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The cost-effectiveness and public health benefit of nalmefene added to psychosocial support for the reduction of alcohol consumption in alcohol-dependent patients with high/very high drinking risk levels: a Markov model

Philippe Laramée, Thor-Henrik Brodtkorb, Nora Rahhali, Chris Knight, Carolina Barbosa, Clément François, Mondher Toumi, Jean-Bernard Daeppen, Jürgen Rehm

BMJ Open 2014;4:e005376 doi:10.1136/bmjopen-2014-005376

 

Most dose–response curves for alcohol consumption on disease and injury outcomes are exponential, and heavy drinking, both episodic and chronic, has a major impact on the burden of alcohol related disease. High levels of alcohol consumption can also prove economically costly through costs related to treatment, to productivity losses and to losses due to alcohol-related crime and accidents. This study reports on a Markov model used to evaluate, as a primary objective, whether nalmefene used in combination with psychosocial support was cost-effective compared with psychosocial support alone in alcohol dependent patients with a high/very high drinking risk level, in line with the indication for nalmefene. A secondary objective was to evaluate the public health benefit of patients entering treatment for alcohol dependence. Analysis based on 1-year clinical data projected on a 5-year horizon, indicated a considerable benefit from nalmefene plus psychosocial support versus psychosocial support alone, consisting in the avoidance of 7179 alcohol-attributable diseases or injuries and 309 deaths per 100,000 patients, and an incremental cost-effectiveness ratio of GBP 5204 per quality-adjusted life year gained. Simplifications of certain modelling features when extrapolating patients’ trajectories after the trial time horizon represent limitations of the decision model in this study.

Abstract
Objectives To determine whether nalmefene combined with psychosocial support is cost-effective compared with psychosocial support alone for reducing alcohol consumption in alcohol-dependent patients with high/very high drinking risk levels (DRLs) as defined by the WHO, and to evaluate the public health benefit of reducing harmful alcohol-attributable diseases, injuries and deaths.

Design 
Decision modelling using Markov chains compared costs and effects over 5 years.

Setting 
The analysis was from the perspective of the National Health Service (NHS) in England and Wales.

Participants 
The model considered the licensed population for nalmefene, specifically adults with both alcohol dependence and high/very high DRLs, who do not require immediate detoxification and who continue to have high/very high DRLs after initial assessment.

Data sources 
We modelled treatment effect using data from three clinical trials for nalmefene (ESENSE 1 (NCT00811720), ESENSE 2 (NCT00812461) and SENSE (NCT00811941)). Baseline characteristics of the model population, treatment resource utilisation and utilities were from these trials. We estimated the number of alcohol-attributable events occurring at different levels of alcohol consumption based on published epidemiological risk-relation studies. Health-related costs were from UK sources.

Main outcome measures 
We measured incremental cost per quality-adjusted life year (QALY) gained and number of alcohol-attributable harmful events avoided.

Results 
Nalmefene in combination with psychosocial support had an incremental cost-effectiveness ratio (ICER) of £5204 per QALY gained, and was therefore cost-effective at the £20 000 per QALY gained decision threshold. Sensitivity analyses showed that the conclusion was robust. Nalmefene plus psychosocial support led to the avoidance of 7179 alcohol-attributable diseases/injuries and 309 deaths per 100 000 patients compared to psychosocial support alone over the course of 5 years.

Conclusions 
Nalmefene can be seen as a cost-effective treatment for alcohol dependence, with substantial public health benefits.

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