Societal implications of medical insurance coverage for imatinib as first-line treatment of chronic myeloid leukemia in China: a cost-effectiveness analysis

Figures & data

Figure 1. Schematic structure of the decision model.

Figure 2. Schematic presentation of the Markov model structure for TKI treatment. Note, patients in CP/AP are not assumed to die from CML (unless post-transplant), but may die of non-CML mortality (not shown for readability).

Table 1. TKI treatment disposition at 12 months: treatment continuations/discontinuations.

	Model value	Xj for Gamma	No. of patients
Nilotinib
Disposition at Month 12 (all patients, n)			266
Off treatment
AE/Abnormal test (Intolerant)	7.1%	3,342	19
Failed (Resistant)	3.8%	2,624	10
AP/BC	0.8%	393	2
Dead	0.8%	468	2
On treatment	87.6%	63,112	233
Imatinib
Disposition at Month 12 (all patients, n)			271
Off treatment
AE/Abnormal test (Intolerant)	9.2%	6,262	25
Failed (Resistant)	5.9%	5,434	16
AP/BC	3.7%	3,231	10
Dead	0.0%	0	0
On treatment	81.2%	68,926	220
Dasatinib
Disposition at Month 12 (all patients, n)			258
Off treatment
AE/Abnormal test (Intolerant)	5.0%	4,440	13
Failed (Resistant)	2.3%	1,384	6
AP/BC	4.3%	3,298	11
Dead	1.6%	1,346	4
On treatment	84.5%	56,877	218

Source: ENESTND Data from Saglio et al.²⁶; DASISION Trial Data from Kantarjian et al.²⁷.

Table 2. TKI treatment disposition at 12 months: response levels.

	Model value	Xj for Gamma	No. of patients
Nilotinib
On treatment at 12 Months			239
Status on treatment at 12 Months
MMR (≤0.1%)	51.9%	33,651	124
CCyR but no MMR (>0.1% to ≤1.0%)	39.7%	19,822	95
MCyR but not CCyR (>1.0% to ≤10%)	8.4%	6,034	20
Less than MCyR (>10%)	0.0%	0	0
Imatinib
On treatment at 12 Months			149
Status on treatment at 12 Months
MMR (≤0.1%)	48.3%	11,020	72
CCyR but no MMR (>0.1% to ≤1.0%)	30.9%	7,177	46
MCyR but not CCyR (>1.0% to ≤10%)	9.4%	1,512	14
Less than MCyR (>10%)	11.4%	0	17
Dasatinib
On treatment at 12 Months			259
Status on treatment at 12 Months
MMR (≤0.1%)	45.9%	24,640	119
CCyR but no MMR (>0.1% to ≤1.0%)	37.5%	26,303	97
MCyR but not CCyR (> 1.0% to ≤10%)	16.6%	11,931	43
Less than MCyR (>10%)	0.0%	0	0

MMR: major molecular response; CCyR: complete cytogenetic response; MCyR: major cytogenetic response.

Source: ENESTND Data from Saglio et al.²⁶; Imatinib data from The First Affiliated Hospital of Soochow University, Jiangsu Province, China; and DASISION Trial Data from Kantarjian et al.²⁷.

Table 3. Monthly transition probabilities from second line TKI to next states.

	Value in model	Distribution type	Events observed	Total at risk	Timeframe (months)
2nd Line CP Resistant → No TKI CP
Nilotinib	2.041%	Beta	47.00	280.00	8.91
Dasatinib	0.616%	Beta	8.00	166.00	8.00
Imatinib	0.198%	Beta	4.00	106.00	19.40
2nd Line CP Resistant → No TKI AP
Nilotinib	1.353%	Beta	32.00	280.00	8.91
Dasatinib	0.694%	Beta	9.00	166.00	8.00
Imatinib	2.646%	Beta	43.00	106.00	19.40
2nd Line CP Intolerant → No TKI CP
Nilotinib	2.041%	same as above	same as above	same as above	same as above
Dasatinib	0.616%	same as above	same as above	same as above	same as above
Imatinib	NA	NA	NA	NA	NA
2nd Line CP Intolerant → No TKI AP
Nilotinib	1.353%	same as above	same as above	same as above	same as above
Dasatinib	0.694%	same as above	same as above	same as above	same as above
Imatinib	NA	NA	NA	NA	NA
2nd Line AP → No TKI AP
Nilotinib	0.986%	Beta	29.00	137.00	24.00
Dasatinib	2.487%	Beta	52.00	174.00	14.10
Imatinib	0.155%	Beta	13.00	181.00	48.00
2nd Line AP → No TKI BC
Nilotinib	1.969%	Beta	52.00	137.00	24.00
Dasatinib	1.732%	Beta	38.00	174.00	14.10
Imatinib	1.661%	Beta	100.00	181.00	48.00

Source: ENESTND Data from Saglio et al.²⁶; DASISION Trial Data from Kantarjian et al.²⁷.

Table 4. TKI drug costs with PAP.

Treatment	Mean daily dose	Daily cost
Imatinib 400 mg	400	¥197.40
Nilotinib 600 mg	600	¥230.30
Nilotinib 800 mg	800	¥307.00
Dasatinib 100 mg	100	¥260.30
Dasatinib 140 mg	140	¥364.40
Imatinib 600 mg	600	¥296.10

Source: The First Affiliated Hospital of Soochow University, Jiangsu Province, China.

Table 5. Cost and clinical effectiveness of IFN, HU, and transplant therapy.

12-month IFN	¥46,749
IFN annual AE costs	¥100
IFN annual outpatient	¥360
IFN annual hospital stay	¥10,000
IFN annual test	¥2,400
12-month HU	¥2,592
HU annual AE costs	¥100
HU annual outpatient	¥360
HU annual hospital stay	¥10,000
HU annual test	¥2,400
Cost of Transplantation	¥286,922
Post-transplant annual average cost	¥50,000
Transplantation 5-year survival	0.79^1
IFN treatment survival years	6.0–9.0^22
HU treatment survival years	3.0–4.8^23

Source: Wang et al.¹; Chen et al.¹¹; Wang et al.²²; Hehlmann et al.²³; Jiang and Huang²⁸; and the data from The First Affiliated Hospital of Soochow University, Jiangsu Province, PR China.

Table 6. Discount rates.

Discounting		Lower value for OWSA	Upper value for OWSA
Costs	3.0%	0.0%	5.0%
QALY	3.0%	0.0%	5.0%

Table 7. Incremental cost-effectiveness ratios (ICER) for patients with insurance coverage.

	Insurance Coverage for imatinib: No	Insurance Coverage for imatinib: Yes	Differences
Discounted costs	¥773,929 ($124,258)	¥1,287,637 ($206,736)	¥513,708 ($82,478)
Discounted productivity loss (patients)	¥210,495 ($33,796)	¥73,424 ($11,789)	−¥137,071 (−$22,007)
Discounted productivity loss (caregivers)	¥161,686 ($25,959)	¥62,080 ($9,967)	−¥99,606 (−$15,992)
Total discounted costs and productivity loss	¥1,146,111 ($184,013)	¥1,423,141 ($228,492)	¥277,030 ($44,479)
QALY	11.4	20.4	9.0
Discounted QALY	8.0	13.5	5.5
Cost effectiveness
Cost/QALY			¥50,641 ($8,131)

Figure 3. One-way sensitivity analyses tornado diagram.

Figure 4. Cost-effectiveness scatter plot.

Figure 5. Cost-acceptability curve: insurance coverage with imatinib vs no insurance coverage.

Table 8. Incremental cost-effectiveness ratios (ICER) for patient with insurance coverage at 3 and 5 years after diagnosis.

	Insurance Coverage for imatinib: No		Insurance Coverage for imatinib: Yes		Differences
	3 years	5 years	3 years	5 years	3 years	5 years
Discounted costs	¥244,040	¥331,387	¥247,535	¥389,651	¥3,495	¥58,264
Discounted productivity loss (patients)	¥89,894	¥126,059	¥23,181	¥35,982	−¥66,713	−¥90,077
Discounted productivity loss (caregivers)	¥68,455	¥92,956	¥15,946	¥25,204	−¥52,509	−¥67,752
Total discounted costs and productivity loss	¥402,389	¥550,402	¥286,662	¥450,837	−¥115,727	−¥99,565
QALY	1.9	2.9	2.6	4.1	0.7	1.2
Discounted QALY	1.8	2.8	2.5	3.9	0.7	1.1
Cost effectiveness
Cost/QALY					Dominance	Dominance

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