Rashid Kazerooni

Cost Utility of Tumour Necrosis Factor-α Inhibitors for Rheumatoid Arthritis

BackgroundRheumatoid arthritis (RA) is a chronic autoimmune disease that affects approximately 1.5 million people in the US. Tumour necrosis factor (TNF)-α inhibitors have been shown to effectively treat and maintain remission in patients with moderately to severely active RA compared with conventional agents. The high acquisition cost of TNF-α inhibitors prohibits access, which mandates economic investigations into their affordability. The lack of head-to-head comparisons between these agents makes it difficult to determine which agent is the most cost effective.ObjectiveThis study aimed to determine which TNF-α inhibitor was the most cost-effective agent for the treatment of moderately to severely active RA from the US healthcare payer’s perspective.MethodsA Markov model was constructed to analyse the cost utility of five TNF-α inhibitors (in combination with methotrexate [+MTX]) versus MTX monotherapy using Bayesian methods for evidence synthesis. The model had a cycle length of 3 months and an overall time horizon of 5 years. Transition probabilities and utility scores were based on published studies. Total direct costs were adjusted to year 2009

Cost Utility of Tumour Necrosis Factor-α Inhibitors for Rheumatoid Arthritis: An Application of Bayesian Methods for Evidence Synthesis in a Markov Model

US using the medical component of the Consumer Price Index. All costs and QALYs were discounted at a rate of 3% per year. Patient response to the different strategies was determined by the American College of Rheumatology (ACR)50 criteria. One-way and probabilistic sensitivity analyses (PSAs) were performed to test the robustness of the base-case scenario. The base-case scenario was changed to ACR20 criteria (scenario 1) and ACR70 criteria (scenario 2) to determine the model’s robustness. Cost-effectiveness acceptability curves and cost-effectiveness frontiers were used to estimate the cost-effectiveness probability of each treatment strategy. A willingness-to-pay (WTP) threshold was defined as three times the US GDP per capita (

Retrospective Evaluation of Inpatient Celecoxib Use After Total Hip and Knee Arthroplasty at a Veterans Affairs Medical Center

US139143 per additional QALY gained). Primary results were presented as incremental cost-effective ratios (ICERs).ResultsEtanercept+MTX was the most cost-effective treatment strategy in the base-case scenario up to a WTP threshold of

Association of Copayment and Statin Adherence Stratified by Socioeconomic Status

US2185497 per QALY gained. At a WTP threshold of greater than

Association Between Statin Adherence and Cholesterol Level Reduction from Baseline in a Veteran Population

US2 185 497 per QALY gained, certolizumab+MTX was the most cost-effective treatment strategy. One-way analyses showed that the base-case scenario was sensitive to the probability of achieving ACR50 criteria for MTX and each TNF-α inhibitor, and changes in the utility score for patients who achieved the ACR50 criteria. With the exception of infliximab, all of the TNF-α inhibitors were sensitive to drug cost per cycle. In the scenario analyses, certolizumab+MTX was a dominant treatment strategy using ACR20 criteria, but etanercept+MTX was a dominant treatment strategy using ACR70 criteria.ConclusionsEtanercept+MTX was a cost-effective treatment strategy in the base-case scenario; however, the model was sensitive to parameter uncertainties and ACR response criteria. Although Bayesian methods were used to determine transition probabilities, future studies will need to focus on head-to-head comparisons of multiple TNF-α inhibitors to provide valid comparisons.

Predictors of adherence to hormonal contraceptives in a female veteran population.

Background:Background: Rheumatoid arthritis (RA) is a chronic autoimmune disease that affects approximately 1.5 million people in the US. Tumour necrosis factor (TNF)-α inhibitors have been shown to effectively treat and maintain remission in patients with moderately to severely active RA compared with conventional agents. The high acquisition cost of TNF-α inhibitors prohibits access, which mandates economic investigations into their affordability. The lack of head-to-head comparisons between these agents makes it difficult to determine which agent is the most cost effective. Abstract: Objective:Objective: This study aimed to determine which TNF-α inhibitor was the most cost-effective agent for the treatment of moderately to severely active RA from the US healthcare payers perspective. Abstract: Methods:Methods: A Markov model was constructed to analyse the cost utility of five TNF-α inhibitors (in combination with methotrexate l+MTXr) versus MTX monotherapy using Bayesian methods for evidence synthesis. The model had a cycle length of 3 months and an overall time horizon of 5 years. Transition probabilities and utility scores were based on published studies. Total direct costs were adjusted to year 2009 dUS using the medical component of the Consumer Price Index. All costs and QALYs were discounted at a rate of 3% per year. Patient response to the different strategies was determined by the American College of Rheumatology (ACR)50 criteria. One-way and probabilistic sensitivity analyses (PSAs) were performed to test the robustness of the base-case scenario. The base-case scenario was changed to ACR20 criteria (scenario 1) and ACR70 criteria (scenario 2) to determine the models robustness. Cost-effectiveness acceptability curves and cost-effectiveness frontiers were used to estimate the cost-effectiveness probability of each treatment strategy. A willingness-to-pay (WTP) threshold was defined as three times the US GDP per capita (dUS139 143 per additional QALY gained). Primary results were presented as incremental cost-effective ratios (ICERs). Abstract: Results:Results: Etanercept+MTX was the most cost-effective treatment strategy in the base-case scenario up to a WTP threshold of dUS546 449 per QALY gained. At a WTP threshold of greater than dUS546 499 per QALY gained, certolizumab+MTX was the most cost-effective treatment strategy. One-way analyses showed that the base-case scenario was sensitive to the probability of achieving ACR50 criteria for MTX and each TNF-α inhibitor, and changes in the utility score for patients who achieved the ACR50 criteria. With the exception of infliximab, all of the TNF-α inhibitors were sensitive to drug cost per cycle. In the scenario analyses, certolizumab+MTX was a dominant treatment strategy using ACR20 criteria, but etanercept+MTX was a dominant treatment strategy using ACR70 criteria. Abstract: Conclusions:Conclusions: Etanercept+MTX was a cost-effective treatment strategy in the base-case scenario; however, the model was sensitive to parameter uncertainties and ACR response criteria. Although Bayesian methods were used to determine transition probabilities, future studies will need to focus on head-to-head comparisons of multiple TNF-α inhibitors to provide valid comparisons.

Association of Copayment and Socioeconomic Status with Hormonal Contraceptive Adherence in a Female Veteran Population

A retrospective cohort study (1.5 years) was performed to investigate the efficacy of celecoxib vs non-celecoxib use in patient who underwent total knee arthroplasty (TKA) and total hip arthroplasty (THA). Study time frame encompassed a pre and post period of a local policy decision opening access to short-term celecoxib use after TKA/THA. Primary end point was the amount of opioid use during their inpatient stay postprocedure. The TKA (n = 81) and THA (n = 60) groups were analyzed independently. Both celecoxib groups used significantly less opioids during their inpatient stay vs noncelecoxib groups, given in oral morphine milligram equivalents (TKA: 203 vs 337 mg, P = .002; THA: 214 vs 336 mg, P = .005). Other secondary outcome measures showed that the celecoxib groups also reported reduction in pain scores, total as needed (PRN) opioid doses, PRN opioid doses per day, average dose of PRN opioids, total PRN opioids, use of intravenous opioids, and rehabilitation facility admissions (in the TKA group only). Linear regression analysis showed a statistically significant inverse relationship between opioid consumption and age. Short-term celecoxib use after TKA/THA may lead to a reduction in overall opioid use and improved pain scores; however, further studies will be required to validate the results of this study.

Predictors of Pregnancy in Female Veterans Receiving a Hormonal Contraceptive Pill, Patch, or Ring

Background: There is a growing body of evidence supporting means testing out of copayment for high-value therapies such as statins. Objective: To investigate association between statin adherence and copayment when stratified by socioeconomic status. Methods: This was a retrospective cohort study set in a network of VA facilities that includes Southern California and Nevada, with an enrollment of 1.4 million veterans. Socioeconomic status was estimated using zip code median household income. Differences in medication possession ratio (MPR) associated with copayment was the primary outcome measure. Odds of attaining low-density lipoprotein cholesterol (LDL) <100 mg/dL was the secondary outcome measure. Separate regression models for each income quintile were performed for each outcome measure, respectively. Results: A total of 4748 patients were included in the analysis. Patients in quintiles two (−0.057, 95% confidence interval [CI] = −0.095 to −0.020) and three (−0.044, CI = −0.081 to −0.007) had statistically significant decreases in MPR associated with having a copayment versus not having a copayment. Quintiles two (odds ratio [OR] = 0.68; 95% CI = 0.47 to 0.98) and three (OR = 0.66; 95% CI = 0.45 to 0.96) also had lower odds of attaining LDL <100 mg/dL when having a copayment. Patients in higher earning quintiles (four and five) did not show any associations with copayment. Conclusion: In the veteran population studied, the association of statin copayment status with adherence varied by socioeconomic status. Middle-income and lower-middle-income patients were more likely to have adherence negatively influenced by having a copayment for statin therapy.

A tobacco cessation treatment model using telehealth: a pilot evaluation in Veterans

To investigate the association between statin adherence and changes in lipid panel outcomes from baseline in a veteran population.

Topiramate-Associated Weight Loss in a Veteran Population

OBJECTIVE The objective was to identify predictors of adherence to hormonal contraceptives in a female veteran population. STUDY DESIGN This was a retrospective cohort study of female veterans from the VA San Diego Healthcare System. The study period was April 1, 2010, to March 31, 2012. Each patient was followed for 1 year from the index date, defined as the date of first contraceptive prescription in the study time period. Adherence was defined as a medication possession ratio ≥ 0.9. Income was estimated using zip-code-based median household income and split into quintiles (quintile 1 being the lowest-earning group). Logistic regression was used to analyze the association between adherence and the independent variables. RESULTS A total of 805 patients were included in the final analysis. The majority of the population was white (62.2%) and receiving a 3-month supply of medication (87.6%). The following independent variables were predictive of increased adherence: 3-month supply versus 1-month supply [odds ratio (OR) 1.79, 95% confidence interval (CI) 1.03-3.13], age group 40-45 versus 18-24 (OR 2.57, 95% CI 1.16-5.70) and income quintiles 3 (OR 1.96, 95% CI 1.16-3.29), 4 (OR 1.77, 95% CI 1.06-2.98) and 5 (OR 1.75, 95% CI 1.03-2.98) each versus quintile 1 as reference group. The following were associated with decreased adherence: new start versus continuing user (OR 0.25, 95% CI 0.18-0.37), OB/GYN provider versus primary care provider (OR 0.60, 95% CI 0.38-0.95), and highest weight group versus lowest weight group (OR 0.40, 95% CI 0.17-0.94). CONCLUSION Hormonal contraceptive adherence in the veteran population is below optimal. Providing 3-month supplies of high-value therapies such as hormonal contraceptives is one strategy that may improve adherence. Initiatives to target lower socioeconomic status or new start populations to increase contraceptive adherence should also be considered. IMPLICATIONS Adherence to hormonal contraceptives is not as well studied in the literature as some other high-value therapies. Identifying predictive variables for adherence may have implications for establishing possible interventions, or refining benefit structures, in order to increase adherence.