Cost effectiveness of duloxetine in the treatment of fibromyalgia in the United States

Abstract

Objective:

To evaluate the cost effectiveness of duloxetine when considered as an alternative treatment for patients in the United States (US) being treated for fibromyalgia pain.

Research design and methods:

A Markov model was used to evaluate the economic and clinical advantages of duloxetine in controlling fibromyalgia pain symptoms over a 2-year time horizon. A base-case treatment sequence was adopted from clinical guidelines, based on tricyclic antidepressants, serotonin-norepinephrine reuptake inhibitors, anticonvulsants, and opioids. Treatment response was modeled using changes from baseline in pain severity, and response thresholds: full response (at least a 50% change), response (30–49% change), and no response (less than a 30% change). Clinical efficacy and discontinuation data were taken from placebo- and active-controlled trials identified in a systematic literature review and mixed-treatment comparison. Utility data were based on EQ-5D data.

Main outcome measures:

Additional symptom-control months (SCMs), defined as the amount of time at a response level of 30% or less, and quality-adjusted life-years (QALYs) over a 2-year time horizon.

Results:

For every 1000 patients, first-line duloxetine resulted in an additional 665 SCMs and 12.3 QALYs, at a cost of $582,911 (equivalent to incremental cost-effectiveness ratios [ICERs] of $877 per SCM and $47,560 per QALY). Second-line duloxetine resulted in an additional 460 SCMs and 8.7 QALYs, at a cost of $143,752 (equivalent to ICERs of $312 per SMC and $16,565 per QALY).

Limitations:

Response data for TCAs are limited to 30% improvement levels, reported trials are small, and have low placebo response rates. The model necessarily assumes that response rates are independent of placement in the treatment sequence.

Conclusions:

The results suggest that the introduction of duloxetine into the standard treatment sequence for fibromyalgia not only provides additional patient benefits, reflected by time spent in pain control, but also is cost effective when compared with commonly adopted thresholds.     

Econometric Cost Structure Estimates for Cellular Telephony in the United States

This article estimates economies of scale for a sample of five cellular telephony firms in the United States. We reject constant returns to scale for all but the smallest firm studied; the remaining firms exhibit decreasing returns to scale. This finding suggests that scale economies cannot be used to justify the current regulated duopoly structure of United States cellular markets.     

Supply and Social Cost Estimates for Biomass from Crop Residues in the United States

The components of social costsincluded in the supply analysis are cashoutlays and opportunity costs associated withharvest and alternative residue uses, potentialenvironmental damage that is avoided byexcluding unsuitable land, and costs in movingresidues from farms to processing plants. Regional estimates account for the growingconditions and crops of the main agriculturalareas of the United States. Estimates includethe main U.S. field crops with potential forresidue harvest: corn, wheat, sorghum, oats,barley, rice and cane sugar. The potentialcontribution of residues to U.S. energy needsis discussed.     

The Economic Cost of Fatal Occupational Injuries in the United States, 1980–97

According to the National Traumatic Occupational Fatalities (NTOF) surveillance system, occupational injuries claimed the lives of over 100,000 American workers from 1980 to 1997. Previous estimates presented aggregate values of life, providing no information on the cost variations for different case or worker characteristics. This research developed an interactive computer program that estimates comprehensive national costs for all occupational fatal injuries reported through NTOF, nearly $85 billion for 1980–97, and specific estimates for the burden on selected groups and characteristics of the fatality. These estimates provide an additional basis for targeting and evaluating the effectiveness of investments in prevention of occupational fatalities. (JEL I18 )     

经济学科在美国

本文将介绍经济学科在美国的情况.由于美国代表了目前全世界现代经济学教学和研究的前沿,了解经济学科在美国的情况,对于如何参与国际经济学界的学术活动是很有必要的.我介绍以下四个方面的情况:第一,美国大学中经济学科的设置;第二,美国大学的经济学教育;第三,美国的经济学博士教育模式在欧洲;第四,中国学生申请留学美国攻读经济学学位时应注意的事项.     

Clinical comorbidities,treatment patterns,and healthcare costs among patients with fibromyalgia newly prescribed pregabalin or duloxetine in usual care

Abstract

Objective:

To assess comorbidities, pain-related pharmacotherapy, and healthcare resource use among patients with fibromyalgia (FM) newly prescribed pregabalin or duloxetine (index event) in usual care settings.

Methods:

Using the LifeLink? Health Plan Claims Database, patients with FM (International Classification of Diseases, Ninth Revision, Clinical Modification code 729.1X) were identified. Patients initiated on duloxetine were propensity score-matched with patients initiated on pregabalin (n?=?826; mean age [standard deviation] of 48.3 [9.3] years for both groups). Prevalence of comorbidities, pain-related pharmacotherapy, and healthcare resource use/costs were examined during the 12-month pre-index and follow-up periods.

Results:

Both patient groups had multiple comorbidities and a substantial pain-related and adjuvant medication burden. In the pregabalin group, use of other anticonvulsants decreased significantly (31.6% vs 24.9%), whereas use of serotonin-norepinephrine reuptake inhibitors (SNRIs; 16.5% vs 22.5%) and topical agents (10.1% vs 13.2%) increased in the follow-up period (p?<?0.01). In the duloxetine group, there were significant decreases in the use of other SNRIs (13.0% vs 5.7%), selective serotonin reuptake inhibitors (41.3% vs 21.7%), and tricyclic antidepressants (18.8% vs 13.2%), and an increase in the use of anticonvulsants (28.6% vs 40.1%; p?<?0.0001). There were significant increases (p?<?0.0001) in pharmacy and total healthcare costs in both cohorts, and a significant increase in outpatient costs (p?=?0.0084) in the duloxetine cohort from pre-index to follow-up. There were no significant differences in median total healthcare costs between the pregabalin and duloxetine groups in both the pre-index ($10,159 vs $9,556) and follow-up ($11,390 vs $11,746) periods.

Limitations:

Limitations of this study are typical of those associated with retrospective database analyses.

Conclusions:

Patients with FM prescribed pregabalin or duloxetine were characterized by a significant comorbidity and pain/adjuvant medication burden. Although healthcare costs increased in both groups, there were no statistically significant differences in direct healthcare costs between the two groups.     

Cost utility of palivizumab prophylaxis among pre-term infants in the United States: a national policy perspective

Abstract

Objective:

The cost-effectiveness of palivizumab has previously been reported among certain guideline-eligible, high-risk premature infants in Medicaid. Because guideline authorities base decisions on a national perspective, the economic model of palivizumab was adapted to include all infants, that is, public and privately insured patients (60% of palivizumab use is public, 40% is private).

Methods:

This study examined four groups of premature infants without chronic lung disease of prematurity or congenital heart disease: (1) <32 weeks gestational age (wGA) and ≤6 months chronologic age (CA); (2) 32–34 wGA, ≤3 months CA, with 2009 American Academy of Pediatrics (AAP) risk factors (RFs); (3) 32–35 wGA, ≤6 months CA, with 2006 AAP RFs; and (4) 32–35 wGA, ≤6 months CA, with ≤1 RF. An average estimate was used between public and private payors for (1) background rates of respiratory syncytial virus hospitalization (RSV-H), (2) direct medical costs associated with RSV-H, and (3) cost of palivizumab. Incremental cost-effectiveness ratios (ICERs) are reported in cost per quality-adjusted life-year (QALY) gained. Sensitivity analyses were performed.

Results:

Palivizumab saved costs and improved QALYs among infants <32 wGA. Palivizumab was cost-effective in infants 32–34 wGA with 2009 AAP RFs ($44,774 per QALY) and in infants 32–35 wGA with 2006 AAP RFs ($79,477 per QALY). The ICER for infants 32–35 wGA with ≤1 RF was $464,476 per QALY. Influential variables in the sensitivity analysis included background rate of RSV-H and cost and efficacy of palivizumab.

Limitations:

The results are not generalizable to populations outside of the US. The model did not examine all RFs. The wholesale acquisition cost was used as a payment benchmark; actual price paid by end providers varies.

Conclusions:

From a national policy perspective, palivizumab remained cost-effective for publically and commercially insured, guideline-eligible, high-risk premature infants. Palivizumab was not cost-effective in infants of 32–35 wGA with ≤1 RF.     

Farm Labor in the United States

The mainstream blames the global savings glut for causing the 2008 global financial crisis and proposes currency realignment to restore balance. However, this view fails to provide solid theoretical and empirical support to the claim that net inflows of foreign savings reduced U.S. long-term real interest rates and inflated asset prices. It also ignores the role of the global financial system in shaping the development strategy and macroeconomic imbalances in emerging Asian economies. Furthermore, forcing currency revaluation in China and other surplus countries may risk reducing global demand instead of shifting demand from the United States to surplus countries. The paper argues that an overhaul of the defunct global financial system lies at the root of global rebalancing; whereas in the short run, the United States should actively pursue demand-enhancing policies to strengthen global economic recovery.     

Economic evaluation of ezetimibe treatment in combination with statin therapy in the United States

Aims: This study assessed the cost-effectiveness of ezetimibe with statin therapy vs statin monotherapy from a US payer perspective, assuming the impending patent expiration of ezetimibe.

Methods: A Markov-like economic model consisting of 28 distinct health states was used. Model population data were obtained from US linked claims and electronic medical records, with inclusion criteria based on diagnostic guidelines. Inputs came from recent clinical trials, meta-analyses, and cost-effectiveness analyses. The base-case scenario was used to evaluate the cost-effectiveness of adding ezetimibe 10?mg to statin in patients aged 35–74 years with a history of coronary heart disease (CHD) and/or stroke, and with low-density lipoprotein cholesterol (LDL-C) levels ≥70?mg/dL over a lifetime horizon, assuming a 90% price reduction of ezetimibe after 1 year to take into account the impending patent expiration in the second quarter of 2017. Sub-group analyses included patients with LDL-C levels ≥100?mg/dL and patients with diabetes with LDL-C levels ≥70?mg/dL.

Results: The lifetime discounted incremental cost-effectiveness ratio (ICER) for ezetimibe added to statin was $9,149 per quality-adjusted life year (QALY) for the base-case scenario. For patients with LDL-C levels ≥100?mg/dL, the ICER was $839/QALY; for those with diabetes and LDL-C levels ≥70?mg/dL, it was $560/QALY. One-way sensitivity analyses showed that the model was sensitive to changes in cost of ezetimibe, rate reduction of non-fatal CHD, and utility weight for non-fatal CHD in the base-case and sub-group analyses.

Limitations: Indirect costs or treatment discontinuation estimation were not included.

Conclusions: Compared with statin monotherapy, ezetimibe with statin therapy was cost-effective for secondary prevention of CHD and stroke and for primary prevention of these conditions in patients whose LDL-C levels are ≥100?mg/dL and in patients with diabetes, taking into account a 90% cost reduction for ezetimibe.     

The Cost of Obesity in the United Kingdom

Summary

This study provides economic information on the costs of obesity in the UK using a modified method of attributable risk to establish the full resource implications of treating obesity and associated diseases. Prevalence estimates of obesity, defined as a Body Mass Index (BMI) greater than 30 kg/m², together with estimates of the risk of obesity-related diseases relative to a BMI range close to ideal, are used as the basis of the costing. The total costs of treating obesity and its related diseases are estimated at £355 million (in 1995 prices). The total costs of treating obesity directly, estimated at £3.8 million, are dominated by the costs arising from the treatment of attributable diseases, estimated at £351 million.     

Graduate Economics Programs in the United States

Sterrett and Barr comment on the results of a survey of graduate programs in economics in the United States and on the marked increase in the number of masters degrees granted by the responding institutions.     

The Real Cost of Financial Capital in the United States,Japan and Korea: Comparison and Convergence Tests

This paper presents alternative measures of the real cost of financial capital in the United States, Japan, and Korea over the 1975-90 period. Japan's cost of financial capital was the lowest among the three countries studied. The U.S. real cost of financial capital was higher than the Korean real cost. Our statistical analyses provide some evidence for shrinking the gap in the real financial costs of Japan and Korea vis a vis the United States. This is the reflection of increasing goods market integration and financial liberalization occurring in Japan and Korea. [F36, G15]     

Location and happiness in the United States

The effect of living in a less urban area on the probability of being happy is estimated. It is shown that less urban areas are associated with higher levels of happiness. Further, it is shown that respondents in the north region are less happy. Data from the National Opinion Research Center’s “General Social Survey” are used.     

Age Discrimination Legislation in the United States

Legislation prohibiting age discrimination in the United States dates back to the 1960s, when along with the Equal Pay Act and the Civil Rights Act barring discrimination against women and minorities, Congress passed the 1967 Age Discrimination in Employment Act. Questions regarding the rationale for and effectiveness of age discrimination legislation are likely to become increasingly important in light of a rapidly aging population in the United States (and other industrialized countries). This article provides a summary, critical review, and synthesis of what we know about age discrimination legislation. It first traces out the legislative history and the evolving case law and discusses implementation of the law. It then reviews the existing research on age discrimination legislation—research that addresses the rationale for the legislation, its effectiveness, and criticisms. (JEL J 1, J 7, L 3)     

Cost effectiveness of oseltamivir for the treatment of influenza in adults,adolescents and children in Finland

Summary

The objective of this study was to perform an economic assessment of the use of oseltamivir, compared with usual care, for the treatment of patients presenting with influenza-like illness in Finland. Three patient subpopulations were distinguished: (i) otherwise healthy adults; (ii) patients at risk; and (iii) children. The analyses were based on a decision analytic model populated with data specific for Finland and using first- and second-order Monte Carlo simulations. Probabilistic sensitivity analyses were performed to assess the impact of uncertainty regarding the most appropriate value for the variables and to derive cost-effectiveness acceptability curves in order to summarise the results. From a societal perspective, oseltamivir treatment was found to reduce costs in all groups. From a healthcare payer's perspective, improvements in outcomes were obtained at relatively modest incremental costs. The estimated incremental cost per day of normal activity gained was €27 in healthy adults, €8 in elderly and at-risk patients, and €14 in children.     

Cost effectiveness of memantine in Alzheimer's disease in the UK

Objective: This analysis assesses the cost-effectiveness of memantine for the treatment of moderate-to-severe Alzheimer's disease (AD) in the UK.

Methods: This cost-utility analysis was based on a Markov model. The model simulated 5-year progress of patients with AD until they need full-time care (FTC), defined as a patient becoming either dependent or institutionalised. Transition probabilities were based on a predictive equation, derived from the London and South-East Region epidemiological study. Resource use, utilities and mortality were obtained from the same study. Memantine efficacy was based on a meta-analysis of six large trials. The model compared memantine to its alternative in the UK, i.e. no pharmacological treatment or background therapy with acetylcholinesterase inhibitors.

Results: Memantine was found to delay the need to FTC by 6 weeks compared with current practice in the UK. It was associated with increased quality-adjusted life-years and cost savings to the healthcare system (probability of this outcome was 96%). The projections were made assuming that benefits from the 6-month treatment were sustained over time, which is regarded as the main limitation. The model underwent extensive sensitivity analyses, which confirmed the base-case findings.

Conclusions: The model suggests that memantine delays the need for FTC and decreases cost. It can be regarded as a cost-effective choice in the management of moderate and severe AD.     

Cost effectiveness of escitalopram versus SNRIs in second-step treatment of major depressive disorder in Sweden

Abstract

Objectives:

Escitalopram is the S-enantiomer of citalopram and is the most discriminating of the selective serotonin reuptake inhibitors (SSRI). The aim of the current analysis was to assess the cost effectiveness of escitalopram versus the serotonin norepinephrine reuptake inhibitors (SNRI) duloxetine and generic venlafaxine as second-step treatment of major depressive disorder.

Methods:

The analysis was based on a decision analytic model. Effectiveness outcomes were quality-adjusted life-years (QALYs) and remission rates; cost outcomes were direct medical costs, including impact of treating adverse events, and indirect costs associated with lost productivity. The analysis was performed from the societal perspective in Sweden over a 6-month timeframe.

Results:

Estimated remission rates showed an incremental effectiveness in favour of escitalopram of 16.4 percentage points compared with both SNRI comparators. The escitalopram strategy was associated with a 0.025 increase in QALYs. Sensitivity analyses demonstrated that the model is robust and that escitalopram remains a cost-effective option when considering future predicted price reductions of generic venlafaxine.

Limitations:

The main limitation in this study was the lack of data available for second-step treatment. The remission rates, which are a key input to the model, were obtained from a relatively small sample of patients on second-step treatment and there are no published relapse rates for second-step treatment. The model also assumed that there was no difference in the adverse event (AE) rates between treatments after the first 8 weeks.

Conclusions:

This cost-effectiveness analysis indicates that, at a willingness-to-pay threshold of £30,000, escitalopram is the most cost-effective second-step treatment option for MDD in Sweden in over 85% cases compared with both venlafaxine and with duloxetine. Benefits for escitalopram included both increased effectiveness and reduced overall costs. The major contributing costs were those associated with productivity loss.

The model was shown to have internal validity and robustness through the use of stochastic simulations and sensitivity analyses, which were conducted around the key efficacy parameters.