Why carry out this study?
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The coronavirus disease 2019 (COVID-19) pandemic is a global crisis impacting individual and population health and the economy more broadly. |
As the treatment landscape continues to evolve, there is a need for a common cost-effectiveness framework to ensure adherence to modeling best practices and incorporation of the most relevant clinical parameters when assessing the value of COVID-19 treatments. |
We describe a cost-effectiveness framework for evaluating acute treatments for hospitalized patients with COVID-19, considering a broad spectrum of potential treatment profiles and perspectives within the US healthcare system. |
What was learned from the study?
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Viewing results in aggregate, we find that treatments that confer at least a mortality benefit are likely to be cost-effective, as all deterministic and sensitivity analyses results fell far below US willingness-to-pay thresholds from both a US health payer and societal perspective. Even with conservative assumptions on societal impact, we find that the societal perspective consistently produced ICERs that were 40–50% lower than ICERs for the health payer perspective. |
Effective COVID-19 treatments for hospitalized patients may not only reduce disease burden but also represent good value for the health system. |
We also demonstrate that, despite limited data available on the long-term impact of invasive mechanical ventilation and productivity of COVID-19 patients post-discharge, it is possible to estimate the cost-effectiveness of inpatient treatments for COVID-19 from a societal perspective using a conservative approach to help guide future decisions on allocation of healthcare resources. |
Digital Features
Introduction
Methods
Analytic Structure
Defining the Treatment Arm
Parameter | Base case | SE | Distribution | Lower–upper | Reference |
---|---|---|---|---|---|
Efficacy inputs for treatment arm | |||||
Hospital level of acute care | |||||
Risk ratio for reduction in patients requiring mechanical ventilation | 0.77 | 0.046 | Log-normal | (0.70–0.84) | [31] |
Hazard ratio for reduction in inpatient mortality for treated (vs BSC) by highest level of acute care received | |||||
Patients without oxygen support | 1.01 | 0.201 | Log-normal | (0.68–1.50) | |
Patients with oxygen support | 0.67 | 0.093 | Log-normal | (0.56–0.80) | |
Patients on mechanical ventilation | 0.89 | 0.081 | Log-normal | (0.76–1.04) | |
Ratio of length of stay for BSC (vs treated) by highest level of acute care among recovering patients | |||||
Patients without oxygen support | 1.13 | 0.051 | Log-normal | (1.02–1.25) | |
Patients with oxygen support | 1.24 | 0.036 | Log-normal | (1.15–1.33) | |
Patients on mechanical ventilation | 1.23 | 0.063 | Log-normal | (1.09–1.39) | |
Utility inputs | |||||
US age-specific utility | |||||
18–29 | 0.920 | 0.002 | Beta | (0.92–0.93) | [37] |
30–39 | 0.900 | 0.002 | Beta | (0.9–0.91) | |
40–49 | 0.870 | 0.002 | Beta | (0.87–0.88) | |
50–59 | 0.840 | 0.003 | Beta | (0.84–0.85) | |
60–69 | 0.820 | 0.003 | Beta | (0.82–0.83) | |
70–79 | 0.790 | 0.004 | Beta | (0.78–0.8) | |
≥ 80 | 0.740 | 0.006 | Beta | (0.72–0.75) | |
Disutility during the hospitalization, by highest level of acute care received | |||||
COVID-19 symptoms | 0.270 | 0.300 | Beta | (0.00–0.95) | [24] |
No oxygen support | 0.110 | 0.300 | Beta | (0.00–1.00) | |
Oxygen support without ventilation | 0.360 | 0.300 | Beta | (0.00–0.96) | |
Mechanical ventilation | 0.560 | 0.300 | Beta | (0.03–0.99) | |
Post discharge disutility for patients requiring mechanical ventilation (applied for 5 years) | |||||
1 year | 0.130 | 0.013 | Beta | (0.1–0.15) | |
2 years | 0.067 | 0.007 | Beta | (0.05–0.08) | |
3 years | 0.062 | 0.006 | Beta | (0.05–0.07) | |
4 years | 0.026 | 0.000 | Beta | (0.02–0.03) | |
5 years | 0.024 | 0.000 | Beta | (0.02–0.03) | |
Hazard ratio for post-discharge mortality for ventilated patients vs general population (applied for 5 years) | 1.33 | 0.13 | Log-normal | (1.09–1.62) | [36] |
Parameter | Base case | SE | Distribution | Lower–upper | Reference |
---|---|---|---|---|---|
Resource use inputs | |||||
Distribution of highest level of acute care at admission | |||||
No oxygen support | 20.06% | N =1751 | Dirichlet | (18.00–22.00%) | |
Oxygen support but no mechanical ventilation | 61.35% | N = 5355 | Dirichlet | (55.00–67.00%) | |
Mechanical ventilation | 18.59% | N = 1623 | Dirichlet | (17.00–20.00%) | |
Inpatient characteristics for both arms | |||||
Time to death for both arms (days, all settings) | 15.00 | 1.50 | Log-normal | (12.34–18.24) | Assumption |
Mean age of patients discharged alive from the hospital | 62.50 | 6.25 | Normal | (50.25–74.75) | |
Mean age of patients dying within the hospital | 78.00 | 7.80 | Log-normal | (64.15–94.84) | [35] |
Best supportive care efficacy-related inputs | |||||
Transition from no oxygen support or oxygen support without mechanical ventilation to mechanical ventilation | |||||
Proportion of patients receiving mechanical ventilation among those not receiving it at admission | 11.36% | 1.14% | Beta | (9.00–14.00%) | |
Proportion of patients with oxygen support at admission among those transitioning to mechanical ventilation | 93.18% | 9.32% | Beta | (66.00–100.00%) | [33] |
Proportion recovering (surviving) during their inpatient stay by highest level of acute care for best supportive care | |||||
No oxygen support | 96.02% | 9.60% | Beta | (65.00–100.00%) | |
Oxygen support but no mechanical ventilation | 84.04% | 8.40% | Beta | (64.00–97.00%) | |
Mechanical ventilation | 73.82% | 7.38% | Beta | (58.00–87.00%) | |
Length of stay by highest level of acute care for best supportive care among patients recovering (surviving) during their inpatient stay | |||||
No oxygen support | 6.00 | 0.75 | Log-normal | (4.70–7.66) | [33] |
Oxygen support but no mechanical ventilation | 12.58 | 1.88 | Log-normal | (9.41–16.82) | [33] |
Mechanical ventilation | 28.00 | 2.80 | Log-normal | (23.03–34.05) | [33] |
Cost use inputs | |||||
Inpatient costs | |||||
No oxygen support bundled payment (DRG 179) | $8767.42 | $1315.11 | Gamma | ($6381.45–11,526.47) | |
Oxygen support without ventilation bundled payment (DRG 177/178) | $13,282.61 | $1992.39 | Gamma | ($9667.87–17,462.56) | |
Mechanical ventilation bundled payment (DRG 207) | $49,631.85 | $7444.78 | Gamma | ($36,125.00–65,250.65) | |
No oxygen support per diem | $1571.54 | $235.73 | Gamma | ($1143.86–2066.09) | |
Oxygen support without ventilation per diem | $1299.02 | $194.85 | Gamma | ($945.50–1707.81) | |
Mechanical ventilation per diem | $2243.39 | $336.51 | Gamma | ($1632.87–2949.37) | |
Annual healthcare costs by age after discharge | |||||
Age group 0–18 | $4432.00 | $443.20 | Gamma | ($3563.34–5300.66) | [41] |
Age group 19–44 | $5741.00 | $574.10 | Gamma | ($4615.78–6866.22) | [41] |
Age group 45–64 | $12,073.00 | $1207.30 | Gamma | ($9706.74–14,439.26) | [41] |
Age group 65–84 | $20,071.00 | $2007.10 | Gamma | ($16,137.16–24,004.84) | [41] |
Age group 85+ | $38,900.00 | $3890.00 | Gamma | ($31,275.74–46,524.26) | [41] |
Additional 1 year costs for patients discharged with mechanical ventilation | $7858.99 | $785.90 | Gamma | ($6318.66–9399.33) | [42] |
Productivity losses by age | |||||
Age group 15–24 | $20,166.00 | $2016.60 | Gamma | ($16,213.54–24,118.46) | [45] |
Age group 25–34 | $64,686.00 | $6468.60 | Gamma | ($52,007.78–77,364.22) | [45] |
Age group 35–44 | $87,023.00 | $8702.30 | Gamma | ($69,966.81–104,079.19) | [45] |
Age group 45–54 | $83,354.00 | $8335.40 | Gamma | ($67,016.92–99,691.08) | [45] |
Age group 55–64 | $67,990.00 | $6799.00 | Gamma | ($54,664.20–81,315.80) | [45] |
Age group 65–74 | $38,504.00 | $3850.40 | Gamma | ($30,957.35–46,050.65) | [45] |
Age group 75–99 | $16,017.00 | $1601.70 | Gamma | ($12,877.73–19,156.27) | [45] |
Drug costs | $2500 | – | – | – | Assumption |
Clinical Inputs
Utilities
Cost Inputs
Societal Costs
Model Base Case, Scenario, and Sensitivity Analyses
Results
Base Case
Payer perspective (no productivity losses included) | Societal perspective (productivity losses included) | |||||||||||
---|---|---|---|---|---|---|---|---|---|---|---|---|
Bundled payment | FFS payment | Bundled payment | FFS payment | |||||||||
BSC | Treated | Diff | BSC | Treated | Diff | BSC | Treated | Diff | BSC | Treated | Diff | |
LY gained | ||||||||||||
Short-term model | 0.042 | 0.041 | − 0.001 | 0.042 | 0.041 | − 0.001 | 0.042 | 0.041 | − 0.001 | 0.042 | 0.041 | − 0.001 |
Post discharge | 12.381 | 12.920 | 0.539 | 12.381 | 12.920 | 0.539 | 12.381 | 12.920 | 0.539 | 12.381 | 12.920 | 0.539 |
Total | 12.423 | 12.961 | 0.538 | 12.423 | 12.961 | 0.538 | 12.423 | 12.961 | 0.538 | 12.423 | 12.961 | 0.538 |
QALY gained | ||||||||||||
Short-term model | 0.005 | 0.010 | 0.005 | 0.005 | 0.010 | 0.005 | 0.005 | 0.010 | 0.005 | 0.005 | 0.010 | 0.005 |
Post discharge | 9.785 | 10.218 | 0.433 | 9.785 | 10.218 | 0.433 | 9.785 | 10.218 | 0.433 | 9.785 | 10.218 | 0.433 |
Total | 9.790 | 10.228 | 0.438 | 9.790 | 10.228 | 0.438 | 9.790 | 10.228 | 0.438 | 9.790 | 10.228 | 0.438 |
Costs | ||||||||||||
Short-term model | ||||||||||||
Drug costs | $0 | $0 | $0 | $0 | $2500 | $2500 | $0 | $0 | $0 | $0 | $2500 | $2500 |
Hospital costs | $23,298 | $22,385 | − $913 | $27,004 | $22,076 | − $4928 | $23,298 | $22,385 | − $913 | $27,004 | $22,076 | − $4928 |
Post discharge | ||||||||||||
Heath costs (no vent) | $186,781 | $201,259 | $14,478 | $186,781 | $201,259 | $14,478 | $186,781 | $201,259 | $14,478 | $186,781 | $201,259 | $14,478 |
Health costs (with vent) | $67,899 | $64,361 | − $3538 | $67,899 | $64,361 | − $3538 | $67,899 | $64,361 | − $3538 | $67,899 | $64,361 | − $3538 |
Productivity losses | $0 | $0 | $0 | $0 | $0 | $0 | $23,281 | $18,279 | − $5002 | $23,281 | $18,279 | − $5002 |
Total | $277,978 | $288,005 | $10,027 | $281,684 | $290,196 | $8512 | $301,259 | $306,284 | $5025 | $304,965 | $308,475 | $3510 |
ICER (cost per QALY) | $22,933 | $19,469 | $11,492 | $8028 |
Scenario Analyses
Perspective | Payment approach | Treatment profilesa | ICER | Relative change from base case (%) | Key drivers for change from base case |
---|---|---|---|---|---|
Payer | Bundled | Base case | $22,933 | – | – |
Mortality + ventilation | $23,178 | 1 | Fewer QALYs gained in hospital slightly increases ICER | ||
Mortality | $25,985 | 13 | Fewer QALYs gained in hospital and no more savings in bundled payments | ||
FFS | Base case | $19,469 | – | – | |
Mortality + ventilation | $29,108 | 50 | Per diem hospital costs no longer offset the cost of the drug | ||
Mortality | $32,864 | 69 | Per diem hospital costs no longer offset the cost of the drug and no more savings in bundled payments | ||
Societal | Bundled | Base case | $11,492 | – | – |
Mortality + ventilation | $11,615 | 1 | Fewer QALYs gained in hospital slightly increases ICER | ||
Mortality | $14,143 | 23 | Fewer QALYs gained in hospital and no more savings in bundled payments | ||
FFS | Base case | $8028 | – | – | |
Mortality + ventilation | $17,545 | 119 | Per diem hospital costs no longer offset the cost of the drug | ||
Mortality | $21,022 | 162 | Per diem hospital costs no longer offset the cost of the drug and no more savings in bundled payments |