Interpreting discordant indirect and multiple treatment comparison meta-analyses: an evaluation of direct acting antivirals for chronic hepatitis C infection.

Indirect treatment comparison (ITC) and multiple treatment comparison (MTC) meta-analyses are increasingly being used to estimate the comparative effectiveness of interventions when head-to-head data do not exist. ITC meta-analyses can be conducted using simple methodology to compare two interventions. MTC meta-analyses can be conducted using more complex methodology, often employing Bayesian approaches, to compare multiple interventions. As the number of ITC and MTC meta-analyses increase, it is common to find multiple analyses evaluating the same interventions in similar therapeutic areas. Depending on the choice of the methodological approach, the conclusions about relative treatment efficacy may differ. Such situations create uncertainty for decision makers. An illustration of this is provided by four ITC and MTC meta-analyses assessing the efficacy of boceprevir and telaprevir for chronic hepatitis C virus infection. This paper examines why these evaluations provide discordant results by examining specific methodological issues that can strengthen or weaken inferences.

Cost-utility analysis of tiotropium versus usual care in patients with COPD in the UK and Belgium.

OBJECTIVE: To evaluate the cost-utility of adding tiotropium to usual care versus usual care alone for patients with moderate to very severe chronic obstructive pulmonary disease (COPD) in the UK and Belgium. METHODS: A four-state Markov model was developed with three disease severity states (moderate, severe, very severe) and death. Severity was based on post-bronchodilator FEV1 and transitions were based on outcomes of the Understanding Potential Long Term Impacts on Function with Tiotropium (UPLIFT®) trial. Utilities were derived from EQ-5D scores for a subset of UPLIFT® patients. UK costs were evaluated separately for England (E), and for Scotland, Wales and Northern Ireland (SWNI). Belgian (B) costs were obtained from local sources. Uncertainty was assessed by deterministic and probabilistic sensitivity analysis (PSA). RESULTS: Adding tiotropium to usual care resulted in an incremental cost per patient of €969 (B), £796 (E), and £812 (SWNI), and incremental QALYs of 0.052 (B), and 0.051 (E, SWNI). The four-year incremental cost-effectiveness ratios (ICER) were €18,617 (B), £15,567 (E) and £15,890 (SWNI) per QALY. Probability of tiotropium being cost-effective at £30,000 (€50,000) per QALY gained was greater than 60%. CONCLUSIONS: At willingness to pay thresholds of £(€) 30,000 per QALY gained, adding tiotropium to usual care is cost-effective.

The cost of paediatric and perianal Crohn's disease in Canterbury, New Zealand.

AIMS: The aim of this study was to determine the direct and indirect costs of Crohn's disease (CD) in paediatric and perianal patients in Canterbury in one year. METHODS: A retrospective cross-sectional analysis was performed. Paediatric CD patients and adult patients with perianal CD were recruited over a three month period. Interviews were conducted to obtain information regarding demographic, socioeconomic factors, and indirect costs. Hospital clinical notes were reviewed to determine direct health care utilisation and costs. RESULTS: Forty-nine patients (24 paediatric and 25 perianal CD) were enrolled. In one year the total costs per patient for paediatric CD were $14,375 with direct and indirect costs comprising $12,583 and $1,792, respectively. The total costs per patient for perianal CD were $20,366 with direct and indirect costs comprising $18,261 and $2,105, respectively. Extrapolating these data across New Zealand, the total cost of paediatric and perianal CD in one year is approximately $25.9 million and $36.7 million, respectively. CONCLUSIONS: Paediatric and perianal CD are high-cost diseases with significant costs borne by patients and their families. Expensive pharmaceuticals comprise a significant proportion of the costs: increased access to these drugs might decrease hospital admissions and prevent work absenteeism and loss of carer productivity.