Análisis del costo y la efectividad de los esquemas de administración de factores de coagulación para el manejo de niños con hemofilia A en México / Cost-effectiveness analysis of prophylaxis vs. ''on demand'' approach in the management in children with hemophilia A in Mexico

Introducción. La hemofilia A es causada por la deficiencia del factor VIII. El tratamiento consiste principalmente en aumentar la concentración del FVIII en la sangre utilizando productos de remplazo. El objetivo de este trabajo fue estimar los beneficios clínicos y económicos del manejo profiláctico con factor VIII en niños con hemofilia A en México. Métodos. Se realizó la evaluación económica del manejo profiláctico (PROF) y del tratamiento sobre demanda (SD). Las estrategias comparadas fueron el manejo profiláctico -consistente en FVIII recombinante 25 UI/kg cada tercer día- vs. tratamiento sobre demanda -consistente en FVIII derivado de plasma 40 UI/kg. Se reportó el número de sangrados evitados (SE). Se empleó una tasa de descuento del 5%. Los resultados se expresaron en pesos mexicanos. Resultados. El costo de incremental de PROF respecto a SD fue de $7,727,554 pesos. El manejo con PROF ofrece una reducción de 112 SE frente al manejo de SD (162.9 vs. 50.7). El costo por SE fue de $68,876 pesos. Conclusiones. Un abordaje con PROF mejora la calidad de vida respecto al manejo SD y reduce el número de hemorragias que enfrentan los niños con hemofilia A. PROF es una alternativa costo-efectiva (RCEI $68,876 pesos) para reducir sangrados de acuerdo con la disponibilidad de pago establecida por las autoridades de salud en México.

Background. Hemophilia A is due to a deficiency of factor VIII. Treatment consists primarily of increasing the concentration of FVIII in the blood using replacement products. The aim of this study was to estimate the clinical and economic benefits of prophylactic management with factor VIII in children with hemophilia A in Mexico. We undertook this study to estimate the clinical and economic benefits of prophylactic management (PROF) with factor VIII (FVIII) in children with severe hemophilia in Mexico. Methods. We carried out an economic evaluation of PROF vs. treatment on demand (OD). The strategies compared were management with PROF consisting of recombinant FVIII (rFVIII) 25 IU kg every other day vs. OD management consisting of plasma-derived FVIII (pdFVIII) 40 IU kg. A Markov model was performed with a time horizon of 16 years in patients with severe hemophilia for 2 years, reporting the number of events of bleeding averted (BA). We used a discount rate of 5%. The results are expressed in Mexican pesos (2012). Results. The incremental cost of PROF regarding SD was $7,727,554 pesos. PROF management provides a reduction of 112 BA vs. OD management (162.9 vs. 50.7). Cost per BA was $68,876 pesos. Conclusions. Management with PROF reduces the number of bleeding events facing children with hemophilia A compared to OD management. PROF is a cost-effective alternative to reduce bleeding ($68,876 pesos per BA) according to the willingness to pay established by health authorities in Mexico.

Costo Efectividad del Tratamiento de Tumores Neuroendócrinos Pancreáticos Avanzados no Operables con Sunitinib en México.

OBJECTIVES: Sunitinib had showed a substantial clinical benefit in patients with non-resectable pancreatic Neuroendocrine Tumors (NET). The objective of this study was to estimate the cost-effectiveness of sunitinib in the treatment of non-resectable pancreatic NET, from the perspective of the Social Security Mexican Institute (IMSS). METHODS: A Markov model (2-week cycles) was used to estimate the health and economic consequences of sunitinib 37.5mg/day+best supportive care (BSC) regarding placebo+BSC (ten-years horizon, discount rate: 5%). Effectiveness measures were: overall survival (OS), progression-free survival (PFS) and quality adjusted life years (QALY). Resource utilization (BSC, adverse events management, medical follow-up) was estimated through a survey with Mexican oncologists (n=10). Unit costs of medication and medical resources were obtained from institutional sources. Sensitivity analyses were performed and acceptability curves were constructed. RESULTS: Sunitinib+BSC gained 0.49 years (PFS), 1.18 years (OS) and 0.70 QALY against placebo+BSC. Sunitinib+BSC increased medical direct costs (2011 US$) per patient in $20,854, which was driven by acquisition costs of sunitinib and medical follow up before progression. ICER's were $42,157, $17,662 and $29,808 per progression-free year, life-year and QALY gained, respectively, which remained robust through±25% changes in main parameters. At willingness to pay higher than $40,000, $22,400 and $37,600 sunitinib+BSC becomes the most cost-effective alternative in regards to PFS, OS and QALYs, respectively. CONCLUSION: At IMSS, sunitinib+BSC would provide substantial clinical benefits to patients suffering unresectable pancreatic NET, although the latter would increase medical costs of treatment and clinical follow up.

Cost Utility of Sirolimus versus Tacrolimus for the Primary Prevention of Graft Rejection in Renal Transplant Recipients in Mexico.

OBJECTIVE: Therapies for end-stage renal disease improve quality of life, and survival. In Mexico, clinicians often must choose between different therapies without the availability of comparative outcomes evaluation. The present study evaluates the comparative cost-utility of sirolimus (SIR) versus tacrolimus (TAC) for the primary prevention of graft rejection in renal transplant recipients in Mexico. METHODS: We used modeling techniques to estimate the cost-effectiveness of SIR versus TAC to prevent graft rejection in patients with end-stage renal disease in the Mexican setting. The model estimates the cost of quality-adjusted life-year (QALY) per patient. We applied a 20-year horizon (1-year Markov cycles). Cost-effectiveness was expressed in terms of cost per QALY. All costs are presented in 2011 US dollars. Probabilistic sensitivity analyses were conducted. RESULTS: The total cost for the SIR treatment arm over the 20-year duration of the model is estimated to be $136,778. This compares with $142,624 for the TAC treatment arm, resulting in an incremental cost of SIR compared with that of TAC of-$5,846. Over 20 years, SIR was estimated to have 8.18 QALYs compared with 7.33 QALYs for TAC. The resulting incremental utility of SIR compared with that of TAC is 0.84 QALY gained. SIR is estimated to be both less costly and more effective than TAC, indicating that it is the dominant strategy. Notably, results suggest that SIR has a 78% probability of being dominant over the TAC strategy and a 100% probability of having an incremental cost-effectiveness ratio at or below $10,064 (1 GDP) per QALY. CONCLUSIONS: These analyses suggest that in the Mexican setting, the use of SIR in place of TAC for the prevention of graft rejection in this population is likely to be cost saving.

[Economic analysis of parecoxib in the management of postsurgical pain in gynecology]. / Análisis económico de parecoxib en el tratamiento del dolor postoperatorio en ginecología.

BACKGROUND: Poorly managed postoperative pain has a negative impact in healing patients and costs of care. METHODS: A model to estimate economic and health consequences of parecoxib 40 mg and morphine 12 mg regarding ketorolac 30 mg, on the management of postoperative pain in gynecologic laparotomy surgery from the perspective of the Mexican Social Security Institute (IMSS) was developed. A systematic review to identify the proportion of patients that rated their analgesic treatment as "excellent" or "good" in the Patient Global Evaluation of Study Medication, 12 hours after administration of the analgesic (responders), was performed. The patients who rated "fair" or "poor" their treatment were administered additional 4 mg of morphine. Costs in the model correspond to the acquisition costs of analgesics in which the institution would incur. RESULTS: The proportion and cost per responder were: morphine: 14.44% and $192.79, ketorolac: 32.44% and $34.82, parecoxib: 35.51% and $121.25.Treatment with morphine was more expensive and less effective than both, ketorolac and parecoxib, while the cost per additional percent point of responders with parecoxib (compared to ketorolac) was $28.15. For the management of postoperative pain, ketorolac and parecoxib are more effective and less expensive than morphine, additionally parecoxib would be an alternative for patients with contraindication to ketorolac use. CONCLUSION: The management of postoperative pain with parecoxib is more effective and, in the context of IMSS, less expensive than morphine, also constitutes an alternative with a reasonable incremental cost compared to ketorolac.

[Economic analysis of dalteparin use in knee surgery at Instituto Mexicano del Seguro Social]. / Análisis económico de dalteparina en la indicacióncirugía de rodilla en el Instituto Mexicano del Seguro Social.

BACKGROUND: Knee surgery is a risk factor for thromboembolic disease. Prophylaxis reduces the risk of this condition. METHODS: Economic and health consequences of drugs preventing and treating thromboembolic disease in patients undergoing knee surgery from the institutional perspective (time horizon: 1 year) were estimated. The measures of effectiveness were: reduction in the number of cases (per 1,000 patients) of deep vein thrombosis, pulmonary embolism, hospital admissions and deaths. Transition probabilities were estimated by meta-analysis. The alternatives were: warfarin (reference), dalteparin, enoxaparin, nadroparin, unfractionated heparin + warfarin, and non-prophylaxis. Data on resources use and costs corresponds to the Instituto Mexicano del Seguro Social (IMSS). Acceptability curves were constructed. RESULTS: No prophylaxis implied three times higher cost ($18,835.10 versus $5,967.10) and less effectiveness in comparison with warfarin. The incremental cost-effectiveness ratios for enoxaparin were $3, $13, $17 and $3 per each additional case of deep vein thrombosis, pulmonary embolism, death and hospital admission avoided. Results of nadroparin and unfractionated heparin were inferior to warfarin (59.1% and 72.9% more costly and less effective in three measures of effectiveness, respectively). Dalteparin showed higher health outcomes and lower cost compared with warfarin (-20.6%). Dalteparin had a higher probability of being cost-effective than enoxaparin. DISCUSSION: thromboprophylaxis is a clinically and economically favorable alternative. The identification of a pharmacoeconomic profile of alternatives to perform it becomes relevant given the increasing pressure on institutional budgets. CONCLUSIONS: Dalteparin would be a cost-saving alternative in thromboprophylaxis of patients undergoing knee surgery at IMSS.

[Economic evaluation of an infant immunization program in Mexico, based on 13-valent pneumococcal conjugated vaccines]. / Evaluación económica de un programa de inmunización infantil en México basado en la vacuna neumocócica conjugada 13-valente.

OBJECTIVES: Vaccination is an effective intervention for reduce child morbidity and mortality associated to pneumococcus. The availability of new anti-pneumococcal vaccines makes it necessary to evaluate its potential impact on public health and costs related to their implementation. The aim of this study was to estimate the cost-effectiveness and cost-utility of immunization strategies based on pneumococcal conjugated vaccines (PCV's) currently available in Mexico from a third payer perspective. MATERIAL AND METHODS: A decision tree model was developed to assess both, economic and health impact, of anti-pneumococcal vaccination in children <2 years (lifetime time horizon, discount rate: 5% annual). Comparators were: no-vaccination (reference) and strategies based on 7, 10 and 13-valent PCV's. Effectiveness measures were: child deaths avoided, life-years gained (LYG) and quality adjusted life years (QALY's) gained. Effectiveness, utility, local epidemiology and cost of treating pneumococcal diseases were extracted from published sources. Univariate sensitivity analysis were performed. RESULTS: Immunization dominates no-vaccination: strategy based on 13-valent vaccine prevented 16.205 deaths, gained 331.230 LY's and 332.006 QALY's and saved US$1.307/child vaccinated. Strategies based on 7 and 10-valent PCV's prevented 13.806 and 5.589 deaths, gained 282.193 and 114.251 LY's, 282.969 and 114.972 QALY's and saved US$1.084 and US$731/child vaccinated, respectively. These results were robust to variations in herd immunity and lower immunogenicity of 10-valent vaccine. CONCLUSIONS: In Mexico, immunization strategies based on 7, 10 and 13-valent PCV's would be cost-saving interventions, however, health outcomes and savings of the strategy based on 13-valent vaccine are greater than those estimated for 7 and 10-valent PCV's.