Article Figures & Tables
Figures
- Figure 1
Incremental cost-effectiveness ratio for scenario A, palivizumab prophylaxis for healthy term infants across the Canadian Arctic compared with no prophylaxis for infants less than 6 months of age at or during the 2009 respiratory syncytial virus (RSV) season (Jan. 1-June 30). †Prophylaxis up to 5 months of age provides 6 months of protection. ‡Scenario C, sensitivity analysis using 78% risk reduction.
- Figure 2
Incremental cost-effectiveness ratio for scenario B, palivizumab prophylaxis compared with no prophylaxis for healthy term infants across the Canadian Arctic up to 5 months of age. *Population at risk is fluid, with equal number meeting inclusion criteria (through birth) as exclusion criteria. †Estimated risk reduction 96%. ‡Prophylaxis up to 5 months of age provides 6 months of protection. RSV = respiratory syncytial virus.
Tables
- Table 1 Variables for cost-effectiveness analysis of palivizumab prophylaxis in term Inuit infants admitted to hospital with infection due to RSV between Jan. 1 and June 30, 2009
Variable Estimate Range or alternative estimate Comments Rate of RSV-related admission Actual data for 2009: number of admissions of healthy term infants*/population at risk in each region, January to June 2009 Minimum estimate 2009 had the lowest rates of RSV-related admissions documented in the previous 30 years.2-7 As other years are likely to have equal or greater rates of RSV infection, cost-effectiveness would be similar or greater. May be underestimate as only 90% were tested for RSV. Births in 2009 Actual number of births - Source: Statistics Canada or territorial governments Healthy term infants 0.92 of births in 2009 - Source: Dr. Maureen Baikie, Chief Medical Officer of Health, Government of Nunavut. In 2011-2013, 9.3% of the population received palivizumab each year (estimate 8% of those aged < 6 mo, 1.3% of those aged 6 mo-2 yr). Population at risk 51/72 of healthy infants - Infants born July 1, 2008, to May 31, 2009 Population that received prophylaxis scenario A 51/72 of healthy infants - Prophylactic administration of palivizumab to all infants born July 1, 2008, to May 31, 2009 (see Table 3) Population that received prophylaxis scenario B 6/12 of healthy infants - Prophylactic administration of palivizumab to infants < 5 mo of age (for 6 mo of protection) during RSV season (see Table 3) Costs for RSV-related admissions Actual cohort of admissions during 2009 RSV season - Included transportation, admission, physician fees and accommodation. No additional fees for resuscitation procedures, emergency visits, medications, outpatient follow-up, underestimating costs.10 Cost of transportation to hospital Actual amounts invoiced by medical evacuation companies for each medical evacuation - Source: medical evacuation companies/airlines Cost of transportation back to home community Equivalent of regularly scheduled economy flight Minimum estimate Source: directly from commercial airlines.
Assumed return flight was economy commercial airlines, when sometime patients are transported by air ambulance with medical personnel.Inpatient costs Actual costs charged by hospital per day of hospital stay, differentiated by ward/ICU - Source: territorial governments, hospital finance departments Physician cost Estimated from OHIP Schedule of Benefits and Fees for pediatrics differentiated by day of admission, ward/ICU fees and whether mechanical ventilation required - This involves 9 hospitals where OHIP billings were mid-range. Exclusion of after-hours, emergency and procedural fees gives minimum estimates of costs. Risk reduction 96% 88% scenario C For preterm Inuit infants in Nunavut13 Palivizumab cost $225.75 per kg of estimated weight + 5% wastage + $50 administration $225.75 per kg of estimated weight +15% wastage + $50 administration Source: AbbVie Canada, as actual drug acquisition cost (see Table 3). Sensitivity analysis increases wastage threefold. Assumes vial sharing. Estimated weight Weight at 50% percentile for each month of age from CDC growth charts - CDC chosen rather than World Health Organization to have higher estimates of cost Note: CDC = US Centers for Disease Control and Prevention, ICU = intensive care unit, OHIP = Ontario Health Insurance Plan, RSV = respiratory syncytial virus.
*Without significant congenital heart or chronic lung disease.
Costs Northwest Territories Nunavut Nunavik Overall Kitikmeot Region Kivalliq Region Qikiqtaaluk Region No. of RSV-related admissions 8 52 22 18 12 30 Total cost of all RSV-related admissions, $ 177 256 2 871 137 1 496 365 1 094 603 280 169 632 139 Total transportation (range per admission) 48 243 (0-24 564) 795 915 (0-41 175) 486 753 (15 211-41 175) 216 086 (3448-22 501) 93 077 (0-18 657) 146 364 (0-22 860) Total inpatient (range per admission) 114 660 (9360-18 720) 1 932 089 (5218-209 266) 950 705 (10 530-166 773) 815 436 (5218-209 266) 165 948 (6396-31 308) 414 340 (2506-88 200) Total physician 14 353 123 933 53 958 49 131 20 845 62 135 Total accommodation 0 19 200 4950 13 950 300 9300 Average cost (range) per RSV-related admission, $ 22 157 (10 988-45 225) 55 214 (12 856-240 410) 68 017 (31 196-217 430) 60 811 (17 454-240 410) 23 347 (17 276-44 277) 21 071 (3978-115 418) - Table 3: Cost, doses and population at risk for universal palivizumab prophylaxis for healthy infants with scenarios A* and B† during the 2009 RSV season
Age; weight, kg Month; monthly cost per dose per eligible healthy term infant, $ December 2008 January 2009 February 2009 March 2009 April 2009 May 2009 Birth; 3.5 880 880 880 880 880 880 1 mo; 4.3 1069 1069 1069 1069 1069 1069 2 mo; 5.05 1247 1247 1247 1247 1247 1247 3 mo; 5.75 1413 1413 1413 1413 1413 1413 4 mo; 6.45 1579 1579 1579 1579 1579 1579 5 mo; 7.0 1709 1709 1709 1709 1709 1709 6 mo; 7.55 - 1840 1840 1840 1840 1840 7 mo; 8.05 - - 1958 1958 1958 1958 8 mo; 8.45 - - - 2053 2053 2053 9 mo; 8.85 - - - - 2148 2148 10 mo; 9.25 - - - - - 2243 Sum Sum scenario A 7897 9737 11 695 13 748 15 896 18 139 77 112 Sum scenario B 7897 7897 7897 7897 7897 7897 47 382 Note: RSV = respiratory syncytial virus.
*Scenario A: Eligible infants are those who would be less than 6 months of age by Jan. 1, 2009 or born before May 31, 2009. Prophylaxis is stopped by May 31, 2009. Annual cost per region = $6423.82 × number of births/year. Monthly doses = number of doses per month x 1/12 × births/year. Annual doses = 51 × 1/12 births/year = 4.25 × births/year. Population at risk = 51/72 × births/year.
†Scenario B: Eligible infants are those who would be less than 6 months of age by Jan. 1, 2009 or born before May 31, 2009. Prophylaxis is stopped by 6 months of age. Model assumes that an equivalent number of infants are born as surpass the age criteria. Annual cost per region = $7897/month × 6/12 births/year = $3947.29 × births. Monthly doses = number of doses per month × 1/12 birth/year = 6/12 × births. Annual doses = 6 × 6/12 births/year. Population at risk = 36/72 × births/year.
- Table 4: Scenario A: Cost-effectiveness of palivizumab prophylaxis versus no prophylaxis in healthy term infants who were less than 6 months of age at the start of the 2009 RSV season or were born during the season per RSV-related hospital admission avoided
Variable Northwest Territories Nunavut Nunavut without Iqaluit Kitikmeot Region Kivalliq Region Qikiqtaaluk Region Qikiqtaaluk Region without Iqaluit Nunavik Total births in 2009 739 816 701 114 245 457 342 250 Healthy newborns* 679.9 750.7 644.9 104.9 225.4 420.4 314.6 230 Estimated rate of RSV-related admission per 1000 population at risk† 16.6 97.8 111.6 296.1 112.7 40.3 49.4 184.1 Base case: no prophylaxis, RSV-related admissions in healthy term infants admitted Jan. 1 to June 30, 2009 No. of RSV-related admissions 8 52 51 22 18 12 11 30 Total cost of admissions, $ 177 256 2 871 137 2 856 561 1 496 365 1 094 603 280 169 265 593 632 139 Scenario A: universal palivizumab prophylaxis for healthy term infants, with 96% risk reduction No. of RSV-related admissions 0.3 2.1 2.0 0.9 0.7 0.5 0.4 1.2 Total cost of admissions, $ 7090 114 845 114 262 59 855 43 784 11 207 10 624 25 286 Estimated cost of palivizumab, $ 4 367 555 4 822 362 4 142 722 673 859 1 447 929 2 700 574 2 020 934 1 477 479 Total cost (palivizumab + admissions), $ 4 374 645 4 937 207 4 256 984 733 714 1 491 713 2 711 781 2 031 558 1 502 765 Scenario A v. base case Incremental cost for RSV prophylaxis, $ 4 197 389 2 066 070 1 400 423 -762 652 397 111 2 431 611 1 765 965 870 625 Incremental cases of RSV infection avoided 7.7 49.9 49.0 21.1 17.3 11.5 10.6 28.8 ICER per RSV-related admission avoided, $ 545 115 41 404 28 580 -36 145 22 954 211 444 166 600 30 230 NNT‡ to prevent 1 RSV-related admission 62.7 10.7 9.3 3.5 9.2 25.8 21.1 5.7 Note: ICER = incremental cost-effectiveness ratio, NNT = number needed to treat, RSV = respiratory syncytial virus.
*Estimated to be 92% of all newborns.
†Admissions for RSV infection between Jan. 1 and June 30, 2009, with population at risk of healthy term infants born after July 1, 2008, to May 31, 2009.
‡1/absolute risk reduction. Absolute risk reduction was defined as the untreated admission RSV rate - ([1 - efficacy] × untreated RSV admission rate). Untreated admission rate = number of admissions with RSV in those not treated/population at risk.
- Table 6: Scenario C: cost-effectiveness of palivizumab prophylaxis versus no prophylaxis in healthy term infants who were less than 6 months of age at the start of the 2009 RSV season or were born during the season per RSV-related hospital admission avoided, with 88% risk reduction and 15% palivizumab wastage
Variable Northwest Territories Nunavut Nunavut without Iqaluit Kitikmeot Kivalliq Qikiqtaaluk Qikiqtaaluk without Iqaluit Nunavik Total births in 2009 739 816 701 114 245 457 342 250 Healthy newborns 679.9 750.7 644.9 104.9 225.4 420.4 314.6 230 Estimated rate of RSV-related admissions per 1000 population at risk† 16.6 97.8 111.6 296.1 112.7 40.3 49.4 184.1 Base case: no prophylaxis, RSV-related admissions in healthy term infants Total no. of RSV-related admissions documented in 2009 in healthy term infants 8 52 51 22 18 12 11 30 Total cost of admissions, $ 177 256 2 871 137 2 856 561 1 496 365 1 094 603 280 169 265 593 632 139 Scenario C: universal palivizumab prophylaxis of healthy term infants, with 88% risk reduction Total no. of RSV-related admissions 0.96 6.24 6.12 2.64 2.16 1.44 1.32 3.6 Total costs of RSV-related admissions, $ 21 271 344 536 342 787 179 564 131 352 33 620 31 871 75 857 Estimated cost of palivizumab, $ 5 009 170 5 653 859 4 874 975 840 427 1 708 285 3 105 148 2 326 264 1 720 849 Total costs (palivizumab + RSV-related admissions), $ 5 030 441 5 998 395 5 217 762 1 019 991 1 839 637 3 138 768 2 358 135 1 796 706 Scenario C v. base case Incremental cost for RSV prophylaxis, $ 4 853 185 3 127 259 2 361 202 -476 374 745 035 2 858 599 2 092 542 1 164 566 Incremental RSV-related admissions avoided 7.0 45.8 44.9 19.4 15.8 10.6 9.7 26.4 ICER per RSV-related admission avoided, $ 714 580 69 087 52 898 -26 877 47 201 277 275 221 724 44 976 NNT to prevent 1 RSV-related admission 77.2 13.1 11.5 4.3 11.4 31.8 26.0 7.0 Note: ICER = incremental cost-effectiveness ratio, NNT = number needed to treat, RSV = respiratory syncytial virus.
- Table 7: ICERs for palivizumab prophylaxis for healthy term infants in the Canadian Arctic, comparing scenario A, in which prophylaxis is continued to end of RSV season, to scenario B, in which prophylaxis is stopped at 5 months of age
Variable Northwest Territories Nunavut Nunavut without Iqaluit Kitikmeot Region Kivalliq Region Qikiqtaaluk Region Qikiqtaaluk Region without Iqaluit Nunavik Base case (no prophylaxis) Total costs, $ 177 256 2 871 137 2 856 561 1 496 365 1 094 603 280 169 265 593 632 139 No. of admissions for RSV infection 8 52 51 22 18 12 11 30 Scenario A Total costs, $ 4 374 645 4 937 207 4 256 984 733 714 1 491 713 2 711 781 2 031 558 1 502 765 No. of admissions for RSV infection 0.3 2.1 2 0.9 0.7 0.5 0.4 1.2 Scenario B Total costs, $ 2 690 852 3 457 312 3 039 106 705 024 1 058 004 1 694 285 1 276 078 990 964 No. of admissions for RSV infection 0.3 11.7 11.6 5.7 4.6 1.4 1.4 7 Scenario A v. base case Incremental costs, $ 4 197 389 2 066 070 1 400 423 -762 652 397 111 2 431 611 1 765 965 870 625 Incremental no. of RSV-related admissions 7.7 49.9 49 21.1 17.3 11.5 10.6 28.8 ICER (cost per RSV-related admission avoided), $ 545 115 41 404 28 580 -36 145 22 954 211 444 166 600 30 230 Scenario B v. base case Incremental costs, $ 2 513 597 586 175 182 545 -791 342 -36 599 1 414 116 1 010 486 358 825 Incremental no. of RSV-related admissions 7.7 40.3 39.4 16.3 13.4 10.6 9.6 23 ICER (cost per RSV-related admission avoided), $ 326 441 14 545 4633 -48 549 -2731 133 407 105 259 15 601 Scenario A v. scenario B Incremental costs, $ 1 683 793 1 479 895 1 217 878 28 690 433 709 1 017 496 755 480 511 801 Incremental no. of RSV-related admissions 0 9.6 9.6 4.8 3.9 0.9 1 5.8 ICER (cost per RSV-related admission avoided), $ - 154 156 126 862 5977 111 207 1 130 551 755 480 88 242 Note: ICER = incremental cost-effectiveness ratio, RSV = respiratory syncytial virus.
- Table 5: Scenario B: cost-effectiveness of palivizumab prophylaxis in infants less than 5 months (6 months of protection) versus no prophylaxis of all healthy term infants 6 months of age at the start of the 2009 per RSV-related hospital admission avoided
Variable Northwest Territories Nunavut Nunavut without Iqaluit Kitikmeot Kivalliq Qikiqtaaluk Qikiqtaaluk without Iqaluit Nunavik Total births in 2009 739 816 701 114 245 457 342 250 Healthy newborns 679.9 750.7 644.9 104.9 225.4 420.4 314.6 230 Rate of RSV infection in healthy infants < 6 mo of age January to June 2009, per 1000 live births 23.5 111.9 127.1 324.1 124.2 52.3 63.6 208.7 Base case: no prophylaxis, RSV-related admissions in healthy term infants admitted Jan. 1 to June 30, 2009 No. of RSV-related admissions among infants < 6 mo of age 8 42 41 17 14 11 10 24 No. of RSV-related admissions among infants ≥ 6 mo of age 0 10 10 5 4 1 1 6 Total cost of RSV-related admissions among infants < 6 mo of age, $ 2 476 100 2 461 523 1 255 638 964 915 255 547 240 971 571 929 Total cost of RSV-related admissions among infants ≥ 6 mo of age, $ 0 395 037 395 038 240 727 129 688 24 622 24 622 60 210 Total cost of all RSV-related admissions, $ 177 256 2 871 137 2 856 561 1 496 365 1 094 603 280 169 265 593 632 139 Scenario B: palivizumab prophylaxis of healthy term infants up to 5 months of age, with 96% risk reduction No. of RSV-related admissions among infants < 6 mo (received prophylaxis) 0.3 1.7 1.6 0.7 0.6 0.4 0.4 1.0 No. of RSV-related admissions among infants ≥ 6 mo of age (did not receive prophylaxis) 0 10 10 5 4 1 1 6 Costs of admissions of infants < 6 mo of age, $ 7090 99 044 98 461 50 226 38 597 10 222 9639 22 877 Cost of admissions of infants ≥ 6 mo of age, $ 0 395 037 395 038 240 727 129 688 24 622 24 622 60 210 Total cost of all RSV-related admissions, $ 7090 494 081 493 499 290 953 168 285 34 844 34 261 83 087 Estimated cost of palivizumab, $ 2 683 762 2 963 231 2 545 607 414 071 889 719 1 659 441 1 241 817 907 877 Total costs (palivizumab + all RSV-related admissions), $* 2 690 852 3 457 312 3 039 106 705 024 1 058 004 1 694 285 1 276 078 990 964 Scenario B v. base case Incremental cost for RSV prophylaxis, $ 2 513 597 586 175 182 545 -791 342 -36 599 1 414 116 1 010 486 358 825 Incremental RSV-related admissions avoided 7.7 30.3 29.4 11.3 9.4 9.6 8.6 17 ICER per RSV-related admission avoided, $ 326 441 14 545 4633 -48 549 -2731 133 407 105 259 15 601 NNT to prevent 1 RSV-related admission among infants < 6 mo of age 44.3 9.3 8.2 3.2 8.4 19.9 16.4 5.0 Note: ICER = incremental cost-effectiveness ratio, NNT = number needed to treat, RSV = respiratory syncytial virus.
*Include the revised cost with 96% risk reduction if < 6 months of age, and full costs if ≥ 6 months of age (no prophylaxis).
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