IntroductionCost–utility assessment of first-line actinic keratosis (AK) treatments for max 25 cm2 AK field.MethodsA probabilistic, 2-year decision tree model was used to assess costs, quality-adjusted life-years (QALY), incremental cost-effectiveness ratio (ICER), cost-effectiveness efficiency frontier, cost-effectiveness acceptability frontier (CEAF), and expected value of perfect information (EVPI) of AK treatments from the Finnish health care payer perspective with 3% discounting per annum. In the model, the first-line AK treatment resulted in complete clearance (CC) or non-CC with or without local skin responses (LSR), or AK recurrence. Non-CC AK was treated with methyl aminolevulinate + photodynamic therapy (MAL + PDT), and AK recurrence was retreated with the previous effective treatment. Costs included primary and secondary health care, outpatient drugs, and LSR management. QALYs were assessed with the EuroQol (EQ-5D-3L). Result robustness was assessed with sensitivity analyses.ResultsThe mean simulated per patient QALYs (costs) were 1.526 (€982) for MAL + PDT, 1.524 (€794) for ingenol mebutate gel (IngMeb) 0.015% (3 days), 1.522 (€869) for IngMeb 0.05% (2 days), 1.520 (€1062) for diclofenac 3% (12 weeks), 1.518 (€885) for imiquimod 3.75% (6 weeks), 1.517 (€781) for imiquimod 5% (4/8 weeks), and 1.514 (€1114) for cryosurgery when treating AK affecting any body part. IngMeb 0.015% was less costly and more effective (dominating) than other AK treatments indicated for face and scalp area with the exception of imiquimod 5% for which the ICER was estimated at €1933/QALY gained and MAL + PDT, which had an ICER of €82,607/QALY gained against IngMeb 0.015%. With willingness-to-pay €2526–18,809/QALY gained, IngMeb 0.015% had >50% probability for cost-effectiveness on the CEAF. IngMeb 0.05% dominated AK treatments indicated for trunk and extremities. EVPIs for face and scalp (trunk and extremities) analyses were €26 (€0), €86 (€58), and €250 (€169) per patient with the willingness-to-pay of €0, €15,000, and €30,000 per QALY gained, respectively.ConclusionIngMebs were cost-effective AK treatments in Finland.FundingLEO Pharma.Electronic supplementary materialThe online version of this article (doi:10.1007/s12325-015-0211-7) contains supplementary material, which is available to authorized users.
A609probabilistic sensitivity analysis suggests that at willingness-to-pay threshold of £20-£30,000 per quality-adjusted life year, the probability of early treatment being cost-effective is 60%. ConClusions: Panretinal photocoagulation administered at the severe NPDR stage is likely to be cost-effective. However, given the limitations of the evidence on current treatments, these results to be interpreted with caution. A trial of early versus deferred laser therapy is needed to provide better data based on modern treatments.objeCtives: CUA of cryosurgery, topical treatments (diclofenac 3% 12 weeks, imiquimod 3.75% 6 weeks or 5% 4/8 weeks, ingenol mebutate gel (IMG) 0.015%/ head 3 days or 0.05%/body 2 days), and methyl aminolevulinate + photodynamic therapy (MAL+PDT) in the treatment of 25cm 2 AK-plague affecting any body part. Methods: A sequential probabilistic decision-tree with 2-year time-horizon was used to assess the cost-utility (incremental cost-effectiveness ratio, ICER) of AK-treatments, and to determine the cost-effectiveness acceptability frontier (CEAF) and expected value of perfect information per patient (EVPI) from health care payer perspective. In the model, the first-line AK-treatment resulted in complete clearance (CC) with or without adverse events (AE), non-CC or AK-recurrence. Non-CC AK was retreated with PDT and AK-recurrence was retreated with the previous treatment. Incident AK-patients (year 2009, n= 3409, organ transplant patients excluded) were identified from the Finnish hospital discharge register to assess AK-related 2-year secondary health care costs for patients initiating different treatment regimens. Other costs included general practitioner, AE-management, and outpatient drugs (5/2014 without VAT; other costs in 2013 value). Quality-adjusted life-years (QALY) were based on EQ-5D. Results were discounted with 3% annually. Results: The mean per patient 2-year QALYs (costs) were 1.519 (€ 727) for IMG 0.015%, 1.518 (€ 887) for MAL+PDT, 1.516 (€ 802) for IMG 0.05%, 1.514 (€ 995) for diclofenac, 1.512 (€ 815) for imiquimod 3.75%, 1.511 (€ 707) for imiquimod 5%, and 1.507 (€ 1010) for cryosurgery. IMG 0.015% had € 2806/QALY gained ICER against imiquimod 5%, and dominated other AK-treatments. IMG 0.05% dominated diclofenac, imiquimod 3.75% and cryosurgery, and had € 21,550/QALY gained ICER against imiquimod 5%. MAL+PDT had € 32,848/QALY gained ICER against IMG 0.05%. Based on the CEAF, IMG 0.015% was the optimal treatment when willingness-to-pay/QALY gained exceeded € 2806. The EVPI was € 25/€ 81/€ 211 with the willingness-to-pay of € 0/€ 15,000/€ 30,000 per QALY gained. ConClusions: IMG 0.015% was the most cost-effective first-line AK-treatment.
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