In light of the Cardiovascular Outcomes for People using Anticoagulation Strategies (COMPASS) trial, our objective was to assess the cost-effectiveness, from the Australian healthcare perspective, of ...rivaroxaban in combination with aspirin versus aspirin alone for the prevention of recurrent cardiovascular disease among patients with stable atherosclerotic vascular disease.
A Markov model was developed using input data from the COMPASS trial to predict the clinical course and costs of patients over a 20-year time-horizon. The model comprised of three health states: ‘Alive without recurrent CVD’, ‘Alive after recurrent CVD’ and ‘Dead’. Costs were from the Australian public healthcare system perspective, and estimated from published sources, as were utility data. The costs of rivaroxaban were based on current acquisition prices on the Australian Pharmaceutical Benefits Schedule (PBS) and assumed as AUD$3.09/day. The main outcome of interest was the incremental cost-effectiveness ratio (ICER) in terms of cost per quality adjusted life year (QALY) gained, and cost per year of life saved (YoLS). Costs and benefits were discounted by 5.0% per year.
Compared to aspirin alone, rivaroxaban plus aspirin was estimated to cost an additional AUD$12,156 (discounted) per person, but lead to 0.516 YoLS (discounted) and 0.386 QALYs gained (discounted), over 20 years. These equated to ICERs of AUD$23,560/YoLS and AUD$31,436/QALY gained. We have assumed a threshold of AUD$50,000/QALY gained to signify cost-effectiveness.
Compared to aspirin, rivaroxaban in combination with aspirin is likely to be cost-effective in preventing recurrent cardiovascular events in patients with stable atherosclerotic vascular disease.
•A large number of people with cardiovascular disease remain undertreated.•Rivaroxaban in addition to aspirin has been shown to reduce secondary CVD.•A Markov model was developed to predict the long-term treatment effect.•Rivaroxaban and aspirin is likely to be cost-effective compared to aspirin alone.
Abstract
Background
Early control of low-density lipoprotein-cholesterol (LDL-C) is an effective way to reduce the risk of coronary heart disease (CHD). However, a comprehensive assessment of ...cost-effectiveness of different lipid-lowering strategies (LLS) for primary prevention of CHD across different ages is lacking.
Objective
To assess the cost-effectiveness of four different LLS initiated at ages 30, 40, 50, and 60 years on the primary prevention of CHD from the UK National Health Service perspective.
Design, setting and participants: We developed a microsimulation model, based on the causal effect of LDL-C on myocardial infarction (MI) or coronary death derived from Mendelian randomisation, comparing initiation of an LLS to current standard of care (control). Data were primarily drawn from 458,727 participants of the UK Biobank study with available data on date of birth, LDL-C, and who were free of MI at first assessment (between 2006 and 2010), with follow-up until 2021.
Interventions: The four LLS were: 1) low/moderate intensity statins; 2) high intensity statins; 3) low/moderate intensity statins and ezetimibe; and 4) inclisiran.
Main outcomes measures: The incremental cost-effectiveness ratio (ICER), defined as the incremental healthcare costs divided by the incremental quality-adjusted life years (QALYs) for each LLS compared to control, with 3.5% annual discounting.
Results
The most effective intervention, low/moderate intensity statins and ezetimibe, was projected to lead to a gain in QALYs of 0.068 per person at age 30 and 0.026 at age 60 compared to control (Figure). The age of intervention with the lowest ICER was age 40, with ICERs of £2,524 (95% uncertainty interval: 1,383, 3,796), £4,466 (3,163, 6,134) £11,118 (8,632, 14,177), and £1,405,123 (1,117,1113, 1,789,012) per QALY gained for strategies 1-4 from age 40 years, respectively (Table).
Conclusions
LDL-C lowering from early ages is a more cost-effective strategy than late intervention. The approach to primary prevention of CHD may improve with a shift to early and sustained lowering of LDL-C.
Figure – Results of 1,000 probabilistic sensitivity analyses presented in a common cost-effectiveness plane, by age of intervention. Inclisiran excluded due to very high costs. Solid line: £20,000 per quality-adjusted life year (QALY) willingness-to-pay threshold; dashed line: £30,000 per QALY willingness-to-pay threshold. Any dot to the right of these lines is considered cost-effective.
Table – Summary of LLS interventions by age of intervention.
Abbreviations: MI – Myocardial infarction; YLL – Years of life lived; QALYs – Quality-adjusted life-years; ICER – Incremental cost-effectiveness ratio.FigureTable
Background
A significant proportion of individuals taking antihypertensive therapies fail to achieve blood pressures <140/90 mmHg. In order to develop strategies for improved treatment of blood ...pressure, we examined the association of blood pressure control with antihypertensive therapies and clinical and lifestyle factors in a cohort of adults at increased cardiovascular risk.
Methods
A cross‐sectional study of 3994 adults from Melbourne and Shepparton, Australia enrolled in the SCReening Evaluation of the Evolution of New Heart Failure (SCREEN‐HF) study. Inclusion criteria were age ≥60 years with one or more of self‐reported ischaemic or other heart disease, atrial fibrillation, cerebrovascular disease, renal impairment or treatment for hypertension or diabetes for ≥2 years. Exclusion criteria were known heart failure or cardiac abnormality on echocardiography or other imaging. The main outcome measures were the proportion of participants receiving antihypertensive therapy with blood pressures ≥140/90 mmHg and the association of blood pressure control with antihypertensive therapies and clinical and lifestyle factors.
Results
Of 3623 participants (1975 men and 1648 women) receiving antihypertensive therapy, 1867 (52%) had blood pressures ≥140/90 mmHg. Of these 1867 participants, 1483 (79%) were receiving only one or two antihypertensive drug classes. Blood pressures ≥140/90 mmHg were associated with increased age, male sex, waist circumference and log amino‐terminal‐pro‐B‐type natriuretic peptide levels.
Conclusions
Most individuals with treated blood pressures above target receive only one or two antihypertensive drug classes. Prescribing additional antihypertensive drug classes and lifestyle modification may improve blood pressure control in this population of individuals at increased cardiovascular risk.
Background
Micafungin demonstrated non‐inferiority to caspofungin as definitive therapy for candidaemia and invasive candidiasis (IC) in a major randomised clinical trial.
Aim
The aim of this study ...was to investigate if micafungin is a cost‐saving option compared with caspofungin for treating candidaemia and IC.
Methods
A decision analytical model was constructed to capture downstream consequences of using either agent as initial therapy for candidaemia and IC. The main outcomes were treatment success and treatment failure (i.e. death, mycological persistence, emergent infection, clinical failure but microbiological success). Outcome probabilities and treatment pathways were derived from the literature. Cost inputs were from the latest Australian resources, and resource use was estimated by expert panel. The analysis was from the Australian hospital perspective. Sensitivity analyses using Monte Carlo simulation were conducted.
Results
Micafungin (AU$52 816) was associated with a lower total cost than caspofungin (AU$52 976), with a net cost‐saving of $160 per patient. This was primarily due to the lower cost associated with alternative antifungal treatment in the micafungin arm. Hospitalisation was the main cost‐driver for both arms. The model outcome was most sensitive to the proportion of treatment success in the micafungin arm. Uncertainty analysis demonstrated that micafungin had a 58% chance of being cost‐saving compared with caspofungin.
Conclusions
Micafungin was cost‐equivalent to caspofungin in treating candidaemia and IC, with variation in drug acquisition cost the critical factor.
The incidence of invasive meningitis disease (IMD) is increasing in Australia. A conjugate vaccine of meningococcal polysaccharide serogroups A, C, W and Y (MenACWY) is currently indicated for ...infants aged 12 months on the Australian National Immunisation Program. This study sought to determine the cost-effectiveness of a broader MenACWY vaccination program for Australians aged 15 to 19 years.
A Markov model was constructed to simulate the incidence and consequences of IMD in Australians aged 0–84 years, with follow up until age 85 years. The model comprised four health states: ‘Alive with no previous IMD’, ‘Alive, post IMD without long-term complications’, ‘Alive, post IMD with long-term complications’ and ‘Dead’. Decision analysis compared the clinical consequences and costs of a vaccination program versus no vaccination from the perspective of the Australian health care system. Age-specific incidence of IMD and fatality rates were derived from Australian surveillance data. Vaccine coverage, vaccine efficacy and herd immunity were based on published data. The total cost for MenACWY vaccination was AU$56 per dose. Costs and health outcomes were discounted by 5% per annum (in the base-case analysis).
Compared to no vaccination, a MenACWY vaccination program targeted at Australians aged 15–19 years was expected to prevent 1664 IMD cases in the Australian population aged 0–84 years followed up until age 85 years. The program would lead to 1131 life years (LYs) and 2058 quality adjusted life years (QALYs) gained at a total cost of AU$115 million (all discounted values). These equated to incremental cost-effectiveness ratios of AU$101,649 per LY gained and AU$55,857 per QALY gained. A probabilistic sensitivity analysis demonstrated a likelihood of cost-effectiveness of 34.6%, assuming a willingness to pay threshold of AU$50,000 per QALY gained.
The likelihood of this program being cost-effective under a willingness to pay threshold AU$50,000 per QALY gained is 35%.
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