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Cost-effectiveness for the management of chronic heart failure: cost-effectiveness analysis of carvedilol for the treatment of chronic heart failure in Japan |
Inomata T |
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Record Status This is a critical abstract of an economic evaluation that meets the criteria for inclusion on NHS EED. Each abstract contains a brief summary of the methods, the results and conclusions followed by a detailed critical assessment on the reliability of the study and the conclusions drawn. Health technology The use of beta-blockers (carvedilol in particular) for chronic heart failure (CHF). The doses in the present study were not specified, but doses of 5 and 20 mg/day were mentioned from the literature.
Economic study type Cost-effectiveness analysis.
Study population The study population comprised hypothetical patients aged 60 years, who were suffering from CHF (NYHA II - III level).
Setting The setting was secondary care. The economic study was carried out at the Department of Internal Medicine and Cardiology, Kitasato University School of Medicine.
Dates to which data relate The effectiveness data were derived from studies published in 1997 and 2000. The resources used were from 2001. The price year was not stated, but it was likely to have been 2001.
Source of effectiveness data The effectiveness data were derived from a review of earlier studies, in particular the results of a double-blind controlled trial on carvedilol (see Other Publications of Related Interest).
Modelling A Markov model was used to examine the cost-effectiveness of carvedilol treatment in comparison with conventional treatments (diuretics, ACE inhibitors and digitalis). It was hypothesised that the patients would be treated as outpatients for a certain time, before hospitalisation for a month due to aggravation of the condition. After hospital discharge, the patients were again treated as outpatients. Death of the patients was due to either aggravation of their heart condition or natural causes. The analysis was carried out, based on the changes in patients' condition, each month (cycle length of Markov model), for lifetime and for 5 years of treatment.
Outcomes assessed in the review The outcomes assessed were the monthly heart failure aggravation rate (hospitalisation rate), the monthly death rate, and the dropout rate for the first month of treatment.
Study designs and other criteria for inclusion in the review Not stated. The present study was mainly based on a double-blind controlled trial.
Sources searched to identify primary studies Criteria used to ensure the validity of primary studies Methods used to judge relevance and validity, and for extracting data Number of primary studies included Three primary studies were included in the review.
Methods of combining primary studies Investigation of differences between primary studies Results of the review The monthly aggravation rate of heart failure (hospitalisation rate) was 2.7% for the conventional treatment group and 0.25% for the carvedilol group.
The monthly death rate was 0.8% for the conventional treatment group and 0.41% for the carvedilol group.
The dropout rate for the first month of treatment was 8% for both groups.
These data formed the principal input parameters for the model.
Measure of benefits used in the economic analysis Survival was used as a measure of benefit. It was derived from the model.
Direct costs The direct costs included were the monthly costs of outpatient treatment, medication and hospitalisation. The costs and the quantities were not reported separately. The cost data were derived using actual data from patients who were suffering from similar conditions to those hypothesised in this study (same category according to NYHA level II or III). A discount rate of 3% was used for the life-long analysis. The price year was not stated, but it was likely to have been 2001.
Statistical analysis of costs No statistical analysis of the costs was carried out.
Indirect Costs The indirect costs were not included.
Sensitivity analysis Sensitivity analyses were carried out to examine the changes in the total costs and survival period. The parameters investigated were the monthly hospitalisation rate, dropout rate, death rate and hospitalisation cost. The ranges used were probably based on the literature, but this was not clearly specified in the paper.
Estimated benefits used in the economic analysis In the life-long analysis, the survival period was 88 months for the conventional treatment group and 121 months for the carvedilol group.
In the 5-year analysis, the survival period was 45 months for the conventional treatment group and 49 months for the carvedilol group.
Cost results In the life-long analysis, the total cost was Y4,256,473 for the conventional treatment group and Y3,259,257 for the carvedilol group.
In the 5-year analysis, the total cost was Y2,143,077 for the conventional treatment group and Y1,336,455 for the carvedilol group.
Synthesis of costs and benefits The costs and benefits were not combined. In the life-long analysis, the cost for the carvedilol group was Y997,216 lower than that for the conventional treatment group, while the survival period was 33 months longer. Carvedilol treatment was therefore a dominant strategy.
In the 5-year analysis, the cost for the carvedilol group was Y806,622 lower than that for the conventional treatment group, while the survival period was 4 months longer. Carvedilol treatment was again dominant.
The results of the sensitivity analyses for the life-long calculation showed that the carvedilol group had better cost-effectiveness results in all of the parameters examined.
Authors' conclusions Although carvedilol treatment required an additional monthly cost of Y6,408 for medication compared with conventional treatment, it reduced the total medical cost by 23% for the life-long analysis and 38% for 5-year analysis. In terms of survival, treatment with carvedilol was found to extend the patients' lives by 4 years. Thus, it can be concluded that carvedilol is a very cost-effective treatment for heart failure in the Japanese medical context.
CRD COMMENTARY - Selection of comparators The rationale for the choice of the comparator was clear and was based on the conventional treatment alternative in Japan. You should decide if this represents a viable approach in your own sett
Validity of estimate of measure of effectiveness The methods used to conduct the review of the literature were not described. Although the author used several sources to derive the input parameters for the Markov model, the effectiveness data were primarily based on one study (see Other Publications of Related Interest). The author presented a comprehensive list of other relevant studies but pointed out that, from the Japanese perspective, the chosen study was the only one evaluating this particular beta-blocker in Japan. Appropriate sensitivity analyses were performed on the effectiveness estimates used in the model, although it was unclear how the ranges were determined.
Validity of estimate of measure of benefit The measure of benefit, survival, was derived from the Markov model using appropriate techniques and cycle length (one month). The use of quality-adjusted life-years, if feasible in this patient domain, would have enhanced the comparability of the results with other programmes.
Validity of estimate of costs The costs related to the perspective of the Japanese health care system were reported in a global manner (the costs and the quantities were not reported separately). The cost data were derived from actual data from similar NYHA-classified patients (level II or III), which may represent a limitation as cost data relating to actual CHF patients would, presumably, be more reliable. The discounting was appropriate and the dates for resource use were given, although the actual price year used was not clear from the paper. As these patients would be affected by loss of productivity, a societal perspective may be of more interest in other settings.
Other issues The author undertook the analysis from a Japanese perspective and, consequently, the results are applicable to that setting. Other effectiveness evidence from clinical trials conducted outside of Japan was cited. Researchers conducting analyses from the perspective of other countries may wish to consider this broader evidence base. The author did not compare the results with those of other studies and did not discuss any limitations of the study. The importance of examining the use of carvedilol from a health economic standpoint was stressed.
Implications of the study Carvedilol was more effective and less costly than conventional treatments. In the Japanese medical context carvedilol is a very cost-effective method. The author did not explicitly call for further research, but the limited number of studies found suggest that this might be beneficial.
Bibliographic details Inomata T. Cost-effectiveness for the management of chronic heart failure: cost-effectiveness analysis of carvedilol for the treatment of chronic heart failure in Japan. Respiration and Circulation 2003; 51(4): 341-345 Other publications of related interest Honda S. Multicenter carvedilol heart failure dose assessment trial (MUCHA). Journal of Cardiac Failure 2000;6 Suppl 3:123.
Indexing Status Subject indexing assigned by CRD MeSH Adrenergic beta-Antagonists; Angiotensin-Converting Enzyme Inhibitors /therapeutic use; Carbazoles /therapeutic use; Cost-Benefit Analysis; Heart Failure /drug therapy; Japan; Markov Chains; Propanolamines /therapeutic use; Ventricular Dysfunction, Left AccessionNumber 22003009331 Date bibliographic record published 30/11/2004 Date abstract record published 30/11/2004 |
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