Cost of stroke in Canada: a 1-year prospective study
R Goeree, G Blackhouse, R Petrovic, S Salama
Pages 147-167 ¦ Abstract ¦ PDF (332 KB)

Slof J, Badia X, Lizán L et al
Zoledronic acid versus pamidronate: cost minimization in bone metastasis
J Med Econ 2005; 8: 1-12

The objective of this study was to evaluate the economic and organisational consequences of the substitution of pamidronate with zoledronic acid in the adjunct treatment of bone metastasis in patients with breast cancer and multiple myeloma in a European context.
A cost minimisation analysis was carried out. Clinical data were extracted from clinical trials of pamidronate versus zoledronic acid. Resource consumption and cost data were collected at different Spanish oncology infusion sites.
While the acquisition cost of zoledronic acid is higher compared with pamidronate, zoledronic acid is superior to pamidronate for the treatment of hypercalcaemia of malignancy and in avoiding palliative radiotherapy. Moreover, it is at least as effective as 90 mg pamidronate in reducing skeletal complications in patients with bone lesions from myeloma or breast cancer. It therefore reduced nurse monitoring, occupation of infusion chairs and radiotherapy sessions, implying savings in health care resources. The net of these expenses in switching from pamidronate to zoledronic acid would produce an additional cost of 134.92 euros per patient per year, which is equivalent to 5.1% of the current drug cost of a treatment with pamidronate.
Savings due to the shorter infusion time and the better outcomes of zoledronic acid in avoiding palliative radiotherapy can almost completely compensate its higher acquisition cost compared with pamidronate.

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Sweet B, Tadlock CG, Waugh W, Hess A, Nguyen A
The WellPoint Outcomes Based FormularySM: enhancing the health technology assessment process
J Med Econ 2005; 8: 13-25

The purpose of this paper is to present an overview of the evidentiary and analytical standards recommended by WellPoint Pharmacy Mangement (WPM) in the formulary submission and re-evaluation process for drug products. Given our commitment to the WellPoint Outcomes Based FormularySM, the guidelines emphasise the importance of randomised, active comparator, naturalistic trials in supporting the clinical and cost-effectiveness case for a drug product. In addition, the guidelines emphasise the need to monitor and validate claims made for the product over its life cycle. Whilst modeled cost-effectiveness claims have a place in formulary assessment, any claim must be amenable to empirical evaluation. It is these requirements for naturalistic trials and the assessment of product performance at the health system level that set the WPM guidelines apart. Further, in stating a preference for product performance claims to be expressed in generic cost per quality-adjusted life-year (QALY) terms, WPM is setting a standard for the development of an objective measure to support resource allocation decisions.
In the first part of the paper, WPM’s commitment to the principles of The WellPoint Outcomes Based FormularySM is reviewed, together with the role of monitoring and validation in the assessment of clinical and modeled cost-effectiveness and system impact claims in formulary evaluation. The second part of the paper details the guidelines’ recommendations for new product assessments in terms of: (i) product description and indication; (ii) target population, treatment patterns and place in therapy; (iii) clinical assessment; (iv) cost-outcome assessment and product claims; (v) budget and system impact claims; and (vi) validating and monitoring claims. The third part of the paper details the guidelines’ recommendations for product re-evaluation. These recommendations are assessed in terms of: (i) monitoring and validating initial claims for product performance; and (ii) re-evaluating claims for cost-effectiveness and system impact given changes in the competitive landscape for products and procedures in the disease state and the increased awareness of comparative clinical performance of competing products and procedures.

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Slof J, Badia X, Magaz S, Láinez MJA, Galván J, Heras J
Cost-efficacy of oral triptans in the treatment of acute migraine
J Med Econ 2005; 8: 27-43

The objective of this study was to compare the efficiency of oral triptans currently used in the treatment of acute migraine in Spain. Using a decision analytic model, a cost-efficacy analysis was performed from the payer’s perspective. Efficacy was assessed in terms of sustained pain-free patients, with data extracted from a recent meta-analysis of clinical trials. Chest-related and central nervous system-related adverse events were also considered. For the economic analysis, the cost of drug treatment and the management of adverse events were determined.
A group of three triptans (naratriptan 2.5 mg, sumatriptan 50 mg and almotriptan 12.5 mg) was found to dominate all other triptans in the sense that the other triptans were more expensive but did not show higher efficacy. Naratriptan 2.5 mg offered the lowest cost of the three, while almotriptan 12.5 mg showed the highest level of efficacy. The incremental cost-efficacy ratio for sumatriptan 50 mg versus naratriptan 2.5 mg was 23.09 euros per sustained pain-free patient. The incremental cost-efficacy ration for almotriptan 12.5 mg versus sumatriptan 50 mg was 10.45 euros per sustained pain-free patient.
However, 95% confidence intervals for efficacy and costs of almotriptan 12.5 mg overlapped with those of rizatriptan 10 mg, while 95% confidence intervals of sumatriptan 50 mg overlapped with those of naratriptan 2.5 mg and eletriptan 40 mg. A third cluster of triptans with overlapping confidence intervals, showing higher costs but not higher efficacy than almotriptan 12.5 mg and rizatriptan 10 mg, included sumatriptan 100 mg, zolmitriptan 5 mg and eletriptan 80 mg.
It is concluded that, combining clinical and economic considerations, rizatriptan 10 mg and, particularly, almotriptan 12.5 mg are the most appealing triptans in Spain.

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Dundar S, Zülfikar B, Kavakli K et al
A cost evaluation of treatment alternatives in mild-to-moderate bleeding episodes in haemophilia patients with inhibitors in Turkey
J Med Econ 2005; 8: 45-54

A decision-analysis model was constructed to assess total direct health care costs of four current first-line treatment options for mild-to-moderate bleeding episodes in haemophilia patients with inhibitors in Turkey: recombinant activated Factor VII (rFVIIa); high-dose Factor VIII; prothrombin complex concentrate (PCC); and activated PCC (aPCC). Resource utilization was based on a retrospective analysis of 105 bleeding episodes treated during the period January 1996 to December 2002. Clinical outcomes were derived from a combination of the retrospective patient data and literature review, both validated by an expert panel of Turkish haemotologists. rFVIIa was more effective and resolved bleed more quickly than any of the alternatives. rFVIIa and PCC were associated with similar direct treatment costs that were relatively lower than those compared with the other options. Given the better efficacy, rFVIIa should be considered the preferred treatment option in the management of haemophilia patients with inhibitors in Turkey.

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Pelletier EM, Hernandez J, Clark MA, Justason Lahue B, Reyes CM, Morady F
Medicare costs and health resource utilisation associated with atrial fibrillation in the elderly
J Med Econ 2005; 8: 55-65

The study objective was to quantify health care utilisation and medical costs for Medicare beneficiaries with atrial fibrillation (AF). patients aged £65 years with an AF diagnosis were identified in the Medicare 5% sample Standard Analytic Files between July and December 1998 and followed for 1 year. Total and AF-related resource use and costs were measured from the Medicare payment perspective.
Among 59,648 AF patients, over 50% had a hospital admission during follow-up, and 88% had a physician encounter with a principal AF diagnosis. AF patients incur significant AF-related medical costs, averaging approximately $670 per patient each year. Estimated direct treatment costs to the Medicare Program AF (identified by claims with a principal AF diagnosis) were $797M, whilst overall 1-year costs for all AF patients totaled $14B. These findings have important policy implications for the cost-effectiveness of new treatments that eliminate or reduce the AF burden in Medicare patients.

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Le Pen C, Ligier M, Berdeaux G
Cost-effectiveness and cost-utility analysis of travoprost versus latanoprost and timolol in the treatment of advanced glaucoma in five European countries: Austria, France, Germany, The Netherlands and the United Kingdom
J Med Econ 2005; 8: 67-84

Dickson M, Kozma C, Barron R, Koman LA
Cost of care comparison between cerebral palsy patients treated with botulinum toxin type A and propensity score-matched controls
J Med Econ 2005; 8: 85-95

This analysis compared children with cerebral palsy treated with botulinum toxin type A (BTX-A) versus those not treated with BTX-A to assess the total cost of care and utilisation in a state run Medicaid program in the United States. A retrospective pre/post design was used with nested case-control matching based on propensity scores. Data for the study were extracted from the paid claims for South Carolina Medicaid recipients from 1995 through 2001. Extracted variables included cost of services, procedures performed and diagnoses. It was hypothesised that BTX-A use would not increase the total cost of care but would be related to cerebral palsy diagnosis (e.g. diplegia, hemiplegia, quadriplegia) when demographic covariates (age, race, gender), comorbid conditions (analgesic use, scliosis, hydrocephalus hip dysplasia, mental retardation, seizures) and hospitalisations were controlled. Conditional logistic regression via a Cox regression model was used to estimate the relationship between BTX-A use and the aforementioned variables. A total of 2,364 patients met the study inclusion and exclusion criteria. After 1:6 matching, a total of 406 patients were used in the analyses (58 cases and 348 matched controls). After matching, no significant differences were noted between the groups on any of the study variables. Regression results indicated that cerebral palsy diagnosis, but not cost, was significantly related to BTX-A treatment. The cerebral palsy categories of diplegia (b=2.55; hazard ration [HR]=5.91), hemiplegia (b=5.43; HR=23.88) and quadriplegia (b=4.23; HR=10.22) were all significant in the model (p£0.01). The mean 2-year cost of treatment for BTX-A users (in US$) was $44,761 (SD $56,643) versus $41,553 (SD $57,844) for non-BTX-A users. These results indicate that, over the 24 months studied, BTX0A did not add to the total cost of care. Whilst the number of subjects is small, it represents the entire population of cerebral palsy patients treated over the study period.

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Knight H, Ryan J, Piercy J, Palache AM, Zoellner YF
A European net-monetary benefit analysis of influenza vaccination in the workplace
J Med Econ 2005; 8: 97-110

Influenza is a major worldwide cause of morbidity and mortality, affecting 5-30% of the population per year, and is also a major cause of workplace absenteeism. This net-benefit analysis assesses the costs and cost-svings of a workplace influenza vaccination programme across eight European countries. A decision-analysis model was developed that examined the net benefit of workplace influenza vaccination. The employer perspective was taken, which considered reduction in time off work as the primary endpoint. This study found that vaccinating employees against influenza can produce significant cost-savings for firms. The net saving increased when the attack rate or wage rate was higher, when the duration of absence from work was longer, or when more people took time off work. Workplace vaccination was found to be cost-saving accress the majority of European countries evaluated. In conclusion, a more structured approach towards influenza prevention for the working population in Europe is warranted.

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Macaya C, Danchin N, Vinken A, Tao WT, Haider T
Economic analysis of the use of contrast media during percutaneous coronary interventions in France and Spain
J Med Econ 2005; 8: 111-130

The iso-osmolar contrast medium iodixanol (Visipaque™; GE Healthcare, UK) has been reported to reduce the risk of major adverse cardiac events and to have a higher success rate when used during percutaneous coronary intervention (PCI) compared with the ionic low-osmolar contrast medium ioxaglate (Hexabrix®; Guerbet, France) for patients at risk of complications. This study assessed to what extent these clinical benefits translate into economic benefits for patients undergoing PCI in France and Spain using a decision tree model. Clinical data were derived from the COURT and VIP trials. Medical resource use data were obtained from panels of French and Spanish interventional cardiologists. Resource use was converted to costs using country-specific tariffs. The study results suggest that using iodixanol rather than ioxaglate confers an economic benefit in addition to the reported clinical benefit in high-risk patients undergoing PCI in both countries. For low-risk patients, iodixanol may be regarded as cost-effective when relating the extra cost to the small reported increase in angiographic success.

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Jönsson L, Carides GW, Burke TA et al 
Cost-effective prevention of renal failure in Type 2 diabetics using losartan
J Med Econ 2005; 8: 131-138

A previous clinical trial (RENAAL) has demonstrated that co-administration of losartan, an angiotensin-II-receptor antagonist, with existing conventional antihypertensive therapy (CT) reduces the risk of development of end-stage renal disease (ESRD) in type 2 diabetes patients with nephropathy compared with CT alone.
The objective of this study was to evaluate the effect of losartan and CT compared with CT alone on the economic cost associated with ESRD in the Nordic region.
The analysis was performed separately for Denmark, Finland, Norway and Sweden using country-specific data on practice patterns and costs of modalities of renal replacement therapy. Average medical costs during the first year of ESRD for a diabetic patient were 53,235 euros in the Nordic region. Cost-savings due to reduced ESRD incidence with losartan were 5,591 euros (Denmark), 6,842 euros (Finland), 7,025 euros (Norway) and 6,776 euros (Sweden) per patient over 4 years. The additional cost of losartan during this period was between 1,130 euros and 1,473 euros. Over 4 years, net cost-savings were 4,118 euros (Denmark), 5,395 euros (Finland), 5,720 euros (Norway) and 5,646 euros (Sweden).
The nephroprotective effects of losartan may be associated with important costsavings in the Nordic region.

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Menter A, Baker T
Cost-efficacy analysis of biological treatments in psoriasis: an 18-month assessment
J Med Econ 2005; 8: 139-146

This study compared the cost-efficacy of the following approved biological treatment strategies for plaque psoriasis over 18 months: (1) alefacept 15 mg intramuscularly weekly for two 12-week courses; (2) efalizumab 1 mg/kg subcutaneously (SC) weekly; and (3) etanercept 50 mg SC twice weekly for 12 weeks followed by a maintenance dose of 50 mg weekly. Direct utilisation-related costs included drug costs, office fees, injection fees and costs incurred due to adverse events and laboratory monitoring. Efficacy was based on response rates from large-scale clinical trials. At 18 months, total utilisation-related costs for alefacept, efalizumab and etanercept were $26,667, $33,365 and $32,962, respectively. Cost-efficacy, calculated using the corresponding response rates for the three therapies, was comparable ($66,669, $75,828 and $61,041, respectively). Thus, for patients with moderate to severe psoriasis who have responded to therapy, two 12-week courses of alefacept 7 months apart, or weekly maintenance treatment with efalizumab or etanercept, resulted in comparable total cost-efficacy.

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Goeree R, Blackhouse G, Petrovic R, Salama S
Cost of stroke in Canada: a 1-year prospective study
J Med Econ 2005; 8: 147-167

The objective of this study was to estimate the 1-year cost of stroke for patients in Canada in 2004 and to determine the factors that contribute to this cost. This work was based on a prospective follow-up study of all patients presenting with a stroke or transient ischaemic attack (TIA) to the emergency room in a large teaching hospital over a 6-month prospective period. All healthcare, social services, patient and caregiver resource utilisation attributable to strokes or TIAs were included in the analysis. There were 365 patients who met the inclusion criteria. The average 1-year cost of managing patients with TIA was the lowest at $17,769, followed by ischaemic strokes at $53,576 and haemorrhagic strokes at $56,573. Predictors for 1-year cost were: type of stroke; discharge severity of stroke; death; marital status; discharge destination; and the presence of diabetes and congestive heart failure. Initial hospitalisation costs represented the majority of 1-year costs of stroke. However, caregiver expenses are significant at between 11% and 27% of the total are 1-year cost.

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This study seeks to determine the cost-effectiveness of the FreeStyle Navigator™ continuous glucose monitoring system compared with self-monitoring of blood glucose (SMBG) when predicting hypoglycaemia and hyperglycaemia in pregnant women with insulin-dependent diabetes mellitus. A Markov model was constructed, and initial model analysis demonstrates that use of the FreeStyle Navigator™ by a patient who is trained in diabetes management is more cost-effective than SMBG, resulting in an incremental cost-effectiveness ratio of $267 per quality-adjusted life-month ($3,204 per quality-adjusted life-year). The real-time glucose level rate of change and trend information provided by the FreeStyle Navigator™ allows appropriately trained patients to improve upon decisions regarding self-treatment to prevent hypoglycaemic and hyperglycaemic episodes, resulting in a lower treatment cost and higher effectiveness than untrained patients. Based on current performance attributes, a device such as the FreeStyle Navigator™ would be more cost-effective than other glucose monitoring devices, meeting the $50,000/QALY willingness-to-pay threshold used by payers for adoption of new technology.

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