Mohan V. Bala

Treatment patterns and distribution of low-density lipoprotein cholesterol levels in treatment-eligible united states adults

To estimate the fraction of United States (U.S.) adults who are eligible for treatment to reduce elevated low-density lipoprotein (LDL) cholesterol levels based on Adult Treatment Panel II (ATP II) guidelines and the percent reduction in LDL cholesterol required by those who qualify for treatment, we analyzed data on 7,423 respondents to Phase 2 of the third National Health and Nutrition Examination Survey (NHANES III) administered between 1991 and 1994. Approximately 28% of the U.S. adult population aged > or = 20 years is eligible for treatment based on ATP II guidelines. Eighty-two percent of adults with coronary heart disease are not at their target LDL cholesterol level of 100 mg/dl. Of those eligible for treatment, 65% report that they receive no treatment. Overall, 40% of people who qualify for drug therapy require an LDL cholesterol reduction of > 30% to meet their ATP II treatment goal. Approximately 75% of those with coronary heart disease who qualify for drug therapy require an LDL cholesterol reduction of >30%. Although elevated LDL cholesterol levels can be treated, prevalence rates in the U.S. adult population remain high. Several recent studies indicate that a considerable percentage of people treated with drug therapy do not reach their treatment goals. The findings in this study provide at least a partial explanation for why many patients receiving therapy do not reach their treatment goals: they require a larger reduction in LDL cholesterol than many therapies can provide.

Willingness to Pay as a Measure of Health Benefits

In this paper, we discuss the use of cost-benefit analysis (CBA) for evaluating new healthcare interventions, present the theoretical basis for the use of willingness to pay as a method for valuing benefits in a CBA and describe how to obtain willingness-to-pay (WTP) measures of health benefits and how to use these values in a CBA.We review selected economic studies on consumer demand and consumer surplus and studies presenting WTP estimates for healthcare interventions. The theoretical foundations of willingness to pay as a measure of commodity value are rooted in consumer demand theory. The area under the fixed income consumer demand curve represents the consumer’s maximum willingness to pay for the commodity. We identify 3 types of potential benefits from a new healthcare intervention, namely patient benefits, option value and altruistic value, and suggest WTP questions for valuing different combinations of these benefits. We demonstrate how responses to these questions can be adjusted for income effects and incorporated into economic evaluations.We suggest that the lack of popularity of CBAs in the health area is related to the perceived difficulty in valuing health benefits as well as concern over how CBA incorporates the distribution of income. We show that health benefits can be valued using simple survey techniques and that these values can be adjusted to any desired income distribution.

Potential Savings in the Cost of Caring for Alzheimer’s Disease

AbstractObjective: To estimate savings in the cost of caring for patientswith Alzheimer’s disease (AD) during 6 months, 1 year and 2 years of treatment with rivastigmine. An intermediate objective was to estimate the relationship between disease progression and institutionalisation.Design and setting: We assessed the relationship between Mini-Mental State Examination (MMSE) score and institutionalisation using a piecewise Cox proportional hazard model. To estimate cost savings from treatments lasting 6 months, 1 year and 2 years, estimates of the probability of institutionalisation were integrated with data from two 6-month phase III clinical trials of rivastigmine and a hazard model of disease progression.Main outcome measures and results: Our data suggest that savings in the overall cost of caring for patients with mild and moderate AD can be as high as

Are QALYs an appropriate measure for valuing morbidity in acute diseases

US4839 per patient after 2 years of treatment. Furthermore, the probability of institutionalisation increases steadily as MMSE score falls. Among our study individuals, age, race, level of education and marital status were significant predictors of institutionalisation, whereas gender had little effect.Conclusions: Using rivastigmine to treat AD results in a delay in disease progression for patients who begin treatment during the mild or moderate stages of the disease. By delaying the probability that a patient will be institutionalised, the cost of caring for AD patients can be significantly reduced.

Cost Effectiveness of Pramipexole in Parkinson's Disease in the US

In this paper, we examine the problems associated with using quality adjusted life years (QALYs) as the measure of effectiveness to evaluate interventions for acute conditions. We illustrate the way in which using commonly accepted benchmarks for costs per QALY, in order to adopt interventions for acute conditions, might result in decisions that are not consistent with maximizing net societal benefit. We suggest that an alternate methodology, such as willingness to pay, may be more appropriate to make allocation decisions for acute conditions.

Optimal assignment of treatments to health states using a Markov decision model: An introduction to basic concepts

AbstractObjective: Pramipexole was recently approved in the US for treatment of the symptoms of idiopathic Parkinson’s disease (PD). Although pramipexole has been found to be safe and efficacious when compared with placebo, little data are yet available on its cost effectiveness when compared with baseline treatment. The aim of this study was to estimate the costs and cost effectiveness (cost utility) of pramipexole compared with baseline treatment in patients with early and advanced PD. Design and Setting: We developed a cost-effectiveness (CE) model in the US setting that linked Unified Parkinson’s Disease Rating Scale (UPDRS) Parts II (activities of daily life) and III (motor) scores to disease progression, costs and patient utility. Data for the model were obtained from clinical trials, a literature review and a survey of 193 patients’ health resource use and utility. We used cost and quality-adjusted life-year (QALY) estimates from the model to estimate the incremental cost effectiveness of pramipexole relative to baseline treatment patterns. We performed separate analyses for patients with early and advanced PD. We also performed extensive sensitivity analyses by adding other dopamine agonists to the no-pramipexole treatment regimen and varying disease progression parameters. The study was conducted from the societal perspective, although data presentation allows interpretation of cost effectiveness from either the societal or payer perspective. Main Outcome Measures and Results: For patients with both early and advanced PD, treatment with pramipexole had higher costs but was more effective than baseline treatment. For patients with early onset of PD, the incremental total CE ratio for pramipexole was

Pharmacogenomics and the evolution of healthcare: Is it time for cost-effectiveness analysis at the individual level?

US8837/QALY. For patients with advanced PD, the incremental CE ratio was

The Estimation and use of Confidence Intervals in Economic Analysis

US12 294/QALY (1997 costs). These ratios were lower than the CE ratios of many widely used medical treatments. Conclusions: Subject to the inherent limitations of modelling chronic disease progression and subsequent healthcare costs and patient utility, the results suggested that pramipexole was a cost effective treatment for patients with early and advanced PD in the US.

On pharmacogenomics and cost-effectiveness analysis at the individual level

Assessing the cost effectiveness of a new health intervention often requires modelling to estimate the impact of the intervention on cost, survival and quality of life over the lifetime of a cohort of patients. Markov modelling is a methodology that is commonly employed to estimate these long-term costs and benefits. As commonly used, these models assume that the patients continue to get the treatments assigned regardless of the change in health states. In this paper, we describe an extension to the Markov modelling approach, called Markov decision modelling. Such a model starts with a set of health states and treatments and optimally assigns treatments to each of the health states.A Markov decision model can be used to identify the optimal treatment strategy not just for the initial disease state, but also as the disease state changes over time. We present a dynamic programming approach to identifying the optimal assignment of treatments, and illustrate this methodology using an example.The Markov decision modelling approach provides an efficient way of identifying optimal assignment of treatments to health states, but, like the standard Markov model, may be of limited use when probabilities of future events depend on past history in a complex fashion. Even with its limitations, Markov decision models offer an opportunity for health economists to inform healthcare decision-makers on how to modify current treatment pathways to incorporate new treatments as they become available.

Economic Value of Thrombolysis with Adjunctive Abciximab in Patients with Subacute Peripheral Arterial Occlusion

AbstractThe efficacy and toxicity of any given drug can vary substantially from one individual to another. The heterogeneity in individual genetics contributes, in part, to this variability. Pharmacogenomics uses each patient’s individual genetic information to identify the drug with the best efficacy-safety profile for that patient. However, heterogeneity is also present in individuals’ preferences for alternate efficacy-safety profiles. We argue that as healthcare evolves towards individualised drug therapy, preference elicitation and cost-effectiveness analysis should also be performed at the individual level to maximise societal welfare.