Using Cost-Effectiveness Analysis to Sharpen Formulary Decision-Making: The Example of Tiotropium at the Veterans Affairs Health Care System

Abstract

The results support the existing Veterans Affairs practice of offering tiotropium to patients with COPD-related hospitalizations. Periodic review of the effectiveness data to determine whether tiotropium would be cost-saving in patients with very severe COPD is suggested. Cost-effectiveness analyses that identify practical criteria-for-use should become an integral part of the formulary process.

Cost Effectiveness of Pharmacological Maintenance Treatment for Chronic Obstructive Pulmonary Disease

“…There were 16 cost-effectiveness studies that used empirical analysis of clinical trial data of individual patients, [28][29][30][31][32][33][34][35][36][37][38][39][40][41][42][43] 14 studies that used Markov modelling, [44][45][46][47][48][49][50][51][52][53][54][55][56][57] and eight that used empirical analysis based on observational data. [58][59][60][61][62][63][64][65] Two studies have used a different approach, such as extrapolating the resource use reduction that was obtained after meta-analyses of clinical trials. [66,67] The 16 empirical analyses of clinical trials were each performed in conjunction with one particular clinical trial or pooled the data from two identical trials.…”

“…The majority of models were designed to estimate the cost effectiveness of either tiotropium or combined inhaled b 2 -agonist/ICS treatment. Of the eight observational studies, five [59][60][61]64,65] were based on claims data, one [58] on data from the Saskatchewan Health databases and two [62,63] on data from providers at three clinical sites. One [58] of the observational studies was performed in Canada, one [64] in Belgium and the other six in the US.…”

“…the incremental costs to reduce one severe exacerbation. [62,66] In both studies, the costs to avoid one admission were roughly around $US2000. One of these studies, comparing tiotropium with ipratropium, used electronic medical record data on healthcare utilization from an actual sample of patients receiving ipratropium.…”

“…Three studies compared tiotropium with placebo, [30,50,67] eight compared tiotropium with ipratropium [31,45,46,48,49,62,66,67] and six compared tiotropium with salmeterol. [45][46][47][48][49][50] Total COPD-related costs, including the cost of tiotropium, were lower for tiotropium in many, but not all, of the comparisons.…”

“…Two studies included only drug costs, [44,58] seven included only exacerbation-related and drug costs, [41][42][43]51,55,62,64] one excluded study drug costs, [30] three included total healthcare costs irrespective of cause [59][60][61] and one included COPD-related costs plus allcause hospitalization costs. [39] Few studies included indirect costs of productivity loss, [34,35,40] or income loss.…”