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| Cost-effectiveness of varenicline compared with nicotine patches for smoking cessation: results from four European countries |
| Bolin K, Wilson K, Benhaddi H, de Nigris E, Marbaix S, Mork AC, Aubin HJ |
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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 This study examined the cost-effectiveness of varenicline compared with nicotine replacement therapy, for smoking cessation in four European countries. The authors concluded that varenicline was cost-effective in Belgium, France, Sweden, and the UK, from the perspective of the health care system. The methods were valid and clearly presented, especially in the appendix. The authors’ conclusions appear to be robust. Type of economic evaluation Study objective This study examined the cost-effectiveness of varenicline compared with nicotine replacement therapy (NRT) for smoking cessation in adults aged 18 to 75 years, in four European countries. Interventions The two interventions were varenicline compared with NRT. Location/setting Belgium, France, Sweden, and the UK/primary care. Methods Analytical approach:The analysis used the Benefits of Smoking Cessation on Outcomes (BENESCO) Markov model to simulate the impact of the two interventions on four smoking-related morbidities: lung cancer, chronic obstructive pulmonary disease, coronary heart disease, and stroke. A lifetime horizon was considered and the authors stated that the perspective of the health care system was adopted.
Effectiveness data:The data for smoking prevalence, morbidity, and mortality were country-specific and were from national databases and published studies. These were supplemented with one set of default data for all countries. Treatment efficacy was the key input and it was defined as the continuous abstinence rate. This was derived from a head-to-head, open-label, randomised controlled trial comparing varenicline against NRT, in a sample of 747 participants from Belgium, France, the UK, the Netherlands, and the USA.
Monetary benefit and utility valuations:: The utility values were from a published study.
Measure of benefit:Quality-adjusted life-years (QALYs) were the summary benefit measure and they were discounted at an annual rate of 3.5%.
Cost data:The economic analysis included the intervention costs (drugs, physician visits, and motivational support visits) and morbidity-related health care costs. A breakdown of cost items was given and the costs and resource use for the interventions were reported in an appendix. The price year was 2007 and all costs were in Euros (EUR) and were discounted at an annual rate of 3.5%.
Analysis of uncertainty:A Monte Carlo simulation was carried out on three variables: the efficacy of the interventions, the morbidity-related health care costs, and the utility weights. Cost-effectiveness acceptability curves were generated. Alternative scenarios were considered for the typical smoking cessation intervention in each country and for the minimum use of health care resources. A deterministic sensitivity analysis was carried out on the morbidity-specific QALY weights, the intervention costs, the health care costs, the discount rate, and the efficacy. Results In a hypothetical cohort of 1,000 smokers, the incremental intervention costs with varenicline over NRT ranged from EUR 54,522 in Sweden to EUR 200,200 in France. The health care costs averted ranged from EUR 99,914 in Belgium to EUR 198,808 in the UK. The QALYs gained ranged from 19.5 in France to 29.9 in Sweden. The incremental analysis showed that varenicline was dominant, as it was less expensive and more effective than NRT in all countries, except France, where the incremental cost per QALY gained with varenicline was EUR 2,803.
In the scenario with a minimum use of health care resources, the incremental cost per QALY gained ranged from EUR 50 in the UK to EUR 2,803 in France.
The sensitivity analysis confirmed the robustness of the base case findings and pointed out the key role played by efficacy rate and intervention costs. However, varenicline was dominant or cost-effective in all cases, with the highest cost-effectiveness ratio of EUR 25,000 for France when the efficacy rate of varenicline was reduced by 4%. Authors' conclusions The authors concluded that varenicline was cost-effective for smoking cessation in Belgium, France, Sweden, and the UK from the perspective of the health care system. CRD commentary Interventions:The authors stated that various studies had proved the efficacy and cost-effectiveness of NRT over unaided smoking cessation, but other studies had shown the superior efficacy of varenicline. The selection of these comparators appears to have been appropriate.
Effectiveness/benefits:No systematic review was reported to identify the relevant sources of data, but most of the inputs were already included in the BENESCO model. The efficacy rates for the two interventions were from a head-to-head trial and this should ensure a high internal validity. The key epidemiological data were from country-specific sources and these appear to have been appropriate. Less information was given for the remaining data. The details of the derivation of the utility values were not reported, but these might also have been already incorporated in the BENESCO model. QALYS were a valid measure of benefit as they capture the impact of the disease on both survival and quality of life.
Costs:The economic analysis was consistent with the viewpoint stated in terms of the cost categories, but the data sources were not clearly described. The unit costs and quantities of resources were presented separately for interventions only. The health care costs were not listed as individual items. The price year, the use of discounting, and the currency were clearly reported. An interesting alternative scenario was analysed, where the resource use for the interventions was at the minimum.
Analysis and results:Only the incremental findings were reported, but they were clearly presented and the analytic approach used to combine the costs and benefits was appropriate. The issue of uncertainty was satisfactorily investigated, but only the results of the deterministic sensitivity analyses were presented in detail. The model was described in the appendix. The authors stated that their results were potentially conservative for varenicline, since productivity costs were not included. The results of this study appear to be transferable to other European countries.
Concluding remarks:The methods were valid and clearly presented, especially in the appendix. The authors’ conclusions appear to be robust. Bibliographic details Bolin K, Wilson K, Benhaddi H, de Nigris E, Marbaix S, Mork AC, Aubin HJ. Cost-effectiveness of varenicline compared with nicotine patches for smoking cessation: results from four European countries. European Journal of Public Health 2009; 19(6): 650-654 Indexing Status Subject indexing assigned by NLM MeSH Adolescent; Adult; Aged; Benzazepines /economics; Cost-Benefit Analysis; Europe; Female; Heart Diseases /epidemiology; Humans; Incidence; Lung Neoplasms /epidemiology; Male; Markov Chains; Middle Aged; Models, Statistical; Nicotine /administration & Nicotinic Agonists /economics; Pulmonary Disease, Chronic Obstructive /epidemiology; Quality-Adjusted Life Years; Quinoxalines /economics; Smoking /adverse effects /mortality; Smoking Cessation /economics /methods; Stroke /epidemiology; Varenicline; Young Adult; dosage /economics AccessionNumber 22010000166 Date abstract record published 29/09/2010 |
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