Drug Acquisition Costs Research Articles

Cost-minimization analysis of two fluid products for resuscitation of critically injured trauma patients

Results of a study to determine potential cost benefits of substituting an alternative electrolyte solution for 0.9% sodium chloride injection for the initial fluid resuscitation of trauma patients are presented. Using data from a randomized clinical trial that compared 24-hour fluid resuscitation outcomes in critically injured trauma patients treated with 0.9% sodium chloride injection and those who received a balanced electrolyte solution (Plasma-Lyte A, Baxter Healthcare), a cost-minimization analysis was performed at a large medical center. The outcomes evaluated included fluid and drug acquisition costs, materials and nurse labor costs, and costs associated with electrolyte replacement. The use of Plasma-Lyte A was associated with a relatively higher fluid acquisition cost but a reduced need for magnesium replacement. During the first 24 hours of hospitalization, 4 of 24 patients (17%) treated with 0.9% sodium chloride injection and none of the patients who received the comparator product (n = 22) required supplemental magnesium. Patients treated with 0.9% sodium chloride injection received a median of 4 g of magnesium (interquartile range [IQR], 2.5-4.0 g), compared with a median of 0 g (IQR 0-2 g) in the comparator group. Taking into account the costs of consumable supplies and nursing labor, the cost-minimization analysis indicated a 24-hour cost differential of $12.35 in favor of Plasma-Lyte A. Substitution of Plasma-Lyte A for 0.9% sodium chloride injection for fluid resuscitation during the first 24 hours after traumatic injury was associated with decreased magnesium replacement requirements and a net cost benefit to the institution.

CP-122 Medicine costs analysis in haemodialysis

BackgroundThe management of anaemia and secondary hyperparathyroidism (SHPT) in haemodialysis patients with chronic kidney disease means a significant consumption of drugs with high economic and health consequences.PurposeTo evaluate the potential...

Barriers and facilitators of thromboprophylaxis for medical-surgical intensive care unit patients: A multicenter survey

BackgroundThe objective of this study was to identify the self-reported barriers to and facilitators of prescribing low-molecular-weight heparin (LMWH) thromboprophylaxis in the intensive care unit (ICU). MethodsWe conducted an interviewer-administered survey of 4 individuals per ICU (the ICU director, a bedside pharmacist, a thromboprophylaxis research coordinator, and physician site investigator) regarding LMWH thromboprophylaxis for medical-surgical patients in 27 ICUs in Canada and the United States. Items were generated by the research team and adapted from previous surveys, audits, qualitative studies, and quality improvement research. Respondents rated the barriers to LMWH use, facilitators (effectiveness, affordability, and acceptability thereof), and perceptions regarding LMWH use. ResultsRespondents had 14.5 (SD, 7.7) years of ICU experience (response rate, 99%). The 5 most common barriers in descending order were as follows: drug acquisition cost, fear of bleeding, lack of resident education, concern about bioaccumulation in renal failure, and habit. The top 5 rated facilitators were preprinted orders, education, daily reminders, audit and feedback, and local quality improvement committee endorsement. Centers using preprinted orders (mean difference [P<.01]) and computerized physician order entry (P<.01) compared with those centers not using those tools reported higher affordability for these 2 facilitators. Compared with physicians and pharmacists, research coordinators considered ICU-specific audit and feedback of thromboprophylaxis rates to be a more effective, acceptable, and affordable facilitator (odds ratio, 6.67; 95% confidence interval, 1.97-22.53; P<.01). Facilitator acceptability ratings were similar within centers but differed across centers (P≤.01). ConclusionsThis multicenter survey found several barriers to use of LMWH including cost, concern about bleeding, and lack of resident knowledge of effectiveness. The diversity of reported facilitators suggests that large scale programs may address generic barriers but also need site-specific interprofessional knowledge translation activities.

An indirect treatment comparison (ITC) and cost-effectiveness analysis of abiraterone acetate and enzalutamide for the treatment of metastatic castration-resistant prostate cancer (mCRPC) post-chemotherapy.

270 Background: Abiraterone acetate (AA) and enzalutamide (ENZ) are two new agents indicated for the treatment of patients with mCRPC. Presently, there is a high level of interest in understanding the relative clinical and economic value of these therapies. The objective of this study was to determine the comparative effectiveness and cost-effectiveness of AA vs. ENZ. Methods: The PICO (population, intervention, comparison, and outcomes) construct was used to assess the comparability of Study COU-AA-301 for AA and the AFFIRM trial for ENZ, and an ITC was conducted using the Bucher method and Bayesian statistics. A survival-based Markov cohort model with three health states (progression-free, progressed, and death) was developed to project cost-effectiveness over a life time horizon. Since only the US price of ENZ was publicly available at the time of analysis, US drug acquisition costs were used. Average wholesale prices for 30-day supplies of AA and ENZ were $7,674 and $8,940, respectively. One-way sensitivity analyses were performed for all probability, utility, and cost values incorporated into the model. Results: The ITC result on overall survival (OS) was HR = 0.95 (95% CI: 0.71-1.26) for AA vs. ENZ on the risk of mortality, after accounting for important differences in comparators and background treatments. In the base case of the economic analysis, AA was found to provide a substantial cost savings of $13,322 per patient vs. ENZ, primarily due to higher acquisition costs. Quality adjusted life years gained were comparable for AA and ENZ. These results were supported by sensitivity analyses. Conclusions: While benefits are similar for OS, AA is cost-saving compared with ENZ for the treatment of patients with mCRPC following treatment with docetaxel.

Anti hypertensive prescribing patterns and cost analysis for primary hypertension: a retrospective study.

The present study was conducted to analyze the current prescription pattern and cost analysis of antihypertensive drugs in hypertensive patients in a tertiary care hospital. A retrospective cross-sectional study was conducted in tertiary care hospital, Bangalore for three months and utilized 300 prescriptions for the analysis. The data analysed from the prescription included patients demographics, stage of hypertension according to JNC VII guidelines, type of drug therapy, class of anti-hypertensive, and cost effectiveness of therapy. Drug acquisition costs was calculated, using the cost of the cheapest available drug and the most commonly prescribed dosage, for each drug on a daily and annual basis. Total annual drug expenditure on buying required doses of all antihypertensive prescribed in the study population for a year was calculated. Monotherapy (48.94%) was leading trends of antihypertensive therapy followed by fixed dose combination (35.04%) and polytherapy (16.01%). The most frequent antihypertensive class to be prescribed were CCBs (38.59%) followed by beta blockers (24.07%). The ranking in terms of cost utilized per year from the highest to the lowest found in this study was: alpha blockers> ACE-inhibitors> ARBs> CCBs> beta blockers > diuretics. The diuretics were most cost-effective (Cost per day: 5.89 ± 2.87; Cost per year: 2129.02 ± 1080.49) in relation to the other antihypertensive prescribed.

EPA-0989 – Cost-effectiveness of atypical antipsychotics (quetiapine, risperidone, aripiprazole or olanzapine) for the treatment of relapse prevention for bipolar disorder in russian federation

To estimate the efficiency of the atypical antipsychotics (quetiapine, risperidone, aripiprazole or olanzapine) used to reduce relapses in bipolar disorder, taking into account costs and effectiveness (QALY). The Russian health care system perspective and a five year temporal horizon have been used. An annual discount rate assumed was of 5%. Taking into account the last literature review on bipolar disorder, four fundamental aspects related with bipolar disorder management were analyzed: relapse rates, inpatient treatment, outpatient treatment and hospitalization rates. The health care direct costs corresponding to the drug acquisition costs have been analyzed together with the costs of inpatient diagnostics, costs of inpatient treatment and costs of hospitality relapses updated with data from Russian health care system. Quetiapine or risperidone treatment presents the lower total costs (€13 562 and €13 097 respectively) versus the other strategies (aripiprazole = €36 328 and olanzapine = €19 957). Quetiapine presents the higher QALY compared with the alternatives (quetiapine = 3.551, risperidone = 3.534, aripiprazole = 3.528 and olanzapine = 3.525). With these results one can emphasize that quetiapine or risperidone treatment is dominant with the cost-effectiveness ratio (CER) of 3 819 and 3 706, respectively, versus aripiprazole or olanzapine groups (CER 10 297 and 5 662 respectively). The incremental CER (quetiapine vs. risperidone) is €27 322 per QALY. The results illustrate that quetiapine is dominant versus aripiprazole or olanzapine. Also quetiapine therapy is within willingness to pay threshold in case of risperidone substitution in Russian patients with bipolar disorder

Economic evaluation of rivaroxaban in stroke prevention for patients with atrial fibrillation in Greece

BackgroundTo undertake an economic evaluation of rivaroxaban relative to the standard of care for stroke prevention in patients with non-valvular atrial fibrillation (AF) in Greece.MethodsAn existing Markov model designed to reflect the natural progression of AF patients through different health states, in the course of three month cycles, was adapted to the Greek setting. The analysis was undertaken from a payer perspective. Baseline event rates and efficacy data were obtained from the ROCKET-AF trial for rivaroxaban and vitamin-K-antagonists (VKAs). Utility values for events were based on literature. A treatment-related disutility of 0.05 was applied to the VKA arm. Costs assigned to each health state reflect the year 2013. An incremental cost effectiveness ratio (ICER) was calculated where the outcome was quality-adjusted-life year (QALY) and life-years gained. Probabilistic analysis was undertaken to deal with uncertainty. The horizon of analysis was over patient life time and both cost and outcomes were discounted at 3.5%.ResultsBased on safety-on-treatment data, rivaroxaban was associated with a 0.22 increment in QALYs compared to VKA. The average total lifetime cost of rivaroxaban-treated patients was €239 lower compared to VKA. Rivaroxaban was associated with additional drug acquisition cost (€4,033) and reduced monitoring cost (-€3,929). Therefore, rivaroxaban was a dominant alternative over VKA. Probabilistic analysis revealed that there is a 100% probability of rivaroxaban being cost-effective versus VKA at a willingness to pay threshold of €30,000/QALY gained.ConclusionRivaroxaban may represent for payers a dominant option for the prevention of thromboembolic events in moderate to high risk AF patients in Greece.

Abstract P6-07-12: Should adjuvant zoledronic acid be used in early-stage, endocrine-sensitive breast cancer?

Abstract Introduction: Adjuvant zoledronic acid (ZA) appears to improve disease-free survival (DFS) in women with endocrine-sensitive breast cancer and low estrogen levels (LEL) including post-menopausal women, and pre-menopausal women treated with LHRH agonists. ZA, however, is also associated with potential adverse events and incremental drug acquisition costs. An overall assessment of the long-term clinical and economic impacts of adjuvant ZA may therefore help guide the decision to adopt this novel therapeutic option. We examined the incremental quality-adjusted life-years (QALY) and costs per QALY associated with adjuvant treatment including ZA relative to treatment without ZA in women with endocrine-sensitive breast cancer and LEL. Methods: A Markov model was developed to compute cumulative costs, from a Canadian perspective, and QALY associated with and without adjuvant ZA over a 25-year horizon. Costs, utilities, DFS and adverse events were derived from relevant clinical trials, the literature and local resources. One-way and probabilistic sensitivity analyses were conducted for key model parameters. Results: Adjuvant ZA was associated with incremental QALY gains of 0.62 and 0.42 and resultant CU estimates of $12,617 and $19,775 per QALY gained in pre- and post-menopausal women, respectively. CU estimates were robust across reasonable uncertainty ranges in all parameters. Conclusions: Adjuvant ZA appears to be associated with long-term QALY gains in women with endocrine-sensitive breast cancer and LEL as well as CU estimates that are below commonly accepted North American thresholds. The favourable long-term clinical and economic impacts observed in this study further support the use of adjuvant ZA in this setting. Citation Information: Cancer Res 2013;73(24 Suppl): Abstract nr P6-07-12.

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Introduction: Eptifibatide is a potent intravenous platelet glycoprotein IIb/IIIa inhibitor administered as adjunctive therapy with percutaneous coronary intervention (PCI). Since the introduction of dual antiplatelet therapy loading before PCI, it is uncertain whether an 18-hour eptifibatide infusion is of value in decreasing thrombotic complications. In June 2009, our institution implemented a protocol change for patients to receive a total infusion of 1 vial (4–18 hours) of eptifibatide. The goal of this study was to evaluate the impact on clinical outcomes and drug cost associated with this shortened eptifibatide infusion as adjunctive therapy for PCI. Methods: A retrospective cohort analysis was conducted comparing patients who received the shortened duration eptifibatide infusion (June 2009 to December 2011) to patients prior to the protocol change (January 2007 to May 2009). Primary endpoints were in-hospital cardiovascular events (death, myocardial infarction, coronary artery bypass, or stroke), target vessel revascularization and major or minor bleeding (major bleeds were any central nervous system, retroperitoneal, gastrointestinal bleed, or the requirement of blood transfusion; minor bleeds were any hematoma or vascular access bleed). The secondary endpoints were 30 day survival and drug acquisition cost represented as average wholesale price. Results: 2884 unique patients were studied with 1647 (57.1%) enrolled in the standard duration group (18–24 hours) and 1237 (42.9%) enrolled in the short duration group. The median infusion time was 18.1 hours (IQR 17.7–18.7) vs. 6.6 hours (IQR 5.6–11.3) in the standard and short duration groups, respectively. Comparing standard and short duration found no differences for rate of in-hospital cardiac events (2.00% vs. 1.86%, respectively; P = 0.78) or in-hospital revascularization (0.24% vs. 0.32%, respectively; P = 0.68). Also, no statistically significant difference was observed in major bleeding (standard 4.3% vs. short 4.4%; P = 0.94) or minor bleeding (standard 3.3% vs. short 2.3%; P=0.09). Employing a shortened infusion reduced eptifibatide use by 1–2 vials (75 mg vial) at cost savings of $388 to $776 per patient in this study. Conclusions: Implementing a protocol that reduced the duration of eptifibatide infusion as adjunctive therapy for PCI provided significant drug cost savings without a significant change in the rates of in-hospital cardiac events or bleeding.

Adjusting For Drug Wastage In Economic Evaluations Of New Therapies For Hematologic Malignancies: A Systematic Review Of The Literature and Implications

The cost of cancer care is rising to levels that appear unsustainable, in large part driven by a rapid increase in expenditures for novel therapies. In 2005, the direct costs of cancer care in the United States were $74 billion, with a prediction that these figures will double this decade as the population ages and we enter an age of biologically-tailored drug development. Historically, the evaluation of the cost-effectiveness of new drug therapies presumes that every milligram of drug is effectively utilized. With manufacturers dictating the availability of vial sizes for parenteral drugs, however, this may not be the case. A recent single-institution study in Canada estimated that an annual loss of $150 000 ($CDN) could be attributed to drug wastage of a parenteral therapy for myelodysplasia (Walker et al., Can J Hosp Pharm 2012). Whether current economic evaluations routinely model the potential for drug wastage, or the strategies to mitigate wastage, has not previously been determined.We sought to identify the frequency of drug wastage modeling in economic evaluations of modern parenteral therapies for hematologic malignancies. All US Food and Drug Administration (FDA) approved parenteral therapies from 2006-2013 (n=14) were identified for review. A systematic review of published English-language economic evaluations for these therapies was conducted and data on the conduct of the cost-analyses were extracted in duplicate. The primary outcome was the proportion of studies that explicitly modeled drug wastage in the base-case analysis, with results presented descriptively. Where possible, we calculated the impact of wastage on incremental cost-effectiveness ratios (ICERs) and drug acquisition costs.Thirty-three publications were retrieved; five of these studies were excluded (3 were non-English language and 2 were review articles). Of the remaining 27 reports, 3 were publicly-funded health technology assessments (HTAs) to inform funding decisions by the UK National Institute for Health and Care Excellence (NICE) and the remainder (n=24) were peer-reviewed publications. Sixteen economic evaluations were of rituximab-based regimens and 6 were bortezomib-based.Drug wastage was considered in the primary or base-case analysis in one third of the publications (9 of 27; 33%); wastage was considered in 2 of the 3 HTAs (67%) and 7 of the 24 peer-reviewed reports (29%). Of the 9 models that considered wastage in the base-case analysis, 2 completed sensitivity analyses in which no drug wastage occurred (i.e. vial sharing between patients). In both studies, consideration of wastage changed the calculated ICER. In one study, the ICER increased by 32% when wastage was incorporated into drug acquisition costs. In the second study, azacitidine (AZA) was compared to decitabine (DEC) for myelodysplasia, with both drugs provided as single-use vials and subject to substantial wastage. When no drug wastage was modeled, AZA was associated with higher costs than DEC (+$2 655 USD) and yielded an ICER of $15 528/QALY. When wastage for both drugs was considered, AZA was associated with lower costs (-$15 890) and AZA dominated DEC. Of the 18 publications that did not model wastage in the primary analysis, no study went on to model wastage in sensitivity analyses. In 4 of these 18 studies, the potential effect of wastage on drug acquisition costs could be calculated from data provided in the publication. The calculated drug acquisition costs if wastage occurred would potentially be +5-16% higher (mean +9%) than the costs modeled in the base-case analyses of these 4 studies.The potential costs associated with drug wastage are considered in only one third of modern cost-effectiveness models. The impact of wastage on calculated ICERs and drug acquisition costs is potentially substantial. The modeling of wastage in base-case and sensitivity analyses is recommended for future economic evaluations of new intravenous therapies for hematologic malignancies. Disclosures:No relevant conflicts of interest to declare.

Cost-minimization analysis of pemetrexed/carboplatin with maintenance pemetrexed (PemC) versus paclitaxel/carboplatin/bevacizumab with maintenance bevacizumab (PCB) in nonsquamous non-small cell lung cancer (NS-NSCLC).

263 Background: The PRONOUNCE trial was a phase III, randomized, open-label U.S. study comparing pemetrexed (PemC) with bevacizumab (PCB) in the treatment of advanced chemo-naive nonsquamous non-small cell lung cancer (NS-NSCLC). The primary endpoint of improved PFS without grade 4 toxicity for PemC over PCB was not met. There were no differences in PFS or OS. This analysis was conducted to estimate differences in costs of treatment and related patient care between the groups to inform evidence-based treatment decision making. Methods: A cost-minimization analysis was performed using data from the PRONOUNCE trial and publically available U.S. unit costs. Drug costs modeled included induction, maintenance, and subsequent therapies. Other estimated medical costs were drug administration, concomitant medications, and treatment of grade 3/4 toxicities. A probabilistic sensitivity analysis (PSA) was conducted to model joint uncertainty associated with model parameters. Results: The average cost of treatment with PemC was $4,689 less than PCB ($30,334 vs $35,024). Drug acquisition and administration costs were less in all modeled settings (induction, maintenance, and subsequent lines) for PemC. Costs associated with concomitant medications and grade 3/4 toxicities were similar ($13,286 vs $13,738). PemC was cost saving in 99% of 10,000 PSA iterations. Conclusions: Based on the PRONOUNCE trial and model results, PemC may present a similarly effective but less costly treatment option for patients in the United States compared with PCB. While treatment decision making should consider the overall safety profile and patient preferences, this study provides estimates of the costs of treatment of these two therapeutic options. The analysis was based on clinical trial data; therefore, the results may not be generalizable to all patients. [Table: see text]

PCN108 - Abiraterone Acetate Versus Enzalutamide for Metastatic Castration-Resistant Prostate Cancer Post Chemotherapy: Cost Effectiveness Analysis

With approvals of abiraterone acetate (AA) and enzalutamide (ENZA) in the past 2 years, the treatment landscape has shifted dramatically for metastatic castration-resistant prostate cancer (mCRPC) patients who failed docetaxel-based chemotherapy. There is increasing interest in the relative cost-effectiveness of these therapies. The objective of this study was to assess the cost-effectiveness of AA versus ENZA among individuals with mCRPC post chemotherapy from a payer perspective. A survival-based Markov cohort model consisting of 3 health states, progression-free, progressed, and dead, was developed to project over 10 year period. Progression between states was determined by overall survival (OS) and radiographic progression free survival (rPFS). An indirect treatment comparison was conducted to determine the relative efficacy of AA and ENZA (data reported separately). Utilities were mapped from FACT-P to EQ-5D based on a review of the literature. Drug acquisition costs in the US were used since ENZA was approved only in the US at the time of analysis. Costs of scheduled and unscheduled follow-up visits were obtained from the Centers for Medicare Services Drug Payment Table and Physician Fee Schedule and represented in 2013 US dollars. Average wholesale prices for a 30-day supply of AA and ENZA were $7,674 and $8,940, respectively. One-way sensitivity analyses were performed against all probability, utility, and cost values incorporated into this cost-effectiveness model. In this analysis, AA provides substantial saving with $13,322 per patient versus ENZA. The main drivers of the model are drug costs, health utility values, and efficacy (OS and rPFS). The robustness of the results was supported by sensitivity analyses. Given similar OS benefits, AA is cost saving compared with ENZA for the treatment of patients with mCPRC post-docetaxel based on US data.

PIN27 - The Cost of Stopping (Futility) Rules Telaprevir and Boceprevir in the Treatment of Genotype 1 Hepatitis C Patients in Brazil

To estimate the cost of treatment discontinuation due to label stopping (futility) rules of telaprevir (TVR) and boceprevir (BOC) triple therapy in Brazilian public (SUS) and private health care system (SS). Treatment costs considered drug acquisition costs from a public and private payer perspective in Brazil. Stopping rules (SR) were defined according to the label of each drug. For TVR the SR were defined at week4 (SR WK4) and at week 12 (SR WK12) as viral load (VL) > 1.000 IU/ML. For BOC, SR were defined at week 12 (SR WK12) as VL >100 UI/mL and at week 24 (SR WK24) as detectable VL. Patients eligible for the SR were gathered for naïve and experienced patients from the respective phase 3 trials. As data for SR WK24 was not published for BOC in naïve patients it was assumed to be the same as SR WK12 and a deterministic sensitivity analysis was carried out. Under the SUS perspective, the average cost of naïve patients interrupting treatment with TVR was R$ 670 compared to an average cost of R$ 3.396 per interrupted treatment with BOC, and for treatment experienced patients, TVR had an average cost of R$ 352 compared to an average cost of R$ 3.041 for BOC per patient meeting the SR. Under the SS perspective, TVR had an average cost of R$ 1.433 per interrupted naïve treatment and R$ 753 per interrupted treatment in experienced patients and BOC had an average treatment cost of R$ 8.305 per naïve patient interrupting treatment and R$ 4.753 per interrupted treatment in experienced patients. BOC had higher costs associated with treatment futility when compared to TVR, especially in treatment experienced patients, in both the public and private health care systems in Brazil.

PUK22 - Cost-Effectiveness of Mirabegron Compared with Antimuscarinics for the Treatment of Patients with Overactive Bladder in the United Kingdom

Mirabegron is a first-in-class beta-3 adrenoceptor agonist for the treatment of overactive bladder (OAB) that demonstrated superior efficacy compared to placebo by reducing OAB symptoms and improving HRQoL. We sought to assess the cost-effectiveness of mirabegron 50 mg in comparison with current antimuscarinics for the treatment of patients with OAB in the UK. A Markov model was developed to simulate the therapeutic management, the changes in symptoms (micturitions and incontinence), and complications in hypothetical cohorts of OAB patients. The model was used to predict costs and QALYs over 5 years in cohorts initially treated with antimuscarinics or mirabegron 50mg. Effectiveness and safety data were based on the results from a mixed treatment comparison (MTC). A calibration approach was used to derive transition probabilities from mean changes in frequency of micturitions and incontinence episodes. Other input data were obtained from several sources, including scientific literature and expert opinions. Costs were evaluated from the UK National Health Service (NHS) perspective and included costs of drug acquisition, GP visits, specialist visit, incontinence pad use and botox injections. Utilities were obtained from equations predicting EQ-5D index scores according to symptom severity, estimated from a clinical trial of Mirabegron. The Mirabegron strategy was slightly more expensive and associated with a greater number of QALYs, as a result of improved persistence, related to a lower risk of adverse event compared to each antimuscarinic. Mirabegron 50mg was found to be cost-effective compared to each antimuscarinic, with an ICER of £340 vs. solifenacin 10mg, £3,607 versus fesoterodine 4mg, £3,715 vs. tolterodine ER 4mg, £3,878 vs. oxybutynin ER 10mg, £8,881 versus trospium chloride MR 60 mg, £12,493 versus solifenacin 5mg, and £14,234 oxybutynin IR 10mg. Treatment with mirabegron appears to be a cost-effective strategy compared with antimuscarinics from a UK NHS perspective.

PCV93 - Cost-Effectiveness Analysis of Atorvastatin Compared to Simvastatin in the Prevention of Cardiovascular Diseases in the Czech Republic

To assess the impact of atorvastatin compared to simvastatin use in the Czech Republic on cardiovascular diseases (CVD), Life-Years Gained (LYG) and Quality-Adjusted Life Years (QALY), based on the real proportional consumption of both statins in particular strengths (10 mg, 20 mg, 40 mg). Life-time cost-effectiveness Markov cohort model was developed with 1 year cycle length and 5 health sates, i.e. Alive without CVD, Alive with experience of CVD, Non-fatal CVD, Fatal CVD and Death. The probability of transition among health states were derived from Framingham equations or from SCORE equations (probability of the first non/fatal CVD), Czech life-tables (background mortality) and international cohort studies (probability of subsequent CVD). Patients enter the model with base-line risk characteristics: age, proportions of males, diabetics, smokers, level of systolic blood pressure and cholesterol (total and HDL) level. The efficacy data for particular statin and its strength were derived from latest meta-analyses. Drug acquisition costs of atorvastatin 10 mg and 20 mg were 10% higher compared to simvastatin 20 mg and 40 mg. The costs of fatal, non-fatal CVD and one-year follow-up after CVD were 1,410 EUR, 1,460 EUR and 580 EUR. Probabilistic sensitivity analysis (PSA) using a willingness to pay (WTP) threshold equal to 1 times GDP per capita (14,300 EUR) was applied. Over a life-time horizon, atorvastatin compared to simvastatin provides 8.14 QALYs vs. 8.07 QALYs, 11.33 LYG vs. 11,24 LYG, 44.8% vs. 46.3% of non-fatal CVD and 28.2% vs. 29.4% of fatal CVD. The increment of total costs was 330 EUR for atorvastatin, ICER for atorvastatin vs. simvastatin was then 4,720 EUR/ QALY. The use of atorvastatin generates 0.07 QALYs more compared to simvastatin per patient in the Czech Republic. There is a 98.5% probability of atorvastatin being cost-effective at the selected WTP.

Cost-effectiveness analysis of treatment with peginterferon-alfa-2a versus peginterferon-alfa-2b for patients with chronic hepatitis C under the public payer perspective in Brazil.

BackgroundChronic hepatitis C affects approximately 170 million people worldwide, and thus being one of the main causes of chronic liver disease. About 20% of patients with chronic hepatitis C will develop cirrhosis over 20 years, and present an increased risk of developing hepatic complications. Sustained virological response (SVR) is associated with a better prognosis compared to untreated patients and treatment failures.The objective of this analysis was to compare treatment costs and outcomes of pegylated interferon-alfa-2a versus pegylated interferon-alfa-2b, both associated with ribavirin, in the therapeutic scheme of 24 weeks and 48 week for hepatitis C genotypes 2/3 and genotype 1, respectively, under the Brazilian Public Health System (SUS) scenario.MethodsTo project disease progression, a Markov model was built based on clinical stages of chronic disease. A Delphi panel was conducted to evaluate medical resources related to each stage, followed by costing of related materials, services, procedures and pharmaceutical products. The evaluation was made from a public payer perspective. The source used for costing was government reimbursement procedures list (SAI/SIH–SUS). Drug acquisition costs were obtained from the Brazilian Official Gazette and “Banco de Preços em Saúde” (government official source). It was assumed a mean patient weight of 70 kg. Costs were reported in 2011 Brazilian Reais (US$1 ≈ $Brz1.80). A systematic review followed by a meta-analysis of the 7 identified randomized controlled trials (RCTs) which compared pegylated interferons, was conducted for obtaining relative efficacy of both drugs: for genotype 2/3, mean rate of SVR was 79.2% for peginterferon-alfa-2a and 73.8% for peginterferon-alfa-2b. For genotype 1, SVR mean rate was 42.09% versus 33.44% (peginterferon-alfa-2a and peginterferon-alfa-2b respectively). Time horizon considered was lifetime. Discount rate for costs and outcomes was 5%, according to Brazilian guidelines for Health Technology Assessment (HTA).ResultsAnalysis showed that peginterferon-alfa-2a is a dominant therapy compared to peginterferon-alfa-2b for genotype 1 ($Brz 4,345 savings and 0.10 LY/0.25 QALY gains) as well for genotype 2/3 ($Brz 8,001 savings and 0.16 LY/0.39 QALY gains). Projections indicated that for each 1000 patients treated with peginterferon-alfa-2a instead of peginterferon-alfa-2b, the amount of resources saved would be of $Brz 4.3 million for genotypes 2/3 and up to $Brz 8 million for genotype 1.ConclusionThese findings suggest that treatment with peginterferon-alfa-2a is more effective and less costly when compared to peginterferon-alfa-2b under SUS perspective in Brazil.

Implementation of antipsychotic selection recommendations at a veterans affairs facility

Introduction: In 2012, the Veterans Affairs (VA) Pharmacy Benefits Management Services created recommendations for antipsychotic selection in schizophrenia and schizoaffective disorders. The recommendations stated that patients must fail two first line agents (haloperidol, loxapine, quetiapine, risperidone or perphenazine) and clozapine (if appropriate) before being allowed to trial second line agents olanzapine, ziprasidone or aripiprazole. The aim of this project was to determine the amount of cost savings that could have been provided had the above recommendations been implemented last year. Use of second generation antipsychotics has been associated with weight gain, diabetes, and worsening lipid profiles. The American Diabetes Association (ADA) has created guidelines regarding cardiometabolic monitoring of second generation antipsychotic agents. A secondary aim of this project was to determine the rate of provider adherence to the ADA recommendations. Methods: A retrospective chart review was performed for patients &amp;gt;18 years of age who were initiated on aripiprazole, ziprasidone, or olanzapine for all indications between July 1, 2011 and July 1, 2012. The costs of the mean doses of these agents were compared to an equivalent mean dose of the first line agent risperidone (4mg) using VA drug acquisition costs. Cardiometabolic monitoring data were collected to include weight, blood pressure, fasting glucose and fasting lipid profiles at baseline and at 12 weeks. Results: Of the 542 patients started on second line agents, only 68 met criteria for their use. A potential cost savings of over $850,000 may have been realized had these criteria been enacted within the one year time period studied. None of the 542 patients had both baseline and follow-up values for weight, blood pressure, fasting glucose and fasting lipid profiles. While roughly 60% of patients had blood pressure and weight values at baseline and 27% had glucose and cholesterol values, less than 14% received follow-up testing with approximately 2% receiving neither baseline nor follow-up testing. Discussion: Significant cost savings can be realized via the use of selection criteria without sacrificing efficacy as most studies do not demonstrate the superiority of one agent and the rates of adverse events between first and second generation agents are more similar than previously thought. This study also highlighted the lack of adequate cardiometabolic monitoring which could lead to cardiovascular disease.

Budget Impact Analysis of a Fixed-Dose Combination of Fluticasone Propionate and Formoterol Fumarate (FP/FORM) in a Pressurized Metered-Dose Inhaler (pMDI) for Asthma

The economic burden of asthma on the UK National Health Service (NHS) is the largest among allergic diseases. Current asthma guidelines recommend adding a long acting β2-agonist (LABA) to a low-dose inhaled corticosteroid (ICS) in patients who are on ICS monotherapy and have uncontrolled asthma. The fixed-dose combination of fluticasone propionate and salmeterol xinafoate (FP/SAL), available in a pressurized metered-dose inhaler (pMDI) device, is the most commonly prescribed ICS/LABA combination. An additional fixed-dose combination of fluticasone propionate and formoterol fumarate (FP/FORM) in pMDI is now available. In a 12-week non-inferiority study, FP/FORM demonstrated comparable efficacy to FP/SAL. The present analysis estimates the annual budget impact for the UK NHS using FP/FORM as an alternative to FP/SAL. Current pMDI prescribing data were from a real-world UK patient database (Cegedim Strategic Data). Annual costs to the NHS for drug acquisition, administration, and monitoring were estimated for FP/FORM and FP/SAL and used to assess the potential budget impact for the NHS for the use of FP/FORM instead of FP/SAL. Varying rates of uptake, adherence, adverse event-related costs, and resource use associated with switching treatment were assessed in scenario analyses. Assuming similar levels of ICS use with both regimens, annual drug acquisition costs per person were lower with FP/FORM (£412) than with FP/SAL (£509). The difference in acquisition costs and otherwise comparable input costs between the treatments, results in potential annual savings of £15,110,279 to the NHS, assuming uptake of FP/FORM over FP/SAL in 50% of existing patients. The introduction of FP/FORM results in cost savings for the NHS in all of the assessed scenario analyses. The comparable efficacy and lower acquisition costs of FP/FORM compared with FP/SAL make it a cost-saving option for the UK NHS for the treatment of asthma patients requiring combination maintenance therapy using a pMDI.

Dalteparin versus Enoxaparin for the prevention of venous thromboembolic events in trauma patients.

The use of low-molecular-weight heparin (LMWH) for the chemoprophylaxis of venous thromboembolism (VTE) in trauma patients is supported by Level-1 evidence. Because Enoxaparin was the agent used in the majority of studies for establishing the efficacy of LMWH in VTE, it remains unclear if Dalteparin provides an equivalent effect. To compare Dalteparin to Enoxaparin and investigate their equivalence as VTE prophylaxis in trauma. Trauma patients receiving VTE chemoprophylaxis in the Surgical Intensive Care Unit of a Level-1 Trauma Center from 2009 (Enoxaparin) to 2010 (Dalteparin) were included. The primary outcome was the incidence of clinically significant VTE. Secondary outcomes included heparin-induced thrombocytopenia (HIT), major bleeding, and drug acquisition cost savings. Equivalence margins were set between -5 and 5%. A total of 610 patient records (277 Enoxaparin, 333 Dalteparin) were reviewed. The two study groups did not differ significantly: blunt trauma 67 vs. 62%, p=0.27; mean Injury Severity Score (ISS) 17±10 vs. 16±10, p=0.34; Acute Physiology and Chronic Health Evaluation (APACHE) II score 17±9 vs. 17±10, p=0.76; time to first dose of LMWH 69±98 vs. 65±67h, p=0.57). The rates of deep venous thrombosis (DVT) (3.2 vs. 3.3%, p=1.00), pulmonary emboli (PE) (1.8 vs. 1.2%, p=0.74), and overall VTE (5.1 vs. 4.5%, p=0.85) did not differ. The absolute difference in the incidence of overall VTE was 0.5% [95% confidence interval (CI): -2.9, 4.0%, p=0.85]. The 95% CI was within the predefined equivalence margins. There were no significant differences in the frequency of HIT or major bleeding. The total year-on-year cost savings, achieved with 277 patients during the switch to Dalteparin, was estimated to be $107,778. Dalteparin is equivalent to Enoxaparin in terms of VTE in trauma patients and can be safely used in this population, with no increase in complications and significant cost savings.

Echinocandins in the treatment of candidaemia and invasive candidiasis: clinical and economic perspectives

Candidaemia and invasive candidiasis (IC) complicate modern medical therapy, contributing to high morbidity and mortality. Managing candidiasis is costly, with an additional healthcare expenditure of nearly US$300 million annually. Recent consensus guidelines have suggested the use of newer antifungal agents, such as echinocandins, for the treatment of candidaemia and IC owing to promising clinical outcomes compared with older-generation antifungal agents, but at higher drug acquisition and administration costs. Comprehensive cost-effectiveness data for echinocandins in treating candidaemia and IC remain relatively scant, underlining the need for more studies to incorporate robust economic analyses into clinical decisions. Assessment of the cost efficiencies of these expensive antifungal agents is essential for maximising health outcomes within the constraints of healthcare resources. This review will explore the epidemiology of candidaemia and IC in the context of clinical and economic aspects of the antifungal agents used to treat IC, especially the echinocandins. Standardising the outcome measure, methodology and reporting of results used in economic studies is central to ensure validity and comparability of the findings. Future studies comparing the economic advantages of all available antifungal treatment options and in the context of new diagnostic tools for fungal infections are anticipated.