Cost-effectiveness of capecitabine in combination with oxaliplatin (XELOX) compared with FOLFOX for the treatment of metastatic colorectal cancer: A Canadian evaluation

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Background: Capecitabine is an oral fluoropyrimidine used to treat patients with metastatic colorectal cancer (mCRC). Recent trials in 1st- and 2nd-line treatment have shown that capecitabine in combination with oxaliplatin (XELOX) is non-inferior to FOLFOX4 in terms of progression-free survival, overall survival and response rates. XELOX offers patients the advantage of treatment every 3 weeks rather than every 2 weeks without the need for lengthy infusions. This analysis evaluated the cost- effectiveness of replacing FOLFOX4 with XELOX for 1st- and 2nd-line treatment of mCRC from both Canadian healthcare system payor and societal perspectives. Methods: Based on evidence of non-inferiority of XELOX vs. FOLFOX4, cost-minimization analyses (CMA) were conducted using phase III clinical trial data. The CMA compared total cost associated with chemotherapy medications, administration of chemotherapy, and treatment related toxicities. For the societal perspective, patients’ costs and time were also included. The costs (or savings) were compared for 1st-line XELOX vs. FOLFOX4 and 2nd-line XELOX vs. FOLFOX4. Due to variation in Canadian clinical practice, sensitivity analyses using the FOLFOX6 regimen as a comparator were performed. Results: Cost savings per patient for XELOX vs. FOLFOX4 from a healthcare system payor perspective and a societal perspective are shown in the Table . XELOX was also associated with cost savings when compared with the simplified administration regimen of FOLFOX6. Reduced costs for chemotherapy administration and costs for patients’ time and travel primarily related to fewer clinic visits offset the increased drug acquisition cost of the XELOX regimen. Conclusions: Replacing FOLFOX with XELOX is associated with cost savings from the healthcare system payor and societal perspectives while preserving clinical efficacy.

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Economic evaluation of donepezil in moderate to severe Alzheimer disease

OBJECTIVE

To investigate the costs to society of Alzheimer disease (AD) care in a multinational, randomized, placebo-controlled trial of donepezil in patients with moderate to severe AD.

METHODS

A total of 290 patients with AD (screening standardized Mini-Mental State Examination score 5 to 17) were randomized to receive either donepezil (n = 144; 5 mg/day for 28 days, followed by 10 mg/day as per clinician's judgment) or placebo (n = 146) for 24 weeks. The authors collected data on patient and caregiver health resource utilization prospectively using the Canadian Utilization of Services Tracking questionnaire. Costs were calculated for patients and caregivers in each group based on resource utilization multiplied by the unit prices for each resource. A cost (the average Ontario minimum wage for 1998 [Can 6.85 dollars per hour]) was assigned to unpaid time that caregivers spent assisting the patient with activities of daily living (ADL).

RESULTS

Patient and caregiver demographics at baseline were similar across the two groups. After adjusting for baseline total cost per patient, the mean total societal cost per patient for the 24-week period was donepezil, Can 9,904 dollars (US 6,686 dollars) and placebo, Can 10,236 dollars (US 6,910 dollars). This net cost saving of Can 332 dollars (US 224 dollars) included the average 24-week cost of donepezil treatment. Most of the cost-saving with donepezil treatment was due to less use of residential care by patients, and caregivers spending less time assisting patients with ADL.

CONCLUSION

This cost-consequence analysis reveals economic benefits of treatment of moderate to severe AD with donepezil.

Economic evaluation of donepezil for the treatment of Alzheimer's disease in Canada

BACKGROUND

Donepezil is a new drug recently approved in the United States and Canada for the treatment of Alzheimer's disease (AD). We estimated the cost-effectiveness of donepezil 5 mg daily as an adjunct to usual care in the management of persons with mild-to-moderate AD defined as a Mini-Mental Health State Examination (MMSE) score in the range 10 to 26.

METHODS

Treatment effect data as MMSE change-over-baseline scores were obtained from a 30-week placebo-controlled trial of donepezil. MMSE scores beyond observed trial data were estimated using a Markov model with 10 cycles of 24 weeks based on the placebo MMSE progression observed in the trial. Data from AD subjects in the Canadian Study of Health and Aging were used to estimate costs of nursing home care, community services, medications, and caregiver time as a function of MMSE score. A clinic-based cohort study from Alberta was used to estimate the distribution of AD patients by MMSE score presenting for treatment. The effectiveness measure for the economic model was expected time (over 5 years) spent with nonsevere AD (MMSE > or = 10).

RESULTS

Over 5 years of treatment, donepezil is predicted to reduce health care costs by CA$929 per patient but increase caregiver time costs by CA$48 per patient for an overall cost saving to society of CA$882 per patient. Patients not receiving donepezil are predicted to spend 2.21 years of the 5 years in nonsevere AD compared with 2.41 years for treated patients (a gain of just over 2 months). Sensitivity analysis reveals that cost savings per patient increase if more AD patients are assumed to survive to 5 years; however, if donepezil treatment continues when patients' MMSE score falls below 10, the incremental cost is higher for treatment at CA$1554 per patient.

CONCLUSION

Based on the limited available data, our model predicts that the use of donepezil for mild-to-moderate AD in Canada is associated with lower 5-year costs and less time spent with severe AD when compared with the alternative of usual care with no donepezil therapy. As more reliable long-term data become available, these predictions should be confirmed and/or updated.

The Canadian experience with risperidone for the treatment of schizophrenia: an overview

OBJECTIVE

To summarize published data to date by Canadian authors and from Canadian sources on risperidone, a novel neuroleptic indicated in the management of schizophrenia and related psychotic disorders. It was introduced in Canada in 1993.

DATA SOURCES

A MEDLINE search was performed using "risperidone" as a keyword. Three Canadian journals were also searched manually.

STUDY SELECTION

Articles published between January 1991 and June 1996 by Canadian authors or involving Canadian patients.

DATA EXTRACTION

Retrieved articles were categorized according to data on efficacy, safety, resource use/economics and other miscellaneous aspects. Articles were abstracted and summarized. Some non-Canadian sources were used for comparison.

DATA SYNTHESIS

The initial Canadian multicentre trial found resperidone (6 mg daily) to be superior to haloperidol (20 mg daily) in reducing positive and negative symptoms, with fewer extrapyramidal side effects (EPS). Various case reports have extended both the clinical use and safety profile of risperidone, while neuro-imaging studies have tried to clarify its mechanism of action. Economic studies suggest substantial cost benefits due to prevention of hospitalization as well as improvement in quality of life.

CONCLUSIONS

Canadian research has contributed considerably to the current knowledge regarding risperidone. Future studies, both controlled and naturalistic, will need to focus on comparisons with the various new compounds now available.

Factors influencing movement of chronic psychiatric patients from the orientation to the working phase of the nurse-client relationship on an inpatient unit

PROBLEM

To identify factors influencing movement of nurse-patient dyads from Peplau's orientation phase to the working phase of the nurse-client relationship in a tertiary care psychiatric setting.

METHODS

Ten nurse-client dyads were interviewed after the initial nurse-client assignment until a consensus was reached between client, nurse, and investigator/CNS that the relationship was in the working phase.

FINDINGS

Factors causing the relationship to progress, from the clients' perspective, were the perceived attitude of the nurse, the nature of the planned therapeutic sessions, and what happened between therapeutic sessions. Factors hindering the development of the relationship included a nurse's or client's unavailability, a sense of distance/inequity, differences in realities/values, and mutual withdrawal. The relationship was perceived as supportive and "powerful" when it progressed to the working phase, but as very negative and like "limbo" if instead it moved to a phase of mutual withdrawal.

CONCLUSIONS

Nurses can help clients move from the orientation phase to the working phase by remaining available, consistent, and acting in a way that promotes trust. When the relationship does not progress to the working phase within 6 months, a therapeutic transfer should be considered.

A follow-up study on alcoholics with and without co-existing affective disorder

Three-hundred male alcoholics were selected from consecutive admissions to hospital. They were divided into three diagnostic sub-groups: primary alcoholics; alcoholics with unipolar affective disorder; and alcoholics with bipolar affective disorder. After three follow-up interviews over a 2-year period after hospital discharge, the three sub-groups reported differences in frequency of mood change, amount of treatment received, and hospital attendance, although there were no clear-cut differences in items associated with their alcoholism. There were, however, some indications that bipolar patients functioned at a better level during the follow-up period, particularly those who were older, had a previous history of longer periods of abstinence, and maintained more frequent contact with Alcoholics Anonymous (AA) and their family doctor.

Methylene blue: a reliable and practical marker for validating compliance on the DST

Assurance of compliance (ingestion of dexamethasone) is crucial for interpreting plasma cortisol results on the DST. In this double-blind study of 13 subjects, methylene blue (MB) 50 mg was combined with dexamethasone 1 mg in single capsules, and the resulting blue-green urinary color after ingestion was found to reliably validate compliance in 100% of patients and controls. The addition of MB did not influence DST results (i.e., plasma cortisol, plasma dexamethasone). Adding MB to dexamethasone as a marker is a reliable and safe means of validating compliance on the DST and is considerably more practical than plasma dexamethasone level determinations.

Psychotropic drug withdrawal and the dexamethasone suppression test

In a prospective study of 25 patients from the time of hospitalization, seven had recently discontinued psychotropic agents (including antidepressants, neuroleptics, and benzodiazepines). All seven had positive dexamethasone suppression test results after 1 week of hospitalization. This phenomenon did not occur in any of the other subjects who had not discontinued such medications. Some of the subjects with postdexamethasone cortisol increases reported drug discontinuation in the drug histories they gave at admission, but in three, drug screening provided the only evidence of prior drug use. Medication withdrawal may be an underappreciated confounding variable in DST studies.

Prediction of response to stabilizing lithium treatment

As lithium has a wide range of biological effects, it is not surprising that the benefit from lithium treatment has been observed in several types of psychiatric disorders. Mood stabilization has been seen in episodic disorders; antiaggressive effect has been reported in mental retardation and other illnesses, and some endocrine and hematological effects have been utilized in internal medicine and neurology. To date, however, only the stabilizing effect on recurrent mood disorders appears to be reliably predictable. The prediction is based primarily on the diagnosis, quality of free interval and frequency of episodes; and several associated indicators can also be helpful. Results of the presented series of studies on the response to stabilizing lithium treatment suggest that such a response is predictable for most patients. The epitome of an excellent lithium responder is a patient with a good quality of remissions, a moderate frequency of recurrences, and a diagnosis of primary affective disorder. If the MMPI profile taken at the patient's optimum is abnormal, the chances of stabilization on lithium alone are greatly reduced. In addition, the responders more frequently have a family history of primary affective disorder and a positive M antigen. It appears that in the present practice the assessment of patients for stabilizing lithium treatment may frequently not be comprehensive enough. As a result, lithium is at present probably overprescribed in North America, and possibly elsewhere as well.

Kidney function and response to lithium treatment

1. Kidney function during long-term lithium treatment was studied in the representative sample of patients with recurrent affective disorders. Creatinine clearance, maximum urinary osmolality and 24-hour urine volume were determined. 2. Patients were divided according to their type of response to long-term lithium treatment, expressed by the effect on the frequency of recurrencies. Various indicators of kidney function were compared in excellent responders and in non-responders. 3. Long-term lithium treatment did not lead to any detectable changes of glomerular filtration in either group. 4. In comparison with responders, non-responders showed a significantly greater increase in 24-hour urine volume and a trend towards a greater reduction of maximum urinary osmolality, and thus a greater impairment of tubular function. 5. The findings stress the need for a careful selection of patients for long-term lithium stabilization.