Prospettive di Health Economicsnell’ottimizzazione CRT

CRT optimization benefits:a Health Economics perspective

Dr Marcello PiacentiFondazione 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

Heart Failure Clin 2013;9:93-106

•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.

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

• 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

Two types of cost-effectiveness analysis are performed

Considered Parameters

• Analysis of outcome • QALYs (Quality Adjusted Life Years)

• Analysis of cost/effectiveness• ICER (Incremental Cost-Effectiveness Ratio)

QALYs = years x QoL ICER = C1-C2/E1-E2

C = costE = 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; 128-1392: 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 cost-effectiveness ratio (ICER) =

Incremental cost-effectiveness ratio (ICER) =

Cnew - Coll

Effnew - Effold

Cnew - Coll

Effnew - Effold

=

=

14.900 €0,32 QALY

15.058 €0,52 QALY

Standard CRT-D

CRT-D SonR

Incremental cost-effectiveness 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 cost-effective

• 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