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Quantifying the value of therapeutic approaches to disease management using registries to undertake cost of illness and cost-effectiveness analysis
thesisposted on 22.03.2017, 01:49 by Ademi, Zanfina
Cardiovascular diseases, comprising occlusive diseases in various arterial beds, impose a major burden on health resources and on the Australian economy, impacting directly through health care expenditure and indirectly through productivity losses. In Australia, 11% of total direct costs are spent on cardiovascular disease, which potentially impacts on 3.2 million people. More effective prevention strategies will lead to more lives being saved each year, an improvement of quality of life, and large gains in productivity. Despite increasing evidence and more efforts being made to control, prevent and treat cardiovascular disease, there remains a significant gap between what works in clinical trials and what works in clinical practice. This ‘lost benefit’ impinges on scarce health care resources. This dissertation has used cardiovascular prospective registries, primarily the Australian Reduction of Atherothrombosis for Continued Heath (REACH) registry, to identify drivers of health care costs, and predictors of pharmaceutical, ambulatory and hospital costs. In addition, modelling techniques were applied to assess the cost-effectiveness of prevention strategies, utilising the best available data sources from clinical practice regarding long term outcomes. A consistent theme throughout the chapters of this dissertation has been to obtain an overall understanding of the burden of those with, or at high risk of atherothrombosis, and to quantify the value of existing therapeutic approaches to atherothrombosis management. Based on the analysis of these results, it is recommended that a greater investment in prophylactic treatment be instituted, in order to provide a greater quality of life and improve productivity among patients with existing peripheral arterial disease. Quantifying the excess cost of cardiovascular risk factors, and particularly the obesity, allowed us to understand allocation of resources to the management and treatment of obesity and comorbidities in this sub-group of the population with atherothrombotic disease. To assess the cost-effectiveness of prevention strategies, a decision-tree Markov model was developed. Two treatment strategies were compared over a five-year period to capture the incidence of non-fatal myocardial infarction, non-fatal stroke, gastrointestinal bleeding and all-cause mortality. Data from the REACH registry were applied to the model to assess the cost-effectiveness of aspirin and statins over five years. Uncertainty analyses were calculated using Monte Carlo simulations. In terms of low-dose of aspirin, our modelling analysis showed that increased aspirin use among high-risk patients would be highly cost-effective. Among those with existing coronary artery disease (secondary prevention), the benefits were achieved through to fewer cases of non-fatal MI, non-fatal stroke and deaths. However, among patients without existing cardiovascular disease (primary prevention), increased uptake of aspirin was of uncertain benefit, with two hemorrhagic bleeding events occurring for every life saved. For the case of statins, our modeling analysis showed that if all patients are treated according to recommended guidelines, there would be good return from the investment For example, increasing statin use from 82% to 100% would be highly cost-effective. The use of this information should be applied to support clinical practice and public health, and to inform the delivery of prevention strategies, so that this can be undertaken in more efficient ways. Considering future implications, as long as atherothrombosis continues to impose a significant morbidity and mortality burden in Australia and many parts of the world, and as long as healthcare resources are limited, there will be a great need to have robust information on disease costs, intervention costs and their cost-effectiveness.