Cost Effectiveness of Rivaroxaban Versus Warfarin for the Prevention of Recurrent Venous Thromboembolism.

Blood ◽  
2012 ◽  
Vol 120 (21) ◽  
pp. 3177-3177 ◽  
Author(s):  
Craig D. Seaman ◽  
Margaret V. Ragni ◽  
Kenneth J. Smith
Keyword(s):  
Venous Thromboembolism ◽  
Cost Effectiveness ◽  
Major Bleeding ◽  
Cost Effective ◽  
Base Case ◽  
Minor Bleeding ◽  
Old Patients ◽  
Life Years ◽  
Recurrent Venous Thromboembolism ◽  
Recurrent Vte

Abstract Abstract 3177 Background: Rivaroxaban is an oral anticoagulant administered once daily that works by direct inhibition of factor Xa. It has been found to be noninferior to warfarin in the prevention of recurrent venous thromboembolism (VTE). Whether rivaroxaban is cost effective in the prevention of recurrent VTE, however, is not known. Methods: To assess the cost effectiveness of rivaroxaban compared with warfarin in the prevention of recurrent VTE, we built a Markov state transition model over a 10-year time horizon. The base case analysis consisted of a hypothetical cohort of 60-year-old patients who were diagnosed with their first VTE and received secondary prophylaxis with either rivaroxaban or warfarin for 6 months. Cost estimates were derived from the Healthcare and Utilization Project (HCUP) and other sources. Probabilities for VTE recurrence and mortality and for major and minor bleeding were based on the EINSTEIN PE trial (NEJM 2012; 366: 1287–97). Outcomes included costs in 2011 United States dollars, quality adjusted life years (QALYs), and incremental cost effectiveness ratios (ICERs) over 10 years from a societal perspective. Results: Base case results are shown in the Table, showing total medication and other medical costs associated with each strategy. Compared with warfarin, the rivaroxaban strategy cost less ($4057 vs $7004) and was more effective (9.30 QALYs vs 9.16 QALYs). Thus, warfarin was dominated by rivaroxaban. In sensitivity analyses, results were most sensitive to changes in the probability of major bleeding with rivaroxaban. As shown in the Figure, when major bleeding with rivaroxaban (base case 1.1%) was less than 4.5%, the ICRE was within the $100,000 per QALY gained acceptability threshold range. Results favoring rivaroxaban were robust to individual variation of other parameter values. Conclusion: Prophylactic anticoagulation with rivaroxaban appears to be a cost effective, and perhaps cost saving, alternative to warfarin for the prevention of recurrent VTE. Disclosures: Off Label Use: Rivaroxaban - Prevention of recurrent venous thromboembolism.

Cost Effectiveness of Adjuvant Interferon in Node-Positive Melanoma

2007 ◽  
Vol 25 (17) ◽  
pp. 2442-2448 ◽  
Author(s):  
Janice N. Cormier ◽  
Yan Xing ◽  
Meichun Ding ◽  
Scott B. Cantor ◽  
Kristi J. Salter ◽  
...  
Keyword(s):  
Cost Effectiveness ◽  
Cost Effective ◽  
Stage Iiib ◽  
Stage Iii ◽  
Base Case ◽  
High Dose ◽  
Stage Iiia ◽  
Stage Iiic ◽  
Old Patients ◽  
Life Years

Purpose To assess the benefits of adjuvant high-dose interferon alfa (HDI) treatment for patients with high-risk melanoma. Methods We designed a decision-analytic probabilistic Markov model to simulate the natural history of patients with stage IIIA, IIIB, and IIIC melanoma and evaluate the outcomes with and without HDI treatment. Outcomes were in quality-adjusted life years (QALYs) and incremental cost-effectiveness ratios (ICERs). Probability estimates and costs were derived from primary patient level data, while the efficacy of HDI and associated utilities were determined from published reports. The base-case analysis was a cohort of 50-year-old patients. Results HDI increased the median life expectancy in patients with stage III melanoma from 3.75 years in the observation cohort to 4.42 years in the HDI cohort. The difference in QALYs ranged from 0.31 years for stage IIIA patients to 0.60 years for stage IIIC patients treated with HDI. HDI was cost effective in patients with stage IIIB and IIIC melanoma, with ICERs of $95,304 and $76,068 per QALY gained, respectively. Using a threshold of $100,000 per QALY gained, HDI was cost effective for all stage III patients younger than 52 years. HDI was not cost effective for patients with stage IIIA disease and for subsets of patients older than 63 years with stage IIIB disease. Conclusion Our model demonstrates that the probability of HDI being cost effective varies substantially by melanoma substage. HDI showed the greatest benefit in terms of QALYs and was most cost effective in patients younger than 60 years with stage IIIC disease.

scholarly journals Extended Treatment with Apixaban for Venous Thromboembolism Prevention in the Netherlands: Clinical and Economic Effects

TH Open ◽  
2018 ◽  
Vol 02 (03) ◽  
pp. e315-e324
Author(s):  
Lisa de Jong ◽  
Judith Gout-Zwart ◽  
Jelena Stevanovic ◽  
Harrie Rila ◽  
Mike Koops ◽  
...  
Keyword(s):  
Venous Thromboembolism ◽  
Cost Effectiveness ◽  
The Netherlands ◽  
Case Analysis ◽  
Cost Effective ◽  
Economic Effects ◽  
Base Case ◽  
Base Case Analysis ◽  
Extended Treatment ◽  
Recurrent Vte

Background Dutch guidelines advise extended anticoagulant treatment with direct oral anticoagulants or vitamin K antagonists for patients with idiopathic venous thromboembolism (VTE) who do not have high bleeding risk. Objectives The aim of this study was to analyze the economic effects of extended treatment of apixaban in the Netherlands, based on an updated and adapted previously published model. Methods We performed a cost-effectiveness analysis simulating a population of 1,000 VTE patients. The base-case analysis compared extended apixaban treatment to no treatment after the first 6 months. Five additional scenarios were conducted to evaluate the effect of different bleeding risks and health care payers' perspective. The primary outcome of the model is the incremental cost-effectiveness ratio (ICER) in costs (€) per quality-adjusted life-year (QALY), with one QALY defined as 1 year in perfect health. To account for any influence of the uncertainties in the model, probabilistic and univariate sensitivity analyses were conducted. The treatment was considered cost-effective with an ICER less than €20,000/QALY, which is the most commonly used willingness-to-pay (WTP) threshold for preventive drugs in the Netherlands. Results The model showed a reduction in recurrent VTE and no increase in major bleeding events for extended treatment in all scenarios. The base-case analysis showed an ICER of €9,653/QALY. The probability of being cost-effective for apixaban in the base-case was 70.0% and 91.4% at a WTP threshold of €20,000/QALY and €50,000/QALY, respectively. Conclusion Extended treatment with apixaban is cost-effective for the prevention of recurrent VTE in Dutch patients.

scholarly journals Economic evaluation of robot-assisted radical prostatectomy compared to open radical prostatectomy for prostate cancer treatment in Ontario, Canada

2020 ◽  
Vol 14 (8) ◽  
Author(s):  
Anna Parackal ◽  
Jean-Eric Tarride ◽  
Feng Xie ◽  
Gord Blackhouse ◽  
Jennifer Hoogenes ◽  
...  
Keyword(s):  
Cost Effectiveness ◽  
Radical Prostatectomy ◽  
Time Horizon ◽  
Cost Effective ◽  
Cost Utility ◽  
Economic Evaluations ◽  
Base Case ◽  
Robot Assisted ◽  
Open Radical Prostatectomy ◽  
Life Years

Introduction: Recent health technology assessments (HTAs) of robot-assisted radical prostatectomy (RARP) in Ontario and Alberta, Canada, resulted in opposite recommendations, calling into question whether benefits of RARP offset the upfront investment. Therefore, the study objectives were to conduct a cost-utility analysis from a Canadian public payer perspective to determine the cost-effectiveness of RARP. Methods: Using a 10-year time horizon, a five-state Markov model was developed to compare RARP to open radical prostatectomy (ORP). Clinical parameters were derived from Canadian observational studies and a recently published systematic review. Costs, resource utilization, and utility values from recent Canadian sources were used to populate the model. Results were presented in terms of increment costs per quality-adjusted life years (QALYs) gained. A probabilistic analysis was conducted, and uncertainty was represented using cost-effectiveness acceptability curves (CEACs). One-way sensitivity analyses were also conducted. Future costs and QALYs were discounted at 1.5%. Results: Total cost of RARP and ORP were $47 033 and $45 332, respectively. Total estimated QALYs were 7.2047 and 7.1385 for RARP and ORP, respectively. The estimated incremental cost-utility ratio (ICUR) was $25 704 in the base-case analysis. At a willingness-to-pay threshold of $50 000 and $100 000 per QALY gained, the probability of RARP being cost-effective was 0.65 and 0.85, respectively. The model was most sensitive to the time horizon. Conclusions: The results of this analysis suggest that RARP is likely to be cost-effective in this Canadian patient population. The results are consistent with Alberta’s HTA recommendation and other economic evaluations, but challenges Ontario’s reimbursement decision.

P5239Cost-effectiveness of direct oral anticoagulants for cancer-associated venous thromboembolism

2019 ◽  
Vol 40 (Supplement_1) ◽  
Author(s):  
J King ◽  
S Bhat ◽  
L J Heath ◽  
C G Derington ◽  
Z Yu ◽  
...  
Keyword(s):  
Venous Thromboembolism ◽  
Cost Effectiveness ◽  
Relative Risk ◽  
Oral Anticoagulants ◽  
Direct Oral Anticoagulants ◽  
Cost Effective ◽  
Low Molecular Weight ◽  
Cost Effectiveness Ratio ◽  
Major Bleed ◽  
Recurrent Vte

Abstract Background Direct oral anticoagulants (DOACs) are at least as effective as low-molecular weight heparins (LMWH) at preventing recurrence after cancer-associated venous thromboembolism (CA-VTE). DOACs are also oral and far less costly, but they may confer a higher bleeding risk than LMWH. Purpose To estimate the cost-effectiveness of DOACs and LMWHs for CA-VTE. Methods We developed a health state transition model to estimate recurrent VTE, bleeding events, quality-adjusted life years (QALY), and direct healthcare costs (2018 United States dollars) associated with DOACs vs. LMWH use. The model had four states: (1) long-term anticoagulation (first 3 months after VTE), (2) extended anticoagulation (more than 3 months after VTE), (3) off anticoagulants, and (4) death. We used a United States healthcare sector perspective, 3-month cycle length, and 1-year time horizon. Event probabilities were derived from the Hokusai Cancer VTE trial and other literature. Event and medication costs were obtained from national sources. We used a threshold of less than $50,000 per QALY gained to define cost-effectiveness. Results Compared to LMWH, DOACs were less costly (mean costs: $8,477 vs. $33,917 per year) and similarly effective (mean QALY: 0.616 vs. 0.622). The incremental cost-effectiveness ratio was $4,479,374 per QALY gained with LMWH, indicating that DOACs are cost-effective (Table 1). In threshold analyses, LMWH therapy only became cost-effective when DOAC recurrent VTE risk increased to at least 72% (relative risk vs. LMWH, 6.19) or DOAC clinically relevant bleeding increased to at least 39% (relative risk vs. LMWH, 10.09). Scenarios Recurrent VTE, % Major bleed, % Mean difference DOAC − LMW ICER DOAC LMWH Relative Risk DOAC LMWH Relative Risk Cost QALY Base case 8.1 11.6 0.71 6.8 4.0 1.75 −$25,440 (−26,496, −24,274) −0.006 (−0.019, 0.008) $4,479,374 DOAC outcome rate threshold at which LMWH becomes cost-effective*   Recurrent VTE 71.5 11.7 6.19 – – – −$6,064 (−7,534, −4,627) −0.121 (−0.136, −0.108) $49,886   Major Bleed – – – 38.9 4.0 10.09 −$2,192 (−3,400, −704) −0.044 (−0.056, −0.030) $49,878 DOAC = direct oral anticoagulant, ICER = incremental cost-effectiveness ratio, LMWH = low-molecular-weight heparin, VTE = venous thromboembolism. Values are mean (95% Uncertainty Interval). Uncertainty was derived from 1,000 stochastic model iterations. *Represents the minimum increased risk with DOAC that would result in LMWH achieving an ICER <$50K per QALY gained. Conclusion In this simulation study, DOACs were a cost-effective oral alternative to LMWH for the treatment of CA-VTE. For LMWH to be cost-effective, DOAC event rates needed to be far higher than what is likely to be observed in clinical practice. Acknowledgement/Funding Agency for Health Research and Quality R18HS026156

Cost-effectiveness of mobile health-based integrated care for atrial fibrillation: Model development and data analysis (Preprint)

2021 ◽  
Author(s):  
Xueyan Luo ◽  
Wei Xu ◽  
Quan Yuan ◽  
Han Lai ◽  
Chunji Huang
Keyword(s):  
Atrial Fibrillation ◽  
Sensitivity Analysis ◽  
Cost Effectiveness ◽  
Integrated Care ◽  
Mobile Health ◽  
Cost Effective ◽  
Sensitivity Analyses ◽  
Base Case ◽  
Life Years ◽  
Mhealth Technology

BACKGROUND Mobile health (mhealth) technology is increasingly used in disease management. Using mhealth tools to integrate and streamline care was found to improve atrial fibrillation (AF) patients’ clinical outcomes. OBJECTIVE This study aimed to investigate the potential clinical and health economic outcomes of mhealth-based integrated care for AF from the perspective of a public healthcare provider in China. METHODS A Markov model was designed to compare outcomes of mhealth-based care and usual care in a hypothetical cohort of AF patients in China. The time horizon was 30 years with monthly cycles. Model outcomes measured were direct medical cost, quality-adjusted life-years (QALYs), and incremental cost-effectiveness ratios (ICERs). Sensitivity analyses were conducted to examine the robustness of base-case results. RESULTS In the base-case analysis, mhealth-based care gained higher QALYs of 0.0818 with an incurred cost of USD1,778. Using USD33,438 per QALY (three times gross domestic product) as the willingness-to-pay threshold, mhealth-based care was cost-effective, with an ICER of USD21,739 per QALY. The one-way sensitivity analysis found compliance to mhealth-based care had the greatest impact on the ICER. In probabilistic sensitivity analysis, mhealth-based care was accepted as cost-effective in 80.91% of 10,000 iterations. CONCLUSIONS This study suggested that the use of mhealth technology in streamlining and integrating care for AF patients was cost-effective in China.

scholarly journals Milk Powder Fortified with Potassium and Phytosterols to Decrease the Risk of Cardiovascular Events among the Adult Population in Malaysia: A Cost-Effectiveness Analysis

Nutrients ◽  
2019 ◽  
Vol 11 (6) ◽  
pp. 1235
Author(s):  
Anita E. Gandola ◽  
Livia Dainelli ◽  
Diane Zimmermann ◽  
Maznah Dahlui ◽  
Patrick Detzel
Keyword(s):  
Cost Effectiveness ◽  
Adult Population ◽  
Grey Literature ◽  
Milk Powder ◽  
Cost Effective ◽  
Sensitivity Analyses ◽  
Base Case ◽  
Discounted Cost ◽  
Life Years ◽  
The Impact

This study evaluated the cost-effectiveness of the consumption of a milk powder product fortified with potassium (+1050.28 mg/day) and phytosterols (+1200 mg/day) to lower systolic blood pressure and low-density lipoprotein cholesterol, respectively, and, therefore, the risk of myocardial infarction (MI) and stroke among the 35–75-year-old population in Malaysia. A Markov model was created against a do-nothing option, from a governmental perspective, and with a time horizon of 40 years. Different data sources, encompassing clinical studies, practice guidelines, grey literature, and statistical yearbooks, were used. Sensitivity analyses were performed to evaluate the impact of uncertainty on the base case estimates. With an incremental cost-effectiveness ratio equal to international dollars (int$) 22,518.03 per quality-adjusted life-years gained, the intervention can be classified as very cost-effective. If adopted nationwide, it would help prevent at least 13,400 MIs, 30,500 strokes, and more than 10,600 and 17,100 MI- and stroke-related deaths. The discounted cost savings generated for the health care system by those who consume the fortified milk powder would amount to int$8.1 per person, corresponding to 0.7% of the total yearly health expenditure per capita. Sensitivity analyses confirmed the robustness of the results. Together with other preventive interventions, the consumption of milk powder fortified with potassium and phytosterols represents a cost-effective strategy to attenuate the rapid increase in cardiovascular burden in Malaysia.

Cost-effectiveness of low-molecular-weight heparin for secondary prophylaxis of cancer-related venous thromboembolism

2005 ◽  
Vol 93 (03) ◽  
pp. 592-599 ◽  
Author(s):  
Kenneth Smith ◽  
Jacques Cornuz ◽  
Mark Roberts ◽  
Drahomir Aujesky
Keyword(s):  
Molecular Weight ◽  
Venous Thromboembolism ◽  
Cost Effectiveness ◽  
Life Expectancy ◽  
Low Molecular Weight Heparin ◽  
Secondary Prophylaxis ◽  
Low Molecular Weight ◽  
Old Patients ◽  
Life Years ◽  
Quality Adjusted Life

SummaryAlthough extended secondary prophylaxis with low-molecular-weight heparin was recently shown to be more effective than warfarin for cancer-related venous thromboembolism, its cost-effectiveness compared to traditional prophylaxis with warfarin is uncertain. We built a decision analytic model to evaluate the clinical and economic outcomes of a 6-month course of low-molecular-weight heparin or warfarin therapy in 65-year-old patients with cancer-related venous thromboembolism. We used probability estimates and utilities reported in the literature and published cost data. Using a US societal perspective, we compared strategies based on quality-adjusted life-years (QALYs) and lifetime costs. The incremental cost-effectiveness ratio of low-molecular-weight heparin compared with warfarin was $149, 865/QALY. Low-molecular-weight heparin yielded a quality-adjusted life expectancy of 1.097 QALYs at the cost of $15, 329. Overall, 46% ($7108) of the total costs associated with low-molecular-weight heparin were attributable to pharmacy costs. Although the low-molecular-weigh heparin strategy achieved a higher incremental quality-adjusted life expectancy than the warfarin strategy (difference of 0.051 QALYs), this clinical benefit was offset by a substantial cost increment of $7,609. Cost-effectiveness results were sensitive to variation of the early mortality risks associated with low-molecular-weight heparin and warfarin and the pharmacy costs for low-molecular-weight heparin. Based on the best available evidence, secondary prophylaxis with low-molecular-weight heparin is more effective than warfarin for cancer-related venous thromboembolism. However, because of the substantial pharmacy costs of extended low-molecular-weight heparin prophylaxis in the US, this treatment is relatively expensive compared with warfarin.

scholarly journals P14.12 The cost-effectiveness of tumor-treating fields in patients with newly diagnosed glioblastoma

2019 ◽  
Vol 21 (Supplement_3) ◽  
pp. iii68-iii69
Author(s):  
X Armoiry ◽  
P Auguste ◽  
C Dussart ◽  
J Guyotat ◽  
M Connock
Keyword(s):  
Cost Effectiveness ◽  
Cost Effective ◽  
Survival Model ◽  
Sensitivity Analyses ◽  
Base Case ◽  
Tumor Treating Fields ◽  
Kaplan Meier ◽  
Life Years ◽  
Secondary Analyses ◽  
The Cost

Abstract BACKGROUND The addition of novel therapy “Tumor-Treating fields” (TTF) to standard radio-chemotherapy with Temozolomide (TMZ) has recently shown superiority over conventional TMZ regimen in patients with glioblastoma. Despite the clinical benefit of TTF, there is a strong concern regarding the cost of this new treatment. A first cost-effectiveness analysis, which was published in 2016, was based on effectiveness outcomes from an interim analysis of the pivotal trial and used a “standard” Markov model. Here, we aimed to update the cost-effectiveness evaluation using a partitioned survival model design and using the latest effectiveness data. MATERIAL AND METHODS A partitioned survival model was developed with three mutually exclusive health states: stable disease, progressive disease, and dead. Parametric models were fitted to the Kaplan-Meier data for overall and progression-free survival. These generated clinically plausible extrapolations beyond the observed data. The perspective of the French national health insurance was adopted and the time horizon was 20 years. Base case results were expressed as cost/life-years (LY) gained (LYG). Secondary analyses were undertaken, with the results presented as cost/per quality adjusted life years (QALY) gained. Last, we undertook deterministic and probabilistic sensitivity analyses. RESULTS After applying 4% annual discounting of benefits and costs, the base case model generated incremental benefit of 0.507 LY at a incremental cost of €258,695 yielding an incremental cost effectiveness ratio (ICER) of €510,273 / LYG. Secondary analyses yielded an ICER of €667,173/QALY. Sensitivity analyses and bootstrapping methods showed the model was relatively robust. The model was sensitive to TTF device costs and the parametric model fitted to the Kaplan-Meier data for overall survival. The cost-effectiveness acceptability curve showed TTF has 0% of being cost-effective under conventional thresholds. CONCLUSION Using a partitioned survival model, uprated costs and more mature survival outcomes, TTF when compared to standard radio-chemotherapy with TMZ is not likely to be cost-effective. This has major implications in terms of access of newly eligible patients

Anticoagulation in Ambulatory Cancer Patients

Blood ◽  
2011 ◽  
Vol 118 (21) ◽  
pp. 2071-2071
Author(s):  
Allyson Pishko ◽  
Kenneth J. Smith ◽  
Margaret V. Ragni
Keyword(s):  
Cost Effectiveness ◽  
Relative Risk ◽  
Cancer Patients ◽  
Mortality Risk ◽  
Base Case ◽  
Minor Bleeding ◽  
Term Survival ◽  
Relative Mortality ◽  
Life Years ◽  
The Cost

Abstract Abstract 2071 Background: Venous thromboembolism (VTE) risk is increased in patients with malignancy, occurring in up to 20%, and is a major cause of cancer mortality. VTE prophylaxis is currently recommended for inpatients with malignancy and in those undergoing surgery (Chest 2008). Despite evidence that low molecular weight heparin (LWMH) has anti-tumor effect and improves short-term survival (Cochrane, 2011), the cost-effectiveness of anticoagulation in ambulatory cancer patients is unknown. Methods: We constructed a Markov model to evaluate prophylactic AC in ambulatory cancer patients with no previous VTE, during 4 months of chemotherapy following diagnosis. In the model, AC was enoxaparin. Major and minor bleeding risk, VTE risk, mortality, and other clinical parameters were obtained from the Cochrane 2011 analysis and other published studies. Drug costs were based on average wholesale price. Outcomes included medical costs, effectiveness measured by mortality reduction, quality-adjusted life-years (QALY), and incremental cost-effectiveness ratio (ICER) over a 24-month time horizon. Results: Base case results are shown in the Table. Compared with no LMWH, primary prophylaxis with LMWH in ambulatory cancer patients over a 4-month period was associated with a relative mortality risk of 0.92 over 24 months (relative risk reduction of 0.08), at a gain of 0.0484 QALY, for an ICER of $76,922/QALY gained, well within the accepted $100,000/QALY threshold. The results were not sensitive to variation in VTE relative risk (RR) with AC (base case RR 0.55), nor to AC-associated major bleeding (base case RR 1.3) or minor bleeding (base case RR 1.05) risks. Variation of the relative mortality risk with AC to ≥ 0.94, or the cost of AC (Figure) to ≥ $1,429/month (base $1,132), increased the ICER to >$100,000/QALY. Discussion: Prophylactic AC appears cost-effective in ambulatory cancer patients during the first four months of chemotherapy. Clinical trials will be needed to confirm the survival benefit of LMWH prophylaxis in ambulatory cancer patients. Disclosures: No relevant conflicts of interest to declare.

Nivolumab versus nivolumab with ipilimumab versus trifluridine/tipiracil for metastatic microsatellite instability-high colorectal cancer: A modeling decision analysis.

2018 ◽  
Vol 36 (4_suppl) ◽  
pp. 829-829
Author(s):  
Jacqueline N. Chu ◽  
Jin G. Choi ◽  
Sassan Ostvar ◽  
James A. Torchia ◽  
Kerry Lynn Reynolds ◽  
...  
Keyword(s):  
Colorectal Cancer ◽  
Overall Survival ◽  
Cost Effectiveness ◽  
Microsatellite Instability ◽  
Cost Effective ◽  
Checkpoint Blockade ◽  
Base Case ◽  
Life Years ◽  
Third Line ◽  
Line Chemotherapy

829 Background: Microsatellite instability-high (MSI-H) metastatic colorectal cancer (mCRC) patients who have failed chemotherapy have shown response to checkpoint blockade. We investigate optimal third-line treatment in MSI-H mCRC with regard to overall survival, quality of life years gained (QALYs), and cost-effectiveness. Methods: A Markov Model was created for a base case of a 57 year old man with MSI-H mCRC refractory to two lines of chemotherapy. Treatments compared were nivolumab, nivolumab with ipilimumab, and trifluridine/tipiracil. Patients could remain stable, progress to fourth-line chemotherapy or palliative care, experience drug toxicity, die from age/sex mortality, or die from cancer over their simulated lifetimes. Transitions between health states were based on the CheckMate 142 and RECOURSE trials. Outcomes were survival or unadjusted life years, QALYs, and incremental cost-effectiveness ratios (ICERs). The willingness to pay threshold was $100,000/QALY. Results: Nivolumab with ipilimumab was the most effective strategy as it yielded more unadjusted life-years (4.24) and QALYs (2.53) compared to nivolumab (3.95 LY, 2.33 QALYs) and trifluridine/tipiracil (0.74 LY, 0.07 QALYs). However, nivolumab with ipilimumab was not cost-effective compared to nivolumab and neither treatment strategy was cost-effective compared to trifluridine/tipiracil. Sensitivity analysis found nivolumab monotherapy could be cost-effective with decrease in drug cost to $2000/dose. Conclusions: Our modeling analysis finds that both single and dual checkpoint blockade yield significantly increased overall survival and QALYs for MSI-H mCRC compared to third-line chemotherapy, but were not cost-effective because of nivolumab cost. Decreases in drug pricing and/or duration of maintenance nivolumab could make nivolumab monotherapy cost-effective. [Table: see text]

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