The Costs of Treating Glaucoma with Combinations of Topical Drugs in Spain

Purpose

This study describes the treatment in ordinary clinical practice in Spain of patients with glaucoma with a two-drug combination therapy. The authors present the treatment outcome as end-of-period intraocular pressure (IOP) and the calculated direct medical costs over a 2-year period.

Methods

Data were extracted retrospectively from patient charts recording the use of all medical resources related to glaucoma. Costs were estimated using unit costs from public sources (2005). Descriptive cost analysis according to combination treatment at baseline was performed.

Results

The study included 216 patients from 21 centers. Around half of the patients were started on a β-blocker/prostaglandin analogue combination, while the rest received various other combinations containing either an α2-agonist or a carbonic anhydrase inhibitor. Across the seven groups considered, there was a statistically significant difference in the costs of the least and the two most costly groups, while the confidence intervals were overlapping in all other pairwise comparisons. The least costly drug combination was brimonidine/timolol. Assessing IOP at the end of follow-up, all the groups were equally effective (overlapping confidence intervals). In a multivariate regression analysis, the drug combination did not have an independent, significant impact on total direct medical costs, drug costs, or end-of-period IOP. Significant determinants of these variables were surgical interventions and one or more changes of drug combination during the follow-up.

Conclusions

Costs are determined by the response to treatment. Inadequate response triggers treatment changes and sometimes eventually surgical interventions, thereby increasing costs significantly.

Cost of multiple sclerosis in the Czech Republic: The COMS study

Background: Information about cost of multiple sclerosis (MS) is available from a number of European countries, but no data from the Czech Republic have been published so far.

Objective: The objective of this study was to establish the cost of MS in the Czech Republic, overall and by level of disease severity.

Methods: Data on demographics, disease history, resource consumption and production losses were collected from 909 patients recruited in 7 MS centres in the Czech Republic. Annual costs were estimated in the societal perspective, using 2007 unit costs. To evaluate the relationship between disability and costs, patients were stratified into those with mild (67%), moderate (27%) and severe (10%) disability using the Expanded Disability Status Scale.

Results: Mean total annual costs per patient were €12,272, of which 51% were direct medical costs, 4% direct non-medical costs and 45% indirect costs. The average annual costs in patients with mild, moderate and severe disability amounted to €9905, €14,064 and €22,880, respectively.

Conclusion: The total costs of MS in the Czech Republic are estimated at €208.6 million per year. Consistent with other studies, the costs increase significantly with the severity of MS.

Costs and outcomes for patients with rheumatoid arthritis treated with biological drugs in Sweden: a model based on registry data

OBJECTIVE

To design an economic model describing the costs and outcomes for patients treated with tumour necrosis factor alpha (TNFalpha) inhibitors for rheumatoid arthritis (RA) in current clinical practice in Sweden, to be used as a tool to estimate cost-effectiveness of the next generation of treatments.

METHODS

The model was constructed as a discrete event simulation (DES) model analysed at patient level. It contains treatment and outcome data for 1903 patients followed in the RA registry for biological drugs in southern Sweden between 1999 and 2007 [the Southern Swedish Arthritis Treatment Group (SSATG) Register]. Resource consumption was based on a survey of 1027 patients in the same region. Costs and quality-adjusted life years (QALYs) are presented for 10(5) years, for patients with the mean characteristics at treatment start in SSATG [Health Assessment Questionnaire (HAQ) score 1.33, disease duration 12.1 years, age 55 years], but also for patients with more or less severe disease. Cost and outcomes (QALYs) are discounted with 3%.

RESULTS

The 10-year costs in the base case amount to USD 336,000 (SD USD 64,000) or EUR 223 000, with a total of 4.4 QALYs. Over 5 years, the costs amount to USD 208,000 or EUR 138,000 and QALYs to 2.5. The results were most sensitive to HAQ level at treatment start, but also to underlying disease progression, age, and disease duration. Starting treatment at a lower HAQ level (0.85) reduces costs by 10% and increase QALYs by 20%.

CONCLUSION

This analysis is based on the longest available follow-up for patients treated with TNFalpha inhibitors and provides an opportunity to explore treatment strategies when new therapies become available using actual clinical practice data.

Health economic issues in rheumatoid arthritis

The objectives of treatment in rheumatoid arthritis (RA) are to reduce temporary symptoms due to inflammatory activity and, more importantly, to preserve function. The introduction of potent disease-modifying anti-rheumatic drugs (DMARDs) in recent years has increased the opportunities for effective treatment. However, these treatments come at a substantially higher cost than traditional DMARDs and therefore compete with other essential interventions for limited resources. They have triggered a debate on whether they represent an efficient use of resources, which patients should be treated, when, and for how long. Cost-effectiveness analysis attempts to estimate the trade-offs involved in these decisions and to provide information that can help in making them. However, in chronic progressive diseases, health gains and any potential associated economic benefits are often most evident in the long-term. As a consequence, the impact of new treatments has to be estimated using models that can project available knowledge, such as results from clinical trials or short-term follow-up studies in clinical practice, into the future. These models also allow scenarios to be explored that provide the best value for money, for example by defining subgroups for which treatment is most effective, or criteria that define when treatment should be stopped. Economic evaluation in RA has a long tradition, with the first study performed about 20 years ago. However, with the recent drug introductions, the field has witnessed an explosion of economic studies. Modelling techniques have become more sophisticated to overcome concerns about their validity. At the same time, they may appear less transparent, making it difficult for non-specialists to understand the details. This article, rather than reviewing all published models and comparing them, attempts to illustrate the inputs required for such studies, and the influence that different approaches and datasets can have on the results.

Rheumatoid arthritis: what does it cost and what factors are driving those costs? Results of a survey in a community‐derived population in Malmö, Sweden

OBJECTIVE

We sought to investigate the cost of living with rheumatoid arthritis (RA) and evaluate the influence of both demographics and specific disease characteristics on these costs.

METHODS

We used a population-based questionnaire to survey 895 patients living in the city of Malmö, Sweden, during 2002. Data were obtained on direct resource consumption, investments, informal care and work capacity, as well as utility, function and patients' assessment of disease severity and pain.

RESULTS

The survey was completed by 613 patients (68%). Their mean age was 66 years, 74% were female and the mean duration of disease was 16.7 years. The total mean annual cost per patient was 108,370 SEK (12,020 EUR). Direct costs represented 41% of that amount and were predominantly for drugs [14% of the participants were receiving treatment with tumour necrosis factor (TNF) blockers], community services and hospitalisation. Function measured with the Health Assessment Questionnaire (HAQ) was the main statistical predictor for all types of costs except sick leave, which was most strongly associated with patients' perception of global health.

CONCLUSION

This is the first study in Sweden to include all costs incurred by a group representative of RA in the community. In comparison with previous studies, total costs had increased by more than 40%. Furthermore, direct costs were higher and constituted a great proportion of total costs because of more intensive treatments (i.e. the use of TNF blockers). Future comparisons will enable health economic evaluations on a community level.

The long-term cost of multiple sclerosis in France and potential changes with disease-modifying interventions

Objective

To evaluate the long-term costs and quality of life (QoL) with and without disease-modifying treatments (DMTs) of patients with multiple sclerosis (MS).

Methods

Data on resource consumption, productivity losses, QoL (utility), and fatigue were collected from 1355 patients registered with a patient association and descriptive analyses was performed.

A Markov model was developed to estimate costs and utility over 20 years using the survey data. Disease progression without DMTs was taken from an epidemiological cohort in France (EDMUS cohort, LYON). Progression under DMTs was estimated from the Stockholm MS registry. Results are presented as cost per quality-adjusted life-years (QALYs), from the societal perspective, in EUR2007, discounted at 3%.

Results

Mean Expanded Disability Status Scale (EDSS) was 4.4 and mean total annual costs per patient were EUR44,400, of which 47% were productivity losses and 11% informal care. Public payers cover an estimated 48% of costs. Mean utility was 0.52, and the loss compared with the normal population was estimated at 0.28. Costs and utility ranged from EUR16,000 and 0.79 at EDSS 1 to EUR76,000 and 0.11 at EDSS 8–9.

Over 20 years, costs were estimated at EUR429,000 and QALYs at 8.96 for patients without DMTs and at EUR433,207 and 9.24 QALYs if all patients were starting treated with DMTs at EDSS 1–3.

Conclusion

Although the data for this analysis come from different sources, the results indicate that the cost increase with DMTs is moderate.

Modeling the cost-effectiveness of a new treatment for MS (natalizumab) compared with current standard practice in Sweden

OBJECTIVE

To estimate the cost-effectiveness of a new treatment (natalizumab) for multiple sclerosis (MS) compared with current standard therapy with disease-modifying drugs (DMDs) in Sweden.

METHODS

A Markov model was constructed to illustrate disease progression based on functional disability (the Expanded Disability Status Scale (EDSS)). The effectiveness of natalizumab was based on a 2-year clinical trial in 942 patients (AFFIRM). The effectiveness of current DMDs was estimated from a matched sample of 512 patients in the Stockholm MS registry. Patients withdrawing from treatment were assumed to follow the disease course of 824 patients with relapsing-remitting disease at onset in the Ontario natural history cohort. Costs and utilities are based on a recent observational study in 1339 patients. All data sets were available at the patient level. Main results are presented from the societal perspective, over a 20-year time frame, in 2005 Euros (euro1 = 9.25 SEK).

RESULTS

In the base case, treatment with natalizumab was less expensive and more effective than treatment with current DMDs. When only healthcare costs were considered, the cost per quality-adjusted life year gained with natalizumab was euro38 145. Results are sensitive only to the time horizon of the analysis and assumptions about effectiveness of natalizumab beyond the trial.

CONCLUSIONS

This cost-effectiveness analysis used registry data, cohort and observational studies to extrapolate the efficacy findings of natalizumab from the AFFIRM clinical trial to measure effectiveness in clinical practice. The analysis results suggest that for the population considered, natalizumab provides an additional health benefit at a similar cost to current DMDs from a societal perspective.

The cost-effectiveness of infliximab in the treatment of ankylosing spondylitis in Spain. Comparison of clinical trial and clinical practice data

OBJECTIVE

To estimate the cost-effectiveness of treating ankylosing spondylitis (AS) with infliximab (Remicade) in Spain for up to 40 years.

METHODS

A previously published disease model was adapted to the Spanish setting using resource consumption from a cross-sectional burden of an illness study in 601 patients in Spain. Cost-effectiveness estimates were based on a placebo-controlled clinical trial as well as an open clinical study in Spain. In the model, patients with insufficient response to treatment at 12 weeks [Bath Ankylosing Spondylitis Disease Activity Index (BASDAI) <4 or > or =50% reduction] discontinue treatment. The results are presented in 2005 euros, from societal and health-care payer perspectives.

RESULTS

In the societal perspective, infliximab treatment dominates standard treatment in both analyses. In the perspective of the health-care system, with the assumption that, over the long term, functional ability of patients on treatment would decline at half the natural rate, the cost per quality-adjusted life year (QALY) gained was estimated at EUR 22 519 (double-blind trial) and EUR 8866 (open study). Assuming that patients' function on treatment remains stable, the cost-effectiveness ratios are EUR 15 157 and EUR 5307, respectively. Under the most conservative assumption (no effect of treatment on progression), the ratios are EUR 31 721 and EUR 13 659, respectively. In addition, the results are sensitive to the time horizon and discontinuation rates.

CONCLUSIONS

Our results indicate that infliximab therapy for patients with active AS should be cost-effective both in the societal perspective (dominating) and in the perspective of the health-care system (ranges from EUR 5300 to EUR 32 000 per QALY) in Spain.

The burden of rheumatoid arthritis and access to treatment: health burden and costs

As part of the study "The burden of rheumatoid arthritis and patient access to treatment", this paper reviews evidence on the health burden of rheumatoid arthritis (RA) in terms of morbidity (DALYs), mortality (% of deaths attributable to RA) and quality of life (utility and loss of QALYs), as well as the economic impact on society. Based on available literature on the prevalence and the cost of RA, combined with economic indicators, the annual cost per patient as well as the total national cost is estimated for Europe and North America (Canada and the United States), as well as Australia, Turkey, the Russian Federation and South Africa. Total costs to society were estimated at <euro>45.3 billion in Europe and at <euro>41.6 billion in the United States. Utility scores were found to be amongst the lowest compared to other diseases.

The burden of rheumatoid arthritis and access to treatment: outcome and cost-utility of treatments

Within the series of articles investigating the burden of rheumatoid arthritis (RA), this paper reviews the methods used for economic assessment of the RA treatments by HTA agencies and other bodies involved in cost-effectiveness analysis and the current status of the field. The overall methods, as well as the challenges, of cost-effectiveness analysis in RA are common to all chronic progressive diseases where much of the treatment benefit is delayed, while costs occur immediately. Also, as in all disabling diseases, much of the costs occur outside the health-care system, due to the rapid loss of work capacity and the need for informal care in the later stages of the disease. Thus, it is essential to adopt a long-term view and consider costs from the perspective of society, rather than the health-care service, to increase the relevance of the results for policy making.

The burden of rheumatoid arthritis and access to treatment: uptake of new therapies

This paper presents data on international differences in use of TNF inhibitors. It is part of a study on burden and cost of RA, access to new therapies and the role of HTA in determining access and cost-effectiveness. United States has the fastest most extensive use of the new drugs, about three times the average in the western European countries and Canada. Eastern and central European countries as well as Australia, South Africa and Turkey lag far behind. However, some smaller European countries, most notably Norway and Sweden have use of the new drugs not far behind the United States. While the income level of the country, and thus the health care expenditures per capita is a major factor for determining use in low and middle income countries, there are still considerable differences among countries with similar high total health care expenditures. Differences in prices are considerable between the US and Europe due to the changes in exchange rates between the US dollar and the Euro, but high and low use is not systematically related to differences in price.

The burden of rheumatoid arthritis and access to treatment: determinants of access

As part of the study "The Burden of Rheumatoid Arthritis (RA) and Patient Access to Treatment", this paper reviews the impact on access to RA drugs of the approval processes, pricing and funding decisions and times to market (access) in different countries. In addition, an overview of health technology assessments (HTA) and the economic literature related to RA treatments is provided. The time from approval to market access ranged from immediate to over 500 days in the countries included in the study. A total of 55 HTA reports were identified, 40 of them in the period between 2002 and 2006; 29 were performed by European HTA agencies, 14 in Canada and 7 in the United States. A total of 239 economic evaluations related to RA were identified in a specialized health economic database (HEED).

Estimation of the cost of MS in Europe: Extrapolations from a multinational cost study

The present study aims at estimating the total cost of MS in Europe based on actual cost data from nine countries and published epidemiological evidence. The epidemiological data are reported as 12 months prevalence estimates and cost data calculated as annual cost per patient at given levels of disease severity. Cost data are extrapolated to the rest of Europe based on a model, using economic indexes adjusting for price level differences in different sectors between countries. The aggregated annual cost estimates are presented in Euro for 2005. In 28 European countries with a population of 466 million, an estimated 380 000 individuals are affected by MS. The total annual cost of MS in Europe is estimated at 12.5 billion in year 2005, corresponding to a cost of 27 per European inhabitant. Direct costs represent slightly more than half of the total cost (6.0 billion). Informal care is estimated at 3.2 billion, and indirect costs due to morbidity at 3.2 billion. Thus, the largest component of costs is found outside the formal health care sector. Although our model appears to predict costs reasonably well, when comparing to previous national studies not included in the estimates, there are considerable uncertainties when extrapolating cost data across countries even within Europe. These weaknesses can only be overcome by collecting primary data. Multiple Sclerosis 2007; 13: 1054—1064. http://msj.sagepub.com

Costs and quality of life of patients with multiple sclerosis in Europe

OBJECTIVE

To assess overall resource consumption, work capacity and quality of life of patients with multiple sclerosis in nine European countries.

METHODS

Information on resource consumption related to multiple sclerosis, informal care by relatives, productivity losses and overall quality of life (utility) was collected with a standardised pre-tested questionnaire from 13,186 patients enrolled in national multiple sclerosis societies or followed up in neurology clinics. Information on disease included disease duration, self-assessed disease severity and relapses. Mean annual costs per patient (Euro, 2005) were estimated from the societal perspective.

RESULTS

The mean age ranged from 45.1 to 53.4 years, and all levels of disease severity were represented. Between 16% and 29% of patients reported experiencing a relapse in the 3 months preceding data collection. The proportion of patients in early retirement because of multiple sclerosis ranged from 33% to 45%. The use of direct medical resources (eg, hospitalisation, consultations and drugs) varied considerably across countries, whereas the use of non-medical resources (eg, walking sticks, wheel chairs, modifications to house and car) and services (eg, home care and transportation) was comparable. Informal care use was highly correlated with disease severity, but was further influenced by healthcare systems and family structure. All types of costs increased with worsening disease. The total mean annual costs per patient (adjusted for gross domestic product purchasing power) were estimated at Euro 18,000 for mild disease (Expanded Disability Status Scale (EDSS) <4.0), Euro 36,500 for moderate disease (EDSS 4.0-6.5) and Euro 62,000 for severe disease (EDSS >7.0). Utility was similar across countries at around 0.70 for a patient with an EDSS of 2.0 and around 0.45 for a patient with an EDSS of 6.5. Intangible costs were estimated at around Euro 13,000 per patient.

Health economic issues in MS

The objectives of MS treatment are to avoid temporary disability due to relapses and to delay progression to permanent disability. There have been intense debates about whether new and costly MS treatments represent efficient use of resources, and which patients should be treated. Cost-effectiveness analysis attempts to estimate the trade-offs involved and to provide information that will assist the decision-making process. In chronic-progressive diseases, health gains and potential associated economic benefits are often most evident in the long term. Consequently, the potential impact of new treatments must be estimated, using models that project available knowledge into the future. These models can also explore scenarios that provide best value for money (e.g. by defining subgroups or criteria when treatment should be stopped). The different findings obtained by various cost-effectiveness studies of new MS treatments can be explained by the variations in methodological approaches, patient definitions and datasets used. The key is to communicate such differences transparently.

Modelling the effect of function and disease activity on costs and quality of life in rheumatoid arthritis

OBJECTIVE

When treatments with the potential to change the natural history of a disease are introduced, their longer-term effect on costs and quality of life (utility) has to be estimated using economic models. However, to remain useful tools, models must be updated when new information becomes available. Our earlier models in rheumatoid arthritis (RA) have been based on functional status, but it has recently been shown that disease activity might have an independent effect on utility. The objective of this study was to improve the model by incorporating the effect of a subjective measure of disease severity and activity (global VAS).

METHODS

A Markov model was constructed with five states according to functional status (HAQ), and each state was subdivided according to the VAS (<40 and >40). Disease development (transition probabilities between the states) was taken from a longitudinal cohort study of patients with early RA in Sweden. A recent population-based survey of 616 patients with RA provided data on costs and utilities. The model incorporates the full distribution of costs and utilities from the survey, and long-term projections are made using Monte Carlo simulation.

RESULTS

The global VAS had a highly significant effect on utilities independently of HAQ. For resource consumption, only HAQ was a significant predictor, with the exception of sick leave, which was correlated with the VAS but not with HAQ. Using the cohort distribution from the longitudinal study, expected mean costs per patient over 10 yr were 106 034 euros (s.d. 5091 euros) (1 euro = SEK 9.20) and the expected number of quality-adjusted life years (QALYs) was 5.08 (s.d. 0.09). Patients starting at HAQ <0.6 but with consistently high VAS scores would have expected costs of 102 830 euros and 4.96 QALYs, while patients with low VAS scores would have costs of 81 603 euros and 6.01 QALYs.

CONCLUSION

Our new model incorporates for the first time the effect of a subjective measure of disease severity and activity on both costs and utility, making it a sensitive tool to estimate the cost-effectiveness of disease-modifying treatments. New data on resource consumption indicate a shift to higher direct costs, particularly in early disease, and lower indirect costs in more advanced disease. The large size of the data sets used in this model reduces the uncertainty and makes estimates very stable.

Cost effectiveness of etanercept (Enbrel) in combination with methotrexate in the treatment of active rheumatoid arthritis based on the TEMPO trial

OBJECTIVE

To estimate the cost effectiveness of combination treatment with etanercept plus methotrexate in comparison with monotherapies in patients with active rheumatoid arthritis (RA) using a new model that incorporates both functional status and disease activity.

METHODS

Effectiveness data were based on a 2 year trial in 682 patients with active RA (TEMPO). Data on resource consumption and utility related to function and disease activity were obtained from a survey of 616 patients in Sweden. A Markov model was constructed with five states according to functional status (Health Assessment Questionnaire (HAQ)) subdivided into high and low disease activity. The cost for each quality adjusted life year (QALY) gained was estimated by Monte Carlo simulation.

RESULTS

Disease activity had a highly significant effect on utilities, independently of HAQ. For resource consumption, only HAQ was a significant predictor, with the exception of sick leave. Compared with methotrexate alone, etanercept plus methotrexate over 2 years increased total costs by 14,221 euros and led to a QALY gain of 0.38. When treatment was continued for 10 years, incremental costs were 42,148 euros for a QALY gain of 0.91. The cost per QALY gained was 37,331 euros and 46,494 euros, respectively. The probability that the cost effectiveness ratio is below a threshold of 50,000 euros/QALY is 88%.

CONCLUSION

Incorporating the influence of disease activity into this new model allows better assessment of the effects of anti-tumour necrosis factor treatment on patients' general wellbeing. In this analysis, the cost per QALY gained with combination treatment with etanercept plus methotrexate compared with methotrexate alone falls within the acceptable range.

The burden of ankylosing spondylitis and the cost-effectiveness of treatment with infliximab (Remicade(R))

OBJECTIVES

In the past, treatment options for ankylosing spondylitis (AS) have been limited, and the introduction of new treatments such as infliximab will have a noticeable impact on health-care budgets. The objective of this study was therefore to assess the current burden of the disease and estimate the cost-effectiveness of infliximab treatments.

METHODS

A cross-sectional retrospective observational study of resource consumption and utility related to disease severity was performed in patients who had participated in a population survey between 1992 and 1994 at the University of Bath and patients regularly followed at the Royal National Hospital for Rheumatic Diseases in Bath for up to 9 years. Mean costs and utility were estimated using a regression model including age, gender, disease duration, disease activity and functional status, and disease development was expressed as annual progression of functional disability. Cost-effectiveness of infliximab was modelled using a 3-month placebo-controlled clinical trial with open 1-yr extension in 70 patients, over a total time frame of 2 yr. In the model, costs and utility controlled for disease severity and age from the observational study were assigned to individual patients. The effect of long-term treatment was evaluated in a hypothetical model over 30 yr.

RESULTS

Fifty-seven per cent of patients answered the questionnaires. The mean age was 57 (s.d. 11.2) yr, 74% were male and mean disease duration was 30.2 (11.7) yr. Mean total costs were estimated at pound 6765 (s.d. pound 166). Indirect costs represented 57.9% and non-medical costs such as investments and informal care accounted for 16.5% of total costs. Mean utility was 0.67 (0.21). In the main model, mean costs for untreated patients are estimated at pound 25,128. For the infliximab group, mean costs (excluding treatment) are estimated at pound 17,240, a reduction of 31%. Thus, part of the treatment cost was offset by savings in other resources ( pound 7888), leaving an incremental cost of pound 6214. Treatment increased the number of quality-adjusted live years (QALYs) by 0.175 QALYs, leading to a cost per QALY gained of pound 35,400 for the first year of treatment. When treatment is assumed to continue for the full 2 yr, the cost per QALY is pound 32,800. When infliximab infusions are given every 8 weeks instead of every 6 weeks, the cost per QALY is reduced to pound 17,300. In the long-term model, the cost per QALY is estimated at pound 9600.

CONCLUSIONS

Non-medical costs and production losses dominate costs in AS, and economic evaluation must therefore adopt a societal perspective. The cost of treatment with infliximab is partly offset by reductions in the cost of the disease and patients' quality of life is increased, leading to a cost per QALY gained in the vicinity of pound 30,000 to pound 40,000 in the short term, but potentially below pound 10,000 in the long term.

The cost of feedback microwave thermotherapy compared with transurethral resection of the prostate for treating benign prostatic hyperplasia

OBJECTIVE

To compare the efficacy of a new microwave thermotherapy for treating benign prostatic hyperplasia (BPH), the ProstaLund Feedback Treatment (PLFT, ProstaLund Operations AB, Lund, Sweden) and transurethral resection of the prostate (TURP) in a clinical trial to their effectiveness in clinical practice over 1 year, to estimate their cost over 1 year, and to evaluate the cost of re-interventions over a longer period (2-3 years).

PATIENTS AND METHODS

In a large randomized international 1-year clinical trial PLFT was as effective as TURP in improving symptoms of BPH and urinary flow. Because PLFT is an outpatient procedure it was less costly than TURP. However, the cost-effectiveness of the new procedure depends on its long-term effectiveness in clinical practice. All 146 patients in the randomized clinical trial were included in the present analysis. The outcome was based on the International Prostate Symptom Score (IPSS) and the bother score, and costs were estimated from treatment-related adverse events and hospitalization. To validate the estimates based on the clinical trial 1-year data on effectiveness and complete resource use in clinical practice were collected in a retrospective observational study from hospital charts and patient questionnaires of 88 patients who had undergone either TURP or PLFT. To assess the number of re-interventions after TURP after the first year information was obtained from hospital and surgical procedure data in the Swedish inpatient registry. The 3-year data for a total of 52,010 patients who had an index hospitalization for TURP between 1990 and 1995 were available for the analysis. The estimate of long-term consequences of PLFT was based on complication and re-intervention data for 87 patients who had undergone PLFT between 1997 and 1999.

RESULTS

The mean 1-year costs in the clinical trial were estimated at [symbol: see text] 1763 for PLFT and [symbol: see text] 3209 for TURP. When all treatment-related resource use in clinical practice for 88 patients was included the costs were estimated at [symbol: see text] 1924 and [symbol: see text] 3264 for PLFT and TURP, respectively. The IPSS and bother scores were not significantly different between the groups in both datasets. Using the registry data the cost of TURP including re-interventions (TURP and bladder neck incisions) was estimated at [symbol: see text] 3159 over 2 years and [symbol: see text] 3185 over 3 years; the respective costs for PLFT were [symbol: see text] 2121 and at [symbol: see text] 2151.

CONCLUSIONS

In the 1-year clinical trial PLFT was as effective but less costly than TURP, but long-term data are still lacking. However, the preliminary analysis over 3 years indicates that the average cost of the procedure remains lower than the total cost of TURP for the same period.

TNF inhibitors in the treatment of rheumatoid arthritis in clinical practice: costs and outcomes in a follow up study of patients with RA treated with etanercept or infliximab in southern Sweden

OBJECTIVES

To evaluate costs, benefits, and cost effectiveness of tumour necrosis factor inhibitor treatment over one year in routine clinical practice.

MATERIALS AND METHODS

At four rheumatology units in southern Sweden treatment of 160 consecutive patients with RA was started with either etanercept or infliximab. The economic analysis was based on 116 patients with complete data who received treatment for at least one year. Details on drug treatment, functional capacity, disease activity, and laboratory values were available during the entire treatment. Information on resource use and QoL was collected at baseline and throughout the first year. The cost effectiveness analysis was based on changes in outcome and costs compared with the year before treatment. Cost per quality adjusted life year (QALY) gained was calculated for the entire sample and for patients with different levels of functional disability.

RESULTS

During the first treatment year direct costs were reduced by 40%, but indirect costs did not change substantially. Patients' QoL improved on treatment-utility increased from an average of 0.28 to 0.65. Assuming that improvement occurred after three months' treatment, the cost per QALY gained is estimated as euro;43 500. If it occurs after six weeks, in parallel with clinical measures, the cost per QALY is euro;36 900. Sensitivity analysis, including all 160 patients, gave an estimated cost per QALY of euro;53 600. The cost per QALY increases for patient groups with less severe disease.

CONCLUSION

For this patient group, cost effectiveness ratios are within the generally accepted threshold of euro;50 000, but need to be confirmed with larger samples.

The cost-effectiveness of infliximab (Remicade) in the treatment of rheumatoid arthritis in Sweden and the United Kingdom based on the ATTRACT study

OBJECTIVE

The cost per quality-adjusted life-year (QALY) of infliximab (Remicade) treatment in rheumatoid arthritis (RA) was estimated on the basis of a clinical trial comparing infliximab plus methotrexate with methotrexate alone in 428 patients with advanced disease [Anti-Tumour Necrosis Factor Trial in Rheumatoid Arthritis with Concomitant Therapy (ATTRACT)].

METHODS

The effect of infliximab on disease progression and related costs and utilities was estimated using two disease progression models based on epidemiological cohorts followed for up to 15 yr in Sweden and the UK. The clinical trial data were used directly in the model and extrapolated to 10 yr using a cohort from the epidemiological studies matched for gender, age, time since onset of RA and disease severity.

RESULTS

One to two years of treatment with infliximab treatment reduced direct and indirect resource consumption in both countries, thereby partly offsetting the treatment cost. In the base case, including both direct and indirect costs, the cost per QALY gained was SEK 32 000 (euro 3440) in Sweden and GBP 21 600 (euro 34 800) for 1 yr of treatment. The respective QALY gains were 0.248 and 0.298. With 2 yr of treatment, the costs per QALY gained were SEK 150 000 (euro 16 100) and GBP 29 900 (euro;48 200).

CONCLUSIONS

Although 1-2 yr of treatment with infliximab will lead to savings in both direct and indirect costs, these will not offset the drug cost. However, the cost-effectiveness ratios remain within the usual range for treatments to be recommended for use.

Productivity, vitality and utility in a group of healthy professionally active individuals with nocturia

OBJECTIVES

To assess the effect of nocturia on productivity, vitality and utility in a selected group of professionally active individuals with nocturia, compared with matched controls, and investigate the effect of symptom severity, to test the hypothesis that lack of sleep caused by frequent sleep interruptions could reduce an individuals' daytime energy and activity levels.

SUBJECTS AND METHODS

Subjects (203) were recruited in Sweden through advertisements, and their suitability for the study assessed in a structured interview. Controls (80) matched for age and gender were randomly selected from a market research panel and given the same interview. Both groups completed a productivity questionnaire, a generic quality-of-life questionnaire with a specific domain for vitality and a utility instrument.

RESULTS

The study group with nocturia had a significantly lower level of vitality and utility, and greater impairment of work and activity, than the control group. Women were more affected than men. Symptom severity correlated with all three measures.

CONCLUSIONS

In an otherwise healthy and professionally active group of individuals, waking at night to void significantly diminishes their overall well-being, vitality and productivity, leading to a significant level of indirect and intangible costs.

Intravenous levosimendan treatment is cost-effective compared with dobutamine in severe low-output heart failure: an analysis based on the international LIDO trial

BACKGROUND

Levosimendan, a novel calcium sensitiser, improves cardiac performance and symptoms without increasing oxygen consumption, and decreases the mortality of patients with low-output heart failure.

AIMS

To estimate the cost-effectiveness of intravenous treatment with levosimendan compared with dobutamine in patients with severe low-output heart failure.

METHODS

This economic evaluation was based on a European clinical trial (LIDO), in which 203 patients with severe heart failure randomly received a 24 h infusion with either levosimendan or dobutamine. Survival and resource utilisation data were collected for 6 months; survival was extrapolated assuming a mean additional lifetime of 3 years based on data from the Cooperative North Scandinavian Enalapril Survival Study trial. Costs were based on study drug usage and hospitalisation in the 6-month follow-up. A sensitivity analysis on dosage of drug and duration of survival was performed.

RESULTS

The mean survival over 6 months was 157+/-52 days in the levosimendan group and 139+/-64 days in the dobutamine group (P<0.01). When extrapolated up to 3 years, the gain in life expectancy was estimated at 0.35 years (discounted at 3%). Levosimendan increased the mean cost per patient by 1108, which was entirely due to the cost of the study drug. The incremental cost per life-year saved (LYS) was 3205 at the European level; in the individual countries the cost per LYS ranged between 3091 and 3331. The result was robust in the sensitivity analysis.

CONCLUSIONS

Although the patients in the levosimendan group were alive for more days and thus at risk of hospitalisation for longer, there was no increase in hospitalisation or hospitalisation costs with levosimendan treatment. The cost per LYS using levosimendan compares favourably with other cost-effectiveness analyses in cardiology.

Cost-utility of interferon beta1b in the treatment of patients with active relapsing-remitting or secondary progressive multiple sclerosis

Economic evaluations of treatments for multiple sclerosis have focused either on relapsing-remitting or secondary progressive disease. None has addressed specifically the question of how treatments affect disease progression from diagnoses to severe disability; however, in both clinical and economic terms this is one of the key questions. This study therefore created a disease model that includes both relapsing and progressive multiple sclerosis and covers the full range of disease severity. In addition, the issue of covariates influencing the cost per QALY and the uncertainty in the estimates is addressed. The model is based on our earlier approach using a Markov model, where disease progression is measured as functional disability (EDSS), costs and utilities associated with different disability levels, and outcome expressed as QALY. Treatment is based on a subgroup of patients with active disease in two placebo-controlled clinical trials and open-label extensions with interferon-beta(1b) in relapsing-remitting or secondary progressive multiple sclerosis, and natural history data are used for the extrapolation beyond the trials. Disease progression (transition probabilities) was estimated using a probit model controlling for differences in patient and disease characteristics, and costs and utilities for different disability levels are taken from large population-based observational studies. Results are presented for Sweden and compared to the United Kingdom. When treatment is given for 36 months (adjusted for compliance) and no further effect is included, the cost per QALY is EURO 7800 (direct, indirect, and informal care costs included, discounted at 3%) over 10 years. The total number of QALYs increases from 3.45 in the no-treatment group to 3.64 in the treatment group. When treatment is prolonged to 54 months, the cost per QALY is EURO 38,700. Using the full range of costs and utilities, the probability that the cost per QALY over a 20-year time-frame is below EURO 50,000 for patients starting treatment at EDSS 3.0 is 80%. In view of the progression of MS over many years models are required to estimate the cost-effectiveness of new treatments. The model proposed here allows estimating disease progression, costs, and QALYs for patients with different characteristics and types of MS, and it can be adapted to different countries. It can hence be used to assess the cost-effectiveness of a defined intervention, such as interferon-beta(1b).

Modelling the costs and effects of leflunomide in rheumatoid arthritis

This study investigated the cost-effectiveness of leflunomide (LEF) compared to methotrexate (MTX) and sulfasalazine (SSZ) in the United Kingdom. A Markov model was constructed using health states defined by Health Assessment Questionnaire score. The model is based on a cohort of patients with recently diagnosed definite RA who were followed for up to 15 years at nine rheumatology clinics in the UK. The treatment effect was calculated based on clinical trials comparing LEF to MTX (one international and one United States trial) and to SSZ (one international trial). Transitions between health states for the first 2 years of treatment were calculated from the clinical trials, while the extrapolation beyond the trial was based on the Early Rheumatoid Arthritis Study cohort, using an ordered probit model. This makes it possible to predict transitions for patients with similar characteristics (age, time since disease onset) as in the trials. Separate analyses were performed for each trial, and all analyses covered a 10-year timeframe. Using the US trial, LEF had slightly lower costs and better effects (44,017 and 4.307 pounds QALYs, compared to 44,988 and 4.158 pounds QALYs for MTX), while for the international trial this was reversed (34,070 and 4.487 pounds QALYs for MTX compared to 36,351 and 4.372 pounds QALYs for LEF). Compared to SSZ, the cost of using LEF was slightly lower, with an increase in QALYs (35,855 and 3.896 pounds QALYs compared to 36,731 and 3.721 pounds QALYs for SSZ). The two trials comparing LEF to MTX gave differing results. One possible reason for this is that MTX patients in the US trial were given folic acid, whereas in the international trial folate supplementation was not mandated. This may have reduced the effectiveness of MTX. In the UK it is standard practice to use folic acid with MTX, and therefore the results from the US trial may be more relevant for the UK. Compared to SSZ, the use of LEF appears to be cost-effective in the UK.

Cost-utility analysis of interferon beta-1b in secondary progressive multiple sclerosis

OBJECTIVES

Interferon beta-1b has recently become available for the treatment of secondary progressive multiple sclerosis (SPMS). This study aims at estimating the cost-effectiveness of this new treatment that has been shown in a clinical trial to reduce the progression of the disease. Effectiveness is measured as the number of quality-adjusted life-years (QALYs) gained from the reduction in progression. Because the clinical trial period will only capture part of the treatment's effect in terms of QALYs gained, since benefits achieved during the trial will have an effect beyond it, the cost-effectiveness analysis involves modeling over the longer term using complementary data.

METHODS

A Markov model with states based on disability expressed by EDSS scores was used. Transition probabilities were calculated directly from clinical trial data for the first 3 years and then extrapolated to 10 years. Mean costs and utilities for each Markov state were calculated from a population-based cross-sectional study in Sweden.

RESULTS

The incremental cost per QALY is SEK 342,700 (US $39,250; US $1 = SEK 8.73, March 10, 2000) when all costs (direct, informal care, and indirect) are included (discounted 3%). When indirect costs are excluded, the cost per QALY is SEK 542,000 ($62,100).

CONCLUSIONS

Cost-effectiveness analysis in SPMS requires that the effect of treatment beyond clinical trials be included. Also, analysis should be done from a societal perspective, since many of the costs occur outside the healthcare system. The cost-utility ratios estimated in this analysis are at or below the mean threshold value indicated in a recent survey of health economists ($60,000).

Cost-effectiveness of new treatments for overactive bladder: the example of tolterodine, a new muscarinic agent: a Markov model

Economic analyses of interventions for chronic diseases require evaluations over a long timeframe to illustrate the benefits and costs of treatments. Clinical trials are generally short and carried out in strictly controlled conditions. They are therefore of limited value for economic evaluation aimed at facilitating decisions about resource allocation. The objective of this study was to develop a simulation model that allows integration of data from different sources to calculate the incremental cost-effectiveness and cost-utility of new treatments for overactive bladder. The model compares tolterodine, a new treatment that aims at alleviating symptoms and improving patients' quality of life, to no treatment. Simulations for Sweden are presented as an example. The Markov model combines clinical, observational, and economic data. Markov states are defined based on severity of symptoms of overactive bladder (frequency of voids and leaks). Specific costs for drug treatment and use of sanitary protections as well as utilities are assigned for each state. The effectiveness of tolterodine is based on controlled clinical trials and open long-term extensions of these trials. Outcome is measured as quality-adjusted life years (QALYs) and as the number of months spent in a state with no or very limited symptoms. During the course of 1 year, patients treated with tolterodine spend more time in states with no or limited symptoms compared to those receiving no treatment. Tolterodine-treated patients having a better quality of life during the year. The mean utility of the treated cohort is 0.70, compared to 0.67 in the no-treatment cohort, which is equivalent to the entire cohort moving by one level to a state with less severe symptoms. Mean total costs per patient in the tolterodine arm are SEK8,595 (US $1,131; 1 US$ = 7.6 SEK) compared to SEK3,286 (US$432) in the no-treatment arm. The extra cost due to tolterodine is SEK380 (US$50) per month, which falls within the range of monthly amounts that patients were willing to pay out of pocket for a 25 or 50% improvement of their symptoms in a previous study. The cost for pads is reduced by 23%. The marginal cost per QALY gained with tolterodine is estimated at SEK213,000 (US$28,000). Based on this simulation model, it appears that treatment of overactive bladder with a well-tolerated pharmacological treatment such as tolterodine is cost-effective.

Modeling cost of treatment with new topical treatments for glaucoma. Results from France and the United Kingdom

Several new topical agents have been introduced recently and it can be expected that the treatment of glaucoma will change, depending on how effectively these agents control intraocular pressure (IOP). IOP is considered the major risk factor in the development of glaucomatous damage. In order to estimate the impact of these new agents on the cost of treating glaucoma, a simulation model was created to estimate the cost of treating patients with a recent diagnosis of primary open-angle glaucoma or ocular hypertension in different countries. The Markov model is based on retrospective chart reviews in different countries and calculates only cost, not outcome. Results are presented for France and the United Kingdom, where current treatment appeared to be comparable. Average one-year costs per patient with current treatment were FF2,389 (US $389) and 380 pounds (US $627), respectively. Costs with the new treatments were lower than with current therapy.

Economic consequences of the progression of rheumatoid arthritis in Sweden

OBJECTIVE

To develop a simulation model for analysis of the cost-effectiveness of treatments that affect the progression of rheumatoid arthritis (RA).

METHODS

The Markov model was developed on the basis of a Swedish cohort of 116 patients with early RA who were followed up for 5 years. The majority of patients had American College of Rheumatology (ACR) functional class II disease, and Markov states indicating disease severity were defined based on Health Assessment Questionnaire (HAQ) scores. Costs were calculated from data on resource utilization and patients' work capacity. Utilities (preference weights for health states) were assessed using the EQ-5D (EuroQol) questionnaire. Hypothetical treatment interventions were simulated to illustrate the model.

RESULTS

The cohort distribution among the 6 Markov states clearly showed the progression of the disease over 5 years of followup. Costs increased with increasing severity of the Markov states, and total costs over 5 years were higher for patients who were in more severe Markov states at diagnosis. Utilities correlated well with the Markov states, and the EQ-5D was able to discriminate between patients with different HAQ scores within ACR functional class II.

CONCLUSION

The Markov model was able to assess disease progression and costs in RA. The model can therefore be a useful tool in calculating the cost-effectiveness of different interventions aimed at changing the progression of the disease.

Direct costs of glaucoma management following initiation of medical therapy. A simulation model based on an observational study of glaucoma treatment in Germany

BACKGROUND

Economic evaluation of new treatments in the field of glaucoma represents a challenge. In the absence of a clear epidemiological link between intra-ocular pressure (IOP) and disease progression to blindness, the economic impact of treatments that lower IOP on long-term outcome cannot be estimated. As an alternative, effectiveness may be expressed as the ability to control IOP over time, making it possible to estimate the cost-effectiveness of therapies. The objective of this study was to investigate treatment strategies for patients newly diagnosed with primary open-angle glaucoma (POAG) or ocular hypertension (OH) in Germany and to estimate the impact of new topical therapies on the total cost of treatment.

METHODS

We performed a retrospective analysis of 200 randomly selected patient charts in 50 ophthalmology practices. Demographics, diagnoses, IOP and detailed resource utilization over 2 years were collected. Resources were valued independently from the quantitative data collection, and a standard charge from the perspective of the third party payer, as well as a cost from the societal viewpoint, was determined for each item. A Markov model was created to calculate total treatment costs with the new therapy.

RESULT

During the 2 years, 54% of patients had their therapy changed at least once. Mean total charge and cost per patient were DM 815 and DM 1274, respectively. Mean IOP at baseline was 31.2 mm at baseline and 18.8 mm after 2 years. IOP at baseline was positively correlated with costs, while IOP reduction after treatment initiation was negatively correlated with costs. Simulations of the effect of new topical therapies on treatment costs to third party payers and to society indicate that a potential reduction or delay of surgical interventions may partly offset the extra cost of the new drugs.

CONCLUSION

Observational data for glaucoma treatment indicate a high frequency of treatment changes that are associated with higher costs. New treatments that control IOP effectively over time may thus reduce the cost of patient management. Their cost-effectiveness for managing IOP will depend on both, their price and their effectiveness.

Economic considerations and outcome measurement in urge incontinence

OBJECTIVES

Urge incontinence exacts a physical, psychological, and economic toll on affected individuals. This article examines different approaches to estimate the burden of urge incontinence on patients and discusses how costs and consequences of treatments can be evaluated and compared to other interventions.

METHODS

Willingness-to-pay methodology was used in Sweden to illustrate patients' distress. Incontinence symptoms were compared to willingness-to-pay amounts and to health-related quality of life (QOL) as measured with a generic profile (SF-36) and a preference-based instrument (EuroQol). These measures were also tested using data from a clinical trial in the United States. A single effectiveness measure ("normal days") that would be meaningful to patients, physicians, and payers and could be used in cost-effectiveness analysis was tested in a multinational clinical trial.

RESULTS

Willingness to pay was significantly correlated with the expected health improvement, incontinence symptoms, and income. SF-36 scores were significantly lower than for the general Swedish population and were correlated with the severity of symptoms. Utility values obtained with EuroQol were also correlated with symptoms. Similar results were obtained in the clinical trial. The composite effectiveness measure was able to discriminate between treatment and placebo, despite a high placebo effect.

CONCLUSIONS

Patients with urge incontinence experience a number of different symptoms that affect activities of daily living and QOL. However, for cost-effectiveness analysis these symptoms should be expressed as a single outcome in order to allow for comparison within the same indication and to other diseases. We tested a disease-specific measure for incontinence and several generic measures to be used in cost-effectiveness analysis.