Health-Economic Comparison of Paricalcitol, Calcitriol and Alfacalcidol for the Treatment of Secondary Hyperparathyroidism during Haemodialysis

Hubertus Rosery; Rito Bergemann; Steven E. Marx; Axel Boehnke; Joel Melnick; Raimund Sterz; Laura Williams

Clin Drug Invest. 2006;26(11):629-638.

3. Results

3.1 Cost-Consequence Analysis

The medication costs of vitamin D therapy differed with respect to the type of administration (intravenous vs oral). While treatment with capsules was associated with mean yearly costs of 375 (Eins Alpha^®, Bocatriol^®, Calcitriol-Nephro^® and Decostriol^®), intravenous treatment was associated with yearly costs of 2478 for alfacalcidol (Eins Alpha^®) and 3979 for paricalcitol (Zemplar^®) [see Table I ].

The incremental number of hospitalisation admissions per year was 0.846 fewer for patients who started and remained on intravenous paricalcitol than for patients being treated with calcitriol.^[22] These fewer hospitalisations led to cost savings of 5394 associated with the use of intravenous paricalcitol versus calcitriol (0.846 fewer hospital admissions per year multiplied by 6376 per hospital admission). Overall cost savings totalled 17901886 (i.e. 3979 - [375471] - 5394) per year. On the basis of these calculations, use of intravenous paricalcitol compared with intravenous alfacalcidol was associated with cost savings of 3893 per year per patient treated for secondary hyperparathyroidism (i.e. 3979 - 2478 - 5394).

3.2 Cost-Effectiveness Analysis

The cost-effectiveness analysis was based on 1-year survival rates with paricalcitol (0.84) and calcitriol (0.80), as reported in the study by Teng et al.^[23] On the basis of the medication and hospitalisation cost assumptions outlined, paricalcitol demonstrated first-order dominance over intravenous alfacalcidol, with cost savings of 3893 and 0.04 incremental life-years saved.

3.3 Cost-Utility Analysis

Utilities scores were calculated by multiplying the probabilities of hospitalisations, survival rates and utility associated with hospitalisation versus non-hospitalisation. Utility scores were totalled for each medicinal therapy and are presented in figure 1.

The sum of the utility scores for each treatment strategyresultedinaquality-adjustedlife-year (QALY) score of 0.378336 for paricalcitol and 0.34784 for calcitriol. Thus, intravenous paricalcitol was associated with an increase of 0.030 QALYs compared with oral calcitriol. When only medication costs were considered, the incremental costs for one additional QALY were estimated to be 118179 (3979 - 375)/0.030496 QALYs) for intravenous paricalcitol compared with oral calcitriol. Inclusion of cost savings associated with decreased number of hospitalisations demonstrated first-order dominance of intravenous paricalcitol (compared with both oral calcitriol and intravenous alfacalcidol treatments).

3.4 Sensitivity Analysis

A sensitivity analysis was conducted to assess the impact of variables with the greatest uncertainty: hospitalisation costs and utilities. Hospitalisation costs were based on G-DRG L60A or G-DRG L60C (see Table II ). Varying the hospitalisation costs between 4290 and 8728 resulted in extremes of an incremental total cost savings of 25 and 5883 with intravenous paricalcitol (see Table IV ) compared with oral calcitriol and intravenous alfacalcidol, respectively.

The utility score that was used in the cost-utility analysis for end-stage renal disease non-hospitalised patients with secondary hyperparathyroidism was selected on the basis of a range of published utility scores for end-stage renal disease and haemodialysis, together with the typical signs and symptoms associated with secondary hyperparathyroidism. Since we were uncertain of the actual values, a sensitivity analysis was performed by varying the utility scores used to calculate QALYs in the model from 0.41 to 0.61. The subsequent range of QALYs was 0.017 to 0.045, respectively. If both medication and hospitalisation costs were included in the model, intravenous paricalcitol remained dominant over oral calcitriol and intravenous alfacalcidol. This means that paricalcitol and hospitalisation costs were less and utilities were greater with paricalcitol compared with oral calcitriol and intravenous alfacalcidol

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Cite this: Health-Economic Comparison of Paricalcitol, Calcitriol and Alfacalcidol for the Treatment of Secondary Hyperparathyroidism during Haemodialysis - Medscape - Nov 01, 2006.

Table I. Medication Costs for Alfacalcidol, Calcitriol and Paricalcitol ^a
Medication	Package size	Cost/pack ()	Cost/dialysis^b ()	Cost/day ()	Cost/year ()
Alfacalcidol
Eins Alpha^® capsule	100 × 0.5μg	103.36	2.41	1.03	375.95
Eins Alpha^® injection	10 × 1.0mL(2 μg/mL)	158.46	15.84	6.79	2478.35
Calcitriol
Bocatriol^® capsule	100 × 0.5μg	104.01	2.43	1.04	379.60
Calcitriol-Nephro^® capsule	100 × 0.5μg	100.82	2.35	1.00	365.00
Decostriol^® capsule	100 × 0.5μg	104.01	2.43	1.04	379.60
Rocaltrol^® capsule	100 × 0.5μg	128.67	3.00	1.29	470.85
Intravenous paricalcitol
Zemplar^®	5 × 5μg	127.18	25.44	10.90	3978.50

^aSource: German Red List, January 2005.
^bAssumes three dialysis sessions per week.

Table II. Diagnosis-related Groups (DRGs) for Kidney Disease With Dialysis in Germany ^a
DRG	Description	Points	Base-case value ()	Costs per admissioncase ()
L60A	Kidney disease with dialysis haemolytic-uraemic syndrome or complex diagnosis and extremely severe complications	3.117	2800	8727.60
L60B	Kidney disease with dialysis not haemolytic-uraemic syndrome but complex diagnosis and extremely severe complications	2.277	2800	6375.60
L60C	Kidney disease with dialysis not haemolytic-uraemic syndrome or complex diagnosis or extremely severe complicationsorKidney disease without dialysis with haemolytic-uraemic syndrome or extremely severe complications	1.532	2800	4289.60

^aReference year for DRG values = 2005.

Table III. Published Utility Scores for End-stage Renal Disease and Haemodialysis
Health state	Score	Reference	Year of publication
End-stage renal disease	0.59	Lawrence et al.^[32]	1995
End-stage renal disease	0.61	Eastman et al.^[33]	1997
End-stage renal failure	0.567	Kiberd and Jindal^[34]	1995
End-stage renal failure due to diabetes	0.61	Diabetes Group^[35]	1996
End-stage renal failure	0.61	van Os et al.^[36]	2000
End-stage renal failure	0.576	Kiberd and Jindal^[37]	1998
Patients with end-stage renal disease treated with
full-care centre haemodialysis	0.66	de Wit et al.^[38]	1998
limited-care centre haemodialysis	0.81	de Wit et al.^[38]	1998
Dialysis	0.41	Kiberd^[39]	1994
Dialysis	0.43	Churchill et al.^[40]	1987
Dialysis	0.453	Coffey et al.^[41]	2002

Table I. Medication Costs for Alfacalcidol, Calcitriol and Paricalcitol ^a
Medication	Package size	Cost/pack ()	Cost/dialysis^b ()	Cost/day ()	Cost/year ()
Alfacalcidol
Eins Alpha^® capsule	100 × 0.5μg	103.36	2.41	1.03	375.95
Eins Alpha^® injection	10 × 1.0mL(2 μg/mL)	158.46	15.84	6.79	2478.35
Calcitriol
Bocatriol^® capsule	100 × 0.5μg	104.01	2.43	1.04	379.60
Calcitriol-Nephro^® capsule	100 × 0.5μg	100.82	2.35	1.00	365.00
Decostriol^® capsule	100 × 0.5μg	104.01	2.43	1.04	379.60
Rocaltrol^® capsule	100 × 0.5μg	128.67	3.00	1.29	470.85
Intravenous paricalcitol
Zemplar^®	5 × 5μg	127.18	25.44	10.90	3978.50

^aSource: German Red List, January 2005.
^bAssumes three dialysis sessions per week.

Table II. Diagnosis-related Groups (DRGs) for Kidney Disease With Dialysis in Germany ^a
DRG	Description	Points	Base-case value ()	Costs per admissioncase ()
L60A	Kidney disease with dialysis haemolytic-uraemic syndrome or complex diagnosis and extremely severe complications	3.117	2800	8727.60
L60B	Kidney disease with dialysis not haemolytic-uraemic syndrome but complex diagnosis and extremely severe complications	2.277	2800	6375.60
L60C	Kidney disease with dialysis not haemolytic-uraemic syndrome or complex diagnosis or extremely severe complicationsorKidney disease without dialysis with haemolytic-uraemic syndrome or extremely severe complications	1.532	2800	4289.60

^aReference year for DRG values = 2005.

Table IV. Sensitivity Analysis of Incremental Costs of Intravenous (IV) Paricalcitol Compared With Oral Calcitriol and IV Alfacalcidol Based on German Diagnosis-related Groups (DRG L60A ^a and L60C ^a)
Variable	Oral calcitriol	IV alfacalcidol
Medication costs ()	-3604	-1501
Hospitalisation costs L60A ()	+7384	+7384
Total incremental costs ()	+3780	+5883
Hospitalisation costs L60C ()	+3629	+3629
Total incremental costs ()	+25	+2128

^aSee Table II .

Table V. Incremental Costs, Incremental Survival Rates and Incremental Utilities of Intravenous (IV) Paricalcitol Compared With Oral Calcitriol and IV Alfacalcidol
Variable	IV paricalcitol	Oral calcitriol	IV alfacalcidol
Medication costs ()		-3604	-1501
Hospitalisation costs L60B^a ()		+5394	+5394
Incremental total costs ()		+1790	+3893
Incremental 1-year survival rate	0.04
Incremental utilities	0.030

^aSee Table II .

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Health-Economic Comparison of Paricalcitol, Calcitriol and Alfacalcidol for the Treatment of Secondary Hyperparathyroidism during Haemodialysis

3. Results

3.1 Cost-Consequence Analysis

3.2 Cost-Effectiveness Analysis

3.3 Cost-Utility Analysis

3.4 Sensitivity Analysis

Tables

Tables

Tables

Tables

Tables

Tables

Tables

References

Authors and Disclosures

Authors and Disclosures

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