The current study aimed to provide evidence on the cost-effectiveness of remdesivir + SC for patients with COVID-19 in Iran. Remdesivir is not a confirmed therapy for COVID-19 and maybe has little effect on patients. However, this strategy can be used as the best available treatment for COVID-19 until an entirely successful treatment is discovered. Our base case results showed that remdesivir + SC, compared to SC alone was not cost-effective at a WTP threshold of three times GDP per capita. Treating patients with COVID-19 with remdesivir + SC would cost approximately 168 PPP dollars per QALD, compared to SC.
Sensitivity analysis revealed that ICER was sensitive to the alteration in the costs of SC for severe and moderate COVID-19 patients, costs of remdesivir + SC for moderate and severe COVID-19 patients, the transition probability of moderate to severe in patients receiving SC, the transition probability of mild to moderate in patients receiving SC, transition probability from recovery after mild state in patients receiving SC, transition probability from mild to moderate in patients receiving remdesivir + SC, transition probability from recovery after mild and moderate in patients receiving remdesivir + SC. The PSA results showed that remdesivir + SC was cost-effective with a 47% probability at a WTP threshold of three times GDP per capita.
Our results are consistent with a previous cost-utility analysis of treating moderate to severe respiratory COVID-19. In the mentioned study, dexamethasone and remdesivir were compared with SC demonstrating that remdesivir in moderate and severe infections was dominated by SC (26). In contrast, another study conducted in South Africa found that remdesivir for non-ventilated patients and dexamethasone for ventilated patients were associated with 1,111 deaths averted and were cost-saving (27). One of the limitations of the latter investigation was the type of model and the lack of structure explanation. In general, no similar study was found with the Markov model.
Although some researchers have shown that remdesivir affects COVID-19, its impact on other variants such as B.1.1.7 and B.1.351 has not been studied and remains unknown. These new variants have rapidly spread around the United Kingdom, South Africa, and then other countries. A rise in the number of cases will put further strain on healthcare resources resulting in more hospitalizations and more fatalities (28, 29).
It should be taken into consideration that Iran had a difficult time supplying and distributing medications in hospitals due to sanctions. Even though medications and basic medical equipment are exempt from economic sanctions, the direct and indirect consequences of sanctions have limited the banking system of Iran (30), making it impossible to import pharmaceuticals and purchase raw materials. This situation has a significant impact on the cost of drugs and the total cost of the treatment process for patients. As a result, there is a significant difference between the costs in Iran and other countries.
Remdesivir has been removed from the list of medicines prescribed to COVID-19 patients in the most recent version of COVID-19 diagnosis and treatment guidelines in Iran. Previously, this agent was used as the first-line treatment for COVID-19 patients. The findings of the current study confirmed the last version of the COVID-19 diagnosis and treatment guideline in Iran. This study takes the healthcare system's perspective into account and only direct medical costs are collected. The COVID-19 has resulted in significant indirect costs for patients and their families, which have not been addressed in this study. Therefore, further studies from various perspectives, particularly the social perspective are recommended.
The current research similar to all others had some limitations. First, most of the transition probabilities considered in this study are taken from international studies, which may differ from reality due to the new and growing COVID-19. Furthermore, the transition probability between diverse states varies with the prevalence of distinct disease variants. Second, the utility values considered in this study are for influenza due to the lack of data for COVID-19 patients. Third, the costs vary widely among COVID-19 patients because many of them have underlying diseases, such as cardiovascular disease, diabetes, and hypertension. The costs of different states of COVID-19, regardless of the underlying disease of patients, are considered in this study. Finally, we tried to reduce some of these limitations by performing sensitivity analysis and changing the parameters.