Ingrid Lekander

Cost-effectiveness of etanercept treatment in early active rheumatoid arthritis followed by dose adjustment.

OBJECTIVES To explore the cost-effectiveness of early biologic treatment, followed by dose-reduction in the case of remission, of active rheumatoid arthritis (RA), compared with standard treatment with methotrexate (MTX) in Sweden. METHODS Effectiveness (function, disease activity, erosions) in early RA for both alternatives was taken from a clinical trial comparing etanercept (ETA) combined with MTX to MTX alone. Patients discontinuing treatment can switch to another or their first biologic treatment. For patients in remission (Disease Activity Score [DAS28] < 2.6), ETA is reduced to half the dose. Return to full dose occurs when DAS28 reaches ≥ 3.2 again. Costs and utilities by level of functional capacity from an observational study are used. The model is analyzed as a micro-simulation and results are presented from the societal perspective for Sweden, for 10 years; costs (€2008) and effects are discounted at 3 percent. Sensitivity analysis was performed for the perspective, the time horizon, switching, and dose-reduction. RESULTS The main analysis conservatively assumes 50 percent switching at discontinuation. The cost per quality-adjusted life-year (QALY) gained with early ETA/MTX treatment is €13,500 (societal perspective, incremental cost of €15,500 and incremental QALYs of 1.15). With 75 percent switching, the cost per QALY gained was €10,400. Over 20 years, the cost per QALY gained was €8,200. Results were further sensitive to the time patients remained on half dose and the perspective. CONCLUSIONS AND POLICY IMPLICATIONS: This study combines clinical trial and clinical practice data to explore cost-effective treatment scenarios in early RA, including the use of biologics. Our results indicate that a situation where a considerable proportion of patients achieve remission, dose-adjustments will increase the cost-effectiveness of treatment.

Cost-effectiveness of real-world infliximab use in patients with rheumatoid arthritis in Sweden

OBJECTIVES The objective of this study was to estimate the cost-effectiveness of infliximab use in patients with rheumatoid arthritis (RA) in Swedish clinical practice, based on patient-level data from the Stockholm TNF-alpha follow-up registry (STURE). METHODS Real-world patient-level data on infliximab use from the STURE registry were implemented in a Markov cohort model, in which health states of functional status were classified according to the Health Assessment Questionnaire Disability Index (HAQ-five categories) and twenty-eight joint count Disease Activity Score (DAS28). The transition probabilities between HAQ and DAS28 states during treatment, as well as discontinuation rates were modeled based on data from the registry for patients using infliximab as their first-line biological treatment. The transition probabilities in the comparator arm, that is, disease progression without biologic treatment, as well as mortality rates, costs, and utilities were based on published literature. The analysis had a societal cost perspective. RESULTS Infliximab was associated with an incremental gain in quality-adjusted life-years of 1.02 and an incremental cost of 23,264 euros per patient compared with progression without biologic treatment, producing an incremental cost-effectiveness ratio (ICER) of 22,830 euros (SEK211,136 or US

Cost-Effectiveness of Hormone Therapy in the United States

31,230). Sensitivity analyses of input parameters and model assumptions produced ICERs in the range from 18,000 euros to 47,000 euros. CONCLUSIONS Results from base-case and sensitivity analyses fell well below established benchmarks for cost-effectiveness in Sweden. The results, therefore, indicated that infliximab treatment for RA has provided good societal value for money in Swedish clinical practice, compared with a scenario of no biological treatment.

Relationship between functional disability and costs one and two years post stroke

OBJECTIVE To estimate the cost-effectiveness of 5 years of treatment with hormone therapy (HT) compared with no treatment for women with menopausal symptoms in the United States. METHODS A Markov cohort simulation model was used with tunnel techniques to assess the cost-effectiveness of HT in women aged 50 years, based on a societal perspective. Clinical data, where possible, used results taken from the Women Health Initiative (WHI). The model had a lifetime horizon with cycle lengths of 1 year and contained the following disease states: hip fracture, vertebral fracture, wrist fracture, breast cancer, colorectal cancer, coronary heart disease, stroke, and venous thromboembolic events. An intervention was modelled by its impact on the disease risks during and after stopping treatment. The model required data on clinical effects, risks, mortality rates, quality of life weights, and costs. The main outcome of the model was cost per quality-adjusted life-year (QALY) gained on HT compared with no treatment. RESULTS The results indicated that it was cost-effective to treat women with menopausal symptoms with HT in the United States. The severity of menopausal symptoms was the single most important determinant of cost-effectiveness, but HT remained cost-effective even where symptoms were mild or effects on symptom relief were small. CONCLUSIONS Treatment of women with menopausal symptoms with HT is cost-effective.

Cost-effectiveness of hormone replacement therapy for menopausal symptoms in the UK

Background and purpose Stroke affects mortality, functional ability, quality of life and incurs costs. The primary objective of this study was to estimate the costs of stroke care in Sweden by level of disability and stroke type (ischemic (IS) or hemorrhagic stroke (ICH)). Method Resource use during first and second year following a stroke was estimated based on a research database containing linked data from several registries. Costs were estimated for the acute and post-acute management of stroke, including direct (health care consumption and municipal services) and indirect (productivity losses) costs. Resources and costs were estimated per stroke type and functional disability categorised by Modified Rankin Scale (mRS). Results The results indicated that the average costs per patient following a stroke were 350,000SEK/€37,000–480,000SEK/€50,000, dependent on stroke type and whether it was the first or second year post stroke. Large variations were identified between different subgroups of functional disability and stroke type, ranging from annual costs of 100,000SEK/€10,000–1,100,000SEK/€120,000 per patient, with higher costs for patients with ICH compared to IS and increasing costs with more severe functional disability. Conclusion Functional outcome is a major determinant on costs of stroke care. The stroke type associated with worse outcome (ICH) was also consistently associated to higher costs. Measures to improve function are not only important to individual patients and their family but may also decrease the societal burden of stroke.

Hospital comparison of stroke care in Sweden : A register-based study

Objective To estimate the cost-effectiveness of five-year treatment of hormone replacement therapy (HRT) compared with no treatment for women with menopausal symptoms in the UK. Method A Markov cohort simulation model with tunnel techniques was used to assess the cost-effectiveness of HRT in women aged 50 years. For the clinical effects of HRT we used, where possible, results taken from the Womens Health Initiative (WHI). The model had a life-time horizon with cycle lengths of one year and contained the following disease states: hip fracture, vertebral fracture, wrist fracture, breast cancer, colorectal cancer, coronary heart disease, stroke and venous thromboembolic events. An intervention was modelled by its impact on the disease risks during and after stopping treatment. The model was populated with UK-specific data on risks, mortality rates, quality-of-life weights and costs. The main outcome of the model was cost per quality-adjusted life year (QALY) gained of HRT compared with no treatment. Results The results indicated that it was cost-effective to treat women with menopausal symptoms with HRT in the UK. The severity of menopausal symptoms was the single most important determinant of cost-effectiveness, but HRT remained cost-effective even where symptoms were mild or effects on symptom relief were small. Conclusions Treatment of women with menopausal symptoms with HRT is cost-effective.

Cost effectiveness of hormone therapy in women at high risks of fracture in Sweden, the US and the UK--results based on the Women's Health Initiative randomised controlled trial

Background and purpose The objective of this study was to estimate the level of health outcomes and resource use at a hospital level during the first year after a stroke, and to identify any potential differences between hospitals after adjusting for patient characteristics (case mix). Method Data from several registries were linked on individual level: seven regional patient administrative systems, Swedish Stroke Register, Statistics Sweden, National Board of Health and Welfare and Swedish Social Insurance Agency. The study population consisted of 14 125 patients presenting with a stroke during 2010. Case-mix adjusted analysis of hospital differences was made on five aspects of health outcomes and resource use, 1 year post-stroke. Results The results indicated that 26% of patients had died within a year of their stroke. Among those who survived, almost 5% had a recurrent stroke and 40% were left with a disability. On average, the patients had 22 inpatient days and 23 outpatient visits, and 13% had moved into special housing. There were significant variations between hospitals in levels of health outcomes achieved and resources used after adjusting for case mix. Conclusion Differences in health outcomes and resource use between hospitals were substantial and not entirely explained by differences in patient mix, indicating tendencies of unequal stroke care in Sweden. Healthcare organisation of regions and other structural features could potentially explain parts of the differences identified.