Pitfalls in the economic evaluation of thrombolysis in myocardial infarction. The impact of national differences in the cost of thrombolytics and of differences in the efficacy across patient subgroups

Cost-effectiveness of immunoglobulin M-enriched immunoglobulin (Pentaglobin) in the treatment of severe sepsis and septic shock

PURPOSE

To measure the cost-effectiveness of a specific polyclonal intravenous immune globulin preparation (Pentaglobin) in adult patients treated for severe sepsis and septic shock.

MATERIALS AND METHODS

Effectiveness data from a meta-analysis of 9 randomized trials (N=435) were used to populate a decision model to estimate the cost-effectiveness of Pentaglobin and its comparator standard therapy from the hospital perspective in Germany.

PRIMARY OUTCOME

all-cause morality; secondary outcome: intensive care unit (ICU) length of stay. Benefit was expressed as lives saved (LS). Published cost data were applied to assess differences in ICU treatment costs. Cost-effectiveness was calculated as incremental cost per LS.

RESULTS

Pentaglobin reduced the risk of mortality (P<.001) but had no effect on ICU length of stay. A baseline risk of mortality of 0.4434 (risk ratio=0.5652; absolute risk reduction=0.1928; number-needed-to-treat=5.19) increased ICU treatment costs with Pentaglobin by 2,037 (22,711 vs 24,747) with a cost per LS of 10,565. Sensitivity analyses on baseline mortality risk (95% confidence interval 0.3293-0.5162) and risk ratio (95% confidence interval 0.4306-0.7420) yielded a cost per LS range of 5,715 to 28,443 with a 56.3% probability of cost-effectiveness of 12,000 or less.

CONCLUSIONS

Pentaglobin is a promising adjuvant therapy both clinically and economically for treatment of adults with severe sepsis and septic shock.

Cost-effectiveness of thrombolytics: a simplified model

OBJECTIVE OF THE STUDY

To construct a simple model for an internal, retrospective cost-effectiveness analysis and to calculate the incremental cost-effectiveness of tissue plasminogen activator (TPA) over streptokinase (SK) in Turkey.

SETTING

Koşuyolu Heart, Education and Research Hospital, Istanbul, Turkey.

METHOD

Among patients who were hospitalized for treatment of acute myocardial infarction (AMI), 196 were randomly selected. One-year mortality rates according to the treatment groups (TPA, SK, other) were determined. Among surviving patients, 28 from TPA and another 28 from SK group were randomly selected for the pharmacoeconomic analysis. Patient treatment data were taken from medical records while data regarding to costs were taken from hospital bills.

MAIN OUTCOME MEASURES

Incremental cost-effectiveness ratio (ICER). The cost part of the ratio was considered as 'the overall-costs', while the effectiveness part was considered as 'lives saved' per treatment group.

RESULTS

With an increased one-year survival rate of 2.37% and an increased cost of euro 1120.8 ($1165.6) per patient in the TPA group, the ICER for the use of TPA instead of SK was euro 47,289 ($49,180.6) per life saved.

CONCLUSION

This model can be a guide for similar analyses. The results of our study (the incremental cost-effectiveness of TPA over SK) will be informative for the decision-makers in Turkey, by whom the medical benefit for money spent would be assessed and judged. We believe that our results make a contribution to similar studies in the literature.

Variability of cost-effectiveness estimates for pharmaceuticals in Western Europe: lessons for inferring generalizability

OBJECTIVES

It has long been suggested that, whereas the results of clinical studies of pharmaceuticals are generalizable from one jurisdiction to another, the results of economic evaluations are location dependent. There has been, however, little study of the causes of variation, whether differences in study results among countries are systematic, or whether they are important for decision making.

METHODS

A literature search was conducted to identify economic evaluations of pharmaceuticals conducted in two or more European countries. The studies identified were then classified by methodological type and analyzed to assess their level of variability and to identify the main causes of variation. Assessments were also made of the extent to which differences in study results among countries were systematic and whether they would lead to a different decision, assuming a range of values of the threshold willingness-to-pay for a life-year or quality-adjusted life-year (QALY).

RESULTS

In total 46 intercountry drug comparisons were identified, 29 in multicountry studies and 17 in comparable single country studies that were considered to be sufficiently similar in terms of methodology. The type of study (i.e., trial-based or modeling study) had some impact on variability, but the most important factor was the extent of variation across countries in effectiveness, resource use or unit costs, allowed by the researcher's chosen methodology. There were few systematic differences in study results among countries, so a decision maker in country B, on seeing a recent economic evaluation of a new drug in country A, would have little basis on which to predict whether the drug, if evaluated, would be more or less cost-effective in his or her country. Given the extent of variation in cost-effectiveness estimates among countries, the importance of this for decision making depends on decision makers' thresholds in willingness-to-pay for a QALY or life-year. If a cost-effectiveness threshold (i.e., willingness-to-pay) for a life-year or QALY of dollar 50,000 were assumed, the same conclusion regarding cost-effectiveness would be reached in most cases.

CONCLUSION

This review shows that cost-effectiveness results for pharmaceuticals vary from country to country in Western Europe and that these variations are not systematic. In addition, constraints imposed by analysts may reduce apparent variability in the estimates. The lessons for inferring generalizability are not straightforward, although the implications of variation for decision making depend critically on the cost-effectiveness thresholds applying in Western Europe.

The limited incorporation of economic analyses in clinical practice guidelines

BACKGROUND

Because there is increasing concern that economic data are not used in the clinical guideline development process, our objective was to evaluate the extent to which economic analyses are incorporated in guideline development.

METHODS

We searched medline and HealthSTAR databases to identify English-language clinical practice guidelines (1996-1999) and economic analyses (1990-1998). Additional guidelines were obtained from The National Guidelines Clearinghouse Internet site available at http://www.guideline.gov. Eligible guidelines met the Institute of Medicine definition and addressed a topic included in an economic analysis. Eligible economic analyses assessed interventions addressed in a guideline and predated the guideline by 1 or more years. Economic analyses were defined as incorporated in guideline development if 1) the economic analysis or the results were mentioned in the text or 2) listed as a reference. The quality of economic analyses was assessed using a structured scoring system.

RESULTS

Using guidelines as the unit of analysis, 9 of 35 (26%) incorporated at least 1 economic analysis of above-average quality in the text and 11 of 35 (31%) incorporated at least 1 in the references. Using economic analyses as the unit of analysis, 63 economic analyses of above-average quality had opportunities for incorporation in 198 instances across the 35 guidelines. Economic analyses were incorporated in the text in 13 of 198 instances (7%) and in the references in 18 of 198 instances (9%).

CONCLUSIONS

Rigorous economic analyses may be infrequently incorporated in the development of clinical practice guidelines. A systematic approach to guideline development should be used to ensure the consideration of economic analyses so that recommendations from guidelines may impact both the quality of care and the efficient allocation of resources.

Changes in mortality of acute myocardial infarction as a function of a changing treatment during the last two decades

Forty years ago, after the establishment of coronary care units, a significant decrease in mortality of acute myocardial infarction was noted. Twenty years ago, the break-through of thrombolysis realized once again a significant decrease in mortality. In this study we compare, in a rather small community hospital, the mortality and safety of thrombolytic therapy in acute myocardial infarction with a more conventional, conservative medical therapy. We examined all cases of acute myocardial infarction between 1978 up to 1998 inclusive, concerning treatment and mortality rate after a six month period. To be included in the study, acute myocardial infarction had to fulfill particular inclusion criteria. A total of 1863 cases of acute myocardial infarction were included. The mortality rate of patients with acute myocardial infarction treated with thrombolytic agents was strikingly lower and statistically very significantly different (p < 0.001) in comparison with the mortality rate of patients treated with heparin or coumarine derivatives. The mortality rate dropped from 10.57% in the coumarine group and from 14.95% in the heparin group to 5.41% in the alteplase group, to 4.95% in the anistreplase group and 4.00% in the streptokinase subgroup. The complications directly connected to the treatment did not seem to be different between the five groups, and they were also not more frequent by using thrombolytic agents. In the last 20 years, better preventive measures (life habits, diet, medication) and trials to better control the risk factors have not influenced greatly the average amount of cholesterol in patients with an acute myocardial infarction. Also the percentage of patients with high blood pressure has hardly decreased over the last 20 years. The mortality associated with acute myocardial infarction has decreased significantly with the use of thrombolytics. In most cases, thrombolytics are administered routinely and safely. In this way, they are the first choice therapy for myocardial infarction in smaller hospitals. To obtain excellent coronary patency, thrombolytic agents with a long half-life and with PAI-1 resistance are required in the future. The current measures and medical therapies seem to be insufficient to control the risk factors for coronary atherosclerosis.