Cost-effectiveness and cost-benefit of sumatriptan in patients with migraine.

OBJECTIVE: To investigate the cost-effectiveness and cost-benefit of initiating sumatriptan therapy in patients with acute migraine who were previously taking nontriptan drugs. PATIENTS AND METHODS: This is an economic analysis of a prospective, pretest-posttest, observational 6-month outcomes study of 178 patients with a physician diagnosis of migraine who received their first prescription for sumatriptan between October 1994 and August 1996 and were members of a mixed-model managed care organization in western Pennsylvania. Migraine-related resource use data were obtained from the managed care organization's medical and pharmacy claims databases. The primary outcome measure for this economic analysis was the total disability time that patients experienced because of migraine. Patients reported time missed from work and usual nonwork activities because of migraine on self-administered questionnaires at baseline and at 3 and 6 months after initiation of sumatriptan. RESULTS: Initiation of sumatriptan resulted in a decrease of 662 migraine-disability-days for work and 1236 migraine-disability-days for nonwork activities during the 6 months of the study (decrease from 27.8 to 17.2 days per person), totaling 1898 migraine-disability-days averted with sumatriptan therapy. Migraine-related medical costs were lower after sumatriptan was initiated ($18,351 vs $26,192), whereas migraine-related pharmacy costs were lower with prior nontriptan drug therapy ($22,209 vs $74,861). The overall net cost savings after sumatriptan was initiated in these patients was $222,332 ($1249 per patient) with a benefit-to-cost ratio of $5.67 gained for each health care dollar spent from a societal perspective. The incremental cost-effectiveness ratio was $25 for each additional migraine-disability-day averted by using sumatriptan vs nontriptan drug therapy. Sensitivity analysis showed that changes in medical costs had little effect on the ratios and that sumatriptan remained cost-beneficial across a wide range of patient wages. CONCLUSION: This study showed that initiation of sumatriptan in patients previously receiving nontriptan therapy was cost-effective and had an economic benefit for patients, employers, and society. Sumatriptan also helped patients and physicians achieve goals recommended by the US Headache Consortium by reducing patients' disability and thus improving their ability to function at work and nonwork activities.

Different approaches to valuing the lost productivity of patients with migraine.

OBJECTIVE: To calculate and compare the human capital approach (HCA) and friction cost approach (FCA) methods for estimating the cost of lost productivity of migraineurs after the initiation of sumatriptan from a US societal perspective. DESIGN: Secondary, retrospective analysis to a prospective observational study. SETTING: A mixed-model managed care organisation in western Pennsylvania, USA. PATIENTS: Patients with migraine using sumatriptan therapy. INTERVENTIONS: Patient-reported questionnaires collected at baseline, 3 and 6 months after initiation of sumatriptan therapy. OUTCOME MEASURES: The cost of lost productivity estimated with the HCA and FCA methods. RESULTS: Of the 178 patients who completed the study, 51% were full-time employees, 13% were part-time, 18% were not working and 17% changed work status. Twenty-four percent reported a clerical or administrative position. From the HCA, the estimated total cost of lost productivity for 6 months following the initiation of sumatriptan was $US117905 (1996 values). From the FCA, the six-month estimated total cost of lost productivity ranged from $US28329 to $US117905 (1996 values). CONCLUSIONS: This was the first study to retrospectively estimate lost productivity of patients with migraine using the FCA methodology. Our results demonstrate that depending on the assumptions and illustrations employed, the FCA can yield lost productivity estimates that vary greatly as a percentage of the HCA estimate. Prospective investigations are needed to better determine the components and the nature of the lost productivity for chronic episodic diseases such as migraine headache.

Pharmacoeconomic fellowships: the need for outcome measures.

Pharmacoeconomic fellowship programmes have been in existence for more than 10 years, but their effectiveness has not been evaluated. The aim of this project was to construct a framework to examine the potential outcome measures for pharmacoeconomic fellowships so that the effectiveness of these programmes may be determined. Using the Donabedian model, the structures, processes, and outcomes of pharmacoeconomic fellowship programmes were investigated. The structures of these programmes include the facilities, qualifications of the teaching staff and organisation, and operations of the institution. Most pharmacoeconomic fellowships are based in academic institutions and the pharmaceutical industry. Credentials of the preceptors and teaching staff consist of an advanced degree and relevant expertise in pharmacoeconomics and outcomes research. The processes of pharmacoeconomic fellowships include the duration of the programme as well as the research skills and the educational components taught. However, current guidelines do not define outcome measures for these pharmacoeconomic fellowships. Potential outcomes may include whether or not a degree was obtained, the management and research skills acquired, as well as the type of experiential training received. Further research is required to develop these outcome measures, so the effectiveness of pharmacoeconomic fellowship programmes may be assessed.

Quality-of-life differences between patients with episodic and transformed migraine.

OBJECTIVE: To determine whether there are any differences in health-related quality of life between patients with migraine and those with transformed migraine. BACKGROUND: There are no published reports comparing the health-related quality of life between patients with migraine and patients with transformed migraine. METHODS: We conducted a retrospective analysis examining the health-related quality of life of patients with transformed migraine and migraine seen at a specialty headache clinic. Data collected included the Short Form-36 (SF-36) and the Migraine Disability Assessment questionnaires as well as demographic information. Both of these forms are part of the initial evaluation at the headache clinic. A t test with Bonferroni correction was used to test for significant differences in the SF-36 domains between the groups. RESULTS: Data were collected for 90 patients, 46 with transformed migraine and 44 with migraine. There were no significant differences between groups with respect to sex, race, or age. Over the last 90 days prior to their first visit, patients with transformed migraine reported having a headache an average of 69 days compared with patients with migraine who averaged 18 days with headache (P<.05). Compared with patients with migraine, patients with transformed migraine had statistically (P<.05) and clinically significant (difference >5 points) lower mean scores on seven of the eight SF-36 domains and both the mental and physical summary scores of the SF-36. CONCLUSIONS: The results of this study suggest that patients with transformed migraine have a lower health-related quality of life than patients with migraine. These findings indicate that the headache chronicity associated with transformed migraine has a significant influence on quality of life. The results highlight the importance of effective management of headaches to avoid the progression of migraine to the more disabling transformed migraine.

Palivizumab for respiratory syncytial virus prophylaxis in high-risk infants: a cost-effectiveness analysis.

BACKGROUND: Prophylactic therapy with palivizumab, a humanized monoclonal antibody, has been shown to reduce the number of respiratory syncytial virus (RSV)-related hospitalizations in preterm infants. The cost-effectiveness of this therapy has not been evaluated from the provider's perspective using cost data. OBJECTIVES: The objectives of this study were to determine the cost per RSV infection episode avoided by using prophylactic palivizumab therapy in a high-risk infant population and to determine whether certain subgroups of infants derived greater benefit from prophylactic therapy. METHODS: A decision-analytic model simulating an RSV infection episode was developed to evaluate the cost-effectiveness of palivizumab prophylaxis from the perspective of the health care system (provider). Data to populate the model were gathered from the medical literature (identified through a MEDLINE search of studies on the incidence of RSV infection) and the IMpact-RSV clinical trial. Data included incidence of RSV infection and the associated health care resource use and costs. Costs to the provider were determined using a university-affiliated hospital cost-accounting system. Cost-effectiveness ratios were calculated over a range of RSV infection incidence rates in a control population. Sensitivity analyses were performed for the cost of palivizumab therapy, the cost of RSV-related hospitalization, and the number of emergency department, physician office, and home health care visits. For the subgroup analysis, infants were classified by gestational age (<32 and > or = 32 weeks) and stratified by severity of chronic lung disease. RESULTS: The cost per additional RSV infection episode avoided ranged from dollars 0 (cost savings) to dollars 39,591 for palivizumab prophylaxis costs of dollars 2500 and from dollars 2702 to dollars 79,706 for palivizumab prophylaxis costs of dollars 4500. The model was insensitive to changes in the number of emergency department, physician office, and home health care visits. The difference in RSV incidence between the treatment and control groups was greater among infants > or = 32 weeks' gestational age than among infants <32 weeks' gestational age. onclusions: The incremental cost-effectiveness of palivizumab compared with no prophylactic therapy was sensitive to changes in the incidence of RSV infection in control infants, the average cost of RSV hospitalization, and the cost of palivizumab. Clinicians may use this information along with additional factors to determine whether palivizumab is cost-effective in their clinical setting and geographic area.

Evaluating health-related quality of life: cost comparison of computerized touch-screen technology and traditional paper systems.

We estimated and compared the costs for three different methods of administering and evaluating the Short Form-36 as a routine part of clinical practice from the provider perspective. In an outpatient pain management practice, we assessed a computer touch-screen system with facsimile and scanning scoring methods. Equipment, supply, and labor costs needed to construct, maintain, and generate reports for each system were measured. The annual fixed, variable, and total costs/survey were calculated. Sensitivity analyses were performed varying the number of surveys administered/year. The facsimile method was the least costly, $9.62 and $5.88/survey, at annual questionnaire volumes of 250 and 1000, respectively. When the annual survey volume increased to 1250 (5 surveys/day), the costs of the facsimile ($5.63/survey) and computer touch-screen ($5.65/survey) methods were nearly equivalent per survey administration. At volumes of 1500 and above, the least costly method was the computer touch screen at $5.47/survey. The system implemented in a clinical practice is dependent not only on questionnaire volume but also on personnel availability, equipment access, required speed of results, and the acceptable level of data error.

Changes in resource use and outcomes for patients with migraine treated with sumatriptan: a managed care perspective.

BACKGROUND: Migraine headaches result in significant patient suffering and high costs to managed care organizations and employers. Studies that evaluate patient outcomes and the financial consequences of migraine treatment are important from a clinical and an economic perspective. METHODS: This prospective, observational study assessed the outcomes of migraineurs in a mixed model staff/ independent practice association managed care organization for patients previously diagnosed as having migraine who received their first prescription for sumatriptan. Data collected included medical as well as pharmacy claims and patient surveys to measure changes in satisfaction, health-related quality of life, workplace productivity, and nonworkplace activity after sumatriptan therapy was initiated. RESULTS: A total of 178 patients completed the study. Results showed significant decreases in the mean number of migraine-related physician office visits, emergency department visits, and medical procedures in the 6 months after sumatriptan therapy compared with the 6 months before sumatriptan was used (P<.05). Four of the health-related quality-of-life dimensions and the physical component summary score measured by the SF-36 (which is a valid, reliable general health status instrument) showed significant improvements at 6 months compared with patients' scores before use of sumatriptan (P<.05). Health-related quality of life measured by the disease-specific instrument MSQ (Migraine-Specific Quality of Life Questionnaire-Version 1.0, 1992 Glaxo Wellcome Inc, Research Triangle Park, NC) showed significant improvement at 3 and at 6 months compared with baseline scores (P<.05). There were also improvements in patient satisfaction and significant reductions in time lost from workplace productivity and nonworkplace activity. CONCLUSION: In the 6 months after sumatriptan therapy was initiated, health care resource use and time lost from workplace productivity and nonworkplace activity were reduced, while health-related quality of life and patient satisfaction scores improved for the managed care migraineurs enrolled in this study.

Medical Outcomes Study Short Form 36: a possible source of utilities?

General health-status questionnaires such as the Medical Outcomes Study 36-Item Short Form Health Survey (SF-36) are frequently used to measure health-related quality of life. The SF-36, in its current form, cannot be used to measure individuals' utilities or preferences for their health state. Recently, several investigators have explored the possibility of obtaining utilities from the SF-36. This article reviews the SF-36 survey, selected measures of utility, and the differences between health-status and utility measures, with an emphasis on use of SF-36 results to derive utility scores. We searched the literature from January 1966 to July 1999 using MEDLINE and HEALTHSTAR. The terms SF-36, health-status instruments, utilities, and preferences were searched to identify studies that had used both the SF-36 and a utility-based instrument. We first discuss studies that were specifically designed to find a predictive equation to obtain utilities from SF-36 scores. We then discuss studies that examined the correlation between the SF-36 and a utility-based instrument but that were not intended to develop a predictive equation as their primary objective. The studies that have tried to derive utilities from the SF-36 using a predictive equation have used different methodologies; to date, no reliable method has been appropriately validated. The poor correlation reported in most of the studies attests to the complex relationship between utility-based instruments and the SF-36. More work is needed to elucidate if utilities can be obtained from the SF-36.