Cost-Effectiveness Analysis of Triptorelin, Goserelin, and Leuprolide in the Treatment of Patients With Metastatic Prostate Cancer: A Societal Perspective.

OBJECTIVES: Metastatic prostate cancer is the most common malignant cancer and the second leading cause of death due to various types of cancer among men after lung cancer. This study aimed to analyze the cost-effectiveness of triptorelin, goserelin, and leuprolide in the treatment of the patients with metastatic prostate cancer from the societal perspective in Iran in 2020. METHODS: This is a cost-effectiveness study in which a 20-year Markov transition modeling was applied. In this study, local cost and quality-of-life data of each health state were gathered from cohort of patients. The TreeAge pro 2020 and Microsoft Excel 2016 software were used to simulate cost-effectiveness of each treatment in the long term. The one-way and probabilistic sensitivity analyses were also performed to measure robustness of the model outputs. RESULTS: The findings indicated that the mean costs and utility gained over a 20-year horizon for goserelin, triptorelin, and leuprolide treatments were $ 13 539.13 and 6.365 quality-adjusted life-years (QALY), $ 18 124.75 and 6.658 QALY, and $ 26 006.92 and 6.856 QALY, respectively. Goserelin was considered as a superior treatment option, given the estimated incremental cost-effectiveness ratio. The one-way and probabilistic sensitivity analyses confirmed the robustness of the study outcomes. CONCLUSIONS: According to the results of the present study, goserelin was the most effective and cost-effective strategy versus 2 other options. It could be recommended to policy makers of the Iran healthcare system to prioritize it in clinical guidelines and reimbursement policies.

Cost-Effectiveness Comparison between Ticagrelor and Clopidogrel in Acute Coronary Syndrome in Iran.

Background: The present study aimed to determine the cost-effectiveness of ticagrelor compared with clopidogrel in Iranian patients with acute coronary syndrome (ACS). Methods: A 1-year decision tree model combined with a 20-year Markov transition model was used to simulate the long-term cost and effectiveness of both ticagrelor and clopidogrel in Iran based on an Iranian payer's perspective. Clinical efficacy data were extracted from the PLATO trial and other published studies. Costs were estimated based on local prices in public sectors. Deterministic and probabilistic sensitivity analyses were used to test the robustness of base-case results over the uncertainties of model inputs. All calculations, analyses, and modeling were done in TreeAge 2011 and Microsoft Excel 2013. Results: Compared with clopidogrel, the treatment of Iranian ACS patients with ticagrelor for 20 years resulted in an additional cost of US$ 2.39 in a hypothetical cohort of 1000 patients. However, ticagrelor led to 7.2 quality-adjusted life-years (QALYs) gained per 1000 hypothetical patients. Accordingly, the estimated incremental cost-effectiveness ratio for this analysis was US$ 332.032 per 1 QALY gained. Conclusion: Ticagrelor was a cost-effective antiplatelet medicine compared with clopidogrel in Iranian patients with ACS. This could help Iran's policymakers to allocate resources more efficiently to ACS.

Determinants and economic burden of HIV/AIDS in Iran: a prospective study.

BACKGROUND: Since the start of the AIDS outbreak, the human immunodeficiency virus (HIV) has infected about 84.2 million people, and approximately 40.1 million people have died due to AIDS-related diseases. So, this study aims to provide a comprehensive population-based description of patient costs and the economic burden of HIV/AIDS in Iran. METHODS: The study population of this cross-sectional cost-of-illness study consisted of HIV-infected patients who were receiving services in Mashhad and were under the supervision of BIDCC. There are four BIDCC centers in Mashhad, we considered all patients referred to these centers. Costs data were evaluated from a social perspective with a bottom-up approach and as a prevalence based. The data from 157 individuals were included in the study. For collecting data on direct and indirect costs belonging to patients and their families, a questionnaire was developed. Also, the Demographic characteristic of participants and the stage of the disease and Transmission category were analyzed. RESULTS: In this study, 57.32 of the subjects were Male. The majority of participants in this study were in the age group 30-59 years (n = 124,78.98%). Based on where the patients live, the majority of patients have lived in the urban region (n = 144, 91.72%). The most common way to transmit this disease is through unprotected sex (30.57%) and then Infected spouse (28.03%), and then injecting drugs (21.02%). The highest cost of this disease is attributed to medicine (10339.32 $ for 6 months), after medicine, the cost of tests was 9101.22 $. CONCLUSION: It seems that to reduce costs for patients with disease HIV/AIDS, the focus should be on diagnostic tests and care. Early diagnosis and rapid initiation of antiviral treatments can be effective in preventing serious and debilitating diseases.

Everolimus and temsirolimus are not the same second-line in metastatic renal cell carcinoma: a systematic review and meta-analysis.

OBJECTIVE: Renal cell carcinoma (RCC) is the most common type of kidney cancer. VEGF inhibitors and mTORs are the most common therapeutic options among the different classes of available treatments. In this study, the effectiveness of Everolimus was compared to Temsirolimus, and Everolimus plusLenvatinib in renal cell carcinoma patients by review of the international clinical evidence. MATERIALS AND METHODS: A systematic review was conducted and all relevant published clinical studies on the efficacy and cost-effectiveness of Everolimus, Temsirolimus, and Lenvatinib plus Everolimus were searched comprehensively in electronic databases including Pubmed, Scopus, Medline, Cochrane Library, and ISI web of science. The Q score and I2 test checked the Heterogeneity and publication bias test, respectively. Egger's test and Begg's test were used to checking publication bias. The hazard ratio (HR) of included studies and subclass analysis were estimated by fixed and random effect models. RESULTS: Out of 1816 found studies, ultimately, were included considering inclusion and exclusion criteria. None of these studies evaluated all three treatment strategies together and each study was about one strategy. Only one study was found for Everolimus plus Lenvatinib, so it was excluded from meta-analysis. Overall, data from 526 patients on Temsirolimus and 648 patients on Everolimus were included in Meta-Analysis. Accordingly, the efficacy of Everolimus and Temsirolimus was not statistically significant in assessed outcomes (PFS, TTSF, and death). However, Everlimus is superior to Temsirolimus in OS (Q = 3.61, p-value: 0.462, I2 = 0%). No heterogeneity or bias was detected. CONCLUSION: According to the results of this study, Everolimus could be related to an increase of OS versus Temsirolimus as a second line treatment of ORCC patients.

Availability and affordability of cardiovascular medicines in a major city of Afghanistan in 2020.

PURPOSE: Affordable access to quality medicines is a critical target of global efforts to achieve universal health coverage. The aim of this study is to measure the affordability and accessibility of cardiovascular medicines in the city of Herat, Afghanistan. METHODS: The price, affordability, and availability data for 18 most sold generic (MSG) and lowest priced generic (LPG) products were collected from public and private pharmacies located in Herat city in Afghanistan in 2020, which in each area, six pharmacies were randomly selected from a combination of public and private ones based on the standardized methodology developed by WHO/HAI. According to this methodology on Medicine Prices, Accessibility, and Affordability, the minimum daily wage of an unskilled governmental worker, and the price of each type of cardiovascular medicines for one-month use were calculated separately. If the cost of the treatment was more than the minimum daily wage, the medicine was considered unaffordable. RESULTS: The mean availability score for lowest price generic (LPG) in public and private pharmacies and based on the countries of origin including Iran, Pakistan, and India was 60%, 46%, and 31%, respectively. Of the 18 medicines surveyed, just Atenolol (Iranian brand) was found in all 30 pharmacies on the day of data collection. All Indian- brand medicines were less than fifty percent available in any of the surveyed public and private pharmacies. Among the medicines exported to Afghanistan, the population of Herat used more medicines made by Pakistan compared to India and Iran (MSG). Indian medicines were the most expensive ones and the Iranian medicines were the cheapest. A wage of less than one day was enough to afford one-month supply of generic medicines at the lowest price. CONCLUSION: Access of patients to cardiovascular medicines in Afghanistan was 46% in this study which is regarded as low access. Most of available cardiovascular medicines in the market of this country were made in Iran, Pakistan and India. Although the Iranian ones were the cheapest, but people used more Pakistani medicines. LPG products were affordable to the studied population.

Evaluation of COVID-19 Treatments in Iran in Comparison with Local Therapeutic Recommendations: A Population-Level Study on Utilization and Costs of Prescription Drugs.

Objective: In this study, we assess population-level data of COVID-19 treatments in Iran compared to Ministry of Health (MOH)-published guidelines to gain a better insight into the quality of care for this disease. Methods: National sales data of each recommended and nonrecommended COVID-19 medicine were used to proxy utilization between March 21, 2020, and March 21, 2021, or Iranian year 1399. COVID-19-attributed sales volume and number of patients were estimated by adjusting sales data with pre-COVID-19 average growth rate, recommended dose, and duration of treatment. Next, they were compared with the MOH guidelines in outpatient and inpatient settings. Furthermore, the list of top 10 molecules of the market and top 10 COVID-19-indicated molecules in terms of values were extracted to assess the economic burden of COVID-19 prescription drugs and their share. Findings: The estimated number of patients receiving COVID-19 treatments in some outpatient medicines such as recommended hydroxychloroquine was over 2.2 million. Favipiravir and remdesivir were collectively about two inpatient medicines 260,000; however, neither of these two medicines was recommended in the MOH guidelines. In some fewer specific medicines such as dexamethasone, prednisolone, azithromycin, and naproxen, the estimated number of COVID-19-attributed patients were incomparable with the officially announced number of confirmed cases in the year of study, which could be related to nonconfirmed diagnosed cases, irrational use, or prescribing, or limitations of our data and study. The total COVID-19-attributed market of candidate medicines was over 15 trillion IR Rials (almost 4.3% of the total market). Remdesivir, with over 60% of the total COVID-19 attributed market, followed by favipiravir, was among the highest value medicines. Conclusion: Despite the release of the COVID-19 guideline by Iran MOH, misalignment in the enforcement of decisions was a serious weakness (cases of favipiravir and remdesivir). This weakness led to some economic burden on the health-care system and raised ethical concerns.

Pegylated versus non-pegylated interferon beta 1a in patients with relapsing-remitting multiple sclerosis: A cost-effectiveness analysis.

Background: Pegylated (PEG) interferon beta 1a has been approved by the United States Food and Drug Administration (USFDA) as an alternative to interferon beta 1a for multiple sclerosis (MS). Due to its higher price, this study aimed to evaluate the cost-effectiveness of PEG-interferon beta 1-a compared with interferon beta 1a from an Iranian payer perspective. Methods: A Markov model was designed according to health states based on Expanded Disability Status Scale (EDSS) and one-month cycles over a 10-year time horizon. Direct medical and non-medical costs were included from a payer perspective. Results: The incremental cost-effectiveness ratio (ICER) was estimated around 11111 US dollars (USD) per quality-adjusted life-year (QALY) gained for the PEG-interferon versus interferon regimen [with currency rate of 29,000 Iranian Rial (IRR) to 1 USD in 2016]. Conclusion: Considering the cost-effectiveness threshold in Iran [three times of gross domestic product (GDP) per capita or 15,945 USD], PEG-interferon beta 1-a could be considered as a cost effective treatment for Iranian patients with MS.

Linagliptin versus sitagliptin in patients with type 2 diabetes mellitus: a network meta-analysis of randomized clinical trials.

BACKGROUND: Diabetes is one of the most common chronic and costly diseases worldwide and type 2 diabetes is the most common type which accounts for about 90% of cases with diabetes. New medication-therapy regimens such as those containing linagliptin alone or in combination with other medications (within the category of DDP-4 inhibitors) must be evaluated in terms of efficacy and compared with other currently used drugs and then enter the medication list of the country. Hence, this study aimed to compare the clinical efficacy of the two drugs, i.e. linagliptin and sitagliptin, in patients with type 2 diabetes. METHODS: A systematic review was conducted to identify all clinical trials published by 2015 which compared the two drugs in patients with type 2 diabetes. Using keywords such as "linagliptin", "type 2 diabetes mellitus", "sitagliptin" and related combinations, we searched databases including Scopus, PubMed, and Web of Science. The quality of the selected studies was evaluated using the Jadad score. Considering primary and secondary outcomes extracted from the reviewed studies, a network meta-analysis was used to conduct a systematic comparison between the two studied drugs. RESULTS: This network meta-analysis included 32 studies (Linagliptin vs PLB: n = 8, Sitagliptin vs PLB: n = 13, Linagliptin + MET vs PLB + MET: n = 4, and Sitagliptin + MET vs PLB + MET: n = 7) and a total of 13,747 patients. The results showed no significant difference between linagliptin and sitagliptin in terms of key efficacy and safety outcomes such as HbA1c changes from baseline, body weight change from baseline, percentage of patients achieving HbA1c <7, and percentage of patients experiencing hypoglycemic events (p > 0.05). The results showed that the efficacy of the two drug regimens was the same. CONCLUSIONS: Based on the results, there was no significant difference between the two drugs, i.e. linagliptin and sitagliptin, in terms of efficacy; in other words, the efficacy of the two drugs was the same. Therefore, the use of these two drugs depends on their availability and cost. Graphical abstract of the network meta-analysis performed to evaluate the alternatives under the study.

Cost-Utility Analysis of Single-Fraction Versus Multiple-Fraction Radiotherapy in Patients with Painful Bone Metastases: An Iranian Patient's Perspective Study.

OBJECTIVES: To evaluate two of the various treatment strategies of bone metastasis- single-fraction radiotherapy and multiple-fraction radiotherapy. METHODS: A multistage Markov decision model was applied to assess the incremental costs per quality-adjusted life-year (QALY) gained of single fraction against multiple fractions. The model had a monthly cycle length over a lifetime horizon with 1000 hypothetical cohort samples. The EuroQol five-dimensional questionnaire was used to estimate the health-related quality of life in patients. To cope with parameters of uncertainty, we conducted a probabilistic sensitivity analysis using a Monte-Carlo simulation technique. Both cost and utility variables were discounted by 3% in the base model. Strategies were assessed considering a willingness-to-pay threshold of US $6578 per QALY gained. RESULTS: The expected mean cost and quality-adjusted life-years were, respectively, US $447.28 and 5.95 months for patients receiving single-fraction radiotherapy and US $1269.66 and 7.87 months for those receiving multiple-fraction radiotherapy. The incremental cost-utility ratio was US $428.38 per QALY. Considering the Iranian gross domestic product per capita (US $6578) as the recommended willingness to pay for 1 QALY gained, the multiple-fraction method was found to be a cost-effective strategy. CONCLUSIONS: Policymakers should advocate the multiple-fraction method instead of the single-fraction method in the treatment of patients with painful bone metastases.

Social accounting matrix and the effects of economic reform on health price index and household expenditures: Evidence from Iran.

Background: Socioeconomic indicators are the main factors that affect health outcome. Health price index (HPI) and households living costs (HLC) are affected by economic reform. This study aimed at examining the effect of subsidy targeting plan (STP) on HPI and HLC. Methods: The social accounting matrix was used to study the direct and indirect effects of STP. We chose 11 health related goods and services including insurance, compulsory social security services, hospital services, medical and dental services, other human health services, veterinary services, social services, environmental health services, laundry& cleaning and dyeing services, cosmetic and physical health services, and pharmaceutical products in the social accounting matrix to examine the health price index. Data were analyzed by the I-O&SAM software. Results: Due to the subsidy release on energy, water, and bread prices, we found that (i) health related goods and services groups' price index rose between 33.43% and 77.3%, (ii) the living cost index of urban households increased between 48.75% and 58.21%, and (iii) the living cost index of rural households grew between 53.51% and 68.23%. The results demonstrated that the elimination of subsidy would have negative effects on health subdivision and households' costs such that subsidy elimination increased the health prices index and the household living costs, especially among low-income families. The STP had considerable effects on health subdivision price index. Conclusion: The elimination or reduction of energy carriers and basic commodities subsidies have changed health price and households living cost index. Therefore, the policymakers should consider controlling the price of health sectors, price fluctuations and shocks.