Abstract
Importance The arrival of new medications for Alzheimer disease (AD) has prompted efforts to measure their value using conventional cost-effectiveness analyses; however, these analyses focus on how much health improvement new medications generate per dollar spent. As AD disproportionately affects older adults, women, racial and ethnic minority individuals, and individuals with lower socioeconomic and educational levels, it is critical to also examine the health equity outcomes of treatment.
Objective To estimate the health equity impact of a hypothetical disease-modifying treatment for early AD in the US and to examine targeted policies to mitigate health care disparities.
Design, Setting, and Participants This economic evaluation, which used a distributional cost-effectiveness analysis, was conducted from June 16, 2022, to January 11, 2024. The study included subgroups defined by race and ethnicity and by social vulnerability quintiles in the US.
Exposures A hypothetical disease-modifying treatment compared with best supportive care.
Main Outcomes and Measures The main outcomes were population-level quality-adjusted life-years (QALYs), lifetime costs, and net health benefits. The social welfare impact and change in health inequality were estimated using the Atkinson index.
Results The distributional cost-effectiveness analysis simulated 316 037 100 individuals from the US population, including 25 subgroups defined by 5 categories of race and ethnicity and population quintiles of social vulnerability, with the fifth quintile representing the most socially vulnerable group. At an opportunity cost benchmark of $150 000 per QALY, treatment was associated with improved population health, adding 28 197 QALYs per year to the US population. Accounting for health inequality preferences (using an aversion level of 11, based on an Atkinson inequality aversion parameter that can range from 0 to infinity, with higher values assigning greater weight to health gains that accrue to the population with the lowest lifetime quality-adjusted life expectancy), treatment was associated with a 0.009% reduction in existing population health inequalities annually. Scenario analyses examining earlier and expanded treatment access suggested a population health improvement of up to 221 358 QALYs.
Conclusions and Relevance The findings of this economic evaluation suggest that treatment for AD could improve population health and health equity. Policies to enable earlier diagnosis and treatment initiation, as well as expanded access to treatment, may further improve treatment and health equity impacts.