Cost-effectiveness and Price of Aripiprazole for Schizophrenia in the Brazilian Public Health System

BACKGROUND: Schizophrenia is a chronic debilitating condition characterized by disorders in thought, affect and behavior. Considering the low effectiveness of antipsychotic drugs for schizophrenia and the potentially high cost of an inadequate choice, a systematic cost-effectiveness evaluation of the list of subsidized antipsychotic drugs is necessary in order to allow an adequate choice of pharmacotherapy for the patient and the financial reality of the Brazilian public health system (SUS). OBJECTIVE: The aims of this study are to conduct a cost-effectiveness analysis of the subsidized antipsychotic drugs for the first-line treatment of schizophrenia in Brazil and aripiprazole, and to discuss a reasonable incorporation price for aripiprazole. METHODS: A three-year Markov model with quarterly cycles was developed in TreeAge Pro® 2009 to assess the cost-effectiveness of six listed oral antipsychotic drugs for the first-line treatment of schizophrenia in the Brazilian public health system (haloperidol, chlorpromazine, risperidone, quetiapine, ziprasidone, and olanzapine) and oral aripiprazole. Outcomes were measured in quality-adjusted life years (QALYs). Reasonable prices for aripiprazole were calculated based on the placement of the drug in the efficiency frontier and the cost-effectiveness ratio of the most efficient comparator. RESULTS: Olanzapine was considered cost-effective adopting any threshold value. If me-too drugs are required to be least as efficient as the comparators, olanzapine would still be cost-effective under 0.031 USD/mg. Aripiprazole was absolutely dominated by risperidone. The sensitivity analysis showed important uncertainty, which was expected. There is, nevertheless, a prominent separation between ziprasidone, quetiapine and the efficiency frontier. Aripiprazole was not considered cost-effective even when its price was set at zero: CER = USD 4,102 vs. USD 3,945 (haloperidol), USD 3,616 (chlorpromazine), USD 3,646 (risperidone) and USD 3,752 (olanzapine) USD/QALY. CONCLUSION: Olanzapine was considered the most cost-effective drug for the first-line treatment of schizophrenia in Brazil. Aripiprazole was dominated by risperidone and was not considered cost-effective against olanzapine. IMPLICATIONS FOR HEALTH CARE PROVISION AND USE: This work demonstrated, using a price adjustment process, that there is no viable price that would make aripiprazole cost-effective for incorporation in the Brazilian public health system in the first-line of treatment of schizophrenia. The drug can be useful in specific cases, since individual variability of response to antipsychotic drugs is important.

Societal Preferences for EQ-5D Health States from a Brazilian Population Survey.

OBJECTIVE: To elicit preference weights for a subset of EuroQol five-dimensional (EQ-5D) questionnaire health states from a representative sample for the state of Minas Gerais, Brazil, using a time trade-off (TTO) method and to analyze these data so as to estimate social preference weights for the complete set of 243 states. METHODS: Data came from a valuation study with 3362 literate individuals aged between 18 and 64 years living in urban areas. The present study was based on quota sampling by age and sex. Face-to-face interviews were conducted in participants' own homes. A total of 99 EQ-5D questionnaire health states were selected, presorted into 26 blocks of six unique health states. Each participant valued one block together with the full health, worst health, and dead states. Each health state was evaluated by more than 100 individuals. TTO data were modeled at both individual and aggregate levels by using ordinary least squares and random effects methods. RESULTS: Values estimated by different models yielded very similar results with satisfactory goodness-of-fit statistics: the mean absolute error was around 0.03 and fewer than 25% of the states had a mean absolute error greater than 0.05. Dummies coefficients for each level within the EQ-5D questionnaire dimensions of health displayed an internally consistent ordering, with the mobility dimension demonstrating the largest value decrement. The values of mean observed transformed TTO values range from 0.869 to-0.235. CONCLUSIONS: The study demonstrates the feasibility of conducting face-to-face interviews using TTO in a Brazilian population setting. The estimated values for EQ-5D questionnaire health states based on this Minas Gerais survey represent an important first step in establishing national Brazilian social preference weights for the EQ-5D questionnaire.

Antenatal care use in Brazil and India: scale, outreach and socioeconomic inequality.

This paper investigates the extent of socioeconomic inequalities in antenatal care use and related medical procedures in Brazil and India, which represent transition economies with contrasting geographical and sociocultural composition and health care provision. Concentration indices and regression analyses applied on recent Demographic Health Survey data reveal high and proportionate distribution of antenatal coverage in Brazil, whereas the Indian case present problems of both scale and equity. Inequalities in access to four or more antenatal visits are significantly pronounced in India, and in Brazil the differences are significant only for those who had six or more visits. Brazil's universal healthcare model which proved effective in promoting equitable distribution of antenatal care could be implemented in India. Future interventions should emphasis quality of care in monitoring essential antenatal services especially targeting the poor and deprived communities.