long-term residents of hospitals or residential care facilities. The sub-sample used in this analysis consisted of 38 151 respondents (52.4% male) between the ages of 20 and 64 y, excluding pregnant women. Health Utilities Index-Mark III (HUI3) scores were used to de®ne normal weight (body mass index (BMI) 19 ± 24.9 kgam 2 ), overweight (BMI 25 ± 29.9 kgam 2 ), obese (BMI 30 ± 34.9 kgam 2 ), and morbidly obese (BMI ! 35 kgam 2 ) individuals. HUI3 scores were age-and gender-standardized. RESULTS: The overall prevalence of obesity (BMI ! 30 kgam 2 ) in this Canadian population was 13.3%. The average difference in HUI3 scores between normal weight and morbidly obese respondents was 0.04 (P`0.001). Statistically signi®cant (P`0.05) differences across BMI categories were found in each of the eight component attributes of the HUI3. The attributes with the most substantial difference between normal and obese patients were cognition, mobility and pain. All demonstrated a ! 2-fold increase in the proportion of individuals in poorer classi®cations of health when normal weight respondents were compared with the morbidly obese. The magnitude of the decrement in utility ratings associated with obesity was comparable with other chronic non-cardiovascular conditions such as migraine or colitis. CONCLUSION:The results indicate that changes in self-rated health status appear to be due to signi®cant changes across several relevant domain attributes. Obesity has a signi®cant impact on both quality of life and health.
Obesity is now recognized as a chronic health condition instead of a cosmetic or lifestyle issue. Orlistat and sibutramine are effective weight‐loss/weight‐maintenance agents. Insurers argue that the high prevalence of obesity (i.e., body mass index (BMI)3 30kg/m2), questionable long‐term health benefits, and cost of these drugs make it unfeasible to cover them. Proponents claim decreases in obesity's comorbidities would offset acquisition costs. OBJECTIVES: To provide evidence for a rational reimbursement policy for pharmacological treatments of obesity in adults. METHODS: A Markov decision analytic model was used to evaluate the cost‐effectiveness of orlistat (120mg TID) and sibutramine (5–20mg QD) relative to diet and exercise alone. The model analyzed a hypothetical population of obese, but otherwise healthy 30 year olds over their lifetime. Estimates of efficacy and tolerance were derived from a meta‐analysis of randomized, placebo‐controlled trials of orlistat and sibutramine. The Framingham Study was used to derive risk‐adjusted equations for the incidence of hypertension, dyslipidemia, and DM as well as the incidence of CV events, CV‐attributable death, and non‐CV death. Equations were adjusted for known risk factors, including BMI. The reference case analysis used the societal perspective and included both direct and indirect costs (discount rate, 3%). Costs were derived from the literature and inflated to year 2000 Canadian dollars (CDN$). Utilities were derived from a Canadian health survey and from the literature. Decision index: incremental cost per quality adjusted life year ($/QALY). A Monte Carlo simulation will be used to perform a sensitivity analyses around: estimated weight‐loss, estimated dropout rates, estimated weight regain, cost of treatment, and major clinical events. RESULTS: Results for the base case (i.e., societal viewpoint) and third party payer (i.e., Ministry of Health) perspectives will be presented and discussed. Emphasis will be placed on the decision model approach for informing formulary decisions on “lifestyle” drugs.
OBJECTIVES: To determine the relative cost‐effectiveness of the inhaled corticosteroids beclomethasone dipropionate (BDP), budesonide (BUD), and fluticasone propionate (FP), for managing moderate to severe asthma in adults over a one‐year time horizon from the perspective of the Ministry of Health (MOH) in Canada. METHODS:A single‐arm meta‐analysis of randomized control trials containing at least one of FP, BUD, and BDP was performed in order to derive estimates of effectiveness and tolerance. A decision tree analysis was then used to model the cost‐effectiveness analysis. Only direct medical costs were included in the analysis (i.e., inpatient care, emergency visits, physician services, nursing services, drugs, diagnostic tests). The time horizon of the study was 52 weeks, precluding discounting. All costs are presented in 1996 Canadian dollars (CDN$). The cost‐effectiveness was the cost per additional symptom‐free day ($/SFD). RESULTS: 69 of 398 articles were included in the metaanalysis. The Monte Carlo base case analysis showed that FP and BUD resulted in an annual cost of $1,383 and $1,147 respectively (p > 0.01). FP produced 216 SFDs while BUD resulted in 214 SFDs, which were not significantly different at p = 0.01 (corrected for multiple comparisons). BDP cost $1,343/year and yielded 213 SFD/year (BDP was excluded from the final analysis, dominated by BUD). With no difference in effectiveness, a cost‐minimization analysis showed that BUD was the cost‐effective alternative, costing $236 CDN less than the FP strategy. CONCLUSIONS: Of the inhaled corticosteroids available on the MOH Formulary in Canada, BUD is a costeffective alternative for the treatment of adults with moderate to severe asthma.
BACKGROUND: Avandia (rosiglitazone) is a novel insulin sensitizing agent. Compared with traditional therapies for type 2 diabetes mellitus (T2DM), it is as efficacious in lowering glycemic parameters with the additional benefit of improving insulin resistance (IR); both of these are linked to increased risk of cardiovascular (CV) events. An evaluation was conducted from a government payer perspective to explore the potential cost‐effectiveness of Avandia compared with less costly generic agents, glyburide and metformin. METHODS: A Markov model was used to calculate direct medical costs and expected survival. The discount rate was 5%. Long‐term outcomes were modeled based on clinical and epidemiologic studies and the 10 year UKPDS data. Costs were obtained from the manufacturer, literature, case costing and provincial sources. The base case analysis considered a 70 y.o. male with T2DM with a risk factor profile representative of the UKPDS cohort. Further analyses of patients with other combinations of CV co‐morbidity were conducted to examine the range of cost‐effectiveness. RESULTS: Avandia, compared to glyburide and metformin, is a potentially attractive option. In the base case Avandia was associated with the highest expected cost but also the greatest survival ($7,781 and 6.254 years); metformin the lowest cost ($3,655) and intermediate survival (6.181 years); glyburide was dominated by metformin ($3,667 and 6.1608 years); the incremental CE ratios for Avandia were $56,888 and $44,237 per LY gained vs. metformin and glyburide respectively. For patients with other clusters of risk factors, the CE ratios ranged from $6,886/LYG (4 additional CV risk factors) up to $59,947/LYG (0 additional risks). The sensitivity analyses showed that the base case results were robust. CONCLUSIONS: While acknowledging the limitations of modeling techniques, the results of this analysis suggest that Avandia, which addresses both dysglycemia and IR, may be a cost‐effective alternative for T2DM compared to the conventional therapies.
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