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Pharmacoeconomics: adding an “adjunctive” comparison contrasting innovative treatment vs no treatment in cases where the original clinical trial compared innovative treatment vs reference treatment
- Andrea Messori (19 August 2008)
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Andrea Messori, Coordinator Laboratorio SIFO di Farmacoeconomia, Firenze, Italy
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Pharmacoeconomic analyses generally consider the same binary comparison of innovative treatment (IT) vs reference treatment (RT) as the one adopted in the most relevant randomized trial. In this context, one methodological point that deserves further scrutiny is whether or not an “adjunctive” comparison of IT vs no treatment (NT) can be useful to better interpret the overall body of cost-effectiveness data. Thus far, researchers in the field of pharmacoeconomics have very rarely employed the “adjunctive” comparison versus NT and, when this was done, the authors did not seem to be fully aware of the merits (or disadvantages) of their methodological choice. Examining one example in detail can be worthwhile. Shepherd et al. [1] evaluated the pharmacoeconomic profile of treatments for previously untreated patients with moderate to severe chronic hepatitis C and, in this context, assessed the cost-effectiveness of peginterferon combined with ribavirin in comparison with the current reference treatment (nonpegylated interferon + ribavirin). In their comparison, IT was peginterferon+ribavirin whereas RT was nonpegylated interferon+ribavirin. In interpreting their results (incremental cost per QALY gained = £12,123 for IT vs RT), Shepherd et al. [1] observed that this pharmacoeconomic index remained within the threshold of £30,000 and therefore concluded that “peginterferon [...] represents good value for money”. However, this conclusion by Shepherd et al. [1] might be profoundly affected by the (hidden) influence of the pharmacoeconomic acceptability of nonpegylated interferon+ribavirin vs nonpegylated interferon alone as well as of nonpegylated interferon alone vs supportive therapy. Hornberger et al. [2] have performed an economic analysis very similar to that of Shepherd et al.[1]. Also in the case of Hornberger’s study [2], IT was peginterferon + ribavirin whereas RT was nonpegylated interferon + ribavirin. The results of Hornberger et al. [2] showed that peginterferon+ribavirin had an incremental cost-effectiveness ratio of US$ 2,082 per QALY gained as compared with nonpegylated interferon+ribavirin. One point of methodological interest is that, to complete their analysis, Hornberger et al. [2] felt the need to incorporate in their assessment an “adjunctive” comparator receiving NT. In comparison with NT, peginterferon+ribavirin was found to have an incremental cost- effectiveness ratio of US$ 5,187 per QALY gained. This finding confirmed the overall pharmacoeconomic acceptability of the IT because both the comparison of IT vs RT and the comparison of IT vs NT showed a favourable pharmacoeconomic profile. From this example it appears that the availability of the result comparing IT vs NT, along with the traditional result comparing IT vs RT, made the analysis of Hornberger et al. [2] more informative than that of Shepherd et al.[1] and therefore strengthened the economic evidence of the results. Hence, there can be some methodological advantage in adding an “adjunctive” comparison contrasting IT vs NT in cases where the original clinical trial compared IT vs RT. This methodological option for pharmacoeconomic studies deserves to be more fully explored in terms of advantages and disadvantages. REFERENCES 1. Shepherd J, Brodin HF, Cave CB, Waugh NR, Price A, Gabbay J. Clinical- and cost-effectiveness of pegylated interferon alfa in the treatment of chronic hepatitis C: a systematic review and economic evaluation. Int J Technol Assess Health Care. 2005;21(1):47-54. 2. Hornberger J, Torriani FJ, Dieterich DT, Brau N, Sulkowski MS, Torres MR, Green J, Patel K. Cost-effectiveness of peginterferon alpha-2a (40kDa) plus ribavirin in patients with HIV and hepatitis C virus co- infection. J Clin Virol. 2006 Aug;36(4):283-91. Competing interests: None declared |
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