A pharmacoeconomic evaluation of two new products for the treatment of overactive bladder.

The objective of this study is to evaluate the cost effectiveness of two new treatments for overactive bladder: once-daily controlled-release oxybutynin, and twice-daily tolterodine, with a comparison with oxybutynin immediate release. Also estimated are the potential cost savings to a health plan budget resulting from increased utilization of the most cost-effective treatment. The design is a decision-tree model based on clinical trial data and expert panel estimates with a six-month time horizon conducted from a payer perspective. The primary outcome measure used in the analysis was treatment success, with success defined as zero incontinence episodes per week. A secondary outcome measure was the expected number of continent days. As first-line therapy, controlled-release oxybutynin is the most cost-effective treatment as measured by expected cost per success and expected cost per continent days. Controlled-release, once-daily oxybutynin yielded the highest expected success rate and the highest number of expected continent days. The expected cost of treatment with controlled-release oxybutynin was lower than tolterodine and equivalent to immediate-release oxybutynin. Increased utilization of controlled-release oxybutynin results in an estimated saving of $0.007 to $0.026 per member per month for a hypothetical HMO. The model was robust, incorporating all assumptions based on univariate and multivariate sensitivity analysis. Initiating treatment with controlled-release oxybutynin is the most cost-effective approach to treatment for overactive bladder.

Comparison of extended-release venlafaxine, selective serotonin reuptake inhibitors, and tricyclic antidepressants in the treatment of depression: a meta-analysis of randomized controlled trials.

The purpose of this study was to summarize and compare the clinical success rates of extended-release venlafaxine, some selective serotonin reuptake inhibitors (SSRIs), and certain tricyclic antidepressants (TCAs). A meta-analytic approach was used to synthesize outcomes from published randomized controlled trials involving patients scoring > or =15 on the Hamilton Rating Scale for Depression (HAM-D) or > or =18 on the Montgomery-Asberg Depression Rating Scale (MADRS). Searches of the MEDLINE, EMBASE, and International Pharmaceutical Abstracts databases were performed, as were searches of references from retrieved articles and reviews. Drugs included in the comparison were extended-release venlafaxine (venlafaxine-XR); the SSRIs citalopram, fluoxetine, fluvoxamine, paroxetine, and sertraline; and the TCAs amitriptyline, imipramine, desipramine, and nortriptyline. Therapeutic success was defined as a 50% decrease in the HAM-D or MADRS score. Data were extracted by 2 independent evaluators, with differences resolved through consensus discussions. Weighted mean success rates were calculated for each drug class, using a random-effects model. The resulting data represent 44 trials with 63 study arms and 4033 patients with depression. Venlafaxine-XR demonstrated a 73.7% success rate, which was statistically significantly greater than that of the studied SSRIs (61.1%) and TCAs (57.9%) (P<0.001). Thus this meta-analysis of randomized controlled studies of patients with depression suggests that venlafaxine-XR is clinically superior in efficacy to SSRIs and TCAs. Venlafaxine-XR also had universally lower, though nonsignificant, dropout rates.

Pharmacoeconomic analysis of topical treatments for tinea infections.

BACKGROUND: A payor-perspective economic analysis of the topical creams ciclopirox, clotrimazole, ketoconazole, miconazole, and terbinafine (TER) used to treat dermatophytosis has been made. This pharmacoeconomic evaluation was conducted in Austria, Germany, and Switzerland. METHODS: A four-phase approach was used. Phase 1: experts were assembled to identify the standard approach for management of fungal infections and a decision tree was constructed to model the process. Phase 2: meta-analysis was used to determine success, failure, and relapse rates. Phase 3: economic analyses performed included cost of regimen, total expected cost, and cost-effectiveness. Phase 4: sensitivity analyses (robustness analysis) were also executed to determine the validity of the assumptions. RESULTS: In the total expected cost analysis, TER demonstrated the lowest overall cost of treating patients. Terbinafine also provided the highest number of disease-free days during the analytic time horizon and, consequently, the lowest cost per disease-free day. Sensitivity analyses suggest that TER is the most cost-effective topical product for treating dermatophytosis in Austria, Germany, and Switzerland. CONCLUSIONS: All analytic scenarios suggest that TER therapy demonstrates lower expected costs and generates more DFDs when compared with the fungistatic topical therapies included in this pharmacoeconomic analysis. Terbinafine is expected to be the most cost-effective choice in Austria, Germany, and Switzerland for treatment of dermatophytosis minor.

Building a computerized disease management operating system.

Under the increasing pressures of the marketplace, there has been a determined move in health care toward the development of disease management systems that improve efficiency, control costs, and ensure the best possible clinical outcome. Achieving these goals requires the ability to perform global analysis of complex and dynamic systems, beginning with point-of-care data collection and including the potential for multiple interfaces along the continuum of care. Our center has developed an integrated disease management system that enables the clinician to continuously monitor and assess relevant clinical and financial information flowing through the practice, providing robust and rigorous outcomes, health economic analysis, and pharmacoeconomic analysis of care at every step in the delivery process. This paper describes the results of pilot studies of the analytic capability of the system and includes an overview of the conceptual parameters employed in its development.

Full-cost determination of different levels of care in the intensive care unit. An activity-based costing approach.

We applied an activity-based costing methodology to determine the full cost of intensive care service at a community hospital, a university hospital and a health maintenance organisation (HMO)-affiliated hospital. A total of 5 patient care units were analysed: the intensive care unit (ICU) and surgical ICU (SICU) at the university setting, the ICU at the community setting, and the SICU and cardiac care unit at the HMO setting. The selection of the different ICU types was based on the types of critical care units that were found in each setting (e.g. the HMO did not have an ICU). Institution-specific cost data and clinical management parameters were collected through surveys and site visits from the 3 respective organisation types. The analysis revealed a marked increase in patient-minute cost associated with mechanical ventilation. Higher costs associated with prolonged neuromuscular blockade have important economic implications with respect to selection of an appropriate neuromuscular blocking agent.

Economic and quality of life outcomes: the four-step pharmacoeconomic research model.

Increasingly, economic data are being considered in formulary decisions. In oncology, pharmacoeconomic evaluations are essential to help decision makers weigh the associated costs and outcomes of competing chemotherapeutic interventions. In this article, we present a four-step pharmacoeconomic research model that can be customized for specific provider or payer systems. The model encompasses problem identification, clinical management analysis, three pharmacoeconomic analyses (cost consequence, expected cost, and cost effectiveness), and a sensitivity analysis--the rank order stability analysis (ROSA)--to validate the findings.

Rank-order stability analysis (ROSA): testing pharmacoeconomic data.

In a pharmacoeconomic analysis, the validity of findings is critical because product ranking may influence formulary decision making. The authors present an approach for examining uncertainty in a pharmacoeconomic analysis that parallels the confidence-interval approach to statistical analysis. This method, rank-order stability analysis (ROSA), is a clear and comprehensive method for validating results of a pharmacoeconomic analysis, as it identifies and evaluates all inputs and values. It is a break-even analysis that identifies the specific point of insensitivity for all parameters analyzed in the pharmacoeconomic model. ROSA is proposed as the preferred method for judging the validity of results derived from estimated parameters in pharmacoeconomic analyses.

Use of anesthesia selection in controlling surgery costs in an HMO hospital.

The cost of induction and maintenance of anesthesia is analyzed in this article from the perspective of a health maintenance organization's (HMO) chief financial officer. While earlier economic studies tended to focus on the raw cost of anesthesia drugs, our model also includes the cost of the clinical labor involved in administering the drug as well as the fixed costs associated with the facility. Such a model is consistent with the goal of an HMO, which is to provide high-quality health care services to its membership while containing costs. Our model disaggregated the costs associated with anesthesia into cost centers. The costs associated with two anesthesia regimens, propofol and thiopental/isoflurane, were calculated and analyzed via cost-minimization methods. Our data were acquired from a prospective economic trial conducted in university, community, and HMO hospitals. Because institutional pricing policies differ greatly, only the findings at the HMO hospital are presented in this report. Our results suggest that intra-abdominal surgical procedures with a duration of less than 4 hours that use propofol for induction and maintenance of anesthesia reduce the total cost of surgery by $202.71, compared with the costs of using thiopental/isoflurane. Sensitivity analysis maintains the robustness of the conclusions with regard to all major parameters.

Pharmacoeconomic analysis of topical treatments for tinea infections.

The purpose of this study was to perform a government-perspective economic analysis of the most widely used topical creams [namely, ciclopirox (CIC), clotrimazole (CLO), ketoconazole (KET), miconazole (MIC), and terbinafine (TER)], for the treatment of 2 types of dermatophyte skin infections: dermatophytosis major (excluding onychomycosis) and dermatophytosis minor. A 3-phase approach was used. In phase I, experts were assembled to identify the standard approach for management of fungal infections and a decision tree was constructed to model the process; in phase II, meta-analysis was used to determine success, failure, and relapse rates; and in phase III, economic analyses were performed including cost of regimen, total expected cost and cost-effectiveness analysis. Sensitivity analyses (robustness analyses) were also performed in phase III. It was found that while TER was successful following 1 week of administration for minor infections and after 2 weeks for major infections, duration of drug treatment was usually twice that time. Other comparators (CIC, CLO, KET and MIC) took 4 weeks to achieve a successful outcome. In addition, an extra 2 weeks were often needed to clear both types of infections because the comparators are fungistatic, whereas TER is fungicidal. In the total expected cost analysis, TER had the lowest overall cost of treating patients for both infection categories. It was also responsible for the highest number of disease-free days and, consequently, the lowest cost per disease-free day. Sensitivity analyses confirmed that TER was the most cost-effective topical agent for treating dermatophytosis major (excluding onychomycosis) and dermatophytosis minor.

A multifactorial approach to understanding anesthesia selection.

A full hospital cost accounting model to track the total costs of surgery and anesthesia for inpatients, from the perspective of a hospital CFO, utilizing time-allocation methodology is presented. This model was tested in a prospective multicenter economic clinical trial in three settings.

Cost-effectiveness analysis for onychomycosis therapy in Canada from a government perspective.

An economic analysis of the oral antifungal drugs griseofulvin (GRI), ketoconazole (KET), and terbinafine (TER), currently registered and used in treating onychomycosis of fingernails and toenails, was performed using a model that incorporates elements of both meta-analysis and pharmacoeconomics. The meta-analysis of published studies determined rates of success, relapse and side-effects. The perspective taken for the analysis was that of the government payer, with expected total cost and cost-effectiveness being calculated. A multiphase approach was used. The studies of onychomycosis of the fingernails showed that TER had a 95.0% success rate, KET 80.9%, and GRI 59.6%. GRI had the lowest acquisition costs. The success rates for onychomycosis of the toenails were: TER 78.3%, KET 40.8%, and GRI 17.5%. GRI had the lowest acquisition costs. However, expected cost comparison showed TER had the lowest cost because of shorter treatment duration. The expected cost of therapy with a 100% government payer perspective for fingernail onychomycosis was the lowest for TER ($439.83), followed by GRI ($480.80), then KET ($755.46). Toenail onychomycosis showed the same order for the comparators, with TER $1049.77, GRI $1388.54 and KET $1936.48. When compared with TER, fingernail cost-effectiveness ratios for GRI and KET were 1.51 and 2.00. Toenail cost-effectiveness ratios were 2.49 and 2.48, respectively. For both fingernail and toenail onychomycosis, TER had the greatest number of disease-free days (973 for fingernails; 1073 for toenails), followed by KET (837; 798), then GRI (702; 569).(ABSTRACT TRUNCATED AT 250 WORDS)

A multinational pharmacoeconomic analysis of oral therapies for onychomycosis. The Onychomycosis Study Group.

Due to increased interest in economic evaluation and the rapid international spread of new healthcare technologies across borders, there is a need to interpret economic evaluations on a worldwide basis. We conducted a multinational cost-effectiveness analysis, from a government payer perspective, comparing four primary oral treatment regimens for onychomycosis of the fingernails and toenails: griseofulvin, itraconazole, ketoconazole and terbinafine. We used a four-step pharmacoeconomic research model which includes all relevant factors affecting costs in 13 countries: Austria, Belgium, Canada, Finland, France, Germany, Greece, Italy, The Netherlands, Portugal, Spain, Switzerland and the U.K. A worldwide meta-analysis of published clinical data served as the statistical input for the pharmacoeconomic model, and demonstrated that terbinafine had the highest success rates (95.0% and 78.3%) of the clinical comparators for fingernails and toenails, respectively. We found that terbinafine was the most effective therapy in relation to cost (therefore giving it the lowest cost-effectiveness ratio) for both infections in all health-care systems analysed.