Department of Health Services Research, CAPHRI Care and Public Health Research Institute, Maastricht University, Maastricht, Limburg, The Netherlands.
School of Population and Public Health, University of British Columbia, Vancouver, BC, Canada.
Med Decis Making. 2020 Nov;40(8):1003-1019. doi: 10.1177/0272989X20961091.
Up to 31% of patients with relapsing-remitting multiple sclerosis (RRMS) discontinue treatment with disease-modifying drug (DMD) within the first year, and of the patients who do continue, about 40% are nonadherent. Shared decision making may decrease nonadherence and discontinuation rates, but evidence in the context of RRMS is limited. Shared decision making may, however, come at additional costs. This study aimed to explore the potential cost-effectiveness of shared decision making for RRMS in comparison with usual care, from a (limited) societal perspective over a lifetime.
An exploratory economic evaluation was conducted by adapting a previously developed state transition model that evaluates the cost-effectiveness of a range of DMDs for RRMS in comparison with the best supportive care. Three potential effects of shared decision making were explored: 1) a change in the initial DMD chosen, 2) a decrease in the patient's discontinuation in using the DMD, and 3) an increase in adherence to the DMD. One-way and probabilistic sensitivity analyses of a scenario that combined the 3 effects were conducted.
Each effect separately and the 3 effects combined resulted in higher quality-adjusted life years (QALYs) and costs due to the increased utilization of DMD. A decrease in discontinuation of DMDs influenced the incremental cost-effectiveness ratio (ICER) most. The combined scenario resulted in an ICER of €17,875 per QALY gained. The ICER was sensitive to changes in several parameters.
This study suggests that shared decision making for DMDs could potentially be cost-effective, especially if shared decision making would help to decrease treatment discontinuation. Our results, however, may depend on the assumed effects on treatment choice, persistence, and adherence, which are actually largely unknown.
多达 31%的复发缓解型多发性硬化症（RRMS）患者在第一年停止使用疾病修正治疗药物（DMD），而继续使用的患者中约有 40%不遵医嘱。共同决策可能会降低不遵医嘱和停药率，但 RRMS 背景下的证据有限。然而，共同决策可能会带来额外的成本。本研究旨在从（有限）社会角度探讨 RRMS 共同决策的潜在成本效益，与常规护理相比，终身比较。
通过改编先前开发的状态转换模型，对 RRMS 中一系列 DMD 与最佳支持治疗相比的成本效益进行了探索性经济评估。探讨了共同决策的三种潜在影响：1）初始 DMD 选择的变化，2）患者停止使用 DMD 的减少，3）对 DMD 的依从性增加。对结合了这三种效果的方案进行了单因素和概率敏感性分析。
每种效果单独以及三种效果的结合导致更高的质量调整生命年（QALYs）和成本，因为 DMD 的利用率增加。DMD 停药率的降低对增量成本效果比（ICER）的影响最大。联合方案的 ICER 为每获得一个 QALY 增加 17875 欧元。ICER 对几个参数的变化很敏感。
本研究表明，DMD 的共同决策可能具有成本效益，特别是如果共同决策有助于减少治疗中断。然而，我们的结果可能取决于对治疗选择、持续时间和依从性的影响，而这些实际上是很大程度上未知的。
