Transcript Farmacoeconomia Epatiti

II SESSIONE
Moderatori: A. Alberti, P. Andreone
Terapia delle Epatiti Virali
Croniche: la prospettiva della
Farmacoeconomia
S. Fagiuoli
25 giugno 2014 Verona
Terapia delle Epatiti Virali Croniche:
la prospettiva della Farmacoeconomia
Stefano Fagiuoli
U.S.C. Gastroenterologia Epatologia e Trapiantologia
Ospedale Papa Giovanni XXIII - Bergamo
Debito pubblico paesi UE
La Spesa Snitaria: le cifre
HCV - Scenario
Attuale
LE CAUSE DELLE MALATTIE EPATICHE:
HCV
TECHNICAL REPORT Hepatitis B and C in the EU neighbourhood: prevalence,
burden of disease and screening policies September 2010
Titanic consideration
April 1912: 2.223 passengers – lifeboat capacity of 1.178 – 32% survivors
Courtesy of prof. P.Toniutto
www.thermstitanic.wikia.com
Percentage of Titanic survivors by class
100
1st Class
80
3rd Class
2nd Class
60
%
40
20
0
Women and children
Men
Total
http://www.icyousee.org/titanic.html
Medical and ethical consideration
1) Is there a risk of being inequitable in having first-class
patients and patients of second- and third-class?
2) Are there patients who can wait for access to new therapies
without having a clinical worsening?
Medical ethics
• EQUITY: the need to distribute equitably the therapeutic
resources available
• INDIVIDUAL JUSTICE: the duty to promote the best
interests of the individual patient
• UTILITY: the duty to strive to obtain the best results for the
correct population using the therapeutic resources
Calman KC and Downie RS. Oxford Textbook of Public Health. Chapter 4.4
Medical Ethics
• EQUITY: the need to distribute equitably the therapeutic
resources available
• INDIVIDUAL JUSTICE: the duty to promote the best
interests of the individual patient
– Medical urgency
• UTILITY: the duty to strive to obtain the best results for the correct
population using the therapeutic resources
Calman KC and Downie RS. Oxford Textbook of Public Health. Chapter 4.4
Principle
“Everything that is effective should be given free”
Archie Cochrane 1971
La valutazione delle tecnologie sanitarie
La valutazione economica in sanità
non si limita al solo esame dei costi
Background and Aims:
C.O.M.E. Study
EASL 2013
We aimed to assess the socio-economic burden of CHDs in Italy
Direct Costs (medical and non medical)
Loss of productivity (days of work/study/daily activities)
Health Related Quality of Life (HRQoL)
Materials and Methods
Type of study
Naturalistic, multicentre, longitudinal Cost of Illness study, adopting the
societal point of view
Patients and
setting
Any CHD adult patient (>18 years) consecutively accessing a
Gastroenterology Unit (Ospedali Riuniti, Bergamo and Ospedale Policlinico
Federico II, Napoli)
Point of view
Society (patients, their family caregivers, National Health Service)
Time horizon
6 months before the enrollment in the study
Data
• Clinical,
• Health Related Quality of Life (EQ-5D),
• Resource consumption (direct costs)
• Medical: (related to hepatic disease) conventional drug and unconventional
treatment (e.g., homeopathy, herbal medicines, vitamins, etc), hospitalization for
reasons attributable to hepatic condition, outpatient medical visits and
diagnostic examinations
• Non Medical: formal (paid) assistance, travelling and/or accommodation
• Loss of productivity (indirect costs)
the “COME” Study Results
1,088 patients enrolled
62.0% male, age range 19-90 (median=59,5)
Chronic Hepatitis
Cirrhosis
HCC
652 (60,0%)
222 (20,4%)
85 (7,8%)
HCV
53,1%
Other
46,9%
HBV
33,9%
HCV
52,3%
HBV
19,0%
Other
28,7%
HCV HBV Other
64,6% 14,6% 20,8%
OLT
129(11.9%)
HCV HBV
26,4% 20,9%
Other
13,0%
HCV: 50,6%
HBV: 27,9%
Others: 21,5%
Co-inf: 1,3%
Other
52,8%
the “COME” Study Results
Direct costs according to main condition
€ 400.00
€ 300.00
Mean
€/patient/month
€ 200.00
€ 100.00
€ 0.00
HBV
hepatitis
(N=221)
HCV
hepatitis
(N=346)
outpatient visits/examinations
€ 16.91
€ 17.48
OTHER
hepatitis
(includes
HBV-HCV
coinfection)
(N=85)
€ 14.89
Conventional: antiviral therapy
€ 239.16
€ 156.32
€ 24.81
Cirrhosis
(N=222)
HCC
(N=85)
OLT
(N=129)
€ 25.46
€ 23.61
€ 8.23
€ 47.95
€ 62.82
€ 150.57
the “COME” Study Results
Direct costs according to main condition
€ 125.00
€ 100.00
Maim
€ 75.00
€/patient/month
€ 50.00
€ 25.00
€ 0.00
HBV
hepatitis
(N=221)
HCV
hepatitis
(N=346)
travelling/accomodation
€ 12.85
€ 12.65
OTHER
hepatitis
(includes
HBV-HCV
coinfection)
(N=85)
€ 13.47
Formal caregiving (assistance)
€ 1.96
€ 3.22
Unconventional therapy
€ 8.40
€ 10.89
Cirrhosis
(N=222)
HCC
(N=85)
OLT
(N=129)
€ 38.45
€ 41.21
€ 79.53
€ 2.66
€ 9.19
€ 9.28
€ 17.77
€ 11.27
€ 22.61
€ 17.30
€ 16.77
the “COME” Study Results
Direct costs according to main condition
€ 125.00
€ 100.00
Main
€ 75.00
€/patient/month
€ 50.00
€ 25.00
€ 0.00
HBV
hepatitis
(N=221)
HCV
hepatitis
(N=346)
travelling/accomodation
€ 12.85
€ 12.65
OTHER
hepatitis
(includes
HBV-HCV
coinfection)
(N=85)
€ 13.47
Formal caregiving (assistance)
€ 1.96
€ 3.22
Unconventional therapy
€ 8.40
€ 10.89
Cirrhosis
(N=222)
HCC
(N=85)
OLT
(N=129)
€ 38.45
€ 41.21
€ 79.53
€ 2.66
€ 9.19
€ 9.28
€ 17.77
€ 11.27
€ 22.61
€ 17.30
€ 16.77
the “COME” Study Results
Direct costs according to main condition
€ 2,400.00
€ 2,200.00
€ 2,000.00
€/patient/month
€ 1,800.00
€ 1,600.00
€ 1,400.00
€ 1,200.00
€ 1,000.00
€ 800.00
€ 600.00
€ 400.00
€ 200.00
€ 0.00
HBV hepatitis
(N=221)
HCV hepatitis
(N=346)
OTHER hepatitis
(includes HBVHCV coinfection) (N=85)
Cirrhosis
(N=222)
HCC
(N=85)
OLT
(N=129)
Hospitalizations
€ 40.08
€ 34.90
€ 132.49
€ 260.48
€ 999.84
€ 1,483.93
Conventional, excluding antiviral therapy
€ 1.64
€ 3.63
€ 11.73
€ 99.14
€ 75.10
€ 917.90
the “COME” Study Results
Direct costs according to main condition
€ 2,400.00
€ 2,200.00
€ 2,000.00
€/patient/month
€ 1,800.00
€ 1,600.00
€ 1,400.00
€ 1,200.00
€ 1,000.00
€ 800.00
€ 600.00
€ 400.00
€ 200.00
€ 0.00
HBV hepatitis
(N=221)
HCV hepatitis
(N=346)
OTHER hepatitis
(includes HBVHCV coinfection) (N=85)
Cirrhosis
(N=222)
HCC
(N=85)
OLT
(N=129)
Hospitalizations
€ 40.08
€ 34.90
€ 132.49
€ 260.48
€ 999.84
€ 1,483.93
Conventional, excluding antiviral therapy
€ 1.64
€ 3.63
€ 11.73
€ 99.14
€ 75.10
€ 917.90
the “COME” Study Results
Direct costs according to main condition
€ 2,400.00
€ 2,200.00
€ 2,000.00
€/patient/month
€ 1,800.00
€ 1,600.00
€ 1,400.00
€ 1,200.00
€ 1,000.00
€ 800.00
€ 600.00
€ 400.00
€ 200.00
€ 0.00
HBV hepatitis
(N=221)
HCV hepatitis
(N=346)
OTHER hepatitis
(includes HBVHCV coinfection) (N=85)
Cirrhosis
(N=222)
HCC
(N=85)
OLT
(N=129)
Hospitalizations
€ 40.08
€ 34.90
€ 132.49
€ 260.48
€ 999.84
€ 1,483.93
Conventional, excluding antiviral therapy
€ 1.64
€ 3.63
€ 11.73
€ 99.14
€ 75.10
€ 917.90
the “COME” Study Results
Direct costs according to main condition
€ 2,400.00
€ 2,200.00
€ 2,000.00
€/patient/month
€ 1,800.00
€ 1,600.00
€ 1,400.00
€ 1,200.00
€ 1,000.00
€ 800.00
€ 600.00
€ 400.00
€ 200.00
€ 0.00
HBV hepatitis
(N=221)
HCV hepatitis
(N=346)
OTHER hepatitis
(includes HBVHCV coinfection) (N=85)
Cirrhosis
(N=222)
HCC
(N=85)
OLT
(N=129)
Hospitalizations
€ 40.08
€ 34.90
€ 132.49
€ 260.48
€ 999.84
€ 1,483.93
Conventional, excluding antiviral therapy
€ 1.64
€ 3.63
€ 11.73
€ 99.14
€ 75.10
€ 917.90
the “COME” Study Results
Direct costs according to main condition
€ 2,600.00
€ 2,400.00
€ 2,200.00
€ 2,000.00
€ 1,800.00
Mean
€/patient/month
€ 1,600.00
€ 1,400.00
€ 1,200.00
€ 1,000.00
€ 800.00
€ 600.00
€ 400.00
€ 200.00
€ 0.00
HBV hepatitis
(N=221)
HCV hepatitis
(N=346)
OTHER hepatitis
(includes HBVHCV coinfection) (N=85)
Cirrhosis
(N=222)
HCC
(N=85)
OLT
(N=129)
travelling/accomodation
€ 12.85
€ 12.65
€ 13.47
€ 38.45
€ 41.21
€ 79.53
Formal caregiving (assistance)
€ 1.96
€ 3.22
€ 2.66
€ 9.19
€ 9.28
€ 17.77
outpatient visits/examinations
€ 16.91
€ 17.48
€ 14.89
€ 25.46
€ 23.61
€ 8.23
Hospitalizations
€ 40.08
€ 34.90
€ 132.49
€ 260.48
€ 999.84
€ 1,483.93
Unconventional therapy
€ 8.40
€ 10.89
€ 11.27
€ 22.61
€ 17.30
€ 16.77
Conventional, excluding antiviral therapy
€ 1.64
€ 3.63
€ 11.73
€ 99.14
€ 75.10
€ 917.90
€ 239.16
€ 156.32
€ 24.81
€ 47.95
€ 62.82
€ 150.57
Conventional: antiviral therapy
Results
Estimated direct costs (€/patient-month) according to etiology and disease condition
3,500
3,043
3,000
2,576
2,410
2,368
€/pt-month
2,500
2,000
1,542
1,500
1,174
1,000
690
500
389
160
575
364
200
0
HCV
HBV OTHER
HEPATITIS
HCV
HBV OTHER
CIRRHOSIS
HCV
HBV OTHER
HCC
HCV
HBV OTHER
OLT
Direct costs: Responder vs Non Responder to AV treatment
Results
€ / month
Responder (N=48)
Non Responder (N=39)
150.0
100.0
EURO
109.8
Direct Costs (HCV)
HEPATITIS
98.5
64.6 63.5
50.0
7.1 5.9
13.1
4.0
13.1
15.3
0.0
Conventional
drug treatment
1000
9.7 8.6
Unconventional Hospitalizations
Outpatient
Formal caregiving
Travelling
treatment
medical visits and
accommodation
examinations
Direct Costs (HCV)
OTHER=OLT+HCC+CIRRHOSIS
Responder (N=6)
600
Non Responder (N=21)
510.1
€ 3.703,2 vs 9.669,6 / yr
400
200
Total
805.8
800
EURO
0.0 3.4
308.6
136.5
100
0
Conventional
drug treatment
13.2
18.7
124.1
16.8
21.3
23.8 13.6
105.6
30.7
Unconventional Hospitalizations
Outpatient
Formal caregiving
Travelling
treatment
medical visits and
accommodation
examinations
Total
Indirect Costs according with Patient condition
Results
Loss of productivity*
3.5
3
2.5
Days/patient/month
2
1.5
1
0.5
0
Informal caregiver's loss of
productivity (days)
Patients'loss of productivity
(days)
HBV
hepatitis
(N=221)
HCV
hepatitis
(N=346)
Other
Cirrhosis
hepatitis
(N=222)
(N=85)
0.12
0.18
0.14
0.27
0.43
0.23
HCC
(N=85)
OLT
(N=129)
0.64
0.77
1.21
1.09
0.98
1.78
* It is reported as mean days lost from work/doing everyday activities per patient-month.
Loss of productivity includes both paid work and unpaid activities, e.g., from students and housewives
Indirect Costs according with Patient condition
Results
Loss of productivity*
3.5
36/yr
3
2.5
Days/patient/month
20,8/yr 21,0/yr
2
1.5
1
4,7/yr
7,2/yr
0.5
0
Informal caregiver's loss of
productivity (days)
Patients'loss of productivity
(days)
HBV
hepatitis
(N=221)
HCV
hepatitis
(N=346)
Other
Cirrhosis
hepatitis
(N=222)
(N=85)
0.12
0.18
0.14
0.27
0.43
0.23
HCC
(N=85)
OLT
(N=129)
0.64
0.77
1.21
1.09
0.98
1.78
* It is reported as mean days lost from work/doing everyday activities per patient-month.
Loss of productivity includes both paid work and unpaid activities, e.g., from students and housewives
Results
EQ-5D-5L (new version)
Results
HRQoL
No Problems
100%
0.3
3.0
9.1
Slight Problems
EQ-5D-5L
Moderate Problems
0.4
0.7
4.7
6.8
3.4
10.1
13.5
Severe Problems
Extreme Problems
0.5
0.8
2.7
3.6
13.6
18.9
15.4
75%
22.5
24.6
50%
87.3
74.1
70.5
60.7
25%
52.1
0%
Mobility
Self-Care
Usual-Activities
Pain/Discomfort
Anxiety/Depression
Results
100%
HRQoL
EQ-5D-5L
No Problems
Slight Problems
0.3
0.4
0.7
4.7
11,9
6.8
%
3.4
10.1
29,6
%
15.4
3.0
9.1
25,9
%
13.5
75%
Moderate Problems
Severe Problems
Extreme Problems
0.5
0.8
2.7
3.6
13.6
39,1
%
22.5
18.9
47,9
%
24.6
50%
87.3
74.1
70.5
60.7
25%
52.1
0%
Mobility
Self-Care
Usual-Activities
Pain/Discomfort
Anxiety/Depression
Conclusions
This study provides with an exhaustive picture of the burden
of CHDs in Italy, considering the point of view of:
The Third party payer (NHS, for direct medical costs)
Patients (HRQoL, productivity loss and some direct costs)
Families (loss of productivity)
Conclusions
The more advanced the Liver disease, the higher are the
Global Costs, increasing from a mean of
300,00 €/month/pt for CH,
up to
550,00 € /month/pt in cirrhotic patients
1.300,00 € /month/ pt in HCC patients
1.450,00 € /month/pt in OLT patients
Conclusions
CHD generates High Costs to the Healthcare System
The use of effective treatments in the Early Stages of
Liver Diseases appears necessary when aiming at:

Reducing worsening of Patient’ Health

Reducing both Direct and Indirect Costs
‡
Real World Costs per SVR of TVR-Based Triple Therapy
Estimated total cost of TVR-based triple therapy in 147 patients at a
single center (Mt Sinai Medical Center, NY)
n=147
Labs and Fees
AE
RBV
$, in Millions
 44% of patients achieved
SVR
 Almost half of all costs
(45%) were spent on
patients who did not
achieve an SVR
 Cost per SVR is
substantially higher when
you consider AEs,
premature DC, and
virologic failures
The median cost per SVR24
was $188,859
Bichoupan K, et al. AASLD 2013. Washington, DC. Oral #244
IFN
n=65
Telaprevir
39
Real World Cost per SVR of HCV Triple Therapy
with PIs
‡
Evaluation of the true direct cost of treatment with PI+PR in unselected sequential
population of patients (n=200) treated at a tertiary care center (BIDMC, Boston) for HCV
GT 1
The mean cost per SVR was $172,889
SVR rate of 49%
TN
R
P/NR
n=57 n=61 n=82
No
Yes
n=118 n=82
No
Yes
n=91 n=109
No
Yes
n=167 n=33
No
Yes
n=161 n=39
Prior Response
Cirrhosis
Anemia
Thrombocytopenia
Hospitalization
TN: Treatment-naïve; R: Relapsers; P/NR: Partial or null responders
Sethi N, et al. AASLD 2013. Washington, DC. #1847
40
Comorbid Conditions Associated with Decision-Making
Regarding HCV Treatment in a Large US HMO
Retrospective study using Kaiser Permanente database to compare characteristics of those treated
vs. those not treated for HCV using IFN-based therapy and to identify significant
predictors of not receiving treatment
• Factors associated with receiving treatment
included age 45–65, male gender, cirrhosis,
HIV, NAFLD, depression, prior liver
transplant
• 15% (7,945/51,984) of the total number of
patients identified with HCV were treated
• 17% (5,533/32,283) of the study population
were treated
• 42% of the total study population were likely
IFN-ineligible or intolerant
• 50% of the study population had a significant
comorbid illness
– 15% were treated, 85% were not treated
Nyberg LM, EASL, 2014, O67
Factors Associated with NOT Receiving Treatment
Independent variables
Odds Ratio
P-value
Anemia
0.329
<0.0001
Autoimmune disorder
0.775
0.0035
Renal dysfunction
0.659
0.0195
Cardiovascular disease
0.602
<0.0001
Psychosis/Bipolar
0.678
0.0051
Severe lung disease
0.555
<0.0001
Substance abuse
0.542
<0.0001
MELD (≥12)
0.385
<0.0001
The best cost-effective hepatitis C therapy for G1
Naive
Relapsers
Partial responders
Null responders
Telaprevir
Boceprevir
Dual
No CC
No RVR
RVR - CC
+++
++
++
+
>1 log drop HCVRNA in lead-in
>1 log drop HCVRNA in lead-in
• Triple therapy is highly cost-effective compared to no therapy in prior relapsers/partial responders.
• Either BOC or TLV should be used in prior interferon-experienced patients when the prior
failure modality is unknown.
• TLV is more cost-effective than BOC in relapsers and partial responders.
• Prior null responders with <1 log drop in HCV-RNA in lead-in should stop therapy.
Camma et al. Hepatology 2012; 56: 850-60.
Camma et al. J Hepatol 2013
Estimation of the values of ICER for Sofosbuvir Based
Triple Therapy versus Dual Therapy under different
modeling assumptions of cost /patient with SBTT
The ICER threshold at 60.000,00 € is reached at a cost of
16.000,00 € per package.
In untreated Gt 1 chronic hepatitis C patients, at a
willingness-to-pay threshold of € 25,000/life year gained,
Sofosbuvir:
IFN-based !!!!
• was cost effective compared with boceprevir in all strategies with the exception
of cirrhosis and IL28B CC patients
• was cost effective compared with telaprevir in IL28B non-CC and Gt 1a
patients, but not cost-effective in IL28B CC and in cirrhosis
IFN-free !!!!
MARKOV Model: variable utilized to build the model
* Sofo+RBV treatment may be prolonged to 6 months
3-mo treatment with
SOF+RBV without LT
In WL
treated*
16%
Control harm
without Sofo+RBV.
Discontinuation
Dropout
In WL
untreated
LT
treated
LT
untreated
Post-LT followup
- HCV risk
(96% SVR)
Death
+HCV risk
Post-LT followup**
**50% enrolled patients (controls) had IFN + RBV after LT
ABBREVIATIONS: HCV, hepatitis C virus; WL, waiting list; LT, liver transplantation; SVR, sustained virological response; Sofo, Sofosburiv; RBV,
ribavirin; IFN, interferon; mo, months
3-mo therapy cost ($)
100,000
10,000
Recipient age (years)
70
18
SVR (%)
100
60
HCV HR
2.09
1.22
Donor age (years)
20
90
MELD
25
6
HCC
Yes
No
Expected value: 50,892
12000
18000
24000
30000
36000
42000
48000
54000
60000
66000
72000
78000
84000
90000
96000
ICER
6-mo therapy cost ($)
10,000
100,000
Recipient age (years)
70
18
SVR (%)
100
60
HCV HR
1.22
2.09
Donor age (years)
20
90
MELD
25
6
HCC
No
Yes
Expected value: 94,536
12000
24000
36000
48000
60000
72000
84000
96000
108000
120000
132000 144000 156000
168000
180000
ICER
6 months
PegIFN + RBV
SOF + RBV
3 months
PegIFN + RBV
SOF + RBV
Conclusion.
Sofosbuvir used as prophylactic pre-transplant therapy in HCC and
HCV patients proved to be a cost-effective treatment strategy
compared with post-LT dual and triple antiviral therapy.
‡
Projected Health Outcomes Impact of HCV on the US VA
Health System from 2014–2024
Analysis of health records from 227,563 chronically HCV infected VA
patients to estimate liver disease stage
Chronically Infected
• All-oral therapies have the potential to substantially reduce morbidity and mortality from HCV
• Most people living with HCV in the VA have early stage chronic HCV
• Deaths from HCV will increase with no treatment
Rein DB, EASL, 2014, P785
53
Frequenza in cui i prezzi dei farmaci in Italia sono più bassi rispetto ad altri Paesi
I prezzi in Italia risultano generalmente più bassi del 18,9% in media per
il mercato in farmacia e dell’8% in media per quello ospedaliero, con un
14,6% in meno come dato complessivo di mercato
CERGAS - Bocconi
IFN free DAA will expand the pool of treatable patients
Mild
Severe
Decomp
HCV chronic disease spectrum
Currently treated
We must strive to obtain appropriate and effective treatment for all patients
Courtesy of Prof.A.Craxì
HCV - Scenario Futuro
Cambio Culturale
Contenimento
SPESA
Accesso Cure
Assistenza
Sanitaria
INVESTIMENTO
in
SALUTE
Valore Aggiunto Sociale
Hepatitis B
Evolution of Approved HBV Therapy Over Time
Peginterferon alfa-2a
Lamivudine
1990
Interferon alfa-2b
1998
Entecavir
2002
Adefovir
2005
Tenofovir
2006
Telbivudine
2008
Therapeutic strategies for HBeAg-negative CHB
Short-term treatment
PegIFN
Follow-up (yrs)
Sustained immune control
HBsAg
Loss
Long-term treatment
NUCs
Maintained HBV DNA undetectable
5-10 Years
HBsAg
seroconv.
Optimal first-line therapy in CHB
HBeAg-ve CHB
48 weeks of PegIFN in patients with good predictors
If not*, long-term therapy with ETV or TDF
*contraindicated, side effects, not patient’s preference or ineffective
EASL CPG: management of CHB virus infection. J Hepatol 2012
On treatment kinetics of HBsAg serum levels in HBeAg(-) CHB to predict SVR
Week 12↓HBsAg
≥ 0.5 Log IU/mL
Week 24 ↓HBsAg
≥ 1 Log IU/mL
Week 12 ↓ HBsAg
< 0.5 Log IU/mL
Week 24 ↓ HBsAg
< 1 Log IU/mL
SVR
PPV
9 pts
8
89%
12 pts
11
92%
no SVR
NPV
39 pts
35
90%
36 pts
35
97%
Moucari et al. Hepatology 2009
Risultati di costo-efficacia PegIFN in prima linea vs NUC
Strategie a confronto
PegINF+TDF in CHB vs TDF in CHB
ICER
Cost-effectiveness plane
DOMINANTE
PegINF+TDF in Cirrosi vs TDF in Cirrosi
1.152
PegINF+ETV in CHB vs ETV in CHB
DOMINANTE
PegINF+ETV in Cirrosi vs ETV in Cirrosi
DOMINANTE
ΔCost (per 1,000)
70
50
30
I risultati dimostrano un incremento di efficacia (QALYs) a
favore delle strategie con PegIFN in prima linea
rispetto all’impiego dei NUC in prima linea.
10
-2
-1.5
-1
-0.5
0
0.5
1
1.5
2
ΔQALY
-10
Tutte le strategie con PegINF in prima linea, ad
esclusione di PegINF+TDF in cirrosi mostrano un
incremento in efficacia (QALYs) corrispondente ad una
riduzione di costi (II quadrante), e possono perciò essere considerate
strategie dominanti
PegIFN+TDF in Cirrosi consente un incremento di un QALY ad
un costo di €1.152.
-30
-50
-70
PEG-INF + TDF in CHB vs TDF in CHB
PEG-INF + TDF in CC vs TDF in CC
PEG-INF + ETV in CHB vs ETV in CHB
PEG-INF + ETV in CC vs ETV in CC
Iannazzo S et al. AVT 2013
Total costs at 10 years for drugs and other health costs calculated for a cohort of 100 patients
Within the Italian health care system, in patients with CHB, tenofovir is a Cost-effective strategy compared with
other available therapies. Public health care authorities would benefit from mathematical models designed to
estimate the future burden of CHB infection together with the impact of treatment and drug resistance
Dig. Liv. Dis. Feb. 2014
Economics is ...
692 patients (mean follow-up: 40 months).
in the North-east of Italy
Males (75.1%), Caucasian (82.4%), mean age 60.2 years (range: 21–87)
HBeAg negative (83.4%), base-line mean HBV-DNA 7.7×105 UI/mL.
Cirrhosis: 22.9%.
Treatment strategies:
1. TDF
2. ETV
3. LAM (add-on NUCs),
4. ADV (add-on strategy),
5. PEG IFN followed by TDF/ETV.
Overall response rate (HBV-DNA negativity): 98%
Dig. Liv. Dis. Feb. 2014
Economics is ...
Incremental cost-effectiveness analysis (ICER)
quality-adjusted life-years (QALYs) and ICER QALYs
Economics is ...
“... study of how societies use scarce resources to
produce valuable commodities and distribute them
among different people”
Paul A Samuelson, Nobel Laureate 1970