Cost Utility Analysis of Dupilumab Versus Endoscopic Sinus Surgery for Chronic Rhinosinusitis With Nasal Polyps

Abstract

Objective Both endoscopic sinus surgery (ESS) and biologic therapies have shown effectiveness for medically‐refractory chronic rhinosinusitis with nasal polyps (CRSwNP) without severe asthma. The objective was to evaluate cost‐effectiveness of dupilumab versus ESS for patients with CRSwNP. Study Design Cohort‐style Markov decision‐tree economic model with a 36‐year time horizon. Methods A cohort of 197 CRSwNP patients who underwent ESS were compared with a matched cohort of 293 CRSwNP patients from the SINUS‐24 and SINUS‐52 Phase 3 studies who underwent treatment with dupilumab 300 mg every 2 weeks. Utility scores were calculated from the SNOT‐22 instrument in both cohorts. Decision‐tree analysis and a 10‐state Markov model utilized published event probabilities and primary data to calculate long‐term costs and utility. The primary outcome measure was incremental cost per quality‐adjusted life year (QALY), which is expressed as an Incremental Cost Effectiveness Ratio. One‐way and probabilistic sensitivity analyses were performed. Results The ESS strategy cost $50,436.99 and produced 9.80 QALYs. The dupilumab treatment strategy cost $536,420.22 and produced 8.95 QALYs. Because dupilumab treatment was more costly and less effective than the ESS strategy, it is dominated by ESS in the base case. One‐way sensitivity analyses showed ESS to be cost‐effective versus dupilumab regardless of the frequency of revision surgery and at any yearly cost of dupilumab above $855. Conclusions The ESS treatment strategy is more cost effective than dupilumab for upfront treatment of CRSwNP. More studies are needed to isolate potential phenotypes or endotypes that will benefit most from dupilumab in a cost‐effective manner. Level of Evidence 2C Laryngoscope, 131:E26–E33, 2021

The Role of Biologics in Chronic Rhinosinusitis With Nasal Polyps

“…A cost-utility analysis using a Markov model showed that ESS strategy, including primary and revision surgery, was more cost-effective than dupilumab for CRSwNP. 39 More studies are needed to determine whether long-term or routine use of biologic therapy is truly a sustainable treatment based on evidence that biologics is a costly intervention.…”

British Rhinological Society Consensus Guidance on the use of biological therapies for Chronic Rhinosinusitis with Nasal Polyps

“…Although biologicals have been shown to reduce the need for surgical intervention for CRSwNP (17), their high costs and the need for long term treatment mean that this is unlikely to be the most cost-effective treatment across the whole population with CRSwNP, even if superior in terms of long-term symptom control in the difficult-to-treat group. Scangas et al undertook a Markov decision tree cost-effectiveness model over 20 years (18), and found, based on US costs (which may not be applicable in all healthcare setting), that a strategy of sinus surgery cost circa $50,000 producing 9.80 QALYs while dupilumab treatment costs $535,000 but produced 8.95 QALYS. Surgery was more cost-effective regardless of the frequency of revision surgery.…”

The value of endoscopic sinus surgery in chronic rhinosinusitis

“…The value of these therapies is currently under investigation and it will be critically important to assess their value in comparison to more traditional medical treatments and ESS. A recent paper has suggested that these biologics are not cost‐effective in patients with CRS who have not undergone ESS 53 . While additional research is needed, the cost of these medications is restrictive for many patients and health care providers at this time, underscoring the need to establish their relative value in a CRS treatment paradigm.…”