Prospettive di Health Economics
nell’ottimizzazione CRT
CRT optimization benefits:
a Health Economics perspective
Dr Marcello Piacenti
Fondazione Toscana G. Monasterio
Istituto di Fisiologia Clinica C.N.R., Pisa
Città della Scienza, Napoli 12 e 13 aprile 2013
Medical economics is a discipline that
provides conceptual and quantitative tools
to address the problem of allocating scarce
resources efficiently
• Any resources committed to health care are no
longer available to other uses
• For the economist, cost is not an amount of money
but rather the consumption of societal resources
that are lost to any other use.
Heart Failure Clin 2013;9:93-106
Cost-effectiveness analysis
Cost-effectiveness analysis is a method of
comparing incremental benefits and costs
• Cost-effectiveness is measured in incremental terms and
therefore requires the identification of an appropriate
comparator
• A therapy must be effective before it can be cost-effective
• Because both costs and outcomes of a disease change with
time, a cost-effectiveness study must capture all relevant
costs and outcomes over the relevant time horizon
Two types of cost-effectiveness analysis
are performed
•
Based on randomized clinical trials (RCT):
• cost and outcomes are prospectively collected with clinical
data (QALYs)
• characteristics of the pts recruited, selected centers
performing the study, short follow-up
• Based on decision-analytical modeling (DAM):
• investigators design a mathematical model to recreate the
natural history of the disease
• permits to test the robustness of the results by subjecting the
model to rigorous sensitivity analyses in which 1 or more input
parameters are varied to test how this influences the reported
results
Considered Parameters
• Analysis of outcome
•
QALYs (Quality Adjusted Life Years)
•
ICER (Incremental Cost-Effectiveness Ratio)
• Analysis of cost/effectiveness
QALYs = years x QoL
ICER = C1-C2/E1-E2
C = cost
E = QALYs gained or lost
A hypothetical scenario to demonstrate the impact of
the analytical time horizon on incremental
costeffectiveness.
(A) Cumulative costs, US Dollars. (B) Cumulative
outcomes (quality-adjusted life years, QALYs).
(C) Incremental cost-effectiveness ratio (ICER) at
various time points (US Dollars per QALY).
Willingness To Pay (WTP)
J Am Coll Cardiol, 2009; 53:765-773, doi:10.1016/j.jacc.2008.11.024
Europace Advance Access published March 2013
At 1 year:
25% deaths or hospitalizations for HF within the group of pts not systematically optimized (group 2)
9% deaths or hospitalizations for HF within the group of pts systematically optimized (SonR or Echo)
(group 1)
Reduction of 65% of HF hospitalization with systematic AV delay optimization with sonR at 1 years F-U
Banz et al 2005: Input parameters
Economical aspects of AV-delay optimization in CRT:
Optimization of CRT increase the efficacy of the treatment
Systematic AV-delay and VV-delay optimization of CRT (by SonR or echocardiography)
generates an increase of 0,1 QALYs annually1,2 compared to those patients without
systematic optimization
1: Kurt Banz. Cardiac resynchronization Therapy (CRT) in Heart Failure-Amodel to Assess Economoc Value of this New Medical
Technology. Value in Heath; Volume 8- Number 2-2005; 128-139
2: Delnoy PP et al: Clear clinical study post hoc. Europace Advance Access published March 2013
Comparison of CRT-D with standard optimization and
CRT-D with SonR optimization vs optimal medical
therapy: a simulation model proposed by Banz et al 2005
*OPT: optimal medical treatment ^cost of device included
1: Kurt Banz. Cardiac resynchronization Therapy (CRT) in Heart Failure-Amodel to Assess Economoc Value of this New Medical Technology.
Value in Heath; Volume 8- Number 2-2005; 128-139
Comparison of CRT-D with standard optimization and
CRT-D with SonR optimization vs optimal medical
therapy: a simulation model proposed by Banz et al 2005
Δ QALY
Incremental costeffectiveness ratio (ICER) =
Cnew - Coll
Effnew - Effold
Incremental costeffectiveness ratio (ICER) =
Cnew - Coll
Effnew - Effold
=
14.900 €
0,32 QALY
Standard CRT-D
=
15.058 €
0,52 QALY
CRT-D SonR
Incremental costeffectiveness ratio (ICER) =
15.058 € - 14.900 €
0,52 - 0,32 QALY
=
790 €/QALY
Sensitivity analysis of cost-effictiveness of CRT-D with
SonR optimization vs Standard CRT-D: △ costs
WTP
Conclusions:
• SonR optimization in CRT evaluated at 1 year of
follow-up increases QALY by reducing hospitalization
• The ICER of CRT-D with SonR vs CRT-D with
standard optimization programming seems costeffective
• The evolution of the SonR algoritm with weekly
optimization of pacing parameters, both at rest and on
effort, might increase even further the responder
percentage and increase cost-effectiveness