A 1-Year Prospective Cost-Effectiveness Analysis of Roflumilast for the Treatment of Patients with Severe Chronic Obstructive Pulmonary Disease
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Rationale: Roflumilast is an oral, once-daily phosphodiesterase IV (PDE4) inhibitor under investigation for chronic obstructive pulmonary disease (COPD). This study investigated the cost effectiveness of roflumilast in patients with severe to very severe COPD from the perspective of the UK society and UK NHS.
Methods: The analysis was conducted alongside a 1-year, randomised, double-blind, placebo-controlled, multinational trial. The trial included 1514 COPD patients aged ≥40 years with a post-bronchodilator forced expiratory volume in 1 second (FEV1) % predicted =50% who were randomised to receive either roflumilast 500μg once daily (n = 761) or placebo (n = 753). Patients in both treatment groups were allowed to receive active treatment with a short-acting bronchodilator (salbutamol or anticholinergic) as needed. About 62% of patients in both groups were using an inhaled corticosteroid at trial entry. They were allowed to continue this on a stable dosage.
Direct healthcare and productivity costs were calculated. Resource utilisation was recorded at every scheduled visit in health economics case report forms (HECRFs). Trial-wide resource use was combined with UK unit cost (2004 values). Roflumilast was assumed to cost €1 per day. Incremental costs were related to the differences in the number of moderate to severe exacerbations and the net proportion of patients with an improvement of at least 4 units on the total score of the St George’s Respiratory Questionnaire (SGRQ). An intention-to-treat analysis was conducted. Costs and health outcomes that were missing after withdrawal of patients from the trial were imputed using multiple imputation with the propensity score method. Various sensitivity analyses were conducted to test the robustness of the data.
Results: In the total group, annual COPD-related costs from a societal perspective were €1637 in the roflumilast group and €1401 in the placebo group. From an NHS perspective, this was €1418 and €1242, respectively. The rate of moderate to severe COPD exacerbations per patient was low, and no statistically significant difference existed between roflumilast (0.96) and placebo (1.06). The net proportion of patients with a relevant improvement on SGRQ total score was higher in the roflumilast group (0.19) than in the placebo group (0.14), but the difference was not statistically significant. From a societal perspective, COPD-related costs were €2356 per exacerbation avoided and €4712 per net additional patient with a relevant improvement on the SGRQ. The probability that roflumilast was cost effective exceeded 70% at a willingness to pay of €5000 to avoid an exacerbation.
In a subgroup of patients with very severe COPD (n = 223), the placebo group had a high exacerbation rate (1.7 per patient per year) whereas roflumilast recipients showed 35% fewer exacerbations (1.1 per patient per year). This resulted in roflumilast dominating placebo. In a subgroup of patients with high healthcare utilisation prior to the study (n = 549) roflumilast recipients showed 19% fewer exacerbations than those receiving placebo, which translated into an ICER of €804 per exacerbation avoided.
Conclusion: Roflumilast increased the overall treatment costs of COPD, although the increase was partly offset by reductions in other forms of healthcare use. Roflumilast has the potential to be cost saving in patients with very severe COPD, due to a statistically significant reduction of exacerbations.
KeywordsChronic Obstructive Pulmonary Disease Chronic Obstructive Pulmonary Disease Patient Severe Chronic Obstructive Pulmonary Disease Chronic Obstructive Pulmonary Disease Exacerbation Roflumilast
The authors wish to acknowledge the support of their colleagues Dr Jan Oostenbrink, Dr Michel van Agthoven and Dr Maiwenn Al. We also thank ALTANA Pharma AG in Konstanz, Germany, for initiating and sponsoring this cost-effectiveness analysis.
The sponsor designed the clinical trial, managed the logistics of this clinical trial and collected the data. The cost-effectiveness study and the HE-CRF were designed in a combined effort. Data entry was performed by Omninare in Germany. Data was analysed and interpreted by the first two authors, who also wrote the manuscript. All other authors contributed to writing and reviewing the manuscript and approved it. All errors and omissions remain the authors’ responsibility.
The Institute for Medical Technology Assessment has a consultancy agreement with ALTANA Pharma AG. The first two authors and the last author do not hold stock or other equities in pharmaceutical companies. The last author has received honoraria and consultancy fees from ALTANA Pharma AG. The fourth author holds stock options in ALTANA Pharma AG.
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