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Cost-utility analysis of eprosartan compared to enalapril in primary prevention and nitrendipine in secondary prevention in Europe: the HEALTH model |
Schwander B, Gradl B, Zollner Y, Lindgren P, Diener HC, Luders S, Schrader J, Antonanzas Villar F, Greiner W, Jonsson B |
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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. CRD summary The objective was to examine the cost-effectiveness of eprosartan and enalapril in the primary prevention and eprosartan and nitrendipine in the secondary prevention of cardiovascular and cerebrovascular disease. The authors concluded that, in primary prevention, eprosartan was cost-effective for certain patients, whilst, in secondary prevention, it was cost-effective for all investigated patients. On the whole, the study used valid methodology and was clearly reported. The authors' conclusions seem to be appropriate. Type of economic evaluation Study objective The objective was to examine the cost-effectiveness of eprosartan and enalapril in primary prevention, and eprosartan and nitrendipine in the secondary prevention of cardiovascular (CV) and cerebrovascular (CBV) disease. Interventions The interventions were eprosartan at 600mg per day for five years, enalapril at 10mg per day for five years, or nitrendipine at 20mg per day for 2.5 years. Location/setting Belgium, Germany, Norway, Spain, Sweden, and UK/the setting was not reported. Methods Analytical approach:This economic evaluation was based on the published Health Economic Assessment of Life with Teveten for Hypertension (HEALTH) model, with a lifetime horizon. The authors stated that the perspective was that of the health care payer.
Effectiveness data:The effectiveness data came from a wide range of sources: for example, the risks of CV and CBV disease were estimated based on the established Framingham algorithms; and a systematic literature search was conducted to derive the estimates of the effect of antihypertensive therapy in reducing the risks of CV and CBV disease. Details of the literature search were not provided, but it was reported that a meta-analysis of 29 randomised controlled trials was found. The main clinical parameters were CV and CBV events and death.
Monetary benefit and utility valuations:The utility weights were derived from a published Swedish study, which used the European Quality of life (EQ-5D) questionnaire, with 11,698 people, of whom 869 had hypertension.
Measure of benefit:The primary measure of benefit was the quality-adjusted life-year (QALY) and these were discounted according to country-specific guidelines for health economic evaluations.
Cost data:The cost analysis included the primary and secondary prevention drugs, monitoring costs, and the direct health care costs associated with CV and CBV events. The cost data, specific to each country, were obtained from published studies. The unit costs were reported for drugs, while the monitoring and treatment costs were given as macro-categories. All costs were inflated to 2007 values using country-specific health care cost indexes and converted into Euros (EUR). They were discounted according to country-specific guidelines for health economic evaluations.
Analysis of uncertainty:Both one-way and probabilistic sensitivity analyses were performed and the results were reported in cost-effectiveness scatter plots and Tornado diagrams. Results In primary prevention, eprosartan compared with enalapril was associated with a cost per QALY gained of EUR 24,036 in Germany, EUR 17,863 in Belgium, EUR 16,364 in the UK, EUR 13,834 in Norway, EUR 11,691 in Sweden, and EUR 7,918 in Spain.
In secondary prevention, eprosartan compared with nitrendipine was associated with a cost per QALY gained of EUR 9,136 in Germany, EUR 6,008 in the UK, EUR 1,695 in Norway, and EUR 907 in Sweden, and savings per QALY gained of EUR 2,054 in Spain, and EUR 5,767 in Belgium.
In primary prevention, the patient's age, their systolic blood pressure reduction, the discount rate, the patient's sex, and their baseline systolic blood pressure had the greatest influence on the results. In secondary prevention, the patient's sex and age had the most significant effect on the results. Authors' conclusions The authors concluded that, at a willingness-to-pay of EUR 30,000 per QALY gained, eprosartan was cost-effective compared with enalapril, in primary prevention, for patients aged 50 years or older with a systolic blood pressure of 160mmHg or more. It was also cost-effective compared with nitrendipine, in secondary prevention, for all investigated patients. CRD commentary Interventions:The interventions were relatively well described and appear to have represented the current practice in the study settings.
Effectiveness/benefits:Various sources were used to derive the effectiveness estimates for the model, all of which appear to have been appropriate. The systematic literature search should have ensured that the most relevant evidence was identified, but more details on this search could have been provided. The fact that meta-analyses were used where possible was good, but no justification was given for their selection. The derivation of the benefit measure was described and appears to have been appropriate.
Costs:The costs appear to have reflected the perspective stated. For some of the cost estimates, only macro-categories were reported, which reduces the possibility of replicating the analysis for other settings. The sources of the costs and other details of the analysis, including the price year and discounting, were adequately reported.
Analysis and results:The authors conducted an appropriate incremental analysis and the full results were presented. The issue of uncertainty was addressed in the sensitivity analyses, the results of which were clearly presented. Overall, the level of reporting was good and country-specific costs and clinical data were presented. The authors acknowledged some limitations to their analysis.
Concluding remarks:On the whole, the study used valid methodology and was clearly reported. The conclusions reached by the authors seem to be appropriate. Funding Supported by a grant from the Solvay Pharmaceuticals GmbH. Bibliographic details Schwander B, Gradl B, Zollner Y, Lindgren P, Diener HC, Luders S, Schrader J, Antonanzas Villar F, Greiner W, Jonsson B. Cost-utility analysis of eprosartan compared to enalapril in primary prevention and nitrendipine in secondary prevention in Europe: the HEALTH model. Value in Health 2009; 12(6): 857-871 Indexing Status Subject indexing assigned by NLM MeSH Acrylates /economics /therapeutic use; Antihypertensive Agents /economics /therapeutic use; Cardiovascular Diseases /drug therapy /economics /prevention & Cost-Benefit Analysis; Enalapril /economics /therapeutic use; Europe; Geography; Humans; Hypertension /drug therapy /economics /prevention & Imidazoles /economics /therapeutic use; Male; Meta-Analysis as Topic; Middle Aged; Monte Carlo Method; Nitrendipine /economics /therapeutic use; Primary Prevention /economics /methods; Quality-Adjusted Life Years; Randomized Controlled Trials as Topic; Risk Assessment /methods; Secondary Prevention /economics /methods; Stroke /drug therapy /economics /prevention & Thiophenes /economics /therapeutic use; control; control; control AccessionNumber 22009102965 Date bibliographic record published 11/11/2009 Date abstract record published 18/11/2009 |
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