Methodological Challenges in the Economic Evaluation of a Gene Therapy for RPE65-Mediated Inherited Retinal Disease: The Value of Vision

The emergence of gene therapies challenge health economists to evaluate interventions that are often provided to a small patient population with a specific gene mutation in a single dose with high upfront costs and uncertain long-term benefits. The objective of this study was to illustrate the methodological challenges of evaluating gene therapies and their implications by discussing four economic evaluations of voretigene neparvovec (VN) for the treatment of RPE65-mediated inherited retinal disease. The checklist for economic evaluations of gene therapies of Drummond et al. was applied to the economic evaluations of VN performed by US Institute for Clinical and Economic Review, two country adaptations of the company model in the UK and the Netherlands, and another US publication. The main differences in methodological choices and their impact on cost-effectiveness results were assessed and further explored with sensitivity analyses using the Dutch model. To enable comparison between the economic evaluations, costs were converted to US dollars. Different methodological choices were made in the economic evaluations of VN resulting in large differences in the incremental cost-effectiveness ratio varying from US$79,618 to US$643,813 per QALY. The chosen duration of treatment effect, source of utility values, discount rate and model structure had the largest impact on the cost-effectiveness. This study underlines the findings from Drummond et al. that standard methods can be used to evaluate gene therapies. However, given uncertainty about (particularly long-term) outcomes of gene therapies, guidance is required on the acceptable extrapolation of treatment effect of gene therapies and on how to handle the uncertainty around this extrapolation in scenario and sensitivity analyses to aid health technology assessment research and align submissions of future gene therapies.

Measuring quality of life in opioid-induced constipation: mapping EQ-5D-3 L and PAC-QOL

BACKGROUND

In health economic evaluations, quality of life should be measured with preference-based utilities, such as the EuroQol 5 Dimension 3-level (EQ-5D-3 L). Non-preference-based instruments (often disease-specific questionnaires) are commonly mapped to utilities. We investigated if the relationship observed between the Patient Assessment of Constipation Quality of Life (PAC-QOL) and the EQ-5D-3 L in patients with chronic idiopathic constipation (CIC) also applies in opioid-induced constipation (OIC).

METHODS

EQ-5D-3 L patient-level data from a clinical study of lubiprostone in OIC (n = 439) were scored using the UK tariff. A published mapping between the PAC-QOL and the EQ-5D-3 L was tested using these data. New mapping formulas were analysed, including PAC-QOL total and subscale scores. The root mean square error (RMSE), the adjusted R(2) and predicted/observed plots were used to test the fit.

RESULTS

The utility measured with the EQ-5D-3 L was 0.450 ± 0.329, with a distinctly bimodal distribution. This significantly improved if patients responded to treatment (defined as an increase of three spontaneous bowel movements per week, with no rescue medication taken). The published mapping in CIC performed poorly in this OIC population, and the PAC-QOL could not be reliably mapped on to the EQ-5D-3 L even when re-estimating coefficients. This was shown in our two mappings (using PAC-QOL total score, and subscale scores) by a high RMSE (0.317 and 0.314) and a low R(2) (0.068 and 0.080), with high utilities underestimated and low utilities overestimated.

CONCLUSIONS

Patients with OIC have a low quality of life which does improve with the resolution of symptoms. However the PAC-QOL cannot be used to estimate the EQ-5D-3 L utility - potentially as the PAC-QOL does not capture the all relevant aspects of the patients quality of life (for example the cause of the opioid use).

Cost effectiveness of lanthanum carbonate in chronic kidney disease patients in Spain before and during dialysis

AIMS

In Spain, the first line treatment of hyperphosphatemia in Chronic Kidney Disease (CKD) consists of calcium-based phosphate binders (CB). However, their use is associated with vascular calcification and an increased mortality risk. The aim of this study was to assess the incremental cost-effectiveness of second-line Lanthanum Carbonate (LC) treatment in patients not responding to CB (calcium carbonate and calcium acetate).

MATERIAL AND METHODS

A lifetime Markov model was developed considering three health states (predialysis, dialysis and death). Transitions between states and efficacy data were obtained from randomized clinical trials and the European Dialysis and Transplant Association Annual report. Mortality rate was adjusted with the relative risk related to serum phosphorus levels. According to the Spanish healthcare system perspective, only medical direct costs were considered. Dialysis costs (2013 prices in Euros) were obtained from diagnosis-related groups. Drug costs were derived from ex-factory prices, adjusted with 7.5% mandatory rebate. Quality of life estimates were based on a published systematic review. Costs and benefits were discounted at 3%. Deterministic and probabilistic sensitivity analyses (PSA) were conducted.

RESULTS

At the end of simulation, costs per patient with LC therapy were <euro>1,169 and <euro>5,044 with CB alone. 4.653 Quality Adjusted Life Years (QALYs) were gained per patient treated with LC, and 4.579 QALYs with CB. CB therapy is dominated by the LC strategy (i.e. lower costs, higher QALYs). Assuming a <euro>30,000/QALY threshold, LC was dominant in 100% of PSA simulations.

CONCLUSIONS

LC is a cost-effective second line treatment of hyperphosphatemia in CKD patients irrespective of dialysis status in Spain.

Does a cardiovascular event change adherence to statin treatment in patients with type 2 diabetes? A matched cohort design

OBJECTIVE

To be effective, adherence to statin treatment is essential. We assessed the effect of an apparent first cardiovascular event on statin adherence rates in type 2 diabetes patients.

RESEARCH DESIGN AND METHODS

A matched cohort study was conducted among type 2 diabetes patients initiating statin treatment for primary prevention in the Groningen University IADB.nl pharmacy database. Patients who had a drug-treated cardiovascular event (index date) after statin initiation were matched to a reference patient without such an event with similar gender, age at statin initiation, initiation date, follow-up period and adherence level before the event. Adherence rates were measured as percentages of days covered (PDC), and shifts in adherence levels (non-adherent/partially adherent/fully adherent) and rates around the event were evaluated.

RESULTS

We could match 375 of the 855 eligible index patients to a reference patient. Index patients had on average a PDC of 81% after the index date; reference patients had a PDC of 71% (p < 0.001) while both had a PDC of 79% before the index date. Index patients were 4.5 times more likely than reference patients to shift from non-adherent to fully adherent (95% CI 1.1-18.8) and 1.8 times more likely to shift from partially adherent to fully adherent (95% CI 1.2-2.6). In the index group, 26% of patients became more adherent after the first cardiovascular event. In contrast, 20% of patients became less adherent.

LIMITATIONS

Medication proxies were used, which could have caused misclassification. Furthermore, a substantial group of index patients could not be matched to a reference patient due to small ranges in matching criteria.

CONCLUSIONS

The occurrence of a drug-treated cardiovascular event appeared to avert the declining statin adherence rate observed in diabetes patients without such an event. On the other hand, one in five patients became less adherent after the event, indicating that there are still important benefits to achieve.

Medication monitoring and optimization: a targeted pharmacist program for effective and cost-effective improvement of chronic therapy adherence

 

BACKGROUND

Community pharmacies provide a promising platform for monitoring and improving therapy adherence and providing pharmaceutical care. Structured methods and appropriate software are important tools to increase pharmacist effectiveness and improve health outcomes. In 2006, the Medication Monitoring and Optimization (MeMO) program was introduced in several community pharmacies in the Netherlands. MeMO facilitates targeted and continuous patient-centered pharmaceutical care around chronic medication, such as for osteoporosis, cardiovascular disease, and asthma/chronic obstructive pulmonary disease (COPD).

OBJECTIVES

To describe the MeMO program and summarize findings from publications on its effectiveness, patient satisfaction, and cost-effectiveness. 

METHODS

In the first part of this article, the MeMO program is extensively described. In the second part, a review of the evidence of effectiveness, cost-effectiveness, and patient satisfaction of the MeMO program is provided. Evidence is based on 5 previously published articles.

RESULTS

The MeMO program starts with structured counseling sessions with patients at the initiation and follow-up of chronic therapies. This process is followed by a continuous phase in which patients' therapy adherence is monitored on a monthly basis, using standardized search algorithms in the pharmacy database. When the algorithm detects a patient's discontinuation of therapy, tailored interventions are used to improve adherence and optimize pharmacotherapy. For osteoporosis patients, treatment discontinuation with bisphosphonates after 1 year dropped from 31.7% to 16.1% (P  less than  0.001). This program was shown to be cost-effective in patients initiating osteoporotic therapy. Future scenarios with lower drug prices (e.g., from generic prescribing) result in cost savings for the MeMO program. For lipid-lowering drugs, the MeMO program has been shown to lower therapy discontinuation after 1 year from 25.9% to 13.6% (P  less than  0.001). By extrapolating these results to patients' lifetimes, the intervention was estimated to be cost-effective, with gains for primary prevention of cardiovascular events, and even cost saving in secondary prevention. Results from the ongoing MeMO asthma/COPD program are promising, showing marked improvements in therapy control and quality of life for asthma and COPD patients. Almost all patients participating in MeMO programs are satisfied with the pharmacy team and have gained knowledge of the effectiveness and administration of their medications and the importance of therapy adherence.

CONCLUSION

The MeMO program is an effective and structured method to improve patients' adherence to chronic medication in the field of osteoporosis, lipid-lowering drugs, and asthma/COPD and is well received by patients. By targeting the program toward nonadherent and high-risk patients, the program showed favorable cost-effectiveness.

Improving adherence to lipid-lowering therapy in a community pharmacy intervention program: a cost-effectiveness analysis

BACKGROUND

Pharmaceutical care in community pharmacies has been shown to improve adherence to chronic therapies. Long-term impact on clinical outcomes or medical cost savings, however, remains understudied. 

OBJECTIVE

To estimate the cost-effectiveness of a pharmaceutical care intervention program in Dutch community pharmacies that improved patients' adherence to lipid-lowering therapy. 

METHODS

An economic evaluation was performed using a time-dependent Markov model from the health care payer perspective. Participants were patients initiating lipid-lowering therapy for primary prevention (40%) or secondary prevention (60%) of cardiovascular events (CVEs). The intervention was the pharmaceutical care program MeMO (Medication Monitoring and Optimisation) in 9 community pharmacies in the Netherlands, based on continuous monitoring and optimization of lipid-lowering therapy in new patients. The follow-up period of the program was 1 year. The main outcome of the intervention program was discontinuation of lipid-lowering therapy. This outcome was extrapolated in the economic model to lifelong costs, quality of life, reductions in cardiovascular events, and incremental cost-effectiveness ratios.

RESULTS

Patients in the MeMO program had a lower risk for therapy discontinuation, RR = 0.49 (0.37 to 0.66); the effectiveness was similar in primary and secondary prevention. In a cohort of 1,000 primary and secondary prevention patients, the MeMO program resulted in a reduction of 7 nonfatal strokes, 2 fatal strokes, 16 nonfatal myocardial infarctions (MIs), 7 fatal MIs, and 16 revascularizations over patients' lifetime. Additional medication, disease management, and intervention costs in the MeMO program were €411,000; the cost savings due to reduced CVEs were €443,000. The MeMO program resulted in 84 quality-adjusted life-years (QALYs) gained and net cost savings of €32,000. Clinical benefits and cost savings were highest in the secondary prevention population.

CONCLUSION

Pharmaceutical care in community pharmacies can improve statin therapy adherence, resulting in better prevention of CVEs. The MeMO program resulted in considerable clinical benefits and net cost savings. Programs by community pharmacies targeted at improving adherence may provide good value for money, and health care insurers should consider reimbursing these activities.

Improving inhaler adherence in patients with chronic obstructive pulmonary disease: a cost-effectiveness analysis

BACKGROUND

The PHARMACOP-intervention significantly improved medication adherence and inhalation technique for patients with COPD compared with usual care. This study aimed to evaluate its cost-effectiveness.

METHODS

An economic analysis was performed from the Belgian healthcare payer's perspective. A Markov model was constructed in which a representative group of patients with COPD (mean age of 70 years, 66% male, 43% current smokers and mean Forced Expiratory Volume in 1 second of % predicted of 50), was followed for either receiving the 3-month PHARMACOP-intervention or usual care. Three types of costs were calculated: intervention costs, medication costs and exacerbation costs. Outcome measures included the number of hospital-treated exacerbations, cost per prevented hospital-treated exacerbation and cost per Quality Adjusted Life-Year. Follow-up was 1 year in the basecase analysis. Sensitivity and scenario analyses (including long-term follow-up) were performed to assess uncertainty.

RESULTS

In the basecase analysis, the average overall costs per patient for the PHARMACOP-intervention and usual care were €2,221 and €2,448, respectively within the 1-year time horizon. This reflects cost savings of €227 for the PHARMACOP-intervention. The PHARMACOP-intervention resulted in the prevention of 0.07 hospital-treated exacerbations per patient (0.177 for PHARMACOP versus 0.244 for usual care). Results showed robust cost-savings in various sensitivity analyses.

CONCLUSIONS

Optimization of current pharmacotherapy (e.g. close monitoring of inhalation technique and medication adherence) has been shown to be cost-saving and should be considered before adding new therapies.

A network meta-analysis of the relative efficacy of treatments for actinic keratosis of the face or scalp in Europe

Background

Several treatments are available for actinic keratosis (AK) on the face and scalp. Most treatment modalities were compared to placebo and therefore little is known on their relative efficacy.

Objectives

To compare the different treatments for mild to moderate AK on the face and scalp available in clinical practice in Europe.

Methods

A network meta-analysis (NMA) was performed on the outcome “complete patient clearance”. Ten treatment modalities were included: two 5-aminolaevulinic acid photodynamic therapies (ALA-PDT), applied as gel (BF-200 ALA) or patch; methyl-aminolevulinate photodynamic therapy (MAL-PDT); three modalities with imiquimod (IMI), applied as a 4-week or 16-week course with 5% imiquimod, or a 2–3 week course with 3.75% imiquimod; cryotherapy; diclofenac 3% in 2.5% hyaluronic acid; 0.5% 5-fluorouracil (5-FU); and ingenol mebutate (IMB). The only data available for 5% 5-FU was from one small study and was determined to be too limited to be reliably included in the analysis. For BF-200 ALA and MAL-PDT, data from illumination with narrow-band lights were selected as these are typically used in clinical practice. The NMA was performed with a random-effects Bayesian model.

Results

25 trials on 5,562 patients were included in the NMA. All active treatments were significantly better than placebo. BF-200 ALA showed the highest efficacy compared to placebo to achieve total patient clearance. BF-200 ALA had the highest probability to be the best treatment and the highest SUCRA score (64.8% and 92.1%), followed by IMI 5% 4 weeks (10.1% and 74.2%) and 5-FU 0.5% (7.2% and 66.8%).

Conclusions

This NMA showed that BF-200 ALA, using narrow-band lights, was the most efficacious treatment for mild to moderate AK on the face and scalp. This analysis is relevant for clinical decision making and health technology assessment, assisting the improved management of AK.

Proactive pharmaceutical care interventions decrease patients' nonadherence to osteoporosis medication

Using a protocolled intervention program, pharmacists can decrease nonadherence to osteoporosis medication, by continuous monitoring and tailored counseling sessions, starting at treatment initiation. In the usual care group, 32.8% of patients initiating osteoporosis medication discontinued or were nonadherent, compared to 19.0% of patients in the intervention group.

PURPOSE

While community pharmacies have been shown to offer a promising platform for osteoporosis management in patients with osteoporosis, more research is needed to determine pharmacists' effects on improving adherence. The aim of this study was to determine the effects of a community pharmacists' intervention program on the 1-year discontinuation and nonadherence rates of patients initiating osteoporosis medication.

METHODS

This intervention study included 937 patients, recruited from 13 Dutch community pharmacies, initiating osteoporosis medication. The intervention group (N = 495), received the Medication Monitoring and Optimization (MeMO) intervention, comprising of continuous monitoring of patients' adherence to their osteoporosis medication and tailored counseling sessions with nonadherent patients. Results were compared to an internal (n = 442) reference group, receiving usual pharmacy care. Primary study outcomes were therapy discontinuation and nonadherence; results were adjusted for potential confounders using Cox proportional hazard analysis. Secondary outcome was patients' satisfaction.

RESULTS

In the usual care group, 32.8% of patients initiating osteoporosis medication discontinued or were nonadherent, compared to 19.0% of patients in the intervention group (P < 0.001). Ninety-three percent of the respondents were satisfied with the pharmacies' services provided. Notably, 31% mentioned that the pharmacy was the only place where they received information on various aspects of administration and acting of their medication.

CONCLUSION

Pharmacists can decrease nonadherence and discontinuation with osteoporosis medication by providing tailored counseling sessions and continuous monitoring of drug use. Pharmaceutical care programs, such as MeMO, contribute to more optimal use of osteoporosis medication.

Proactive pharmaceutical care interventions improve patients' adherence to lipid-lowering medication

BACKGROUND

Lipid-lowering drugs are effective preventive medication for patients at risk of cardiovascular complications. However, medication adherence is suboptimal, thereby decreasing therapy effectiveness. Pharmaceutical care interventions may increase therapy adherence.

OBJECTIVE

To assess the effect of a proactive pharmaceutical care intervention program, Medication Monitoring and Optimization (MeMO), on therapy discontinuation and adherence with lipid-lowering drugs as well as patients' satisfaction with the intervention program.

METHODS

This prospective intervention study included 1002 patients initiating lipid-lowering drug therapy from 9 Dutch community pharmacies. In the intervention group (n = 500), the MeMO program was used, comprising continuous monitoring of patients' adherence to lipid-lowering drugs and personal counseling with nonadherent patients. The intervention group was compared with a historical reference group (n = 502) receiving usual care. Outcomes were therapy discontinuation and adherence.

RESULTS

Discontinuation rates with lipid lowering drugs in the first year after drug initiation were 13.6% for the intervention group and 25.9% in the usual care group; continued but non-adherent use was 3.2% and 7.6% in these groups. Patients in the MeMO program had a decreased risk to discontinue medication of 51% (95% confidence interval: 34%-63%). Results were not affected by potential confounders. Patient satisfaction with MeMO was very high; one quarter of patients mentioned that they only received information about their medication from their pharmacy.

CONCLUSIONS

Improving adherence to lipid lowering drugs can be achieved by a proactive pharmaceutical care program. Pharmacists can contribute to optimal use of chronic medication, which is likely to reduce healthcare costs.

Inhaled corticosteroids and the occurrence of oral candidiasis: a prescription sequence symmetry analysis

OBJECTIVES

The primary aim of the study was to gain insight into the relative risk of clinically relevant oral candidiasis following inhaled corticosteroid (ICS) initiation over time. A secondary aim was to analyse the influence of patient characteristics and co-medication on the occurrence of this adverse effect.

METHODS

Drug prescription data from 1994 to 2011 were retrieved from the IADB.nl database. To study the influence of ICS use on occurrence of oral candidiasis, a prescription symmetry analysis was used, including patients using medication for oral candidiasis up to 1 year before or after ICS initiation. The relative risk was calculated by dividing the number of patients receiving medication for oral candidiasis after ICS initiation by the number of patients receiving the same medication before ICS initiation. Sub-analyses were conducted to compare the relative risks at several time points after ICS initiation and to account for therapy persistence by only including chronic users of ICS. A multivariate logistic regression model was used to identify predictive factors.

RESULTS

A total of 52,279 incident users of ICS therapy were identified, of which 1,081 received medication for oral candidiasis up to 1 year before or after ICS initiation. A total of 701 patients received medication for oral candidiasis after ICS initiation, while 361 received these medications in the reversed sequence, resulting in a sequence ratio (SR) of 1.94 (95 % CI 1.71-2.21). In the first 3 months after ICS initiation, the SR was 2.72 (95 % CI 2.19-3.38) and then decreased to 1.47 (95 % CI 1.11-1.95) 9-12 months after ICS initiation. Predictive factors were higher daily dose of ICS and concomitant use of oral corticosteroids.

CONCLUSIONS

This study found a significant and clinically relevant increased number of patients receiving medication for oral candidiasis in the first year after therapy initiation with ICS. Relative risk is highest in the first 3 months, but remains increased up to at least 1 year after ICS initiation. This study stresses the need for patient education and inhalation instruction.

Persistence with osteoporosis medication among newly-treated osteoporotic patients

Low persistence with osteoporosis medication is associated with higher fracture risk. Previous studies estimated that 1-year persistence with osteoporosis medication is low. Our aim was to study persistence with osteoporosis medication among patients with long-term follow-up (to 5 years). The InterAction Database (IADB) was used to analyze persistence of 8610 Dutch patients initiating osteoporosis drugs between 2003 and 2011. Drugs under study were alendronate, risedronate, ibandronate, etidronate, raloxifene and strontium ranelate. Cumulative persistence rates were calculated after different time frames (3 months-5 years) using survival analysis. Multivariate Cox proportional hazard analyses were used to identify determinants of non-persistence. Furthermore, switching rates of persistent patients who initiated bisphosphonate therapy were analyzed. Persistence with osteoporosis therapy was 70.7 % (95 % CI, 69.7-71.7), 58.5 % (95 % CI, 57.4-59.6 %), 25.3 % (95 % CI, 24.1-26.5) after 6 months, 1 and 5 years, respectively. Determinants associated with higher risk to non-persistence within the first year were daily dosing regimen [HR, 1.76 (95 % CI, 1.46-2.14)], age <60 years [HR, 1.26 (95 % CI, 1.19-1.34)] and use of glucocorticoids [HR, 1.16 (95 % CI, 1.07-1.26)]. Monthly dosing schedule and use of generic brands of alendronate did not show a significant association with non-persistence. Approximately 4.0 % of patients initiating therapy with weekly alendronate or weekly risedronate switched therapy. Persistence with osteoporosis medication is low. Because low persistence is strongly associated with higher fracture risk, interventions to improve persistence are recommended. This study identified several patient groups in whom such interventions may be most relevant.

Meta-analysis using individual patient data: efficacy and durability of topical alicaforsen for the treatment of active ulcerative colitis

BACKGROUND

The antisense ICAM-1 inhibitor alicaforsen has been studied in four phase 2 studies in ulcerative colitis (UC). Recruited patients varied as to the extent of their colitis and in the severity of disease at entry.

AIM

To investigate the efficacy of alicaforsen enema in specific UC populations. Efficacy was analysed for short-term (week 6-10) and long-term (week 30) outcomes compared with either placebo or a high-dose mesalazine (mesalamine) enema in patients with disease extent up to 40 cm from the anal verge in patients with moderate or severe disease, and in patients with both of these features.

METHODS

Individual patient data meta-analyses of 200 patients from four phase 2 studies evaluating nightly alicaforsen 240 mg enema and comparators. Patient data were pooled and analysed in a single data set. Continuous outcomes were evaluated using anova; dichotomous outcomes were evaluated using Pearson chi-square or Fisher's exact tests.

RESULTS

Alicaforsen showed superior efficacy vs. placebo in: patients with disease extent up to 40 cm, patients with moderate and severe disease and especially when both those conditions were satisfied. In these patient groups, mesalazine also showed short-term efficacy. At week 30, however, the efficacy of mesalazine waned and alicaforsen became significantly more efficacious.

CONCLUSIONS

This post hoc meta-analysis showed that alicaforsen is effective in patients with active UC, especially in patients with distal disease, which is of moderate/severe activity. The efficacy of alicaforsen was durable in these sub-groups, suggesting a disease-modifying effect. This analysis suggests that alicaforsen enema may offer an effective, potentially durable response in moderate/severe distal active UC.

The pharmacists' potential to provide targets for interventions to optimize pharmacotherapy in patients with asthma

BACKGROUND

Despite of pharmacists' specialized knowledge of medication and his/her regular contact with patients, the expertise of the pharmacist may not be used enough yet. Furthermore, the potential of pharmacy dispensing data is underestimated.

OBJECTIVE

To provide targets for tailored interventions in asthma patients and to illustrate the potential value of pharmacists in the identification of these targets using individual pharmacy dispensing data.

SETTING

We performed a cross sectional retrospective analysis assessing the quality of asthma patients' pharmacotherapeutic treatment.

METHOD

Drug dispensing data from 2008 to 2009 were retrieved from a Dutch pharmacy database. All asthma patients were screened for potential suboptimal pharmacotherapy in 2009. Results were projected to a single community pharmacy to provide an estimate of the number of patients eligible for potential interventions.

MAIN OUTCOME MEASURES

(1) frequent use of short-acting β-agonists without preventive medication, (2) concomitant use of β-blockers, (3) multiple short courses of oral corticosteroids without using inhaled corticosteroids and 4) use of long-acting β-agonist without inhaled corticosteroids.

RESULTS

A total of 8,504 patients were eligible for analysis of the quality of their asthma treatment. 20.9 % of all asthma patients used >100 DDD short-acting β-agonists per year, whereas between 21.2 % (≥ 400 DDD) and 31.4 % (100-199 DDD) of these patients did not receive preventive medication. Approximately 5.2 % of the asthma patients are using β-blockers concomitantly and 21.8 % of them received non-cardioselective β-blockers. 6.3 % of the asthma patients received two or more oral courses of corticosteroids in 2008 and 17.4 % of these patients did not receive inhaled corticosteroids in 2009. 2.9 % of the patients used a long-acting β-agonists without inhaled corticosteroids. 8.4 % of the asthma patients using both long-acting β-agonists and inhaled corticosteroids received these drugs in two separate inhalers. We estimated that about 400 asthma patients could be identified in an average pharmacy population (8,000 patients) and 33 (95 % CI 22-44) of these patients would be eligible for interventions.

CONCLUSION

This study shows the potential for pharmacists to use their own pharmacy records to identify suboptimal therapy of asthma patients, who may be targets for tailored interventions.

COPD in the working age population: the economic impact on both patients and government

OBJECTIVES

To explore the full economic impact, on both patients and government, as a result of COPD in the working age population.

METHODS

The economic impact of COPD due to medical treatment, impaired productivity and early retirement was assessed in a cross sectional cost analysis of the Dutch COPD population aged 45-64 years. The costing year was 2009 and input parameters were derived from both national data sources and the international COPD uncovered survey.

RESULTS

While direct medical costs for COPD patients of working age were relatively low (€ 91 million), the amount of lost productivity (income) due to early retirement (€ 223 million) exceeded over two times their medical costs. In addition, costs for the government were considerable because of lost tax revenues (€ 77 million) and COPD related disability pensions paid (€ 180 million). Apart from lost productivity due to early retirement, costs due to impaired productivity for working COPD patients were € 63 million.

CONCLUSIONS

The costs of COPD for both patients of working age as for the government were considerable, making this population a priority for prevention and intervention programs of healthcare providers, employers and government.

Sodium intake, ACE inhibition, and progression to ESRD

High sodium intake limits the antihypertensive and antiproteinuric effects of angiotensin-converting enzyme (ACE) inhibitors in patients with CKD; however, whether dietary sodium also associates with progression to ESRD is unknown. We conducted a post hoc analysis of the first and second Ramipril Efficacy in Nephropathy trials to evaluate the association of sodium intake with proteinuria and progression to ESRD among 500 CKD patients without diabetes who were treated with ramipril (5 mg/d) and monitored with serial 24-hour urinary sodium and creatinine measurements. Urinary sodium/creatinine excretion defined low (<100 mEq/g), medium (100 to <200 mEq/g), and high (≥200 mEq/g) sodium intake. During a follow-up of >4.25 years, 92 individuals (18.4%) developed ESRD. Among those with low, medium, and high sodium intakes, the incidence of ESRD was 6.1 (95% confidence interval [95% CI], 3.8-9.7), 7.9 (95% CI, 6.1-10.2), and 18.2 (95% CI, 11.3-29.3) per 100 patient-years, respectively (P<0.001). Patients with high dietary sodium exhibited a blunted antiproteinuric effect of ACE inhibition despite similar BP among groups. Each 100-mEq/g increase in urinary sodium/creatinine excretion associated with a 1.61-fold (95% CI, 1.15-2.24) higher risk for ESRD; adjusting for baseline proteinuria attenuated this association to 1.38-fold (95% CI, 0.95-2.00). This association was independent from BP but was lost after adjusting for changes in proteinuria. In summary, among patients with CKD but without diabetes, high dietary salt (>14 g daily) seems to blunt the antiproteinuric effect of ACE inhibitor therapy and increase the risk for ESRD, independent of BP control.

Cost-effectiveness of lanthanum carbonate in the treatment of hyperphosphatemia in chronic kidney disease before and during dialysis

OBJECTIVES

Hyperphosphatemia is a common and harmful condition in patients with chronic kidney disease (CKD). We determined the cost-effectiveness of the noncalcium-based phosphate binder lanthanum carbonate (LC) as second-line treatment of hyperphosphatemia after therapy failure with calcium-based binders (CB).

METHODS

Two CKD populations were modeled: 1) predialysis CKD patients and 2) incident dialysis patients. Patients not responding to CB with a serum phosphate (SP) level >5.5 mg/dl received a trial with LC. Patients not responding to LC (SP >4.6 mg/dl) returned to CB treatment. Patient-level data were obtained from clinical trials in predialysis and dialysis. Time-dependent, life-long Markov models (discounting at 3.5% annually) were developed, using a UK National Health Service perspective.

RESULTS

The health gains with second-line LC treatment compared to CB treatment were 44 and 56 quality-adjusted life-years (QALYs) for the predialysis and incident dialysis populations, respectively. Second-line LC was a cost-saving strategy in the predialysis population because of the cost-savings of delayed CKD progression. Second-line LC was cost-effective at £6900 (90% probability interval: £5800-£8300) per QALY gained in the dialysis population. Results were robust to plausible variations in other model parameters; inclusion of future unrelated dialysis costs had a large influence on cost-effectiveness estimates.

CONCLUSIONS

Second-line treatment with LC is associated with considerable clinical benefits and good value for money in CKD, irrespective of dialysis status. These results support Kidney Disease Outcomes Quality Initiative guidelines to treat CKD patients with hyperphosphatemia irrespective of dialysis status.

Compliance, persistence, and switching patterns for ACE inhibitors and ARBs

OBJECTIVES

To investigate compliance, persistence, and switching patterns for angiotensin-converting enzyme (ACE) inhibitors and angiotensin receptor blockers (ARBs).

STUDY DESIGN

Drug-utilization analysis using a large prescription database.

METHODS

Prescription data for more than 50,000 incident users of ACE inhibitors or ARBs were collected, cumulating close to 200,000 patient-years of medication use. Incidence, drug dosage, 1-year compliance, long-term persistence, and switching patterns were analyzed. The specific drugs investigated were captopril, enalapril, lisinopril, perindopril, ramipril, and fosinopril (ACE inhibitors), and losartan, valsartan, irbesartan, candesartan, and olmesartan (ARBs). Results were adjusted for age, sex, starting date, and comorbidities.

RESULTS

The 1-year compliance (88.3% vs 88.3%, P = .996) and 3-year persistence (81.9% vs 82.4%, P = .197) rates were similar between ACE inhibitors and ARBs. Users of ACE inhibitors more often switched therapy (24.2% vs 13.1%, P <.001), primarily to an ARB. Variations in compliance, persistence, and switching behavior were detected between specific ACE inhibitors, but not between specific ARBs.

CONCLUSIONS

Although residual confounding and indication bias cannot be ruled out, this study showed that compliance, persistence, and switching behavior varied between specific ACE inhibitors but not between specific ARBs. These results support prescribing of cheap generic ARBs as opposed to expensive ARBs. Apart from factors leading to therapy switches, compliance and persistence were similar between ACE inhibitors and ARBs.

Review of regulatory recommendations for orphan drug submissions in the Netherlands and Scotland: focus on the underlying pharmacoeconomic evaluations

BACKGROUND

Pharmacoeconomic evaluations of new drug therapies are often required for reimbursement or guidance decisions. However, for orphan drugs, country-specific requirements exist. In the Netherlands, orphan drug developers can be exempted from providing a full pharmacoeconomic evaluation, whereas in Scotland, no such exceptions can be made, although additional modifying factors specific to orphan products may be considered.

OBJECTIVE

The aim of the present work was to identify differences in the outcomes of the recommendations for orphan drugs for rare diseases between 2 European countries: Scotland and the Netherlands.

METHODS

All orphan drug reports to the Dutch Committee for Pharmaceutical Assistance (Commissie Farma-ceutische Hulp [CFH]) and orphan drugs guidance issued by the Scottish Medicines Consortium (SMC) through May 2009 were reviewed from the respective organizations' Web sites. The following were gathered from the pharmacoeconomic analyses and recommendations for reimbursement in the Netherlands or guidance for drug use in Scotland: drug indication, outcome of pharmacoeconomic evaluation, recommendation, and exact date.

RESULTS

Dossiers for 38 orphan drugs were submitted to the CFH; 37 were submitted to the SMC. Only 1 submission to the CFH included a full pharmacoeconomic analysis; all other reports included only a cost analysis. Twenty-four submissions to the SMC were accompanied by a full pharmacoeconomic evaluation; no information could be obtained for 4 drugs. The remaining reports either did not include a cost-effectiveness analysis or were deemed insufficient by the SMC. Forty-three percent (10/23) of the cost-utility analyses submitted to the SMC reported an unfavorable outcome of more than £30,000/ quality-adjusted life-year (QALY) gained; of these, only 2 (20%) reporting incremental cost-utility ratios of £43.717 to £81.000 were granted a restricted positive recommendation. The CFH gave positive recommendations for reimbursement for 36 of 38 submissions (95%). Of the 37 orphan drugs submitted to the SMC, 19 (51%) received a positive recommendation for use. Seventy-three percent (8/11) of submissions to the SMC with an unfavorable cost-effectiveness estimate (ie, more than £30,000 [€34,000 or US $48,000] per QALY gained) received a negative recommendation for reimbursement.

CONCLUSIONS

Ninety-five percent of orphan drug submissions were approved for reimbursement in the Netherlands, compared with 51% in Scotland, during the period of interest. Moreover, cost-effectiveness or cost-utility analyses were included in 24 of 37 submissions in Scotland, compared with only 1 of 38 in the Netherlands.

Misdiagnosis and mistreatment of a common side-effect--angiotensin-converting enzyme inhibitor-induced cough

AIMS

Angiotensin-converting enzyme inhibitors (ACEi) are frequently prescribed for various cardiovascular and renal diseases. A common side-effect of these drugs is a persistent dry cough. Physicians who fail to recognize a dry cough to be ACEi-related may attempt to treat it with antitussive agents instead of recommended ACEi substitution. Prescription behaviour in the general population considering treatment of the side-effect with antitussive agents has not been studied before.

METHODS

Drug dispensing data between 2000 and 2007 were retrieved from the IADB.nl database. A prescription sequence symmetry analysis was used to determine whether antitussive agents were prescribed more often following ACEi initiation than the other way around. A logistic regression model was fitted to determine predictors.

RESULTS

We identified 27 446 incident users of ACEi therapy. One thousand and fifty-four patients were incident users of both ACEi and antitussives within a half-year time span. There was an excess of patients being prescribed antitussive agents after ACEi initiation (703 vs. 351), adjusted sequence ratio 2.2 [confidence interval (CI) 1.9, 2.4]. Female patients were more likely to be prescribed antitussive agents following ACEi therapy initiation, odds ratio 1.4 (CI 1.1, 1.9), age and co-medications were not significant predictors.

CONCLUSIONS

There was a significant and clinically relevant excess of patients receiving antitussives after ACEi initiation. The results suggest that cough as a side-effect of ACEi is not recognized as being ACEi-related or is symptomatically treated with antitussive agents instead of ACEi substitution. The estimated frequency of antitussive treatment of ACEi-induced dry cough is 15%.

Cost-effectiveness of varicella vaccination programs: an update of the literature

Varicella is one of the most common infectious diseases in childhood, caused by the varicella zoster virus. Although vaccines are available, there are only a few countries with an early-childhood vaccination program. Most countries mainly focus on vaccination of high-risk groups, such as susceptible healthcare workers. One of the main concerns with a routine early-childhood vaccination program is a potential (temporal) increase of the incidence of herpes zoster among elderly adults. In this review, we focus on the cost-effectiveness of varicella vaccination and on the methodology used in the health-economic studies. In particular, we focus on the perspective adopted, type of model used, the modeled effect on herpes zoster, the vaccine efficacy and price, and on the value of time lost by infection. The vast majority of studies show vaccination of high-risk groups - including susceptible adolescents - to be cost saving. Routine early-childhood vaccination programs are always cost saving if indirect costs of production losses are included, or cost effective, as long as the potential negative effects on zoster are not taken into account. We note that most studies included in the review used old vaccine prices and a single dose of the varicella vaccine, whereas multiple doses are now becoming the standard. Despite that, those aspects limit the timeliness of our review and we believe that the current work does provide useful insights in the cost-effectiveness of varicella vaccination.

Pharmacoeconomic evaluations of pharmacogenetic and genomic screening programmes: a systematic review on content and adherence to guidelines

The fields of pharmacogenetics and pharmacogenomics have become important practical tools to progress goals in medical and pharmaceutical research and development. As more screening tests are being developed, with some already used in clinical practice, consideration of cost-effectiveness implications is important. A systematic review was performed on the content of and adherence to pharmacoeconomic guidelines of recent pharmacoeconomic analyses performed in the field of pharmacogenetics and pharmacogenomics. Economic analyses of screening strategies for genetic variations, which were evidence-based and assumed to be associated with drug efficacy or safety, were included in the review. The 20 papers included cover a variety of healthcare issues, including screening tests on several cytochrome P450 (CYP) enzyme genes, thiopurine S-methyltransferase (TMPT) and angiotensin-converting enzyme (ACE) insertion deletion (ACE I/D) polymorphisms. Most economic analyses reported that genetic screening was cost effective and often even clearly dominated existing non-screening strategies. However, we found a lack of standardization regarding aspects such as the perspective of the analysis, factors included in the sensitivity analysis and the applied discount rates. In particular, an important limitation of several studies related to the failure to provide a sufficient evidence-based rationale for an association between genotype and phenotype. Future economic analyses should be conducted utilizing correct methods, with adherence to guidelines and including extensive sensitivity analyses. Most importantly, genetic screening strategies should be based on good evidence-based rationales. For these goals, we provide a list of recommendations for good pharmacoeconomic practice deemed useful in the fields of pharmacogenetics and pharmacogenomics, regardless of country and origin of the economic analysis.