Cost-utility of treatments for pulmonary arterial hypertension: a Markov state-transition decision analysis model.
OBJECTIVE
Clinicians must choose between an increasing number of medications for the treatment of pulmonary arterial hypertension (PAH) with different routes of administration, adverse effects, costs and efficacies. We constructed a decision analysis to help inform treatment choices in PAH.


METHODS
We created a Markov-type model to evaluate 1-year treatment with bosentan, treprostinil, epoprostenol, inhaled iloprost, sildenafil, sitaxentan and ambrisentan. Transition probabilities were based on observed transitions between WHO functional classes, adjusted by relative risk of improvement in a 6-minute walk test. Utilities were based on reported values for each functional class, adjusted for burden of treatment administration. Costs were estimated from Medicare and Medicaid reimbursement data. Sensitivity analyses evaluated changes in efficacy, utilities and costs.


RESULTS
Treatment with sildenafil was less costly and resulted in a greater gain in quality-adjusted life-years (QALYs) compared with other treatments. Treatment with ambrisentan and bosentan resulted in the same gain in QALYs as sildenafil, but at a higher cost. Sensitivity analyses had minimal impact on these results.


CONCLUSIONS
Based on this model, sildenafil is a cost-effective treatment for PAH with a low price and a net increase in QALYs. The results from this analysis are a tool to help guide clinicians in deciding which PAH medications to use; however, the final decisions should be individualized because the effectiveness of therapy, resulting utilities and acceptable costs will differ with each patient.
Garin
Margaret C
MC
Department of Medicine, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania, USA.
Clark
Leslie
L
Chumney
Elinor C G
EC
Simpson
Kit N
KN
Highland
Kristin B
KB
D000959:Antihypertensive Agents / Q000191:economics* / Q000627:therapeutic use*; D003362:Cost-Benefit Analysis; D003661:Decision Support Techniques; D016527:Drug Costs; D004359:Drug Therapy, Combination; D006801:Humans; D006976:Hypertension, Pulmonary / Q000188:drug therapy* / Q000191:economics*; D008390:Markov Chains; D008484:Medicaid / Q000191:economics; D006278:Medicare / Q000191:economics; D011788:Quality of Life; D019057:Quality-Adjusted Life Years; D014481:United States; D014486:United States Food and Drug Administration
D000959:Antihypertensive Agents