Considering the growing trend of aging in the world, it is essential to pay attention to age-related diseases, so that with timely diagnosis and treatment of diseases, we can move in the direction of reducing the overall costs of the health system and improving the people's quality of life. As a disease of old age, sarcopenia will be great importance to use the most effective management strategies due to the various possible consequences and significant financial burden.
A comparison of different management strategies for sarcopenia was conducted from the perspective of Iran's health system. Because of the little comprehensive evidence regarding the clinical effectiveness of sarcopenia interventions, in this study, the research steps were designed and implemented in a systematic and step-by-step manner based on the best available evidence.
Base-case results indicated that vitamin D was the cost-effective strategy. Other combination strategies with vitamin D, including vitamin D and protein (P + D), vitamin D and protein along with exercise (P + D + E), and vitamin D along with exercise (D + E), despite the higher effectiveness and the increase in the amount of QALYs obtained, according to Iran's cost-effectiveness threshold were not cost-effective. Regarding the P + D and D strategies, the two undominated options in this evaluation, the comparative results showed that the estimated ICER of P + D compared to the D strategy was approximately five times more than the cost-effectiveness threshold.
In this regard, it can be said that although sarcopenia interventions lead to an increase in QALY values during the lifetime, this increase was not significant. For this reason, only interventions that can be done at a relatively low cost will be cost-effective. Of course, these results have been obtained according to the available evidence regarding the effectiveness of interventions. More complete and accurate evidence in this regard in the future can have different results.
The results of DSA and PSA also completely confirm the robustness of base-case results. In this regard, in the considered cost-effectiveness threshold, the Monte-Carlo simulation showed that the probability of the cost-effectiveness of the D strategy alone is more than 95%. The only other strategy with an optimal chance in this simulation was the P + D + E with less than a 5% chance of cost-effectiveness.
In this study, the EVPI was also calculated. According to the simulation, EVPI was estimated to be $273. This means that at the desired cost-effectiveness threshold, the expected value of obtaining perfect information about the uncertainty of some model parameters was $273. This amount increased with the increase of cost-effectiveness threshold limits. In general, obtaining perfect information can help identify the most appropriate treatment option with higher certainty (39).
Based on our knowledge, the evaluation carried out in the present study was the first economic evaluation regarding sarcopenia management interventions so far. Previously, in general, only one economic evaluation was done in the field of sarcopenia disease, which evaluated screening methods for this disease (40). Other economic studies have focused on the costs of disease, such as the study by Janssen et al. (2004) and Goates et al. (2019) in the United States (41, 42) and the study by Sousa et al. (2016) in Portugal (15).
In this evaluation, according to the available evidence, increasing the HRQoL, reducing the risk of falling, reducing the risk of fracture, and reducing the probability of death were considered outcomes of disease management interventions, and other possible outcomes were ignored due to the limitations of the evidence.
In this evaluation, a combination of supplements, exercise, and WBV was considered, and the medicines that were sometimes prescribed to treat sarcopenic patients were not included in the study. In this regard, it should be noted that a particular medicine for treating and reducing sarcopenia complications has not yet been approved. On the other hand, our investigations from review studies showed that no significant efficacy of the investigated medicines was reported (43–45).
As mentioned in the methods section, at the beginning of the structure of the decision analysis model, patients were divided into two groups, treatment acceptance and non-treatment acceptance. However, due to the lack of evidence in this regard separately for the compared interventions, the probability of treatment acceptance was considered 90% in the model for all interventions. However, considering this division at the beginning of the model was only because of drawing attention to the importance of the difference in treatment acceptance and adherence in different interventions on the results of economic evaluation. In such a way, it was likely that interventions with exercises had a lower acceptance and adherence rate among patients at elderly ages. This problem also shows the importance of producing evidence in this regard.
Also, in this study, the initial effectiveness of the interventions was considered on the three indicators of muscle mass, muscle strength, and muscle function. Considering that quantitative evidence regarding the difference in the effectiveness of the interventions on the three mentioned indicators was not available, the effectiveness of the treatment was weighted equally. This issue can also be considered another limitation of the present study.
Generally, by expanding the evidence and providing more access to the values of the required parameters, and removing the limitations of the study, more complete models can be designed and implemented in the future to identify the most cost-effective strategies in the management of sarcopenia.