Cost-effectiveness of cinacalcet in secondary hyperparathyroidism in the United States

Figures & data

Figure 1.  Model structure. SHPT: secondary hyperparathyroidism; CV: cardiovascular; PTH: parathyroid hormone;

denotes we follow observations for PTH, calcium, and phosphorus and death as recorded in the trial;

denotes we project the PTH, calcium, and phosphorus based on the last observations recorded during the trial; The sub-tree starting at #1 is cloned, i.e., a copy is attached to a node in another branch of the tree. The cloned sub-tree, denoted clone 1, is attached to the ‘Flexible Vitamin D’ node.

Table 1.  Model inputs: Event rates.

Parameter	Mean (base case)		Source
Lab values: Annual rate of deterioration
Vitamin D
PTH in the PTH 300–800 group	10%		38,47,48
PTH in the PTH > 800 group	20%		38,47,48
Ca in the PTH 300–800 group	5%		Assumption
Ca in the PTH > 800 group	15%		Assumption
P in the PTH 300–800 group	5%		Assumption
P in the PTH > 800 group	15%		Assumption
Cinacalcet
PTH, Ca, and P deterioration rate	0%		38
Event rates
	Age group	Mortality rate/1000 PYs
	18–34	45
	35–44	74
Mortality rate for dialysis patients (Age-specific data)	45–54	94	As reported in LDO
	55–64	126
	65–74	165
	75–84	219
	85+	261
Rate of CV event	291.2/1000 PYs
Rate of fracture	28/1000 PYs		54
Rate of parathyroidectomy	12/1000 PYs		55
RR of 2nd CV event after first CV event	2.22		51,52
RR of 2nd fracture event after first fracture event	2.30		77
Probability of patients unsuitable for parathyroidectomy surgery	15% of patients 55–74 years and 25% ≥ 75 years		47,48
RR of death after parathyroidectomy (30-day)	2.72		53

CV, cardiovascular; PTH, parathyroid hormone; Ca, calcium; P, phosphorous; RR, relative risk; PTH groups based on baseline PTH levels.

Table 2.  Model inputs: Costs and utility.

Parameter	Mean (base case)	Source
Costs
Cinacalcet	$0.4200 per mg	58
Vitamin D	$2.8295 per mcg^a	57
Calcium carbonate/calcium acetate	$0.4 per g^b	58
Sevelamer hydrochloride	$2.7 per g^c	58
Lanthanum carbonate	$5.5 per g^c	58
Magnesium-containing phosphate binders	$0.101 per g^c	58
Aluminum-containing phosphate binders	$0.0918 per g^c	58
CV event (chronic) (initial and follow-up care)	$40,027^d	59
Major fracture-related hospitalization	$24,139^d	59
Parathyroidectomy	$12,000^d	60,61,78
Utility
Hemodialysis patient, baseline	0.66	63
Dialysis patient with CV event	0.42^e	64
Dialysis patient with fracture	0.53^f	65
Dialysis patient with PTH > 800	0.56^g	47,48
Number of cycles (months) for which disutility was applied (including the cycle of event)
CV event	3	Assumption
Fracture	3	Assumption
PTH > 800	1	Assumption

CV, cardiovascular; PTH, parathyroid hormone.

^a Average Sales Price of paricalcitol/doxercalciferol/calcitriol +6%; ^b85% of Average Wholesale Price (AWP) of both medications; ^c85% of AWP; ^d Costs inflated to 2009 values using the Consumer Price Index62; ^eCV hospitalization (utility = 0.63). Value used in model is this value multiplied by utility value for dialysis (0.66); ^fHip fractures (utility = 0.80). Value used in model is this value multiplied by utility value for dialysis (0.66); ^gAssumed 15% reduction. Value used in model is (100% − 15%) multiplied by utility value for dialysis (0.66).

Figure 2.  Tornado diagram (one-way and structural sensitivity analysis). CV: cardiovascular; PTH: parathyroid hormone; Ca: calcium; P: phosphorous; QALY: quality adjusted life year; USRDS: United States Renal Data System; Note: The base case is based on the Block variant. For one-way sensitivity analysis, the black (dark) bar indicates that the impact on ICER when model parameter is changed to a lower value and a grey (light) bar indicates impact on ICER when model parameter is changed to a higher value compared to the base case.

Table 3.  Baseline model results (using various definitions of effectiveness).

	Block			Danese			Cunningham
	Cinacalcet + Vitamin D	Vitamin D only	Difference	Cinacalcet + Vitamin D	Vitamin D only	Difference	Cinacalcet + Vitamin D	Vitamin D only	Difference
Cost of cinacalcet	$33,847	$0	$33,847	$29,655	$0	$29,655	$30,663	$0	$30,663
Cost of Vitamin D	$8014	$11,160	−$3147	$7185	$11,019	−$3834	$7570	$11,160	−$3590
Cost of phosphate binders	$4003	$3428	$575	$3618	$3467	$151	$3803	$3428	$375
Cost of events	$85,267	$78,321	$6946	$74,563	$78,316	−$3754	$53,896	$78,321	−$24,425
Total discounted cost	$112,040	$80,332	$31,708	$99,118	$79,685	$19,432	$82,331	$80,332	$1999
Discounted life-years	6.19	5.39	0.80	5.65	5.39	0.26	5.93	5.39	0.54
Discounted QALY	3.82	3.24	0.58	3.47	3.20	0.27	3.64	3.24	0.39
ICER (Cost/LY gained)			$39,593			$74,458			$3728
ICER (Cost/QALY gained)			$54,560			$72,456			$5064
Cost per LY alive	$18,246	$15,091	$3155	$17,705	$15,066	$2638	$14,023	$15,091	−$1068

QALY, quality adjusted life year; LY, Life year; ICER, incremental cost-effectiveness ratio; USRDS, United States Renal Data System.

Figure 3.  Cost-effectiveness acceptability curve of cinacalcet vs vitamin D (costs without dialysis).

Figure 4.  Probabilistic sensitivity analysis, explained variance at willingness to pay $100,000/QALY gained.

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