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HMG versus rFSH for ovulation induction in developing countries: a cost-effectiveness analysis based on the results of a recent meta-analysis |
Al-Inany H G, Abou-Setta A M, Aboulghar M A, Mansour R T, Serour G I |
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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 study compared two drugs (gonadotrophins) used for ovarian stimulation in in vitro fertilisation (IVF) or intracytoplasmic sperm injection (ICSI) cycles. The drugs compared were recombinant follicle-stimulating hormone (rFSH) and human menopausal gonadotrophin (HMG). No further details of the drugs were reported.
Economic study type Cost-effectiveness analysis.
Study population The study population was not explicitly stated, but it might have been any IVF patient.
Setting The setting was an Egyptian IVF-ET Centre. The economic study was carried out in Cairo, Egypt.
Dates to which data relate The effectiveness data were derived from a meta-analysis published in 2005 that included 8 studies published between 1998 and 2003. The costs were derived from official published sources published between 2001 and 2005 and from the authors' setting, and reflected 2005 prices.
Source of effectiveness data The effectiveness data were derived mainly from a completed meta-analysis and from further published studies.
Modelling The authors simulated IVF or ICSI cycles by constructing a state transition Markov model using TreeAge Pro 2005 software (Software Inc., Williamstown, MA) to compare rFSH versus HMG in terms of their cost-effectiveness. The Markov model was run for three IVF cycles.
Outcomes assessed in the review Patients deciding to commence with either IVF or ICSI entered the model cycles and were equally subjected to the following transition probabilities:
the probability of failed stimulation or IVF when using either HMG or rFSH;
the probability of clinical pregnancy when using either HMG or rFSH;
the probability of miscarriage when using either HMG or rFSH;
the probability of ovarian hyperstimulation syndrome (OHSS) when using HMG or rFSH; and
the probability of discontinuing treatment at the end of each cycle (failed clinical pregnancy).
Study designs and other criteria for inclusion in the review The authors used a published meta-analysis to derive estimates of effectiveness. The meta-analysis included 8 randomised controlled trials. Two further studies were also used but their designs were not described.
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 Overall, 10 primary studies, eight of which were included in the published meta-analysis, provided the effectiveness evidence.
Methods of combining primary studies The authors used a completed meta-analysis. The results derived from other studies were not combined with the results of the meta-analysis.
Investigation of differences between primary studies The authors do not appear to have investigated differences between the primary studies.
Results of the review The probability of failed stimulation or IVF was 0.038 when using HMG and 0.041 when using rFSH.
The probability of clinical pregnancy was 0.310 when using HMG and 0.265 when using rFSH.
The probability of miscarriage was 0.136 when using HMG and 0.122 when using rFSH.
The probability of OHSS was 0.019 when using HMG and 0.010 when using rFSH.
The probability of discontinuing treatment after the first cycle was 0.489, after the second cycle 0.524, and after the third cycle 0.571.
Measure of benefits used in the economic analysis The authors used the number of ongoing pregnancies per cycle as the measure of benefit in the economic analysis. This was derived directly from the model.
Direct costs The health care costs included in the analysis covered rFSH and HMG units, oocyte retrieval, lab procedure, embryo transfer, OHSS treatment, miscarriage, antenatal care, gonadotrophin-releasing hormone analogues, beta human chorionic gonadotrophin test, and luteal phase. Retail prices were used for the drug costs, while all other costs were derived from the authors' setting (Egyptian IVF-ET Centre, Maadi, Cairo, Egypt). The authors reported that patient charges were used instead of actual costs. With the exception of antenatal and luteal phase support, where summary costs were used, all other costs were reported separately from the quantities. Discounting was not relevant as the costs were incurred during a short time (less than 2 years). All costs were reported for the price year 2005.
Statistical analysis of costs The costs were treated deterministically.
Indirect Costs The indirect costs were not included in the analysis.
Sensitivity analysis The authors conducted a sensitivity analysis to test the robustness of the results to variability in the data, assuming an equal effectiveness of 25% for ongoing live birth rates for both drug options. In addition, a discontinuation rate of 0% was also tested.
Estimated benefits used in the economic analysis By the end of the third cycle, the probability of an ongoing pregnancy was 40.8% when using HMG and 35.9% when using rFSH.
Cost results The total cost of 100,000 cycles was EGP 1,392,633,925.4 in the HMG arm and EGP 1,870,117,337.4 in the rFSH arm.
Synthesis of costs and benefits The average cost-effectiveness ratios were calculated. The average cost per ongoing pregnancy was EGP 13,946 (+/- 6,512) in an HMG cycle and EGP 18,721 (+/- 8,749) when using rFSH. HGM therefore dominated rFSH as it was cheaper and more cost-effective.
The sensitivity analysis demonstrated that when equal effectiveness of 25% was assumed for both drug options, the cost per ongoing pregnancy would be EGP 9,297+ (/- 1,058) in HMG cycles and EGP 13,118 (+/- 2,541) with rFSH.
When the discontinuation rate was assumed to be 0%, the cost per ongoing pregnancy would be EGP 43,287 for rFSH and EGP 36,093 for HMG.
Authors' conclusions The analysis demonstrated that human menopausal gonadotrophin (HMG) is more cost-effective than recombinant follicle-stimulating hormone (rFSH).
CRD COMMENTARY - Selection of comparators The choice of the comparators was explicitly justified, as the two drugs seem to be the most commonly used treatment options and to represent current practice in the authors' setting. You should decide if this represents a valid health technology in your own setting.
Validity of estimate of measure of effectiveness The authors mainly used estimates of effectiveness from a published systematic review and meta-analysis. Few details of the systematic review were reported, so it is not possible to evaluate its validity here. A sensitivity analysis was undertaken in relation to the efficacy estimates.
Validity of estimate of measure of benefit The authors used the number of ongoing pregnancies at the end of each treatment option as the measure of benefit in the economic analysis. This was derived directly from the model. The measure of benefit appears to have appropriately covered the benefits of treatment.
Validity of estimate of costs Although not explicitly stated, the analysis of the costs was most probably performed from the perspective of the patient as IVF appears to have been provided through private care. Most of the relevant categories of costs appear to have been included in the analysis. Although the resource use per patient was reported, the costs and the quantities were not reported separately for all cost categories as the authors reported summary costs in many cases. This would not enable the analysis to be easily reworked for other settings. The cost estimates where derived from the authors' setting and patient charges, and were treated deterministically. Discounting was not performed since the costs were incurred during a short time. The price year was reported, thus enhancing future reflation exercises.
Other issues The authors compared their study with other published studies and reported the main methodological differences. The issue of generalisability of the results was not directly addressed. The authors do not appear to have presented their results selectively. The patient characteristics of those enrolled in the study were not reported, therefore, the conclusions were accordingly generalised across all infertile women. The authors reported, as a limitation to their study, the fact that cryo-cycles were not included in the analysis because of a lack of estimates in the published meta-analysis.
Implications of the study The authors did not make any explicit recommendations for changes in policy or practice, or the need for further research. However, their discussion highlighted areas where more information is needed.
Bibliographic details Al-Inany H G, Abou-Setta A M, Aboulghar M A, Mansour R T, Serour G I. HMG versus rFSH for ovulation induction in developing countries: a cost-effectiveness analysis based on the results of a recent meta-analysis. Reproductive BioMedicine Online 2006; 12(2): 163-169 Indexing Status Subject indexing assigned by NLM MeSH Cost-Benefit Analysis; Developing Countries; Female; Follicle Stimulating Hormone /administration & Humans; Markov Chains; Menotropins /administration & Ovulation Induction; Pregnancy; Recombinant Proteins /administration & dosage; dosage; dosage AccessionNumber 22006000407 Date bibliographic record published 31/07/2006 Date abstract record published 31/07/2006 |
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