Patel Niraj, Malicka Alicja N, McGinnity Siobhan, Anderson Richard B, Paolini Antonio G, Crosland Paul
Deakin University, Geelong, Australia, School of Health and Social Development, Faculty of Health, Institute for Health Transformation, Deakin Health Economics.
Department of Speech Pathology, Orthoptics and Audiology, School of Allied Health, Human Services and Sport, La Trobe University, Bundoora, Victoria, Australia.
Ear Hear. 2022 Mar/Apr;43(2):507-518. doi: 10.1097/AUD.0000000000001112.
The aim of this study was to conduct an economic evaluation for the treatment of subjective tinnitus using different modalities of cognitive behavioral therapy (CBT) in Australia.
A decision tree model was used to conduct a cost-utility analysis for CBT to determine the cost effectiveness for tinnitus treatments, in terms of cost per responder and cost per quality-adjusted life-year (QALY), from a health system perspective using a 2-year time horizon. Meta-analysis was used to differentiate the levels of effectiveness between three delivery methods for CBT: individual face-to-face care (fCBT), group sessions (gCBT), and a supported internet program (iCBT). One-way sensitivity analysis and probabilistic sensitivity analysis (PSA) explored the uncertainty surrounding model inputs and outcomes. Results were presented as incremental cost-effectiveness ratios compared with no treatment, and as net monetary benefit at a $50,000 willingness-to-pay threshold.
Compared with no treatment, the incremental cost per responder was $700 for gCBT, $871 for iCBT, and $1380 for fCBT. The base case incremental cost-effectiveness ratio was $35,363 per QALY for fCBT, $17,935 per QALY for gCBT, and $22,321 per QALY for iCBT compared with no treatment, although there was substantial uncertainty around the QALY gain for responders. Net monetary benefit was $356 (fCBT), $555 (gCBT), and $487 (iCBT), indicating the treatments were cost effective compared with no treatment. One-way sensitivity analysis revealed the results were most sensitive to the probability of a positive response to treatment and treatment length. The PSA found the probability of being cost effective compared with no treatment for gCBT was 99.8%, iCBT 98.4%, and fCBT 71.5% at a willingness-to-pay of $50,000 per QALY, although QALY gain remained at a fixed value in the PSA.
CBT for tinnitus was likely to be cost effective compared with no treatment regardless of treatment modality, assuming they are not mutually exclusive. Of the interventions, gCBT was the lowest cost per responder and lowest cost per QALY. Internet CBT obtained comparable economic outcomes due to similar treatment effectiveness and cost. Group CBT and iCBT warrant greater adoption in clinical practice for the treatment of subjective tinnitus. Further research on preference-based utility measures for varying levels of tinnitus severity and the durability of treatment effect is required to enhance the quality of economic evaluation in this field.
本研究旨在对澳大利亚使用不同形式的认知行为疗法（CBT）治疗主观性耳鸣进行经济学评估。
采用决策树模型对CBT进行成本效用分析，以从卫生系统角度，使用2年时间跨度，根据每位有反应者的成本和每质量调整生命年（QALY）的成本，确定耳鸣治疗的成本效益。荟萃分析用于区分CBT三种实施方式之间的有效性水平：个体面对面治疗（fCBT）、团体治疗（gCBT）和支持性互联网项目（iCBT）。单向敏感性分析和概率敏感性分析（PSA）探讨了模型输入和结果周围的不确定性。结果以与未治疗相比的增量成本效益比呈现，并以每QALY支付意愿阈值为50,000美元时的净货币效益呈现。
与未治疗相比，gCBT每位有反应者的增量成本为700美元，iCBT为871美元，fCBT为1380美元。与未治疗相比，基础病例的增量成本效益比为fCBT每QALY 35,363美元，gCBT每QALY 17,935美元，iCBT每QALY 22,321美元，尽管有反应者的QALY增益存在很大不确定性。净货币效益为fCBT 356美元，gCBT 555美元，iCBT 487美元，表明与未治疗相比，这些治疗具有成本效益。单向敏感性分析显示，结果对治疗阳性反应的概率和治疗时长最为敏感。PSA发现，在每QALY支付意愿为50,000美元时，与未治疗相比，gCBT具有成本效益的概率为99.8%，iCBT为98.4%，fCBT为71.5%，尽管在PSA中QALY增益保持在固定值。
假设耳鸣的CBT治疗方式并非相互排斥，与未治疗相比，无论采用何种治疗方式，CBT治疗主观性耳鸣可能都具有成本效益。在这些干预措施中，gCBT每位有反应者的成本最低，每QALY的成本也最低。由于治疗效果和成本相似，互联网CBT获得了可比的经济结果。团体CBT和iCBT在临床实践中更值得采用以治疗主观性耳鸣。需要进一步研究基于偏好的效用测量方法，以评估不同程度耳鸣严重程度和治疗效果的持久性，从而提高该领域经济评估的质量。
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