Mickael Löthgren

The impact on schizophrenia-related hospital utilization and costs of switching to long-acting risperidone injections in Sweden

AimTo estimate changes in resource usage, hospitalization rates, and costs in actual practice in Sweden for schizophrenia patients after switching to long-acting injectable risperidone (Risperdal Consta).MethodsA retrospective chart review within-subject mirror-image study using actual practice chart review data was used to compare annual hospital bed-days and annual hospital episodes for adults with schizophrenia or schizoaffective disorder before and after switching to Risperdal Consta in the period 1 January 2003 to 30 June 2005. Secondary endpoints included mean length of hospital stay per episode, the cost of hospitalization, and the cost of antipsychotic treatment. The base case analytical approach allocated all hospital episodes overlapping the switch date entirely to pre-switch treatment. In order to investigate the impact of inpatient care ongoing at the time of the switch, the change in bed-days per year was also estimated using an alternative analytical approach inspired by economic modelling.ResultsOne-hundred sixty-four patients were enrolled at nine geographically diverse sites. The switch to Risperdal Consta was associated with a significant reduction in mean annual days in hospital from 39 to 21xa0days per year (45%), which was linked to a significant reduction in the number of hospitalizations from 0.86 to 0.63 per year (27%). The alternative “modelling-inspired” estimate of the reduction in mean annual days in hospital was also 27%.ConclusionA naturalistic mirror-image study found that switching to long-acting injectable risperidone led to sizeable reductions in inpatient resource use. These results coincide with the findings of other international studies.

Direct hospital resource utilization and costs of treating patients with multiple myeloma in Southwest Sweden: A 5-year retrospective analysis

BACKGROUNDnApproximately 570 patients are diagnosed with multiple myeloma (MM) in Sweden each year. Few studies have estimated the cost of treatment for these patients.nnnOBJECTIVEnThe purpose of this study was to retrospectively investigate the direct hospital resource utilization and costs associated with the treatment of patients with MM in southwest Sweden.nnnMETHODSnPatients aged > or =18 years who initiated first-line chemotherapy in the year 2001 at hospitals in southwestern Sweden were included in this retrospective chart review. Direct hospital-based resources and their corresponding costs (year-2006 euros) for each patient were calculated until the patients death, or until December 31, 2005. Costs for outpatient and terminal stage care related to MM were not included.nnnRESULTSnNinety-four patients were included; 20 were still alive at study completion. Mean age at diagnosis was 76 years and patients were followed for a mean of 32.7 months; 55% were males and 74% had at least 1 comorbidity. First-, second-, and third-line treatment lasted a mean of 24.3, 5.8, and 2.6 months, and included 2.8, 2.6, and 3.1 chemotherapy drugs per patient, respectively. Of the 80 patients who received first-line chemotherapy, 72 were prescribed melphalan and 55 patients received a combination of melphalan and prednisone, as recommended by Swedish treatment guidelines. The mean total cost per patient was euro88,199, or euro2770 per patient-month. Therapy-induced and comorbidity-related events constituted 42% of total costs, as much as autologous stem-cell transplantation and inpatient care together. Chemotherapy, bisphosphonate, and blood cell-enhancement drugs each amounted to only 2% of total costs, but chemotherapy drugs increased from euro29/month in first-line therapy to euro453/month in third-line therapy.nnnCONCLUSIONSnThe cost of treating Swedish patients with MM varied greatly between individuals but, overall, chemotherapy drugs constituted only a minor part of the total monthly cost (2%), whereas costs for inpatient stays and therapy-induced adverse events or comorbidity-related events accounted for 35% and42%, respectively. There was no significant differencein monthly cost between treatment lines.

Cost Effectiveness of Darunavir/Ritonavir 600/100 mg bid in Protease Inhibitor-Experienced, HIV-1-Infected Adults in Belgium, Italy, Sweden and the UK

AbstractBackground: Two phase II trials (POWER 1 and 2) have demonstrated that darunavir co-administered with low-dose ritonavir (DRV/r) provides significant clinical benefit compared with control protease inhibitors (PIs) in highly treatment-experienced, HIV-1-infected adults, when co-administered with optimized background therapy (OBR).n Objective: To determine whether DRV/r is cost effective compared with control PIs, from the perspective of Belgian, Italian, Swedish and UK reimbursement authorities, when used in treatment-experienced patients similar to those included in the POWER 1 and 2 trials.n Methods: An existing Markov model containing health states defined by CD4 cell count ranges (>500, 351–500, 201–350, 101–200, 51–100 and 0–50 cells/mm3) and death was adapted for use in four European healthcare settings. Baseline demographics, CD4 cell count distribution and antiretroviral drug usage reflected those reported in the POWER 1 and 2 trials. Virological/immunological response rates and matching transition probabilities over the patients lifetime were based on results from the POWER trials and published data. After treatment failure, patients were assumed to switch to a tipranavir-containing regimen plus OBR. For each CD4 cell count range, utility values and HIV-related mortality rates were obtained from the published literature. National all-cause mortality data and published data on the increased risk of non HIV-related mortality in HIV-infected individuals were taken into account in the model. Data from observational studies conducted in each healthcare setting were used to determine resource-use patterns and costs associated with each CD4 cell count range. Unit costs were derived from official local sources; a lifetime horizon was taken and discount rates were selected based on local guidelines.n Results: In the base-case analysis, quality-adjusted life-year (QALY) gains of up to 1.397 in Belgium, over 1.171 in Italy, 1.142 in Sweden and 1.091 in the UK were predicted when DRV/r-based therapy was used instead of control PI-based treatment. The base-case analyses predicted an incremental costeffectiveness ratio (ICER) of h11 438/QALY in Belgium, h12 122/QALY in Italy, h10 942/QALY in Sweden and h16 438/QALY in the UK. Assuming an acceptability threshold of h30 000/QALY, DRV/r-based therapy remained cost effective over all parameter ranges tested in extensive one-way sensitivity analyses. Probabilistic sensitivity analysis revealed a 95% (Belgium), 97% (Italy), 92% (Sweden) or 78% (UK) probability of attaining an ICER below this threshold.n Conclusion: From four European payer perspectives, DRV/r-based antiretroviral therapy is predicted to be cost effective compared with currently available control PIs, when both are used with an OBR in treatment-experienced, HIV-1-infected adults who failed to respond to more than one PI-containing regimen.

Cost effectiveness of long-acting risperidone in Sweden

BackgroundIn Sweden, risperidone long-acting injectable (RLAI) is generally used in a population of schizophrenia patients who are at a high risk of being non-compliant. However, RLAI might also be suitable for use in the general schizophrenia population.ObjectivesTo analyse the clinical and economic effects of RLAI in the Swedish treatment practice using a discrete-event simulation (DES) model. Treatment outcomes and direct costs were analysed for both the high-risk non-compliant patient population and the general schizophrenia population.MethodsAn existing DES model was adapted to simulate the treatment of schizophrenia in Sweden. Model inputs were based on literature research and supplemented with expert opinion. In the high-risk non-compliant schizophrenia population, RLAI was compared with haloperidol LAI. The analysis was built upon differences in symptom reduction, time between relapses, compliance and adverse effect profile between the two drugs. Main outcomes were the predicted incremental (discounted) costs (€) and effects (QALYs). In the general schizophrenia population, RLAI was compared with oral olanzapine. This analysis was built upon differences in compliance and adverse effects between the drugs. Multivariate probabilistic sensitivity analyses (PSA) were carried out to assess the sensitivity of the results of the two analyses.ResultsIn the high-risk non-compliant patient population, RLAI was predicted to generate 0.103 QALYs per patient over 3 years while realizing cost savings of €5013 (year 2007 values) compared with haloperidol LAI. The main driver of the cost effectiveness of RLAI was the difference in Positive and Negative Syndrome Scale (PANSS) reduction between the two drugs, followed by the difference in adverse effects. The PSA showed that, in this setting, RLAI had a probability of 100% of being cost effective at a willingness-to-pay (WTP) threshold of €43 300 per QALY gained, compared with haloperidol LAI. The probability that RLAI combines additional effectiveness with cost savings compared with haloperidol LAI was estimated at 94%.When analysing RLAI in the general schizophrenia population, it was predicted to generate 0.043 QALYs and save €239 per patient over 5 years compared with olanzapine. Compliance was the main driver of the cost effectiveness of RLAI in this scenario. In the PSA it was shown that RLAI had a probability of 78% of being cost effective at a WTP threshold of €43 300 per QALY gained, compared with olanzapine. The estimated probability that RLAI combines additional effectiveness with cost savings was 50% and the probability that RLAI is less effective and more costly than olanzapine was negligible (0.2%).ConclusionsTreatment with RLAI is suggested to result in improved QALYs combined with cost savings compared with haloperidol LAI among the Swedish, high-risk non-compliant schizophrenia patient population. In the general schizophrenia population, RLAI also resulted in positive incremental QALYs and cost savings, when compared with olanzapine. However, the estimates used in the model for compliance and symptom reduction need further validation through naturalistic-based studies with reasonable follow-up to more definitely establish the real-life differences between RLAI and the comparators in the considered patient populations and to further reduce the uncertainty of these parameters.

A Pharmacoeconomic Analysis of Compliance Gains on Antipsychotic Medications

BackgroundCompliance among patients with schizophrenia is typically poor. Consequently, treatments that are equally efficacious under trial-based conditions but face different compliance rates in clinical practice (e.g. due to adverse-effect profile, ease of use, reputation) may have differences in effectiveness not observed during trials. This study analyses the impact of differences in compliance with atypical antipsychotics using a pharmacoeconomic discrete-event simulation (DES) model, adapted to the Swedish treatment setting.MethodsAn existing 5-year DES model was adapted to reflect a Swedish setting; the analysis was conducted from a third-party payer perspective, with only direct costs included.The two treatment arms were identical except for percentage of compliant patients. Non-compliant patients experienced shorter time between relapses and had inferior symptom control than their compliant counterparts. The difference in compliance rates was varied from 0% to 15%, and incremental costs and effects were recorded and analysed.ResultsWith a 5%, 10% and 15% difference in compliance rate, incremental effects increased to 0.021, 0.037 and 0.062, respectively, while generating cost savings of Swedish kronor (SEK)31 500, SEK62 000 and SEK104 500, respectively (SEK9.25 = €1, year 2007 values). Hence, each percentage point of compliance gain is predicted to roughly result in a cost saving of SEK6000 and a QALY gain of 0.004. On average, the model predicts that, with a 15% increase in compliance, 0.5 relapses are prevented, the average Positive And Negative Syndrome Scale (PANSS) score decreases by 3.3 points and patients spend 22 fewer days in hospital over 5 years.ConclusionsThe DES model predicts that increases in compliance may lead to considerable cost savings and health improvements. Therefore, when determining the cost effectiveness of a new antipsychotic, efficacy rates from clinical trials should not be taken at face value, but should be interpreted in tandem with expectations concerning compliance, in light of product characteristics such as adverse effects. These results further suggest that efforts to improve compliance among patients with schizophrenia are expected to prove cost effective if compliance gains and the resulting health improvements and cost savings are in balance with the additional costs.

Hospitalisation Utilisation and Costs in Schizophrenia Patients in Finland before and after Initiation of Risperidone Long-Acting Injection

Objectives. Quantify changes in hospital resource use in Finland following initiation of risperidone long-acting injection (RLAI). Materials and Methods. A retrospective multi-center chart review (naturalistic setting) was used to compare annual hospital bed-days and hospital episodes for 177 schizophrenia patients (mean age 47.1 years, 52% female, 72% hospitalized) before and after initiation of RLAI (between January 2004 and June 2005) using the within-patient “mirror-image” study design. The base case analytical approach allocated hospital episodes overlapping the start date entirely to the preinitiation period. In order to investigate the impact of inpatient care ongoing at baseline, the change in bed-days was also estimated using an alternative analytical approached related to economic modelling. Results. In the conventional analysis, the mean annual hospitalisation costs declined by €11,900 and the number of bed-days was reduced by 40%, corresponding to 0.19 fewer hospital episodes per year. The reductions in bed-days per patient-year were similar for patients switched to RLAI as inpatients and as outpatients. In the modelling-based analysis, an 8% reduction in bed-days per year was observed. Conclusion. Despite uncertainty in the choice of analytic approach for allocating inpatient episodes that overlapping this initiation, consistent reductions in resource use are associated with the initiation of RLAI in Finland.

Medical Resource Utilization and Cost of HIV-Related Care in the Highly Active Antiretroviral Therapy Era at a University Clinic in Sweden

AbstractIntroduction: Little is known regarding healthcare costs for HIV/AIDS patients in the era of highly active antiretroviral therapy (HAART) and subgroups of patients according to the severity and progression of HIV infection in Sweden. The objective of this study is therefore to describe the direct medical resource use and cost of healthcare for HIV patients at a university clinic in Sweden.n Methods: A patient registry database for HIV treatment at the Department of Infectious Diseases, Sahlgrenska University Hospital, between 2000 and 2005 provided information on patient characteristics, antiretroviral drugs and dosages, tests and diagnostic procedures, outpatient visits and inpatient stays. The review used publicly available unit costs with a county council perspective, expressed in 2006 Euros.n Results: Two hundred and eighty-five patients with a mean age of 38 years in 2000 (64% men) were followed for 1368 patient-years. They had a mean (median) of 6.3 (0) inpatient days, 4.1 (3.7) physician visits, 4.2 (3.8) nurse visits, 2.6 (0.7) counsellor visits and 11.5 (7.7) tests and diagnostic procedures per patient-year. Only 12 deaths were recorded during the study period, and the proportion of treated patients with successful treatment (HIV-RNA <50 copies/mL) increased from 74% to 92% during the period. The mean cost per patient-month amounted to h1069. The main cost driver was HIV drugs (51%), followed by inpatient stays (including hospitalizations for opportunistic infections; 22%), outpatient physician, nurse or therapist visits (19%) and diagnostics and tests (7%). All non-drug costs increased with a decreasing CD4 cell count.n Conclusions: Overall, approximately half of the direct costs of HIV treatment were not related to antiretroviral treatment. The non-antiretroviral costs were inversely correlated with HIV-induced immune deficiency.

Predicting Direct Costs of HIV Care During the First Year of Darunavir-Based Highly Active Antiretroviral Therapy Using CD4 Cell Counts: Evidence from POWER

AbstractBackground: Given the association between CD4 cell counts and HIV-related morbidity/mortality, new antiretroviral therapies could potentially lower the direct costs of HIV care by raising CD4 cell counts.n Objectives: To predict the effects of the ritonavir-boosted, HIV protease inhibitor (PI) darunavir on the direct costs of care, while accounting for CD4 cell counts, during the first year of therapy in highly treatment-experienced, HIV-infected adults in different healthcare settings.n Methods: The mean annual per-patient cost of darunavir/ritonavir (DRV/r) and control PI-based highly active antiretroviral therapy (HAART) was calculated from the proportional use of antiretroviral agents in the DRV/r and control PI arms of the pooled POWER 1 and 2 trials, applying drugacquisition costs for five healthcare settings. Non-antiretroviral-related costs by CD4 cell count, derived from non-interventional studies in the same settings, were applied to the POWER data (proportion of patients with CD4 cell counts in different strata at week 48) to estimate mean annual nonantiretroviral-related costs per patient in patients receiving DRV/r or control PI-based HAART during year 1.n Results: Across all settings, the mean annual per-patient cost of DRV/r-based treatment was 2–19% higher than that of control PI-based therapy during the first year of therapy. By raising CD4 cell counts, however, DRV/r-based regimens were predicted to lower mean annual non-antiretroviral-related costs by 16–38% compared with control PI-based therapy. When combined, the total annual per-patient cost of HIV care during the first year of therapy was estimated to be 7%lower in the DRV/r compared with the control PI arm using US data, 8% lower using Swedish data, budget neutral using UK and Belgian data and 5% higher using Italian data.n Conclusions: Darunavir-based HAART may lower non-antiretroviral-related costs comparedwith control PI-based therapy in highly treatment-experienced, HIV-infected patients during the first year of therapy by improving patients CD4 cell counts. These costs could partly/fully offset the increased acquisition cost of DRV/r in this patient population over the same period.