Cost utility analysis of immunosuppressive regimens in adult renal transplant recipients in England and Wales

Figures & data

Figure 1 Graphical representation of the economic model.

Abbreviation: BCAR, biopsy-confirmed acute rejection.

Table 1 Base case results (25 years, 3.5% discount rate, adverse events, half-cycle correction) (individual costs [£] and costs [£]/QALY)

Comparators
Resource	Prograf	Advagraf	Belatacept	Cyclosporin	Sirolimus I	Sirolimus II
Antibody induction	1,685	1,685	1,685	1,685	1,685	1,685
Immunosuppressant	38,549	32,749	69,429	32,793	27,826	27,591
Concomitant prescribing	22,399	24,300	22,105	23,919	8,427	22,147
Total treatment cost	62,633	58,734	93,218	58,397	37,938	51,423
BCAR	219	254	534	317	287	488
Re-transplantation	3,358	3,000	3,434	3,382	3,375	3,423
Dialysis	59,108	52,311	61,105	59,732	59,539	60,815
Adverse events	2,342	2,433	2,891	5,358	2,758	2,735
Total costs (£)	127,661	116,733	161,182	127,187	103,896	118,884
Outcomes
Life-years	11.78	12.00	11.70	11.75	11.76	11.71
QALYs	7.99	8.19	7.92	7.97	7.97	7.93
ICER (Cost [£]/QALY)	–	Prograf dominated by Advagraf	Belatacept dominated by Prograf	21,244	1,542,449	143,697

Notes: ICER: Prograf versus comparator; Sirolimus I: CNI minimization; Sirolimus II: CNI avoidance. Prograf and Advagraf (Astellas Pharma UK Ltd., Chertsey, UK).

Abbreviations: QALYs, quality adjusted life-years; ICER, incremental cost-effectiveness ratio; BCAR, biopsy-confirmed acute rejection; CNI, calcineurin inhibitor.

Figure 2 Cost-effectiveness plots for all comparator products compared with Prograf (Astellas Pharma UK Ltd., Chertsey, UK).

Abbreviation: QALY, quality adjusted life-years.

Figure 3 Cost-effectiveness acceptability curve for Prograf (Astellas Pharma UK Ltd., Chertsey, UK) versus cyclosporin.

Abbreviation: QALY, quality adjusted life-years.

Table 2 Sensitivity analysis results: ICERs (Prograf versus comparators) expressed as costs (£) per QALY

Comparator
Time horizon (years)	Advagraf	Belatacept	Ciclosporin	Sirolimus I	Sirolimus II
10	Prograf dominated by Advagraf	Belatacept dominated by Prograf	22,373	2,363,544	216,914
15	Prograf dominated by Advagraf	Belatacept dominated by Prograf	20,713	1,951,984	179,579
20	Prograf dominated by Advagraf	Belatacept dominated by Prograf	21,158	1,704,163	157,703
Price of Prograf = price of Adoport	Prograf dominated by Advagraf	Belatacept dominated by Prograf	Ciclosporin dominated by Prograf	865,205	Sirolimus dominated by Prograf
Price of Advagraf = price of Prograf	Prograf dominated by Advagraf (−£4,841)	Belatacept dominated by Prograf	21,244	1,542,449	143,697
Price of Advagraf increase by 5% to 20%	Prograf dominated by Advagraf (−£45,596 to −£21,487)	Belatacept dominated by Prograf	21,244	1,542,449	143,697
Price of Advagraf increase by 40%	Prograf less expensive and less effective than Advagraf (£10,658)	Belatacept dominated by Prograf	21,244	1,542,449	143,697
No discount rate	Prograf dominated by Advagraf	Belatacept dominated by Prograf	35,446	1,377,573	130,499
AEs not included	Prograf dominated by Advagraf	Belatacept dominated by Prograf	156,481	1,569,462	150,130
Half-cycle not included	Prograf dominated by Advagraf	Belatacept dominated by Prograf	15,877	1,587,538	147,002

Notes: Sirolimus I: CNI minimization; Sirolimus II: CNI avoidance; Adoport^® – generic twice-daily tacrolimus. Prograf and Advagraf (Astellas Pharma UK Ltd., Chertsey, UK).

Abbreviations: AEs, adverse events; ICERs, incremental cost-effectiveness ratios; CNI, calcineurin inhibitor; QALY, quality adjusted life-years.

Figure 4 Tornado diagram of key variables for Prograf versus Advagraf (ICER [cost/QALY]).

Notes: Prolonged release tacrolimus: Advagraf; immediate release tacrolimus: Prograf.
Abbreviations: CAPD, continuous ambulatory peritoneal dialysis; HD, hemodialysis; QALY, quality adjusted life-years; ICER, incremental cost-effectiveness ratio.

Table S1 Unit costs (£)

Variable	Value	Reference
Initial age	45 yrs	Kramer et al^Citation1 age range 18–65
Mean body weight	70.3 kg	Kramer et al^Citation1
Cost per mg: Prograf	£1.62
Cost per mg: Advagraf	£1.24
Cost per mg: Adoport	£1.18
Cost per mg: Cyclosporin	£0.03	BNF 66^Citation2
Cost per mg: Sirolimus	£3.74
Cost per mg: Belatacept	£1.42
Cost of HD (year)	£41,428	Baboolal et al^Citation4 and CPI^Citation3
Cost of CAPD (year)	£20,785
Transplantation	£25,469	Beaudet et al^Citation5 and CPI^Citation3
Acute kidney injury without compilation or comorbidity	£1,935	2012–2013 NHS tariff information^Citation6

Note: Prograf and Advagraf (Astellas Pharma UK Ltd., Chertsey, UK).

Abbreviations: CAPD, continuous ambulatory peritoneal dialysis; HD, hemodialysis; BNF, British National Formulary; NHS, UK National Health Service; CPI, consumer price index.

Table S2 Survival data

Variable	Value (%)	Reference
Patient survival with a functioning graft (0–5 years)
0	100.00	http://www.organdonation.nhs.uk/statistics/transplant_activity_report/archive_activity_reports/pdf/ukt/activity_report_2012_13.pdf^Citation7
1	97.41
2	95.77
3	94.24
4	92.71
5	91.19
Graft survival (in patients with no BCAR) (0–5 years)
0	100.00	http://www.organdonation.nhs.uk/statistics/transplant_activity_report/archive_activity_reports/pdf/ukt/activity_report_2012_13.pdf^Citation7 and Opelz^Citation8
1	94.51
2	93.00
3	91.23
4	89.46
5	87.69
Graft survival (in patients with BCAR) (0–5 years)
0	100.00	http://www.organdonation.nhs.uk/statistics/transplant_activity_report/archive_activity_reports/pdf/ukt/activity_report_2012_13.pdf^Citation7 and Opelz^Citation8
1	91.66
2	90.20
3	88.48
4	86.76
5	85.04
Patient survival on dialysis (0–10 years)
0	100.00	http://www.renalreg.com/Reports/2012.html^Citation9
1	84.80
2	74.20
3	67.50
4	59.50
5	51.80
6	44.60
7	38.10
8	34.70
9	31.20
10	26.90

Abbreviation: BCAR, biopsy-confirmed acute rejection.

Table S3 Utility values

Variable	Value	Reference
Utility values (EQ-5D index)
Functioning renal transplant	0.71	Lee et al^Citation10
Hemodialysis	0.44
Peritoneal dialysis	0.53

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