Canadian Health Care Perspective Research Articles

An Economic Analysis of SC24 in Canada: A Randomized Study of SBRT Compared With Conventional Palliative RT for Spinal Metastases

Purposexx.xx was a multicenter randomized controlled phase 2/3 trial conducted in Canada and Australia. Patients with painful spinal metastases were randomized to either 24 Gy/2 stereotactic body radiotherapy (SBRT) or 20 Gy/5 conventional external beam radiotherapy (CRT). The study met its primary endpoint demonstrating superior complete pain response rates (CRR) at 3 months following SBRT (35%) vs CRT (14%). SBRT planning and delivery is resource intensive. Given its benefits in xx.xx, we performed an economic analysis to determine the incremental cost-effectiveness of SBRT compared to CRT. MethodsThe trial recruited 229 patients. Cost-effectiveness was assessed using a Markov model taking into account observed survival, treatments costs, including retreatment, and quality of life (QoL) over the lifetime of the patient. The EORTC-QLU-C10D was used to determine QoL values. Transition probabilities for outcomes were from available patient data. Health system costs were from the Canadian health care perspective and based on 2021 Canadian dollars (CDN). The incremental cost-effectiveness ratio (ICER) was expressed as the ratio of incremental cost to quality-adjusted life years (QALY). Impact of parameter uncertainty was investigated using deterministic and probabilistic sensitivity analyses. RESULTSThe base case for SBRT compared to CRT had an ICER of $9,040CDN per QALY gained. Sensitivity analyses demonstrated that the ICER was most sensitive to variations in the utility assigned to the “No local failure” ($5,457CDN to $241,051CDN per QALY), adopting low and high estimates of utility) and the cost of the SBRT (ICERs ranging from $7,345 to $123,361CDN per QALY). It was more robust to variations in assumptions around survival and the response rate. ConclusionsSBRT is associated with higher upfront costs compared to CRT. The ICER shows that, within the Canadian health care system, SBRT with 2 fractions is likely to be cost-effective relative to CRT.

EPH112 Economic Impact of Rapid Treatment Initiation of HIV with Bictegravir/Emtricitabine/Tenofovir Alafenamide (B/F/TAF) from a Canadian Healthcare Perspective

Antiretroviral therapy (ART) is the standard of care to treat human immunodeficiency (HIV). However, evidence suggests that delaying the initiation of ART increases the incidence of HIV by contributing to its transmission. The objective of this study was to assess, from a Canadian perspective, the potential epidemiological and economic impact of rapid initiation of HIV treatment with bictegravir/emtricitabine/tenofovir alafenamide (B/F/TAF) compared to current initiation in clinical practice.

Cost-effectiveness of Artificial Intelligence-Aided Colonoscopy for Adenoma Detection in Colon Cancer Screening.

Artificial intelligence-aided colonoscopy significantly improves adenoma detection. We assessed the cost-effectiveness of the GI Genius technology, an artificial intelligence-aided computer diagnosis for polyp detection (CADe), in improving colorectal cancer outcomes, adopting a Canadian health care perspective. A Markov model with 1-year cycles and a lifetime horizon was used to estimate incremental cost-effectiveness ratio comparing CADe to conventional colonoscopy polyp detection amongst patients with a positive faecal immunochemical test. Outcomes were life years (LYs) and quality-adjusted life years (QALY) gained. The analysis applied costs associated with health care resource utilization, including procedures and follow-ups, from a provincial payer's perspective using 2022 Canadian dollars. Effectiveness and cost data were sourced from the literature and publicly available databases. Extensive probabilistic and deterministic sensitivity analyses were performed, assessing model robustness. Life years and QALY gains for the CADe and conventional colonoscopy groups were 19.144 versus 19.125 and 17.137 versus 17.113, respectively. CADe and conventional colonoscopies' overall per-case costs were $2990.74 and $3004.59, respectively. With a willingness-to-pay pre-set at $50,000/QALY, the incremental cost-effectiveness ratio was dominant for both outcomes, showing that CADe colonoscopy is cost-effective. Deterministic sensitivity analysis confirmed that the model was sensitive to the incidence risk ratio of adenoma per colonoscopy for large adenomas. Probabilistic sensitivity analysis showed that the CADe strategy was cost-effective in up to 73.4% of scenarios. The addition of CADe solution to colonoscopy is a dominant, cost-effective strategy when used in faecal immunochemical test-positive patients in a Canadian health care setting.

An Implementation Science Laboratory as One Approach to Whole System Improvement: A Canadian Healthcare Perspective.

Implementation science (IS) has emerged as an integral component for evidence-based whole system improvement. IS studies the best methods to promote the systematic uptake of evidence-based interventions into routine practice to improve the quality and effectiveness of health service delivery and patient care. IS laboratories (IS labs) are one mechanism to integrate implementation science as an evidence-based approach to whole system improvement and to support a learning health system. This paper aims to examine if IS labs are a suitable approach to whole system improvement. We retrospectively analyzed an existing IS lab (Alberta, Canada’s Implementation Science Collaborative) to assess the potential of IS labs to perform as a whole system approach to improvement and to identify key activities and considerations for designing IS labs specifically to support learning health systems. Results from our evaluation show the extent to which IS labs support learning health systems through enabling infrastructures for system-wide improvement and research.

A cost-utility analysis of apalutamide for metastatic castrationsensitive prostate cancer.

Earlier application of oral androgen receptor-axis-targeted therapies in patients with metastatic castration-sensitive prostate cancer (mCSPC) has established improvements in overall survival, as compared to androgen deprivation therapy (ADT) alone. Recently, the use of apalutamide plus ADT has demonstrated improvement in mCSPC-related mortality vs. ADT alone, with an acceptable toxicity profile. However, the cost-effectiveness of this therapeutic option remains unknown. We used a state-transition model with probabilistic analysis to compare apalutamide plus ADT, as compared to ADT alone, for mCSPC patients over a time horizon of 20 years. Primary outcomes included expected life-years (LY), quality-adjusted life-years (QALY), lifetime cost (2020 Canadian dollars), and incremental cost-effectiveness ratio (ICER). Parameter and model uncertainties were assessed through scenario analyses. Health outcomes and cost were discounted at 1.5%, as per Canadian guidelines. For the base-case analysis, expected LY for ADT and apalutamide plus ADT were 4.11 and 5.56, respectively (incremental LY 1.45). Expected QALYs were 3.51 for ADT and 4.84 for apalutamide plus ADT (incremental QALYs 1.33); expected lifetime cost was $36 582 and $255 633, respectively (incremental cost $219 051). ICER for apalutamide plus ADT, as compared to ADT alone, was $164 700/QALY. Through scenario analysis, price reductions ≥50% were required for apalutamide in combination with ADT to be considered cost-effective, at a cost-effectiveness threshold of $100 000/QALY. Apalutamide plus ADT is unlikely to be cost-effective from the Canadian healthcare perspective unless there are substantial reductions in the price of apalutamide treatment.

Cost Effectiveness of Ribociclib in Combination with Fulvestrant for the Treatment of Postmenopausal Women with HR+/HER2- Advanced Breast Cancer Who Have Received No or Only One Prior Line of Endocrine Therapy: A Canadian Healthcare Perspective.

The MONALEESA-3 trial demonstrated the efficacy and safety of ribociclib plus fulvestrant versus placebo plus fulvestrant for patients with hormone receptor-positive and human epidermal growth factor receptor 2-negative (HR+/HER2-) advanced breast cancer (ABC). This analysis evaluated the cost effectiveness of ribociclib plus fulvestrant versus fulvestrant in patients with HR+/HER2- ABC from a Canadian healthcare payer perspective. The incremental cost-effectiveness ratio (ICER), expressed as incremental costs per quality-adjusted life-year (QALY) gained for ribociclib plus fulvestrant versus fulvestrant, was estimated using a semi-Markov cohort model developed in Microsoft Excel, with states for progression-free, post-progression, and dead. A 15-year time horizon was used. Survival distributions for progression-free survival (PFS), post-progression survival (PPS), and time to discontinuation (TTD) were based on parametric survival distributions fit to data from MONALEESA-3. Health-state utilities were estimated using EQ-5D index values collected in MONALEESA-3. Direct costs of ABC treatment (medication and administration costs, follow-up and monitoring, adverse events, subsequent treatments) were based on Canadian-specific values from published sources. Costs (2019 CAN$) and QALYs were discounted at 1.5% annually. In the base case, ribociclib plus fulvestrant was estimated to result in gains of 1.19 life-years and 0.96 QALYs versus fulvestrant, at an incremental cost of $151,371. The ICER of ribociclib plus fulvestrant versus fulvestrant was $157,343 per QALY gained based on the mean of probabilistic analyses. Results were sensitive to parametric distributions used for projecting long-term TTD, PFS, and PPS. For patients with HR+/HER2- ABC, ribociclib plus fulvestrant is projected to result in substantial gains in QALYs compared with fulvestrant. At its current list price, ribociclib used in combination with fulvestrant is likely to be cost effective in these patients at a threshold ICER of $157,343. These results may be useful in deliberations regarding reimbursement and access to this treatment.

MO551A COST-OFFSET ANALYSIS OF THE ROXADUSTAT DIALYSIS-DEPENDENT GLOBAL PHASE 3 PROGRAM: A CANADIAN HEALTHCARE PERSPECTIVE

Abstract Background and Aims Chronic kidney disease (CKD) is a costly public health issue, which affects 13.4% of the population globally. Anaemia is a common complication in patients with CKD resulting in reduced health-related quality of life and high healthcare costs. The objective of this analysis was to estimate the direct medical care cost offsets of the investigational agent roxadustat for the treatment of anaemia in patients with dialysis-dependent (DD) CKD from a Canadian healthcare perspective. Method Data from the roxadustat global phase 3 program were used to estimate the incidence of rescue therapy or iron supplementation use (i.e. intravenous iron, erythropoiesis-stimulating agents [ESAs] or red blood cell transfusions) and major adverse cardiovascular events (MACE+) for roxadustat compared with ESAs in DD patients with anaemia of CKD. MACE+ included myocardial infarction, stroke, unstable angina requiring hospitalization, congestive heart failure (CHF) requiring hospitalization, cardiovascular death and other death. Published Canadian cost data were used to estimate event costs. Drug acquisition costs for roxadustat and ESAs were not considered. A hypothetical cohort of 10,000 Canadian adult DD patients (90% undergoing haemodialysis, 10% undergoing peritoneal dialysis) with treatable anaemia was modelled to determine net medical care cost offsets annually and cumulatively compared with ESAs over a 4-year time horizon. Results Preliminary results for patients with DD CKD show that, compared with ESAs, roxadustat could produce sizeable net medical care cost offsets resulting from reductions in rescue therapy or iron supplementation use, specifically red blood cell transfusions, and from reductions in MACE+, specifically CHF hospitalizations. For the entire cohort of patients with DD CKD, cumulative medical care cost offsets for roxadustat were an estimated $162,609 for rescue therapy or iron supplementation use and $1,027,070 for MACE+ compared with ESAs. Conclusion This analysis provides evidence that treatment with roxadustat in DD patients with anaemia of CKD could result in considerable medical care cost offsets for roxadustat compared with ESAs.

Cost Effectiveness of Ribociclib Plus a Nonsteroidal Aromatase Inhibitor in Pre-/Perimenopausal, HR+ and HER2− Advanced Breast Cancer: A Canadian Healthcare Perspective

The MONALEESA-7 trial demonstrated the efficacy and safety of ribociclib plus a nonsteroidal aromatase inhibitor (NSAI) [with goserelin] for pre-/perimenopausal women with hormone receptor-positive and human epidermal growth factor receptor 2-negative advanced breast cancer. This analysis evaluated the cost effectiveness of ribociclib plus NSAI vs NSAI monotherapy and tamoxifen monotherapy from the perspective of the Canadian healthcare system. The incremental cost-effectiveness ratio expressed as incremental costs per quality-adjusted life-year (QALY) gained for ribociclib plus an NSAI vs an NSAI and vs tamoxifen was estimated using a semi-Markov cohort model developed in Microsoft Excel with a 15-year time horizon and states for progression-free survival, post-progression survival, and dead. Survival distributions for progression-free survival, post-progression survival, and time to discontinuation as well as health-state utilities were estimated using data from MONALEESA-7. Direct costs of advanced breast cancer treatment were based on Canadian-specific values from published sources. Costs ($CAN 2019) and QALYs were discounted at 1.5% annually. Ribociclib plus an NSAI was estimated to yield gains of 1.42 life-years and 1.17 QALYs vs an NSAI, and 2.61 life-years and 2.12 QALYs vs tamoxifen, at incremental costs of $209,701 and $220,836, respectively. In probabilistic analyses, the incremental cost-effectiveness ratio for ribociclib plus an NSAI was estimated to be $178,872 per QALY gained vs an NSAI and $104,400 per QALY gained vs tamoxifen. Results of deterministic analyses were similar (incremental cost-effectiveness ratios of $177,245 and $103,316 vs NSAI and tamoxifen, respectively). Results were sensitive to parametric distributions used for projecting progression-free survival and the time horizon. At its current list price, ribociclib used in combination with NSAI is likely to be co-effective relative to an NSAI alone or tamoxifen alone if the willingness-to-pay threshold is less than approximately $178,000 per QALY. These results have informed deliberations regarding reimbursement and access to this treatment in Canada and may be useful for decision makers in other settings.

POS-321 TRANSLATING THE FINDINGS OF THE ROXADUSTAT NDD GLOBAL PHASE 3 PROGRAM INTO COST OFFSETS FROM A CANADIAN HEALTHCARE PERSPECTIVE

Chronic kidney disease (CKD) is a costly public health issue, with an estimated prevalence of 13.4% globally. Anemia is a common complication associated with CKD resulting in reduced health-related quality of life and high healthcare costs. The objective of this analysis was to estimate the direct medical care cost offsets of investigational agent roxadustat for the treatment of anemia in patients with non-dialysis dependent (NDD) CKD from a Canadian healthcare perspective. Data from the roxadustat global Phase 3 program were used to estimate the projected incidence of rescue therapy use (intravenous iron, erythropoiesis stimulating agents or red blood cell transfusions) and major adverse cardiovascular events-plus (MACE+) for roxadustat compared to standard of care (placebo) in NDD patients with anemia of CKD. MACE+ events included myocardial infarction, stroke, hospitalized unstable angina, hospitalized congestive heart failure, cardiovascular death, and other death. Published Canadian cost data were used to estimate the cost of each medical event. A hypothetical cohort of 10,000 NDD Canadian patients with anemia of CKD aged 18 years and older was modeled with net medical care cost offsets calculated in Canadian dollars for each of the five years and cumulatively. Patients who transitioned to dialysis during the time horizon of the analysis were also evaluated in this cost offsets analysis. Compared to standard of care, preliminary results of the model for patients with NDD CKD and patients who transitioned to dialysis during the five year horizon of the analysis showed that roxadustat could produce net medical care cost offsets resulting from the reductions in rescue therapy usage and reduction in MACE+ events (specifically hospitalizations due to HF). Cumulative medical care cost offsets for patients with NDD CKD and patients who transitioned to dialysis during the five year horizon of the analysis compared with standard of care were estimated for rescue therapy use ($1,428,501) and MACE+ ($1,496,865). This cost offsets analysis provides evidence that treatment with roxadustat, in NDD patients with anemia of CKD and patients who transition to dialysis, could result in lower total medical care net costs compared to the costs of standard of care.

Cause-effect chains in S-LCA based on DPSIR framework using Markov healthcare model: an application to \u201cworking hours\u201d in Canada

PurposeThis study has two aims: first, propose the use of the driver-pressure-state-impact-response (DPSIR) framework to expand the normal focus of impact pathways in social life cycle assessment (S-LCA) on endpoint impacts to a systematic analysis to find links between the main sources of social issues and impacts; second, develop a new impact assessment method to quantify the lifetime health and economic outcomes associated with social subcategories, for the first time, using decision analytic models.MethodsThe DPSIR framework is mapped to the corresponding elements of the S-LCA context in relation to the social subcategories defined in the UNEP/SETAC methodological sheets. Next, a more robust approach is developed for cause-impact chains between social subcategories and impacts on human well-being based on decision-analytic models (decision trees and Markov models) using healthcare approaches and data. Finally, the health and economic consequences associated with social subcategories are quantified by using Quality Adjusted Life Years (QALYs) and costs based on medical literature and healthcare studies.Results and discussionThe method was applied to the “working hours” social subcategory in Canada. The cause-effect chain is built using DPSIR framework in relation to the current social issue in Canada of working more than standard hours. Results of the decision analytic model show that working standard hours is more effective and cost-saving than working more than standard hours from the Canadian healthcare perspective. Working standard hours compared to more than standard hours led to an increase of 0.73 QALY and decrease in cost of $6702 per worker. Based on an estimated 2.4 million Canadian workers working more than standard hours, this resulted in a total gain of 1.7 million QALYs and saving of $16 billion overall. Using cost-effectiveness analysis, possible interventions at multiple entry points of the cause-effect chain within DPSIR framework are proposed to reduce the negative health impacts and associated costs of working more than standard hours in Canada.ConclusionsApplying the method on other subcategories could help decision-makers establish the cause-effect aspects of the social performance of their product systems using a quantitative systematic analysis from a life cycle perspective. This approach supports corporate decision-makers to quantify social impacts associated with their product supply chains by calculating QALYs and healthcare costs of their socio-economic conditions enabling them to identify possible interventions to improve the social performance.

A cost-utility analysis of apalutamide for the treatment of patients with metastatic castration-sensitive prostate cancer (mCSPC).

e19369 Background: The therapeutic landscape for patients with mCSPC has evolved over the last decade given the growing body of evidence demonstrating efficacy for the earlier application of oral androgen receptor signaling inhibitors, such as with abiraterone and enzalutamide. Recently the success of the TITAN trial established the superior efficacy of apalutamide combined with androgen deprivation therapy (ADT), with a 33% reduction in mortality versus ADT alone, and a tolerable toxicity profile. However, with substantially higher costs than ADT alone, the cost-effectiveness of this combination is critical to evaluate. Methods: A cost-utility analysis of apalutamide+ADT versus ADT alone was conducted from the Canadian healthcare perspective. A state-transition model with probabilistic analysis was used to compare the two strategies over a lifetime horizon. Model inputs were informed by the TITAN trial (transition probabilities, adverse events [AE], subsequent therapy), published literature (utilities) and Canadian costing resources (systemic therapy [initial and subsequent], routine care [physician visits, imaging], AE, end-of-life care costs). Primary outcomes included expected life-year gains (LYG), quality-adjusted life-years (QALY), lifetime cost (in 2018 Canadian dollars), and the incremental cost-effectiveness ratio (ICER). Multiple scenario analyses were conducted to assess parameter and model uncertainty. Cost and effectiveness were discounted at 1.5% as per Canadian guidelines. Results: From the base-case analysis expected LYG and QALY for ADT and apalutamide+ADT were 4.11, 5.57 and 3.50, 4.85, respectively. Expected cost over a lifetime horizon was $37,553 and $254,205, respectively. The ICER for apalutamide+ADT as compared to ADT alone was $160,483/QALY. Through scenario analysis, cost-effectiveness of apaluatmide+ADT was achieved with apalutamide price reductions of >50%, relative to a cost-effectiveness threshold (CET) of $100,000/QALY. Scenario analysis of alternative long-term survival expectations with apalutamide+ADT demonstrated cost-effectiveness (relative to CET $100,000/QALY) with expected improvements in the 5-year survival rate of 29% as compared to ADT (versus base-case expected improvement in 5-year survival of 15%). Conclusions: Apalutamide+ADT is unlikely to be cost-effective from the Canadian healthcare perspective at current list prices. Improvement in cost-effectiveness is most likely to be achieved through price reductions in apalutamide drug costs.

PCN73 COST-EFFECTIVENESS OF BLINATUMOMAB VERSUS STANDARD OF CARE IN ADULT PATIENTS WITH PHILADELPHIA-CHROMOSOME-POSITIVE RELAPSED OR REFRACTORY B-CELL PRECURSOR ACUTE LYMPHOBLASTIC LEUKEMIA FROM A CANADIAN HEALTHCARE SECTOR PERSPECTIVE

To evaluate the cost-effectiveness of blinatumomab vs. standard of care (SOC) therapy in patients with Philadelphia-chromosome-positive (Ph+) relapsed or refractory (R/R) B-cell precursor acute lymphoblastic leukemia (BCP-ALL) from a Canadian healthcare perspective. A partitioned survival model was used to estimate the incremental cost-effectiveness ratio (ICER) of blinatumomab vs. SOC. Where available, model estimates were informed by the ALCANTARA study and a historical comparator (HC) study. The HC population was matched to patients in ALCANTARA using inverse probability of treatment weights (IPTW). Parametric distributions were fit to individual patient data from the studies to estimate relapse-free and overall survival. Since utility data were not available in ALCANTARA, utilities were informed by the TOWER study in patients with R/R ALL. Cost estimates were from published sources. A lifetime (30-year) time horizon was used. The model assumed patients surviving to 3 years would be cured and no longer at risk of ALL-related death. Alternative cure definitions and model assumptions were tested in probabilistic and deterministic sensitivity analyses. Probabilistic analyses projected a 1.24 life year gain and 1.00 additional quality-adjusted life years (QALYs) for blinatumomab vs SOC. While blinatumomab medication costs were CAD 127,543 higher vs. SOC, they were partially offset by lower incremental administration (CAD -51,070), transplant (CAD -4,162), and post-relapse (CAD -4,331) costs. The mean probabilistic ICER for blinatumomab vs. SOC was CAD 68,185/QALY and blinatumomab was cost-effective in 70% of simulations at an ICER threshold of CAD 100,000/QALY. Along with the cure assumptions, key drivers for the ICER were the duration of blinatumomab therapy and model time horizon. Compared with SOC, blinatumomab is a cost-effective treatment option for adults with Ph+ R/R BCP-ALL from a Canadian healthcare perspective. Blinatumomab provides a valuable alternative to systemic agents, as demonstrated by the improvement in survival and quality of life.

Nivolumab in the Treatment of Metastatic Renal Cell Carcinoma: A Cost-Utility Analysis.

Nivolumab improves overall survival and health-related quality of life compared with everolimus in metastatic renal cell carcinoma (mRCC). This study assesses the cost-utility of nivolumab from the Canadian health care payer perspective. To evaluate the cost-utility of nivolumab, a Markov cohort model that incorporated data from the phase 3 CheckMate-025 trial and other sources was developed. The incremental cost per quality-adjusted life month (QALM) gained for nivolumab was calculated. A lifetime horizon was used in the base-case with costs and outcomes discounted 3% annually. The probabilities of progression and death from cancer and utility values were captured from the CheckMate-025 trial. Expected costs were based on Ontario fees and other sources. Scenario and sensitivity analyses were conducted to assess uncertainty. Compared with everolimus, nivolumab provided an additional 4.2 QALM at an incremental cost of $34,153. The resulting incremental cost-effectiveness ratio was $8138/QALM gained. Assuming a willingness to pay (WTP) threshold of $4167/QALM ($50,000/quality-adjusted life-year [QALY]), nivolumab was not cost-effective. In 1-way sensitivity analyses, nivolumab cost, median overall survival, and median treatment duration were sensitive to changes. Furthermore, the results were sensitive to the WTP threshold and nivolumab became a cost-effective strategy with a WTP of $8333/QALM ($100,000/QALY). Compared with everolimus, nivolumab is unlikely to be cost-effective for the treatment of mRCC from a Canadian health care perspective with its current price assuming a WTP of $50,000/QALY. Although mRCC patients derive a meaningful clinical benefit from nivolumab, considerations should be given to avoid drug wastage and increase the WTP threshold to render this strategy more affordable.

Abstract P4-12-08: Palbociclib in hormone receptor positive advanced breast cancer: A cost-utility analysis

Abstract Introduction The addition of palbociclib to letrozole improves progression free survival (PFS) and response rates compared to letrozole alone in the 1st line treatment of hormone receptor positive advanced breast cancer. However palbociclib increases toxicity (i.e. neutropenia) and costs more than $6,250 per month in Canada. This study assesses the cost-utility of palbociclib from the Canadian healthcare payer perspective. Methods To evaluate the cost-utility of palbociclib, a probabilistic discrete event simulation model was developed. The model was parameterized with data from the phase 2 and 3 PALOMA 1 and 2 trials and other sources. The incremental cost per quality-adjusted life-month (QALM) gained for palbociclib was calculated. A time horizon of 15 years was used in the base case with costs and effectiveness discounted 5% annually. The time to progression and death were derived from a Weibull and exponential distribution. Expected costs were based on Ontario fees and other sources. Probabilistic sensitivity analyses were conducted to account for parameter uncertainty. Results Compared to letrozole alone, the addition of palbociclib provided an additional 14.7 QALM at an incremental cost of $161,508. The resulting incremental cost-effectiveness ratio was $10,999 per QALM gained. Assuming a willingness to pay (WTP) of $4,167 per QALM, the addition of palbociclib was not cost-effective and the probability of palbociclib to be cost-effective was 0%. Cost-effectiveness acceptability curves derived from a probabilistic sensitivity analysis showed that at a WTP of $11,667 per QALM gained, the probability of palbociclib to be cost-effective was 50%. Conclusion Compared with letrozole alone, the addition of palbociclib is unlikely to be cost-effective for the treatment of advanced breast cancer from a Canadian healthcare perspective with its current price. While advanced breast cancer patients derive a meaningful clinical benefit from palbociclib, considerations should be given to increase the WTP threshold and reduce the drug pricing, to render this strategy more affordable. Citation Format: Raphael J, Helou J, Naimark DM. Palbociclib in hormone receptor positive advanced breast cancer: A cost-utility analysis [abstract]. In: Proceedings of the 2017 San Antonio Breast Cancer Symposium; 2017 Dec 5-9; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2018;78(4 Suppl):Abstract nr P4-12-08.

A Cost-Utility Analysis of Artificial Urinary Sphincter Versus Advance Male Sling In Post Prostatectomy Stress Urinary Incontinence: A Canadian Healthcare Perspective

A Cost-Utility Analysis of Artificial Urinary Sphincter Versus Advance Male Sling In Post Prostatectomy Stress Urinary Incontinence: A Canadian Healthcare Perspective

Palbociclib in hormone receptor positive advanced breast cancer: A cost-utility analysis

IntroductionThe addition of palbociclib to letrozole improves progression-free survival in the first-line treatment of hormone receptor positive advanced breast cancer (ABC). This study assesses the cost-utility of palbociclib from the Canadian healthcare payer perspective. MethodsA probabilistic discrete event simulation (DES) model was developed and parameterised with data from the PALOMA 1 and 2 trials and other sources. The incremental cost per quality-adjusted life-month (QALM) gained for palbociclib was calculated. A time horizon of 15 years was used in the base case with costs and effectiveness discounted at 5% annually. Time-to- progression and time-to-death were derived from a Weibull and exponential distribution. Expected costs were based on Ontario fees and other sources. Probabilistic sensitivity analyses were conducted to account for parameter uncertainty. ResultsCompared to letrozole, the addition of palbociclib provided an additional 14.7 QALM at an incremental cost of $161,508. The resulting incremental cost-effectiveness ratio was $10,999/QALM gained. Assuming a willingness-to-pay (WTP) of $4167/QALM, the probability of palbociclib to be cost-effective was 0%. Cost-effectiveness acceptability curves derived from a probabilistic sensitivity analysis showed that at a WTP of $11,000/QALM gained, the probability of palbociclib to be cost-effective was 50%. ConclusionThe addition of palbociclib to letrozole is unlikely to be cost-effective for the treatment of ABC from a Canadian healthcare perspective with its current price. While ABC patients derive a meaningful clinical benefit from palbociclib, considerations should be given to increase the WTP threshold and reduce the drug pricing, to render this strategy more affordable.

Cost effectiveness of the addition of a comprehensive CT scan to the abdomen and pelvis for the detection of cancer after unprovoked venous thromboembolism

ImportanceUnprovoked venous thromboembolism (VTE) can be the first manifestation of cancer. It is unclear if extensive screening for occult cancer including a comprehensive computed tomography (CT) scan of the abdomen/pelvis is cost-effective in this patient population. ObjectiveTo assess the health care related costs, number of missed cancer cases and health related utility values of a limited screening strategy with and without the addition of a comprehensive CT scan of the abdomen/pelvis and to identify to what extent testing should be done in these circumstances to allow early detection of occult cancers. Participants and settingCost effectiveness analysis using data that was collected alongside the SOME randomized controlled trial which compared an extensive occult cancer screening including a CT of the abdomen/pelvis to a more limited screening strategy in patients with a first unprovoked VTE, was used for the current analyses. Main outcomes and measuresAnalyses were conducted with a one-year time horizon from a Canadian health care perspective. Primary analysis was based on complete cases, with sensitivity analysis using appropriate multiple imputation methods to account for missing data. ResultsData from a total of 854 patients with a first unprovoked VTE were included in these analyses. The addition of a comprehensive CT scan was associated with higher costs ($551 CDN) with no improvement in utility values or number of missed cancers. Results were consistent when adopting multiple imputation methods. Conclusions and relevanceThe addition of a comprehensive CT scan of the abdomen/pelvis for the screening of occult cancer in patients with unprovoked VTE is not cost effective, as it is both more costly and not more effective in detecting occult cancer.

Cost-effectiveness of pazopanib compared with sunitinib in metastatic renal cell carcinoma in Canada.

In Canada and elsewhere, pazopanib and sunitinib-tyrosine kinase inhibitors targeting the vascular endothelial growth factor receptors-are recommended as first-line treatment for patients with metastatic renal cell carcinoma (mrcc). A large randomized noninferiority trial of pazopanib versus sunitinib (comparz) demonstrated that the two drugs have similar efficacy; however, patients randomized to pazopanib experienced better health-related quality of life (hrqol) and nominally lower rates of non-study medical resource utilization. The cost-effectiveness of pazopanib compared with sunitinib for first-line treatment of mrcc from a Canadian health care system perspective was evaluated using a partitioned-survival model that incorporated data from comparz and other secondary sources. The time horizon of 5 years was based on the maximum duration of follow-up in the final analysis of overall survival from the comparz trial. Analyses were conducted first using list prices for pazopanib and sunitinib and then by assuming that the prices of sunitinib and pazopanib would be equivalent. Based on list prices, expected costs were CA$10,293 less with pazopanib than with sunitinib. Pazopanib was estimated to yield 0.059 more quality-adjusted life-years (qalys). Pazopanib was therefore dominant (more qalys and lower costs) compared with sunitinib in the base case. In probabilistic sensitivity analyses, pazopanib was dominant in 79% of simulations and was cost-effective in 90%-100% of simulations at a threshold cost-effectiveness ratio of CA$100,000. Assuming equivalent pricing, pazopanib yielded CA$917 in savings in the base case, was dominant in 36% of probabilistic sensitivity analysis simulations, and was cost-effective in 89% of simulations at a threshold cost-effectiveness ratio of CA$100,000. Compared with sunitinib, pazopanib is likely to be a cost-effective option for first-line treatment of mrcc from a Canadian health care perspective.

Potential cost-effectiveness for using patient decision aids to guide osteoporosis treatment.

We use a model to predict whether using a patient decision aid in patients considering bisphosphonate therapy would be a good use of health resources. We found that if the decision aid improved adherence, and only marginally increased time physicians needed with their patients, then the decision-aid would be cost-effective. Oral bisphosphonates have been shown to reduce the risk of osteoporotic fracture. Adherence is crucial but suboptimal. A recent study suggests that a patient decision aid, which facilitates shared decision-making, could be effective in increasing adherence to bisphosphonates. But decision aids come at a cost in terms of additional time spent with physicians. This study considers the emerging evidence on the role of patient decision aids in improving adherence to bisphosphonates and their potential costs to inform future decision-making and research priorities. We estimate the hypothetical cost-effectiveness of a patient decision aid detailing the benefits and risks of bisphosphonates for osteoporotic patients, from a Canadian healthcare perspective. A previously developed and validated Markov microsimulation model was adapted to include use of a patient decision aid to support the decision of whether to initiate bisphosphonate therapy, and subsequent influence on adherence and future fractures. We considered 2014 costs and benefits in terms of quality-adjusted life-years (QALYs). A patient decision aid that could improve treatment initiation rates or persistence (adherence) by 20%, or a linear combination of the two, in osteoporotic women aged 70+ over a 3-year treatment period was found to have an incremental cost-effectiveness ratio below $50,000/QALY. Patient decision aids have the potential to be cost-effective in osteoporosis so long as they increase adherence under certain conditions. Funding further research on the long-term effectiveness and costs of a patient decision aid which outlines all treatment options for osteoporosis patients is justified.

PSS19 - Cost-effectiveness of Secukinumab compared to current treatments for the treatment of moderate to severe plaque Psoriasis in Canada

To assess the cost-effectiveness of secukinumab versus current therapies for plaque psoriasis in adults from the Canadian healthcare perspective. A Markov model was designed to determine the cost-effectiveness of secukinumab 300mg for moderate to severe plaque psoriasis over a 10-year horizon versus secukinumab 150mg, adalimumab, etanercept, infliximab, ustekinumab (45mg or 90mg), and standard of care (oral systemics, topicals, and phototherapy, SoC). Year 1 of the model consisted of 4-week cycles with 4 Psoriasis Area and Severity Index (PASI) response level-based health-states (PASI ≥ 90, 75-89, 50-74, and < 50). Years 2-10 used annual cycles, with 3 health-states (PASI ≥ 75, PASI <75, and death). Decisions to switch to SoC were made at week 12 and 52, then annually. Efficacy data from a network meta-analysis informed first-year model transitions. Resource use, costs, and utilities were collected from clinical trials, published literature, expert opinion, and standard Canadian sources. The order of treatments by increasing quality-adjusted life years (QALYs) were: SoC, etanercept, adalimumab, ustekinumab 45mg, secukinumab 150mg, ustekinumab 90mg, secukinumab 300mg, and infliximab. The cost-effectiveness frontier showed etanercept was strongly dominated, while adalimumab, ustekinumab 45mg, secukinumab 150mg and ustekinumab 90mg were weakly dominated by secukinumab 300mg. The ICER for secukinumab 300mg versus SoC was $87,368/QALY gained. The ICER for infliximab versus secukinumab 300mg was $1,039,403/QALY gained. Deterministic sensitivity analyses indicated the results are most sensitive to time horizon, cost of biologics, and utility values. The probabilistic sensitivity analysis demonstrated that at a willingness-to-pay threshold of ~$90,000/QALY, secukinumab 300mg has the highest probability of being the cost-effective option. For adults with moderate to severe plaque psoriasis, secukinumab 300mg was associated with increased QALYs at a lower incremental cost compared to etanercept, adalimumab, ustekinumab and secukinumab 150mg. For each QALY gained versus SoC, treatment with secukinumab costed an additional $87,368.