发基于价值的护理模式的理想目标。我们从保险公司和患者的角度评估了腹泻型肠易激综合征（IBS-D）的治疗方法的成本效益比较。
我们构建了一个决策分析模型，评估了指南推荐的和最近 FDA 批准的药物、补充剂、低 FODMAP 饮食、认知行为疗法（CBT）之间的权衡。结果和成本来自于临床试验和国家数据库的系统评价。健康收益用质量调整生命年（QALY）表示。
从保险公司的角度来看，标签内的处方药（利福昔明、鲁比前列酮、阿洛司琼）比标签外的治疗方法、低 FODMAP 或 CBT 更昂贵。保险公司的治疗偏好受平均批发处方药价格的驱动，在标准支付意愿范围内的敏感性分析中，健康收益不影响治疗偏好，支付意愿高达 150000 美元/QALY。从患者的角度来看，由于有效的治疗方法减少了因 IBS 而导致的工资损失，而且还考虑了低 FODMAP 食物的自付费用和参加 CBT 预约的自付费用，处方药物治疗和神经调节剂似乎更可取。在成本效益分析中，治疗效果取决于患者对额外健康收益的支付意愿阈值，因此治疗效果对患者的治疗偏好有影响，但在较低的支付意愿阈值下，治疗效果不如自付费用重要。
成本是患者和保险公司对 IBS 治疗价值的关键决定因素，但不同的成本驱动了患者和保险公司的治疗偏好。不同的成本驱动因素似乎可以解释患者和保险公司在实践中 IBS 治疗偏好的不一致。
