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Economic Evaluation of Specific Immunotherapy Versus Symptomatic Treatment of Allergic Rhinitis in Germany

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Abstract

Objective: To use published data to compare the economic consequences of specific immunotherapy (SIT) lasting 3 years with those of continuous symptomatic treatment in patients with either pollen or mite allergy.

Design and setting: The evaluation was conducted from the following 3 perspectives in Germany: (i) society; (ii) healthcare system; and (iii) statutory health insurance (SHI) provider. A modelling approach was used which was based on secondary analysis of existing data. The follow-up period was 10 years. The break-even point of cumulated costs, their difference per patient and the additional cost per additional patient free from asthma symptoms [incremental costeffectiveness ratio (ICER)] were used as target variables, each from the viewpoint of SIT. The types of costs were direct and indirect (society), direct (healthcare system) and those incurred by SHI (i.e. expenses). In the base-case analysis, the average values of the clinical parameters and average case-related costs/expenses were applied.

Main outcome measures and results: The break-even point was reached between year 6 and year 8 after the start of therapy, resulting in net savings of between 650 and 1190 deutschmarks (DM) per patient after 10 years. The ICERs of SIT were between -DM3640 and -DM7410, depending on study perspective and nature of the allergy (1990 values for symptomatic treatment and treatment of asthma, 1995 values for SIT; DM1 ≈ $US0.58). The sensitivity analysis demonstrated the robustness of the model and its results. First, all the independent variables of the model were varied. Secondly, the influence of the model variables was quantified using a deterministic model. SIT was more likely to result in net savings than in additional costs. An economic parameter (cost for symptomatic treatment) had the highest influence on the results.

Conclusions: This evaluation showed that SIT for 3 years is economically advantageous in patients who are allergic to pollen or mites and whose symptoms are inadequately controlled by continuous symptomatic treatment. After 10 years, the administration of SIT leads to net savings from the perspectives of society, the healthcare system and SHI (third-party payer) in Germany.

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Acknowledgements

The authors would like to thank the following physicians in Germany who participated in the Medical Advisory Committee: Dr Wolfgang Jorde (internist/allergology, Mönchengladbach), Dr Rolf F. Kroidl (internist/pneumology/allergology, Stade) and Professor Dr Gerhard Schultze-Werninghaus (Department of Pneumology and Allergology, University Clinic, Bochum). The investigation was funded by the following 3 German manufacturers whose allergen extracts have been subject to this economic evaluation: Allergopharma Joachim Ganzer KG (Reinbek), Bencard Allergie GmbH (München), HAL ALLERGIE GmbH (Düsseldorf). However, the views expressed in this paper are solely those of the authors.

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  1. PAREXEL GmbH InForMed Outcomes Research & Pharmacoeconomics, Klinikum Westend, Haus 18, Spandauer Damm 130, D-14050, Berlin, Germany

    Peter K. Schädlich & Josef G. Brecht

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  1. Peter K. Schädlich
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Correspondence to Peter K. Schädlich.

Appendices

Appendices

Appendix A

Asthma: Prevalence, Incidence, Remission and Excess Mortality

Table VII summarises the clinical parameters related to asthma for use in the decision tree derived from the secondary analysis of clinical trials, observational studies and epidemiological information.

Table VII
figure Tab7

Clinical parameters related to asthma for use in the decision tree

Full size image

The prevalence of patients in the categories ‘asthmatic’ and ‘without asthma symptoms’ at the end of each interval was calculated in 2 steps because of the different disease courses. In the first step, they were estimated on the basis of each subpopulation at the start of treatment, patients with asthma and patients without asthma symptoms, according to the parameter values given in table VII.

In the initial subpopulation (patients with asthma), the decreasing prevalence of patients with asthma was given by:

$$\rm cumulative \ survival \ of \ asthmatic \ patients \ \times \ cumulative \ prevalence \ after \ remission$$

The increasing prevalence of patients without asthmatic symptoms was given by:

$$\rm cumulative \ survival \ of \ patients \ with \ asthma \ \times \ cumulative \ remission$$

In the initial subpopulation (patients without asthma symptoms), the increasing prevalence of patients with asthma was given by:

$$\rm cumulative \ incidence \ of \ asthma \ \times \ cumulative \ survival \ of \ patients \ with \ asthma\ \ \times \ cumulative \ prevalence \ after \ remission$$

The decreasing prevalence of patients without asthma symptoms was given by:

$$\rm (1 - \ cumulative \ incidence \ of \ asthma) + (\ cumulative \ incidence \ of \ asthma \ \times \ cumulative \ survival \ of \ paitents \ with \ asthma \ \times \ cumulative \ natural \ remission)$$

In the second step, these interim results were combined according to the prevalence of patients with asthma and patients without asthma symptoms, respectively, that are given at the start of treatment.

Appendix B

Reduction in the Need for Anti-Allergic Pharmacotherapy

The reduction in the need for anti-allergic pharmacotherapy after SIT was derived from secondary analysis of 23 clinical trials and observational studies[19,20,24–27,33–49] using 3 steps: (i) the proportion of patients without anti-allergic pharmacotherapy was sorted by interval from 1 year after initiation of SIT up to 6.5 years, according to the available sources; (ii)these empirical proportions were each weighted by the difference between the total number of patients and the number of patients without anti-allergic comedication as observed in each publication; and (iii)logarithmic regression with regard to the value and weight of each empirical proportion led to the following exponential function which describes the average cumulative reduction:

$$\rm Cr_i = 1-e(^{ni \times a-b})$$

where Cri is the average cumulative reduction in the number of patients with any anti-allergic comedication after i years, e is Euler’s number, ni is the number of the year, a = −0.062905 and b = 0.439544. The limits of this average were based on the range of the empirical proportions. The lower limit is given by:

$$\rm Cr_i = 0.805-e(^{ni \times a-b})$$

The upper limit is given by:

$$\rm Cr_i = 1.1435-e(^{ni \times a-b})$$

The reduction in the need for anti-allergic pharmacotherapy in the group assigned to symptomatic treatment is given in table VIII. The values of the remission rates per year were obtained from secondary analysis of epidemiological information.[6,50,51]

Table VIII
figure Tab8

Reduction in the need for anti-allergic pharmacotherapy with symptomatic treatment

Full size image

Appendix C

Total Differential: Impact Analysis

Because of the analytic depiction of the target variable (difference in direct medical cost per patient after 10 years) in the form of a functional correlation with the exogenous parameters (see the Methods section), the extent of the correlation between these parameters and the target variable can be described by the total differential method.[64,65]

In the first step, the correlation between the target variable and the independent variables (effectiveness and economic parameters) was modelled via curve adaptation using a quadratic function. The total differential revealed the relative weight of each independent variable in the second step. The correlation between the relative weight of each independent variable and the value of the target variable can then be described as an elasticity under ceteris-paribus conditions, i.e. the amount of percentage alteration of the target variable after altering 1 independent variable by 1% while the remaining independent variables are kept constant with their average values at the same time. Table VI summarises this procedure for SIT in seasonal (pollen) and perennial (mite) allergy, respectively, for those independent variables with the highest impact.

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Schädlich, P.K., Brecht, J.G. Economic Evaluation of Specific Immunotherapy Versus Symptomatic Treatment of Allergic Rhinitis in Germany. Pharmacoeconomics 17, 37–52 (2000). https://doi.org/10.2165/00019053-200017010-00003

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