Cost and cost-effectiveness analysis of ondansetron versus metoclopramide regimens: a hospital perspective from Italy

Cost-effectiveness analysis of granisetron-based versus standard antiemetic regimens in low-emetogenic chemotherapy: a hospital-based perspective from Malaysia

BACKGROUND

In a prospective cohort study of antiemetic therapy conducted in Malaysia, a total of 94 patients received low emetogenic chemotherapy (LEC) with or without granisetron injections as the primary prophylaxis for chemotherapy-induced nausea and vomiting (CINV). This study is a retrospective cost analysis of two antiemetic regimens from the payer perspective.

MATERIALS AND METHODS

This cost evaluation refers to 2011, the year in which the observation was conducted. Direct costs incurred by hospitals including the drug acquisition, materials and time spent for clinical activities from prescribing to dispensing of home medications were evaluated (MYR 1=$0.32 USD). As reported to be significantly different between two regimens (96.1% vs 81.0%; p=0.017), the complete response rate of acute emesis which was defined as a patient successfully treated without any emesis episode within 24 hours after LEC was used as the main indicator for effectiveness.

RESULTS

Antiemetic drug acquisition cost per patient was 40.7 times higher for the granisetron-based regimen than for the standard regimen (MYR 64.3 vs 1.58). When both the costs for materials and clinical activities were included, the total cost per patient was 8.68 times higher for the granisetron-based regimen (MYR 73.5 vs 8.47). Considering the complete response rates, the mean cost per successfully treated patient in granisetron group was 7.31 times higher (MYR 76.5 vs 10.5). The incremental cost-effectiveness ratio (ICER) with granisetron-based regimen, relative to the standard regimen, was MYR 430.7. It was found to be most sensitive to the change of antiemetic effects of granisetron-based regimen.

CONCLUSIONS

While providing a better efficacy in acute emesis control, the low incidence of acute emesis and high ICER makes use of granisetron as primary prophylaxis in LEC controversial.

Chemotherapy-induced emesis: quality of life and economic impact in the context of current practice in Canada

In this study, we estimated the proportion of patients who experience chemotherapy-induced nausea and vomiting (CINV) in current practice and evaluated the impact of CINV on quality of life and cost in Canada. Patients receiving highly emetogenic chemotherapy were recruited from 4 Canadian oncology centers. Patients used diaries to record information on their activities, incidence of nausea and vomiting, and health resources consumed each day for 5 days following chemotherapy. They also completed the Functional Living Index-Emesis (FLIE) questionnaire and a health utility instrument before chemotherapy and 5 days later. Of the 323 patients recruited, 266 (82%) completed their diary. On day 1, 26% of patients reported nausea or vomiting (acute emesis). From day 2 to day 5 after chemotherapy, 44% reported nausea or vomiting (delayed emesis). Patients who experienced nausea or vomiting during the study period had a decrease in FLIE score of 22% and a decrease in health utility of 15%. Patients with nausea or vomiting reported an average of 19 hours per cycle during which they were unable to perform their normal activities. Also, friends or relatives spent an average of 10 hours helping these patients. Incremental medical costs per patient experiencing CINV were $61 Canadian. Including productivity losses, total incremental costs were $592 Canadian per patient. Despite use of antiemetics, CINV remains problematic, impacting the quality of life of patients with cancer and increasing costs.

Cost-effectiveness of aprepitant for the prevention of chemotherapy-induced nausea and vomiting associated with highly emetogenic chemotherapy

OBJECTIVE

Chemotherapy-induced nausea and vomiting (CINV) is a significant problem for cancer patients. Aprepitant, a novel NK-1 receptor antagonist, is approved for use with 5-HT3 antagonists and corticosteroids to prevent CINV associated with highly emetogenic chemotherapy. Nevertheless, the cost-effectiveness of standard aprepitant use has not been established.

METHODS

We developed a Markov model to compare three strategies for CINV: conventional treatment with a 5-HT3 antagonist and a corticosteroid, conventional treatment plus aprepitant, and conventional treatment with aprepitant added after the onset of CINV. Data from published clinical trials provided probabilities and utilities for the model. Data from the Centers for Medicare and Medicaid Services and the Federal Supply Scale provided costs for medical resources and medications utilized. Resource use data were based on a randomized clinical trial and routine clinical practice. The incremental cost-effectiveness ratio (ICER) for each aprepitant strategy was calculated in US$ per healthy day equivalent (HDE) and converted to dollars per quality-adjusted life-year (QALY). Univariate and probabilistic sensitivity analyses addressed uncertainty in model parameters.

RESULTS

Adding aprepitant after CINV occurred cost $264 per HDE ($96,333/QALY). The three-drug strategy cost $267/HDE with a 95% confidence range of $248-$305/HDE ($97,429/QALY; $90,396-$111,239/QALY). In univariate analyses, the most influential factors on the ICER were: the cost of aprepitant, the likelihood of delayed CINV without aprepitant, the likelihood of acute CINV with/without aprepitant, and the increase in HDE from avoiding CINV.

CONCLUSIONS

Aprepitant provides modest incremental benefits compared with conventional management of CINV. Routine aprepitant use appears most cost-effective when the likelihood of delayed CINV or the cost of rescue medications is high.

Health outcomes and cost-effectiveness of aprepitant in outpatients receiving antiemetic prophylaxis for highly emetogenic chemotherapy in Germany

BACKGROUND

Chemotherapy-induced nausea and vomiting (CINV) remains a major adverse effect of cancer therapy. We aimed to determine outcomes associated with use of aprepitant in outpatients undergoing highly emetogenic chemotherapy in Germany from a patient's and payer's perspective.

METHODS

A decision-analytic model compared an aprepitant regimen (aprepitant/ondansetron/dexamethasone) to a control regimen (ondansetron/dexamethasone) over a five days period. Clinical results and resource utilisation observed in aprepitant phase III clinical trials were assigned German unit cost data.

RESULTS

Complete response over one chemotherapy cycle was observed in 68% of patients in the aprepitant group (N=514) compared to 48% of patients in the control group (N=518). Patients were estimated to have gained an equivalent of 15 additional hours of perfect health per cycle (0.63 quality-adjusted life days) with aprepitant-based regimen compared to control regimen. Cost per quality-adjusted life year gained with aprepitant was estimated at euro28,891.

CONCLUSIONS

Aprepitant substantially improved CINV-related health outcomes in patients undergoing highly emetogenic chemotherapy. Incremental benefits materialised in a cost-effective fashion.

The cost of chemotherapy-induced nausea and vomiting in Italy

GOALS OF WORK

The aim of this paper is to analyze the costs of chemotherapy-induced nausea and vomiting (CINV) in Italy.

MATERIALS AND METHODS

In this prospective observational study at seven public oncology centers, incidence and intensity of CINV daily for 8 days after chemotherapy in consecutive patients receiving cisplatin-containing chemotherapy were recorded. All costs related to CINV (direct medical, direct nonmedical, and indirect) were recorded (in 2003 euros).

MAIN RESULTS

A total of 172 patients were enrolled; cost data were available for 168 patients. Thirty-seven percent of patients experienced acute CINV, and 57% experienced delayed CINV; 39% achieved total control, defined as no nausea, vomiting, or rescue therapy. Mean per-patient costs of acute and delayed CINV were 30.03 euro from the hospital perspective, 4.9 euro from the patient perspective, and 26.85 euro from the National Health Service (NHS) perspective. Costs of CINV were highly variable among oncology centers, largely because of differences in procedures for preventing delayed CINV. These costs were four times higher when antiemetic drugs were prescribed and paid for by the NHS than when antiemetic prophylaxis was provided directly from hospital pharmacies. Moreover, in the delayed phase, the NHS incurred a 94% increase in costs for patients without total control. Overall costs for patients who did not experience total control of CINV were 35.57 euro higher than for those who did (85% increase).

CONCLUSIONS

Costs of CINV for the Italian NHS could be reduced if hospitals furnished antiemetic prophylaxis directly to patients. Better control of both acute and delayed CINV would improve patient well-being as well as reduce the budgetary impact of CINV in Italy.

Tolerability of the Compound ABHR in Hospice Patients

BACKGROUND

Compounded formulations comprised of multiple medications may be useful for some patients with refractory nausea and vomiting. The combination of lorazepam, diphenhydramine, haloperidol, and metoclopramide (ABHR) has been used for more than a decade in the management of nausea and vomiting, but the tolerability of this combination in hospice patients has not been examined.

OBJECTIVE

Determine the tolerability of the ABHR compound in both younger and elderly hospice patients.

DESIGN

Retrospective cohort study.

SETTING/SUBJECTS

A total of 11,181 ABHR prescriptions dispensed to 8600 hospice patients in the home care setting were analyzed.

RESULTS

A total of 42 ABHR prescriptions were discontinued secondary to adverse drug reactions (ADRs) in 39 patients. Older patients appear to be more sensitive to the effects of ABHR, however, this trend did not achieve statistical significance when looking at extrapyramidal symptoms (EPS) specifically in these patients. The overall incidence of EPS was low, as only 0.1% of all prescriptions discontinued secondary to an ADR were consistent with EPS.

CONCLUSIONS

The compound ABHR is generally well tolerated in the majority of hospice patients. More investigation is warranted to determine the efficacy and tolerability of similar pharmaceutical compounds used commonly in the hospice patient population.

Economic Evaluation of a New Antiemetic Drug ??? Palonosetron versus Ondansetron

OBJECTIVES

This study aimed to identify, measure and evaluate expected costs of innovative palonosetron-based antiemetic therapy versus ondansetron-based treatment, the ultimate aim being to measure the drug price ratio (DPR) of the two pharmacological treatments in five different European countries.

METHODS

A decision model compared two antiemetic treatments - palonosetron and ondansetron - in terms of expected costs of emesis management from a hospital perspective. The model was compiled for 374 patients. The clinical superiority of palonosetron in preventing acute and delayed emesis, measured in terms of: (i) complete response rates, (ii) number of emetic episodes, and (iii) administration of rescue medication, was derived from a previously published clinical trial. The cost data were gathered through economic questionnaires distributed in 11 European hospital centres. The expected costs of emesis management with palonosetron and ondansetron at ondansetron prices were used to calculate the DPR for palonosetron in each of the five European countries.

RESULTS

In the baseline analysis, DPR varied from 1.55 (in Russia) to 2.60 (in the UK). The sensitivity analysis of the unit costs of emetic episodes and rescue medication identified a range from 1.39 (in Germany) to 4.09 (in Russia). Even in the least favourable clinical scenario, palonosetron was a preferred antiemetic strategy with a DPR >1 in all five countries.

CONCLUSIONS

This is the first economic evaluation analysis of palonosetron. The results demonstrate that palonosetron, because of its superior clinical efficacy in controlling emesis, could have a favourable DPR when compared with ondansetron in all five countries considered and still offer lower or equal net treatment costs for the hospital.

Variability of cost-effectiveness estimates for pharmaceuticals in Western Europe: lessons for inferring generalizability

OBJECTIVES

It has long been suggested that, whereas the results of clinical studies of pharmaceuticals are generalizable from one jurisdiction to another, the results of economic evaluations are location dependent. There has been, however, little study of the causes of variation, whether differences in study results among countries are systematic, or whether they are important for decision making.

METHODS

A literature search was conducted to identify economic evaluations of pharmaceuticals conducted in two or more European countries. The studies identified were then classified by methodological type and analyzed to assess their level of variability and to identify the main causes of variation. Assessments were also made of the extent to which differences in study results among countries were systematic and whether they would lead to a different decision, assuming a range of values of the threshold willingness-to-pay for a life-year or quality-adjusted life-year (QALY).

RESULTS

In total 46 intercountry drug comparisons were identified, 29 in multicountry studies and 17 in comparable single country studies that were considered to be sufficiently similar in terms of methodology. The type of study (i.e., trial-based or modeling study) had some impact on variability, but the most important factor was the extent of variation across countries in effectiveness, resource use or unit costs, allowed by the researcher's chosen methodology. There were few systematic differences in study results among countries, so a decision maker in country B, on seeing a recent economic evaluation of a new drug in country A, would have little basis on which to predict whether the drug, if evaluated, would be more or less cost-effective in his or her country. Given the extent of variation in cost-effectiveness estimates among countries, the importance of this for decision making depends on decision makers' thresholds in willingness-to-pay for a QALY or life-year. If a cost-effectiveness threshold (i.e., willingness-to-pay) for a life-year or QALY of dollar 50,000 were assumed, the same conclusion regarding cost-effectiveness would be reached in most cases.

CONCLUSION

This review shows that cost-effectiveness results for pharmaceuticals vary from country to country in Western Europe and that these variations are not systematic. In addition, constraints imposed by analysts may reduce apparent variability in the estimates. The lessons for inferring generalizability are not straightforward, although the implications of variation for decision making depend critically on the cost-effectiveness thresholds applying in Western Europe.

Economics and health-related quality of life in antiemetic therapy: recommendations for trial design

Emesis (nausea and vomiting) is one of the most important toxicities associated with chemotherapy. Although it is not life threatening, it has a major impact on a patient's health-related quality of life (HRQL) and overall response to chemotherapy. New antiemetics are expensive and well-conducted comparative health economic studies are rare. The aim of the study was to review the literature in the area of chemotherapy-induced emesis in cancer patients and to offer recommendations for the inclusion of these outcomes in the design of clinical trials for new antiemetic therapies. The economic literature was reviewed based on methodological standards for economic evaluation. Many studies did not comply with standards, specifically with regard to the choice of alternatives, chosen perspective, setting, type of emesis, measurement of costs and defining outcomes (including health-related quality of life). These issues are described for each study and recommendations for trial design are presented. The role of economic data is to support decision making in choosing between competing antiemetic therapies. It is the combination of clinical outcomes, costs and health-related quality of life, which will allow treating physicians to comprehensively assess the relative value of antiemetic therapies and to provide the most cost-effective therapy for their patients.

Recent advances in pediatrics

The challenging issues in pediatric pharmacotherapy are both profound and exciting. Microtechnologies for evaluating the impact of genetics in disease (e.g., using polymerase chain reactions) and the possibilities of therapeutic interventions create major clinical and ethical dilemmas that remain to be resolved. Inclusion of pediatric patients in drug development and marketing trials also remains a point of contention. Finally, well-established therapies should not be overlooked in favor of new but unestablished treatment approaches. Future columns will continue to use the current format, in which a few selected topics of high therapeutic importance are discussed. The research technologies, discussion of new drug therapy interventions, and preventive strategies most likely to benefit the health care of infants, children, and adolescents will remain the scope of this column.

Using cost-effectiveness analysis for formulary decision making: from theory into practice

The growth of expenditures on healthcare and pharmaceutical products is a concern to third-party payers because of the absence of market discipline (price signals that consumers face). Cost-effectiveness analysis is a method that allows third-party payers to systematically make judgements about the 'value for money' of these products. It moves beyond simple unit price comparisons of alternate interventions/products to consider the full stream of relevant cost and benefits. As formulary committees begin to adopt the systematic use of cost-effectiveness analyses to inform the debate, the exercise will move from an academic to a more practical application. This transition will require several important changes including defining the purpose of cost-effectiveness analysis, measurement of outcomes and data, format of reports, and contractual arrangements between the pharmaceutical industry and analysts. As more 'real world' experience is gained in the practical application of cost-effectiveness analysis, the quality of data will improve as will its value as an aid to decision making.