論文No2125
Cost-effectiveness of intrapleural use of tissue plasminogen activator and DNase in pleural infection: evidence from the MIST2 randomised controlled trial
Ramon Luengo-Fernandez, Erika Penz, Melissa Dobson, Ioannis Psallidas, Andrew J. Nunn, Nick A. Maskell, Najib M. Rahman
European Respiratory Journal 54 (2) 1801550; DOI: 10.1183/13993003.01550-2018 Published 1 August 2019
＜背景＞
MIST2試験（(Second Multicentre Intrapleural Sepsis Trial)は組織プラスミノゲン活性化(t-PA)typeとリコンビナントヒトDNaseの
胸腔内注入がそれぞれ単剤あるいはプラセボよりも有効であることを示した。
しかし、治療コストが問題であり、併用療法の全体のコスト効率は不明である。
＜方法＞
MIST2試験の経済的評価が実施され、併用療法のコスト効率を評価した。
コストに関連する薬剤費、最初の入院費用、その後の入院費用を含めた。
アウトカムは人年で測定した。全コストは2016年のユーロで計算した。
＜結果＞
平均の年間コストはt-PA-DNase群で最も低かった
(EUR 10 605 for t-PA, EUR 17 856 for DNase, EUR 13 483 for placebo and EUR 7248 for t-PA–DNase; p=0.209）。
平均の１年生存期待値は 0.988 for t-PA, 0.923 for DNase, and 0.969 for both placebo and t-PA–DNase (p=0.296)であった。
DNase, プラセボは人年でみると効果が弱く、t-PAより費用が高かった。
プラセボとt-PA-DNaseを比較すると、プラセボによる人年あたりの漸増コストはEUR 1.6 billionであり、
t-PA-DNaseが0.85倍のコストであった。
＜感想＞
胸腔感染に対してt-PAとDNaseの併用はトータルコストとしても安くなったようです。
The MIST2 (Second Multicentre Intrapleural Sepsis Trial) trial showed that combined intrapleural use of tissue plasminogen activator (t-PA) and recombinant human DNase was effective when compared with single agents or placebo. However, the treatment costs are significant and overall cost-effectiveness of combined therapy remains unclear.
An economic evaluation of the MIST2 trial was performed to assess the cost-effectiveness of combined therapy. Costs included were those related to study medications, initial hospital stay and subsequent hospitalisations. Outcomes were measured in terms of life-years gained. All costs were reported in euro and in 2016 prices.
Mean annual costs were lowest in the t-PA–DNase group (EUR 10 605 for t-PA, EUR 17 856 for DNase, EUR 13 483 for placebo and EUR 7248 for t-PA–DNase; p=0.209). Mean 1-year life expectancy was 0.988 for t-PA, 0.923 for DNase, and 0.969 for both placebo and t-PA–DNase (p=0.296). Both DNase and placebo were less effective, in terms of life-years gained, and more costly than t-PA. When placebo was compared with t-PA–DNase, the incremental cost per life-year gained of placebo was EUR 1.6 billion, with a probability of 0.85 of t-PA–DNase being cost-effective.
This study demonstrates that combined t-PA–DNase is likely to be highly cost-effective. In light of this evidence, a definitive trial designed to facilitate a thorough economic evaluation is warranted to provide further evidence on the cost-effectiveness of this promising combined intervention.