A cost analysis of the management of attention-deficit/hyperactivity disorder (ADHD) in children in the UK

SUMMARY

A decision analysis was performed to model the effects and health economic differences of current UK management approaches to attention-deficit/hyperactivity disorder (ADHD) in children aged between 6 and 16 years. The approaches modelled were: medication using a standard immediate-release methylphenidate (MPH-IR) (once, twice or three times daily); medication using CONCERTA®XL (OROS®* methylphenidate; MPH), a long-acting once-daily formulation of methylphenidate; or behavioural therapy (BEH). Starting treatment with BEH alone resulted in the highest annual cost (UK£2,147), while the costs of starting treatment with MPH-IR alone (£1,332), or OROS®* MPH alone (£1,362) were comparable. Treatment switches to behavioural treatment or combined treatment (medication and behavioural) due to treatment failure occurred in 11.8% of OROS®* MPH and 24.2% of MPH-IR patients. Probabilistic sensitivity analyses showed that the results were sensitive towards treatment success and the proportion of patients with comorbidities, although conclusions were not altered. UK treatment costs over 1 year appear comparable regardless of whether patients were treated first with OROS®* MPH or MPH-IR. Treating patients first with BEH and then adding stimulant medication if needed resulted in higher overall annual treatment costs.

CONCERTA® XL and OROS® are trademarks of ALZA Corporation, USA.     

miRNA在诊治卵巢癌中的应用

综述miRNA在诊治卵巢癌中的研究现状,探索这一治疗方案在卵巢癌治疗中的应用价值。     

俄罗斯的经济转轨与市场规则构建

苏联的解体,俄罗斯的独立,标志着俄罗斯经济转轨的正式开始。俄罗斯的经济转轨的目标,就是建立在私有制基础上的市场经济体制。俄罗斯政府最初选择了英美的自由市场经济模式的发展道路,采取"休克"疗法。但这一切并没有像预期的那样消除俄罗斯的经济危机。普京就任俄罗斯总统,俄罗斯的经济转轨进入了一个新时代。在目标模式上,由转轨之初对英美模式的推崇逐渐转变为对近似于德国的社会市场经济模式的追求;在转轨方法上,由转轨之初激进的"休克疗法"逐渐转变为追求渐进的改革。俄罗斯的经济转轨过程也就是其构建市场规则、建立市场经济秩序的过程。     

波兰经济转轨概观(1989-2000)

从1989年开始,波兰采用"休克疗法"式的改革,对国有经济实行快速私有化,成功地进行了经济转轨,使波兰的经济增长速度不断加快,综合国力显著提高,取得了良好的经济效果.波兰现已成为中东欧地区经济转轨最成功的国家.     

复方大黄制剂结合三联疗法治疗幽门螺杆菌感染疗效观察

目的观察中西医结合根除幽门螺杆菌的疗效。方法经胃镜和组织学检查,选择120例HP阳性的消化性溃疡或慢性萎缩性胃炎患者,随机分为两组,对照组采用标准三联疗法,治疗组采用标准三联的同时口服复方大黄制剂,疗程为1周,4周后复查胃镜及14C尿素呼气试验或快速尿素酶试验。结果中西医结合治疗组的根除率及胃镜组织学治愈好转率较标准三联对照组均有明显的提高,并有统计学意义,P〈0.05。结论复方大黄制剂可以提高幽门螺杆菌的根除率,并且促进胃炎、消化性溃疡患者的组织学修复,不良反应少。     

The cost-effectiveness of disease-modifying therapies for the treatment of relapsing-remitting multiple sclerosis

Background: The safety and efficacy of disease-modifying therapies (DMTs) for relapsing-remitting multiple sclerosis (RRMS) has been established; however, it is not clear which provides optimal value, given benefit-risk profiles and costs.

Aims: To compare the cost-effectiveness of current DMTs for patients with RRMS in the US.

Materials and methods: A Markov model predicting RRMS course following initiation of a DMT was created comparing outcomes (e.g. relapses, disease progression) and costs of natalizumab (NTZ), dimethyl fumarate (DMF), and peginterferon beta-1a (PEG) with fingolimod (FIN), glatiramer acetate (GA, 20?mg daily), and subcutaneous interferon beta-1a (IFN, 44?mcg), respectively, over 10 years. RRMS and secondary-progressive MS (SPMS) EDSS state transitions were predicted in 3-month cycles in which patients were at risk of death, relapse, or discontinuation. Upon DMT discontinuation, natural history progression and relapse rates were applied. Incremental cost-effectiveness ratios (ICERs) were estimated for the cost per relapse avoided, relapse-free years gained, progression avoided, and progression-free years gained. The impact of model parameters on outcomes was evaluated via one-way sensitivity analyses.

Results: Costs ranged from $561,177 (NTZ) to $616,251 (GA). NTZ, DMF, and PEG were dominant (less costly and more effective) compared to FIN, GA, and IFN, respectively, for all ICERs. Variability in drug costs and parameters that affected drug cost accrual (e.g. discontinuation rates and the decision to drop out after SPMS conversion) had a considerable impact on ICERs.

Limitations: Several simplifying assumptions were made that may represent potential limitations of this analysis (e.g. a constant treatment effect over time was assumed).

Conclusions: The results from this analysis suggest that the NTZ, DMF, and PEG are cost-effective DMT choices compared to FIN, GA, and IFN, respectively. The actual impact on a particular plan will vary based on drug pricing and other factors affecting drug cost accrual.     

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.     

Respiratory-related medical expenditure and inpatient utilisation among COPD patients receiving long-acting bronchodilator therapy

Abstract

Objective:

To evaluate chronic obstructive pulmonary disease (COPD)-related expenditure and hospitalisation in COPD patients treated with tiotropium versus alternative long-acting bronchodilators (LABDs).

Methods:

Data were from the Thomson Reuters MarketScan Research Databases. COPD patients ≥35 years with at least one LABD claim between July 1, 2004 and June 30, 2006 were classified into five cohorts based on index LABD: monotherapy with tiotropium, salmeterol/fluticasone propionate, formoterol fumarate, or salmeterol or combination therapy. Demographic and clinical characteristics were evaluated for a 6-month pre-period and COPD-related utilisation and total costs were evaluated for a 12-month follow-up period. LABD relationship to COPD-related costs and hospitalisations were estimated by multivariate generalised linear modelling (GLM) and multivariate logistic regression, respectively.

Results:

Of 52,274 patients, 53% (n?=?27,457) were male, 71% (n?=?37,271) were ≥65?years, and three LABD cohorts accounted for over 90% of the sample [53% (n?=?27,654) salmeterol/fluticasone propionate, 23% (n?=?11,762) tiotropium, and 15% (n?=?7755) combination therapy]. Patients treated with salmeterol/fluticasone propionate (p?<?0.001), formoterol fumarate (p?=?0.032), salmeterol (p?=?0.004), or with combination therapy (p?<?0.001) had higher COPD-related costs and a greater risk of inpatient admission (p?<?0.01 for all) versus tiotropium.

Limitations:

These data are based on administrative claims and as such do not include clinical information or information on risk factors, like smoking status, that are relevant to this population.

Conclusions:

Patients treated with tiotropim had lower COPD-related expenditures and risk of hospitalisation than patients treated with other LABDs     

Randomized,open-label study to evaluate patient-reported outcomes with fingolimod after changing from prior disease-modifying therapy for relapsing multiple sclerosis: EPOC study rationale and design

Abstract

Objective:

The study to Evaluate Patient OutComes, Safety, and Tolerability of Fingolimod (EPOC; NCT01216072) aimed to test the hypothesis that therapy change to oral Gilenya (Novartis AG, Stein, Switzerland) (fingolimod) improves patient-reported outcomes compared with standard-of-care disease-modifying therapy (DMT) in patients with relapsing multiple sclerosis; safety and tolerability were also assessed. This communication describes the study rationale and design.

Methods:

EPOC is a phase 4, open-label, multi-center study conducted in the US and Canada of patients with relapsing forms of multiple sclerosis who are candidates for therapy change. Therapy change eligibility was determined by the treating physician (US patients) or required an inadequate response to or poor tolerance for at least 1 MS therapy (Canadian patients). Patients were randomly assigned in a 3:1 ratio to 6 months of treatment with once-daily oral fingolimod 0.5?mg or standard-of-care DMTs. The primary study end-point was the change from baseline in treatment satisfaction as determined by the global satisfaction sub-scale of the Treatment Satisfaction Questionnaire for Medication. Secondary end-points included changes from baseline in perceived effectiveness and side-effects, and measures of activities of daily living, fatigue, depression, and quality-of-life. A 3-month open-label fingolimod extension was available for patients randomly assigned to the DMT group who successfully completed all study visits.

Results:

Enrollment has been completed with 1053 patients; the patient population is generally older and has a longer duration of disease compared with populations from phase 3 studies of fingolimod.

Limitations:

Inclusion criteria selected for patients with a sub-optimal experience with a previous DMT, limiting the collection of data on therapy change in patients who were satisfied with their previous DMT.

Conclusions:

Results of the EPOC study are anticipated in early 2013 and will inform treatment selection by providing patient-centered data on therapy switch to fingolimod or standard-of-care DMTs.

Trial Registration:

ClinicalTrials.gov NCT01216072.     

Effectiveness of step therapy policies for specialty pharmaceuticals in immune disorders

Abstract

Objective:

To assess the effectiveness of managed care plans that limited access to infusion biologics via a step therapy policy.