|
Cost effectiveness of leukotriene receptor antagonists versus inhaled corticosteroids for initial asthma controller therapy: a pragmatic trial |
Wilson EC, Sims EJ, Musgrave SD, Shepstone L, Blyth A, Murdoch J, Mugford HM, Juniper EF, Ayres JG, Wolfe S, Freeman D, Gilbert RF, Harvey I, Hillyer EV, Price D |
|
|
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 leucotriene receptor antagonists (LTRAs), compared with inhaled corticosteroids, for initial asthma control. The authors concluded that LTRAs were unlikely to be cost-effective. The study was generally well carried out and, despite some uncertainty, the authors’ conclusions appear to be appropriate. Type of economic evaluation Study objective This study examined the cost-effectiveness of leucotriene receptor antagonists (LTRAs), compared with inhaled corticosteroids, for initial asthma control. Interventions Patients with asthma symptoms received either a LTRA (montelukast or zafirlukast) or inhaled corticosteroids (beclometasone dipropionate, budesonide, or fluticasone propionate). Methods Analytical approach:The analysis was based on a study, with a two-year horizon. The authors stated that the UK NHS and a societal perspective were adopted.
Effectiveness data:The clinical data came from a pragmatic, multicentre, randomised controlled trial (RCT) of 326 patients from 53 primary care practices in the UK. The length of follow-up was two years. The clinical outcomes were the patient's scores on the Asthma Control Questionnaire (ACQ) and the Mini Asthma Quality of Life Questionnaire (MiniAQLQ). These were assessed at two months and two years.
Monetary benefit and utility valuations:The utility values were from the European Quality of life (EQ-5D) questionnaire, which was completed by patients in the RCT.
Measure of benefit:The summary benefit measures were quality-adjusted life-years (QALYs) and a composite of the MiniAQLQ and ACQ scores. QALYs were discounted at 3.5% per annum.
Cost data:The economic analysis included the costs of prescribed medications and devices, over-the-counter medications, and primary and secondary care. The costs of lost productivity due to asthma treatment or exacerbations were considered. The medical costs were from NHS sources, and the productivity costs were calculated using the human capital approach, based on the days off work. The resource use was based on actual consumption by patients enrolled in the RCT. All costs were discounted at the annual rate of 3.5% and were in UK pounds sterling (£). The price year was 2005.
Analysis of uncertainty:Non-parametric bootstrapping created 95% confidence intervals for the incremental costs and outcomes. A cost-effectiveness acceptability curve was constructed to display the probability that the intervention was cost-effective at various thresholds. Results Over two years, the cost per patient was significant higher for those on LTRAs, compared with corticosteroids, with an incremental cost of £228 (95% CI 93 to 349) to the NHS or £204 (95% CI 74 to 308) to society. The difference in QALYs between the groups was not significant, with a decrease in QALYs of -0.073 (95% CI -0.143 to 0.010) with LTRAs. There were no significant differences in MiniAQLQ and ACQ scores.
For both time horizons, both perspectives, and both outcome measures, inhaled corticosteroids dominated LTRAs, as the inhaled corticosteroids produced a benefit or QALY gain at lower costs.
The LTRAs were cost-effective, compared with inhaled corticosteroids, in less than 3.5% of simulations, at a willingness-to-pay threshold of £30,000 per QALY. Authors' conclusions The authors concluded that LTRAs were unlikely to be cost-effective, compared with inhaled corticosteroids, for initial asthma control. CRD commentary Interventions:The choice of the interventions was clear and justified. The usual practice was included and these interventions might be appropriate for other settings.
Effectiveness/benefits:The evidence was from a UK RCT, which had a large sample of patients who were from several primary care practices. Few other details were provided, which makes it difficult to assess the quality of the trial, but the full details were published elsewhere and these should be consulted to assess the quality of the data. Both a disease-specific benefit measure and QALYs were appropriately used. The quality of life scores were measured using the patients in the RCT that supplied the clinical data.
Costs:The economic analysis was consistent with the stated perspectives. A breakdown of the costs was given, with both the unit costs and the resource quantities. The resource use was from the RCT and this should have ensured that detailed information was used. A statistical analysis of the costs was conducted and they appear to have been appropriately adjusted for the price year and inflation.
Analysis and results:The results were clearly reported and an incremental analysis was appropriately undertaken to synthesise the costs and QALYs. Limited details were provided for the sensitivity analysis, which was restricted to the production of cost-effectiveness acceptability curves and the methods were not described; the extent of uncertainty remains unclear. The authors discussed some limitations to their study.
Concluding remarks:The study was generally well carried out and, despite some uncertainty, the authors’ conclusions appear to be appropriate. Funding Funded by the NIHR Health Technology Assessment programme, UK. Bibliographic details Wilson EC, Sims EJ, Musgrave SD, Shepstone L, Blyth A, Murdoch J, Mugford HM, Juniper EF, Ayres JG, Wolfe S, Freeman D, Gilbert RF, Harvey I, Hillyer EV, Price D. Cost effectiveness of leukotriene receptor antagonists versus inhaled corticosteroids for initial asthma controller therapy: a pragmatic trial. PharmacoEconomics 2010; 28(7): 585-595 Indexing Status Subject indexing assigned by NLM MeSH Administration, Inhalation; Adolescent; Adrenal Cortex Hormones /administration & Adult; Aged; Aged, 80 and over; Asthma /drug therapy /economics; Child; Cost-Benefit Analysis; Great Britain; Humans; Leukotriene Antagonists /administration & Middle Aged; Quality-Adjusted Life Years; Treatment Outcome; Young Adult; dosage /economics /therapeutic use; dosage /economics /therapeutic use AccessionNumber 22010001237 Date bibliographic record published 10/11/2010 Date abstract record published 03/08/2011 |
|
|
|