Prices, profits, and innovation: examining criticisms of new psychotropic drugs' value

Defining 'therapeutic value' of medicines: a scoping review

OBJECTIVES

In recent years, discussions on the importance and scope of therapeutic value of new medicines have intensified, stimulated by the increase of prices and number of medicines entering the market. This study aims to perform a scoping review identifying factors contributing to the definition of the therapeutic value of medicines.

DESIGN

Scoping review.

DATA SOURCES

We searched the MEDLINE, CINAHL, Embase, Business Source Premier, EconLit, Regional Business News, Cochrane, Web of Science, Scope and Pool databases through December 2020 in English, German, French, Italian and Spanish.

ELIGIBILITY CRITERIA

Studies that included determinants for the definition of therapeutic value of medicines were included.

DATA EXTRACTION AND SYNTHESIS

Data were extracted using the mentioned data sources. Two reviewers independently screened and analysed the articles. Data were analysed from April 2021 to May 2022.

RESULTS

Of the 1883 studies screened, 51 were selected and the identified factors contributing to the definition of therapeutic value of medicines were classified in three categories: patient perspective, public health perspective and socioeconomic perspective. More than three-quarters of the included studies were published after 2014, with the majority of the studies focusing on either cancer disorders (14 of 51, 27.5%) or rare diseases (11 of 51, 21.6%). Frequently mentioned determinants for value were quality of life, therapeutic alternatives and side effects (all patient perspective), prevalence/incidence and clinical endpoints (all public health perspective), and costs (socioeconomic perspective).

CONCLUSIONS

Multiple determinants have been developed to define the therapeutic value of medicines, most of them focusing on cancer disorders and rare diseases. Considering the relevance of value of medicines to guide patients and physicians in decision-making as well as policymakers in resource allocation decisions, a development of evidence-based factors for the definition of therapeutic value of medicines is needed across all therapeutic areas.

Access to essential psychotropic medicines in Addis Ababa: A cross-sectional study

BACKGROUND

Mental disorders are becoming a growing public health problem worldwide, especially in low- and middle-income countries. Regular and adequate supplies of appropriate, safe, and affordable medications are required to provide quality mental health services. However, significant proportions of the population with severe mental disorders are not getting access to treatment. Among others, the availability and affordability of psychotropic medicines are significant barriers for many patients in meeting their medication needs. This study aimed to assess the availability, prices, and affordability of essential psychotropic medicines in the private and public health sectors of Addis Ababa, the capital city of Ethiopia.

METHODS

A cross-sectional study design was used in 60 retail medicine outlets from the public and private sectors. Stratified random and quota sampling were applied to select the retail outlets. Data was entered and analyzed using the preprogrammed WHO/HAI workbook and SPSS V.25.

RESULTS

The mean availability of Lower Priced Generic (LPG) psychotropic medicines was 24.33% in Addis Ababa (28.7% in the public sector and 19.80% in the private sector). The Patient prices for the LPG ranged from 0.52-6.43 MPRs in public and 1.08-24.28 MPRs in private sectors. Standard treatment costs varied from 0.1-7.8 days' wages in public and 0.8-25 days' wages in private sectors for the lowest-paid government worker to purchase a month's supply.

CONCLUSIONS

Essential psychotropic medicines were poorly available, with high prices and low affordability in Addis Ababa. An efficient supply across all levels of care and financial protection for essential medicines should be in place to ensure access.

Comparative efficacy and risk of harms of immediate- versus extended-release second-generation antidepressants: a systematic review with network meta-analysis

BACKGROUND

Major depressive disorder (MDD) has detrimental effects on an individual's personal life, leads to increased risk of comorbidities, and places an enormous economic burden on society. Several 'second-generation' antidepressants are available as both immediate-release (IR) and extended-release formulations. The advantage of extended-release formulations may be the potentially improved adherence and a lower risk of adverse events.

OBJECTIVE

We conducted a systematic review to assess the comparative efficacy, risk of harms, and patients' adherence of IR and extended-release antidepressants for the treatment of MDD.

DATA SOURCE

English-language abstracts were retrieved from PubMed, EMBASE, the Cochrane Library, PsycINFO, and International Pharmaceutical Abstracts from 1980 to October 2012, as well as from reference lists of pertinent review articles and grey literature searches.

ELIGIBILITY CRITERIA

We included head-to-head randomized controlled trials (RCTs) of at least 6 weeks' duration that compared an IR formulation with an extended-release formulation of the same antidepressant in adult patients with MDD. We also included placebo-controlled trials to conduct a network meta-analysis. To assess harms and adherence, in addition to RCTs, we searched for observational studies with ≥1,000 participants and a follow-up of ≥12 weeks.

STUDY APPRAISAL AND SYNTHESIS METHODS

We dually reviewed abstracts and full texts and assessed quality ratings. Lacking head-to-head evidence for many comparisons of interest, we conducted network meta-analyses using Bayesian methods. Our outcome measure of choice was response on the Hamilton Depression Rating Scale.

RESULTS

We located seven head-to-head trials and 94 placebo- and active-controlled trials for network meta-analysis. Overall, our analyses indicate that IR and extended-release formulations do not differ substantially with respect to efficacy and risk of harms. The evidence is mixed with respect to differences in adherence, indicating lower adherence for IR formulations.

LIMITATIONS

The lack of head-to-head comparisons for many drugs compromises our conclusions. Network meta-analyses have methodological limitations that need to be taken into consideration when interpreting findings.

CONCLUSION

Available evidence currently shows no clear differences between the two formulations and therefore we cannot recommend a first choice. However, if adherence or compliance with one medication is an issue, then clinicians and patients should consider the alternative medication. If adherence or costs are a problem with one formulation, consideration of the other formulation to provide an adequate treatment trial is reasonable.

Pharmacological and psychosocial management of mental, neurological and substance use disorders in low- and middle-income countries: issues and current strategies

Mental, neurological, and substance use disorders (MNS) are among the largest sources of medical disability in the world, surpassing both cardiovascular disease and cancer. The picture is not different in low- and middle-income countries (LAMIC) where the relative morbidity associated with MNS is increasing, as a consequence of improvement in general health indicators and longevity. However, 80 % of individuals with MNS live in LAMIC but only close to 20 % of cases receive some sort of treatment. The main aim of this article is to provide non-specialist health workers in LAMIC with an accessible guide to the affordable essential psychotropics and psychosocial interventions which are proven to be cost effective for treating the main MNS. The MNS discussed in this article were selected on the basis of burden, following the key priority conditions selected by the Mental Health Action Programme (mhGAP) developed by the World Health Organization (WHO) (anxiety, stress-related and bodily distress disorders; depression and bipolar disorder; schizophrenia; alcohol and drug addiction; and epilepsy), with the addition of eating disorders, because of their emergent trend in middle-income countries. We review best evidence-based clinical practice in these areas, with a focus on drugs from the WHO Model List of Essential Medicines and the psychosocial interventions available in LAMIC for the management of these conditions in primary care. We do this by reviewing guidelines developed by prestigious professional associations and government agencies, clinical trials conducted in LAMIC and systematic reviews (including Cochrane reviews) identified from the main international literature databases (MEDLINE, EMBASE and PsycINFO). In summary, it can be concluded that the availability and use of the psychotropics on the WHO Model List of Essential Medicines in LAMIC, plus an array of psychosocial interventions, can represent a cost-effective way to expand treatment of most MNS. The translation of these findings into policies can be achieved by relatively low supplementary funding, and limited effort engendered by governments and policy makers in LAMIC.

What is the value of 'me-too' drugs?

The objective of this article is to estimate the value of 'follow-on' or 'me-too' drugs from the payer, industry and societal perspectives. Since me-too drugs do not bring additional clinical benefits, they are only valuable to payers if they save costs. An empirical model was constructed to identify the factors affecting whether a me-too drug results in cost savings to the pharmaceutical budgets of payers. These factors included the intensity of promotional spending, price discount and time to entry. Twenty-seven second-entrant products with limited differentiation were identified; their launch dates ranged from 1988 to 2009. On average, me-too drugs launch 2.5 years after the first entrant, with 20 % more promotional investment, and capture 38 % of market share within 4 years. Peak market share is significantly affected by share of voice (p < 0.001) but not price discount (p = 0.77). Launch delay was significant in terms of reducing both market share (p < 0.001) and price (p < 0.05). With a launch price 15 % below the incumbent, cumulative savings from use of a me-too drug peak at over $1000 million, but decrease rapidly after the first entrant becomes generic and only amount to $450 million over the me-too drug's lifecycle. With a price discount less than 10 %, cumulative savings are negative over the life of the me-too drug. Therefore, me-too drugs may be cost saving in the short term, but can represent a cost in the longer term. From a societal perspective, me-too drugs always decrease the economic surplus if they do not grow the market. If me-too drugs grow the market by 20 %, they augment, on average, the economic surplus only if the variable costs (including promotional investment) do not increase by more than $300 million per year.

Commonalities and differences in HTA outcomes: a comparative analysis of five countries and implications for coverage decisions

OBJECTIVE

To identify diverging HTA recommendations across five countries, understand the rationale for decision-making in specific therapeutic categories, and suggest ways forward to minimize these inter-country differences.

METHODS

A comparative analysis of HTA recommendations for 287 drug-indication pairs appraised by five countries (England, Scotland, Sweden, Canada, and Australia) between 2007 and 2009, including an in-depth analysis of two case studies. Agreement levels were measured using kappa scores. Associations were explored through correspondence analysis.

RESULTS

Significant inter-country variability in the HTA recommendations exists: 46% of the drug-indication pairs studied received diverging recommendations across countries. The level of agreement between agencies was poor to moderate. Associations between HTA recommendations issued by each HTA body per therapy area (cancer, orphan, CNS) differed from the general pattern observed across the complete sample. Expectations from HTA bodies in terms of relative effectiveness differ depending on the drug and disease's characteristics, although agency-specific guidelines are homogeneous for all treatments.

POLICY IMPLICATIONS

Distinguishing and accounting for the specifics underpinning individual conditions and their characteristics in HTA processes may constitute a way forward to improved HTA methods, while increasing transparency in the expectations that HTA bodies have in terms of relative effectiveness of the drug depending on these characteristics.

Pharmacological treatment of schizophrenia

BACKGROUND

A lack of human and financial resources, as well as effective health systems, leads to a worldwide treatment gap for schizophrenia. The aim of this paper is to propose evidence-based antipsychotics interventions for people with schizophrenia with special focus in low and middle income countries (LAMIC) reality.

METHOD

A comprehensive search was conducted to locate the main clinical trials, reviews and relevant meta-analyses, and a number of the main recent international clinical practice guidelines.

RESULTS

First- and second-generation antipsychotics are similarly effective in the acute treatment of psychotic symptoms. In LAMIC, the treatment of choice for medical treatment of psychotic conditions is the group of so-called 'first generation antipsychotics' (FGAs) preferentially delivered in a community-based service model.

CONCLUSIONS

Although the symptomatic control is essential, it is not the ultimate goal of treatment. The main aim of treatment is to improve functional recovery and social reintegration of patients.

Should financial incentives be used to differentially reward 'me-too' and innovative drugs?

Strategies to change the existing mix of innovative and 'me-too' drugs are intended to increase societal value of a given investment in R&D by providing an incentive for firms to invest in drugs that are more likely to be clinically innovative. How can financial incentives be used to change this mix? Will a strategy have its intended consequence or will it have the unintended outcome of reducing the rate at which the population burden of disease is reduced? The perspective of this review is a country such as Australia, Canada or the UK that has universal health insurance and a drug reimbursement process that is informed by economic evidence. A review of the literature was performed and the views of both the proponents and the opponents of such strategies and the mechanisms by which they could be implemented were summarized. The debate is based largely on hypothesized responses by firms to changes in incentives rather than empirical evidence. The main point of contention is whether a changed mix of new molecular entities (NMEs) increases or decreases the total amount of clinical innovation launched each year. The argument presented in this article is that, despite the limited empirical evidence, it is possible to improve our assessment of the likely costs and consequences of a proposed strategy by appealing to economic theory and observations about the reimbursement process. First, the empirical evidence supporting the view that changing a mix of drugs will improve clinical innovation is based on the average launched drug, not the marginal innovative drug otherwise not developed, and therefore could be misleading. Second, the dynamic and complex nature of evidence of clinical innovation will reduce the feasibility of using contractually based mechanisms to implement such a strategy. Also, a single country is unlikely to have an impact on R&D decisions, and variation in the per capita economic value of new drugs would make multi-jurisdiction contracts with one firm difficult to implement. Third, the quality of evidence of the clinical innovation of the lead drug could be reduced if there are fewer or no follow-on drugs. Finally, the existing inefficiencies in the process of displacement to finance new technologies from a capped budget reduces the efficiency with which any additional potential clinical innovation from NMEs will be translated to reduced population burden of disease. The article concludes that it is possible that such a strategy could be costly to implement, and the impact on global burden of disease uncertain in both direction and magnitude. This is likely to be the case even if the average clinical innovation content of innovative NMEs is higher than for me-too NMEs and the mechanisms designed to change the mix of NMEs are effective. Other options to improve the effectiveness with which pharmaceutical clinical innovation reduces burden of disease should be explored, including improved efficiency of both firm R&D and the process of disinvestment to finance new technologies.

Racial and ethnic disparities in the treatment of a Medicaid population with schizophrenia

OBJECTIVE

To assess health care disparities among black and Latino adults with schizophrenia receiving services during the period July 1994-June 2006, and to evaluate trends in observed disparities.

DATA SOURCES

Administrative claims data from the Florida Medicaid program. Data sources included membership files (demographic information), medical claims (diagnostic, service, and expenditure information), and pharmacy claims (prescriptions used and expenditures).

STUDY DESIGN

We identified adults with at least two schizophrenia claims during a fiscal year. We used generalized estimating equation models to estimate disparities in spending on psychotropic drugs, psychiatric inpatient services, all mental health services, and all health services.

PRINCIPAL FINDINGS

Spending on psychotropic drugs, mental health, and all health was 0.9-70 percent lower for blacks and Latinos than for whites. With the exception of blacks with substance use disorder comorbidity, minorities were less likely than whites to use psychiatric inpatient services. Psychiatric inpatient spending among users did not differ by race/ethnicity. With the exception of psychiatric inpatient utilization/spending, trend analyses showed no change or modest reductions in disparities.

CONCLUSIONS

Black and Latino Medicaid recipients diagnosed with schizophrenia experience health care disparities. Some but not all disparities narrowed modestly over the study period.

[Scientific evidence and the cost of innovations in the health-care system]

When depicting the relationship between evidence and the cost of an innovation in the health-care system, the overall risks of assessment, the redistribution of risks in a regulated market, and the ethical consequences must first be taken into account. There are also evidence-based criteria and economic considerations which are relevant when calculating the cost of an innovation. These topics can indicate, but not exhaustively deal with the complicated relationship between scientific evidence and calculating the cost of an innovation in the health-care system. The following three statements summarize the current considerations in the continuing discussion of this topic: *Scientific evidence undoubtedly exists which should be taken into consideration when calculating the cost of an innovation in the health-care system. *The existing scientific evidence is, however, not sufficient to reach such a decision. Additional information about the benefit perceived by the patient is required. *No standardized method exists to measure this additional information. Therefore, a definition problem also exists in the health-care system when setting a price according to scientific evidence.

Who are the new users of antipsychotic medications?

OBJECTIVE

This study examined changes in the prevalence of antipsychotic medication use and the characteristics of antipsychotic users in the U.S. population between 1996 and 2005.

METHODS

Data from the Medical Expenditure Panel Survey from 1996-1997 and 2004-2005 were used to examine the rate of first- and second-generation antipsychotic medication use and changes in the characteristics of users of all ages. Trends were examined in the level of use by antipsychotic users, both in terms of defined daily dose units and number of prescriptions.

RESULTS

The rate of antipsychotic use has increased substantially between 1996-1997 and 2004-2005, but the average dose measured both by defined daily dose units and number of prescriptions has remained constant. The rapid diffusion of antipsychotic medications did not occur among individuals with schizophrenia, but rather it included substantial growth among those with newer on-label conditions (such as bipolar disorder) and a high, constant rate of off-label use. Demographic, financial, and insurance characteristics of users have remained fairly constant, with few exceptions. The average age of antipsychotic users declined during the study period, because more children were using these medications in 2004-2005. However, the gender, racial, ethnic, and insurance composition of users has been fairly stable over time.

CONCLUSIONS

The rapid diffusion of second-generation antipsychotic medications was achieved by large increases in the rate of use in certain subpopulations, most notably youths. Increasing understanding about the marginal efficacy and side-effect risks of newer and more expensive antipsychotic agents, even when prescribed as indicated, suggests that the dramatic increase in use warrants careful attention.

Medicare inpatient treatment for elderly non-dementia psychiatric illnesses 1992--2002; length of stay and expenditures by facility type

We summarize Medicare utilization and payment for inpatient treatment of non-dementia psychiatric illnesses (NDPI) among the elderly during 1992 and 2002. From 1992 to 2002, overall mean Medicare expenditures per elderly NDPI inpatient stay declined by $2,254 (in 2002 dollars) and covered days by 2.8. However, these changes are complicated by expanded use of skilled nursing facilities and hospital psychiatric units, and decreased use of long-stay hospitals and general hospital beds. This suggests that inpatient treatment for NDPI is shifting into less expensive settings which may reflect cost-cutting strategies, preferences for less restrictive settings, and outpatient treatment advances.

Who are the new users of antipsychotic medications?

OBJECTIVE

This study examined changes in the prevalence of antipsychotic medication use and the characteristics of antipsychotic users in the U.S. population between 1996 and 2005.

METHODS

Data from the Medical Expenditure Panel Survey from 1996-1997 and 2004-2005 were used to examine the rate of first- and second-generation antipsychotic medication use and changes in the characteristics of users of all ages. Trends were examined in the level of use by antipsychotic users, both in terms of defined daily dose units and number of prescriptions.

RESULTS

The rate of antipsychotic use has increased substantially between 1996-1997 and 2004-2005, but the average dose measured both by defined daily dose units and number of prescriptions has remained constant. The rapid diffusion of antipsychotic medications did not occur among individuals with schizophrenia, but rather it included substantial growth among those with newer on-label conditions (such as bipolar disorder) and a high, constant rate of off-label use. Demographic, financial, and insurance characteristics of users have remained fairly constant, with few exceptions. The average age of antipsychotic users declined during the study period, because more children were using these medications in 2004-2005. However, the gender, racial, ethnic, and insurance composition of users has been fairly stable over time.

CONCLUSIONS

The rapid diffusion of second-generation antipsychotic medications was achieved by large increases in the rate of use in certain subpopulations, most notably youths. Increasing understanding about the marginal efficacy and side-effect risks of newer and more expensive antipsychotic agents, even when prescribed as indicated, suggests that the dramatic increase in use warrants careful attention.