Background. There is increasing evidence highlighting the effectiveness of patient decision aids (PtDAs), but evidence supporting their cost-effectiveness is lacking. We consider patients with obstructive sleep apnea (OSA), in whom a PtDA may decrease nonadherence to treatment by empowering patients to receive the option that is most congruent with their own values. Objective. To determine the potential costs and benefits of delivering a PtDA to patients with moderate OSA. Methods. A Markov cohort decision-analytic model was developed for patients with moderate OSA, comparing a PtDA to usual care over 5 years from a societal perspective. Data for patient preference for treatment options was taken from a recent randomized crossover trial, event data (cardiovascular, motor vehicle accidents) came from national databases and published literature. Potential improvements in adherence are unknown, so we considered a realistic range of values. Outcome measures were 5-year costs (in 2010 Canadian dollars), quality-adjusted life years (QALYs), and the incremental cost-effectiveness ratio (ICER). Results. When adherence to treatment was unchanged, the PtDA strategy was dominated by incurring lower QALYs and higher costs. When nonadherence was decreased by 20% in the PtDA arm (corresponding to an increase in adherence from 63% to 70% for continuous positive airway pressure and from 77% to 82% for mandibular advancement splints in year 1), the ICER fell to $62,414/QALY. Costs associated with the treatment devices and delivering the PtDA had the greatest effect on cost-effectiveness. Limitations. The model relies on surrogate measures and opinions for key parameters. Conclusions: The cost-effectiveness of PtDAs will depend on contextual factors, but a framework is described for properly considering their long-term cost-effectiveness. A number of important questions around the appropriateness of benefit measurement for PtDA trials are highlighted.
MulleyAGTrimbleCElwynG. Stop the silent misdiagnosis: patients’ preferences matter. BMJ. 2012;345:e6572.
2.
EddyDM. Clinical decision making: from theory to practice. Rationing resources while improving quality. How to get more for less. JAMA. 1994;272(10):817–24.
3.
BarryMJEdgman-LevitanS. Shared decision making—pinnacle of patient-centered care. N Engl J Med. 2012;366(9):780–1.
4.
StaceyDBennettCLBarryMJ. Decision aids for people facing health treatment or screening decisions. Cochrane Database Syst Rev. 2011;(10):CD001431.
5.
OsterbergLBlaschkeT. Adherence to medication. N Engl J Med. 2005;353(5):487–97.
6.
StewartMBrownJBBoonHGalajdaJMeredithLSangsterM. Evidence on patient-doctor communication. Cancer Prev Control. 1999;3(1):25–30.
7.
StalmeierPFM. Adherence and decision aids: a model and a narrative review. Med Decis Mak Int J Soc Med Decis Mak. 2011;31(1):121–9.
8.
MontoriVMShahNDPencilleLJ. Use of a decision aid to improve treatment decisions in osteoporosis: the osteoporosis choice randomized trial. Am J Med. 2011;124(6):549–56.
9.
Van SteenkisteBvan der WeijdenTStoffersHEJHKesterADMTimmermansDRMGrolR. Improving cardiovascular risk management: a randomized, controlled trial on the effect of a decision support tool for patients and physicians. Eur J Cardiovasc Prev Rehabil Off J Eur Soc Cardiol Work Groups Epidemiol Prev Card Rehabil Exerc Physiol. 2007;14(1):44–50.
10.
WeymillerAJMontoriVMJonesLA. Helping patients with type 2 diabetes mellitus make treatment decisions: statin choice randomized trial. Arch Intern Med. 2007;167(10):1076–82.
11.
KingJMoultonB. Group Health’s participation in a shared decision-making demonstration yielded lessons, such as role of culture change. Health Aff Proj Hope. 2013;32(2):294–302.
12.
YaggiHKConcatoJKernanWNLichtmanJHBrassLMMohseninV. Obstructive sleep apnea as a risk factor for stroke and death. N Engl J Med. 2005;353(19):2034–41.
13.
MulgrewATNasvadiGButtA. Risk and severity of motor vehicle crashes in patients with obstructive sleep apnoea/hypopnoea. Thorax. 2008;63(6):536–41.
14.
MarinJMCarrizoSJVicenteEAgustiAGN. Long-term cardiovascular outcomes in men with obstructive sleep apnoea-hypopnoea with or without treatment with continuous positive airway pressure: an observational study. Lancet. 2005;365(9464):1046–53.
15.
BalkEMoorthyDObadanN. Diagnosis and treatment of obstructive sleep apnea in adults. Comparative Effectiveness Review No. 32. (Prepared by Tufts Evidence-based Practice Center under Contract No. 290-2007-10055-1) [Internet]. 2011 [cited 2013 Dec 3]. Available from: www.effectivehealthcare.ahrq.gov/reports/final.cfm
16.
PhillipsCLGrunsteinRRDarendelilerMA. Health outcomes of continuous positive airway pressure versus oral appliance treatment for obstructive sleep apnea: a randomized controlled trial. Am J Respir Crit Care Med. 2013;187(8):879–87.
17.
TrzepizurWGagnadouxFAbrahamP. Microvascular endothelial function in obstructive sleep apnea: impact of continuous positive airway pressure and mandibular advancement. Sleep Med. 2009;10(7):746–52.
18.
ItzhakiSDorchinHClarkGLavieLLaviePPillarG. The effects of 1-year treatment with a Herbst mandibular advancement splint on obstructive sleep apnea, oxidative stress, and endothelial function. Chest. 2007;131(3):740–9.
19.
GaletkeWPuzzoLPriegnitzCAnduleitNRanderathWJ. Long-term therapy with continuous positive airway pressure in obstructive sleep apnea: adherence, side effects and predictors of withdrawal—a “real-life” study. Respir Int Rev Thorac Dis. 2011;82(2):155–61.
20.
AlmeidaFRHenrichNMarraC. Patient preferences and experiences of CPAP and oral appliances for the treatment of obstructive sleep apnea: a qualitative analysis. Sleep Breath. 2013;17(2):659–66.
21.
FleethamJAyasNBradleyD. Canadian Thoracic Society 2011 guideline update: diagnosis and treatment of sleep disordered breathing. Can Respir J Can Thorac Soc. 2011;18(1):25–47.
22.
SadatsafaviMMarraCAAyasNTStradlingJFleethamJ. Cost-effectiveness of oral appliances in the treatment of obstructive sleep apnoea-hypopnoea. Sleep Breath Schlaf Atm. 2009;13(3):241–52.
23.
SiebertUAlagozOBayoumiAM. State-transition modeling: a report of the ISPOR-SMDM Modeling Good Research Practices Task Force–3. Med Decis Making. 2012;32(5):690–700.
24.
AlGhanimNComondoreVRFleethamJMarraCAAyasNT. The economic impact of obstructive sleep apnea. Lung. 2008;186(1):7–12.
25.
FergusonKACartwrightRRogersRSchmidt-NowaraW. Oral appliances for snoring and obstructive sleep apnea: a review. Sleep. 2006;29(2):244–62.
26.
HoffsteinV. Review of oral appliances for treatment of sleep-disordered breathing. Sleep Breath Schlaf Atm. 2007;11(1):1–22.
27.
YoungTBlusteinJFinnLPaltaM. Sleep-disordered breathing and motor vehicle accidents in a population-based sample of employed adults. Sleep. 1997;20(8):608–13.
GeorgeCF. Reduction in motor vehicle collisions following treatment of sleep apnoea with nasal CPAP. Thorax. 2001;56(7):508–12.
30.
AnandamAPatilMAkinnusiMJaoudePEl SolhAA. Cardiovascular mortality in obstructive sleep apnea treated with continuous positive airway pressure or oral appliance: an observational study. Respirology [Internet]. 2013 [cited 2013 Dec 3]. Available from: http://onlinelibrary.wiley.com/doi/10.1111/resp.12140/abstract
BrazierJRatcliffeJSalomanJTsuchiyaA. Measuring and Valuing Health Benefits for Economic Evaluation. Oxford, UK: Oxford University Press; 2007.
33.
Canadian Agency for Drugs and Technologies in Health. Guidelines for the Economic Evaluation of Health Technologies. 3rd ed.Ottawa, ON, Canada: Canadian Agency for Drugs and Technologies in Health; 2006.
Groot KoerkampBMyriam HuninkMGStijnenTWeinsteinMC. Identifying key parameters in cost-effectiveness analysis using value of information: a comparison of methods. Health Econ. 2006;15(4):383–92.
36.
SadatsafaviMBansbackNZafariZNajafzadehMMarraC. Need for speed: an efficient algorithm for calculation of single-parameter expected value of partial perfect information. Value Health J Int Soc Pharmacoeconomics Outcomes Res. 2013;16(2):438–48.
37.
KennedyADMSculpherMJCoulterA. A multicentre randomised controlled trial assessing the costs and benefits of using structured information and analysis of women’s preferences in the management of menorrhagia. Health Technol Assess Winch Engl. 2003;7(8):1–76.
38.
MurrayEDavisHTaiSSCoulterAGrayAHainesA. Randomised controlled trial of an interactive multimedia decision aid on benign prostatic hypertrophy in primary care. BMJ. 2001;323(7311):493–6.
39.
MurrayEDavisHTaiSSCoulterAGrayAHainesA. Randomised controlled trial of an interactive multimedia decision aid on hormone replacement therapy in primary care. BMJ. 2001;323(7311):490–3.
40.
ArterburnDWellmanRWestbrookE. Introducing decision aids at group health was linked to sharply lower hip and knee surgery rates and costs. Health Aff (Millwood). 2012;31(9):2094–104.
41.
Oshima LeeEEmanuelEJ. Shared decision making to improve care and reduce costs. N Engl J Med. 2013;368(1):6–8.
42.
WalshTBarrPJThompsonROzanneEO’NeillCElwynG. Undetermined impact of patient decision support interventions on healthcare costs and savings: systematic review. BMJ. 2014;348:g188.
43.
GageBFCardinalliABOwensDK. Cost-effectiveness of preference-based antithrombotic therapy for patients with nonvalvular atrial fibrillation. Stroke J Cereb Circ. 1998;29(6):1083–91.
44.
McDaidCGriffinSWeatherlyH. Continuous positive airway pressure devices for the treatment of obstructive sleep apnoea-hypopnoea syndrome: a systematic review and economic analysis. Health Technol Assess Winch Engl. 2009;13(4):iii–iv, xi–xiv, 1–119, 143–274.
45.
JenkinsonCStradlingJPetersenS. How should we evaluate health status? A comparison of three methods in patients presenting with obstructive sleep apnoea. Qual Life Res Int J Qual Life Asp Treat Care Rehabil. 1998;7(2):95–100.
46.
MarJRuedaJRDurán-CantollaJSchechterCChilcottJ. The cost-effectiveness of nCPAP treatment in patients with moderate-to-severe obstructive sleep apnoea. Eur Respir J. 2003;21(3):515–22.
47.
BixlerEOVgontzasANLinHM. Prevalence of sleep-disordered breathing in women: effects of gender. Am J Respir Crit Care Med. 2001;163(3 Pt 1):608–13.
US Department of Transportation, National Highway Traffic Safety Administration National Center for Statistics and Analysis. Traffic safety facts 2005 [Internet]. 2006 [cited 2013 Dec 3]. Available from: http://www-nrd.nhtsa.dot.gov/pdf/nrd-30/NCSA/TSFAnn/TSF2005.pdf
50.
AndersonKMOdellPMWilsonPWKannelWB. Cardiovascular disease risk profiles. Am Heart J. 1991;121(1 Pt 2):293–8.
51.
WilliamsGR. Incidence and characteristics of total stroke in the United States. BMC Neurol. 2001;1:2.
52.
MalacridaRGenoniMMaggioniAP. A comparison of the early outcome of acute myocardial infarction in women and men. The Third International Study of Infarct Survival Collaborative Group. N Engl J Med. 1998;338(1):8–14.
53.
CarandangRSeshadriSBeiserA. Trends in incidence, lifetime risk, severity, and 30-day mortality of stroke over the past 50 years. JAMA. 2006;296(24):2939–46.
54.
MahoneyEMJurkovitzCTChuH. Cost and cost-effectiveness of an early invasive vs conservative strategy for the treatment of unstable angina and non-ST-segment elevation myocardial infarction. JAMA. 2002;288(15):1851–8.
55.
BradleyCJKrollJHolmes-RovnerM. The health and activities limitation index in patients with acute myocardial infarction. J Clin Epidemiol. 2000;53(6):555–62.
56.
PickardASJohnsonJAFeenyDH. Responsiveness of generic health-related quality of life measures in stroke. Qual Life Res Int J Qual Life Asp Treat Care Rehabil. 2005;14(1):207–19.
57.
SorensenSVKansalARConnollyS. Cost-effectiveness of dabigatran etexilate for the prevention of stroke and systemic embolism in atrial fibrillation: a Canadian payer perspective. Thromb Haemost. 2011;105(5):908–19.
58.
GoereeRBowenJMBlackhouseG. Economic evaluation of drug-eluting stents compared to bare metal stents using a large prospective study in Ontario. Int J Technol Assess Health Care. 2009;25(2):196–207.
Supplementary Material
Please find the following supplemental material available below.
For Open Access articles published under a Creative Commons License, all supplemental material carries the same license as the article it is associated with.
For non-Open Access articles published, all supplemental material carries a non-exclusive license, and permission requests for re-use of supplemental material or any part of supplemental material shall be sent directly to the copyright owner as specified in the copyright notice associated with the article.
