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Mattingly TJ, Esterly AA, Kaltenboeck A. Implementing Maximum Fair Price Without Hurting Pharmacies. JAMA HEALTH FORUM 2024; 5:e240921. [PMID: 38728020 DOI: 10.1001/jamahealthforum.2024.0921] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/12/2024] Open
Abstract
This Viewpoint discusses challenges pharmacies may face under the Inflation Reduction Act and steps that can be taken to prevent unintended consequences.
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Affiliation(s)
- T Joseph Mattingly
- Department of Pharmacotherapy, University of Utah College of Pharmacy, Salt Lake City
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Arbel R, Azab AN, Oberoi M, Aboalhasan E, Star A, Elhaj K, Khalil F, Alnsasra H. Dapagliflozin versus sacubitril-valsartan for heart failure with mildly reduced or preserved ejection fraction. Front Pharmacol 2024; 15:1357673. [PMID: 38567348 PMCID: PMC10985250 DOI: 10.3389/fphar.2024.1357673] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2023] [Accepted: 03/01/2024] [Indexed: 04/04/2024] Open
Abstract
Background and aim Heart failure with preserved ejection fraction (HFpEF) is associated with an increased risk of heart failure (HF) hospitalizations and cardiovascular death (CVD). Both dapagliflozin and sacubitril-valsartan have recently shown convincing reductions in the combined risk of CVD and HF hospitalizations in patients with HF and mildly reduced ejection fraction (HFmrEF) or HFpEF. We aimed to investigate the cost-per-outcome implications of dapagliflozin vs sacubitril-valsartan in the treatment of HFmrEF or HFpEF patients. Methods We compared the annualized cost needed to treat (CNT) to prevent the composite outcome of total HF hospitalizations and CVD with dapagliflozin or sacubitril-valsartan. The CNT was estimated by multiplying the annualized number needed to treat (aNNT) by the annual cost of therapy. The aNNT was calculated based on data collected from the DELIVER trial for dapagliflozin and a pooled analysis of the PARAGLIDE-HF and PARAGON-HF trials for sacubitril-valsartan. Costs were based on 2022 US prices. Scenario analyses were performed to attenuate the differences in the studies' populations. Results The aNNT with dapagliflozin in DELIVER was 30 (95% confidence interval [CI]: 21-62) versus 44 (95% CI: 25-311) with sacubitril-valsartan in a pooled analysis of PARAGLIDE-HF and PARAGON-HF, with an annual cost of $4,951 and $5,576, respectively. The corresponding CNTs were $148,547.13 (95% CI: $103,982.99-$306,997.39) for dapagliflozin and $245,346.77 (95% CI: $139,401.58-1,734,155.60) for sacubitril-valsartan for preventing the composite outcome of CVD and HF hospitalizations. The CNT for preventing all-cause mortality was lower for dapagliflozin than sacubitril-valsartan $1,128,958.15 [CI: $401,077.24-∞] vs $2,185,816.71 [CI: $607,790.87-∞]. Conclusion Dapagliflozin provides a better monetary value than sacubitril-valsartan in preventing the composite outcome of total HF hospitalizations and CVD among patients with HFmrEF or HFpEF.
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Affiliation(s)
- Ronen Arbel
- Maximizing Health Outcomes Research Lab, Sapir College, Ashkelon, Israel
| | - Abed N. Azab
- Department of Cardiology, Soroka University Medical Center, Beersheba, Israel
- Department of Nursing, Department of Clinical Biochemistry and Pharmacology, Faculty of Health Sciences, Ben Gurion University of the Negev, Be’er Sheva, Israel
| | - Mansi Oberoi
- University of Nebraska Medical Center, Omaha, NE, United States
| | - Enis Aboalhasan
- Maximizing Health Outcomes Research Lab, Sapir College, Ashkelon, Israel
| | - Artyom Star
- Department of Cardiology, Soroka University Medical Center, Beersheba, Israel
| | - Khaled Elhaj
- Department of Cardiology, Soroka University Medical Center, Beersheba, Israel
| | - Fouad Khalil
- University of Nebraska Medical Center, Omaha, NE, United States
| | - Hilmi Alnsasra
- Department of Cardiology, Soroka University Medical Center, Beersheba, Israel
- Faculty of Health Sciences, Ben Gurion University of the Negev, Be’er Sheva, Israel
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Tajeu GS, Ruiz-Negrón N, Moran AE, Zhang Z, Kolm P, Weintraub WS, Bress AP, Bellows BK. Cost of Cardiovascular Disease Event and Cardiovascular Disease Treatment-Related Complication Hospitalizations in the United States. Circ Cardiovasc Qual Outcomes 2024; 17:e009999. [PMID: 38328916 PMCID: PMC11099996 DOI: 10.1161/circoutcomes.123.009999] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/22/2023] [Accepted: 11/17/2023] [Indexed: 02/09/2024]
Abstract
BACKGROUND Cardiovascular disease (CVD) is among the costliest conditions in the United States, and cost-effectiveness analyses can be used to assess economic impact and prioritize CVD treatments. We aimed to develop standardized, nationally representative CVD events and selected possible CVD treatment-related complication hospitalization costs for use in cost-effectiveness analyses. METHODS Nationally representative costs were derived using publicly available inpatient hospital discharge data from the 2012-2018 National Inpatient Sample. Events were identified using the principal International Classification of Diseases, Ninth Revision and International Classification of Diseases, Tenth Revision codes. Facility charges were converted to costs using charge-to-cost ratios, and total costs were estimated by applying a published professional fee ratio. All costs are reported in 2021 US dollars. Mean costs were estimated for events overall and stratified by age, sex, and survival status at discharge. Annual costs to the US health care system were estimated by multiplying the mean annual number of events by the mean total cost per discharge. RESULTS The annual mean number of hospital discharges among CVD events was the highest for heart failure (1 087 000 per year) and cerebrovascular disease (800 600 per year). The mean cost per hospital discharge was the highest for peripheral vascular disease ($33 700 [95% CI, $33 300-$34 000]) and ventricular tachycardia/ventricular fibrillation ($32 500 [95% CI, $32 100-$32 900]). Hospitalizations contributing the most to annual US health care costs were heart failure ($19 500 [95% CI, $19 300-$19 800] million) and acute myocardial infarction ($18 300, [95% CI, $18 200-$18 500] million). Acute kidney injury was the most frequent possible treatment complication (515 000 per year), and bradycardia had the highest mean hospitalization costs ($17 400 [95% CI, $17 200-$17 500]). CONCLUSIONS The hospitalization cost estimates and statistical code reported in the current study have the potential to increase transparency and comparability of cost-effectiveness analyses for CVD in the United States.
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Affiliation(s)
- Gabriel S. Tajeu
- Department of Health Services Administration and Policy, Temple University, Philadelphia, PA
| | | | - Andrew E. Moran
- Division of General Medicine, Columbia University Irving Medical Center, New York, NY, USA
| | | | - Paul Kolm
- MedStar Health Research Institute and Department of Medicine, Georgetown University, Washington, DC
| | - William S. Weintraub
- MedStar Health Research Institute and Department of Medicine, Georgetown University, Washington, DC
| | - Adam P. Bress
- Department of Population Health Sciences, University of Utah, Salt Lake City, UT
| | - Brandon K. Bellows
- Division of General Medicine, Columbia University Irving Medical Center, New York, NY, USA
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Mudumba R, Chan HH, Cheng YY, Wang CC, Correia L, Ballreich J, Levy J. Cost-Effectiveness Analysis of Trastuzumab Deruxtecan Versus Trastuzumab Emtansine for Patients With Human Epidermal Growth Factor Receptor 2 Positive Metastatic Breast Cancer in the United States. VALUE IN HEALTH : THE JOURNAL OF THE INTERNATIONAL SOCIETY FOR PHARMACOECONOMICS AND OUTCOMES RESEARCH 2024; 27:153-163. [PMID: 38042333 DOI: 10.1016/j.jval.2023.11.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/06/2023] [Revised: 09/20/2023] [Accepted: 11/22/2023] [Indexed: 12/04/2023]
Abstract
OBJECTIVES To assess the cost-effectiveness of trastuzumab deruxtecan compared with trastuzumab emtansine as second-line therapy for patients with human epidermal growth factor receptor 2 positive metastatic breast cancer from a US healthcare sector perspective. METHODS A 3-state partitioned survival model was developed to estimate the cost-effectiveness of trastuzumab deruxtecan compared with trastuzumab emtansine. For both treatments, modeled patients were administered treatment intravenously every 3 weeks indefinitely or until disease progression. Transition parameters were principally derived from the updated DESTINY-Breast03 phase III randomized clinical trial. Costs include drug costs extracted from Centers for Medicare and Medicaid Services average sales price and administrative, adverse event, and third-line therapy costs derived from published literature, measured in 2022 US dollars. Health utilities for health states and disutilities for adverse events were sourced from published literature. Effects were measured in quality-adjusted life years (QALYs). We conducted both probabilistic sensitivity analysis and comprehensive scenario analysis to test model assumptions and robustness, while utilizing a lifetime horizon. RESULTS In our base-case analysis, total costs for trastuzumab deruxtecan were $1 266 945, compared with $820 082 for trastuzumab emtansine. Total QALYs for trastuzumab deruxtecan were 5.09, compared with 3.15 for trastuzumab emtansine. The base-case incremental cost-effectiveness ratio was $230 285/QALY. Probabilistic sensitivity analysis indicated that trastuzumab deruxtecan had an 11.1% probability of being cost-effective at a $100 000 per QALY willingness-to-pay threshold. CONCLUSIONS Despite the higher efficacy of trastuzumab deruxtecan in patients with human epidermal growth factor receptor 2 positive metastatic breast cancer, our findings raise concern regarding its value at current prices.
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Affiliation(s)
- Rahul Mudumba
- Department of Health Policy and Management, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, MD, USA.
| | - Hui-Hsuan Chan
- Department of Health Policy and Management, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, MD, USA
| | - Yuan-Yuan Cheng
- Department of Health Policy and Management, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, MD, USA
| | - Chien-Chen Wang
- Department of Health Policy and Management, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, MD, USA
| | - Luis Correia
- Department of Health Policy and Management, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, MD, USA
| | - Jeromie Ballreich
- Department of Health Policy and Management, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, MD, USA
| | - Joseph Levy
- Department of Health Policy and Management, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, MD, USA
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Bryan AS, Moran AE, Mobley CM, Derington CG, Rodgers A, Zhang Y, Fontil V, Shea S, Bellows BK. Cost-effectiveness analysis of initial treatment with single-pill combination antihypertensive medications. J Hum Hypertens 2023; 37:985-992. [PMID: 36792728 PMCID: PMC10425570 DOI: 10.1038/s41371-023-00811-3] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2022] [Revised: 01/26/2023] [Accepted: 02/03/2023] [Indexed: 02/17/2023]
Abstract
Hypertension guidelines recommend initiating treatment with single pill combination (SPC) antihypertensive medications, but SPCs are used by only one-third of treated hypertensive US adults. This analysis estimated the cost-effectiveness of initial treatment with SPC dual antihypertensive medications compared with usual care monotherapy in hypertensive US adults.The validated BP Control Model-Cardiovascular Disease (CVD) Policy Model simulated initial SPC dual therapy (two half-standard doses in a single pill) compared with initial usual care monotherapy (half-standard dose when baseline systolic BP < 20 mmHg above goal and one standard dose when ≥20 mmHg above goal). Secondary analyses examined equivalent dose monotherapy (one standard dose) and equivalent dose dual therapy as separate pills (two half-standard doses). The primary outcomes were direct healthcare costs, quality-adjusted life-years (QALYs), and incremental cost-effectiveness ratio (ICER) over 10 years from a US healthcare sector perspective.At 10 years, initial dual drug SPC was projected to yield 0.028 (95%UI 0.008 to 0.051) more QALYs at no greater cost ($73, 95%UI -$1 983 to $1 629) than usual care monotherapy. In secondary analysis, SPC dual therapy was cost-effective vs. equivalent dose monotherapy (ICER $8 000/QALY gained) and equivalent dose dual therapy as separate pills (ICER $57 000/QALY gained). At average drug prices, initiating antihypertensive treatment with SPC dual therapy is more effective at no greater cost than usual care initial monotherapy and has the potential to improve BP control rates and reduce the burden of CVD in the US.
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Taylor RS, Lad SP, White JL, Stauss TG, Healey BE, Sacks NC, McLin R, Patil S, Jaasma MJ, Caraway DL, Petersen EA. Health care resource utilization and costs in patients with painful diabetic neuropathy treated with 10 kHz spinal cord stimulation therapy. J Manag Care Spec Pharm 2023; 29:1021-1029. [PMID: 37610114 PMCID: PMC10508838 DOI: 10.18553/jmcp.2023.29.9.1021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/24/2023]
Abstract
BACKGROUND: Diabetic peripheral neuropathy, a common comorbidity of diabetes, is a neurodegenerative disorder that targets sensory, autonomic, and motor nerves frequently associated with painful diabetic neuropathy (PDN). PDN carries an economic burden as the result of reduced work and productivity. A recent multicenter randomized controlled trial, SENZA-PDN (NCT03228420), assessed the impact of high-frequency (10 kHz) spinal cord stimulation (SCS) on pain relief. The effects of high-frequency SCS on health care resource utilization and medical costs are not known. OBJECTIVE: To evaluate the effect of high-frequency (10 kHz) SCS on health care resource utilization (HRU) and medical costs in patients with PDN using data from the SENZA-PDN trial. METHODS: Participants with PDN were randomly assigned 1:1 to receive either 10 kHz SCS plus conventional medical management (CMM) (SCS treatment group) or CMM alone (CMM treatment group). Patient outcomes and HRU up to the 6-month follow-up are reported here. Costs (2020 USD) for each service was estimated based on publicly available Medicare fee schedules, Medicare claims data, and literature. HRU metrics of inpatient and outpatient contacts and costs are reported as means and SDs. Univariate and bivariate analyses were used to compare SCS and CMM treatment groups at 6 months. RESULTS: At 6-month follow up, the SCS arm experienced approximately half the mean rate of hospitalizations per patient compared with the CMM treatment group (0.08 vs 0.15; P = 0.066). The CMM treatment group's total health care costs per patient were approximately 51% higher compared with the SCS treatment group (equivalent to mean annual cost per patient of $9,532 vs $6,300). CONCLUSIONS: Our analysis of the SENZA-PDN trial indicates that the addition of 10 kHz SCS therapy results in lower rates of hospitalization and consequently lower health care costs among patients with PDN compared with those receiving conventional management alone.
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Affiliation(s)
- Rod S. Taylor
- MRC/CSO Social and Public Health Sciences Unit, Robertson Centre for Biostatistics, School of Health & Wellbeing, University of Glasgow, UK
| | | | | | | | | | - Naomi C. Sacks
- PRECISIONheor, Boston, MA
- EpidStrategies, A Division of ToxStrategies, LLC, Boston, MA
| | - Ronaé McLin
- PRECISIONheor, New York, NY, now with Case Western Reserve University School of Medicine, Cleveland, OH
| | | | | | | | - Erika A. Petersen
- Department of Neurosurgery, University of Arkansas for Medical Sciences, Little Rock, AR
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Alnsasra H, Tsaban G, Solomon A, Khalil F, Aboalhasan E, Azab AN, Azuri J, Hammerman A, Arbel R. Dapagliflozin versus empagliflozin in patients with chronic kidney disease. Front Pharmacol 2023; 14:1227199. [PMID: 37601066 PMCID: PMC10436293 DOI: 10.3389/fphar.2023.1227199] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2023] [Accepted: 07/24/2023] [Indexed: 08/22/2023] Open
Abstract
Background and Aim: Dapagliflozin and empagliflozin have demonstrated favorable clinical outcomes among patients with chronic kidney disease (CKD). However, their comparative monetary value for improving outcomes in CKD patients is unestablished. We examined the cost-per-outcome implications of utilizing dapagliflozin as compared to empagliflozin for prevention of renal and cardiovascular events in CKD patients. Methods: For calculation of preventable events we divided the allocated budget by the cost needed to treat (CNT) for preventing a single renal or cardiovascular event. CNT was derived by multiplying the annualized number needed to treat (aNNT) by the annual therapy cost. The aNNTs were determined based on data from the DAPA-CKD and EMPEROR-KIDNEY trials. The budget limit was defined based on the threshold recommended by the United States' Institute for Clinical and Economic Review. Results: The aNNT was 42 both dapagliflozin (95% confidence interval [CI]: 34-59) and empagliflozin (CI: 33-66). The CNT estimates for the prevention of one primary event for dapagliflozin and empagliflozin were comparable at $201,911 (CI: $163,452-$283,636) and $209,664 (CI: $164,736-$329,472), respectively. However, diabetic patients had a higher CNT with dapagliflozin ($201,911 [CI: $153,837-$346,133]) than empagliflozin ($134,784 [CI: $109,824-$214,656]), whereas non-diabetic patients had lower CNT for dapagliflozin ($197,103 [CI: $149,029-$346,133]) than empagliflozin ($394,368 [CI: $219,648-$7,093,632]). The CNT for preventing CKD progression was higher for dapagliflozin ($427,858 [CI: $307,673-$855,717]) than empagliflozin ($224,640 [CI: $169,728-$344,448]). For preventing cardiovascular death (CVD), the CNT was lower for dapagliflozin ($1,634,515 [CI: $740,339-∞]) than empagliflozin ($2,990,208 [CI: $1,193,088-∞]). Conclusion: Among patients with CKD, empagliflozin provides a better monetary value for preventing the composite renal and cardiovascular events in diabetic patients while dapagliflozin has a better value for non-diabetic patients. Dapagliflozin provides a better monetary value for the prevention of CVD, whereas empagliflozin has a better value for the prevention of CKD progression.
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Affiliation(s)
- Hilmi Alnsasra
- Department of Cardiology, Soroka University Medical Center, Beersheba, Israel
- Faculty of Health Sciences, Ben Gurion University of the Negev, Beer-Sheva, Israel
| | - Gal Tsaban
- Department of Cardiology, Soroka University Medical Center, Beersheba, Israel
- Faculty of Health Sciences, Ben Gurion University of the Negev, Beer-Sheva, Israel
| | - Adam Solomon
- Faculty of Health Sciences, Ben Gurion University of the Negev, Beer-Sheva, Israel
| | - Fouad Khalil
- Sanford School of Medicine, University of South Dakota, Vermillion, SD, United States
| | - Enis Aboalhasan
- Maximizing Health Outcomes Research Lab, Sapir College, Sderot, Israel
| | - Abed N. Azab
- Department of Cardiology, Soroka University Medical Center, Beersheba, Israel
- Department of Nursing, Department of Clinical Biochemistry and Pharmacology, Faculty of Health Sciences, Ben Gurion University of the Negev, Beer-Sheva, Israel
| | - Joseph Azuri
- Diabetes Clinic, Maccabi Healthcare Services, Tel Aviv, Israel
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Ariel Hammerman
- Department of Pharmaceutical Technology Assessment, Clalit Health Services Headquarters, Tel Aviv, Israel
| | - Ronen Arbel
- Maximizing Health Outcomes Research Lab, Sapir College, Sderot, Israel
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Hiligsmann M, Silverman SS, Singer AJ, Pearman L, Mathew J, Wang Y, Caminis J, Reginster JY. Cost-Effectiveness of Sequential Abaloparatide/Alendronate in Men at High Risk of Fractures in the United States. PHARMACOECONOMICS 2023; 41:819-830. [PMID: 37086385 DOI: 10.1007/s40273-023-01270-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 03/19/2023] [Indexed: 05/03/2023]
Abstract
BACKGROUND AND OBJECTIVES Abaloparatide (ABL) significantly increases bone mineral density in men with osteoporosis similar to what was reported in postmenopausal women with osteoporosis. The cost effectiveness of sequential treatment with ABL followed by alendronate (ALN) in men at high fracture risk was compared to relevant alternative treatments. METHODS A Markov-based microsimulation model based on a lifetime US healthcare decision maker perspective was developed to evaluate the cost (expressed in US$2021) per quality-adjusted life-years (QALYs) gained of sequential ABL/ALN. Comparators were sequential treatment unbranded teriparatide (TPTD)/ALN, generic ALN monotherapy, and no treatment. Discount rates of 3% were used. Consistent with practice guidelines, patients received 18 months of ABL or TPTD followed by ALN for 5 years, or 5 years of ALN monotherapy. Analyses were conducted in high-risk men aged over 50 years defined as having a bone mineral density T-score ≤-2.5 and a recent fracture. Time-specific risk of subsequent fracture after a recent fracture, incremental costs up to 5 years following fractures, real-world medication adherence, and mostly US men-specific data were included in the model. One-way and probabilistic sensitivity analyses were conducted to assess the robustness of results. RESULTS Over the full age range, sequential ABL/ALN led to more QALYs for lower costs than sequential unbranded TPTD/ALN, while no treatment was dominated (more QALYs, lower costs) by ALN monotherapy. The costs per QALY gained of sequential ABL/ALN were lower than the US threshold of US$150,000 versus generic ALN monotherapy. The probabilities that sequential ABL/ALN was cost effective compared to ALN monotherapy were estimated at 51% in men aged 50 years and between 88 and 90% in those aged ≥ 60 years. CONCLUSIONS Sequential therapy using ABL/ALN may be cost effective compared with generic ALN monotherapy in US men aged ≥ 50 years at high fracture risk, especially in those aged ≥ 60 years. Unbranded TPTD/ALN and no treatment were dominated interventions (less QALY, more costs) compared with ABL/ALN or ALN monotherapy.
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Affiliation(s)
- Mickaël Hiligsmann
- Department of Health Services Research, CAPHRI Care and Public Health Research Institute, Maastricht University, P.O. Box 616, 6200 MD, Maastricht, The Netherlands.
| | - Stuart S Silverman
- Cedars-Sinai Medical Center, Los Angeles and the OMC Clinical Research Center, Beverly Hills, CA, USA
| | - Andrea J Singer
- MedStar Georgetown University Hospital and Georgetown University Medical Center, Washington, DC, USA
| | | | | | | | | | - Jean-Yves Reginster
- Division of Public Health, Epidemiology and Health Economics, University of Liège, Liège, Belgium
- Chair for Biomarkers of Chronic Diseases, College of Science, King Saud University, Riyadh, Kingdom of Saudi Arabia
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Alnsasra H, Tsaban G, Solomon A, Khalil F, Aboalhasan E, Weinstein JM, Azuri J, Hammerman A, Arbel R. Effect of Dapagliflozin Versus Empagliflozin on Cardiovascular Death in Patients with Heart Failure Across the Spectrum of Ejection Fraction: Cost per Outcome Analysis. Am J Cardiovasc Drugs 2023; 23:323-328. [PMID: 37067768 DOI: 10.1007/s40256-023-00578-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 03/13/2023] [Indexed: 04/18/2023]
Abstract
BACKGROUND Dapagliflozin and empagliflozin have shown clinical benefits in patients with heart failure (HF). Their comparative monetary value remains undetermined, and we therefore sought to compare the cost-per-outcome implications of utilizing dapagliflozin versus empagliflozin to prevent cardiovascular death (CVD) in patients with HF across the spectrum of ejection fraction. METHODS We estimated the cost needed to treat (CNT) to prevent one CVD with either dapagliflozin or empagliflozin. CNT was estimated by multiplying the annualized number needed to treat (aNNT) by the annual cost of therapy. The aNNTs were calculated based on data from the DAPA-HF and DELIVER trials for dapagliflozin, and the EMPEROR-Reduced and EMPEROR-Preserved trials for empagliflozin. Drug costs were calculated as 75% of the 2022 US National Average Drug Acquisition Cost. RESULTS The aNNT to prevent one event of CVD was 110 (95% confidence interval [CI] 58-∞) for dapagliflozin in a pooled analysis of DAPA-HF and DELIVER versus 204 (95% CI 71-∞) for empagliflozin in a pooled analysis of the EMPEROR-Reduced and EMPEROR-Preserved trials. The annual costs of therapy were $4807 and $4992, respectively. The corresponding CNTs were $528,770 (95% CI $278,806-∞) for dapagliflozin and $1,018,368 (95% CI $354,432-∞) for empagliflozin. This remained consistent in Europe, using the price estimates in Germany, with CNT (€77,490 for dapagliflozin and €143,708 for empagliflozin). CONCLUSION In incorporating data from all four outcomes trials of sodium-glucose cotransporter 2 inhibitors, dapagliflozin provides better monetary value for preventing CVD events in patients with HF across the spectrum of ejection fraction.
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Affiliation(s)
- Hilmi Alnsasra
- Department of Cardiology, Soroka University Medical Center, Rager Av., POB 84101, Beersheva, Israel.
- Faculty of Health Sciences, Ben Gurion University of the Negev, Beersheva, Israel.
| | - Gal Tsaban
- Department of Cardiology, Soroka University Medical Center, Rager Av., POB 84101, Beersheva, Israel
- Faculty of Health Sciences, Ben Gurion University of the Negev, Beersheva, Israel
| | - Adam Solomon
- Faculty of Health Sciences, Ben Gurion University of the Negev, Beersheva, Israel
| | - Fouad Khalil
- Sanford School of Medicine, University of South Dakota, Vermillion, SD, USA
| | - Enis Aboalhasan
- Maximizing Health Outcomes Research Lab, Sapir College, Sderot, Israel
| | - Jean Marc Weinstein
- Department of Cardiology, Soroka University Medical Center, Rager Av., POB 84101, Beersheva, Israel
- Faculty of Health Sciences, Ben Gurion University of the Negev, Beersheva, Israel
| | - Joseph Azuri
- Diabetes Clinic, Central District, Maccabi Healthcare Services, Tel Aviv, Israel
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Ariel Hammerman
- Department of Pharmaceutical Technology Assessment, Clalit Health Services Headquarters, Tel-Aviv, Israel
| | - Ronen Arbel
- Maximizing Health Outcomes Research Lab, Sapir College, Sderot, Israel
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Yoo M, Nelson RE, Cutshall Z, Dougherty M, Kohli M. Cost-Effectiveness Analysis of Six Immunotherapy-Based Regimens and Sunitinib in Metastatic Renal Cell Carcinoma: A Public Payer Perspective. JCO Oncol Pract 2023; 19:e449-e456. [PMID: 36599117 PMCID: PMC10022876 DOI: 10.1200/op.22.00447] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023] Open
Abstract
PURPOSE Several new treatment combinations have been approved in metastatic renal cell carcinoma (mRCC). To determine the optimal therapy on the basis of cost and health outcomes, we performed a cost-effectiveness analysis of approved immunotherapy-tyrosine kinase inhibitor/immunotherapy drug combinations and sunitinib using public payer acquisition costs in the United States. METHODS We constructed a decision model with a 10-year time horizon. The seven treatment drug strategies included atezolizumab + bevacizumab, avelumab + axitinib, pembrolizumab + axitinib, nivolumab + ipilimumab (NI), nivolumab + cabozantinib, lenvatinib + pembrolizumab, and sunitinib. The effectiveness outcome in our model was quality-adjusted life-years (QALYs) with utility values on the basis of the published literature. Costs included drug acquisition costs and costs for management of grade 3-4 drug-related adverse events. We used a partitioned survival model in which patients with mRCC transitioned between three health states (progression-free, progressive disease, and death) at monthly intervals on the basis of parametric survival function estimated from published survival curves. To determine cost-effectiveness, we constructed incremental cost-effectiveness ratios (ICERs) by dividing the difference in cost by the difference in effectiveness between nondominated treatments. RESULTS The least expensive treatment was sunitinib ($357,948 US dollars [USD]-$656,100 USD), whereas the most expensive was either lenvatinib + pembrolizumab or pembrolizumab + axitinib ($959,302 USD-$1,403,671 USD). NI yielded the most QALYs (3.6), whereas avelumab + axitinib yielded the least (2.5). NI had an incremental ICER of $297,465 USD-$348,516 USD compared with sunitinib. In sensitivity analyses, this ICER fell below $150,000 USD/QALY if the initial 4-month cost of NI decreased by 22%-38%. CONCLUSION NI was the most effective combination for mRCC, but at a willingness-to-pay threshold of $150,000 USD/QALY, sunitinib was the most cost-effective approach.
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Affiliation(s)
- Minkyoung Yoo
- Division of Epidemiology, Department of Internal Medicine, University of Utah School of Medicine, Salt Lake City, UT
| | - Richard E Nelson
- Division of Epidemiology, Department of Internal Medicine, University of Utah School of Medicine, Salt Lake City, UT.,Informatics Decision Enhancement and Surveillance (IDEAS) Center, VA Salt Lake City Healthcare System, Salt Lake City, UT
| | | | - Maura Dougherty
- Department of Economics, University of Utah, Salt Lake City, UT
| | - Manish Kohli
- Division of Oncology, Department of Medicine, University of Utah, Salt Lake City, UT.,Huntsman Cancer Institute, Salt Lake City, UT
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11
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Ding Y, Miller GE. The Impact of Sharing Drug Rebates at the Point of Sale on Out-of-Pocket Payments for Enrollees in Employer-Sponsored Insurance. VALUE IN HEALTH : THE JOURNAL OF THE INTERNATIONAL SOCIETY FOR PHARMACOECONOMICS AND OUTCOMES RESEARCH 2023; 26:226-233. [PMID: 36114087 DOI: 10.1016/j.jval.2022.08.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/30/2021] [Revised: 07/18/2022] [Accepted: 08/05/2022] [Indexed: 06/15/2023]
Abstract
OBJECTIVES This study aimed to estimate the impact of sharing drug rebates at the point of sale on out-of-pocket spending by linking estimated rebates to administrative claims data for employer-sponsored insurance enrollees in 2018. METHODS We applied the drug rebate rate to the retail price of each brand name drug fill, allocated the reductions to out-of-pocket spending based on cost-sharing provisions, and aggregated each individual's out-of-pocket spending across drug fills. We assumed that generic drugs have no rebates for employer-sponsored insurance. We assessed the impact of sharing rebates at the point of sale on out-of-pocket spending overall, for the therapeutic classes and specific drugs with the highest average out-of-pocket spending per user, and by health plan type. RESULTS Across 4 simulations with different assumptions about the degree of cross-fill effects, we found that 10.4% to 12.2% of enrollees in our sample would have realized savings on out-of-pocket spending if rebates were shared to the point of sale. Among those with savings, approximately half would save $50 or less, and 10% would save > $500 annually. We calculated that a premium increase of $1.06 to $1.41 per member per month among the continuously enrolled, insured population would be sufficient to finance the out-of-pocket savings in our sample. CONCLUSIONS Our study suggests that, for a small percentage of enrollees, sharing drug rebates at the point of sale would likely improve the affordability of high-priced brand name drugs, especially drugs that face significant competition.
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Affiliation(s)
- Yao Ding
- Division of Research and Modeling, Center for Financing, Access and Cost Trends, Agency for Healthcare Research and Quality, Rockville, MD, USA.
| | - G Edward Miller
- Division of Research and Modeling, Center for Financing, Access and Cost Trends, Agency for Healthcare Research and Quality, Rockville, MD, USA
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12
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Żelewski P, Wojna M, Sygit K, Cipora E, Gąska I, Niemiec M, Kaczmarski M, Banaś T, Karakiewicz B, Kotwas A, Zabielska P, Partyka O, Pajewska M, Krzych-Fałta E, Bandurska E, Ciećko W, Czerw A. Comparison of US and EU Prices for Orphan Drugs in the Perspective of the Considered US Orphan Drugs Act Modifications and Discussed Price-Regulation Mechanisms Adjustments in US and European Union. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2022; 19:12098. [PMID: 36231399 PMCID: PMC9566473 DOI: 10.3390/ijerph191912098] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 07/25/2022] [Revised: 09/16/2022] [Accepted: 09/20/2022] [Indexed: 06/16/2023]
Abstract
The 2019 worldwide sales of Orphan Drugs were estimated at $136 billion USD, which constituted 16% of the global pharmaceutical prescription market and is expected to grow by 12% in the next 5 years. A better understanding of Orphan Drug pricing may contribute to on-going discussions on Orphan Drug Act (ODA) corrections in US or modifications of price setting mechanisms in EU. The objective of the study was comparison and analysis of the prices of Orphan Drugs in US and EU. All drugs with Orphan Drug status were compared in the US and EU. For the US prices, the US Department of Veterans Affairs (VA) was sourced. The EU List Prices came from six EU countries: Denmark, France, Germany, Greece, Poland, Spain. We found US prices to be higher than the six selected EU countries. The average Price Ratio was 1.64. The prices across EU countries were more homogeneous, while the number of the reimbursed and therefore available to patient medicines varied and was correlated with GDP per capita r = 0.87. Considered implementation of the External Reference Price system in US may generate significant savings in the US but may result in upward pressure on pricing of Orphan Drugs in EU. Centralization of the Orphan Drugs pricing negotiations in EU may prevent such development and offer a win-win opportunity for all involved parties.
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Affiliation(s)
- Paweł Żelewski
- Department of Economics, Kozminsky University, 03-301 Warsaw, Poland
| | - Michał Wojna
- Department of Economics, Kozminsky University, 03-301 Warsaw, Poland
- Department of Health Economics and Medical Law, Medical University of Warsaw, Żwirk i Wigury 81 St., 02-091 Warsaw, Poland
| | - Katarzyna Sygit
- Faculty of Health Sciences, Calisia University, 62-800 Kalisz, Poland
| | - Elżbieta Cipora
- Medical Institute, Jan Grodek State University in Sanok, 38-500 Sanok, Poland
| | - Izabela Gąska
- Medical Institute, Jan Grodek State University in Sanok, 38-500 Sanok, Poland
| | - Mateusz Niemiec
- Medical Institute, Jan Grodek State University in Sanok, 38-500 Sanok, Poland
| | - Mateusz Kaczmarski
- Medical Institute, Jan Grodek State University in Sanok, 38-500 Sanok, Poland
| | - Tomasz Banaś
- Department of Gynaecology and Oncology, Jagiellonian University Medical College, 31-501 Cracow, Poland
- Department of Radiotherapy, Maria Sklodowska-Curie Institute-Oncology Centre, 31-115 Cracow, Poland
| | - Beata Karakiewicz
- Subdepartment of Social Medicine and Public Health, Department of Social Medicine, Pomeranian Medical University in Szczecin, 70-204 Szczecin, Poland
| | - Artur Kotwas
- Subdepartment of Social Medicine and Public Health, Department of Social Medicine, Pomeranian Medical University in Szczecin, 70-204 Szczecin, Poland
| | - Paulina Zabielska
- Subdepartment of Social Medicine and Public Health, Department of Social Medicine, Pomeranian Medical University in Szczecin, 70-204 Szczecin, Poland
| | - Olga Partyka
- Department of Health Economics and Medical Law, Medical University of Warsaw, Żwirk i Wigury 81 St., 02-091 Warsaw, Poland
- Department of Economic and System Analyses, National Institute of Public Health—NIH—National Research Institute, 00-791 Warsaw, Poland
| | - Monika Pajewska
- Department of Economic and System Analyses, National Institute of Public Health—NIH—National Research Institute, 00-791 Warsaw, Poland
| | - Edyta Krzych-Fałta
- Department of Basic of Nursing, Faculty of Health Sciences, Medical University of Warsaw, 01-445 Warsaw, Poland
| | - Ewa Bandurska
- Center for Competence Development, Integrated Care and e-Health, Medical University of Gdańsk, 80-204 Gdansk, Poland
| | - Weronika Ciećko
- Center for Competence Development, Integrated Care and e-Health, Medical University of Gdańsk, 80-204 Gdansk, Poland
| | - Aleksandra Czerw
- Department of Health Economics and Medical Law, Medical University of Warsaw, Żwirk i Wigury 81 St., 02-091 Warsaw, Poland
- Department of Economic and System Analyses, National Institute of Public Health—NIH—National Research Institute, 00-791 Warsaw, Poland
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13
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Tsaban G, Alnsasra H, El Nasasra A, Abu-Salman A, Abu-Dogosh A, Weissberg I, Golan YBB, Barrett O, Westreich R, Aboalhasan E, Azuri J, Hammerman A, Arbel R. Aspirin with Low-Dose Ticagrelor or with Low-Dose Rivaroxaban for Secondary Prevention: A Cost per Outcome Analysis. Am J Cardiovasc Drugs 2022; 22:677-683. [DOI: 10.1007/s40256-022-00543-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 07/01/2022] [Indexed: 11/01/2022]
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14
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Mattingly TJ, Lewis M, Socal MP, Bai G. State-level policy efforts to regulate pharmaceutical benefits managers (PBMs). Res Social Adm Pharm 2022; 18:3995-4002. [DOI: 10.1016/j.sapharm.2022.07.045] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2022] [Revised: 07/26/2022] [Accepted: 07/26/2022] [Indexed: 11/25/2022]
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15
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Hammerman A, Moore CM, Aboalhasan E, Azuri J, Arbel R. Oral versus subcutaneous semaglutide for prevention of major adverse cardiovascular events: cost per outcome analysis of SUSTAIN-6 and PIONEER-6. Postgrad Med 2022; 134:654-658. [PMID: 35701876 DOI: 10.1080/00325481.2022.2090794] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
BACKGROUND Semaglutide, a glucagon-like peptide-1 receptor agonist (GLP1a), reduces the risk of major adverse cardiovascular events (MACE) in patients with Type 2 diabetes mellitus (T2DM). An oral version of semaglutide is now available, and patients may prefer it over the subcutaneous form. Our objective was to compare the value for money of the two modalities by assessing the cost needed to treat (CNT) to prevent MACE. METHODS The CNT to prevent MACE was figured by multiplying the one-year number needed to treat (NNT) with either oral or subcutaneous semaglutide by the annual cost of therapy. Efficacy estimates and the resulting NNT figures were extracted from the published results of the SUSTAIN-6 and the PIONEER-6 trials for the injectable and oral versions of semaglutide, respectively. Drug costs were estimated as 75% of the United States national average drug acquisition cost listing in June 2021. We performed a scenario analysis to mitigate the primary differences between the populations in the two trials. Sensitivity analysis was performed to evaluate the effect of price changes of the interventions. RESULTS The CNT to prevent one MACE with subcutaneous semaglutide in SUSTAIN-6 was $966,693 ($594,888-$5,035,302) compared to $948,689 ($463,465-∞) with oral semaglutide in PIONEER-6. The scenario analysis demonstrated a 17% lower CNT for oral semaglutide. The difference between CNTs was sensitive to price fluctuations of the two interventions. CONCLUSIONS Oral and subcutaneous semaglutide prescribed to prevent MACE in patients with T2DM provide similar value for money. The choice between both therapies should be guided mainly by patient preferences.
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Affiliation(s)
- Ariel Hammerman
- Community Medical Services, Clalit Health Services Headquarters, Tel Aviv, Israel
| | - Candace Makeda Moore
- Research Software department, Netherlands eScience Center, Amsterdam, The Netherlands
| | - Enis Aboalhasan
- Maximizing Health Outcomes Research Lab, Sapir College, Sderot, Israel
| | - Joseph Azuri
- Maccabi Healthcare Services, Diabetes Clinic, Tel Aviv, Israel.,Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Ronen Arbel
- Community Medical Services, Clalit Health Services Headquarters, Tel Aviv, Israel.,Maximizing Health Outcomes Research Lab, Sapir College, Sderot, Israel
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16
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Hammerman A, Moore CM, Aboalhasan E, Azuri J, Arbel R. Usefulness of Empagliflozin Versus Oral Semaglutide for Prevention of Cardiovascular Mortality in Patients With Type 2 Diabetes Mellitus. Am J Cardiol 2022; 170:128-131. [PMID: 35197207 DOI: 10.1016/j.amjcard.2022.01.027] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/07/2021] [Revised: 12/30/2021] [Accepted: 01/04/2022] [Indexed: 11/01/2022]
Abstract
Empagliflozin and oral semaglutide reduce the incidence of cardiovascular mortality (CVM) in patients with type 2 diabetes mellitus. However, these therapies impose a significant financial burden on healthcare systems. Therefore, we compared the value for money of empagliflozin versus oral semaglutide to prevent CVM. We calculated the cost needed to treat to prevent 1 case of CVM using either drug by multiplying the annualized number needed to treat to prevent 1 event by the annual cost of the therapy. Efficacy estimates were extracted from published randomized controlled trials data. We performed a scenario analysis to mitigate the primary differences between the populations of randomized controlled trials. Drug costs were calculated as 75% of the United States National Average Drug Acquisition Cost listing. The annualized number needed to treat for empagliflozin in EMPA-REG-OUTCOME was 141 (95% confidence interval [CI] 104 to 230) and 141 (95% CI 96 to 879) for oral semaglutide in PIONEER 6. The annual treatment costs are $4,797 for empagliflozin versus $7,133 for oral semaglutide. Therefore, the corresponding costs needed to treat are $676,385 ($498,894-$1,101,039) and $1,005,855 (95% CI $684,837-$6,270,544) respectively. In conclusion, our findings suggest that empagliflozin provides better value for money than oral semaglutide to prevent CVM in patients with type 2 diabetes mellitus at the current United States prices of the interventions.
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17
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Dapagliflozin Versus Sacubitril-Valsartan to Improve Outcomes of Patients with Reduced Ejection Fraction and Diabetes Mellitus. Am J Cardiovasc Drugs 2022; 22:325-331. [PMID: 34671945 DOI: 10.1007/s40256-021-00506-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 09/28/2021] [Indexed: 12/11/2022]
Abstract
BACKGROUND Comorbid heart failure with reduced ejection fraction (HFrEF) and type 2 diabetes mellitus (DM) is associated with a very high risk of HF events. Sacubitril-valsartan, an angiotensin receptor-neprilysin inhibitor (ARNI), and dapagliflozin, a sodium-glucose cotransporter-2 inhibitor, improve HF outcomes in these patients, but their comparative value for money in this patient population has not yet been determined. OBJECTIVE We aimed to compare the cost needed to treat (CNT) to avoid an HF event with each drug. METHODS CNT was estimated by multiplying the annualized number needed to treat (NNT) to prevent one HF event by the annual cost of each therapy. HF events were defined as the first event of hospitalization for HF or cardiovascular mortality. Drug efficacy data were extracted from published secondary analyses of patients with DM in the DAPA-HF and PARADIGM-HF trials. Drug costs were estimated as 75% of the 2021 US National Average Drug Acquisition Cost listing. Sensitivity analysis was performed on parameters that may have affected the CNT. RESULTS The annualized NNT was 24 (95% confidence interval [CI] 16-54) for dapagliflozin and 57 (95% CI 31-433) for the ARNI. At an annual cost of $US4523 and 5099, respectively, the CNT was $US108,563 (95% CI 72,375-244,267) for dapagliflozin and $US290,671 (95% CI 158,084-2,208,079) for the ARNI. CONCLUSIONS Dapagliflozin seems to offer greater value for money than the ARNI for patients with HFrEF and DM. Our results provide support for contemporary guidelines advocating the use of dapagliflozin in these patients.
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18
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Dong OM, Poonnen PJ, Winski D, Reed SD, Vashistha V, Bates J, Kelley MJ, Voora D. Cost-Effectiveness of Tumor Genomic Profiling to Guide First-Line Targeted Therapy Selection in Patients With Metastatic Lung Adenocarcinoma. VALUE IN HEALTH : THE JOURNAL OF THE INTERNATIONAL SOCIETY FOR PHARMACOECONOMICS AND OUTCOMES RESEARCH 2022; 25:582-594. [PMID: 35365302 PMCID: PMC8976872 DOI: 10.1016/j.jval.2021.09.017] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/17/2021] [Revised: 08/18/2021] [Accepted: 09/30/2021] [Indexed: 06/04/2023]
Abstract
OBJECTIVES A cost-effectiveness analysis comparing comprehensive genomic profiling (CGP) of 10 oncogenes, targeted gene panel testing (TGPT) of 4 oncogenes, and no tumor profiling over the lifetime for patients with metastatic lung adenocarcinoma from the Centers for Medicare and Medicaid Services' perspective was conducted. METHODS A decision analytic model used 10 000 hypothetical Medicare beneficiaries with metastatic lung adenocarcinoma to simulate outcomes associated with CGP (ALK, BRAF, EGFR, ERBB2, MET, NTRK1, NTRK2, NTRK3, RET, ROS1), TGPT (ALK, BRAF, EGFR, ROS1), and no tumor profiling (no genes tested). First-line targeted cancer-directed therapies were assigned if actionable gene variants were detected; otherwise, nontargeted cancer-directed therapies were assigned. Model inputs were derived from randomized trials (progression-free survival, adverse events), the Veterans Health Administration and Medicare (drug costs), published studies (nondrug cancer-related management costs, health state utilities), and published databases (actionable variant prevalences). Costs (2019 US$) and quality-adjusted life-years (QALYs) were discounted at 3% per year. Probabilistic sensitivity analyses used 1000 Monte Carlo simulations. RESULTS No tumor profiling was the least costly/person ($122 613 vs $184 063 for TGPT and $188 425 for CGP) and yielded the least QALYs/person (0.53 vs 0.73 for TGPT and 0.74 for CGP). The costs per QALY gained and corresponding 95% confidence interval were $310 735 ($278 323-$347 952) for TGPT vs no tumor profiling and $445 545 ($322 297-$572 084) for CGP vs TGPT. All probabilistic sensitivity analysis simulations for both comparisons surpassed the willingness-to-pay threshold ($150 000 per QALY gained). CONCLUSION Compared with no tumor profiling in patients with metastatic lung adenocarcinoma, tumor profiling (TGPT, CGP) improves quality-adjusted survival but is not cost-effective.
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Affiliation(s)
- Olivia M Dong
- Duke Center for Applied Genomics and Precision Medicine, Department of Medicine, Duke University School of Medicine, Durham, NC, USA; Department of Veterans Affairs, Durham VA Medical Center, Durham, NC, USA
| | - Pradeep J Poonnen
- Department of Veterans Affairs, Durham VA Medical Center, Durham, NC, USA; Duke University Medical Center, Durham, NC, USA
| | - David Winski
- Department of Veterans Affairs, VA Boston Healthcare System, Boston, MA, USA
| | - Shelby D Reed
- Department of Veterans Affairs, Durham VA Medical Center, Durham, NC, USA; Duke Cancer Institute, Durham, NC, USA; Duke Department of Population Health Sciences, Duke University School of Medicine, Durham, NC, USA
| | - Vishal Vashistha
- Section of Hematology/Oncology, Raymond G. Murphy New Mexico Veterans Affairs Medical Center, Albuquerque, NM, USA
| | - Jill Bates
- Department of Veterans Affairs, Durham VA Medical Center, Durham, NC, USA; Division of Practice Advancement and Clinical Education, UNC Eshelman School of Pharmacy, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA; Department of Veterans Affairs, National Oncology Program, Durham, NC, USA
| | - Michael J Kelley
- Department of Veterans Affairs, Durham VA Medical Center, Durham, NC, USA; Duke University Medical Center, Durham, NC, USA; Duke Cancer Institute, Durham, NC, USA; Department of Veterans Affairs, National Oncology Program, Durham, NC, USA
| | - Deepak Voora
- Duke Center for Applied Genomics and Precision Medicine, Department of Medicine, Duke University School of Medicine, Durham, NC, USA; Department of Veterans Affairs, Durham VA Medical Center, Durham, NC, USA; Department of Veterans Affairs, National Oncology Program, Durham, NC, USA.
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Neumann PJ, Podolsky MI, Basu A, Ollendorf DA, Cohen JT. Do Cost-Effectiveness Analyses Account for Drug Genericization? A Literature Review and Assessment of Implications. VALUE IN HEALTH : THE JOURNAL OF THE INTERNATIONAL SOCIETY FOR PHARMACOECONOMICS AND OUTCOMES RESEARCH 2022; 25:59-68. [PMID: 35031100 DOI: 10.1016/j.jval.2021.06.014] [Citation(s) in RCA: 13] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/22/2021] [Revised: 06/18/2021] [Accepted: 06/23/2021] [Indexed: 06/14/2023]
Abstract
OBJECTIVES We investigated how health technology assessment (HTA) organizations around the world have handled drug genericization (an allowance for future generic drug entry and subsequent drug price declines) in their guidelines for cost-effectiveness analyses (CEAs). We also analyzed a large sample of published CEAs to examine prevailing practices in the field. METHODS We reviewed 43 HTA guidelines to determine whether and how they addressed drug genericization in their CEAs. We also selected a sample of 270 US-based CEAs from the Tufts Medical Center's CEA Registry, restricting the sample to studies on pharmaceuticals published from 1991 to 2019 and to analyses taking a lifetime time horizon. We determined whether each CEA examined genericization (and if so, whether in base case or sensitivity analyses), and how inclusion of genericization influenced the estimated incremental cost-effectiveness ratios. RESULTS Fourteen (33%) of the 43 HTA guidelines mention genericization for CEAs and 4 (9%) recommend that base case analyses include assumptions about future drug price changes due to genericization. Most published CEAs (95%) do not include assumptions about future generic prices for intervention drugs. Only 2% include such assumptions about comparator drugs. Most studies (72%) conduct sensitivity analyses on drug prices unrelated to genericization. CONCLUSIONS The omission of assumptions about genericization means that CEAs may misrepresent the long run opportunity costs for drugs. The field needs clearer guidance for when CEAs should account for genericization, and for the inclusion of other price dynamics that might influence a drug's cost-effectiveness.
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Affiliation(s)
- Peter J Neumann
- Center for the Evaluation of Value and Risk in Health, Tufts Medical Center, Boston, MA, USA.
| | - Meghan I Podolsky
- Center for the Evaluation of Value and Risk in Health, Tufts Medical Center, Boston, MA, USA
| | - Anirban Basu
- The CHOICE Institute, University of Washington, Seattle, WA, USA
| | - Daniel A Ollendorf
- Center for the Evaluation of Value and Risk in Health, Tufts Medical Center, Boston, MA, USA
| | - Joshua T Cohen
- Center for the Evaluation of Value and Risk in Health, Tufts Medical Center, Boston, MA, USA
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20
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Mccandlish JA, Feizullayeva C, Spyropoulos A, Cronin PP, Naidich J, Brenner B, Mcginn T, Sanelli PC, Cohen SL. Comparison of guidelines for evaluation of suspected PE in pregnancy: a cost-effectiveness analysis. Chest 2021; 161:1628-1641. [PMID: 34914975 DOI: 10.1016/j.chest.2021.11.036] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2021] [Revised: 11/11/2021] [Accepted: 11/27/2021] [Indexed: 11/29/2022] Open
Abstract
BACKGROUND Pulmonary embolism (PE) remains a leading cause of maternal mortality, yet diagnosis remains challenging. International diagnostic guidelines vary significantly in their recommendations, making it difficult to determine an optimal policy for evaluation. RESEARCH QUESTION Which societal-level diagnostic guideline for evaluation of suspected PE in pregnancy is an optimal policy in terms of its cost-effectiveness? STUDY DESIGN AND METHODS We constructed a complex Markov decision model to evaluate the cost-effectiveness of each identified societal guideline for diagnosis of PE in pregnancy. Our model accounted for risk stratification, empiric treatment, diagnostic testing strategies, as well as short- and long-term effects from PE, treatment with low-molecular weight heparin, and radiation exposure from advanced imaging. We considered clinical and cost outcomes of each guideline from a U.S. health care system perspective with a lifetime horizon. Clinical effectiveness and costs were measured in time-discounted quality-adjusted life years (QALYs) and U.S. dollars respectively. Strategies were compared using the incremental cost-effectiveness ratio (ICER) with a willingness-to-pay threshold of $100,000 per QALY. One-way, multi-way, and probabilistic sensitivity analyses were performed. RESULTS We identified six international societal-level guidelines. Base-case analysis showed the guideline proposed by the American Thoracic Society-Society of Thoracic Radiology (ATS-STR) yielded the highest health benefits (22.90 QALYs) and was cost-effective, with an ICER of $7,808 over the guideline proposed by the Australian Society of Thrombosis and Haemostasis and the Society of Obstetric Medicine of Australia and New Zealand (ASTH-SOMANZ). All remaining guidelines were dominated. The ATS-STR guideline-recommended strategy yielded an expected additional 2.7 QALYs per 100 patients evaluated over the ASTH-SOMANZ. Conclusions were robust to sensitivity analyses, with the ATS-STR guideline optimal in 86% of probabilistic sensitivity analysis scenarios. INTERPRETATION The ATS-STR guideline for diagnosis of suspected PE in pregnancy is cost-effective and generates better expected health outcomes than guidelines proposed by other medical societies.
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Affiliation(s)
- John Austin Mccandlish
- Imaging Clinical Effectiveness and Outcomes Research (ICEOR), Department of Radiology, Northwell Health, Manhasset, New York; Center for Health Innovations and Outcomes Research (CHIOR), Feinstein Institutes for Medical Research and Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Manhasset, New York; Georgia Institute of Technology, Atlanta, Georgia
| | - Chinara Feizullayeva
- Imaging Clinical Effectiveness and Outcomes Research (ICEOR), Department of Radiology, Northwell Health, Manhasset, New York; Center for Health Innovations and Outcomes Research (CHIOR), Feinstein Institutes for Medical Research and Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Manhasset, New York
| | - Alex Spyropoulos
- The Institute for Health System Science, The Feinstein Institutes for Medical Research and The Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Manhasset, NY, USA; Department of Medicine, Anticoagulation and Clinical Thrombosis Services, Northwell Health at Lenox Hill Hospital, New York, NY, USA; Department of Obstetrics and Gynecology, I.M. Sechenov First Moscow State Medical University, Moscow, Russia
| | - Paul P Cronin
- Emory University Hospital Department Of Radiology and Imaging Science, Atlanta, Georgia
| | - Jason Naidich
- Imaging Clinical Effectiveness and Outcomes Research (ICEOR), Department of Radiology, Northwell Health, Manhasset, New York
| | - Benjamin Brenner
- Department of Hematology, Rambam Health Care Campus, Haifa, Israel; The Ruth and Bruce Rappaport Faculty of Medicine, Technion - Israel Institute of Technology, Haifa, Israel; Department of Obstetrics and Gynaecology, The First I.M. Sechenov Moscow State Medical University (Sechenov University), Moscow, Russia
| | - Thomas Mcginn
- Center for Health Innovations and Outcomes Research (CHIOR), Feinstein Institutes for Medical Research and Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Manhasset, New York
| | - Pina C Sanelli
- Imaging Clinical Effectiveness and Outcomes Research (ICEOR), Department of Radiology, Northwell Health, Manhasset, New York; Center for Health Innovations and Outcomes Research (CHIOR), Feinstein Institutes for Medical Research and Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Manhasset, New York
| | - Stuart L Cohen
- Imaging Clinical Effectiveness and Outcomes Research (ICEOR), Department of Radiology, Northwell Health, Manhasset, New York; Center for Health Innovations and Outcomes Research (CHIOR), Feinstein Institutes for Medical Research and Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Manhasset, New York.
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Westermann-Clark E, Pepper AN, Lockey RF. Anaphylaxis: Access to Epinephrine in Outpatient Setting. Immunol Allergy Clin North Am 2021; 42:175-186. [PMID: 34823746 DOI: 10.1016/j.iac.2021.09.004] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Epinephrine is a lifesaving medication to treat systemic allergic reactions including anaphylaxis. Epinephrine autoinjectors (EAIs) are expensive, not available everywhere in the world, and shortages can limit their access. Epinephrine prefilled syringes and epinephrine kits are lower-cost alternatives to EAIs. Advantages, disadvantages, and costs of available products are discussed and the socioeconomic factors impacting access to EAIs described. EAIs designed for infants also are discussed.
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Affiliation(s)
- Emma Westermann-Clark
- Division of Allergy and Immunology, Department of Internal Medicine, University of South Florida Morsani College of Medicine, Tampa, FL, USA.
| | - Amber N Pepper
- Division of Allergy and Immunology, Department of Internal Medicine, University of South Florida Morsani College of Medicine, Tampa, FL, USA
| | - Richard F Lockey
- Division of Allergy and Immunology, Department of Internal Medicine, University of South Florida Morsani College of Medicine, Tampa, FL, USA; James A. Haley Veterans Affairs Hospital, Tampa, FL, USA
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22
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Marcum ZA, Chang CY, Barthold D, Holmes HM, Lo-Ciganic WH. Industry Payments to Physicians and Prescribing Branded Memantine and Donepezil Combination. Neurol Clin Pract 2021; 11:181-187. [PMID: 34484885 DOI: 10.1212/cpj.0000000000000870] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2020] [Accepted: 03/05/2020] [Indexed: 11/15/2022]
Abstract
Background Once-daily extended-released memantine with donepezil (hereafter memantine/donepezil) may improve medication adherence but has a 60-fold higher cost compared with combined generic components. Little is known about factors associated with prescribing memantine/donepezil. We examined the association between pharmaceutical industry payments to physicians and prescribing memantine/donepezil in Medicare. Methods A cross-sectional study was conducted. Using 2015-2016 Centers for Medicare and Medicaid Services Open Payments and Part D prescription databases, we identified unique physicians who prescribed ≥11 memantine/donepezil prescriptions from 2015 to 2016. Outcome variable was the number of memantine/donepezil prescriptions written per physician per year. The key independent variable was physician receipt of industry payments defined in 2 models: (1) number of payments and (2) amount of payment ($100 units) for memantine/donepezil received per physician per year. Multivariable Poisson regression was used, adjusting for potential confounders. Results Among 4,895 unique eligible physicians in 2015-2016, the median number of memantine/donepezil prescriptions per physician per year was 19.5 (25th percentile 13, 75th percentile 32). Physicians received between 0 and 75 payments per year (median 1, 25th percentile 0, 75th percentile 2.5) for memantine/donepezil, totaling an average of $92 per year (median $10.5, 25th percentile $0, 75th percentile $33.20). Every 1 additional payment received was associated with a 2% increase in new memantine/donepezil prescriptions prescribed per physician per year (rate ratio [RR] 1.02, 95% confidence interval [CI] 1.02-1.02). Every $100 increase in payment for memantine/donepezil was associated with a 0.3% increase in new memantine/donepezil prescriptions prescribed per physician per pear (RR 1.003, 95% CI 1.002-1.004). Conclusions Receipt of industry payments for memantine/donepezil was independently associated with increased likelihood of physician prescribing memantine/donepezil in Medicare.
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Affiliation(s)
- Zachary A Marcum
- Department of Pharmacy (ZAM, DB), University of Washington, Seattle; Department of Pharmaceutical Outcomes and Policy (C-YC, W-HL-C), Center for Drug Evaluation and Safety (C-YC, W-HL-C), College of Pharmacy, University of Florida, Gainesville; and Division of Geriatric and Palliative Medicine (HMH), The University of Texas Health Science Center at Houston, McGovern Medical School
| | - Ching-Yuan Chang
- Department of Pharmacy (ZAM, DB), University of Washington, Seattle; Department of Pharmaceutical Outcomes and Policy (C-YC, W-HL-C), Center for Drug Evaluation and Safety (C-YC, W-HL-C), College of Pharmacy, University of Florida, Gainesville; and Division of Geriatric and Palliative Medicine (HMH), The University of Texas Health Science Center at Houston, McGovern Medical School
| | - Douglas Barthold
- Department of Pharmacy (ZAM, DB), University of Washington, Seattle; Department of Pharmaceutical Outcomes and Policy (C-YC, W-HL-C), Center for Drug Evaluation and Safety (C-YC, W-HL-C), College of Pharmacy, University of Florida, Gainesville; and Division of Geriatric and Palliative Medicine (HMH), The University of Texas Health Science Center at Houston, McGovern Medical School
| | - Holly M Holmes
- Department of Pharmacy (ZAM, DB), University of Washington, Seattle; Department of Pharmaceutical Outcomes and Policy (C-YC, W-HL-C), Center for Drug Evaluation and Safety (C-YC, W-HL-C), College of Pharmacy, University of Florida, Gainesville; and Division of Geriatric and Palliative Medicine (HMH), The University of Texas Health Science Center at Houston, McGovern Medical School
| | - Wei-Hsuan Lo-Ciganic
- Department of Pharmacy (ZAM, DB), University of Washington, Seattle; Department of Pharmaceutical Outcomes and Policy (C-YC, W-HL-C), Center for Drug Evaluation and Safety (C-YC, W-HL-C), College of Pharmacy, University of Florida, Gainesville; and Division of Geriatric and Palliative Medicine (HMH), The University of Texas Health Science Center at Houston, McGovern Medical School
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Levy J, Ippolito B. Branded Price Variation in the United States Drug Market, 2010 to 2019. VALUE IN HEALTH : THE JOURNAL OF THE INTERNATIONAL SOCIETY FOR PHARMACOECONOMICS AND OUTCOMES RESEARCH 2021; 24:1237-1240. [PMID: 34452701 DOI: 10.1016/j.jval.2021.04.1272] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/11/2020] [Revised: 02/27/2021] [Accepted: 04/11/2021] [Indexed: 06/13/2023]
Abstract
The transaction price for branded drugs in the United States often varies widely by the eventual payer, a fact that can complicate research and policy discussions surrounding drug pricing. We combine publicly-available data on branded drug prices from a host of sources-prices paid by Medicare (Parts B and D), the Veterans Affairs Administration (VA), those included in the Federal Supply Schedule (FSS), invoice prices paid by pharmacies described in National Average Drug Acquisition Costs (NADAC), list prices, and payments ultimately received by drug makers-to illustrate how prices vary across the U.S. market and how these relationships changed from 2010 to 2019. We document large variation across payers and find VA prices are generally the lowest, averaging nearly 50% below list prices during our study period, which is meaningfully lower than the average prices manufacturers ultimately receive. Some net prices, like those in Part D and average payments received by manufacturers, have diverged substantially from list prices in the last decade and are now much closer to the published VA and FSS prices. In part, this reflects unexpected net price increases among published VA and FSS prices that is worthy of future study.
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Affiliation(s)
- Joseph Levy
- Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA.
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Parizo JT, Goldhaber-Fiebert JD, Salomon JA, Khush KK, Spertus JA, Heidenreich PA, Sandhu AT. Cost-effectiveness of Dapagliflozin for Treatment of Patients With Heart Failure With Reduced Ejection Fraction. JAMA Cardiol 2021; 6:926-935. [PMID: 34037681 DOI: 10.1001/jamacardio.2021.1437] [Citation(s) in RCA: 62] [Impact Index Per Article: 20.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
Importance In the Dapagliflozin and Prevention of Adverse Outcomes in Heart Failure (DAPA-HF) trial, dapagliflozin was shown to reduce cardiovascular mortality and hospitalizations due to heart failure while improving patient-reported health status. However, the cost-effectiveness of adding dapagliflozin therapy to standard of care (SOC) is unknown. Objective To estimate the cost-effectiveness of dapagliflozin therapy among patients with chronic heart failure with reduced ejection fraction (HFrEF). Design, Setting, and Participants This Markov cohort cost-effectiveness model used estimates of therapy effectiveness, transition probabilities, and utilities from the DAPA-HF trial and other published literature. Costs were derived from published sources. Patients with HFrEF included subgroups based on diabetes status and health status impairment due to heart failure. We compiled parameters from the literature including DAPA-HF, on which our model is based, and many other sources from December 2019 to February 27, 2021. We performed our analysis in February 2021. Exposures Dapagliflozin or SOC. Main Outcomes and Measures Hospitalizations for heart failure, life-years, quality-adjusted life-years (QALYs), costs, and the cost per QALY gained (incremental cost-effectiveness ratio). Results In the model, dapagliflozin therapy yielded a mean of 0.78 additional life-years and 0.46 additional QALYs compared with SOC at an incremental cost of $38 212, resulting in a cost per QALY gained of $83 650. The cost per QALY was similar for patients with or without diabetes and for patients with mild or moderate impairment of health status due to heart failure. The cost-effectiveness was most sensitive to estimates of the effect on mortality and duration of therapy effectiveness. If the cost of dapagliflozin decreased from $474 to $270 (43% decline), the cost per QALY gained would drop below $50 000. Conclusions and Relevance These findings suggest that dapagliflozin provides intermediate value compared with SOC, based on American College of Cardiology/American Heart Association benchmarks. Additional data regarding the magnitude of mortality reduction would improve the precision of cost-effectiveness estimates.
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Affiliation(s)
- Justin T Parizo
- Division of Cardiovascular Medicine, Stanford University School of Medicine, Stanford, California
| | - Jeremy D Goldhaber-Fiebert
- Stanford Health Policy, Centers for Health Policy and Primary Care and Outcomes Research, The Freeman Spogli Institute, Department of Medicine, Stanford University, Stanford, California
| | - Joshua A Salomon
- Stanford Health Policy, Centers for Health Policy and Primary Care and Outcomes Research, The Freeman Spogli Institute, Department of Medicine, Stanford University, Stanford, California
| | - Kiran K Khush
- Division of Cardiovascular Medicine, Stanford University School of Medicine, Stanford, California
| | - John A Spertus
- St Luke's Mid America Heart Institute, University of Missouri-Kansas City
| | - Paul A Heidenreich
- Division of Cardiovascular Medicine, Stanford University School of Medicine, Stanford, California.,Division of Cardiology, Veterans Affairs Palo Alto Health Care System, Palo Alto, California
| | - Alexander T Sandhu
- Division of Cardiovascular Medicine, Stanford University School of Medicine, Stanford, California
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Arbel R, Aboalhasan E, Hammerman A, Azuri J. Icosapent Ethyl for Primary Versus Secondary Prevention of Major Adverse Cardiovascular Events in Hypertriglyceridemia: Value for Money Analysis. Am J Med 2021; 134:e415-e419. [PMID: 33450273 DOI: 10.1016/j.amjmed.2020.12.023] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/18/2020] [Revised: 12/02/2020] [Accepted: 12/03/2020] [Indexed: 02/07/2023]
Abstract
BACKGROUND Icosapent ethyl (IPE) is approved for the prevention of major adverse cardiovascular events (MACE) in patients with hypertriglyceridemia. However, due to budget constraints, access to IPE will inevitably be limited to a fraction of eligible patients. To help maximize value for money spent, we estimated the number of preventable MACE when providing IPE for primary versus secondary prevention. METHODS The number of preventable MACE was estimated by dividing the available budget by the cost needed to treat (CNT) to prevent one MACE. CNT was calculated as the product of the number needed to treat (NNT) to prevent 1 MACE by therapy cost. NNT values were determined according to the Reduction of Cardiovascular Events with Icosapent Ethyl-Intervention Trial (REDUCE-IT) results. The budget limit was set as the United States' threshold suggested by the Institute for Clinical and Economic Review. Sensitivity analysis was performed regarding the cost of IPE in the United States. RESULTS The NNT to prevent 1 MACE over 4.9 years in the Reduction of Cardiovascular Events with Icosapent Ethyl-Intervention Trial primary prevention cohort was 59 (95% confidence interval [CI]: 24-∞) versus 14 (11-21) for secondary prevention. At an annual IPE cost of $2915, the CNT to prevent 1 MACE was $842,726 (95% CI: $342,804-∞) and $199,969 ($157,118-$299,953) accordingly. A total of $819 million worth of IPE can avoid 4762 MACE (95% CI: 0-11,707) versus 20,069 (13,379-25,541), when provided as primary versus secondary prevention therapy; P < .001. The number of avoided MACE is sensitive to IPE price. CONCLUSIONS Prioritizing IPE therapy for patients with an established cardiovascular disease may provide significantly more value for money than primary prevention.
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Affiliation(s)
- Ronen Arbel
- Maximizing Health Outcomes Research Lab, Sapir College, Sderot, Israel.
| | - Enis Aboalhasan
- Maximizing Health Outcomes Research Lab, Sapir College, Sderot, Israel
| | - Ariel Hammerman
- Department of Pharmaceutical Technology Assessment, Clalit Health Services Headquarters, Tel-Aviv, Israel
| | - Joseph Azuri
- Diabetes Clinic, Central District, Maccabi Healthcare Services, Tel Aviv, Israel; Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
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Arbel R, Aboalhasan E, Hammerman A, Azuri J. Usefulness of Sodium-Glucose Cotransporter 2 Inhibitors for Primary Prevention of Heart Failure in Patients With Type 2 Diabetes Mellitus. Am J Cardiol 2021; 150:65-68. [PMID: 34001339 DOI: 10.1016/j.amjcard.2021.03.040] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/12/2020] [Revised: 03/18/2021] [Accepted: 03/22/2021] [Indexed: 01/25/2023]
Abstract
The sodium-glucose cotransporter 2 inhibitors (SGLT2i) empagliflozin, canagliflozin, and dapagliflozin reduce the risk of heart failure (HF) events in patients with diabetes mellitus (DM) at high risk for HF. Differences in HF outcomes between SGLT2i were demonstrated in a recent-published meta-analysis. Nevertheless, comparative cost-effectiveness analyses of SGLT2i provided for this indication have not been published yet. Therefore, we aimed to provide a preceding economic comparison of the costs required for improving HF outcomes by these three SGLT2i. The primary outcome was the cost needed to treat (CNT) to prevent one event of hospitalization for HF or cardiovascular mortality. CNT is calculated by multiplying the annualized number needed to treat to prevent one event by the annual cost of therapy. Clinical outcome data were extracted from pre-specified cohorts of HF-naïve patients in the pivotal randomized controlled trials (RCTs). Costs of interventions were estimated as 75% of the US National Average Drug Acquisition Cost listing. Sensitivity analysis was performed to mitigate differences between the RCT's populations. We figured the CNT for the primary prevention of HF events in DM patients to be $542,328 ($409,044-$905,412) for empagliflozin, $2,347,488 ($1,066,208-∞) for canagliflozin and $2,128,374 ($1,204,740-$48,140,518) for dapagliflozin. Sensitivity analysis confirmed the cost benefit of empagliflozin. Our findings suggest that between the available SGLT2i, the cost of primary prevention of HF in patients with DM at high risk for HF is lowest with empagliflozin. These findings may help choose an SGLT2i until head-to-head RCTs, and comprehensive cost-effective analyses for this indication are available.
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Affiliation(s)
- Ronen Arbel
- Maximizing Health Outcomes Research Lab, Sapir College, Sderot, Israel.
| | - Enis Aboalhasan
- Maximizing Health Outcomes Research Lab, Sapir College, Sderot, Israel
| | - Ariel Hammerman
- Department of Pharmaceutical Technology Assessment, Clalit Health Services Headquarters, Tel-Aviv, Israel
| | - Joseph Azuri
- Diabetes Clinic, Central District, Maccabi Healthcare Services, Israel; Sackler Faculty of Medicine, Tel Aviv University, Israel
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Lakdawalla D, Li M. Association of Drug Rebates and Competition With Out-of-Pocket Coinsurance in Medicare Part D, 2014 to 2018. JAMA Netw Open 2021; 4:e219030. [PMID: 33950205 PMCID: PMC8100863 DOI: 10.1001/jamanetworkopen.2021.9030] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
IMPORTANCE Prior research has documented the increase in prescription drug rebates and the coincident increase in out-of-pocket burden for patients paying coinsurance tied to list prices. OBJECTIVE To describe the out-of-pocket burden on patients with coinsurance and assess its association with pharmaceutical competition, which increases payers' leverage to seek higher rebates. DESIGN, SETTING, AND PARTICIPANTS This retrospective cohort study used branded prescription drugs with US sales reported by publicly traded companies. The study included drugs with nonmissing, nonnegative rebates between 2014 and 2018 from SSR Health. Data analysis was conducted from June to December 2020. EXPOSURES Level of branded and generic competition and calendar year. MAIN OUTCOMES AND MEASURES Retail price markup (ie, the ratio of rebate to net price) paid by patients at the point of sale and effective out-of-pocket share (ie, coinsurance multiplied by list price divided by net price) of a standard Part D plan. Trends in these outcomes were examined and then stratified by degree of competition. RESULTS There were 3322 unique National Drug Codes in the analysis, representing 232 distinct molecules from 138 therapeutic classes in 34 disease areas. The ratio of rebate to net prices was higher and increased faster for drugs with branded and generic competitors (from 83% to 172%) than for drugs with only branded competitors (from 61% to 115%) and those without generic equivalents (from 33% to 49%). Hypothetical patients paying standard Part D coinsurance on drug list prices would have experienced an effective out-of-pocket share increase from 48% to 64% in the initial coverage phase, and from 10% to 13% in the catastrophic coverage phase between 2014 and 2018. In the coverage gap, the share increased from 92% in 2014 to 98% in 2016 and then decreased to 90% in 2018. Compared with drugs with no competition, effective out-of-pocket share paid by patients grew 50% faster for drugs with branded competitors and 100% faster for those with branded and generic competitors. CONCLUSIONS AND RELEVANCE This study found substantial increases in cost-sharing burden for patients paying coinsurance on drug list prices between 2014 and 2018, especially in markets with more pharmaceutical competition. Payers passing rebates through to patients at the point of sale could restore the benefits of competition and rebates.
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Affiliation(s)
- Darius Lakdawalla
- Leonard D. Schaeffer Center for Health Policy and Economics, University of Southern California, Los Angeles
- School of Pharmacy, University of Southern California, Los Angeles
- Sol Price School of Public Policy, University of Southern California, Los Angeles
| | - Meng Li
- Leonard D. Schaeffer Center for Health Policy and Economics, University of Southern California, Los Angeles
- Department of Health Services Research, The University of Texas MD Anderson Cancer Center, Houston
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Arbel R, Aboalhasan E, Hammerman A, Azuri J. Dapagliflozin vs. sacubitril-valsartan for prevention of heart failure events in non-diabetic patients with reduced ejection fraction: a cost per outcome analysis. Eur J Prev Cardiol 2020; 28:1665-1669. [PMID: 33624086 DOI: 10.1093/eurjpc/zwaa136] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/18/2020] [Revised: 10/23/2020] [Accepted: 11/13/2020] [Indexed: 01/21/2023]
Abstract
AIMS The Angiotensin Receptor-Neprilysin Inhibitor sacubitril-valsartan (ARNI) and dapagliflozin, a sodium-glucose transport protein 2 inhibitor, reduce the risk of heart failure hospitalization (hHF) and cardiovascular (CV) mortality in patients with reduced ejection fraction (HFrEF). Their comparative value for money is undetermined. Therefore, our aim was to compare the cost per outcome implications of utilizing dapagliflozin vs. ARNI for preventing heart failure (HF) events of non-diabetic patients with HFrEF. METHODS AND RESULTS We calculated the cost needed to treat (CNT) to prevent one HF event. The cost needed to treat was estimated by multiplying the annualized number needed to treat (NNT) to prevent one event by each therapy's annual cost. Efficacy estimates were extracted from published secondary analyses of non-diabetic patients in DAPA-HF and PARADIGM-HF trials. Drug costs were estimated as 75% of the 2020 US National Average Drug Acquisition Cost listing. Sensitivity analysis was performed to mitigate differences between the trial's populations and drug costs in various countries.The annualized NNT to prevent one HF event for dapagliflozin was 31 (95% CI 21-71) vs. 33 (95% CI 24-62) for ARNI. The CNT of dapagliflozin in the US is $141 112 (95% CI $95 592-$323 192) compared to $158 169 (95% CI $115 032-$297 166) for sacubitril-valsartan. The CNT results were sensitive to drug costs in various countries. CONCLUSION Dapagliflozin and ARNI provide comparable value for money for preventing HF events in non-diabetic patients with HFrEF. In healthcare settings where dapagliflozin's price is significantly lower than ARNI, it provides superior value for money.
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Affiliation(s)
- Ronen Arbel
- Maximizing Health Outcomes under Budget Constraints Research Lab, Department of Technology Marketing, Sapir College, Sderot, Israel
| | - Enis Aboalhasan
- Maximizing Health Outcomes under Budget Constraints Research Lab, Department of Technology Marketing, Sapir College, Sderot, Israel
| | - Ariel Hammerman
- Department of Pharmaceutical Technology Assessment, Clalit Health Services Headquarters, Tel-Aviv, Israel
| | - Joseph Azuri
- Diabetes Clinic, Central District, Maccabi Healthcare Services, Israel.,Sackler Faculty of Medicine, Tel Aviv University, Israel
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60 Years after Kefauver: Household income required to buy prescription drugs in the United States and abroad. Res Social Adm Pharm 2020; 17:1489-1495. [PMID: 33221266 DOI: 10.1016/j.sapharm.2020.11.007] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2020] [Revised: 10/01/2020] [Accepted: 11/11/2020] [Indexed: 11/20/2022]
Abstract
BACKGROUND Assessing drug prices relative to income in the US compared to other Organization for Economic Co-Operation and Development (OECD) countries provides context for policymakers seeking to improve access and affordability. METHODS Using current drug p. rice and income data, we recreate a historical analysis presented in 1960 to the Senate Subcommittee on Antitrust and Monopoly led by Sen. Estes Kefauver. We identified frequently prescribed generic and brand name drugs for US and international comparison by drug price category (low-price generics, mid-price brands, and high-price specialty brands) as a function of income. We further extend our analysis to consider US prices relative to the current Federal Poverty Level (FPL). RESULTS For the low-price drugs, all fell below 1% of all of the US income levels presented. Mid-price drugs were below 10% of income for those at the US median household income level but approached 30% of income for those at the FPL. High-price drugs varied greatly, reaching over 600% FPL for one product. CONCLUSIONS Americans receive bargain prices on par with international comparators for many low-priced generics drugs. For commonly used mid-priced drugs or high-priced specialty products, whether or not drug prices are considered a bargain in the US compared to international markets may depend on individual income. External reference pricing policies may help inform the negotiation for some drug prices, but affordability may still be limited for lower wage earners.
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Turkistani F, Sawad AB. Pharmaceutical pricing benchmarks: governmental versus private sector. J Comp Eff Res 2020; 9:1091-1100. [PMID: 33052057 DOI: 10.2217/cer-2020-0106] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
Purpose: To explore the best pricing benchmark for workers' compensation drugs reimbursement at retail pharmacies. Materials & methods: We used California workers' compensation system (CAWCS) total cost of pharmacy dispensed medications (2017-2019) as a proxy to estimate drug prices using alternative pricing mechanism fee schedules. Results: CAWCS paid 65.6% of the average wholesale price (AWP), 104.1% of Medi-Cal, 122.1% of the wholesale acquisition cost (WAC), 140.1% of the national average drug acquisition cost (NADAC), and 253.5% of the federal upper limit. In addition, we found the AWP-based formulas: CAWCS = AWP - 34.4%, Medi-Cal = AWP - 36.9%, WAC = AWP - 46.3%, NADAC = AWP - 53.2%, and federal upper limit = AWP - 74.1%. We found that AWP: 50% for generics and AWP - 18.2% for brands are the lowest paying formulas. The estimated median cost savings were $8.7 million (by adapting 97% of the WAC) and $9.5 million (by adapting the NADAC) across all states. Conclusion: NADAC was the best pricing benchmark for reimbursement of pharmacy dispensed drugs.
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Affiliation(s)
- Fatema Turkistani
- Clinical & Hospital Pharmacy Department, College of Pharmacy, Taibah University, Medina, Saudi Arabia
| | - Aseel Bin Sawad
- Clinical Pharmacy Department, College of Pharmacy, Umm Al-Qura University, Makkah, Saudi Arabia
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Ross EL, Soeteman DI. Cost-Effectiveness of Esketamine Nasal Spray for Patients With Treatment-Resistant Depression in the United States. Psychiatr Serv 2020; 71:988-997. [PMID: 32631129 PMCID: PMC7920520 DOI: 10.1176/appi.ps.201900625] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
OBJECTIVE This study aimed to estimate the cost-effectiveness of esketamine, a novel intranasally dosed antidepressant, for patients in the United States with treatment-resistant depression. METHODS A decision-analytic model parameterized with efficacy data from phase 3 randomized trials of esketamine was used to simulate the effects of treatment with esketamine versus oral antidepressants over a 5-year horizon, from both societal and health care sector perspectives. Outcomes included remission and response of depression, quality-adjusted life-years (QALYs), costs, and incremental cost-effectiveness ratios (ICERs) for esketamine. Value-based prices were calculated, defined as the per-dose price at which esketamine would become cost-effective given cost-effectiveness thresholds of $50,000/QALY, $100,000/QALY, and $150,000/QALY. Uncertainty in these outcomes was assessed with probabilistic sensitivity analyses. Key model parameters included the efficacy of esketamine versus oral antidepressants (relative risk of 1.39 for remission; 1.32 for response) and the monthly cost of esketamine ($5,572 for month 1; $1,699-$2,244 thereafter). RESULTS Over 5 years, esketamine was projected to increase time in remission from 25.3% to 31.1% of life-years, resulting in a gain of 0.07 QALYs. Esketamine increased societal costs by $16,617 and health care sector costs by $16,995. Base case ICERs were $237,111/QALY (societal) and $242,496/QALY (health care sector). Probabilistic sensitivity analysis showed a greater than 95% likelihood that esketamine's ICER would be above $150,000/QALY. At a cost-effectiveness threshold of $150,000/QALY, esketamine's value-based price was approximately $140/dose (versus a current price of $240/dose). CONCLUSIONS Esketamine is unlikely to be cost-effective for management of treatment-resistant depression in the United States unless its price falls by more than 40%.
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Affiliation(s)
- Eric L Ross
- Department of Psychiatry, McLean Hospital, Belmont, Massachusetts (Ross); Department of Psychiatry, Massachusetts General Hospital (Ross), Department of Psychiatry, Harvard Medical School (Ross), and Center for Health Decision Science, Harvard T. H. Chan School of Public Health, all in Boston (Soeteman)
| | - Djøra I Soeteman
- Department of Psychiatry, McLean Hospital, Belmont, Massachusetts (Ross); Department of Psychiatry, Massachusetts General Hospital (Ross), Department of Psychiatry, Harvard Medical School (Ross), and Center for Health Decision Science, Harvard T. H. Chan School of Public Health, all in Boston (Soeteman)
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Tatar M, Keeshin SW, Mailliard M, Wilson FA. Cost-effectiveness of Universal and Targeted Hepatitis C Virus Screening in the United States. JAMA Netw Open 2020; 3:e2015756. [PMID: 32880650 PMCID: PMC7489814 DOI: 10.1001/jamanetworkopen.2020.15756] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/16/2020] [Accepted: 06/24/2020] [Indexed: 12/11/2022] Open
Abstract
Importance Between 2 and 3.5 million people live with chronic hepatitis C virus (HCV) infection in the US, most of whom (approximately 75%) are not aware of their disease. Despite the availability of effective HCV treatment in the early stages of infection, HCV will result in thousands of deaths in the next decade in the US. Objective To investigate the cost-effectiveness of universal screening for all US adults aged 18 years or older for HCV in the US and of targeted screening of people who inject drugs. Design, Setting, and Participants This simulated economic evaluation used cohort analyses in a Markov model to perform a 10 000-participant Monte Carlo microsimulation trail to evaluate the cost-effectiveness of HCV screening programs, and compared screening programs targeting people who inject drugs with universal screening of US adults age 18 years or older. Data were analyzed in December 2019. Exposures Cost per quality-adjusted life-year (QALY). Main Outcomes and Measures Cost per QALY gained. Results In a 10 000 Monte Carlo microsimulation trail that compared a baseline of individuals aged 40 years (men and women) and people who inject drugs in the US, screening and treatment for HCV were estimated to increase total costs by $10 457 per person and increase QALYs by 0.23 (approximately 3 months), providing an incremental cost-effectiveness ratio of $45 465 per QALY. Also, universal screening and treatment for HCV are estimated to increase total costs by $2845 per person and increase QALYs by 0.01, providing an incremental cost-effectiveness ratio of $291 277 per QALY. Conclusions and Relevance The findings of this study suggest that HCV screening for people who inject drugs may be a cost-effective intervention to combat HCV infection in the US, which could potentially decrease the risk of untreated HCV infection and liver-related mortality.
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Affiliation(s)
- Moosa Tatar
- Matheson Center for Health Care Studies, the University of Utah, Salt Lake City
| | - Susana W. Keeshin
- Division of Infectious Disease, the University of Utah School of Medicine, Salt Lake City
| | - Mark Mailliard
- University of Nebraska Medical Center College of Medicine, Omaha
| | - Fernando A. Wilson
- Matheson Center for Health Care Studies, the University of Utah, Salt Lake City
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Sherrow C, Attwood K, Zhou K, Mukherjee S, Iyer R, Fountzilas C. Sequencing Systemic Therapy Pathways for Advanced Hepatocellular Carcinoma: A Cost Effectiveness Analysis. Liver Cancer 2020; 9:549-562. [PMID: 33083280 PMCID: PMC7548874 DOI: 10.1159/000508485] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/19/2019] [Accepted: 05/06/2020] [Indexed: 02/04/2023] Open
Abstract
INTRODUCTION Hepatocellular carcinoma (HCC) is the most common form of liver cancer worldwide and carries a poor prognosis. Historically, sorafenib was the only available systemic treatment for advanced HCC. However, in recent years, 6 new treatments have been approved by the US Food and Drug Administration (FDA): regorafenib, lenvatinib, cabozantinib, pembrolizumab, ramucirumab, and nivolumab. Data are lacking regarding the most appropriate sequencing pathway for these agents. Our objective was to conduct a comprehensive cost effectiveness analysis (CEA) of different 1st- and 2nd-line treatment pathways for HCC reflecting all new drug approvals, and then use our data to provide guidance for clinicians on which pathway is the most cost-effective. MATERIALS AND METHODS Markov models were used to evaluate the cost effectiveness of 8 different 1st- and 2nd-line treatment sequences. The model allowed for 9 possible states. Cost effectiveness ratios (CER) and incremental CER (ICER) were calculated to compare costs between different pathways and against a willingness-to-pay (WTP) threshold. Efficacy and toxicity data were extracted from the landmark trials for each agent. All agents except ramucirumab were included. The cost of each agent was based on the wholesale acquisition cost (WAC) in USD as of June 2019. Monte-Carlo methods were used to simulate the experience of 1,000,000 patients per treatment sequence for a 12-month period. RESULTS The pathway with the lowest CER was sorafenib, followed by pembrolizumab (USD 227,741.03/quality-adjusted life year [QALY]). ICER analysis supported implementing 2nd-line pembrolizumab-based pathways at a higher WTP threshold of 300,000/quality-adjusted life year. Sensitivity analysis did not substantially change these results. CONCLUSIONS The most cost-effective strategy was 1st-line tyrosine kinase inhibitor therapy followed by 2nd-line immunotherapy. All pathways exceeded a commonly accepted WTP of USD 100-150,000/QALY. Our preliminary results warrant further studies to best inform real-world practices.
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Affiliation(s)
- Christopher Sherrow
- Department of Pharmacy, Roswell Park Comprehensive Cancer Center, Buffalo, New York, USA
| | - Kristopher Attwood
- Department of Biostatistics and Bioinformatics, Roswell Park Comprehensive Cancer Center, Buffalo, New York, USA
| | - Kehua Zhou
- Catholic Health System Internal Medicine Training Program, State University of New York at Buffalo, Buffalo, New York, USA
| | - Sarbajit Mukherjee
- GI Division, Department of Medicine, Roswell Park Comprehensive Cancer Center, Buffalo, New York, USA
| | - Renuka Iyer
- GI Division, Department of Medicine, Roswell Park Comprehensive Cancer Center, Buffalo, New York, USA
| | - Christos Fountzilas
- GI Division, Department of Medicine, Roswell Park Comprehensive Cancer Center, Buffalo, New York, USA,*Christos Fountzilas, MD FACP, Department of Medicine, GI Division and Early Phase Clinical Trial Program, Roswell Park Comprehensive Cancer Center, Scott Bieler Clinical Science Center, 9th Floor P-938, Elm and Carlton Streets, Buffalo, NY 14263 (USA),
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Glickman A, Brennecke A, Tayebnejad A, Matsuo K, Guntupalli SR, Sheeder J. Cost-effectiveness of apixaban for prevention of venous thromboembolic events in patients after gynecologic cancer surgery. Gynecol Oncol 2020; 159:476-482. [PMID: 32854972 DOI: 10.1016/j.ygyno.2020.07.096] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2020] [Accepted: 07/23/2020] [Indexed: 10/23/2022]
Abstract
OBJECTIVE The cost-effectiveness of apixaban was compared with enoxaparin for prevention of postoperative venothromboembolic events (VTE) in gynecologic oncology patients. Current guidelines recommend thromboprophylaxis with low molecular weight heparin for 28 days following gynecologic cancer surgery, but recent trials suggest that oral apixaban may be a safe, patient-preferred alternative. Apixaban was superior to enoxaparin in a Canadian cost-effectiveness analysis using orthopedics trial data. METHODS Medication costs, adherence rates, event rates, event costs, and utility decrements were estimated using prior clinical trial data and literature review for input into a short-term decision model to simulate outcomes in a hypothetical cohort of 1000 patients. Incremental cost-effectiveness ratios (ICERs) were calculated as net cost difference per quality-adjusted life year (QALY) gained. Input values at which net costs and QALYs were equivalent and ICERs at upper and lower bounds were evaluated. RESULTS Using aggregated costs, apixaban was less expensive and more effective than enoxaparin, and remained so or had high value in all scenarios on sensitivity analysis. Examining disaggregated ICERs, apixaban was cost-effective for deep venous thrombosis (DVT); of high value for clinically-relevant non-major bleeding (CRNMB) ($411); low value for major bleeding ($183,465), VTE-related death ($2,711,229), and all-cause mortality ($297,522); and not cost-effective for pulmonary embolism prevention. CONCLUSIONS Apixaban is more cost-effective than enoxaparin for the prevention of postoperative VTE in patients with gynecologic cancer. This appears to be driven largely by DVT and CRNMB prevention.
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Affiliation(s)
- Amanda Glickman
- Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, University of Colorado School of Medicine Anschutz Medical Campus, Aurora, CO, USA
| | - Alyse Brennecke
- Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, University of Colorado School of Medicine Anschutz Medical Campus, Aurora, CO, USA
| | - Anna Tayebnejad
- Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, University of Colorado School of Medicine Anschutz Medical Campus, Aurora, CO, USA
| | - Koji Matsuo
- Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, University of Southern California Keck School of Medicine, Los Angeles, CA, USA
| | - Saketh R Guntupalli
- Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, University of Colorado School of Medicine Anschutz Medical Campus, Aurora, CO, USA
| | - Jeanelle Sheeder
- Division of Family Planning, Department of Obstetrics and Gynecology, University of Colorado School of Medicine Anschutz Medical Campus, Aurora, CO, USA.
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Ippolito B, Levy JF, Anderson GF. Abandoning List Prices In Medicaid Drug Reimbursement Did Not Affect Spending. Health Aff (Millwood) 2020; 39:1202-1209. [PMID: 32634350 DOI: 10.1377/hlthaff.2019.01354] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
State fee-for-service Medicaid programs have traditionally based payments to pharmacies for drugs on a percentage of the drugs' list price. Because list prices have increased more quickly than the prices actually paid by pharmacies, estimating appropriate reimbursements has become challenging. In recent years most states have switched to models where payments were based instead on results from a survey of pharmacy invoices. We examined how this changed fee-for-service Medicaid drug spending. We found that the policy change had minimal, if any, effects on overall Medicaid drug spending. This was at least partially explained by concomitant sharp increases in dispensing fees paid to pharmacies, designed to help cover operating expenses and profit margins. We discuss ways to improve invoice-based pricing approaches and lower costs if desired.
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Affiliation(s)
- Benedic Ippolito
- Benedic Ippolito is an economist at the American Enterprise Institute, in Washington, D.C
| | - Joseph F Levy
- Joseph F. Levy is an assistant scientist in the Department of Health Policy and Management at the Johns Hopkins Bloomberg School of Public Health, in Baltimore, Maryland
| | - Gerard F Anderson
- Gerard F. Anderson is a professor of health policy and management and a professor of international health at the Johns Hopkins Bloomberg School of Public Health, a professor of medicine at the Johns Hopkins School of Medicine, and director of the Johns Hopkins Center for Hospital Finance and Management
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Mattingly TJ, Love BL. Changes in Cost-Effectiveness for Chronic Hepatitis C Virus Pharmacotherapy: The Case for Continuous Cost-Effectiveness Analyses. J Manag Care Spec Pharm 2020; 26:879-886. [PMID: 32584675 PMCID: PMC10391261 DOI: 10.18553/jmcp.2020.26.7.879] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
BACKGROUND Cost-effectiveness evaluations for hepatitis C virus (HCV) treatments have been published frequently, but new products with significant cost and effectiveness differences make these analyses obsolete. How valuable are economic models for a fixed time period in a dynamic market? OBJECTIVE To estimate the cost-effectiveness of the best available HCV treatment at different points in time, using the same comparator to demonstrate how rapid innovation in a disease area influences economic outcomes. METHODS A Markov model was used to calculate the cost-effectiveness of treatment in 2010, 2012, 2014, 2016, and 2018 compared with a standard comparator (no treatment) from the payer perspective. Expected drug costs and treatment effectiveness estimates for sustained virologic response (SVR) were calculated using recommended regimens for each of the 6 HCV genotypes at each time point and distribution of genotypes in the United States. Patients entered the model with different stages of fibrosis. Utility estimates for each health state were used to calculate quality-adjusted life-years (QALYs) earned at each cycle. Incremental cost-effectiveness ratios were reported for each year to compare the "treatment versus no treatment" decision at that time. RESULTS No HCV treatment resulted in a gain of 11.54 QALYs over a 20-year time horizon at a cost of $42,938. Costs for treated groups were $69,075, $123,267, $125,431, $86,782, and $56,470 for the 2010, 2012, 2014, 2016, and 2018 scenarios, respectively. QALYs gained for treated groups were 12.90, 12.97, 13.34, 13.39, and 13.46 for the 2010, 2012, 2014, 2016, and 2018 scenarios, respectively. The incremental cost-effectiveness ratios in each year compared with no treatment were $19,218 per QALY, $56,104 per QALY, $45,829 per QALY, $23,699 per QALY, and $7,048 per QALY. CONCLUSIONS Treatment effectiveness for HCV has increased steadily, while treatment costs increased substantially from 2010-2014 before decreasing to its lowest point in 2018. Thus, the dynamic nature of innovation creates the need for iterative cost-effectiveness analyses. DISCLOSURES No outside funding supported this study. Mattingly reports unrelated consulting from the National Health Council, Bristol Myers Squibb, G&W Laboratories, Allergy and Asthma Foundation of American, and the Massachusetts Health Policy Commission. Love reports an unrelated research grant from the American Cancer Society.
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Affiliation(s)
- T. Joseph Mattingly
- Department of Pharmaceutical Health Services Research, University of Maryland School of Pharmacy, Baltimore
| | - Bryan L. Love
- Department of Clinical Pharmacy and Outcomes Sciences, University of South Carolina College of Pharmacy, Columbia
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Mattingly TJ, Hogue MD. Pharmacy's Call for Authorities to Aggressively Enforce Laws Addressing Price Gouging. J Manag Care Spec Pharm 2020; 26:952-955. [PMID: 32329404 PMCID: PMC10391148 DOI: 10.18553/jmcp.2020.20166] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Early reports of potential treatment for coronavirus disease (COVID-19) have raised concerns related to pharmaceutical distribution. Despite the lack of high-quality evidence, the mere hope of effectiveness of potential treatments, such as hydroxychloroquine, has led to surges in demand for these products, and many pharmacists are already informally reporting shortages through social channels. As manufacturers and wholesale distributors struggle to fulfill orders for drugs such as hydroxychloroquine, short-term price increases may seem reasonable in a free market when demand increases. However, any price increases by manufacturers, wholesale distributors, and pharmacies might be seen as exploitive gouging of consumers during a declared emergency. In addition to concerns of price gouging, increases in prescription drug utilization during the pandemic may lead to increases in spending for all payers as members may be treated for COVID-19. This article explores pharmaceutical supply chain and drug pricing nuances that may cause problems for payers and pharmacies as the country battles this global pandemic. DISCLOSURES: No funding supported the writing of this article. Mattingly reports unrelated consulting fees from the National Health Council, Bristol Myers Squibb, G&W Laboratories, Allergy and Asthma Foundation of American, and the Massachusetts Health Policy Commission. Hogue has nothing to disclose.
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Affiliation(s)
- T Joseph Mattingly
- Department of Pharmaceutical Health Services Research, University of Maryland School of Pharmacy, Baltimore, California
| | - Michael D Hogue
- Loma Linda University School of Pharmacy and Center for Interprofessional Education, Loma Linda, California
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Mattingly TJ, Slejko JF, Onukwugha E, Perfetto EM, Kottilil S, Mullins CD. Value in Hepatitis C Virus Treatment: A Patient-Centered Cost-Effectiveness Analysis. PHARMACOECONOMICS 2020; 38:233-242. [PMID: 31788751 PMCID: PMC7081653 DOI: 10.1007/s40273-019-00864-8] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/30/2023]
Abstract
BACKGROUND Innovations in hepatitis C virus (HCV) therapy included in traditional comparative evaluations focus on sustained virologic response (SVR) without addressing challenges patients report beyond virologic cure. This study aims to evaluate the cost-effectiveness of HCV drug therapy with a patient-centered approach. METHODS An individual-based Markov model was constructed using guidance from a stakeholder advisory board (SAB), a patient Delphi panel, and published literature to evaluate direct-acting antivirals (DAAs) compared to no treatment. The United States (US) health sector and societal perspectives were considered for 10- and 20-year time horizons. Inputs for treatment costs and effectiveness reflect a generic regimen. Indirect costs used for the societal model included estimates from self-reported productivity in a matched-control sample. Beyond the traditional quality-adjusted life-year (QALY) health outcome, this study included two novel measures developed from the Delphi panel and SAB: infected life-years and workdays missed. All costs were measured in 2018 US dollars. RESULTS Health sector costs and QALYs were higher in the treatment group in both 10- and 20-year models. Total infected life-years and workdays missed were reduced in the treatment group for both models. When costs of absenteeism, presenteeism, and patient/caregiver time were included, the DAA intervention was cost-saving at both 10 and 20 years. Health sector results were sensitive to drug costs and utility estimates for post-SVR health states. Societal results were sensitive to presenteeism estimates and drug costs. CONCLUSION Treatment was cost-effective from a health sector perspective and cost-saving when including non-health costs such as patient/caregiver time and productivity.
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Affiliation(s)
- T Joseph Mattingly
- Department of Pharmacy Practice and Science, University of Maryland School of Pharmacy, 20 North Pine Street, N415, Baltimore, MD, 21201, USA.
| | - Julia F Slejko
- Department of Pharmaceutical Health Services Research, University of Maryland School of Pharmacy, Baltimore, MD, USA
| | - Eberechukwu Onukwugha
- Department of Pharmaceutical Health Services Research, University of Maryland School of Pharmacy, Baltimore, MD, USA
| | - Eleanor M Perfetto
- Department of Pharmaceutical Health Services Research, University of Maryland School of Pharmacy, Baltimore, MD, USA
- National Health Council, Washington, DC, USA
| | | | - C Daniel Mullins
- Department of Pharmaceutical Health Services Research, University of Maryland School of Pharmacy, Baltimore, MD, USA
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Warburton A, Serafini R, Shuham B, Leader A, Barazani S, Moser JA, Meah Y. Leveraging NADAC to Steer Drug Formularies in Resource-Limited Clinics. JOURNAL OF SCIENTIFIC INNOVATION IN MEDICINE 2019. [DOI: 10.29024/jsim.21] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023] Open
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Hochheiser L, Hornberger J, Turner M, Lyman GH. Multi-gene assays: effect on chemotherapy use, toxicity and cost in estrogen receptor-positive early stage breast cancer. J Comp Eff Res 2019; 8:289-304. [DOI: 10.2217/cer-2018-0137] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2023] Open
Abstract
Aim: To assess multi-gene assay (MGA) effects on chemotherapy use, toxicities, recurrences, and costs in estrogen receptor-positive early breast cancer. Methods: Meta-analysis performed using data from public databases. Results: Studies included 12,202 women. Relative to no testing, chemotherapy use was higher with 12-gene and 70-gene and lower with PAM50 (commercial) and 21-gene MGAs. Overall, 1643 distant recurrences occurred with no testing, declining by 231 (21-gene), 121 (70-gene), 54 (12-gene) and 94 (PAM50); only the 21-gene assay resulted in no risk of increasing the number of distant recurrences. Relative to ‘no testing’, total cost of care declined only with 21-gene MGA. Conclusion: MGAs differ in chemotherapy use and related outcomes for women with estrogen receptor-positive early breast cancer.
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Affiliation(s)
- Lou Hochheiser
- Professor Emeritus, Department of Family Practice, University of Vermont, Burlington, VT 83001, USA
| | | | | | - Gary H Lyman
- Fred Hutchinson Cancer Center & The University of Washington, Seattle, WA 98109, USA
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Hung A, Mullins CD, Slejko JF, Haines ST, Shaya F, Lugo A. Using a Budget Impact Model Framework to Evaluate Antidiabetic Formulary Changes and Utilization Management Tools. J Manag Care Spec Pharm 2019; 25:342-349. [PMID: 30816818 PMCID: PMC7210727 DOI: 10.18553/jmcp.2019.25.3.342] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
BACKGROUND Traditional budget impact models predict the financial consequences of a new drug entering the market. This study provides an example of applying the budget impact framework to a new research question of interest to managed care organizations-what is the budget impact of our formulary and utilization management (UM) policy changes? OBJECTIVE To predict the 3-year annual budgetary impact of TRICARE's antidiabetic formulary and UM policy changes using TRICARE claims data. METHODS A budget impact model was built in Microsoft Excel using health plan claims data for a 3-year time horizon. Model outcomes included spending on antidiabetic medications and medications used for side effect treatment. In sensitivity analyses, medical costs from inpatient, outpatient, and emergency room visits were also estimated. Model inputs included health plan antidiabetic medication utilization, as well as publicly available drug cost, rebate, dispensing fee, and patient cost-sharing estimates. Type of enrollee and pharmacy were also incorporated into the model. Sensitivity analyses varied estimates for utilization switch rates between preferred and nonpreferred agents, drug costs, rebates, and dispensing fees, as well as predicted impact from implementation delays. RESULTS For the 623,827 affected by the formulary and UM policy changes, the model predicted annual savings that increased from $24 million in the first year to $43 million in the third year after the changes. The majority of savings came from drug acquisition costs, as opposed to rebates, copays, and dispensing fees. Sensitivity analyses found savings across all varied parameters and scenarios except an unlikely scenario when 0% of utilization switched from nonpreferred to preferred agents. The model also predicted that the formulary and UM policy changes would lead to $529,439 in savings from medical visit costs in Year 3. CONCLUSIONS This budget impact model predicted cost savings from the payer's formulary and UM policy changes. DISCLOSURES This project was supported by grant number F32HS024857 from the Agency for Healthcare Research and Quality (AHRQ), which contracted with the University of Maryland School of Pharmacy to conduct this study. The content is solely the responsibility of the authors and does not necessarily represent the official views of the AHRQ, which had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; or design to submit the manuscript for publication. The findings discussed in this manuscript represent the views of the authors and do not necessarily reflect the views of the Department of Defense, the Defense Health Agency, nor the Departments of the Army, Navy, and Air Force. Hung reports a grant from the AHRQ, during the conduct of the study, and personal fees from CVS Health and BlueCross BlueShield Association, outside the submitted work. Mullins reports grants and personal fees from Bayer and Pfizer and personal fees from Boehringer-Ingelheim, Janssen/J&J, Regeneron, and Sanofi, outside the submitted work. Mullins, Slejko, and Shaya are employed by the University of Maryland School of Pharmacy. Haines and Lugo have nothing to disclose. Part of this content was previously presented as a poster at the 2017 AMCP Managed Care & Specialty Pharmacy Annual Meeting; March 27-30, 2017; Denver, CO, and as poster and oral presentations at the 2017 AMCP Nexus Meeting; October 16-19, 2017; Dallas, TX. Part of this content was published as Hung's PhD dissertation.
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Affiliation(s)
- Anna Hung
- Duke Clinical Research Institute, Durham, North Carolina
| | | | | | | | - Fadia Shaya
- University of Maryland School of Pharmacy, Baltimore
| | - Amy Lugo
- Defense Health Agency, San Antonio, Texas
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Evaluating the Cost-Effectiveness of Hydrogel Rectal Spacer in Prostate Cancer Radiation Therapy. Pract Radiat Oncol 2018; 9:e172-e179. [PMID: 30342180 DOI: 10.1016/j.prro.2018.10.003] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2018] [Revised: 10/01/2018] [Accepted: 10/04/2018] [Indexed: 12/22/2022]
Abstract
PURPOSE A hydrogel rectal spacer (HRS) is a medical device that is approved by the U.S. Food and Drug Administration to increase the separation between the prostate and rectum. We conducted a cost-effectiveness analysis of HRS use for reduction in radiation therapy (RT) toxicities in patients with prostate cancer (PC) undergoing external beam RT (EBRT). METHODS AND MATERIALS A multistate Markov model was constructed from the U.S. payer perspective to examine the cost-effectiveness of HRS in men with localized PC receiving EBRT (EBRT alone vs EBRT + HRS). The subgroups analyzed included site of HRS placement (hospital outpatient, physician office, ambulatory surgery center) and proportion of patients with good baseline erectile function (EF). Data on EF, gastrointestinal and genitourinary toxicities incidence, and potential risks associated with HRS implantation were obtained from a recently published randomized clinical trial. Health utilities and costs were derived from the literature and the 2018 Physician Fee Schedule and were discounted 3% annually. Quality-adjusted life years (QALYs) and costs were modeled for a 5-year period from receipt of RT. Probabilistic sensitivity analysis and value-based threshold analyses were conducted. RESULTS The per-patient 5-year incremental cost for spacers administered in a hospital outpatient setting was $3578, and the incremental effectiveness was 0.0371 QALYs. The incremental cost-effectiveness ratio was $96,440/QALY for patients with PC undergoing HRS insertion in a hospital and $39,286/QALY for patients undergoing HRS insertion in an ambulatory facility. For men with good baseline EF, the incremental cost-effectiveness ratio was $35,548/QALY and $9627/QALY in hospital outpatient and ambulatory facility settings, respectively. CONCLUSIONS Based on the current Medicare Physician Fee Schedule, HRS is cost-effective at a willingness to pay threshold of $100,000. These results contain substantial uncertainty, suggesting more evidence is needed to refine future decision-making.
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Mattingly TJ, Levy JF, Slejko JF, Onwudiwe NC, Perfetto EM. Estimating Drug Costs: How do Manufacturer Net Prices Compare with Other Common US Price References? PHARMACOECONOMICS 2018; 36:1093-1099. [PMID: 29752675 PMCID: PMC6061401 DOI: 10.1007/s40273-018-0667-9] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/15/2023]
Abstract
BACKGROUND Drug costs are frequently estimated in economic analyses using wholesale acquisition cost (WAC), but what is the best approach to develop these estimates? Pharmaceutical manufacturers recently released transparency reports disclosing net price increases after accounting for rebates and other discounts. OBJECTIVE Our objective was to determine whether manufacturer net prices (MNPs) could approximate the discounted prices observed by the U.S. Department of Veterans Affairs (VA). METHODS We compared the annual, average price discounts voluntarily reported by three pharmaceutical manufacturers with the VA price for specific products from each company. The top 10 drugs by total sales reported from company tax filings for 2016 were included. The discount observed by the VA was determined from each drug's list price, reported as WAC, in 2016. Descriptive statistics were calculated for the VA discount observed and a weighted price index was calculated using the lowest price to the VA (Weighted VA Index), which was compared with the manufacturer index. RESULTS The discounted price as a percentage of the WAC ranged from 9 to 74%. All three indexes estimated by the average discount to the VA were at or below the manufacturer indexes (42 vs. 50% for Eli Lilly, 56 vs. 65% for Johnson & Johnson, and 59 vs. 59% for Merck). CONCLUSIONS Manufacturer-reported average net prices may provide a close approximation of the average discounted price granted to the VA, suggesting they may be a useful proxy for the true pharmacy benefits manager (PBM) or payer cost. However, individual discounts for products have wide variation, making a standard discount adjustment across multiple products less acceptable.
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Affiliation(s)
- T Joseph Mattingly
- University of Maryland School of Pharmacy, 20 North Pine Street, N415, Baltimore, MD, 21201, USA.
| | - Joseph F Levy
- University of Maryland School of Pharmacy, 20 North Pine Street, N415, Baltimore, MD, 21201, USA
| | - Julia F Slejko
- University of Maryland School of Pharmacy, 20 North Pine Street, N415, Baltimore, MD, 21201, USA
| | | | - Eleanor M Perfetto
- University of Maryland School of Pharmacy, 20 North Pine Street, N415, Baltimore, MD, 21201, USA
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Whittington MD, Campbell JD, McQueen RB. Achieving high value care for all and the perverse incentives of 340B price agreements. Neurol Clin Pract 2018; 8:148-152. [PMID: 29708214 PMCID: PMC5914743 DOI: 10.1212/cpj.0000000000000437] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
Section 340B of the Public Health Service Act requires drug manufacturers to enter into price agreements with the Department of Health and Human Services. These agreements result in variation in the price paid to acquire a drug by sector, which complicates the price used in cost-effectiveness analyses. We describe the transactions and sectors in a 340B agreement using a multiple sclerosis drug. Cost-effectiveness estimates were calculated for the drug using drug prices from the manufacturer and payer perspective. We found the amount paid to the manufacturer (340B price) was a good value ($118,256 per quality-adjusted life-year); however, from the payer drug cost perspective, good value ($196,683 per quality-adjusted life-year) was not achieved. Given that emerging value frameworks incorporate cost-effectiveness, these price variations may have downstream negative consequences, including inaccurate coverage and reimbursement policy recommendations. Upcoming policy changes to the 340B program should incentivize pricing schemes hinged on transparency and value.
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Affiliation(s)
- Melanie D Whittington
- Department of Clinical Pharmacy, University of Colorado Anschutz Medical Campus, Aurora
| | - Jonathan D Campbell
- Department of Clinical Pharmacy, University of Colorado Anschutz Medical Campus, Aurora
| | - R Brett McQueen
- Department of Clinical Pharmacy, University of Colorado Anschutz Medical Campus, Aurora
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