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Tazi A, Errachidi F, Sonawane D, Tahri G, Rao S, Mehta S. An economic model to understand the cost-effectiveness of olanzapine orally dispersible tablets (ODT) and olanzapine film coated tablets as a group compared with other oral atypical antipsychotics for treating schizophrenia in Morocco. Ann Gen Psychiatry 2024; 23:33. [PMID: 39294740 PMCID: PMC11412040 DOI: 10.1186/s12991-024-00516-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/07/2024] [Accepted: 08/06/2024] [Indexed: 09/21/2024] Open
Abstract
BACKGROUND Antipsychotic medications are the primary treatment for schizophrenia, with olanzapine being an effective medication for schizophrenia. The economic cost for each individual with schizophrenia is high, with antipsychotic medication being a major expense. This study aims to develop an economic decision model that compares different treatment options for schizophrenia patients, including olanzapine Orally Dispersible Tablets (ODT), olanzapine [ODT + Standard Oral Tablet (SOT)], risperidone (ODT + SOT), and aripiprazole (ODT + SOT), to determine their cost-effectiveness with an objective to optimize healthcare resource allocation in Morocco. METHODS The study used published medical literature and a clinical expert panel to develop a decision analytic model. This model was designed to capture parameters such as adherence levels, treatment discontinuation, relapse with and without hospitalization, quality-adjusted life years (QALYs), treatment-related adverse events, healthcare resource utilization, and associated costs. The main outcomes of interest included the total annual direct cost per treatment, QALYs, and incremental cost-effectiveness ratio (ICER) per 1 QALY gained. One-way and probabilistic sensitivity analyses were employed to account for parameter uncertainty. RESULTS According to the simulation model, the ODT and ODT + SOT as a group form of olanzapine was the most effective treatment option in terms of the lowest percentages of inpatient relapse, and patients who remained stable (11% and 79% respectively) than risperidone (19% and 62% respectively) and aripiprazole ODT (26% and 50% respectively) and ODT + SOT formulation groups. Olanzapine (ODT + SOT) therapy group was cost-effective when compared to the combined group of ODT + SOT forms of risperidone [ICER: Moroccan Dirham (MAD) 103,907], and aripiprazole (ICER: MAD 65,047). Additionally, olanzapine ODT was found to be cost-effective compared to olanzapine SOT with an ICER of MAD 3921, risperidone ODT with an ICER of MAD 1,02,298, risperidone SOT with an ICER of MAD 31,088, and aripiprazole ODT or SOT formulations. All the above ICERs fall under the willingness-to-pay threshold in Morocco of MAD 250,832.40. Sensitivity analyses confirmed the reliability of the findings. CONCLUSIONS The model concluded that olanzapine ODT is the most cost-effective first-line treatment option for schizophrenia in Morocco when compared to other atypical antipsychotic medications in ODT and SOT formulations.
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Affiliation(s)
- Ahmed Tazi
- Department of Pharmacology & Biology, Sidi Mohamed Ben Abdellah University (USMBA), Fez, Morocco
| | - Faouzi Errachidi
- Department of Pharmacology & Biology, Sidi Mohamed Ben Abdellah University (USMBA), Fez, Morocco
| | - Dipesh Sonawane
- Department of Medical Affairs and Clinical Research, Sun Pharmaceutical Industries Limited, Western Express Highway, Goregaon East (Near JVLR Junction), Mumbai, 400 063, India.
| | - Ghizlane Tahri
- Department of Medical Affairs and Clinical Research, Sun Pharmaceuticals Morocco LLC, El Maârif-Casablanca, Morocco
| | - Sameer Rao
- Department of Medical Affairs and Clinical Research, Sun Pharmaceutical Industries Limited, Western Express Highway, Goregaon East (Near JVLR Junction), Mumbai, 400 063, India
| | - Suyog Mehta
- Department of Medical Affairs and Clinical Research, Sun Pharma Laboratories Ltd, Mumbai, India
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Adhikari K, Kamal KM, Jeun KJ, Nolfi DA, Ashraf MN, Zacker C. Real-World Effectiveness, Economic, and Humanistic Outcomes of Selected Oral Antipsychotics in Patients with Schizophrenia: A Systematic Review Evaluating Global Evidence. CLINICOECONOMICS AND OUTCOMES RESEARCH 2024; 16:621-645. [PMID: 39257455 PMCID: PMC11385900 DOI: 10.2147/ceor.s469024] [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: 04/23/2024] [Accepted: 08/03/2024] [Indexed: 09/12/2024] Open
Abstract
Background Schizophrenia is a complex, chronic mental health disorder that confers a substantial disease burden globally. Oral antipsychotic treatments (OATs) are the mainstay for treating early and advanced stages of schizophrenia. Our systematic review aimed to synthesize literature describing real-world effectiveness, economic, and humanistic outcomes of OATs (asenapine, brexpiprazole, cariprazine, iloperidone, lumateperone, lurasidone, olanzapine/samidorphan, paliperidone, and quetiapine) for successful management of the disease. Methods PubMed, American Psychological Association PsycINFO (EBSCOhost), and Cumulative Index of Nursing and Allied Health Literature were searched according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Studies reporting real-world effectiveness, costs, humanistic, behavioral (eg, interpersonal relations, suicide ideation), medication adherence, and product-switching outcomes for selected OATs published in English from January 2010 to March 2022 were identified and evaluated qualitatively. Results We included 48 studies with different designs providing extensive evidence on schizophrenia. All studies were conducted in countries outside of the United States. In most studies, antipsychotic medications were more effective than placebo, suggesting their value in the management of schizophrenia. Sixteen studies measured the economic outcomes of OATs. Eight studies assessed humanistic outcomes, while one reported behavioral outcomes in three second-generation antipsychotics. Medication adherence was described in two studies, while five studies evaluated product switching. Non-adherence was commonly reported for OATs. Medication non-adherence and treatment discontinuation were predominant factors contributing to the economic burden of schizophrenia. Conclusion Our research showcased a significant knowledge gap across OATs spanning the humanistic and behavioral outcomes and medication adherence and switching, suggesting a need for robust evidence generation to help clinicians and payers make informed decisions regarding treatment opportunities and cost-effective strategies for patients with schizophrenia.
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Affiliation(s)
- Keyuri Adhikari
- Department of Pharmaceutical Systems and Policy, West Virginia University School of Pharmacy, Morgantown, WV, USA
| | - Khalid M Kamal
- Department of Pharmaceutical Systems and Policy, West Virginia University School of Pharmacy, Morgantown, WV, USA
| | - Ki Jin Jeun
- Department of Pharmaceutical Systems and Policy, West Virginia University School of Pharmacy, Morgantown, WV, USA
| | - David A Nolfi
- Gumberg Library, Duquesne University, Pittsburgh, PA, USA
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Bray G, Moncrieff J, Priebe S, Marston L, Lewis G, Haynes N, Pinfold V, Johnson S, Hunter RM. Cost-Utility Analysis of Antipsychotic Reduction and Discontinuation in Patients With Long-Term Schizophrenia and Psychosis in English Mental Health Trusts: The RADAR Study. VALUE IN HEALTH : THE JOURNAL OF THE INTERNATIONAL SOCIETY FOR PHARMACOECONOMICS AND OUTCOMES RESEARCH 2024:S1098-3015(24)02800-6. [PMID: 39127250 DOI: 10.1016/j.jval.2024.07.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/29/2024] [Revised: 07/22/2024] [Accepted: 07/25/2024] [Indexed: 08/12/2024]
Abstract
OBJECTIVES The current recommended treatment for patients with recurrent episodes of schizophrenia and related conditions is antipsychotic medication. However, many antipsychotic users remain functionally impaired and experience serious physical and mental side effects. This study aims to assess the cost-effectiveness of a gradual antipsychotic reduction and discontinuation strategy compared with maintenance treatment over 24 months from mental health services, health and social care, and societal perspectives. METHODS Nineteen mental health trusts recruited patients to the Research into Antipsychotic Discontinuation and Reduction (RADAR) randomized controlled trial. Quality-adjusted life-years were calculated from patient-reported EQ-5D-5L, with years of full capability calculated from the patient-reported ICECAP-A. Mental health services use and medication was collected from medical records. Other resource use and productivity loss was collected using self-completed questionnaires. Costs were calculated from published sources. RESULTS A total of 253 participants were randomized: 126 assigned to antipsychotic dose reduction and 127 to maintenance. There were no significant differences between arms in total costs for any perspectives. There were no significant difference in quality-adjusted life-years (-0.035; 95% CI: -0.123 to 0.052), whereas years of full capability were significantly lower in the reduction arm compared with the maintenance arm (baseline-adjusted difference: -0.103; 95% CI: -0.192 to -0.014). The reduction strategy was dominated by maintenance for all analyses and was not likely to be cost-effective. CONCLUSIONS It is unlikely that gradual antipsychotic reduction and discontinuation strategy is cost-effective compared with maintenance over 2-years for patients with schizophrenia and other recurrent psychotic disorders who are on long-term antipsychotics.
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Affiliation(s)
- George Bray
- Office of Health Economics, London, England, UK
| | - Joanna Moncrieff
- Division of Psychiatry, University College London and North East London NHS Foundation Trust, London, England, UK
| | - Stefan Priebe
- Unit for Social and Community Psychiatry, Queen Mary University of London, London, England, UK
| | - Louise Marston
- Research Department of Primary Care and Population Health, University College London, London, England, UK
| | - Glyn Lewis
- Division of Psychiatry, University College London and North East London NHS Foundation Trust, London, England, UK
| | - Nadia Haynes
- Research and Development Department, North East London NHS Foundation Trust, London, England, UK
| | | | - Sonia Johnson
- Division of Psychiatry, University College London and North East London NHS Foundation Trust, London, England, UK
| | - Rachael Maree Hunter
- Research Department of Primary Care and Population Health, University College London, London, England, UK.
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Wang GHM, Svensson M, Shao H, Vouri SM, Park H. Cost-effectiveness analysis of monthly, 3-monthly, and 6-monthly long-acting injectable and oral paliperidone in adults with schizophrenia. J Manag Care Spec Pharm 2023; 29:884-895. [PMID: 37523313 PMCID: PMC10397333 DOI: 10.18553/jmcp.2023.29.8.884] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/02/2023]
Abstract
BACKGROUND: Paliperidone is among the most cost-effective antipsychotics in adults with schizophrenia, and it has different formulations, including oral paliperidone extended-release (ER) and long-acting injectable (LAI) paliperidone formulations administered every month (PP1M), 3 months (PP3M), or 6 months (PP6M). However, cost-effectiveness analyses comparing different paliperidone formulations were limited. OBJECTIVE: To compare the cost-effectiveness across different paliperidone formulations. METHODS: A Markov model was developed to simulate 1,000 adults aged 40 years with stable schizophrenia transitioning among stable disease-medication adherent, stable disease-medication nonadherent, relapse with hospitalization, relapse with ambulatory care, and death states every 3 months for 5 years. Drug costs were estimated using the prices listed in the Veterans Affairs Federal Supply Schedule, and costs for treating complications were estimated from published studies. All costs were estimated from the US health care system perspective and standardized to 2022 US dollars using the Consumer Price Index Inflation Calculator. Quality-adjusted life-years (QALYs) were estimated using relapse rates from randomized clinical trials and health-related quality of life scores from observational studies. The estimated future costs and QALYs were discounted at 3%. We reported incremental net monetary benefits between alternative formulations at the $50,000 willingness-to-pay (WTP) threshold with a positive value indicating cost-effectiveness. The impact of parameter uncertainty on study outcomes was assessed using 1-way deterministic and probabilistic sensitivity analyses. RESULTS: In adults with schizophrenia stabilized with paliperidone ER, switching to LAI formulations was associated with increased QALY (PP1M = 0.05, PP3M = 0.14, PP6M = 0.15) and increased cost (PP1M = 49,433, PP3M = 26,698, PP6M = 26,147), leading to a negative incremental net monetary benefit (PP1M = -$46,804, PP3M = -$19,508, PP6M = -$18,886) compared with continuing ER. Among LAI formulations, PP6M was cost-saving with the most QALYs gained (cost = $63,277, QALY = 3.731), followed by PP3M (cost = $63,828, QALY = 3.729) and PP1M (cost = $86,563, QALY = 3.638). At the $50,000 WTP threshold, the probabilities for PP1M, PP3M, and PP6M being cost-effective compared with paliperidone ER were 0.4%, 10.2%, and 9.8%, respectively. The probability of PP6M being cost-effective was 92.6% for the PP6M-PP1M pair and 55.2% for the PP6M-PP3M pair, and 91.1% of PP3M use was cost-effective in the PP3M-PP1M pair. The results were generally robust in the sensitivity analyses, even at the $190,000 WTP threshold. CONCLUSIONS: For patients with schizophrenia stabilized with paliperidone ER, switching to LAI formulations was not cost-effective, suggesting the high drug costs for LAI may not justify the improved quality of life within 5 years. Among LAI formulations, PP6M was cost-effective over PP1M and PP3M.
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Affiliation(s)
- Grace Hsin-Min Wang
- Department of Pharmaceutical Outcomes & Policy, College of Pharmacy, University of Florida, Gainesville
| | - Mikael Svensson
- Department of Pharmaceutical Outcomes & Policy, College of Pharmacy, University of Florida, Gainesville
| | - Hui Shao
- Department of Pharmaceutical Outcomes & Policy, College of Pharmacy, University of Florida, Gainesville
| | - Scott Martin Vouri
- Department of Pharmaceutical Outcomes & Policy, College of Pharmacy, University of Florida, Gainesville
- Center for Drug Evaluation and Safety, College of Pharmacy, University of Florida, Gainesville
| | - Haesuk Park
- Department of Pharmaceutical Outcomes & Policy, College of Pharmacy, University of Florida, Gainesville
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Kearns B, Cooper K, Cantrell A, Thomas C. Schizophrenia Treatment with Second-Generation Antipsychotics: A Multi-Country Comparison of the Costs of Cardiovascular and Metabolic Adverse Events and Weight Gain. Neuropsychiatr Dis Treat 2021; 17:125-137. [PMID: 33505160 PMCID: PMC7829121 DOI: 10.2147/ndt.s282856] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/19/2020] [Accepted: 11/18/2020] [Indexed: 12/28/2022] Open
Abstract
PURPOSE Cardiovascular and metabolic adverse events are costly to treat, and their incidence is increased amongst people with schizophrenia, with different rates observed for second-generation antipsychotics. To inform treatment choice, this study sought to estimate the lifetime costs associated with antipsychotic choice, and how these costs varied across European countries. METHODS Systematic searches were conducted to identify evidence on effectiveness and costs. A Markov model was developed to assess the costs of ten antipsychotics: aripiprazole, brexpiprazole, cariprazine, lumateperone, lurasidone, olanzapine, paliperidone, quetiapine, risperidone and ziprasidone. Costs were obtained for seven countries: Italy, Hungary, France, Slovenia, Spain, Sweden and the UK. The costs considered were adverse events (including diabetes, myocardial infarction, stroke and weight gain), drug costs, relapse, treatment discontinuation and schizophrenia management. Two adult populations were modelled; initiating either acute or maintenance treatment, with a lifetime horizon for both. RESULTS Lurasidone was associated with the lowest lifetime costs amongst patients initiating acute treatment compared to all other atypical antipsychotics considered. The second lowest costs were for ziprasidone. These results were observed for all seven countries. The main drivers of cost differences were rates of diabetes and cardiovascular diseases, which were lowest for lurasidone, followed by ziprasidone then lumateperone. Costs for managing weight gain were lowest for lurasidone and ziprasidone. Similar results were observed for patients initiating maintenance treatment. CONCLUSION Diabetes and cardiovascular events are large drivers of lifetime costs for people with schizophrenia. Lurasidone is predicted to have the lowest rates of these adverse events, and so the lowest costs amongst patients initiating acute treatment in seven European countries compared to nine other antipsychotics. Future research should investigate the individual costs of relapse management, including differences in the costs and proportions of hospitalizations.
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Affiliation(s)
- Benjamin Kearns
- School of Health and Related Research, The University of Sheffield, Sheffield, UK
| | - Katy Cooper
- School of Health and Related Research, The University of Sheffield, Sheffield, UK
| | - Anna Cantrell
- School of Health and Related Research, The University of Sheffield, Sheffield, UK
| | - Chloe Thomas
- School of Health and Related Research, The University of Sheffield, Sheffield, UK
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Jin H, Tappenden P, Robinson S, Achilla E, MacCabe JH, Aceituno D, Byford S. A Systematic Review of Economic Models Across the Entire Schizophrenia Pathway. PHARMACOECONOMICS 2020; 38:537-555. [PMID: 32144726 DOI: 10.1007/s40273-020-00895-6] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/10/2023]
Abstract
BACKGROUND Schizophrenia is associated with a high economic burden. Economic models can help to inform resource allocation decisions to maximise benefits to patients. OBJECTIVES This systematic review aims to assess the availability, quality and consistency of conclusions of health economic models evaluating the cost effectiveness of interventions for schizophrenia. METHODS An electronic search was performed on multiple databases (MEDLINE, EMBASE, PsycINFO, Cochrane database of systematic reviews, NHS Economic Evaluation Database and Health Technology Assessment database) to identify economic models of interventions for schizophrenia published between 2005 and 2020. Two independent reviewers selected studies for inclusion. Study quality was assessed using the National Institute for Health and Care Excellence (NICE) checklist and the Cooper hierarchy. Model characteristics and conclusions were descriptively summarised. RESULTS Seventy-three models met inclusion criteria. Seventy-eight percent of existing models assessed antipsychotics; however, due to inconsistent conclusions reported by different studies, no antipsychotic can be considered clearly cost effective compared with the others. A very limited number of models suggest that the following non-pharmacological interventions might be cost effective: psychosocial interventions, stratified tests, employment intervention and intensive intervention to improve liaison between primary and secondary care. The quality of included models is generally low due to use of a short time horizon, omission of adverse events of interventions, poor data quality and potential conflicts of interest. CONCLUSIONS This review highlights a lack of models for non-pharmacological interventions, and limitations of the existing models, including low quality and inconsistency in conclusions. Recommendations on future modelling approaches for schizophrenia are provided.
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Affiliation(s)
- Huajie Jin
- King's Health Economics, Institute of Psychiatry, Psychology and Neuroscience, King's College London, Box 024, The David Goldberg Centre, London, SE5 8AF, UK.
| | - Paul Tappenden
- Health Economics and Decision Science, School of Health and Related Research, University of Sheffield, Regent Court, 30 Regent Street, Sheffield, S1 4DA, UK
| | - Stewart Robinson
- School of Business and Economics, Loughborough University, Epinal Way, Loughborough, Leicestershire, LE11 3TU, UK
| | | | - James H MacCabe
- Department of Psychosis Studies, PO63, Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, SE5 8AF, UK
| | - David Aceituno
- King's Health Economics, Institute of Psychiatry, Psychology and Neuroscience, King's College London, Box 024, The David Goldberg Centre, London, SE5 8AF, UK
| | - Sarah Byford
- King's Health Economics, Institute of Psychiatry, Psychology and Neuroscience, King's College London, Box 024, The David Goldberg Centre, London, SE5 8AF, UK
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Yi ZM, Men P, Qu S, Li C, Yu X, Zhai S. Comparative cost-effectiveness of amisulpride and olanzapine in the treatment of schizophrenia in China. Expert Rev Pharmacoecon Outcomes Res 2020; 20:313-320. [PMID: 32293194 DOI: 10.1080/14737167.2020.1752670] [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: 10/24/2022]
Abstract
BACKGROUND Both amisulpride and olanzapine are leading treatments for schizophrenia in China. This study aimed to investigate the long-term cost-effectiveness of amisulpride and olanzapine in the treatment of schizophrenia in China. METHODS A decision-analytic Markov model was developed to simulate the lifetime clinical and economic outcomes of schizophrenia treatment from the healthcare payer perspective. The long-term costs and QALYs were estimated. Sensitivity analyses were performed to explore the impact of variance of parameters on the results. RESULTS Treatment with amisulpride provided an effectiveness gain of 16.59 QALYs at an average cost of USD 25,884 whereas olanzapine resulted in 16.38 QALYs at a cost of USD 34,839 over a lifetime horizon. One-way sensitivity analysis suggested that the most sensitive variable was the unit cost of olanzapine. In a probabilistic sensitivity analysis based on a Monte Carlo simulation with a lifetime horizon, the probability of amisulpride being cost-effective was 99.8% at a willingness-to-pay threshold of USD 9,322, the GDP per capita in China 2018. A scenario analysis with updated olanzapine unit cost suggested an ICER of 7,857 USD/QALY. CONCLUSIONS Amisulpride is likely to be a cost-effective option with increased effectiveness compared with olanzapine in the treatment of schizophrenia patients in China.
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Affiliation(s)
- Zhan-Miao Yi
- Department of Pharmacy, Peking University Third Hospital , Beijing, China.,Department of Pharmacy Administration and Clinical Pharmacy, School of Pharmaceutical Science, Peking University , Beijing, China.,Institute for Drug Evaluation, Peking University Health Science Center , Beijing, China
| | - Peng Men
- Department of Pharmacy, Peking University Third Hospital , Beijing, China.,Institute for Drug Evaluation, Peking University Health Science Center , Beijing, China
| | - Shuli Qu
- Real-World Insights, IQVIA , Shanghai, China
| | - Chaoyun Li
- Health Economics & Outcome Research, Sanofi , Shanghai, China
| | - Xin Yu
- Department of Psychiatry, Peking University Sixth Hospital , Beijing, China
| | - Suodi Zhai
- Department of Pharmacy, Peking University Third Hospital , Beijing, China.,Institute for Drug Evaluation, Peking University Health Science Center , Beijing, China
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Abdall-Razak A, Macaulay A, Tiefenbach J, Borges K, Mathema S, Zuberi S. A cost-utility analysis of Amisulpride and Paliperidone in the treatment of Schizophrenia. Heliyon 2019; 5:e02343. [PMID: 31687534 PMCID: PMC6819947 DOI: 10.1016/j.heliyon.2019.e02343] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2018] [Revised: 04/27/2019] [Accepted: 08/14/2019] [Indexed: 11/10/2022] Open
Abstract
Background Schizophrenia is a severe, long-term neurodevelopmental disorder that results in increased morbidity and mortality. Amisulpride and Paliperidone are two antipsychotics used to treat schizophrenia in the UK. This evaluation compares the cost-utility of each drug; no similar research has been conducted in the UK. Methods A cost utility analysis was performed looking at the benefits in terms of Quality Adjusted Life Years within one year of the treatment, and the costs in pound sterling, discounted to the 2016/2017 value. This evaluation was from the perspective of the National Health Service, the biggest provider of health within the United Kingdom. Outcomes The cost utility analysis found an incremental cost effectiveness ratio of £10,941 per added Quality Adjusted Life Year for using Paliperidone, instead of the more widely used Amisulpride. Interpretation This is below the NICE threshold of £20–30,000 per QALY. Hence, it is within reason to suggest shifting diagnostic practices to Paliperidone.
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Affiliation(s)
- Ali Abdall-Razak
- Imperial College School of Medicine, South Kensington, SW7 2AZ, UK
| | - Alex Macaulay
- Imperial College School of Medicine, South Kensington, SW7 2AZ, UK
| | | | - Karen Borges
- King's College School of Medicine, London, WC2R 2LS, UK
| | - Sina Mathema
- King's College School of Medicine, London, WC2R 2LS, UK
| | - Sameer Zuberi
- Imperial College School of Medicine, South Kensington, SW7 2AZ, UK
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Arteaga Duarte CH, Fakra E, Van Gils C, Guillon P. The clinical and economic impact of three-monthly long-acting formulation of paliperidone palmitate versus the one-monthly formulation in the treatment of schizophrenia in France: A cost-utility study. Encephale 2019; 45:459-467. [PMID: 31542210 DOI: 10.1016/j.encep.2019.03.001] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2018] [Revised: 02/24/2019] [Accepted: 03/11/2019] [Indexed: 10/26/2022]
Abstract
OBJECTIVES Schizophrenia entails a considerable humanistic and economic burden. Improved treatment continuity to antipsychotic therapy is paramount to reduce the risk of relapse. The novel three-monthly paliperidone palmitate treatment (PP3M) offers the longest dosing interval currently available in France. This study assesses its cost-effectiveness, versus the currently available one-monthly long-acting treatment (PP1M) in French schizophrenic patients. METHODS A Markov model with monthly cycles was developed and adapted. It encompassed [a] administration of PP3M or PP1M in first-line, [b] a period where the patient does not receive any active treatment, and [c] a follow-up treatment line consisting of a treatment mix reflecting French clinical practice. Relapse rates in first-line were based on a pivotal non-inferiority head-to-head trial, and treatment discontinuation rates were based on French real-world data. Accounting for differences in drug exposure, time-dependent monthly relapse rates were applied following discontinuation to first line. The impact of a less frequent injection schedule for PP3M in QoL was accounted for through the application of a utility differential. The collective perspective was adopted throughout a 5-year time horizon. Four percent discount rates were applied on costs and outcomes. RESULTS PP3M was dominant when compared to PP1M, featuring an incremental QALY of 0.123 and a cost saving effect (-669€) resulting from reduced therapy costs (drug acquisition, administration and monitoring) and relapse-related costs. Sensitivity analysis supported the robustness of the results. CONCLUSION With slightly better QALY outcomes and a cost-saving effect when compared to PP1M, introducing PP3M is an improvement to the current treatment in France.
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Affiliation(s)
- C H Arteaga Duarte
- IQVIA, Corporate Village, Davos Building, Da Vincilaan 7, 1930 Zaventem, Belgium.
| | - E Fakra
- Department of Psychiatry, University Hospital of Saint-Etienne, TAPE Laboratory, EA7423, Jean Monnet University, 42100 Saint-Étienne, France.
| | - C Van Gils
- IQVIA, Corporate Village, Davos Building, Da Vincilaan 7, 1930 Zaventem, Belgium
| | - P Guillon
- Janssen-Cilag, Rue Camille Desmoulins 1, TSA 91003, 92787 Issy-les-Moulineaux, France
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Henrique ICB, de Mendonça Lima T, de Melo DO, Aguiar PM. Economic evaluations on the use of aripiprazole for patients with schizophrenia: A systematic review. J Clin Pharm Ther 2019; 45:1-15. [PMID: 31436857 DOI: 10.1111/jcpt.13034] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2019] [Revised: 07/22/2019] [Accepted: 07/25/2019] [Indexed: 11/30/2022]
Abstract
WHAT IS KNOWN AND OBJECTIVES Schizophrenia is a serious mental disorder and is associated with substantial economic and social burden. Cost-effectiveness analysis is important to assess the costs of different therapeutic options. However, there is a lack of information on the reporting quality of economic evaluations, cost drivers, as well as updated data focused on aripiprazole, an antipsychotic drug commonly prescribed in schizophrenia. This study evaluates and summarizes the evidence of economic evaluations of the use of aripiprazole in schizophrenia. In addition, we aimed to identify cost drivers and critically assess the reporting qualities of these studies. METHODS A comprehensive literature research was conducted using PubMed, NHS Economic Evaluation Database, CEA Registry and LILACS databases dated until March 2018. Full economic analyses of aripiprazole in schizophrenia that were based on decision analytical models and published in English, Portuguese or Spanish languages were included. Two independent authors identified the studies and performed data extraction and quality assessment using 24 items from the Consolidated Health Economic Evaluation Reporting Standards (CHEERS) statement. RESULTS AND DISCUSSION A total of 79 potential studies were identified, of which 17 studies performing model-based economic evaluations fully met the eligibility criteria. Of these, 15 were industry-funded studies. A trend favouring olanzapine, lurasidone and paliperidone could be observed, whereas aripiprazole was extensively described as a dominated alternative. However, notably, 93% of the industry-funded studies presented results favouring their sponsors, only two of them being the manufacturer of aripiprazole. Cost drivers were usually related to the relapse rates/probabilities regardless of the funding source. The overall quality of reporting of the economic analyses was poor, with most studies scoring around 12-13 points. The most frequent problems were the lack of description of relevance of the outcome measures, characteristics of the base case population and report of precision measures for all the parameters of the model. WHAT IS NEW AND CONCLUSION No consistent conclusion on the cost-effectiveness of aripiprazole could be drawn due to the context-specific costs, conflicting parameters of effectiveness and safety, and bias related to industry sponsorship. Cost drivers, though, were usually related to the relapse rates/probabilities. In addition, poor reporting quality of the studies performing full economic analysis requires further improvement to ensure greater transparency of the findings.
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Affiliation(s)
| | | | - Daniela Oliveira de Melo
- Institute of Environmental, Chemical and Pharmaceutical Sciences, Federal University of Sao Paulo, Diadema, Brazil
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Zhou J, Millier A, François C, Aballéa S, Toumi M. Systematic review of utility values used in the pharmacoeconomic evaluations for schizophrenia: implications on cost-effectiveness results. JOURNAL OF MARKET ACCESS & HEALTH POLICY 2019; 7:1648973. [PMID: 31489150 PMCID: PMC6713214 DOI: 10.1080/20016689.2019.1648973] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 05/24/2019] [Revised: 07/18/2019] [Accepted: 07/22/2019] [Indexed: 06/10/2023]
Abstract
Background and Objectives: Utility elicitation studies for schizophrenia generate different utility values for the same health states. We reviewed utility values used in schizophrenia pharmacoeconomic evaluations and evaluated the impact of their selection on the incremental cost-effectiveness ratio (ICER). Methods: A systematic search was performed in Medline and Embase. Health state definitions, associated utility values, elicitation studies, and value selection processes were extracted. Sets of utility values for all schizophrenia health states were used in a cost-effectiveness model to evaluate the ICER. Results: Thirty-five cost-utility analyses (CUAs) referring to 11 utility elicitation studies were included. The most frequent health states were 'stable' (28 CUAs, 7 utility elicitation studies, 10 values, value range 0.650-0.919), 'relapse requiring hospitalisation' (18, 5, 7, 0.270-0.604), 'relapse not requiring hospitalisation' (18, 5, 10, 0.460-0.762), and 'relapse only' (10, 5, 6, 0.498-0.700). Seventeen sets of utility values were identified with difference in utility values between relapse and stable ranging from -0.358 to -0.050, resulting in ICERs ranging from -56.2% to +222.6% from average. Conclusion: The use of utility values for schizophrenia health states differs among CUAs and impacts on the ICER. More rigorous and transparent use of utility values and sensitivity analysis with different sets of utility values are suggested for future CUAs.
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Affiliation(s)
- Junwen Zhou
- Public Health Department, Aix-Marseille University, Marseille, France
| | - Aurélie Millier
- Health Economic and Outcome Research Department, Creativ-Ceutical, Paris, France
| | - Clément François
- Public Health Department, Aix-Marseille University, Marseille, France
- Health Economic and Outcome Research Department, Creativ-Ceutical, Paris, France
| | - Samuel Aballéa
- Health Economic and Outcome Research Department, Creativ-Ceutical, Rotterdam, Netherlands
| | - Mondher Toumi
- Public Health Department, Aix-Marseille University, Marseille, France
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Men P, Yi Z, Li C, Qu S, Xiong T, Yu X, Zhai S. Comparative efficacy and safety between amisulpride and olanzapine in schizophrenia treatment and a cost analysis in China: a systematic review, meta-analysis, and cost-minimization analysis. BMC Psychiatry 2018; 18:286. [PMID: 30185173 PMCID: PMC6125952 DOI: 10.1186/s12888-018-1867-8] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/15/2018] [Accepted: 08/28/2018] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND Amisulpride was introduced into China in 2010 as a second-generation atypical antipsychotic, while olanzapine has been on the market since 1999 as one of the leading treatments for schizophrenia in China. Since more Chinese patients are gaining access to amisulpride, the study aims to compare the efficacy, safety, and costs between amisulpride and olanzapine for schizophrenia treatment in China. METHODS PubMed, Embase, the Cochrane library, China National Knowledge Infrastructure (CNKI) and WanFang database were systematically searched for randomized controlled trials (RCTs) up to July 2018. The Cochrane Risk of Bias tool was utilized to assess the quality of included studies. A meta-analysis was performed to compare the efficacy and safety of amisulpride and olanzapine, followed by a cost-minimization analysis using local drug and medical costs reported in China. RESULTS Twenty RCTs with 2000 patients were included in the systematic review. There were no significant differences between amisulpride and olanzapine on efficacy measures based on scores from the Positive and Negative Syndrome Scale, the Scale for the Assessment of Negative Symptoms, the Brief Psychiatric Rating Scale and the Clinical Global Impressions-Severity or Improvement. For safety outcomes, amisulpride was associated with lower fasting blood glucose and less abnormal liver functions as well as significantly lower risks of weight gain, constipation, and somnolence; olanzapine was associated with significantly lower risks of insomnia and lactation/amenorrhea/sexual hormone disorder. No significant differences were found in risks of extrapyramidal symptoms (EPS), tremor, akathisia, abnormal corrected QT interval. Cost-minimization analysis showed that amisulpride was likely to be a cost-saving alternative in China, with potential savings of 1358 Chinese Yuan (CNY) per patient for a three-month schizophrenia treatment compared with olanzapine. CONCLUSION As the first meta-analysis and cost-minimization analysis comparing the efficacy, safety and cost of amisulpride and olanzapine within a Chinese setting, the study suggests that amisulpride may be an effective, well-tolerated, and cost-saving antipsychotic drug alternative in China.
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Affiliation(s)
- Peng Men
- 0000 0004 0605 3760grid.411642.4Department of Pharmacy, Peking University Third Hospital, N. Huayuan Rd, Beijing, China ,0000 0001 2256 9319grid.11135.37Institute for Drug Evaluation, Peking University Health Science Center, Beijing, China ,0000 0001 2256 9319grid.11135.37Department of Pharmacy Administration and Clinical Pharmacy, School of Pharmaceutical Science, Peking University, Beijing, China
| | - Zhanmiao Yi
- 0000 0004 0605 3760grid.411642.4Department of Pharmacy, Peking University Third Hospital, N. Huayuan Rd, Beijing, China ,0000 0001 2256 9319grid.11135.37Institute for Drug Evaluation, Peking University Health Science Center, Beijing, China ,0000 0001 2256 9319grid.11135.37Department of Pharmacy Administration and Clinical Pharmacy, School of Pharmaceutical Science, Peking University, Beijing, China
| | - Chaoyun Li
- 0000 0004 0485 8549grid.476734.5Health Economics & Outcome Research, Sanofi, Yanan Rd, Shanghai, China
| | - Shuli Qu
- Real-World Insights, IQVIA, W. Beijing Rd, Shanghai, China
| | - Tengbin Xiong
- 0000 0004 1798 0615grid.459847.3Department of Psychiatry, Peking University Sixth Hospital, N. Huayuan Rd, Beijing, China
| | - Xin Yu
- 0000 0004 1798 0615grid.459847.3Department of Psychiatry, Peking University Sixth Hospital, N. Huayuan Rd, Beijing, China
| | - Suodi Zhai
- Department of Pharmacy, Peking University Third Hospital, N. Huayuan Rd, Beijing, China. .,Institute for Drug Evaluation, Peking University Health Science Center, Beijing, China.
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Zhou J, Millier A, Toumi M. Systematic review of pharmacoeconomic models for schizophrenia. JOURNAL OF MARKET ACCESS & HEALTH POLICY 2018; 6:1508272. [PMID: 30128087 PMCID: PMC6095033 DOI: 10.1080/20016689.2018.1508272] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/14/2018] [Revised: 07/24/2018] [Accepted: 07/26/2018] [Indexed: 06/08/2023]
Abstract
Background: Economic models are broadly used in the economic evaluation of antipsychotics in schizophrenia. Our objective was to summarize the structure of these models. Methods: Model-based economic evaluations of antipsychotics in schizophrenia were identified through Medline and Embase. General information was extracted including analysis type, model type, perspective, population, comparator, outcome, and timeframe. Model-specific structures for decision tree (DT), cohort- and patient-level Markov model (CLMM, PLMM), and discrete-event simulation (DES) models were extracted. Results: A screen of 1870 records identified 79 studies. These were mostly cost-utility analyses (n = 48) with CLMM (n = 32) or DT models (n = 29). They mostly applied payer perspective (n = 68), focused on general schizophrenia for relapse prevention (n = 73), compared pharmacotherapies as first-line (n = 71), and evaluated incremental cost per quality-adjusted life year (QALY) gained (n = 40) with a 1-year (n = 32) or 5-year (n = 26) projection. DT models progressed with the branching points of response, relapse, discontinuation, and adherence. CLMM models transitioned between disease states, whereas PLMM models transitioned between adverse event states with/without disease state. DES models moved forward with times to remission, relapse, psychiatrist visit, and death. Conclusions: A pattern of pharmacoeconomic models for schizophrenia was identified. More subtle structures and patient-level models are suggested for a future modelling exercise.
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Affiliation(s)
- Junwen Zhou
- Public Health Department, Aix-Marseille University, Marseille, France
| | - Aurélie Millier
- Health Economics and Outcomes Research Department, Creativ-Ceutical, Paris, France
| | - Mondher Toumi
- Public Health Department, Aix-Marseille University, Marseille, France
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Einarson TR, Bereza BG, Tedouri F, Van Impe K, Denee TR, Dries PJT. Cost-effectiveness of 3-month paliperidone therapy for chronic schizophrenia in the Netherlands. J Med Econ 2017; 20:1187-1199. [PMID: 28762843 DOI: 10.1080/13696998.2017.1363050] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
BACKGROUND A new depot formulation of paliperidone has been developed that provides effective treatment for schizophrenia for 3 months (PP3M). It has been tested in phase-3 trials, but no data on its cost-effectiveness have been published. PURPOSE To determine the cost-effectiveness of PP3M compared with once-monthly paliperidone (PP1M), haloperidol long-acting therapy (HAL-LAT), risperidone microspheres (RIS-LAT), and oral olanzapine (oral-OLZ) for treating chronic schizophrenia in The Netherlands. METHODS A previous 1-year decision tree was adapted, based on local inputs supplemented with data from published literature. The primary analysis used DRG costs in 2016 euros from the insurer perspective, as derived from official lists. A micro-costing analysis was also conducted. For the costing scenario, official list prices were used. Clinical outcomes included relapses (treated as outpatients, requiring hospitalization, total), and quality-adjusted life-years (QALYs). Rates and utility scores were derived from the literature. Economic outcomes were the incremental cost/QALY-gained or relapse-avoided. Model robustness was examined in scenario, 1-way, and probability sensitivity analyses. RESULTS The expected cost was lowest with PP3M (8,781€), followed by PP1M (10,325€), HAL-LAT (11,278€), RIS-LAT (11,307€), and oral-OLZ (13,556€). PP3M had the fewest total relapses/patient (0.36, 0.94, 1.39, 1.21, and 1.70, respectively), hospitalizations (0.11, 0.46, 0.40, 0.56, and 0.57, respectively), emergency room visits (0.25, 0.48. 0.99, 0.65, and 1.14, respectively) and the most QALYs (0.847, 0.735, 0.709, 0.719, and 0.656, respectively). In both cost-effectiveness and cost-utility analyses, PP3M dominated all other drugs. Sensitivity analyses confirmed base case findings. In the costing analysis, total costs were, on average, 31.9% higher than DRGs. CONCLUSIONS PP3M dominated all commonly used drugs. It is cost-effective for treating chronic schizophrenia in the Netherlands. Results were robust over a wide range of sensitivity analyses. For patients requiring a depot medication, such as those with adherence problems, PP3M appears to be a good alternative anti-psychotic treatment.
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Affiliation(s)
- Thomas R Einarson
- a Leslie Dan Faculty of Pharmacy , University of Toronto , Toronto , ON , Canada
| | - Basil G Bereza
- a Leslie Dan Faculty of Pharmacy , University of Toronto , Toronto , ON , Canada
| | - Fadi Tedouri
- b Janssen Janssen Pharmaceutica NV , Beerse , Belgium
| | | | - Tom R Denee
- c Janssen-Cilag BV , Tilburg , The Netherlands
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Németh B, Molnár A, Akehurst R, Horváth M, Kóczián K, Németh G, Götze Á, Vokó Z. Quality-adjusted life year difference in patients with predominant negative symptoms of schizophrenia treated with cariprazine and risperidone. J Comp Eff Res 2017; 6:639-648. [PMID: 28511548 DOI: 10.2217/cer-2017-0024] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
Abstract
AIM Our study aimed at estimating differences in quality-adjusted life year (QALY) gain for patients with predominant negative symptoms of schizophrenia treated with cariprazine compared with risperidone. MATERIALS & METHODS A Markov model was built, based on the Mohr-Lenert approach and data derived from clinical trials, to estimate potential QALY gains of patients. RESULTS Patients had higher probability of reaching better health states treated with cariprazine compared with risperidone. In the model, this resulted in an estimated QALY gain of 0.029 per patient, after 1 year of treatment. CONCLUSION Cariprazine, which showed clinically meaningful improvement in the symptoms, and personal and social performance, can also provide significant QALY gain in the treatment of patients with predominant negative symptoms of schizophrenia compared with risperidone.
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Affiliation(s)
| | | | - Ron Akehurst
- School of Health & Related Research, The University of Sheffield, UK
| | - Margit Horváth
- Business Development Department, Gedeon Richter Plc., Budapest, Hungary
| | - Kristóf Kóczián
- Business Development Department, Gedeon Richter Plc., Budapest, Hungary
| | - György Németh
- Medical Division, Gedeon Richter Plc., Budapest, Hungary
| | - Árpád Götze
- Business Development Department, Gedeon Richter Plc., Budapest, Hungary
| | - Zoltán Vokó
- Syreon Research Institute, Budapest, Hungary.,Department of Health Policy & Health Economics, Eötvös Loránd University, Budapest, Hungary
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Millier A, Horváth M, Ma F, Kóczián K, Götze A, Toumi M. Healthcare resource use in schizophrenia, EuroSC findings. JOURNAL OF MARKET ACCESS & HEALTH POLICY 2017; 5:1372027. [PMID: 29081923 PMCID: PMC5645906 DOI: 10.1080/20016689.2017.1372027] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/31/2017] [Accepted: 08/22/2017] [Indexed: 05/16/2023]
Abstract
Background: It is unclear if the burden associated with schizophrenia is affected by the type and severity of patient's symptoms. Objective: This study aims to quantify healthcare resource use associated with different profiles of schizophrenia symptoms. Study design: Post-hoc analysis of data from a naturalistic follow-up study. Setting: Secondary psychiatric services in France, Germany and the UK. Patients: EuroSC cohort:, representative sample of 1,208 schizophrenia patients Main outcome measure: We classified patients into eight health states, according to the Lenert classification (HS1-HS8), and estimated 6-month healthcare resource use (outpatient and day clinic visits, and hospitalisations) across the health states. Results: Approximately half of the patients were classed as having mild symptoms (HS1), with around 20% experiencing moderate, predominantly negative symptoms (HS2). The remaining health states were represented by <10% of patients each. Very few patients experienced extremely severe symptoms (HS8). No health state was associated with excess utilisation across all resource types. In terms of outpatient visits, patients were estimated to see a psychiatrist most often (3.01-4.15 visits over 6 months). Hospital admission was needed in 11%(HS1) - 35%(HS8) of patients and inpatient stays were generally prolonged for all health states (39-57 days). The average number of inpatient days was highest for patients in HS8 (18.17 days), followed by patients with severe negative symptoms (HS4; 13.37 days). In other health states characterised by severe symptoms (HS5-HS7), the average number of inpatient days was approximately half of those seen for HS4 (6.09-7.66). Conclusion: While none of the symptom profiles was associated with excess resource usage, hospitalization days were highest for HS with severe, predominantly negative or extremely severe symptoms. Patients with predominantly negative, moderate or severe symptoms appeared to have a high number of psychologist visits - an interesting finding that may reflect a specific therapeutic approach to the treatment of these patients.
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Affiliation(s)
- A. Millier
- Health Economics and Outcomes Research, Creativ-Ceutical, Paris, France
- CONTACT A. Millier Creativ-Ceutical, 215 rue du Faubourg Saint Honoré, Paris75008, France
| | - M. Horváth
- Market Access, Medical & Marketing, Gedeon Richter Plc, Budapest, Hungary
| | - F. Ma
- Health Economics and Outcomes Research, Creativ-Ceutical, Beijing, China
| | - K. Kóczián
- Market Access, Medical & Marketing, Gedeon Richter Plc, Budapest, Hungary
| | - A. Götze
- Market Access, Medical & Marketing, Gedeon Richter Plc, Budapest, Hungary
| | - M. Toumi
- Public Health Department, Aix-Marseille University, France
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Zaprutko T, Göder R, Kus K, Rakhman L, Bilobryvka R, Nowakowska E. The Cost of Inpatient Care of Schizophrenia and Treatment Schedules Used in German Academic Center: Kiel. Psychiatr Q 2016; 87:595-603. [PMID: 26687383 PMCID: PMC5047937 DOI: 10.1007/s11126-015-9412-0] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/05/2022]
Abstract
The authors aimed at analyzing the costs of inpatient care of schizophrenia in Kiel (Germany). The study was also to present treatment regimens used at the German Academic Center. Moreover, the study is a continuation and complement of the previous study conducted in Polish and Ukrainian Academic Center. Therefore, it helps increase the awareness and knowledge of residents concerning the cost of inpatient care of schizophrenia. The analysis was based on 105 hospital records of patients treated between January 2012 and June 2013. According to inclusion criteria, 50 adult patients (27 women and 23 men) were included in the study. The study was approved by the Ethics Committee of the Medicine Faculty of CAU in Kiel. The cost of schizophrenia treatment of 50 patients in Kiel was EUR 604,280.90 ([Formula: see text] = EUR 12,085.62). The duration of hospital stay was on average [Formula: see text] = 51.02 days. The patients were treated with neuroleptics of all generations. The most popular atypical neuroleptic was amisulpride and the most popular typical neuroleptic was haloperidol. Patients from Kiel were provided a comprehensive non-pharmacological treatment. Treatment regiments and evaluations of costs of schizophrenia vary between countries. The costs of inpatient care of schizophrenia are high in Kiel. Treatment of schizophrenia seems to be comprehensive in Kiel and wide range of treatment opportunities contribute to a more effective treatment confirmed by less frequent relapses of schizophrenia than in Lviv (Ukraine), for example. Comprehensive treatment should be available everywhere, because it is a right of every patient.
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Affiliation(s)
- Tomasz Zaprutko
- Department of Pharmacoeconomics and Social Pharmacy, Poznan University of Medical Sciences, 79 Dąbrowskiego Street, 60529, Poznan, Poland.
| | - Robert Göder
- Department of Psychiatry and Psychotherapy, Christian-Albrechts-Universität zu Kiel, 147 Niemannsweg Street, 24105, Kiel, Germany
| | - Krzysztof Kus
- Department of Pharmacoeconomics and Social Pharmacy, Poznan University of Medical Sciences, 79 Dąbrowskiego Street, 60529, Poznan, Poland
| | - Lyudmyla Rakhman
- Department of Psychiatry, Psychology and Sexology, Lviv National Medical University, 95 Kulparkivska Street, L'viv, 79021, Ukraine
| | - Rostyslav Bilobryvka
- Department of Psychiatry, Psychology and Sexology, Lviv National Medical University, 95 Kulparkivska Street, L'viv, 79021, Ukraine
| | - Elżbieta Nowakowska
- Department of Pharmacoeconomics and Social Pharmacy, Poznan University of Medical Sciences, 79 Dąbrowskiego Street, 60529, Poznan, Poland
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Comparative cost-effectiveness of 11 oral antipsychotics for relapse prevention in schizophrenia within Singapore using effectiveness estimates from a network meta-analysis. Int Clin Psychopharmacol 2016; 31:84-92. [PMID: 26619182 DOI: 10.1097/yic.0000000000000111] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
This study modelled the cost-effectiveness of 11 oral antipsychotics for relapse prevention among patients with remitted schizophrenia in Singapore. A network meta-analysis determined the relative efficacy and tolerability of 11 oral antipsychotics (amisulpride, aripiprazole, chlorpromazine, haloperidol, olanzapine, paliperidone, quetiapine, risperidone, sulpiride, trifluoperazine and ziprasidone). The clinical estimates were applied in a Markov model to estimate lifetime costs and quality-adjusted life-years gained. Quality-of-life data were obtained from published literature. Resource utilization and cost data were retrieved from local hospital databases. The annual direct cost of healthcare services for a patient experiencing a relapse episode was three-fold that of a patient not in relapse of schizophrenia. The most favourable pharmacological treatment for relapse prevention was olanzapine with an annual probability of relapse of 0.24 (0.13-0.38) with placebo as a reference of 0.75 (0.73-0.78). Olanzapine emerged as the dominant treatment with the highest quality-adjusted life-years gained and lowest lifetime costs. Ziprasidone, aripiprazole and paliperidone incurred higher lifetime costs compared with no treatment. Probability and cost of relapse were key drivers of cost-effectiveness in sensitivity analyses. The data can help prescribers in choosing appropriate treatment and payers in allocating resources for the clinical management of this serious psychiatric disorder.
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Zaprutko T, Kus K, Bilobryvka R, Rakhman L, Göder R, Michalak M, Pogłodziński A, Nowakowska E. Schizophrenia and Employment: Evaluation From Professionals Point of View. Psychiatr Q 2015; 86:569-79. [PMID: 25736799 DOI: 10.1007/s11126-015-9354-6] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
Schizophrenia is a severe and chronic disorder requiring long-lasting and comprehensive treatment. Because of this disorder patients are socially isolated. Consequently, schizophrenia has a significant economic burden both in a group of direct and indirect costs. The aim was to analyse experts' opinions in the field of psychiatry concerning work possibilities among people with schizophrenia and to present the importance of employment for more effective treatment. A worldwide study was conducted between June 2011 and June 2013 using a questionnaire consisting of six open-closed questions and a short metrics. The questionnaire was delivered to experts and spread all over the world by post and via the internet. Over 3000 questionnaires were sent and the addressed specialists were requested to return them. From received 403 questionnaires 320 were included into the study, based on adopted inclusion and exclusion criteria. Although patients are afraid of looking for a job, respondents indicated that they crave for employment. The number of people that are able to work during remission of schizophrenia is considerably higher (50.35 %) than the number of actually employed (15.85 %). Non-pharmacological therapies were indicated as important to improve patients' chances of finding a job during remission of schizophrenia. The number of people that can work during remission of schizophrenia is considerably higher than the number of affected people employed. Patients crave for a job and supported employment should be treated as priority by health-care decision makers.
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Affiliation(s)
- Tomasz Zaprutko
- Department of Pharmacoeconomics and Social Pharmacy, Poznan University of Medical Sciences, 79 Dąbrowskiego Street, 60529, Poznań, Poland.
| | - Krzysztof Kus
- Department of Pharmacoeconomics and Social Pharmacy, Poznan University of Medical Sciences, 79 Dąbrowskiego Street, 60529, Poznań, Poland
| | - Rostyslav Bilobryvka
- Department of Psychiatry, Psychology and Sexology, Lviv National Medical University, 95 Kulparkivska Street, 79021, Lviv, Ukraine
| | - Lyudmyla Rakhman
- Department of Psychiatry, Psychology and Sexology, Lviv National Medical University, 95 Kulparkivska Street, 79021, Lviv, Ukraine
| | - Robert Göder
- Department of Psychiatry and Psychotherapy, Christian-Albrechts-Universität zu Kiel, 147 Niemannsweg Street, 24105, Kiel, Germany
| | - Michał Michalak
- Department of Computer Sciences and Statistics, Poznan University of Medical Sciences, 79 Dąbrowskiego Street, 60529, Poznań, Poland
| | - Andrzej Pogłodziński
- Department of Adult Psychiatry, Poznan University of Medical Sciences, 27 Szpitalna Street, 60572, Poznań, Poland
| | - Elżbieta Nowakowska
- Department of Pharmacoeconomics and Social Pharmacy, Poznan University of Medical Sciences, 79 Dąbrowskiego Street, 60529, Poznań, Poland
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Costs and Resource Utilization Among Medicaid Patients with Schizophrenia Treated with Paliperidone Palmitate or Oral Atypical Antipsychotics. Drugs Real World Outcomes 2015; 2:377-385. [PMID: 26689953 PMCID: PMC4674518 DOI: 10.1007/s40801-015-0043-4] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/29/2022] Open
Abstract
BACKGROUND Non-adherence to antipsychotic therapy among patients with schizophrenia is a key driver of relapse, which can lead to costly inpatient stays. Long-acting injectables (LAIs) may improve adherence, thus reducing hospitalizations, but inpatient cost reductions need to be balanced against higher drug acquisition costs of LAIs. Real-world evidence is needed to help quantify the economic value of oral atypical antipsychotics compared with LAIs. OBJECTIVE The objective of this study was to compare healthcare costs and resource utilization between once-monthly paliperidone palmitate (PP) and oral antipsychotic therapy (OAT) in a population of Medicaid beneficiaries with schizophrenia. METHODS A retrospective, observational study was performed using Truven Health MarketScan Medicaid claims data from 2009 to 2012. Marginal structural modeling, a form of weighted repeated measures analysis to control for differences between cohorts and time-varying confounding, was used to estimate monthly costs of care in 2012 US dollars and resource utilization over a 12-month period for patients in each cohort. RESULTS While per-month mental-health prescription costs were US$1019 higher in the PP cohort, approximately 55 % of this premium was offset by lower inpatient and outpatient care costs, producing a mean monthly total cost differential of US$434 (95 % CI 298-569, p < 0.0001) for all-cause costs and US$463 (95 % CI 374-552, p < 0.0001) for mental-health-related costs. Use of PP also resulted in a 0.44 and 0.47 reduction in the odds of all-cause and mental-health-related hospitalizations and a 0.09 reduction in the odds of all-cause emergency department visits (p < 0.0001, p < 0.0001, and p = 0.0134, respectively) over the 12-month follow-up period. CONCLUSIONS Treatment with long-acting injectable antipsychotics, such as PP, may reduce inpatient and outpatient healthcare services utilization and associated costs. These findings also suggest that patients with schizophrenia taking once-monthly PP may stand a lower risk of hospitalization than patients on OAT.
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Geng J, Yu H, Mao Y, Zhang P, Chen Y. Cost effectiveness of dipeptidyl peptidase-4 inhibitors for type 2 diabetes. PHARMACOECONOMICS 2015; 33:581-597. [PMID: 25736235 DOI: 10.1007/s40273-015-0266-y] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/04/2023]
Abstract
BACKGROUND Dipeptidyl peptidase-4 (DPP-4) inhibitors are a new class of antidiabetic drugs used for treating type 2 diabetes mellitus. While many studies have reported on the cost-effectiveness of DPP-4 inhibitors for treating type 2 diabetes, a systematic review of economic evaluations of DPP-4 inhibitors is currently lacking. OBJECTIVES The aim of this systematic review was to assess the cost effectiveness of DPP-4 inhibitors for patients with type 2 diabetes. DATA SOURCES MEDLINE, EMBASE, National Health Service Economic Evaluation Database (NHS EED), Web of Science, EconLit databases, and the Cochrane Library were searched in November 2013. STUDY ELIGIBILITY CRITERIA, PARTICIPANTS AND INTERVENTIONS Studies assessing the cost effectiveness of DPP-4 inhibitors for type 2 diabetes were eligible for analysis. DPP-4 inhibitor monotherapy or combinations with other antidiabetic agents were included in the review. The DPP-4 inhibitors were all marketed drugs. Two reviewers independently reviewed titles, abstracts, and articles sequentially to select studies for data abstraction based on the inclusion and exclusion criteria. Disagreements were resolved by consensus. STUDY APPRAISAL AND SYNTHESIS METHODS The quality of included studies was assessed according to the 24-item checklist of the Consolidated Health Economic Evaluation Reporting Standards (CHEERS) statement. The costs reported by the included studies were converted to US dollars via purchasing power parities (PPP) in the year 2013 using the CCEMG-EPPI-Center Cost Converter. RESULTS A total of 11 published studies were selected for inclusion; all were cost-utility analyses. Nine studies were conducted from a payer perspective and one used a societal perspective; however, the perspective of the other study was unclear. Four studies were of good quality, six were of moderate quality, and one was of low quality. Of the seven studies comparing DPP-4 inhibitors plus metformin with sulfonylureas plus metformin, six concluded that DPP-4 inhibitors were cost effective in patients with type 2 diabetes who were no longer adequately controlled by metformin monotherapy. Five studies compared DPP-4 inhibitors with thiazolidinediones, and whether DPP-4 inhibitors were cost effective was uncertain. Only two economic evaluations provided data to compare DPP-4 inhibitors versus insulin, and the results favored the use of DPP-4 inhibitors as second-line therapy. LIMITATIONS Synthesis of the data was impossible because of heterogeneity in the methodology and data sources of the economic evaluations, and the inclusion criteria excluded conference abstracts. It was difficult to find reliable weightings for each of the items of the CHEERS checklist, and the ratings were dichotomous. CONCLUSIONS AND IMPLICATIONS OF KEY FINDINGS This study provides the first systematic evaluation of DPP-4 inhibitors for patients with type 2 diabetes. It found that, in patients with type 2 diabetes who do not achieve glycemic targets with antidiabetic monotherapy, DPP-4 inhibitors as add-on treatment may represent a cost-effective option compared with sulfonylureas and insulin. However, high-quality cost-effectiveness analyses that utilize long-term follow-up data and have no conflicts of interest are still needed.
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Affiliation(s)
- Jinsong Geng
- National Key Laboratory of Health Technology Assessment (Ministry of Health), Collaborative Innovation Center of Social Risks Governance in Health, School of Public Health, Fudan University, Shanghai, 200032, China
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Baser O, Xie L, Pesa J, Durkin M. Healthcare utilization and costs of Veterans Health Administration patients with schizophrenia treated with paliperidone palmitate long-acting injection or oral atypical antipsychotics. J Med Econ 2015; 18:357-65. [PMID: 25525771 DOI: 10.3111/13696998.2014.1001514] [Citation(s) in RCA: 53] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
OBJECTIVE This study aimed to compare real world healthcare costs and resource utilization between patients with schizophrenia treated with paliperidone palmitate long-acting injection (PP) and oral atypical antipsychotics (OAT). METHODS Patients (18-64 years) were selected from the Veterans Health Administration dataset (1 July 2007-31 May 2012). Patients with 2+ claims for PP or 2+ claims for the same OAT comprised the two study cohorts with the first prescription date designated as the index date. Participation in the VA healthcare system for 24 months pre- and 12 months post-index, schizophrenia diagnosis (International Classification of Disease 9th Revision Clinical Modification [ICD-9-CM] code 295.1x-6x, 295.8x-9x) and ≥1 claim for an antipsychotic medication during the baseline period were required. Propensity scores and Mahalanobis metric distances with calipers were used to create two matched cohorts. All-cause healthcare utilization and costs for the 12-month follow-up period were compared between matched cohorts. RESULTS The matching process produced two cohorts of 335 patients with similar baseline characteristics. During the 12-month follow-up period, patients in the PP cohort had lower mean inpatient costs (18,560 vs $31,505, p = 0.002), lower frequency of hospitalization (34% vs 53%, p < 0.001) and fewer average inpatient days (13.24 vs 24.18, p = 0.002) vs matched OAT patients. While mean pharmacy costs were higher for the PP cohort ($10,063 vs $4167, p < 0.001), mean total healthcare costs were not significantly different ($45,529 vs $52,569, p = 0.128). CONCLUSION VA patients, diagnosed with schizophrenia and treated with PP, had lower inpatient costs and admission rates compared to a matched cohort of OAT patients. Total healthcare costs were not significantly different.
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Zaprutko T, Nowakowska E, Kus K, Bilobryvka R, Rakhman L, Pogłodziński A. The cost of inpatient care of schizophrenia in the Polish and Ukrainian academic centers--Poznan and Lviv. ACADEMIC PSYCHIATRY : THE JOURNAL OF THE AMERICAN ASSOCIATION OF DIRECTORS OF PSYCHIATRIC RESIDENCY TRAINING AND THE ASSOCIATION FOR ACADEMIC PSYCHIATRY 2015; 39:165-173. [PMID: 25216718 PMCID: PMC4361770 DOI: 10.1007/s40596-014-0198-4] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/16/2014] [Accepted: 06/23/2014] [Indexed: 06/01/2023]
Abstract
OBJECTIVE The authors aimed to analyze and compare treatments of schizophrenia in Poznan and Lviv to present the potential differences between Poland and Ukraine in pharmacotherapy and economic availability of medicines, to emphasize the role of academic centers in the effective treatment of schizophrenia, and to raise the awareness of residents about economics and the cost of inpatient care. METHODS The analysis was based on 307 hospital records of patients treated in 2010 and 2011 and data from the hospital accounting department. Per the inclusion criteria, 108 adult patients (50 in Poznan and 58 in Lviv) were enrolled in the study. Monetary values were converted into euros (EUR) at the rate published by the National Bank of Poland (NBP) on October 9, 2012. RESULTS The total cost of schizophrenia treatment in Poznan was EUR 160,489.26, x = EUR 3,209.78 per patient, and in Lviv it was EUR 30,943.38, x = EUR 533.5 per patient. Treatment schedules differed between Poznan and Lviv, and pharmacotherapy was limited economically, especially in Lviv. CONCLUSION Although the results differ between Poznan and Lviv, the study shows that schizophrenia treatment is expensive in both centers. Differences in the health care systems make use of innovative neuroleptics unavailable especially in Lviv, which may contribute to non-compliance or higher level of relapses. Distinctive efforts to improve therapies should be made and efforts to equalize access to innovative pharmacotherapy should be supported to improve the therapy's efficacy and the economic values of schizophrenia treatment.
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Mirabzadeh A, Bakhshi E, Khodae MR, Kooshesh MR, Mahabadi BR, Mirabzadeh H, Biglarian A. Cost prediction of antipsychotic medication of psychiatric disorder using artificial neural network model. JOURNAL OF RESEARCH IN MEDICAL SCIENCES : THE OFFICIAL JOURNAL OF ISFAHAN UNIVERSITY OF MEDICAL SCIENCES 2013; 18:782-5. [PMID: 24381622 PMCID: PMC3872587] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/15/2013] [Revised: 05/01/2013] [Accepted: 07/14/2013] [Indexed: 10/31/2022]
Abstract
BACKGROUND Antipsychotic monotherapy or polypharmacy (concurrent use of two or more antipsychotics) are used for treating patients with psychiatric disorders (PDs). Usually, antipsychotic monotherapy has a lower cost than polypharmacy. This study aimed to predict the cost of antipsychotic medications (AM) of psychiatric patients in Iran. MATERIALS AND METHODS For this purpose, 790 patients with PDs who were discharged between June and September 2010 were selected from Razi Psychiatric Hospital, Tehran, Iran. For cost prediction of AM of PD, neural network (NN) and multiple linear regression (MLR) models were used. Analysis of data was performed with R 2.15.1 software. RESULTS Mean ± standard deviation (SD) of the duration of hospitalization (days) in patients who were on monotherapy and polypharmacy was 31.19 ± 15.55 and 36.69 ± 15.93, respectively (P < 0.001). Mean and median costs of medication for monotherapy (n = 507) were $8.25 and $6.23 and for polypharmacy (n =192) were $13.30 and $9.48, respectively (P = 0.001). The important variables for cost prediction of AM were duration of hospitalization, type of treatment, and type of psychiatric ward in the MLR model, and duration of hospitalization, type of diagnosed disorder, type of treatment, age, Chlorpromazine dosage, and duration of disorder in the NN model. CONCLUSION Our findings showed that the artificial NN (ANN) model can be used as a flexible model for cost prediction of AM.
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Affiliation(s)
- Arash Mirabzadeh
- Department of Psychiatric, Social Determinants of Health Research Center, University of Social Welfare and Rehabilitation Sciences (USWRS), Tehran, Iran
| | - Enayatollah Bakhshi
- Department of Biostatistics, University of Social Welfare and Rehabilitation Sciences (USWRS), Tehran, Iran
| | - Mohamad Reza Khodae
- Department of Psychiatric, University of Social Welfare and Rehabilitation Sciences (USWRS), Tehran, Iran
| | - Mohamad Reza Kooshesh
- Master of Sciences of Psychology, Pediatric Neurorehabilitation Research Center, University of Social Welfare and Rehabilitation Sciences (USWRS), Tehran, Iran
| | - Bibi Riahi Mahabadi
- Master of Sciences of Psychology, Family Clinic, Shahid Beheshti University of Medical Sciences and Health Services, Tehran, Iran
| | | | - Akbar Biglarian
- Department of Biostatistics, University of Social Welfare and Rehabilitation Sciences (USWRS), Tehran, Iran,Address for correspondence: Dr. Akbar Biglarian, Department of Biostatistics, University of Social Welfare and Rehabilitation Sciences (USWRS), Koodakyar Street, Daneshjoo Ave, Evin, Tehran, Iran. E-mail:
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Achilla E, McCrone P. The cost effectiveness of long-acting/extended-release antipsychotics for the treatment of schizophrenia: a systematic review of economic evaluations. APPLIED HEALTH ECONOMICS AND HEALTH POLICY 2013; 11:95-106. [PMID: 23494934 DOI: 10.1007/s40258-013-0016-2] [Citation(s) in RCA: 37] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/01/2023]
Abstract
BACKGROUND Antipsychotic medication is the mainstay of treatment in schizophrenia. Long-acting medication has potential advantages over daily medication in improving compliance and thus reducing hospitalization and relapse rates. The high acquisition and administration costs of such formulations raise the need for pharmacoeconomic evaluation. OBJECTIVE The aim of this article is to provide a comprehensive review of the available evidence on the cost effectiveness of long-acting/extended-release antipsychotic medication and critically appraise the strength of evidence reported in the studies from a methodological viewpoint. METHODS Relevant studies were identified by searching five electronic databases: PsycINFO, MEDLINE, EMBASE, the NHS Economic Evaluation Database and the Health Technology Assessment database (HTA). Search terms included, but were not limited to, 'long-acting injection', 'economic evaluation', 'cost-effectiveness' and 'cost-utility'. No limits were applied for publication dates and language. Full economic evaluations on long-acting/extended-release antipsychotics were eligible for inclusion. Observational studies and clinical trials were also checked for cost-effectiveness information. Conference abstracts and poster presentations on the cost effectiveness of long-acting antipsychotics were excluded. Thirty-two percent of identified studies met the selection criteria. Pertinent abstracts were reviewed independently by two reviewers. Relevant studies underwent data extraction by one reviewer and were checked by a second, with any discrepancies being clarified during consensus meetings. Eligible studies were assessed for methodological quality using the quality checklist for economic studies recommended by the NICE guideline on interventions in the treatment and management of schizophrenia. RESULTS After applying the selection criteria, the final sample consisted of 28 studies. The majority of studies demonstrated that risperidone long-acting injection, relative to oral or other long-acting injectable drugs, was associated with cost savings and additional clinical benefits and was the dominant strategy in terms of cost effectiveness. However, olanzapine in either oral or long-acting injectable formulation dominated risperidone long-acting injection in a Slovenian and a US study. Furthermore, in two UK studies, the use of long-acting risperidone increased the hospitalization days and overall healthcare costs, relative to other atypical or typical long-acting antipsychotics. Finally, paliperidone extended-release was the most cost-effective treatment compared with atypical oral or typical long-acting formulations. From a methodological viewpoint, most studies employed decision analytic models, presented results using average cost-effectiveness ratios and conducted comprehensive sensitivity analyses to test the robustness of the results. LIMITATIONS Variations in study methodologies restrict consistent and direct comparisons across countries. The exclusion of a large body of potentially relevant conference abstracts as well as some papers being unobtainable may have increased the likelihood of misrepresenting the overall cost effectiveness of long-acting antipsychotics. Finally, the review process was restricted to qualitative assessment rather than a quantitative synthesis of results, which could provide more robust conclusions. CONCLUSIONS Atypical long-acting (especially risperidone)/extended-release antipsychotic medication is likely to be a cost-effective, first-line strategy for managing schizophrenia, compared with long-acting haloperidol and other oral or depot formulations, irrespective of country-specific differences. However, inconsistencies in study methodologies and in the reporting of study findings suggest caution needs to be applied in interpreting these findings.
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Affiliation(s)
- Evanthia Achilla
- Centre for Economics of Mental and Physical Health, Health Service and Population Research Department, PO24 Institute of Psychiatry, King's College London, De Crespigny Park, London SE5 8AF, UK
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