Volume 7, 2004
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Economic evaluation of MF59 adjuvanted vaccine against influenza in the high-risk
elderly population in France
J Piercy, J Ryan, F Megas
Pages 1-18 ¦ Abstract ¦ PDF (145 KB)
Improvement of headache symptoms and reduction in headache usage in patients
treated with botulinum toxin type A
P McAllister
Pages 19-28 ¦ Abstract ¦ PDF (103 KB)
A cost-utility analysis of adjunctive treatment with newer antiepileptic drugs
in the UK
E Remak, J Hutton, CE Selai, MR Trimble, MJ Price
Pages 29-40 ¦ Abstract ¦ PDF (484 KB)
The longitudinal cost of end-stage renal disease in persons with diabetes in
the United States
DL Manninen, FB Dong, EJ Dasbach, GW Carides, WH Herman, AJ Collins
Pages 41-51¦ Abstract ¦ PDF (178 KB)
Economic evaluation of extended and conventional prophylaxis with enoxaparin
against venous thromboembolism in patients undergoing surgery for abdominal cancer
D Gozzard, J Hutchinson, A Lloyd, A Hutchings
Pages 53-65 ¦ Abstract ¦ PDF (117 KB)
Impact on health outcome and costs of influenza treatment with oseltamivir in
elderly and high-risk patients
B Sander, M Gyldmark, R Aultman, FY Aoki
Pages 67-83 ¦ Abstract ¦ PDF (662 KB)
The clinical and economic impact of pneumacoccal conjugate vaccine associated
herd immunity in Canada
MW Ford, E Grace, ECY Wang
Pages 85-92 ¦ Abstract ¦ PDF (121 KB)
A clinical- and cost-effectiveness comparison of venlafaxine and selective serotonin
reuptake inhibitors (SSRIs) in the management of patients with major depressive
disorder from the perspective of an Austrian sickness fund
P Howard, C Knight
Pages 93-106 ¦ Abstract ¦ PDF (154 KB)
Economic impact of recombinant activated factor VII in the control of bleeds
associated with abdominal prostatectomy
IAO Odeyemi, PW Friedrich, M Levi
Pages 107-115 ¦ Abstract ¦ PDF (137 KB)
Economic modelling of antiplatelet therapy in the secondary prevention of stroke
SM Beard, L Gaffney, L Bamber, J De Platchett
Pages 117-134 ¦ Abstract ¦ PDF (142 KB)
Piercy J, Ryan J Megas F
Economic evaluation of MF59 adjuvanted vaccine against influenza in the high-risk
elderly population in France
J Med Econ 2004; 7: 1-18
It is accepted that routine vaccination of elderly patients against influenza
is a cost-effective strategy. This economic evaluation compares standard vaccination
with MF59 adjuvanted vaccine - an adjuvanted trivalent influenza vaccination -
in the high-risk elderly population in France. A cohort approach was developed
to estimate the costs saved and deaths avoided by using adjuvanted vaccination
in the high-risk elderly. Using the established link between immunogenicity and
protective efficacy, adjuvanted vaccination provides increased efficacy against
influenza-related events, such as hospitalisations, primary care consultations
and death. When the cost of vaccination strategies and influenza-related events
are accounted for, it was found that adjuvanted vaccination results in fewer deaths
and more life-years gained than standard vaccination. This is achieved with relatively
little extra cost. At attack rates approaching 10%, adjuvanted vaccination is
a dominant strategy. This implies that both a reduction in costs and an increase
in benefits is observed. Therefore, on the evidence presented in this paper, the
MF59 adjuvanted vaccine should be the vaccine of choice.
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McAllister P
Improvement of headache symptoms and reduction in headache usage in patients
treated with botulinum toxin type A
J Med Econ 2004; 7: 19-28
The charts of 132 consecutive patients receiving botulinum toxin type A (BoNT-A;
BOTOX®, Allergan Inc, USA) for headache prevention were reviewed retrospectively.
During a follow-up visit, patients reported their overall improvement in headache
symptoms. Headache medication utliisation and costs for the 6 months before and
durign treatment were compared using the Average Wholesale Price. THe mean BoNT-A
dose used was 101.9 units and 131/132 patients (99%) reported some improvement
in headache symptoms. Patients reported an average of 77% improvement in their
headache symptoms from baseline. BoNT-A treatment resulted in a 47.2% reduction
in the use of headache medications. The average monthly cost of all oral headache
medications declined from $242.7 to $89.2, a significant reduction of 63.3% (p<0.001).
A total of 122/132 patients (92.4%) reported no side efects. The costof BoNT-A
treatment appears to be offset to a large degree by the reduction in headache
medication usage. Interpretation of these results is limited by the retrospective,
uncontrolled and open-label design of the analysis.
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Remak E, Hutton J, Selai CE, Trimble MR, Price MJ
A cost-utility analysis of adjunctive treatment with newer antiepileptic drugs
in the UK
J Med Econ 2004; 7: 29-40
A recent review found that economic assessment of epilepsy treatment relies largely
on hypothetical modelling of outcomes and combining these with resource and cost
data from different sources. Prospective evaluations combining cost studies with
outcome assessments are lacking. However, such a prospective observational study
has been carried out previously, but only partially reported. We present a comprehensive
cost-utility analysis of adjunctive newer antiepileptic rugs (AEDs) based on observational
data from that study, and assess the uncertainty of the results using bootstrapping.
A total of 125 patients with intractable epilepsy were recruited. Each patient
was about to start treatment with a new adjunctive AED [clobazam (non-proprietary)
gabapentin (Neurontin®, Parke Davis, UK), lamotrigine (Lamictal®, GlaxoSmithKline,
UK), topiramate (Topamax®, Janssen-Cilag, UK), or vigabatrin (Sabril®, Aventis
Pharma, UK)]. Patients completed semi-structured interviwes on resource use, side
effects, and the EuroQol EQ-5D. Patients were followed up for 6 months. Patient-specific
cost and utility data were analysed separately for each AED on an intent-to-treat
basis. Uncertainty in the estimated incremental cost-utility ratios was quantified
using the non-parametric bootstrap method, and cost-effectiveness acceptability
curves were calculated.
At 6 months, 78 patients were still on their prescribed drug. Only topiramate
and vigabatrin patients showed an increase in EQ-5D scores, and therefore dominated
other AEDs. Topiramate had an incremental cost-effectiveness ration of £7,869/QALY
compared with vigabatrin, and had more than a 50% chance of being optimal if the
ceiling ration was above £10,000/QALY.
Observational studies provide a valuable source of information for the economic
evaluation of AEDs. In this study non-parametric bootstrapping was used to confirm
the cost-effectiveness of adjunctive topiramate for patients with refractory epilepsy.
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Manninen DL, Dong FB, Dasbach EJ, Carides GW, Herman WH, Collins AJ
The longitudinal cost of end-stage renal disease in persons with diabetes in
the United States
J Med Econ 2004; 7: 41-51
The objective of this study was to estimate the longitudinal direct medical costs
associated with end-stage renal disease (ESRD) in persons with diabetes. Data
from the United States Renal Data System for 1997 and 1998 were analysed to estimate
monthly Medicare payments for services provided for the 24-month period beginning
12 months prior to the date of first ESRD service. A tota of 14,254 patients with
diabetes and ESRD were identified for analysis. Medicare payments averaged US$450
per person (95% CI: US$401, US$499) 12 months prior to initiation of dialysis.
In the month before initiation of dialysis, Medicare payments increased to an
average of US$5,210 ((5% CI: US$5,090, US$5,330) per patient. Medicare payments
further increased to an average of US$12,531 per person (95% CI: US$12,368, US$12,695)
for the first month of dialysis - a 28-fold increase compared with 12 months earlier.
Not only are the healthcare costs significant in the year following initiation
of dialysis, but the healthcare costs increase substantially in the year prior
to initiation of dialysis in persons with diabetes.
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Gozzard D, Hutchinson J, Lloyd A, Hutchings A
Economic evaluation of extended and conventional prophylaxis with enoxaparin
against venous thromboembolism in patients undergoing surgery for abdominal cancer
J Med Econ 2004; 7: 53-65
This study assesses the cost-effectivness of extended enoxaparin prophylaxis
(EEP) and conventional enoxaparin prophylaxis (CEP) compared with conventional
unfractionated heparin prophylaxis (CUP) against venous thromboembolism (VTE)
in patients undergoing surgery for abdominal cancer.
A decision tree model compares CEP (enoxaparin 40 mg once daily for 8±2 days),
EEP (CEP plus 21 days outpatient prophylaxis with enoxaparin 40 mg once daily),
and CUP (unfractionated heparin (UFH) 5,000 IU three times daily for 8±2 days).
The primary effectiveness measure was symptomatic VTE. Secondary effectiveness
measures included life-years gained.
CEP was associated with reduced costs and similar rates of symptomatic VTE compared
with UFH. The cost per life year gained with EEP was estimated to be £15,200 compared
with UFH and £22,700 compared with CEP.
Extended prophylaxis reduces symptomatic VTE events but increases cost. In patients
undergoing surgery for abdominal malignancy, conventional prophylaxis with enoxaparin
40 mg once daily was found to be at least as effective as UFH, anc cost saving
at current prices.
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Sander B, Gyldmark M, Aultman R, Aoki FCY
Impact on health outcome and costs of influenza treatment with oseltamivir in
elderly and high-risk patients
J Med Econ 2004; 7: 67-83
The main objective of this study was to evaluate health outcomes and costs to
the healthcare payer of treating influenza with oseltamivir in a high-risk population.
Data from published literature, clinical trials and public sources were used to
develop a decision-analytic model simulating a highrisk population in the UK.
The underlying clinical pathway predicts morbidity and mortality due to influenza,
and its specified complications for the two influenza treatment strategies—oseltamivir
and usual care. Health outcomes (quality-adjusted life years [QALYs], days to
return to normal activity) and costs were estimated for events in the model. Robustness
of the results was tested by probabilistic, univariate and multivariate sensitivity
analyses.
Treatment with oseltamivir within 48 hours results in reduced morbidity, which
translates into faster recovery and return to normal activity. Economic evaluation
showed that treatment with oseltamivir in a high-risk population in the UK is
a cost-effective strategy in all analysed scenarios with cost-utility ratios between
£225 and £17,900 per QALY gained.
Treatment with oseltamivir is effective in terms of health outcome and cost for
highrisk patients from the perspectives of the individual patient and healthcare
payer.
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Ford MW, Grace E, Wang ECY
The clinical and economic impact of pneumococcal conjugate vaccine associated
herd immunity in Canada
J Med Econ 2004; 7: 85-92
Since mid-2001 a heptavalent pneumococcal conjugate vaccine (PCV-7) against seven
common pneumococcal serotypes has been available in Canada. The purpose of this
study was to build upon existing economic evaluations and use recent herd immunity
evidence to estimate the real-world clinical and economic effectiveness of PCV-7
in Canada. Effectiveness trial data evaluating the broad population level benefits
of a PCV-7 programme in the United States (US) was reviewed. Estimates of the
clinical and economic impacts of PCV-7 on adult pneumococcal disease were determined
based on epidemiological and cost data available from the US and Canada. Using
recent effectiveness data demonstrating the herd immunity effect of PCV-7, Canada
could prevent 8,531 cases of adult pneumococcal disease with an estimated reduction
of 51 cases of meningitis, 785 cases of bacteraemia, and 7,695 cases of pneumonia,
respectively. This reduction in adult disease, not only represents a substantial
clinial benefit but is also expected to save an additional Canadian $40 million
from the Canadian healthcare system perspective.
Herd immunity resulting from a universal childhod PCV-7 programme will have a
substantial clinical and economic impact on populations ›/=20 years of age, therby
making PCV-7 a clinically important and cost-saving intervention for the Canadian
healthcare system.
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Howard P, Knight C
A clinical- and cost-effectiveness comparison of venlafaxine and selective serotonin
reuptake inhibitors (SSRIs) in the management of patients with major depressive
disorder from the perspective of an Austrian sickness fund
J Med Econ 2004; 7:93-106
This study evaluated the relative clinical- and cost-effectiveness of venlafaxine
(Efectin®, Wyeth Pharmaceuticals, Austria) extended release (ER), venlafaxine
instant release (IR) and selective serotonin reuptake inhibitors (SSRIs) in the
treatment of major depressive disorder. The study took an Austrian sickness fund
perspective and the evaluation originally formed part of a reimbursement submission
of venlafaxine ER to the Hauptverband - an umbrella organisation representing
the Austrian sickness funds.
At the time of the submission venlafaxine IR was reimbursed but published data
and clinical practice suggested that it might be clinically inferior, less concneient
and less acceptable to patients than the newer ER formulation. We believe this
is the first study to directly compare the two venlafaxine formulations.
Major depressive disorder is a serious mental illness associated with considerable
morbidity and a significant economic burden. An extensive literature review was
carried out to retrieve the relevant clinical data and a meta-analysis of the
homogeneous data was undertaken to establish the most clinically effective first-line
treatment. An Austrian Delphi panel was used to provide treatment pattern data
and to estimate oputcomes for patients undergoing further lines of treatment.
A 16-week time horizon was adopted and decision analysis was employed to model
the cost-effectiveness of the respective agents.
Venlafaxine ER was found to be the most clinically effective antidepressant in
terms of symptom-free days (SFDs) with 32 SFDs. SSRIs as a class were the least
clinically effective with 27 SFDs. This does not suggest that one treatment should
be used to the detriment of another as patients will need the option to switch
treatments, possibly many times, before symptom control is achieved. Rather it
suggests that clinically effective treatments are available as options to patients
and physicians, so that the maximum opportunity for clinical remission is possible.
When the treatments were compared from a cost-effectiveness perspective, venlafaxine
ER, despite having the highest acquisition cost, was the most cost-effective intervention,
with an incremental cost of €2.11 to achieve an additional SFD.
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Odeyemi IAO, Friedrich PW, Levi M
Economic impact of recombinant activated factor VII in the control of bleeds
associated with abdominal prostatectomy
J Med Econ 2004; 7: 107-115
Trans-abdominal prostatectomy—often the treatment of choice for otherwise healthy
patients with clinically localised prostate cancer—is associated with considerable
bleeding. This can result in the need for blood transfusion. However, the increasing
cost of blood, safety fears, and the pressure on available blood stock are leading
to efforts to reduce or eliminate blood transfusion, where possible, in elective
surgery settings.
The objective of this study was to explore the economic impact of a recent doubleblind
placebo-controlled dose-escalating, randomised clinical trial, which showed that
a single injection of recombinant factor VIIa (rFVIIa; NovoSeven®*) could reduce
perioperative blood loss and eliminate the need for transfusion in patients undergoing
abdominal prostatectomy.
We modelled the clinical outcomes of the three patient groups in the original
trial and applied unit costs from the Netherlands (where the trial took place)
to the mean resource use associated with the treatment groups. The mean cost of
abdominal prostatectomy for the placebo group, a lower dose rFVIIa group (20 µg/kg)
and a higher dose rFVIIa group (40 µg/kg) was 9,602 euros (US$11,527), 9,958 euros (US$11,954)
and 9,522 euros (US$11,430), respectively. The model was sensitive to the number
of packed cells for the placebo group, unit cost of packed cells and the unit
cost of rFVIIa.
Our study concludes that, compared with placebo, the use of rFVIIa at 40 µg/kg
as a haemostatic agent in abdominal prostatectomy lowers overall treatment costs
and reduces surgery time by conferring transfusion freedom. The potential for
such clinical and economic outcomes in other surgical settings should be explored
in more extensive studies.
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Beard SM, Gaffney L, Bamber L, De Platchett J
Economic modelling of antiplatelet therapy in the secondary prevention of stroke
J Med Econ 2004; 7: 117-134
We used a UK-based health economics model to focus on preventative treatment
in patients surviving acute stroke-related events. The health state transition
model considered clinical recurrent events based on non-fatal transient ischaemic
attacks, non-fatal other vascular events, and further acute strokes. Treatment
was compared based on modified-release (MR) single agent dipyridamole, MR dipyridamole
in combination with aspirin (Asasantin® Retard*), low-dose aspirin (ASA), clopidogrel
(Plavix®*), and placebo.
Resource use and unit cost data were based on a survey of UK-based clinicians
and standard national cost sources for 2002. Compared to aspirin, Asasantin® Retard
was associated with 29 fewer strokes over a 5-year period for every 1,000 patients
treated, at an additional cost per treated patient of £64. This equated to a cost
per avoided stroke of £2,255, and cost per life year gained of £5,103. Overall,
the analysis suggests that Asasantin® Retard provides additional benefits over
aspirin, and has a favourable cost-effectiveness profile.
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