Interventions:
The selection of the comparators was appropriate, as calcium-based binders, such as calcium carbonate and calcium acetate, were the first-line options for the treatment of hyperphosphataemia in the UK and in many other countries.
Effectiveness/benefits:
No systematic search was reported to identify the relevant sources of evidence. Two clinical trials were selected as the main sources for the efficacy data and trials generally are valid sources, but there were few patients who had not started dialysis and they were pooled with dialysis patients who had similar characteristics. Few details of these two trials were provided. The epidemiological data were from large databases and observational studies, but it was unclear if these studies were conducted in the UK. Extensive sensitivity analysis was conducted on the clinical parameters. Both benefit measures were appropriate for capturing the impact of the disease on the patients’ health. Life-years and QALYs allow comparisons with the benefits of other health care interventions. The utility values were from published sources, but the methods used to elicit them were not given.
Costs:
The categories of costs were representative of the NHS perspective as stated. The sources were appropriate for the UK setting and the resource quantities were generally from the clinical trials or UK guidelines. A key assumption was the exclusion of future dialysis costs, in the base case, and these appear to have been the main driver of the cost-effectiveness results. The unit costs and resource quantities were not presented separately. The costs were varied stochastically in the probabilistic sensitivity analysis. The price year was reported, allowing reflation exercises.
Analysis and results:
The results were extensively presented. An incremental approach was used to assess uncertainty in deterministic and probabilistic sensitivity analyses; the results were clearly illustrated and discussed. The authors stated that conservative assumptions against lanthanum carbonate were made, where there was uncertainty. They stated that this was the first study analysing the cost-effectiveness of lanthanum carbonate in patients who had not started dialysis. The transferability of the results was not discussed and the findings may be specific to the UK or settings with similar epidemiology and prices.
Concluding remarks:
The methods were valid and various areas of uncertainty were considered. The authors’ conclusions appear to be robust, but dependent on the future dialysis costs.