Economic Evaluation of Mandibular Advancement Device to Treat Obstructive Sleep Apnea

Background: Obstructive sleep apnea/hypopnea syndrome (OSAHS) is a breathing disorder characterized by cessation of airflow due to repeated collapse of the upper airway during sleep. Patients with moderate OSAHS are commonly offered Continuous Positive Airway Pressure (CPAP) therapy as standard care. Mandibular advancement device (MAD) is an alternative therapy offered either as first- or second-line treatment, but evidence on their cost-effectiveness is limited. Research objective: To assess the cost-effectiveness of MAD compared to CPAP in the treatment of moderate OSAHS patients in the Netherlands and Belgium. Methods: Information on the current care pathway was elicited from interviews with clinical experts, the American Academy of Sleep Medicine (AASM) guideline and the Dutch obstructive sleep apnea guideline. The prognosis of a hypothetical cohort of 50-year-old patients with moderate OSAHS was simulated with a Markov model to estimate the costs and quality-adjusted life-years (QALYs) for both CPAP and MAD. The most influential factors incorporated in the model were compliance and switch of therapy. Values for all input parameters, including the risks of developing cardiovascular events and motor vehicle crashes (MVC) are based on literature and expert opinion. Costs and effects were estimated over a 5-year time horizon using a healthcare provider perspective and were discounted at a rate of 4% and 1.5% for the Netherlands and 3% and 1.5% for Belgium, respectively. Robustness of the results was investigated with one-way sensitivity and scenario analyses. Results: Compared with CPAP, MAD is less expensive (€4,510 vs. €5,301) and almost equally effective (3.43 vs. 3.49) resulting in an incremental cost-effectiveness ratio (ICER) of €15,392 saved per QALY lost in the Netherlands while in Belgium MAD was by €828.36 less expensive, yielding 0.0514 fewer QALYs (ICER= €16,117/QALY). The parameters with the highest impact on ICER for patients treated in the Netherlands were the cost of MAD device and titration and the cost of pulmonologist visit while for Belgium, the costs of CPAP device and CPAP titration were the most influential parameters. Quality-of-life values, compliance rates, costs of the most important cost parameters and the probabilities of switching treatment, cardiovascular events and MVC were varied in the scenario analyses. Under the majority of the scenarios MAD remained less cost-effective compared to CPAP in both countries. For the Netherlands this held true given a willingness-to-pay threshold range of €20,000 - €80,000/QALY. Conclusions: Over a 5-year time horizon, MAD therapy may be considered not cost-effective in the treatment of moderate OSAHS patients, having potential for cost savings and demonstrating slightly less effectiveness compared to CPAP. Further research on the efficacy of both treatments regarding the reduction of associated long-term risks and improvement in the quality of life is required so that more reliable data can be used as input in the respective economic evaluations. Similarly, more long-term studies using a uniform compliance definition are needed to inform future cost-effectiveness analyses.