Timo Maljanen

Antipsychotics and antidepressants: An analysis of cost growth in finland from 1999 to 2005

BACKGROUNDnAntipsychotics and antidepressants are among the fastest-growing therapeutic classes, but the reasons behind recent cost growth are not clear.nnnOBJECTIVEnThe aim of this study was to assess the explicit factors behind ambulatory antipsychotic and antidepressant cost growth in Finland, as well as the relative importance of the factors associated with the drug group-specific cost growth.nnnMETHODSnThe data used in this study were retrospectively collected from the Finnish National Health Insurances register on reimbursed drug purchases. The study period ranged from January 1, 1999, through December 31, 2005, and the obtained data included information on the patient identity number, total cost of the purchase, Anatomic Therapeutic Chemical classification code of the purchased product, and defined daily dose amount of the purchase. Using the retrieved data, antipsychotic and antidepressant cost growth was disaggregated into price and volume factors to create a formula that includes factors about the size of the population, patients per population, volume of treatment per patient, and the mean cost per 1 day of treatment. The relative effect of the factors associated with the drug group-specific cost growth was also examined. Because the purpose of this work was to analyze the factors contributing to the cost growth, we disregarded factors that were negative.nnnRESULTSnDuring the study period, the proportion of antipsychotic users of the total population decreased from 2.4% to 2.2% and the mean cost per 1 day of treatment with antipsychotics increased from euro1.37 to euro2.94. The proportion of antidepressant users increased from 4.8% to 6.3%, and mean cost per 1 day of treatment decreased from euro1.06 to euro0.79. In 1999, the consumption of second-generation antipsychotics accounted for 22% of total consumption, and in 2005 their proportion was 62%. Drug choices among anti-depressants did not change substantially. The total cost growth of antipsychotics and antidepressants was 211% and 19%, respectively. Approximately 80% of the antipsychotic cost growth resulted from the rise in the mean cost per 1 day of treatment. The increase in patients per population accounted for approximately 60% of the antidepressant cost growth.nnnCONCLUSIONnThis retrospective analysis found that the factors associated with the growing antipsychotic and antidepressant expenditures in Finland from 1999 through 2005 varied between these 2 drug classes.

The Helsinki Psychotherapy Study: Effectiveness, Sufficiency, and Suitability of Short- and Long-Term Psychotherapy

Both short- and long-term psychotherapies have been shown to be effective for the treatment of patients suffering from mood or anxiety disorders [1–4]. Therapies of the same length have, on average, been found to be equally effective [5]. Short-term therapies, on which most of the studies have concentrated, have generally been found as effective as psychiatric medication and more effective than being on a waiting-list, thus proving that improvement in treatment is not just due to the placebo effect or regression to the mean [6, 7]. Long-term therapies, mostly psychodynamic, although widely used in clinical practice, have been studied to a lesser extent, and, in particular, comparative research on the effectiveness of long-term and short-term therapies is scarce [2, 3, 8]. Furthermore, only a few studies have explored the effectiveness or cost effectiveness of therapies during a long follow-up and with regard to outcomes other than symptoms, such as work ability or social functioning.

The cost-effectiveness of short-term and long-term psychotherapy in the treatment of depressive and anxiety disorders during a 5-year follow-up

Both short-term and long-term psychotherapies are used extensively in treating different mental disorders, but there have been practically no attempts to compare their cost-effectiveness. The aim of this study, which is part of the Helsinki Psychotherapy Study, is to assess the cost-effectiveness of two short-term therapies compared to that of a long-term therapy. In this study 326 outpatients suffering from mood or anxiety disorder were randomized to solution-focused therapy (SFT), short-term psychodynamic psychotherapy (SPP) or to long-term psychodynamic psychotherapy (LPP). Psychiatric symptoms and working ability were assessed at baseline and then 4-9 times during a 5-year follow-up using eight widely used measures including e.g. Beck Depression Inventory (BDI), Hamilton Depression Rating Scale (HDRS), Symptom Check List, anxiety scale (SCL-90-Anx), Hamilton Anxiety Rating Scale (HARS), Symptom Check List, Global Severity Index (SCL-90-GSI), and the Work-subscale (SAS-Work) of the Social Adjustment Scale (SAS-SR). Both direct and indirect costs were measured. During the 5-year follow-up period statistically significant improvements were observed in all health indicators in all therapy groups. At first the recovery was faster in the short-term therapy groups than in the LPP group, but taking the whole follow-up period into account, the effectiveness of the LPP was somewhat greater than that of the short-term therapies. Especially the direct costs were, however, much higher in the LPP group than in the short-term therapy groups. Thus the long-term therapy can hardly be regarded as cost-effective compared to short-term therapies when patients are randomized to the therapy groups.

Confounding and missing data in cost-effectiveness analysis: comparing different methods

IntroductionCommon approaches in cost-effectiveness analyses do not adjust for confounders. In nonrandomized studies this can result in biased results. Parametric models such as regression models are commonly applied to adjust for confounding, but there are several issues which need to be accounted for. The distribution of costs is often skewed and there can be a considerable proportion of observations of zero costs, which cannot be well handled using simple linear models. Associations between costs and effectiveness cannot usually be explained using observed background information alone, which also requires special attention in parametric modeling. Furthermore, in longitudinal panel data, missing observations are a growing problem also with nonparametric methods when cumulative outcome measures are used.MethodsWe compare two methods, which can handle the aforementioned issues, in addition to the standard unadjusted bootstrap techniques for assessing cost-effectiveness in the Helsinki Psychotherapy Study based on five repeated measurements of the Global Severity Index (SCL-90-GSI) and direct costs during one year of follow-up in two groups defined by the Defence Style Questionnaire (DSQ) at baseline. The first method models cumulative costs and effectiveness using generalized linear models, multiple imputation and bootstrap techniques. The second method deals with repeated measurement data directly using a hierarchical two-part logistic and gamma regression model for costs, a hierarchical linear model for effectiveness, and Bayesian inference.ResultsThe adjustment for confounders mitigated the differences of the DSQ groups. Our method, based on Bayesian inference, revealed the unexplained association of costs and effectiveness. Furthermore, the method also demonstrated strong heteroscedasticity in positive costs.ConclusionsConfounders should be accounted for in cost-effectiveness analyses, if the comparison groups are not randomized.JEL classificationC1; C3; I1

Impact of Generic Price Linkage System and Reference Price System on prices of pharmaceuticals – comparison of Austria and Finland

Objectives The aim of this study is to assess the Generic Price Linkage system and the system that includes Generic Substitution and Reference Pricing by comparing prices of generics and originators and the number of generics entering the market in Austria and in Finland. Policies targeted: Generic Price Linkage, Generic Substitution, Reference Pricing. Stakeholders: Austria: Main Association of Austrian Social Security Institutions, pharmaceutical industry, patients. Finland: Finnish Medicines Agency, Pharmaceuticals Pricing Board, Social Insurance Institution, pharmaceutical industry, pharmacies, patients. Region covered: EURO, Austria and Finland.

Assessing The Quality Of Health Economic Evaluations Attached To Price Applications For New Pharmaceuticals Proposed For Inclusion In The Finnish Reimbursement System

PHP91 Assessing THe QuAliTy Of HeAlTH ecOnOmic evAluATiOns ATTAcHed TO Price APPlicATiOns fOr new PHArmAceuTicAls PrOPOsed fOr inclusiOn in THe finnisH reimbursemenT sysTem Maljanen T., Koskinen H., Tuominen U. The Social Insurance Institution, Helsinki, Finland Objectives: In most western countries it is a prerequisite before a new drug is approved into the reimbursement system that its cost-effectiveness has been demonstrated. The pricing authorities’ assessment of the cost-effectiveness is usually based on a health economic evaluation required from the applicant. In Finland these evaluations have been obligatory since 1998. The objective of this study is to assess the present quality of these economic evaluations. MethOds: This study is based on a random sample of 13 economic evaluations submitted with price applications in Finland in 2012. These evaluations were assessed using a structured questionnaire with 25 different items. The items assessed include e.g. the choice of comparator, the method of analysis, the structure of the model, the estimation costs and health effects and the assessment of uncertainty. Results: Only two of the 13 evaluations were reliable enough for their results to be used as such in the pricing and reimbursement decision. In seven evaluations the results were of some use in the decision making. Among the reasons limiting their usefulness were that they contained uncertain assumptions, that some costs items were excluded from the analysis, and that the effectiveness of the treatments was based mainly on assumptions. Four economic evaluations could not be used in the decision making at all because the comparator was wrong, the effectiveness estimates were biased, or there was a lot of uncertainty attached to the key parameters (effectiveness, quality of life and costs). cOnclusiOns: There is still much to be improved in the quality of the submitted economic evaluations. This need for improvements is highlighted by the fact that the era of prolonged austerity has made it all the more important that only drugs with an acceptable cost-effectiveness ratio are accepted into the reimbursement system.