Early supplemented low-protein diet restriction for chronic kidney disease patients in Taiwan - A cost-effectiveness analysis.

BACKGROUND: Low-protein diet (LPD) together with supplementation with ketoanalogs (KA) is associated with slower decline of estimated glomerular filtration rate (eGFR) in chronic kidney disease (CKD). We compared potential clinical and economic outcomes of KA supplement initiation at eGFR 15 - 29 mL/min/1.73 m2 vs. eGFR < 15 mL/min/1.73 m2 in CKD patients on LPD from the healthcare payer's perspective. METHODS: Markov model was designed to simulate outcomes of adult patients with eGFR 15 - 29 mL/min/1.73 m2 on two strategies LPD with KA supplementation; watchfulwaiting on LPD alone and KA initiation when eGFR declined to < 15 mL/min/1.73 m2. Medical cost and quality-adjusted life-years (QALYs) were calculated over 10 years. Results The early-initiation group gained higher QALYs (3.926 QALYs vs. 3.787 QALYs) with lower cost (USD 564,637 vs. USD 914,236) (USD 1 = NTD 30) when compared with the watchful-waiting group in base-case analysis. Sensitivity analysis indicated that early KA initiation at eGFR at 17 - 29 mL/min/1.73 m2 would be the preferred cost-effective option, if relative reduction of eGFR decline associated with LPD plus KA was > 4%. 10,000 Monte Carlo simulations showed the early-initiation group to be less costly with higher QALYs gained than the watchful-waiting group by USD 343,665 (95% CI 342,139 - 345,191) and 0.160 QALYs (95% CI 0.140 - 0.180), respectively. CONCLUSIONS: Early KA supplementation with LPD in CKD patients appeared to be cost-saving and gained higher QALYs in Taiwan. Acceptance of early supplemented LPD as cost-effective depended upon the reduction of eGFR decline associated with KA plus LPD and eGFR level to initiate KA supplementation.

The Health Technology Assessment Environment in Mainland China, Japan, South Korea, and Taiwan-Implications for the Evaluation of Diabetes Mellitus Therapies.

BACKGROUND: Diabetes mellitus (DM) is associated with a significant global economic and humanistic burden. The condition presents a real challenge in Asia, which accounts for more than 60% of individuals with DM globally. Health technology assessment (HTA) is a field of scientific research used to inform policy and clinical decision making relating to the introduction and diffusion of health technologies. OBJECTIVES: This article, examines the present use and predicted evolution of HTA with respect to pricing and reimbursement of drugs in mainland China, Japan, South Korea, and Taiwan. It makes specific reference to important assessment considerations for DM therapies, which should assist key stakeholders in choosing which data to capture, and what approaches to use, to help quantify the value of treatment. METHODS: The findings are informed by two Advisory Board discussions, a literature review, and the authors' personal experience. RESULTS: HTA already has a key role in South Korea and Taiwan, with current systems undergoing important changes. In contrast, in mainland China and Japan, HTA is not yet formally utilized, although this appears likely to change. Several elements are important for HTA to be meaningful and impactful for DM therapies, including a clear, transparent analytical framework for HTA that includes all relevant costs and outcomes; availability of local DM epidemiologic, economic, and quality-of-life data; acceptance of modeling as a core methodology; availability of real-life patient data; and recognition of specific evidence requirements associated with biosimilars. HTA has the potential to assist payors in making informed decisions about the coverage of DM medications.

Public views of community pharmacists in Taiwan.

OBJECTIVE: A large-scale national survey was conducted to assess the general public's attitudes about, need for and satisfaction with community pharmacists and the services they provide in Taiwan. METHOD: Computer-assisted telephone interviews were conducted by a contract agency using random-digit dialing procedures to achieve a nationally representative sample of adult residents. An 18-item interview survey questionnaire was developed based on previous similar surveys and a pretest-type process was employed by monitoring early responses of interviews to ensure understanding by respondents. KEY FINDINGS: A total of 9066 phone exchanges were dialed resulting in 2658 conversations with potential respondents and 1089 completed interviews. Overall, 45.6% of respondents agreed that community pharmacists always treat them sincerely and 41.2% agreed that community pharmacists have the ability to answer their questions. Fewer respondents agreed that community pharmacists were the first professional they consulted for answers about medication use (31.7%) and that they generally trusted the pharmacist (33.2%). Older respondents had more favourable perceptions and respondents with more education had less favourable perceptions. About half of the respondents reported a need for medication use instructions, help in developing personal medication records and help in filling chronic-disease prescriptions. A majority of respondents were satisfied with specific pharmacist services; however, only 8.5-22.5% of respondents previously had experienced these services. Fewer respondents reported general satisfaction with community pharmacist services. CONCLUSION: Although generally consumers had less-than-positive perceptions about community pharmacists, their responses revealed some level of trust of pharmacists, awareness of the services that pharmacists may be able to provide and satisfaction with services provided by pharmacists.

Clinical pharmacist counseling improves outcomes for Taiwanese asthma patients.

OBJECTIVE: To assess the impact of an asthma educational program provided by a nurse combined with asthma counseling provided by a pharmacist on asthma knowledge, quality of life and clinical outcomes in Taiwanese patients with asthma. SETTING: All patients were recruited from Pulmonary Medicine outpatient clinic, the Tri-Service General Hospital, Taipei, Taiwan. Asthma education was given in three one-hour sessions offered during monthly clinic visits. METHOD: A total of 91 asthma patients were randomly assigned to a nurse-administered education program (Group 1), the education program with additional pharmacist counseling (Group 2), or a control group receiving routine care only (control). Three questionnaires were used for assessment at months 0, 3 and 6. Outcomes were compared between groups to determine efficacy. MAIN OUTCOME MEASURE: Asthma knowledge, health-related quality of life, and medication adherence were measured at baseline and 3 and 6 months after enrollment. RESULTS: A total of 104 patients were enrolled; 91 completed the study. Knowledge scores of patients in Groups 1 and 2 increased significantly compared to control group. Both intervention groups showed significant increases in knowledge scores with longer follow-up. Group 2 showed a significant improvement in clinical symptoms between baseline (month 0) and month 6 (4.99 vs. 4.21, P=0.008). No significant differences in medication adherence were seen among groups. CONCLUSION: Regular nurse-administered asthma education with additional pharmacist counseling improves asthma knowledge and clinical symptoms in asthma patients.

Taiwanese version of the EQ-5D: validation in a representative sample of the Taiwanese population.

BACKGROUND/PURPOSE: We know of no validated Taiwanese-language instrument to measure a utility of the patient's health. Our aim was to evaluate the reliability and validity of a Taiwanese version of the EuroQol instrument (EQ-5D) in a Taiwanese population. METHODS: Questionnaires containing the Taiwanese versions of the EQ-5D and the Short-Form 12 Health Survey (SF-12) were sent to 12,923 people in Taiwan in December 2002. Concurrent validity of the EQ-5D was analyzed by assuming that subjects with problems in any EQ-5D dimensions had decreased SF-12 scores. Discriminant validity of the EQ-5D was analyzed by assuming that subjects with the following characteristics had lowered EQ-5D indexes and scores on the EQ-5D visual analog scale (VAS): more chronic diseases than others, serious illness, more hospitalizations in the past year than others, poor general health, and more outpatient visits than others. Test-retest reliability was analyzed in a subgroup of respondents who were evaluated twice within a month by using the intraclass correlation coefficient and the kappa method. RESULTS: The general survey response rate was 12.7% (1644 of 12,923). SF-12 scores were lower in subjects reporting problems on EQ-5D dimensions than in others without such problems (p < 0.01). Subjects with more health problems than others had lower EQ-5D indexes and VAS scores (p < 0.01). The physical dimension of the EQ-5D was more strongly correlated with the SF-12 Physical Component Summary than with the Mental Component Summary; this finding satisfied the a priori hypothesis. For test-retest reliability of items on the EQ-5D, kappa values ranged from 0.49 to 1 (p < 0.001). CONCLUSION: The Taiwanese EQ-5D instrument appears to be a moderately valid and reliable tool for measuring the health status of the general population in Taiwan.

Pharmacoeconomic evaluation of schizophrenia in Taiwan: model comparison of long-acting risperidone versus olanzapine versus depot haloperidol based on estimated costs.

Antipsychotics are the keystone in schizophrenia treatment. Although the benefits of the new generation of antipsychotics has been demonstrated over the last decade, the issues of patient compliance and higher purchasing price of atypical antipsychotics remain unresolved. Risperidone is the only atypical antipsychotic agent with long-acting formulation. Long-acting risperidone is a water-based injection and it has been associated with a low level of pain. The aim of the present study was to test whether an improvement in compliance with the use of a long-acting risperidone, compared with olanzapine and depot haloperidol, can increase the effectiveness and the cost-effectiveness indexes. An economic comparison model with decision tree, rather than a prospective design with real clinical drug trial, was applied. The unit cost for each medical procedure was obtained from the claimed-database of the Bureau of National Health Insurance in Taiwan. An executive committee simulated the incidence of extrapyramidal side-effects and proposed a therapeutic model for each strategy based on a literature review. The probabilities of treatment response of different agents and those of different mental health states were estimated by the executive committee and 10 senior psychiatrists who were randomly selected. Sensitivity analysis was performed for drug cost-effectiveness and compliance improvement for using long-acting risperidone. The results showed that long-acting risperidone is more cost-effective than either olanzapine or depot haloperidol for treating schizophrenia patients whose conditions are stable and whose illness duration ranges from 1 to 5 years. The comparison model with the Kaplan-Meier decision tree may serve as an alternative to prospectively designed studies for cost-effectiveness of atypical antipsychotics.

What is next for pharmacoeconomics and outcomes research in Asia?

OBJECTIVES: Pharmacoeconomics and outcomes research have the potential for rapid adoption in the Asia Pacific region. Nevertheless, the region is characterized by great diversity in social and economic development, ethnicity, population size, health-care system, culture, language, and religion. Thus, the rate of adoption is also quite diverse across the region. METHODS: Among the countries reviewed in this article, governments take varying levels of interest in applying this research in health policy decisions. For example, some countries have already implemented systems that require pharmacoeconomic studies as one component of a new pharmaceutical product's approval for reimbursement, whereas others recommend such data but do not require it in policy and medical decision making. The literature in the countries reviewed is actually quite robust given the early stages of development of this field in most countries. The academic community has members trained in this field of research in all the countries reviewed and some universities have established departments whereas others have just introduced a few classes in the area. RESULTS: At the moment, pharmacoeconomics and outcomes research are being conducted mainly by academics. In addition, some pharmaceutical researchers are active and pharmaceutical companies are currently preparing to conduct more of this research as part of their strategy for Asian drug development. CONCLUSIONS: Prospects for future growth and development in this field are quite good in Asia as rapid healthcare inflation, increasing rates of chronic conditions and aging population, and increasing technology diffusion will underpin the need for greater awareness of the need to incorporate economic efficiency into the health-care systems.