Population-Level Strategies for Nirmatrelvir/Ritonavir Prescribing—A Cost-effectiveness Analysis. (25th November 2022)

• Record Type: Journal Article
• Authors: Savinkina, Alexandra; Paltiel, A David; Ross, Joseph S; Gonsalves, Gregg
• Is Part Of: Open forum infectious diseases. Volume 9:Number 12(2022)
• Publication Date: 2022-11-25
• Subjects: COVID-19 -- allocation -- cost-effectiveness -- nirmatrelvir/ritonavir; Communicable diseases -- Periodicals; Medical microbiology -- Periodicals; Infection -- Periodicals; 616.9
• DOI: 10.1093/ofid/ofac637
• Languages: English
• ISSNs: 2328-8957

Abstract

Abstract: Background: New coronavirus disease 2019 (COVID-19) medications force decision-makers to weigh limited evidence of efficacy and cost in determining which patient populations to target for treatment. A case in point is nirmatrelvir/ritonavir, a drug that has been recommended for elderly, high-risk individuals, regardless of vaccination status, even though clinical trials have only evaluated it in unvaccinated patients. A simple optimization framework might inform a more reasoned approach to the trade-offs implicit in the treatment allocation decision. Methods: We conducted a cost-effectiveness analysis using a decision-analytic model comparing 5 nirmatrelvir/ritonavir prescription policy strategies, stratified by vaccination status and risk for severe disease. We considered treatment effectiveness at preventing hospitalization ranging from 21% to 89%. Sensitivity analyses were performed on major parameters of interest. A web-based tool was developed to permit decision-makers to tailor the analysis to their settings and priorities. Results: Providing nirmatrelvir/ritonavir to unvaccinated patients at high risk for severe disease was cost-saving when effectiveness against hospitalization exceeded 33% and cost-effective under all other data scenarios we considered. The cost-effectiveness of other allocation strategies, including those for vaccinated adults and those at lower risk for severe disease, depended on willingness-to-pay thresholds, treatment cost and effectiveness, and the likelihood of severe disease. Conclusions: Priority for nirmatrelvir/ritonavir treatment should be given to unvaccinated persons at high risk of severe disease from COVID-19. Further priority may be assigned by weighing treatment effectiveness, disease severity, drug cost, and willingness to pay for deaths averted.