Article 1: Cost-Utility Analysis of Dapagliflozin Compared to

Sulfonylureas for Type 2 Diabetes as Second-Line Treatment in Indian

Healthcare Payer's Perspective

Diabetes is a leading public health burden in the world with approximately 431 million people
and type 2 diabetes (T2DM) is the most common cause of diabetes (90%). Published literature
indicate that nearly half (range 24.1–75.1%) of diabetes cases among adults were undiagnosed
(about 174.8 million), and 72 million were found in India, resulting in 8.8% of global burden.
T2DM is one of the leading causes of mortality and morbidity in India, as it is the second most
common individual cause of death, accounting for more than 5% of all deaths.
Cost-utility analysis was employed to estimate the costs and health outcomes using a Markov
model with 1-year cycle length during a lifetime horizon based on an Indian payer's perspective.
A treatment pathway with dapagliflozin as second-line therapy was compared to sulfonylureas
after failure of initial metformin therapy. Both costs and outcomes were discounted at a 3%
annual discount rate. The results were presented as the incremental cost-effectiveness ratio
(ICER). One-way and probabilistic sensitivity analyses were performed to test parameter
uncertainties.

This figure represent the Markov model

Clinical and cost data were collected from literature reviews and available secondary data
sources.
The time frame of the study was 1 year but I don’t think it’s enough to base the analysis on just
this year though the author tried using previous reviews but I think an effective comparison for
it to be accurate, the time frame should be extended.
All costs were expressed in Indian rupees (₹), adjusted to the values in the year 2019 using the
consumer price indexes (CPI), converted to the United State dollars (USD) with the exchange
rate of ₹74.68 per USD.
The incremental cost-effectiveness ratio (ICER) was calculated by a difference in costs (Indian
rupees, ₹) divided by a difference in life years (LY) or quality-adjusted life years (QALY) gained
between two aforementioned alternatives. In addition, the incremental net benefit (INB) was
calculated as the multiplication of the WTP (willingness to pay) threshold and incremental QALY
minus incremental cost.

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Based on the study, Compared to sulfonylurea, dapagliflozin was estimated to incur an
additional cost of ₹182,632 (US$2,446) with an expected 3.49 life years (LY) or 1.72 quality
adjusted life years (QALY) gained, resulting in an ICER of ₹52,270 (US$699) per LY gained, or
₹106,133 (US$1,421) per QALY gained. Uncertainty analyses showed that the ICER values were
not sensitive to changes in most parameters; dapagliflozin had a 100% chance of being cost-
effective compared to sulfonylureas.
There are two types of measures of project worth i.e. undiscounted and discounted. The basic
underlying difference between these two lies in the consideration of time value of money in the
project investment. Undiscounted measures do not take into account the time value of money,
while discounted measures do.
Some limits that could have biased the results of this study may be:

 The narrow time frame of the study

 Some secondary effects may be neglected
 Limited data
In spite of these limitations, the study suggested that dapagliflozin would be cost-effective to be
prescribed as second-line therapy compared to sulfonylureas for treatment of T2DM based on
an Indian healthcare payer’s perspective. This could provide the evidence-based information for
physicians to make decisions on prescribing dapagliflozin as second-line therapy compared to
sulfonylureas for T2DM patients in India.
The results from this study can also be used as the useful information for decision-makers in
Lebanon, since Lebanon now is considered one of the low incomes countries especially during
the economic crisis.
If we were the decision maker, the only thing we may add or modify is the time of the study
since we’re studying drugs that can have influence on patient’s health after many years and not
right after taking of the drug.

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Article 2: Cost-Effectiveness Analysis Comparing Two Approaches for
Empirical Antifungal Therapy in Hematological Patients with
Persistent Febrile Neutropenia

Invasive fungal infection (IFI) is a serious health problem in hematological patients and
hematopoietic stem cell transplant (HSCT) recipients, resulting in a significant morbidity and
mortality rate. Persistent febrile neutropenia (PFN) is a common clinical presentation of IFI in
hematological patients.
The aim of this study was to compare the cost-effectiveness of two different approaches of EAT
in hematological patients with PFN: the diagnosis-driven antifungal therapy (DDAT) approach
versus the standard approach of EAT.
A decision tree to assess the cost-effectiveness of both approaches was developed. Outcome
probabilities and treatment pathways were extrapolated from two studies: a prospective
cohort study following the DDAT approach and a randomized clinical trial following the
standard approach.
The author gathered the information from two studies already done on both therapies.
The time frame of the study wasn’t clear in the study but it’s basically short since it’s based on
the results of two other studies already done.
The costs here are the hospital stay and the consumed resources costs, as for the antifungal
prices they were extracted from the wholesale prices.
The overall probability of a successful response associated with the DDAT approach was 36.5%
compared to 33.9% of success probability for the EAT approach.
In the DDAT approach, AT was not indicated in 33 (38.8%) episodes of PFN, and 16 (48.5%) of
these fulfilled the five composite endpoints considered for an overall successful response. Of
the remaining episodes, 17 (51.5%) did not achieve a successful response because the fever
was not resolved for at least 48 h during the neutropenia.
The average costs for the management of a PFN episode were €11,910 for the DDAT approach
and €17,789 for the EAT approach. The economic advantage per PFN episode in the DDAT
approach was €5,879 (33%) compared to the EAT approach.
In sum, effectiveness wise, DDAT is more effective, as for the costs the EAT approach has
higher costs.
But if we want to analyze this result: The cost-saving of DDAT approach over the EAT approach
could be due to several factors. First, there is a reduction of antifungal therapy, representing a

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direct cost saving. Second, costs derived from adverse effects and from the use of a second-line
of AT, often resulting in a prolonged hospital stay.
As mentioned in article 1: There are two types of measures of project worth i.e. undiscounted
and discounted. The basic underlying difference between these two lies in the consideration of
time value of money in the project investment. Undiscounted measures do not take into
account the time value of money, while discounted measures do.
Though, there is some limitations that the study did or didn’t mention, that could have biased
the results such as:

 The variability in sensitivity of both analysis

 Interpersonal variability
 External variations that are not taken into consideration
After analyzing the results, we think that the results could be applied in Lebanon since it’s an
evolution in fungal therapy that doesn’t rely on economy or ethnicity or any other factors that
change from a country to another.
One thing we would change if we were the decision makers, is to analyze the financial capacity
of the patients and the WTP willingness to pay such service so that we can generalize this study
worldwide.

Done By: Rana soulak. Taline el ghareeb & Lama Abi Farraj

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