Saskia Schawo

Probabilistic Markov Model Estimating Cost Effectiveness of Methylphenidate Osmotic-Release Oral System Versus Immediate-Release Methylphenidate in Children and Adolescents: Which Information is Needed?

BackgroundIncidence of attention deficit hyperactivity disorder (ADHD) in children and adolescents has been increasing. The disorder results in high societal costs. Policymakers increasingly use health economic evaluations to inform decisions on competing treatments of ADHD. Yet, health economic evaluations of first-choice medication of ADHD in children and adolescents are scarce and generally do not include broader societal effects.ObjectivesThis study presents a probabilistic model and analysis of methylphenidate osmotic-release oral system (OROS) versus methylphenidate immediate-release (IR). We investigate and include relevant societal aspects in the analysis so as to provide cost-effectiveness estimates based on a broad societal perspective.MethodsWe enhanced an existing Markov model and determined the cost effectiveness of OROS versus IR for children and adolescents responding suboptimally to treatment with IR. Enhancements included screening of a broad literature base, updated utility values, inclusion of costs and effects on caregivers and a change of the model type from deterministic to probabilistic.ResultsThe base case scenario resulted in lower incremental costs (€−5815) of OROS compared with IR and higher incremental quality-adjusted life-year (QALY) gains (0.22). Scenario analyses were performed to determine sensitivity to changes in transition rates, utility of caregivers, medical costs of caregivers and daily medication dose.ConclusionsThe results indicate that, for children responding suboptimally to treatment with IR, the beneficial effect of OROS on compliance may be worth the additional costs of medication. The presented model adds to the health economic information available for policymakers and to considerations on a broader perspective in cost-effectiveness analyses.

Doelmatigheid in praktijkrichtlijnen voor medicijnen: resultaten van een ‘quick scan’

SamenvattingIn dit onderzoek wordt nagegaan in hoeverre de richtlijnen van medische specialisten en huisartsen voor de top 5 van belangrijkste geneesmiddelengroepen, gemeten naar uitgaven in 2007, aandacht besteden aan doelmatigheid. Bij de meeste richtlijnen is maar beperkt aandacht besteed aan economische overwegingen. De richtlijnen Cardiovasculair risicomanagement en de richtlijn Angststoornissen zijn de enige richtlijnen waarbij het aspect ‘doelmatigheid’ op systematische wijze is meegenomen. Weinig of geen aandacht voor doelmatigheid leidt niet automatisch tot een verkeerde aanbeveling. In de richtlijnen over maagzuurremmers en astma is bijvoorbeeld nauwelijks rekening gehouden met economische overwegingen, maar zijn de aanbevelingen uit de richtlijnen in overeenstemming met de conclusies uit de literatuur ten aanzien van doelmatigheid. Economische informatie kan worden gebruikt om aanbevelingen aan te scherpen, beter te onderbouwen of te differentiëren naar specifieke subgroepen van patiënten. Een HTA- expert binnen een richtlijnwerkgroep kan de kwaliteit van economische evaluaties en toepasbaarheid voor de Nederlandse setting beoordelen en bijdragen tot een goede integratie van deze kennis in de aanbevelingen van de richtlijn.AbstractEconomic evidence in practice guidelines for medications: results of a ‘quick scan’The present paper examined the extent to which guidelines of medical specialists and general practitioners with respect to the five most important medications by means of expenditures in 2007 consider cost effectiveness. Most guidelines pay only limited attention to economic evidence. The guidelines on cardiovascular risk management and anxiety disorders are the only guidelines which systematically regard cost effectiveness of medications. Little or no attention for economic evidence does not necessarily lead to wrong recommendations. For example, the guidelines on stomach complaints and asthma hardly consider economic evidence. Nevertheless, the recommendations of these guidelines are in agreement with the conclusions in the literature regarding cost-effectiveness. Economic evaluations may be used to support recommendations or differentiate between specific subgroup of patients. Appointing an economic expert to guideline development committees could allow for the quality of the economic evaluations and their applicability to the Dutch setting to be assessed. The economic expert could contribute to the integration of economic considerations in guidelines of medical specialists and general practitioners.Keywords: Guidelines, Medication, Evaluation, Cost effectiveness, Quick Scan

The cost-effectiveness of family/family-based therapy for treatment of externalizing disorders, substance use disorders and delinquency: a systematic review

BackgroundFamily therapy and family-based treatment has been commonly applied in children and adolescents in mental health care and has been proven to be effective. There is an increased interest in economic evaluations of these, often expensive, interventions. The aim of this systematic review is to summarize and evaluate the evidence on cost-effectiveness of family/family-based therapy for externalizing disorders, substance use disorders and delinquency.MethodsA systematic literature search was performed in PubMed, Education Resource information Centre (ERIC), Psycinfo and Cochrane reviews including studies conducted after 1990 and before the first of August of 2013. Full economic evaluations investigating family/family-based interventions for adolescents between 10 and 20 years treated for substance use disorders, delinquency or externalizing disorders were included.ResultsSeven hundred thirty-one articles met the search criteria and 51 studies were initially selected. The final selection resulted in the inclusion of 11 studies. The quality of these studies was assessed. Within the identified studies, there was great variation in the specific type of family/family-based interventions and disorders. According to the outcomes of the checklists, the overall quality of the economic evaluations was low. Results varied by study. Due to the variations in setting, design and outcome it was not feasible to pool results using a meta-analysis.ConclusionsThe quality of the identified economic evaluations of family/family-based therapy for treatment of externalizing disorders, adolescent substance use disorders and delinquency was insufficient to determine the cost-effectiveness. Although commonly applied, family/family-based therapy is costly and more research of higher quality is needed.

The search for relevant outcome measures for cost-utility analysis of systemic family interventions in adolescents with substance use disorder and delinquent behavior: a systematic literature review

PurposeSystemic family interventions have shown to be effective in adolescents with substance use disorder and delinquent behavior. The interventions target interactions between the adolescent and involved systems (i.e. youth, family, peers, neighbors, school, work, and society). Next to effectiveness considerations, economic aspects have gained attention. However, conventional generic quality of life measures used in health economic evaluations may not be able to capture the broad effects of systemic interventions. This study aims to identify existing outcome measures, which capture the broad effects of systemic family interventions, and allow use in a health economic framework.MethodsWe based our systematic review on clinical studies in the field. Our goal was to identify effectiveness studies of psychosocial interventions for adolescents with substance use disorder and delinquent behavior and to distill the instruments used in these studies to measure effects. Searched databases were PubMed, Education Resource Information Center (ERIC), Cochrane and Psychnet (PsycBOOKSc, PsycCRITIQUES, print). Identified instruments were ranked according to the number of systems covered (comprehensiveness). In addition, their use for health economic analyses was evaluated according to suitability characteristics such as brevity, accessibility, psychometric properties, etc.ResultsOne thousand three hundred seventy-eight articles were found and screened for eligibility. Eighty articles were selected, 8 instruments were identified covering 5 or more systems.ConclusionsThe systematic review identified instruments from the clinical field suitable to evaluate systemic family interventions in a health economic framework. None of them had preference-weights available. Hence, a next step could be to attach preference-weights to one of the identified instruments to allow health economic evaluations of systemic family interventions.