Cost-effectiveness analysis of three different combinations of inhalers for severe and very severe chronic obstructive pulmonary disease patients at a tertiary care teaching hospital of South India

Abstract

Background:This study aims at simplifying the practical patient management and offers some general indications for pharmacotherapeutic choice by the implementation of (Global Initiative for Chronic Lung Disease) guidelines. This study was designed to evaluate the clinical and economic consequences of salmeterol/fluticasone (SF), formoterol/budesonide (FB), and formoterol/fluticasone (FF) in severe and very severe chronic obstructive pulmonary disease (COPD) patients.Objectives:The aim was to find out the most cost-effective drug combination between the three combinations (SF/FB/FF) in COPD patients.Materials and Methods:A prospective observational comparative study (cost-effectiveness analysis), in which 90 severe (30 ≤ forced expiratory volume in 1 s [FEV1] <50% predicted) and very severe (FEV1 < 30% predicted) COPD patients (outpatients/inpatients) who are prescribed with any one of the following combinations (SF/FB/FF) were selected. In our study, we have divided 90 COPD patients into three groups (Group I, Group II, and Group III) each group consisting of 30 patients. Group I was prescribed with medication SF, Group II with medication FB, and Group III with medication FF. We used five different parameters such as spirometry test (mean FEV1 initial and final visit), number of symptom-free days (SFDs), number of moderate and severe exacerbations, Number of days of hospitalization and direct, indirect, and total cost to assess the cost-effectiveness of SF/FB/FF. Comparison of cost and effects was done during the period of 6 months of using SF/FB/FF.Results:The average FEV1 for Group I, Group II, and Group III subjects at initial visit was 33.47%, 33.73%, and 33.20% and was increased to 36.60%, 35.8%, and 33.4%, respectively. A 3% increment in FEV1 was reported for Group I subjects (SF) and was highly significant statistically (t = −8.833, P = 0.000) at 95% CI. For Group II subjects (FB), a 2% increment in FEV1 was reported and was highly significant statistically (t = −9.001, P = 0.000) at 95% CI. For Group III (FF) subjects 0.2% increment in FEV1. The overall mean total cost for Group I, Group II, and Group III subjects during the 6 months period was found to be Rs. 29,725/-, Rs. 32,602/- and Rs. 37,155/-. Incremental cost-effectiveness of FB versus SF was Rs. 37,781/- per avoided exacerbation and Rs. 661/-per SFD.Conclusion:This study highlights the favorable therapeutic performance of combined inhaled bronchodilators and corticosteroids (SF/FB/FF), thus suggesting that healthcare costs would be also affected positively. Results from our study showed that SF and FB were the most effective strategies in the treatment of COPD, with a slight clinical superiority of SF. The FF strategy was not much effective (i.e. associated with fewer outcomes and higher costs).

Systematic Review and Quality Appraisal of Cost-Effectiveness Analyses of Pharmacologic Maintenance Treatment for Chronic Obstructive Pulmonary Disease: Methodological Considerations and Recommendations

“…The studies, including two that were not industry funded, used very different methods, contrasting with the frequently used Markov models in other drug categories. The first non-industry-funded study was a CEA performed alongside a 6-month prospective observational study in a tertiary care hospital in South India [27]. It included a small cohort ( n  = 90) of patients with severe and very severe COPD irrespective of their history of exacerbations.…”

“…The four new studies in this review had considerable limitations: a small cohort and an inappropriate population [27], no usual care control group [28], a combination of data from two different countries [29] and limited follow-up [30]. Therefore, the evidence regarding the cost effectiveness of LABA/ICS in patients with COPD is inconclusive.…”

“…Reasons were not always explicitly stated, but the perspectives did not differ from their country’s recommendations or at least also included the recommended perspective [34]; 15 took a healthcare payer perspective (Supplementary Appendix Table A2). Four of these also applied a societal perspective [17, 18, 27, 30], two only used the societal perspective [15, 31] and another did not explicitly mention the perspective, but it seemed to have been undertaken from a healthcare perspective [28]. A total of 15 studies were modelling studies; the remaining three were performed alongside a clinical trial or used observational data, and all but two studies used efficacy data for their main effect estimate (QHES item 3).…”

“…The time horizons (QHES item 8) differed considerably between the studies (Tables 1, 2, 3, 4, 5). For analyses conducted alongside clinical trials, the time horizons were 3 and 6 months [27, 30]. Time horizons in the modelling studies ranged from 1 year to lifetime, and cycle length varied between 1 month and 1 year (Supplementary Appendix Table A2).…”

“…Some studies did not use an appropriate population [27], correct effectiveness data [29] or correct comparators [28, 31]. All but two studies [27, 28] were funded by the pharmaceutical company that produced the maintenance treatment studied, and this was clearly stated (QHES item 16). However, the influence of the funder was not always clear, although the choice of comparator in the economic evaluation was obviously largely driven by the choice of comparator in the clinical studies.…”