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Cost-utility analysis of depot atypical antipsychotics for chronic schizophrenia in Croatia |
Jukic V, Jakovljevic M, Filipcic I, Herceg M, Silic A, Tomljanovic T, Zilbershtein R, Jensen RC, Hemels ME, Einarson TR |
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Record Status This is a critical abstract of an economic evaluation that meets the criteria for inclusion on NHS EED. Each abstract contains a brief summary of the methods, the results and conclusions followed by a detailed critical assessment on the reliability of the study and the conclusions drawn. CRD summary This study evaluated the cost-effectiveness of long-acting injectable paliperidone palmitate for people with stable chronic schizophrenia and a history of relapse and hospitalisation. The authors concluded that paliperidone was the most cost-effective long-acting injectable atypical antipsychotic, compared with risperidone and olanzapine, in Croatia. The reporting was insufficient to allow a full critique of the methods. Given the limitations, the results should be considered to be highly uncertain. Type of economic evaluation Study objective This study evaluated the cost-effectiveness of long-acting injectable paliperidone palmitate for people with stable chronic schizophrenia and a history of relapse and hospitalisation. Interventions Paliperidone was compared with long-acting risperidone and long-acting olanzapine. Full details of dosages were presented, including initial doses, follow up doses, maintenance doses, and doses for acute relapse. Some patients were assumed to receive oral antipsychotics. Patients for whom two treatments failed, received clozapine. Methods Analytical approach:A published decision tree (see Other Publications of Related Interest) was adapted for Croatia. Treatments were evaluated over one year. The model allowed patients, who were unable or unwilling to tolerate treatment, to switch in accordance with UK National Institute for Health and Care Excellence (NICE) guidelines. The authors stated that the perspective was that of the National Health Service in Croatia. Effectiveness data:The primary clinical effectiveness data were adherence rates, dosing rates, stable disease rates, emergency room visits, hospitalisation rates, and days in remission. These were from a variety of published studies. Monetary benefit and utility valuations:The utility values were averages calculated from several published studies. Measure of benefit:The primary measure of benefit was quality-adjusted life-years (QALYs). Cost data:The resource use included the dosages of drugs, derived from the European Medicines Agency and published studies; medical use, such as primary care visits and psychiatric visits; and hospital use, such as emergency room visits and hospitalisations. Drug costs used Croatian government prices. Medical and hospital costs used local and hospital-specific prices. Values were inflated to 2011 Euros (EUR) using the consumer price index for Croatia. The cost per patient treated was measured in 2012 EUR. Analysis of uncertainty:Various sensitivity analyses were undertaken, including one-way, threshold and probabilistic sensitivity analysis. Results The annual cost per patient was EUR 5,061 for paliperidone, EUR 5,168 for risperidone, and EUR 6,410 for olanzapine. Paliperidone produced 0.817 QALYs, compared with 0.807 QALYs for risperidone, and 0.812 QALYS for olanzapine. Paliperidone dominated both risperidone and olanzapine, as it was less costly and more effective. Sensitivity analyses suggested that the results were insensitive to varying the costs and hospitalisation rates, but sensitive to changes in adherence. Probabilistic sensitivity analysis indicated that paliperidone dominated olanzapine in about 77.3% of simulations; and risperidone in about 56.8% of simulations. Paliperidone was cost-effective, assuming a willingness-to-pay for a QALY gained of EUR 30,000, compared with risperidone, in about 93% of simulations. Authors' conclusions The authors concluded that paliperidone palmitate was the most cost-effective long-acting injectable atypical antipsychotic, compared with risperidone and olanzapine, for chronic relapsing schizophrenia in Croatia. CRD commentary Interventions:The interventions were well described, but it was not clear how the various dosages were implemented within the model. Daily oral antipsychotics were not compared with the long-acting injectable antipsychotics. Effectiveness/benefits:The methods used to select the data were not reported, and the effectiveness sources were not described. It was therefore unclear whether the best available evidence was used. The authors indicated that the average of the utility values from five studies was used. It was unclear why or how these studies were chosen and whether they were similar enough to pool their data. Taking an average may have been too simple. Adherence for paliperidone was based on assumed equivalent side-effects to risperidone. It is unclear if this assumption was justified, and the results were sensitive to variations in adherence. The authors did not consider quality of life changes due to the side-effects of medication; it is unclear how these could affect the utility scores and overall cost-effectiveness. Costs:The unit costs of drugs, medical staff and hospitalisations were clearly reported. Their resource use details were not presented, so it is not possible to ascertain how these unit costs were used. The unit costs appear to have been from relevant sources, and were appropriately inflated, where necessary, but it was unclear if the price year was 2011 or 2012. Analysis and results:Schizophrenia is a chronic, lifelong condition. The short time horizon was unlikely to have captured the long-term adherence and outcomes for patients with schizophrenia taking any of the medications. Probabilistic sensitivity analyses were conducted using pair-wise comparisons; it would have been more appropriate to present all comparisons simultaneously using cost-effectiveness acceptability curves or a cost-effectiveness acceptability frontier. The authors acknowledged some limitations: the adherence and hospitalisation rates might not have been valid for Croatia, as they were from elsewhere; the population was very specific; and the effects of adverse events on quality of life and costs were not assessed. Concluding remarks:The reporting was insufficient to allow a full critique of the methods. In addition to the limitations discussed, the lack of robust data on adherence and hospitalisations increases the uncertainty in the results. Funding Funded by Janssen, Belgium, manufacturer of paliperidone palmitate. Bibliographic details Jukic V, Jakovljevic M, Filipcic I, Herceg M, Silic A, Tomljanovic T, Zilbershtein R, Jensen RC, Hemels ME, Einarson TR. Cost-utility analysis of depot atypical antipsychotics for chronic schizophrenia in Croatia. Value in Health Regional Issues 2013; 2(2): 181-188 Other publications of related interest Einarson TR, Geitona M, Chaidemenos A, et al. Pharmacoeconomic analysis of paliperidone palmitate for treating schizophrenia in Greece. Annals of General Psychiatry 2012; 11: 18. Indexing Status Subject indexing assigned by CRD MeSH Antipsychotic Agents; Cost-Benefit Analysis; Croatia; Humans; Injections; Quality-Adjusted Life Years; Schizophrenia AccessionNumber 22013045658 Date bibliographic record published 08/11/2013 Date abstract record published 05/02/2014 |
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