A Cost-per-Number Needed to Treat Analysis Assessing the Efficiency of Biologic Drugs in Moderate to Severe Plaque Psoriasis

BACKGROUND AND OBJECTIVES

Psoriasis is a chronic inflammatory skin disease with an estimated prevalence in Spain of 2.3% of the population. Approximately 30% of patients have moderate-to-severe forms. Treatment with biologic agents is proving to be a step forward in the management of the disease, although these treatments are very expensive. The objective of this study was to determine the efficiency, in terms of cost per number needed to treat (NNT), of the biologic drugs available in Spain for the treatment of moderate to severe plaque psoriasis.

METHODS

NNT data were obtained from a network meta-analysis that included all randomized clinical trials of biologic drugs sold in Spain. The cost of each treatment was calculated based on the approved dosage for the first year of treatment, as indicated in the Summary of Product Characteristics. These data were used to calculate the cost per NNT of the drugs for various PASI scores (75, 90, and 100). A sensitivity analysis was performed taking into consideration only the PASI-response measurement time (after 10, 12, or 16 weeks, depending on the drug).

RESULTS

The order of efficiency, from most to least efficient, in the case of a PASI 75 response was ixekizumab > ustekinumab 45mg > ustekinumab 90mg > secukinumab > infliximab > etanercept > adalimumab. The order for PASI 90 was ixekizumab >secukinumab >ustekinumab 45mg > ustekinumab 90mg > infliximab > adalimumab > etanercept. The order for PASI 100 was ixekizumab > secukinumab > infliximab > ustekinumab 90mg > ustekinumab 45mg > adalimumab > etanercept. The sensitivity analysis showed some changes in the order, depending on the response-assessment period.

CONCLUSIONS

The findings show a link between the efficacy of the biologic therapies available in Spain for the treatment of moderate-to-severe plaque psoriasis and their efficiency. Ixekizumab had the lowest cost per NNT for all PASI-response scores (75, 90, and 100) during the first year of treatment.

On heterogeneity of treatment effects and clinical freedom

Three decades ago, John R Hampton announced the death of clinical freedom. Since then, evidence-based medicine has been the predominant paradigm in clinical research. By applying a population-based approach, the randomised controlled trial has become the cornerstone for demonstrating the overall effect of a treatment and for developing guidelines. The new patient-centred medicine movement is rediscovering the important implications of heterogeneity of treatment effects for clinical practice and that a better understanding of such variability can contribute to improve health outcomes for individual patients through practicing a science-based clinical freedom.

Evidence based medicine and patient centered medicine: some thoughts on thier integration

Evidence-based medicine (EBM) and patient-centered medicine (PCM) are two movements that have emerged with great force in health systems in recent years. EBM has a population approach, and its primary objective is the generalization and improvement of health outcomes in the average patient. PCM has a personalized approach, focuses on individualization and improving health outcomes in specific patients. While EBM has its conceptual anchor in research, PCM has it in medical care. Despite EBM and PCM being perceived as conflicting movements, the profound changes that are currently taking place in health systems can facilitate the confluence of clinical research and medical care. This article constitutes a reflection on how research methods should approach the individual patient and medical practice should approach future patients. EBM and PCM, like research and medical practice, are two sides of the same coin, which should complement and aid each other. It is difficult to see how one of them can reach its full potential without the other as a continual reference, because PCM should not be practiced without being based on the best available evidence and it is impossible to imagine an EBM whose ultimate goal is disconnected from the individual patient.

Prasugrel compared to clopidogrel in patients with acute coronary syndrome undergoing percutenaous coronary intervention: a Spanish model-based cost effectiveness analysis

OBJECTIVE

To assess the long-term cost-effectiveness of 12 months treatment of prasugrel compared to clopidogrel in patients with acute coronary syndrome (ACS) undergoing percutaneous coronary intervention (PCI) in the Spanish health care system.

METHODS

A Markov state transition model was developed to estimate health outcomes, quality adjusted life years (QALYs), life years (LY), and costs over patients' lifetimes. Clinical inputs were based on an analysis of the TRITON-TIMI 38 clinical trial. Hospital readmissions captured during the trial in a sub-study of patients from eight countries (and subsequent re-hospitalisations modelled to accrue beyond the time horizon of the trial), were assigned to Spanish diagnosis-related group payment schedules to estimate hospitalisation costs.

RESULTS

Mean total treatment costs were ?11,427 and ?10,910 for prasugrel and clopidogrel respectively. The mean cost of the study drug was ?538 higher for prasugrel vs. clopidogrel, but rehospitalisation costs at 12 months were ?79 lower for prasugrel due to reduced rates of revascularisation. Hospitalisation costs beyond 12 months were higher with prasugrel by ?55, due to longer life expectancy (+0.071 LY and +0.054 QALYs) associated with the decreased nonfatal myocardial infarction rate in the prasugrel group. The incremental cost per life year and QALY gained with prasugrel was ?7,198, and ?9,489, respectively.

CONCLUSION

Considering a willingness-to-pay threshold of ?30,000/QALY gained in the Spanish setting, prasugrel represents a cost-effective option in comparison with clopidogrel among patients with ACS undergoing PCI.

[Depression: a social mortgage. Latest advances in knowledge of the cost of the disease]

INTRODUCTION

Following the latest examination of the worldwide mental health situation, the World Health Organization has estimated that depression produces the greatest decrement in health compared with other chronic diseases, and has encouraged to all countries to increase investment and resources in this field.

METHODOLOGY

On investing resources for the care of patients with depression, cost of illness studies are a complement to morbidity-mortality studies, and are of great relevance in defining health care policies. The present study describes the economic impact of depression in our setting, in the light of the most recent publications on this subject.

RESULTS

The total cost of depression in Europe has been estimated to reach 118 billion euros, and most of this amount (61 %) is due to indirect costs associated with sick leave and productivity losses. The economic burden of depression in Spain could add up to 5.005 million euros a year, with a resource category distribution very similar to that found in Europe as a whole.

CONCLUSIONS

Health care systems and society must cope with the important costs of depression, which implies intense resource utilization, fundamentally outside the health care sector as such. There are a number of areas in which improvements can be made in order to reduce this important burden associated with depression, though the incorporation of health economics to public health care policies must become a priority.

Cost of severe hypoglycaemia in patients with type 1 diabetes in Spain and the cost-effectiveness of insulin lispro compared with regular human insulin in preventing severe hypoglycaemia

OBJECTIVES

To determine the costs of severe hypoglycaemia (SH) in a population of patients with type 1 diabetes mellitus in the Spanish healthcare system and the cost-effectiveness of insulin lispro over regular insulin in preventing SH episodes.

METHODS

A retrospective study of 100 patients in three Spanish health centres was performed. Resource utilisation data were collected only for interventions specifically relating to the hypoglycaemic episode. The direct medical costs determined in the analyses were: costs of hospitalisation, diagnostic tests carried out, costs of treatment administered and other associated costs such as visits to the endocrinologist and re-training in glucose control, transportation and assistance of a care-giver. In addition, indirect costs such as days of lost productivity were measured. The incidence rates of SH for insulin lispro and regular insulin were obtained from the literature. The incremental cost-effectiveness of insulin lispro over regular insulin was calculated.

RESULTS

The overall mean cost per episode of SH was 366 euro, comprised of 65.4% direct costs and 35.6% indirect costs. The largest cost was for hospitalisation at 183 euro per episode. The SH episodes incidence rates for 100 patients per year were 33 and 73 for insulin lispro and 48 (p < 0.05) and 117 (p < 0.01) for regular insulin, in the two clinical trials found in the literature. The additional cost to prevent one episode of SH with insulin lispro over regular insulin ranged from 277 euro to insulin lispro dominance.

CONCLUSIONS

Severe hypoglycaemia has a significant impact on the total cost of diabetes. The use of insulin lispro is associated with reductions in annual costs because of SH and, possibly, the overall effect may be cost neutral or cost saving when total costs are considered. The cost of SH should be included in the analysis of total socio-economic burden of diabetes.

The validity and reliability of the global index of safety (GIS)

OBJECTIVE

The global index of safety (GIS) is an adverse event (AE) based instrument designed to evaluate the safety profile of drugs. This paper presents the evaluation of the inter-rater reliability and validity of a 94-item GIS for antipsychotics through Rasch analysis.

RESEARCH DESIGN AND METHODS

A total of 194 psychiatrists participating in an outpatient pharmacoepidemiologic study of olanzapine in schizophrenia rated the severity that each AE would have on a 5-point scale. Reliability was determined through a paired comparison design involving the new independent ratings of 101 different psychiatrists participating in another study of olanzapine in acute inpatient units. Spearman's, Pearson's and Intra-class correlation (ICC) coefficients were used to estimate the inter-rater reliability of the AE weights. Validity was analyzed through the Rasch rating scale model.

RESULTS

Reliability coefficient estimates were excellent (Spearman = 0.99, Pearson = 0.99, ICC = 0.98), supporting the inter-rater reliability of the item weights. Through goodness-of-fit statistics and the investigation of the hierarchy of item calibrations, Rasch analysis confirmed the validity of the instrument.

CONCLUSION

The data presented here on inter-rater reliability estimates of adverse events related to antipsychotic drugs indicate that GIS is a promising alternative for the evaluation of the safety profile of drugs.

[Economic analyses of olanzapine in the treatment of schizophrenia and bipolar disorder]

Schizophrenia generates important costs for society both direct, as a consequence of hospitalization and outpatient treatment, and indirect; related to loss of productivity. The atypical antipsychotics, such as olanzapine, have supposed an important advance in the treatment of schizophrenia. The greater cost of atypical antipsychotics with respect to conventional drugs has led to the conduction of pharmacoeconomic studies to determine its efficiency. This article reviews the complete pharmacoeconomic studies that compare olanzapine with haloperidol and risperidone in the treatment of schizophrenia. Cost analyses comparing olanzapine and haloperidol show that the former drug does not add increased cost to therapy, and even contributes to lessen expenses fundamentally as a result of a decrease in hospitalizations. In the economic evaluations comparing olanzapine and risperidone, the results are not conclusive, and in general, the total costs associated with both treatments were similar. In the treatment of bipolar disorder, although few studies have estimated the economic impact of olanzapine, it has been observed a reduction of hospitalization costs associated to the treatment with olanzapine.

Psychometric validation of a generic health-related quality of life measure (EQ-5D) in a sample of schizophrenic patients

OBJECTIVE

The aim of this study was to evaluate the construct validity of a generic health related quality of life (HRQOL) instrument - the EQ-5D - in a sample of schizophrenic patients receiving antipsychotic treatment.

RESEARCH DESIGN AND METHODS

A total of 2128 schizophrenic patients treated with olanzapine, 417 treated with risperidone, and 112 with haloperidol responded to the EQ-5D. The study also assessed the effect of patient age, gender, and co-morbidity variables on patient's HRQOL Main outcomes measures: EQ-5D scores at the start of treatment and after 3 and 6 months of therapy were compared with results from the Clinical Global Impression (CGI) severity of illness scale and the (GAF) scale. The effect of antipsychotics and sociodemographic variables on patient's HRQOL over time was tested through a three-factor doubly multivariate repeated measures MANCOVA.

RESULTS

High scores in the GAF scale and low scores in the CGI were linked with high scores on the EQ-5D scale. The correlational effects observed between the EQ-5D and the clinical indices ranged from 0.33 to 0.54. A significant effect of 'visit time' as well as an interaction of 'visit time' x drug, 'visit time' x gender, and 'visit time' x co-morbidity was observed.

CONCLUSIONS

Results suggest the EQ-5D is a valid instrument capable of detecting HRQOL differences between schizophrenic patients with different degrees of severity of illness.

Bone mineral density referral for dual-energy X-ray absorptiometry using quantitative ultrasound as a prescreening tool in postmenopausal women from the general population: a cost-effectiveness analysis

The aim of our study was to assess, from the perspective of the National Health Services in Spain, the cost-effectiveness of quantitative ultrasound (QUS) as a prescreen referral method for bone mineral density (BMD) assessment by dual-energy X-ray absorptiometry (DXA) in postmenopausal women of the general population. Using femoral neck DXA and heel QUS. We evaluated 267 consecutive postmenopausal women 65 years and older and attending primary care physician offices for any medical reason. Subjects were classified as osteoporotic or nonosteoporotic (normal or osteopenic) using the WHO definition for DXA. Effectiveness was assessed in terms of the sensitivity and specificity of the referral decisions based on the QUS measurement. Local costs were estimated from health services and actual resource used. Cost-effectiveness was evaluated in terms of the expected cost per true positive osteoporotic case detected. Baseline prevalence of osteoporosis evaluated by DXA was 55.8%. The sensitivity and specificity for the diagnosis of osteoporosis by QUS using the optimal cutoff thresholds for the estimated heel BMD T-score were 97% and 94%, respectively. The average cost per osteoporotic case detected based on DXA measurement alone was 23.85 euros. The average cost per osteoporotic case detected using QUS as a prescreen was 22.00 euros. The incremental cost-effectiveness of DXA versus QUS was 114.00 euros per true positive case detected. Our results suggest that screening for osteoporosis with QUS while applying strict cufoff values in postmenopausal women of the general population is not substantially more cost-effective than DXA alone for the diagnosis of osteoporosis. However, the screening strategy with QUS may be an option in those circumstances where the diagnosis of osteoporosis is deficient because of the difficulty in accessing DXA equipment.

A Rasch model analysis to test the cross-cultural validity of the EuroQoL-5D in the Schizophrenia Outpatient Health Outcomes Study

OBJECTIVE

To investigate the pan-European, cross-cultural validity of the EuroQol-5D (EQ-5D) for assessing quality of life in the Schizophrenia Outpatient Health Outcomes (SOHO) Study.

METHOD

The EQ-5D items investigated were mobility, self-care, usual activities, pain/discomfort and anxiety/depression. A Rasch rating scale model (a form of differential item functioning) was used to identify invariance of item calibrations for the 10 European countries participating in the SOHO study.

RESULTS

There was general congruence in the EQ-5D item calibration pattern. The rank of average EQ-5D item calibrations was similar for all countries except Denmark. Denmark showed slight misfits for mobility and pain/discomfort.

CONCLUSION

The EQ-5D is an appropriate measure of health-related quality of life across European countries and translations.

[What is an efficient health technology in Spain?]

INTRODUCTION

Despite the growing recognition of the potential applications of cost-effectiveness assessments, a criterion to establish what is an efficient health technology does not exist in Spain. The objective of this work is to describe the limits and the criteria used in Spain to recommend the adoption of health interventions.

METHOD

A review of the economic evaluations of health technologies published in Spain from 1990 to 2001 was conducted. Complete economic assessments in which the cost-effectiveness ratio was expressed as cost per life-year gained (LYG), cost per quality-adjusted-life-year (QALY) or cost per saved live were selected. Those interventions in which the authors established recommendations (adoption or rejection) and the criteria used were analyzed.

RESULTS

Twenty (20%) of the 100 complete economic evaluations fulfilled the selection criteria. In16 studies, the results were expressed as cost per LYG, in 6 studies as cost per QALY and in 1 as cost per saved live. A total of 82 health interventions were assessed and some kind of recommendation was established in 44 of them. All technologies with a cost-effectiveness ratio lower than 30,000 euros (5 million pesetas) per LYG were recommended for adoption by the authors. Up to that limit there was no a clear tendency.

CONCLUSIONS

Although the results must be interpreted with much precaution, given the limitations of the study, the limits of cost-effectiveness presented in this work could be a first reference to which would be an efficient health intervention in Spain.

Global index of safety (GIS): a new instrument to assess drug safety

There is an asymmetry between the extraordinary development of measures and tools aimed at studying the beneficial effects of the drugs and the more limited methods to assess their safety profile. The goal of our study was to develop a global measuring tool to assess drugs' safety. We conducted a survey of Spanish psychiatrists in mental health centers and outpatient treatment units to assess the severity scores that they would assign to a list of the most common adverse events (AEs) that usually occur with antipsychotic treatment. The severity scores were then applied to the list of AEs that really occurred along a naturalistic pharmacoepidemiological study on the use of different antipsychotics in the treatment of schizophrenia. The Global Index of Safety (GIS) of the experimental group treated with olanzapine (OLZ) was compared with the GIS of the control group and with the GIS of specific antipsychotics for which the number of treated patients was greater than 100. A total of 194 psychiatrists rated the severity of each AE on a scale of 1 (insignificant) to 5 (extremely severe). The individual severity was applied to the 2949 schizophrenic patients included in a pharmacoepidemiological study. A GIS was calculated for every group of patients receiving the same treatments. The GIS of the control group was higher (4.3) than that calculated from the experimental group (2.5) (P < 0.001). The GIS of the risperidone (3.6) and haloperidol (6.0) subgroups were higher than that calculated from the OLZ group (P < 0.001). The development of a GIS may facilitate the comparison of the safety of several drugs and may constitute a very valuable aid for those involved in selecting drugs.

[Incidence of extrapyramidal symptoms during treatment with olanzapine, haloperidol and risperidone: results of an observational study]

OBJECTIVES

To analyze the incidence of extrapyramidal symptoms (EPS) and the concomitant use of anticholinergic drugs in outpatients diagnosed of schizophrenia treated with olanzapine (OLZ) in comparison with haloperidol (HAL) and risperidone (RIS) under routine clinical practice conditions.

MATERIAL AND METHODS

The analysis was carried out on the basis of the information obtained in the EFESO study, an observational, prospective study carried out in outpatients diagnosed of schizophrenia and treated with olanzapine compared to other antipsychotic agents used in the clinical practice. The incidence of EPS in the OLZ treated group compared to the haloperidol and risperidone treatment groups in which over 100 patients were included is analyzed in the present work. The study duration was 6 months and the data were collected by 293 psychiatrists from mental health care areas.

RESULTS

The percentage of patients who presented at least one adverse event (AE) (p 3/4 0.001) was less in the OLZ groups (47.8%) compared to those of the HAL (79.8%) and RIS (57.2%) subgroups. A lower percentage of patients treated with OLZ (36.9%) presented EPS in comparison to the RIS (49.6%) and HAL (76%) subgroups (p 3/4 0.001). A lower rate of patients from the OLZ group (10.2%) received anticholinergic treatments compared to the RIS (19.9%) and HAL (44%) subgroups (p< 0.001 in both cases).

CONCLUSIONS

OLZ-treated patients presented a lower incidence of EPS and required less anticholinergic treatment than the HAL and RIS treated patients. These results, obtained in naturalistic conditions, coincide with the conclusions reached in randomized clinical trials carried out prior to the marketing of OLZ.

Comparative pharmacoeconomic study of vancomycin and teicoplanin in intensive care patients

Randomized clinical trials and meta-analyses have not demonstrated any statistically significant differences between teicoplanin and vancomycin with regard to efficacy. A cost-minimization analysis was conducted to compare the economical impact of the treatment with vancomycin and teicoplanin in intensive care patients. Information on resource utilization was retrospectively collected from 100 consecutive clinical histories of patients hospitalized in a Spanish Intensive Care Unit, who had been given a glycopeptide antibiotic (50 teicoplanin and 50 vancomycin) for the treatment of a suspected or proven infection. Although personnel, material, and monitoring costs were higher in the vancomycin group, the acquisition costs and the total costs were much lower in this group, so the resulting total costs per day were 5508 ptas (33 euros) for vancomycin-treated patients and 9893 ptas (59.5 euros) for teicoplanin-treated patients. The savings with vancomycin for a 10-day course of treatment would be approximately 40697 ptas (244.5 euros) per patient. Results were consistent for a variety of conditions that were included in the sensitivity analysis.

Economic evaluation in a randomized phase III clinical trial comparing gemcitabine/cisplatin and etoposide/cisplatin in non-small cell lung cancer

INTRODUCTION

Information on the relative cost-effectiveness of treatments for cancer is being increasingly sought as pressure on health care resources increases. The objective of this study was to assess the cost-effectiveness of gemcitabine/cisplatin (GC) versus cisplatin/etoposide (CE) in patients with advanced non-small cell lung cancer (NSCLC), using resource utilization data collected in conjunction with the first randomized clinical trial comparing both combinations.

METHODS

Efficacy and medical care resource utilization data were collected prospectively in an open-label, multicenter, randomized, comparative, phase III trial conducted in Spain which compared gemcitabine/cisplatin and cisplatin/etoposide in 135 chemonaive patients with Stage IIIB or IV NSCLC. There were no differences between both regimens when survival was used as primary end-point, so a cost-minimization analysis was used to compare them. In addition, cost-effectiveness analyses were conducted when percentage of responses and time to progression were used as secondary end-points.

RESULTS

There were no differences between both regimens when survival was selected as the efficacy end-point. Despite the higher chemotherapy cost of GC when compared to CE, there were no differences in total direct costs (584523 pts for GC and 589630 pts for CE; P=NS) between both regimens. Potential savings with GC were mainly associated with a decrease in hospitalization rate. There were differences in favor of GC when response rate (40.6% for GC and 21.9% for CE; P<0.05) and time to disease progression (8.7 months for GC and 7.2 months for CE; P<0. 05) were used as clinical end-points. GC presented a favorable cost-effectiveness profile when compared to CE.

CONCLUSIONS

This prospective economic evaluation conducted alongside a clinical trial offers valuable preliminary information on the potential efficiency of the combination gemcitabine-cisplatin in NSCLC. Future assessments based on larger clinical trials focused on survival and naturalistic economic studies conducted in real clinical practice settings are necessary to confirm these findings.

Doses of olanzapine, risperidone, and haloperidol used in clinical practice: results of a prospective pharmacoepidemiologic study. EFESO Study Group. Estudio Farmacoepidemiologico en la Esquizofrenia con Olanzapina

OBJECTIVE

The objectives of this study were to determine the doses of olanzapine (OLZ), risperidone (RIS), and haloperidol (HAL) used in clinical practice in outpatients with schizophrenia and the rates of occurrence of extrapyramidal symptoms (EPS) and other adverse events, clinical response, and use of concomitant medications.

METHODS

The present study involved a subset of patients from a 6-month, open-label, prospective observational study. Data were collected by 293 psychiatrists at mental health centers and other outpatient treatment facilities in Spain. Medications and doses used, occurrence of EPS and other adverse events, and scores on the Clinical Global Impression (CGI) of Severity Scale and Global Assessment of Function (GAF) were recorded. Clinical response was defined as a decrease of > or = 2 points on the CGI, with a final CGI score < or = 4.

RESULTS

A total of 2657 patients were included in the analysis. The initial and overall mean daily doses for the 3 groups were as follows: OLZ, 12.2 and 13.0 mg, respectively; RIS, 5.2 and 5.4 mg; and HAL, 13.9 and 13.6 mg. Initial and overall median daily doses were the same in each group: OLZ, 10 mg; RIS, 6 mg; and HAL, 10 mg. A significantly lower proportion of OLZ-treated patients (36.9%) experienced EPS compared with RIS-treated (49.6%) and HAL-treated (76.0%) patients (P < or = 0.001). A significantly lower proportion of patients in the OLZ group (47.8%) experienced adverse events compared with patients in the RIS (57.2%) and HAL (79.8%) groups (P < or = 0.001). A significantly greater proportion of OLZ-treated patients (37.3%) were responders compared with RIS-treated patients (31.5%) (P < 0.05). In all 3 groups, patients who had an initial CGI score > or = 5 received significantly higher overall mean daily doses than did patients with an initial CGI score < 5 (P < 0.001). A significantly lower proportion of OLZ-treated patients (10.2%) were receiving concomitant anticholinergic medication at the end of the study (month 6) compared with RIS-treated (19.9%) and HAL-treated (44.0%) patients (P < 0.001).

CONCLUSION

The mean daily doses recorded in this analysis based on data from a naturalistic setting are consistent with recommendations based on clinical trials. Compared with both RIS- and HAL-treated patients, OLZ-treated patients were less likely to experience EPS or other adverse events, and less likely to use concomitant anticholinergic medications. OLZ-treated patients were also more likely to respond to treatment than were RIS-treated patients.

The safety of olanzapine compared with other antipsychotic drugs: results of an observational prospective study in patients with schizophrenia (EFESO Study). Pharmacoepidemiologic Study of Olanzapine in Schizophrenia

INTRODUCTION

Results of controlled clinical trials should be confirmed through safety and effectiveness studies in nonselected patient cohorts treated according to routine clinical practice.

METHOD

Outpatients with schizophrenia (ICD-10 criteria) entered this prospective, naturalistic study when they received a new prescription for an antipsychotic drug. Treatment assignment was based on purely clinical criteria, as the study did not include any experimental intervention. Safety was evaluated through the collection of spontaneous adverse events and a specific questionnaire for extrapyramidal symptoms. Global clinical status was measured through the Clinical Global Impressions-Severity (CGI-S) and the Global Assessment of Functioning (GAF) scales.

RESULTS

From the 2967 patients included, 2128 patients were treated with olanzapine as monotherapy or combined with other drugs (olanzapine group), and 821 were treated with other antipsychotic drugs as monotherapy or combined with other drugs (control group). There were no statistical differences between treatment groups at baseline regarding age, gender, disease duration, or severity of symptoms. Olanzapine was well tolerated and effective in this study. Overall incidence of adverse events was significantly lower in the olanzapine group compared with the control group (p < .001). Somnolence and weight gain were significantly more frequent in the olanzapine group, and akathisia, dystonia, extrapyramidal syndrome, hypertonia, hypokinesia, and tremor were significantly higher in the control group. Clinical improvement at endpoint, measured through the mean change in the CGI-S and the GAF, was significantly higher in the olanzapine group compared with the control group (p = .004).

CONCLUSION

These results show that olanzapine is safe and effective in nonselected schizophrenic outpatients and are consistent with the efficacy and safety profile that olanzapine has shown in previous controlled clinical trials.

Cost-effectiveness of fluoxetine plus pindolol in patients with major depressive disorder: results from a randomized, double-blind clinical trial

Some preliminary studies have suggested that the beta-adrenoceptor 5-HT1A antagonist pindolol (PIN) could increase the effect of selective serotonin reuptake inhibitors (SSRIs). We prospectively estimated the cost-effectiveness of fluoxetine and pindolol versus fluoxetine plus placebo, using results from the first double-blind randomized clinical trial comparing both treatments. Efficacy and medical care resource utilization were collected prospectively in a parallel, randomized, double-blind clinical trial conducted in a single centre in Spain. Average cost-effectiveness (cost/% response and cost/% remission) as well as the incremental cost-effectiveness were calculated for both treatments. A 'bootstrap' method was used to calculate confidence limits around the incremental cost-effectiveness ratio. A significantly greater percentage of patients (one-tailed P < 0.05) in the fluoxetine FLX + PIN group than in the FLX + PLA group had experienced a therapeutic response (74.5% versus 58.97%) at 6 weeks. Direct medical costs were lower in the FLX + PIN group (mean 2508 pesetas per patient) than in the FLX + PLA group (mean 31870 pesetas per patient). Hospital admissions due to worsening of depressive symptoms were significantly lower (P < 0.05) in the FLX + PIN group (0/55) than in the FLX + PLA group (4/56). The observed differences in average costs and percentage response in the study were -29362 pesetas (< 0) and 15.6% (> 0), respectively, and the resulting cost-effectiveness ratio was negative. These outcomes indicate that the FLX + PIN option completely dominates FLX + PLA. These results suggest that, over a course of 6 weeks of treatment, the combination of fluoxetine and pindolol incurs lower direct medical costs than treatment with fluoxetine placebo. Despite their limitations, economic assessments in addition to clinical trials allow a 'dynamic assessment' on the potential success of the drug, both from a clinical and an economic point of view, allowing decisions on priorities to be made earlier.

Service utilization and costs of first-onset schizophrenia in two widely differing health service areas in North-East Spain. PSICOST Group

OBJECTIVE

The aim of the study was to analyse the cost-incidence of schizophrenia in two areas with widely differing health service systems.

METHOD

The costs of patients with schizophrenia in the 3 years after the first service contact were evaluated (i) in an area (A) with fully developed mental health community programmes and (ii) in another area (B) without such programmes. The assessment included a standard description of services, as well as clinical, social and disability aspects.

RESULTS

Sociodemographic and clinical characteristics were comparable. The mean direct costs for both areas in the 3-year period were, respectively, 4287 dollars and 6540 dollars in year 1, 2416 dollars and 2888 dollars in year 2, and 2120 dollars and 1862 dollars in year 3. Direct costs in area A were 35% lower than those in area B during the first year, 16.4% lower during the second year, and 12.2% higher during the third year.

CONCLUSION

Direct costs were higher in the area that lacked intermediate mental health services, mainly due to hospitalization. Non-provision of intermediate mental health care may lead to inefficiencies in the healthcare system.

[The costs of treatment with the new antidepressants in clinical practice]

OBJECTIVE

To assess if, in usual clinical practice, the patterns of use of new antidepressant are associated to different health resource utilisation.

DESIGN

Naturalistic, retrospective, observational study.

SETTING

Urban health center.

PATIENTS

DSM-IIIR diagnostic criteria of depressive disorder and treatment with a new antidepressant (n = 328).

INTERVENTIONS

Information on resource utilisation was collected in those patients treated with fluoxetine (FLX), fluvoxamine (FLV) sertraline (SER), paroxetine (PAR) and venlafaxine (VLF). Direct, indirect and total costs were compared according to the different patterns of use (stable therapy, upward dose titration, switching or augmentation) and according to the initially prescribed antidepressant. The follow-up period was 6 months.

RESULTS

Direct and total daily costs of those patients with unestable therapy (upward dose titration, switching or augmentation) were 55% (p < 0.01) and 87% (p = 0.001) higher than for patients with stable therapy, respectively. Patients who initiated therapy on SER, VLF and PAR had 35% (p < 0.05), 80% (p < 0.05) and 37% (p < 0.05), respectively, higher average total costs per day than patients who initiated therapy with FLX. Regarding direct costs, patients who initiated therapy on SER and VLF had 48% (p < 0.001) and 58% (p < 0.05) higher average costs per day than patients who initiated therapy with FLX.

CONCLUSIONS

New antidepressants show different patterns of use in a clinical practice setting, being FLX the agent more associated to a stable pattern of use. The pattern of use is associated to different health resource utilisation. Patients under stable therapy show lower health costs than those who need upward titration, switching or augmentation strategies. It is necessary to conduct randomized naturalistic studies to confirm these results.

Randomized database studies: a new method to assess drugs' effectiveness?

The need to evaluate drugs' effects in real clinical practice is increasingly important. Randomized clinical trials (RCTs) and database analyses (DBA) are the two main methods to assess treatments effectiveness. RCTs remain the "gold standard" for comparing alternative treatments. However, they are conducted under strict, protocol-driven conditions that may limit their generalizability. Advantages of new high quality clinical databases, on the other hand, include the simple and economic access to large number and range of cases, and the ability to capture all aspects of actual medical practice. The main potential limitation of DBA is the potential for comparison bias due to the lack of randomization. Despite the efforts to design naturalistic trials and to use sophisticated statistical techniques to minimize selection bias, the inherent limitations of both methods (problems of external and internal validity, respectively) have not been completely solved. Thus, the actual challenge is the development of some new strategy capable of generating results with an acceptable balance between internal and external validity. As randomization is essential to minimize comparison bias, we point out the possibility to include randomization modules in computer-based patient records. The theoretical foundation of these "randomized database studies" is the simultaneous use of both experimental and observational methods in the assessment of drugs' effectiveness. The progressive standardization of clinical practice and the development and adoption of improved computer-based patient records could facilitate the use of this new research strategy.

[Pattern of usage of new antidepressants in clinical practice]

INTRODUCTION

Data from naturalistic studies have reported differences in the clinical use of antidepressants referring to the need for adjusting doses, treatment duration, tolerability and use of concomitant medication. These differences could be considered as an indicator of the effectiveness of antidepressants in clinical practice settings.

OBJECTIVES

It is a naturalistic, retrospective, observational study which objective is to evaluate and compare the pattern of antidepressant use (fluoxetine, fluvoxamine, paroxetine, sertraline, venlafaxine) and to establish if there is a relation between the different pattern of use and the effectiveness of them.

DATA AND METHODS

A retrospective dataset of patients who initiated therapy on fluoxetine, fluvoxamine, paroxetine, sertraline, or venlafaxine with a follow-up period of 6 months was used. Information about clinical characteristics of patients and antidepressant pattern of use were collected. Pattern of antidepressant use were defined as: "initial doses", "upward dose titration", "augmentation strategy", "switching" and "early interruption of treatment". The efficacy of the therapy was assessed by the CGI-improvement.

RESULTS

Fluoxetine was the antidepressant more associated with a statistical significance (p = 0.001) to an stable pattern of use (initial doses without upward dose titration, switching or augmentation). After controlling for other observed baseline characteristics, patients who remained on their initial antidepressant therapy, with a stable pattern of use were 1.61 times more likely than patients who had an adjustment to therapy to experience a treatment response. Patients who initiated treatment with sertraline or venlafaxine were 2.155 and 4.831 times less likely, respectively, to experience a response relative to patients who initiated therapy on fluoxetine.

CONCLUSIONS

The need to upward dose titration, switching or augmentation in the treatment could be indicated a worse therapeutic control of the symptoms. Patients treated with fluoxetine are in a stable pattern of use more likely than patients in the other antidepressants, this fact is related with better global therapeutic results.

A review of methodologies for assessing drug effectiveness and a new proposal: randomized database studies

The need to evaluate the effects of health technologies in clinical practice is increasingly important. In this article, we review the advantages and limitations of naturalistic randomized clinical trials (RCTs) and database analyses, the two primary methods for evaluating treatment effectiveness. Also, we comment on a newer research strategy, cross-design synthesis, which proposes the complementary use of both experimental RCTs and observational database methodologies to avoid the main weaknesses of each: respectively, the lack of external and internal validity. Finally, we propose a new strategy--randomized database studies--capable of generating results with an acceptable balance between internal and external validity. This strategy consists of the simultaneous use of both experimental and observational tools in the assessment of drugs' effectiveness. Randomization is essential to minimize comparison bias, and one possibility for such studies is that randomization modules could be included in computer-based patient records. Although we identify some of the difficulties in implementing the process, the progressive standardization of clinical practice and the development and widespread adoption of improved computer-based patient records could facilitate the use of randomized database studies as a new method of research.

[Double-blind clinical trial comparing 5 days of dirithromycin versus 7 days of diacetylmidecamycin in acute bronchitis and acute exacerbations of chronic bronchitis]

BACKGROUND

Dirythromycin has several pharmacokinetic characteristics (long half life and high tissue concentrations) which suggest the possibility of administering shorter treatments than those conventionally used. The aim of this study was to determine and compare the efficacy of a 5 day treatment with dirythromycin once a day, versus diacetylmidecamycin twice a day over 7 days in the treatment of patients with acute bronchitis and acute exacerbations of chronic bronchitis.

METHODS

A parallel, multicentric, randomized, double blind clinical study was carried out in 8 Spanish hospitals.

RESULTS

One hundred seventy-four patients were included in the study, with 87 (80 evaluable) being randomly assigned to receive dirythromycin (500 mg/day over 5 days) and 87 (83 evaluable) diacetylmidecamycin (600 mg, twice daily over 7 days). A favorable symptomatic response (cure or improvement) was observed in 72/80 of the first group (90%) and in 74/83 (89.2%) of the second group. No statistically significant differences were found in the efficacy and safety between the two treatment groups in either the evaluable patients or on intention to treat analysis.

CONCLUSIONS

The results of this study suggest that the administration of dirythromycin, once a day over 5 days, is as safe and effective as diacetylmidecamycin, twice a day over 7 days, in the treatment of acute bronchitis and acute exacerbations of chronic bronchitis.

[Cost effectiveness analysis of olanzapine versus haloperidol in the treatment of schizophrenia++ in Spain]

BACKGROUND

Cost-effectiveness of olanzapine in comparison with haloperidol, in Spanish schizophrenic patients, was analysed using a clinical decision model.

METHODS

The model represents a simulation of the different clinical and therapeutic possibilities that an hypothetical cohort of patients could experienced in a 5-years period of treatment. Efficacy was measured as months with partial-complete remission. Most information was obtained from the HGAJ randomised clinical trial. Other information was estimated through literature reviews and the opinion of an expert panel.

RESULTS

Average cost-effectiveness for olanzapine was lower (116,476 pesetas per month with partial-complete remission) than for haloperidol (134,762 pesetas per month with partial-complete remission). Olanzapine produced more than half year (6.7 months) with partial complete remission, in comparison with haloperidol, with antincrementar cost-effectiveness of 32,516 pesetas per month with partial-complete remission, in comparison with haloperidol. The results were not sensitive to changes in the values of the main variables used in the analysis.

CONCLUSIONS

According to this analysis, olanzapine presents a good cost-effectiveness relationship in comparison with baloperidol, in Spanish schizophrenic patients. The analysis will be completed when new studies comparing olanzapine with other antipsychotics are available.

Use of confidence intervals and sample size calculations in health economic studies

OBJECTIVE

To discuss the calculation and application of confidence intervals in pharmacoeconomic studies.

DATA SYNTHESIS

The increasing frequency with which pharmacoeconomic evaluations are made within clinical trials makes it possible to obtain information on the outputs and costs of an intervention in each patient of a sample under study. This allows the same statistical principles commonly used in clinical trials to be applied to cost or cost-effectiveness data. The methodology described in this article would allow expression of cost-effectiveness ratios in the form of confidence intervals. The calculation of the cost-effectiveness ratio by means of a confidence interval may have important practical consequences, both in decision-making on the choice of 1 intervention versus another and in calculating the size of the sample necessary to identify statistically significant differences, from both clinical and economic points of view.

CONCLUSIONS

The complementary use of confidence intervals and sensitivity analysis makes it possible to measure uncertainty related and unrelated to variability in sample data, allowing the decision to adopt 1 technology or another to be based on the most objective information available. Although several ethical and methodologic concerns remain to be addressed, this methodology may contribute to improving the more rational and efficient use of drugs.

[Economic assessment on medications: effects on pharmaceutical industry and health administration]

The present article discuss briefly the different methods of economic assessment of drugs, how and where the methods can be included alongside clinical trials, and discuss their influence in the pharmaceutical industry and health care administration. There are several methodological limitations when adding the economic assessment into a clinical trial principally because they differs in the aims. Economic assessment is interested in efficiency and clinical trials in security and efficacy. Pharmaceutical industry have been developing pharmacoeconomic departments in order to increase the internal efficiency of the viability of new products and to generate studies for regulatory authorities. At the moment, for regulatory purposes in Spain, an economic assessment is nor required but is recommended. The standardization of the methodology of the economic assessment is a key issue that may produce the spread and adoption in health care decision making process.

Drug utilisation studies as tools in health economics

Drug utilisation and many pharmacoeconomic studies use pharmacoepidemiological methods characterised by the study of drugs from a socioeconomic perspective. Drug utilisation studies may be defined as studies of the marketing, distribution, prescription and use of drugs in a society, with special emphasis on the resulting medical, social and economic consequences. Pharmacoeconomic studies are used to measure drug efficiency, through comparison of the costs and effects of alternative therapies. Drug utilisation studies can provide highly valuable information, at a reasonable price, on the costs and effects (harmful and beneficial) of drugs. Such studies make available much useful information including indirect data on morbidity, the pharmaceutical component of the treatment cost of an illness, therapeutic compliance, the incidence of adverse reactions, the effectiveness of drug consumption and the choice of comparators. This information can be of great use in the subsequent elaboration of pharmacoeconomic studies, or in the selection of problematic areas in which these studies may be applied. Pharmacoeconomic studies, in turn, can be used to discover the economic repercussions of inappropriate prescribing and to quantify the cost effectiveness of various therapeutic interventions. The use of drug utilisation studies in conjunction with pharmacoeconomic analysis can result in more cost effective utilisation of medicines and a better utilisation of pharmacoeconomic methods, both of which contribute to a more rational use of drugs.

[The quality of clinical trials published in Spain: an evaluation by an analysis of 3 journals during the 1985-1991 period]

BACKGROUND

The evaluation by readers of a published clinical trial requires that the methodology used in its design and realization be specified in detail. In the present study the quality of clinical trials published in Spain during 1985-1991 has been appraised.

METHODS

This is a revision of all clinical studies published from 1985 to 1991 in the following Spanish medical journals: Medicina Clínica, Revista Clínica Española and Revista Española de Enfermedades Digestivas; the studies were assessed by three persons through the use of a questionnaire (checklist) which contained 15 evaluation sections relative to the methodology used in carrying out a study.

RESULTS

Only an average of 5.5 (+/- 2.8) aspects of the 15 evaluated aspects were considered adequate in the total of clinical trials. Three of the aspects evaluated: "objective of the study", "end point" and "criteria for assessment of outcome" were considered adequate in more than 75% of the cases. Aspects relative to "loss to follow-up", "statistical methods", "analysis of the results", "collection of adverse events", and "approval by an ethical committee" accounted for most methodological defects, being the percentage of studies with correct information below 20%. As to the remaining sections considered, they were found adequate in an intermediate to low percentage (near 30%). There were no differences in quality among the three journals. A slight increase in quality was observed during the last years.

CONCLUSIONS

Major methodological deficiencies appear in the clinical studies published in Spain during the last seven years. The recently approved regulations on clinical trials plus the use of checklists by investigators and journal editors, where detailed ethic and methodological aspects are appraised, can contribute to an increase in quality.

Evaluation of pharmacoeconomic studies: utilization of a checklist

OBJECTIVE

To review the fundamental concepts used in clinical economic analysis and establish a simple model to systematically evaluate the quality of pharmacoeconomic studies.

DATA SOURCES

A MEDLINE search was used to identify pertinent pharmacoeconomic literature, including reviews.

STUDY SELECTION

Selected literature evaluating the methodology of health economics studies was used.

CONCLUSIONS

The number of studies presenting a pharmacoeconomic evaluation has increased progressively; however, the quality of the studies has not improved in parallel. The existence of different types of pharmacoeconomic studies does not justify their arbitrary use and the achievement of valid conclusions must be based on sound knowledge of the concepts employed, as well as on use of the most adequate tool in each instance. By evaluating pharmacoeconomic studies systematically, the more common errors (i.e., in planning the study or interpreting the results) can be detected and thus prevented. The checklist we present has 12 sections, each of which includes several subsections. After evaluating the corresponding subsections, each section is labeled as "correct," "acceptable," "doubtful," "incorrect," or "not applicable." From this qualitative evaluation, aspects that have been dealt with correctly and those needing improvement will become apparent. Also, the checklist permits the user to verify whether the results have been correctly obtained and, therefore, whether the conclusions are valid. The use of a checklist for evaluating pharmacoeconomic studies may be useful for researchers, journal editors, and the audience when performing, receiving, reading, or accepting a clinical economic study.