Cost-effectiveness analysis of tranexamic acid for the treatment of traumatic brain injury, based on the results of the CRASH-3 randomised trial: a decision modelling approach
Williams J, Roberts I, Shakur-Still H, Lecky FE, Chaudhri R, Miners A
BMJ global health. 2020;5(9)
INTRODUCTION An estimated 69 million traumatic brain injuries (TBI) occur each year worldwide, with most in low-income and middle-income countries. The CRASH-3 randomised trial found that intravenous administration of tranexamic acid within 3 hours of injury reduces head injury deaths in patients sustaining a mild or moderate TBI. We examined the cost-effectiveness of tranexamic acid treatment for TBI. METHODS A Markov decision model was developed to assess the cost-effectiveness of treatment with and without tranexamic acid, in addition to current practice. We modelled the decision in the UK and Pakistan from a health service perspective, over a lifetime time horizon. We used data from the CRASH-3 trial for the risk of death during the trial period (28 days) and patient quality of life, and data from the literature to estimate costs and long-term outcomes post-TBI. We present outcomes as quality-adjusted life years (QALYs) and 2018 costs in pounds for the UK, and US dollars for Pakistan. Incremental cost-effectiveness ratios (ICER) per QALY gained were estimated, and compared with country specific cost-effective thresholds. Deterministic and probabilistic sensitivity analyses were also performed. RESULTS Tranexamic acid was highly cost-effective for patients with mild TBI and intracranial bleeding or patients with moderate TBI, at £4288 per QALY in the UK, and US$24 per QALY in Pakistan. Tranexamic acid was 99% and 98% cost-effective at the cost-effectiveness thresholds for the UK and Pakistan, respectively, and remained cost-effective across all deterministic sensitivity analyses. Tranexamic acid was even more cost-effective with earlier treatment administration. The cost-effectiveness for those with severe TBI was uncertain. CONCLUSION Early administration of tranexamic acid is highly cost-effective for patients with mild or moderate TBI in the UK and Pakistan, relative to the cost-effectiveness thresholds used. The estimated ICERs suggest treatment is likely to be cost-effective across all income settings globally.
Use of tranexamic acid in trauma patients: an analysis of cost effectiveness for use in Brazil
Pinto MA, Silva JG, Chedid AD, Chedid MF
ABCD, Arquivos Brasileiros de Cirurgia Digestiva. 2016;29((4)):282-286.
Introduction:: Use of tranexamic acid (TXA) in trauma has been the subject of growing interest by researchers and health professionals. However, there are still several open questions regarding its use. In some aspects medical literature is controversial. The points of disagreement among experts include questions such as: Which patients should receive TXA in trauma? Should treatment be performed in the pre-hospital environment? Is there any need for laboratory parameters before starting TXA treatment? What is the drug safety profile? The main issue on which there is still no basis in literature is: What is the indication for treatment within massive transfusion protocols? Objective:: Answer the questions proposed based on critical evaluation of the evidence gathered so far and carry out a study of cost-effectiveness of TXA use in trauma adapted to the Brazilian reality. Methods:: A literature review was performed through searching Pubmed.com, Embase and Cab Abstract by headings "tranexamic AND trauma", in all languages, yielding 426 articles. Manuscripts reporting on TXA utilization for elective procedures were excluded, remaining 79 articles. Fifty-five articles were selected, and critically evaluated in order to answer study questions. The evaluation of cost effectiveness was performed using CRASH-2 trial data and Brazilian official population data. Results:: TXA is effective and efficient, and should be administered to a wide range of patients, including those with indication evaluated in research protocols and current indication criteria for TXA should be expanded. As for the cost-effectiveness, the TXA proved to be cost-effective with an average cost of R$ 61.35 (currently US$16) per year of life saved. Conclusion:: The use of TXA in trauma setting seems to be effective, efficient and cost-effective in the various groups of polytrauma patients. Its use in massive transfusion protocols should be the subject of further investigations. Introducao:: O uso do acido tranexamico (TXA) no trauma tem sido alvo de interesse crescente por parte de pesquisadores e profissionais de saude. No entanto, seus beneficios ainda nao foram completamente definidos. Os pontos de divergencia entre especialistas incluem questoes como: quais pacientes devem receber TXA no trauma? O tratamento deve ser realizado em ambiente pre-hospitalar? Ha necessidade de exames laboratoriais para indicar o tratamento? Qual o perfil de seguranca da droga? A principal questao para a qual ainda nao existe qualquer embasamento na literatura e: qual a indicacao do tratamento dentro de protocolos de transfusao macica? Objetivo:: Responder as questoes propostas, com base em avaliacao critica da evidencia reunida ate o momento e realizar estudo de custo-efetividade do uso do TXA no trauma adaptado a realidade brasileira. Metodos:: Foi realizada revisao da literatura atraves de estrategia de busca: PubMed.com, Embase e no Cab Abstract pelos descritores "tranexamic AND trauma", em todos idiomas, resultando em 426 artigos. Foram excluidos aqueles relativos as operacoes eletivas, restando 79 artigos. Cinquenta e cinco foram selecionados e avaliados criticamente com vistas a responder as questoes em estudo. A avaliacao de custo-efetividade foi realizada utilizando dados do estudo CRASH-2 e populacionais oficiais brasileiros. Resultados:: Atraves da analise da evidencia disponivel chegou-se a conclusao de que o acido tranexamico e tratamento eficaz e efetivo, devendo ser administrado a ampla gama de pacientes, incluindo todos aqueles com indicacao ja avaliada nos protocolos de pesquisa publicados e provavelmente devam-se expandir os criterios de indicacao. Quanto a avaliacao de custo-efetividade, o TXA mostrou-se bastante custo-eficaz com gasto medio de R$ 61,35 por ano de vida salvo. Conclusao:: O uso do acido tranexamico no trauma parece ser eficaz, efetivo e custo-eficaz nos diversos grupos de pacientes politraumatizados. Seu uso em protocolos de transfusao macica ainda deve ser objeto de futuras investigacoes.
Cost-effectiveness analysis of administering tranexamic acid to bleeding trauma patients using evidence from the CRASH-2 trial
Guerriero C, Cairns J, Perel P, Shakur H, Roberts I, CRASH 2 Trial Collaborators
PLoS ONE. 2011;6((5):):e18987.
OBJECTIVE To assess the cost effectiveness of giving tranexamic acid (TXA) to bleeding trauma patients in low, middle and high income settings. METHODS The CRASH-2 trial showed that TXA administration reduces the risk of death in bleeding trauma patients with a small but statistically significant increase in non-intensive care stay. A Markov model was used to assess the cost effectiveness of TXA in Tanzania, India and the United Kingdom (UK). The health outcome was the number of life years gained (LYs). Two costs were considered: the cost of administering TXA and the cost of additional days in hospital. Cost data were obtained from hospitals, World Health Organization (WHO) database and UK reference costs. Cost-effectiveness was measured in international dollars ($) per LY. Both deterministic and probabilistic sensitivity analyses were performed to test the robustness of the results to model assumptions. FINDINGS Administering TXA to bleeding trauma patients within three hours of injury saved an estimated 372, 315 and 755 LYs per 1,000 trauma patients in Tanzania, India and the UK respectively. The cost of giving TXA to 1,000 patients was $17,483 in Tanzania, $19,550 in India and $30,830 in the UK. The incremental cost of giving TXA versus not giving TXA was $18,025 in Tanzania, $20,670 in India and $48,002 in the UK. The estimated incremental cost per LY gained of administering TXA is $48, $66 and $64 in Tanzania, India and the UK respectively. CONCLUSION Early administration of TXA to bleeding trauma patients is likely to be highly cost effective in low, middle and high income settings. TRIAL REGISTRATION This paper uses data collected by the CRASH 2 trial: Controlled-Trials.com ISRCTN86750102, Clinicaltrials.gov NCT00375258 and South African Clinical Trial Register DOH-27-0607-1919.