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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 2019 54: 1801550; DOI: 10.1183/13993003.01550-2018
Ramon Luengo-Fernandez
1Health Economics Research Centre, Nuffield Dept of Population Health, University of Oxford, Oxford, UK
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  • ORCID record for Ramon Luengo-Fernandez
Erika Penz
2Dept of Medicine, University of Saskatchewan, Saskatoon, SK, Canada
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Melissa Dobson
3Oxford Respiratory Trials Unit, Nuffield Dept of Clinical Medicine, University of Oxford, Oxford, UK
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Ioannis Psallidas
3Oxford Respiratory Trials Unit, Nuffield Dept of Clinical Medicine, University of Oxford, Oxford, UK
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Andrew J. Nunn
4MRC Clinical Trials Unit, University College London, London, UK
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Nick A. Maskell
5Academic Respiratory Unit, Bristol Medical School, University of Bristol, Bristol, UK
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Najib M. Rahman
3Oxford Respiratory Trials Unit, Nuffield Dept of Clinical Medicine, University of Oxford, Oxford, UK
6Oxford NIHR Biomedical Research Centre, Oxford, UK
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  • For correspondence: najib.rahman@ndm.ox.ac.uk
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    FIGURE 1

    Cost-effectiveness acceptability curve. t-PA: tissue plasminogen activator.

Tables

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  • TABLE 1

    Unit costs

    Unit cost EURSource
    Study medications, per dose
     Alteplase 10 mg164British National Formulary
     Pulmozyme 2.5 mg19British National Formulary
    Initial hospital stays, per day
     Initial stay, nonsurgery502NHS Reference Costs
     Initial stay, surgery955NHS Reference Costs
    Subsequent admissions
     Hospital stay#756#NHS Reference Costs

    Individual hospitalisation costs were applied in the main analysis. Based on the British National Formulary (www.bnf.org) and NHS Reference Costs [21]. #: weighted average for the 37 different reasons patients were readmitted during study follow-up.

    • TABLE 2

      Number of days in hospital over the 12-month follow-up period

      t-PADNasePlacebot-PA–DNase
      Subjects44414845
      Initial hospital stay
       Number of days, nonsurgical14.48±20.2122.59±58.7423.65±54.9011.43±9.31
       Number of days, surgical2.05±9.305.66±18.071.17±4.360.24±1.15
       Number of days, total16.52±22.7928.24±61.4124.81±56.1111.78±9.43
      Subsequent hospital stays
       Patients with one or more subsequent admissions3 (7)1 (2)4 (8)1 (2)
       Number of days0.75±2.960.75±4.831.38±6.540.16±1.04
      Total hospital stays
       Number of days17.27±24.7929.00±62.0126.19±56.6611.93±9.57

      Data are presented as n, mean±sd or n (%). t-PA: tissue plasminogen activator.

      • TABLE 3

        Mean costs and outcomes over the 12-month follow-up period

        t-PADNasePlacebot-PA–DNase
        Subjects44414845
        Costs EUR
         Trial medications98622701213
         Initial hospital stay, nonsurgical7155±999111 164±27 89211 687±27 1335701±4604
         Initial hospital stay, surgical1953±88745401±17 2471113±4159234±1098
         Subsequent admissions511±20261065±6820682±2865102±682
         Total costs10 605±15 41317 856±34 86113 483±28 7987248±4922
        Life-years gained0.988±0.0810.923±0.2280.969±0.1470.969±0.153
        Cost-effectiveness of placebo versus trial interventions
         ICERt-PA dominantPlacebo dominantNAEUR 1.6 billion
         Probability placebo cost-effective0.240.81NA0.04

        Data are presented as n or mean±sd. t-PA: tissue plasminogen activator; ICER: incremental cost-effectiveness ratio; NA: not applicable.

        • TABLE 4

          Cost-effectiveness of treatments for pleural infection at 12 months

          Incremental costs EUR (95% CI)Incremental life-years (95% CI)Incremental cost-effectiveness ratioProbability of intervention being cost-effective#
          t-PA–DNase0.86
          t-PA3357 (−335–8114)0.019 (−0.025–0.062)EUR 178 1660.12
          Placebo2878 (−4280–10 874)−0.019 (−0.061–0.020)t-PA both more effective and less costly0.03
          DNase4373 (−6700–15 940)−0.045 (−0.116–0.016)t-PA both more effective and less costly0.001

          t-PA: tissue plasminogen activator. #: assuming a cost-effectiveness threshold of GBP 30 000 (EUR 34 220) per life-year gained.

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            ERJ-01550-2018_Online supplementary appendix ERJ-01550-2018_Online_supplementary_appendix

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          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 Aug 2019, 54 (2) 1801550; DOI: 10.1183/13993003.01550-2018

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          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 Aug 2019, 54 (2) 1801550; DOI: 10.1183/13993003.01550-2018
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