Cost-effectiveness of denosumab for the prevention of skeletal-related events in patients with solid tumors and bone metastases in the United States.

Aims: Bone complications (also known as skeletal-related events [SREs]) pose significant health and financial burdens on patients with bone metastases. Denosumab demonstrated superiority over zoledronic acid in delaying the time to first SRE. This study examined the lifetime cost-effectiveness of denosumab vs zoledronic acid from both US payer and societal perspectives.Methods: This analysis used a lifetime Markov model and included patients with breast cancer, prostate cancer, and other solid tumors and bone metastases. The societal perspective included direct medical, direct non-medical, and indirect costs associated with denosumab and zoledronic acid; the payer perspective included direct medical costs only. Bone complication rates for each tumor type were estimated from three pivotal phase 3 studies and modified to reflect real-world incidence.Results: From a societal perspective, compared with zoledronic acid, denosumab use resulted in an incremental cost of $9,043, an incremental benefit of 0.128 quality-adjusted life-years (QALYs), a lifetime cost per QALY of $70,730, and a net monetary benefit (NMB) of $10,135 in favor of denosumab. Direct drug costs for denosumab ($28,352) were higher than zoledronic acid/untreated ($578), but were offset by reduced costs associated with bone complications. From a payer perspective, denosumab use was associated with an incremental cost of $13,396, and an incremental benefit of 0.128 QALYs, for a cost of $104,778 per QALY and an NMB of $5,782 in favor of denosumab.Limitations: Some model inputs had limited information and, given that the results may be sensitive to changes in these inputs, our findings should be interpreted within the context of the data inputs and modeling assumptions used in the analysis.Conclusions: Denosumab is a cost-effective option to prevent bone complications in patients with solid tumors when considering both payer and broader societal perspectives.

Health-Related Quality of Life of Patients With Multiple Myeloma Treated in Routine Clinical Practice in France.

INTRODUCTION: New therapies for multiple myeloma (MM) have improved life expectancy, but health-related quality of life (HRQoL) data from patients with MM in the real-world setting are lacking. This study, conducted in France, explored the associations between treatment outcomes and HRQoL in patients with MM. PATIENTS AND METHODS: This observational, cross-sectional, multicenter study enrolled patients (≥ 18 years old) with symptomatic MM who had consulted a physician at least once between February and March 2016. HRQoL was assessed using the European Organization for Research and Treatment of Cancer (EORTC) Core Quality of Life questionnaire (QLQ-C30) and the Quality of Life Multiple Myeloma module (QLQ-MY20). RESULTS: In total, 445 patients were included in the study; 402 (90%) completed the EORTC QLQ-C30 and QLQ-MY20 questionnaires. HRQoL decreased significantly with treatment line. Patients in the first treatment-free interval had relatively high scores. At later lines, patients receiving active treatment had better scores than those whose treatment had ended. High EORTC QLQ-C30 global health status scores were associated with good treatment response, few adverse events, and long duration of treatment, and were strongly influenced by the Eastern Cooperative Oncology Group performance status. Global health status scores correlated well with the 4 items of the QLQ-MY20 (future perspective, 0.46; body image, 0.41; disease symptoms, -0.57; side effects of treatment, -0.53). CONCLUSION: Effective treatment options in MM can help maintain HRQoL by influencing treatment response levels and delaying disease progression.

Creating an index to measure health state of depressed patients in automated healthcare databases: the methodology.

Background and objective: Automated healthcare databases (AHDB) are an important data source for real life drug and healthcare use. In the filed of depression, lack of detailed clinical data requires the use of binary proxies with important limitations. The study objective was to create a Depressive Health State Index (DHSI) as a continuous health state measure for depressed patients using available data in an AHDB. Methods: The study was based on historical cohort design using the UK Clinical Practice Research Datalink (CPRD). Depressive episodes (depression diagnosis with an antidepressant prescription) were used to create the DHSI through 6 successive steps: (1) Defining study design; (2) Identifying constituent parameters; (3) Assigning relative weights to the parameters; (4) Ranking based on the presence of parameters; (5) Standardizing the rank of the DHSI; (6) Developing a regression model to derive the DHSI in any other sample. Results: The DHSI ranged from 0 (worst) to 100 (best health state) comprising 29 parameters. The proportion of depressive episodes with a remission proxy increased with DHSI quartiles. Conclusion: A continuous outcome for depressed patients treated by antidepressants was created in an AHDB using several different variables and allowed more granularity than currently used proxies.

Cost-Effectiveness of Dolutegravir in HIV-1 Treatment-Experienced (TE) Patients in France.

OBJECTIVES: To evaluate the cost-effectiveness of a new generation integrase inhibitor (INI), dolutegravir (DTG), in France, in treatment-experienced (TE) and INI-naïve HIV-infected adults with at least two classes resistance compared to raltegravir (RAL), by adapting previously published Anti-Retroviral Analysis by Monte Carlo Individual Simulation (ARAMIS) model. METHODS: ARAMIS is a microsimulation Markov model with a lifetime time horizon and a monthly cycle length. Health states are defined as with or without opportunistic infection and death. In the initial cohort, efficacy and safety data were derived from a phase III study comparing DTG to RAL. Antiretroviral treatment algorithms, accounting for patient history, were based on French guidelines and experts opinion. Costs are mainly including treatment costs, routine HIV and opportunistic infection care, and death. Utilities depend on CD4+ cell count and the occurrence of opportunistic infections. RESULTS: The ARAMIS model indicates in the TE population that DTG compared to RAL over a life time is associated with 0.35 additional quality-adjusted life years (QALY; 10.75 versus 10.41) and additional costs of €7,266 (€390,001 versus €382,735). DTG increased costs are mainly related to a 9.1-month increase in life expectancy for DTG compared with RAL, and consequently a longer time spent on ART. The incremental cost-effectiveness ratio (ICER) for DTG compared with RAL is €21,048 per QALY gained. About 83% and 14% of total lifetime costs are associated with antiretroviral therapy and routine HIV care respectively. Univariate deterministic sensitivity analyses demonstrate the robustness of the model. CONCLUSION: DTG is cost-effective in the management of TE INI naive patients in France, from a collective perspective. These results could be explained by the superior efficacy of DTG in this population and its higher genetic barrier to resistance compared to RAL. These data need to be confirmed with longer-term real life data.

Cost-Effectiveness of Dolutegravir in HIV-1 Treatment-Naive and Treatment-Experienced Patients in Canada.

INTRODUCTION: The Antiretroviral Analysis by Monte Carlo Individual Simulation (ARAMIS) model was adapted to evaluate the cost-effectiveness of dolutegravir (DTG) in Canada in treatment-naive (TN) and treatment-experienced (TE) human immunodeficiency virus (HIV)-1 patients. METHODS: The ARAMIS-DTG model is a microsimulation model with a lifetime analytic time horizon and a monthly cycle length. Markov health states were defined by HIV health state (with or without opportunistic infection). DTG was compared to efavirenz (EFV), raltegravir (RAL), darunavir/ritonavir, rilpivirine (RPV), elvitegravir/cobicistat, atazanavir/ritonavir and lopinavir/ritonavir in TN patients and to RAL in TE patients. The initial cohort, the main efficacy data and safety data were derived from phase III clinical trials. Treatment algorithms were based on expert opinion. Costs normalized to the year 2013 included antiretroviral treatment cost, testing, adverse event, HIV and cardiovascular disease care and were derived from the literature. RESULTS: Dolutegravir was estimated to be the dominant strategy compared with all comparators in both TN and TE patients. Treatment with DTG was associated with additional quality-adjusted life-years that ranged from 0.17 (vs. RAL) to 0.47 (vs. EFV) in TN patients and was 0.60 in TE patients over a lifetime. Cost savings ranged from Can$1393 (vs. RPV) to Can$28,572 (vs. RAL) in TN patients and amounted to Can$3745 in TE patients. Sensitivity analyses demonstrated the robustness of the model. CONCLUSIONS: Dolutegravir is a dominant strategy in the management of TN and TE patients when compared to recommended comparators. This is mainly related to the high efficacy and high barrier to resistance. FUNDING: ViiV Healthcare.

Challenges in measuring and valuing productivity costs, and their relevance in mood disorders.

Lost productivity is often excluded from economic evaluations, which may lead to an underestimation of the societal benefits of treatment. However, there are multiple challenges in reliably estimating and reporting productivity losses. This article explores the main challenges, ie, selecting an appropriate valuation method (ie, human capital, friction cost, or multiplier), avoiding double counting, and accounting for equity. It also discusses the use of presenteeism instruments and their application in clinical trials, with a specific focus on their relevance in individuals with mood disorders. Further research and discussion is required on the development of reliable techniques for measuring and valuing productivity changes due to presenteeism.

Cost and burden of gastroesophageal reflux disease among patients with persistent symptoms despite proton pump inhibitor therapy: an observational study in France.

BACKGROUND: Gastrointestinal reflux disease (GERD) is a common disorder that negatively impacts health-related quality of life (HRQL) and work productivity. Many patients have only a partial response to proton pump inhibitor (PPI) therapy and continue to experience GERD symptoms despite optimized treatment. This observational study aimed to provide information on symptoms, HRQL, resource usage, costs and treatment pathways associated with partial response to PPI therapy in French patients with GERD. METHODS: Patients with partial response to PPI therapy, defined as persistent GERD symptoms ≥3 days/week despite optimized treatment with a PPI, were recruited for this 12-month observational study. GERD symptoms, HRQL, work productivity and resource use were assessed by patient surveys. Costs were calculated based on lost work productivity and resource use. RESULTS: The patient population (n=262; mean age, 54 years; 40% men) carried a significant symptom burden, with 98% of patients having moderate-to-severe GERD symptoms and 65% of patients experiencing daily symptoms at baseline. HRQL and work productivity were significantly impaired, with a greater degree of impairment in patients with higher symptom burden. The mean total cost per patient over the 12-month follow-up period was €5237, of which €4674 (89%) was due to lost work productivity. CONCLUSIONS: Partial response to PPI therapy for GERD is associated with a high symptom burden, significant impairment of HRQL and work productivity, and substantial GERD-related costs.

Partial response to proton pump inhibitor therapy for GERD: observational study of patient characteristics, burden of disease, and costs in the USA.

BACKGROUND: Disease burden and associated costs are not well understood among patients with gastroesophageal reflux disease (GERD) who have persistent symptoms despite optimized proton pump inhibitor (PPI) therapy. The aim of this study was to investigate disease burden and costs of GERD in partial responders to PPI therapy. METHODS: The Partial Response to PPI treatment: the Cost to Society and the Burden to the Patient in the US (REMAIN US) study was a 12-month, multicenter, noninterventional, observational study of 552 partial PPI responders in the USA. Participating sites were comprised of family practice (n = 30), internal medicine (n = 8), and specialist (gastroenterologist) centers (n = 15). GERD symptoms, health-related quality of life (HRQL), and impact on productivity were evaluated from patient-reported outcome instruments. Resource utilization data were also collected. RESULTS: Patients had a high symptom burden, impaired HRQL, and reduced productivity while at work and in daily activities, despite optimized PPI therapy. Mean annual GERD-related costs were US$9944 per patient, comprising total direct costs and mean productivity loss costs of US$4068 and US$5876 per patient, respectively. CONCLUSION: Patients with GERD and a partial response to PPI therapy have considerable direct and indirect costs, along with substantial impairments in HRQL and productivity.

The use and performance of productivity scales to evaluate presenteeism in mood disorders.

OBJECTIVE: Mood disorders are associated with a high societal cost, mainly due to presenteeism. The objective of this study was to review the use of 10 instruments that rate presenteeism in mood disorders and to provide recommendations regarding the appropriateness of instruments in different study settings. METHODS: A systematic review of the literature was conducted to identify scales used to measure presenteeism, including the World Health Organization Health and Work Performance Questionnaire, the Lam Employment Absence and Productivity Scale, the Sheehan Disability Scale, the Work Limitation Questionnaire, and Work Productivity and Activity Impairment questionnaire. Study characteristics and major results (by symptom level, by treatment arm, correlation to other scales, and use of monetization) were data extracted. RESULTS: Twenty-nine studies were identified. The Sheehan Disability Scale, the Work Limitation Questionnaire, and Health and Work Performance Questionnaire were the most commonly used instruments. The majority (60%) of scales demonstrated higher presenteeism in individuals with mood disorders than in individuals without. The Lam Employment Absence and Productivity Scale, the Sheehan Disability Scale, and the Work Limitation Questionnaire showed that presenteeism increased with increasing severity of disease. Few studies reported results on presenteeism by treatment, with only small between-treatment differences observed. Good correlations between presenteeism instruments and clinical or quality-of-life scales were reported. Three studies converted results from presenteeism scales into monetary units. CONCLUSIONS: Limited experiential evidence exists comparing the performance of presenteeism scales in mood disorders. Therefore, recommendations for inclusion of a presenteeism tool must be driven by instrument properties (ease of administration, amenability to monetization) and the study type. Future research should focus on the responsiveness of the instrument and on how mood disorders impact self-reported assessment.

Cost-effectiveness evaluation in Sweden of escitalopram compared with venlafaxine extended-release as first-line treatment in major depressive disorder.

OBJECTIVES: Major depressive disorder (MDD) is a major public health concern associated with a high burden to society, the health-care system, and patients and an estimated cost of €3.5 billion in Sweden. The objective of this study was to assess the cost-effectiveness of escitalopram versus generic venlafaxine extended-release (XR) in MDD, accounting for the full clinical profile of each, adopting the Swedish societal perspective, and identifying major cost drivers. METHODS: Cost-effectiveness of escitalopram versus venlafaxine XR was analyzed over a 6-month time frame, on the basis of a decision tree, for patients with MDD seeking primary care treatment in Sweden. Effectiveness outcomes for the model were quality-adjusted life-years and probability of sustained remission after acute treatment (first 8 weeks) and sustained for 6 months. Cost outcomes included direct treatment costs and indirect costs associated with sick leave. RESULTS: Compared with generic venlafaxine XR, escitalopram was less costly and more effective in terms of quality-adjusted life-years (expected gain 0.00865) and expected 6-month sustained remission probability (incremental gain 0.0374). The better tolerability profile of escitalopram contributed to higher expected quality-adjusted life-years and lower health-care resource utilization in terms of pharmacological treatment of adverse events (though only a minor component of treatment costs). Expected per-patient saving was €169.15 for escitalopram versus venlafaxine. Cost from sick leave constituted about 85% of total costs. CONCLUSIONS: Escitalopram was estimated as more effective and cost saving than generic venlafaxine XR in first-line MDD treatment in Sweden, driven by the effectiveness and tolerability advantages of escitalopram. The study findings are robust and in line with similar pharmacoeconomic analyses.

Impact of treatment success on health service use and cost in depression: longitudinal database analysis.

BACKGROUND: Research has consistently demonstrated a relationship between depression and increased levels of health service use over the short term. However, much less is known about how this relationship is influenced by the success, or otherwise, of depression management strategies, and the economic impact over the longer term. OBJECTIVE: To investigate the economic impact of non-remission on health service use and costs over 12 months from the index episode in patients with depression. METHODS: A naturalistic, longitudinal study was carried out using data from a large primary care UK general practice research database between 2001 and 2006. The records of 88 935 patients aged ≥18 years, diagnosed with depression and in receipt of at least two antidepressant prescriptions (for amitriptyline, citalopram, escitalopram, fluoxetine, paroxetine, sertraline or venlafaxine) in the first 3 months after the index prescription were included. The main outcome measures were health service use and cost over the 12-month study period, by remission status, where remission is defined as patients not using antidepressants for at least 6 months after antidepressant treatment has ended. RESULTS: Sociodemographic and clinical characteristics were similar for participants classified as in remission and those not in remission. Over 12 months from the index prescription, patients classified as non-remitters spent longer, on average, than patients classified as remitters on concomitant psychotropic medication (204 days vs 93 days, respectively), and had more contact with primary care services (17 vs 13 GP visits), secondary care psychiatrists and other specialists (47% vs 40%). Days in hospital, accident and emergency attendances and psychological therapy contacts did not differ between the groups. Total 12-month costs per participant were significantly lower for remitters (mean £656 vs £937; mean difference £317; p < 0.0001). Total costs fell over time for both groups, but at a faster rate for those in remission, and for those who remitted earlier after the index prescription than for those who remitted later. CONCLUSIONS: Successful cessation of antidepressant medication treatment in adults with depression can result in significant cost savings to the health service.

The 6-month persistence on SSRIs and associated economic burden.

OBJECTIVES: To assess persistence on SSRIs (most prescribed antidepressants) and associated healthcare costs in a naturalistic setting. METHODS: For this retrospective cohort study based on a US reimbursement claims database, all adults with a claim for a SSRI (citalopram, escitalopram, fluoxetine, paroxetine or sertraline) related to a diagnosis of depression were included. Patients should have had no previous reimbursement for any antidepressant within the previous 6 months. Non-persistence was defined as failing to renew prescription within 30 days in the 6-month period after the index date. RESULTS: In the 45,481 patients included, persistence decreased from 95.5% at 1 month, to 52.6% at 2 months, 37.6% at 3 months and 18.9% at 6 months. Among factors associated with higher 6-month persistence were age 18-34 years, physician's specialty, treatment with escitalopram, absence of abuse history and psychotropic prescription history. During the 6-month after index date, healthcare costs tended to be higher in non-persistent than in persistent patients although not significantly (RR=1.05, adjusted p=0.055). CONCLUSION: Despite some limitations associated with the use of computerized administrative claims data (residual unmeasured confounding), these results highlight a generally low persistence rate at 6 months. Special attention should be given to persistence on treatment, with consideration of potential antidepressant impact.

Cost effectiveness of escitalopram versus SNRIs in second-step treatment of major depressive disorder in Sweden.

OBJECTIVES: Escitalopram is the S-enantiomer of citalopram and is the most discriminating of the selective serotonin reuptake inhibitors (SSRI). The aim of the current analysis was to assess the cost effectiveness of escitalopram versus the serotonin norepinephrine reuptake inhibitors (SNRI) duloxetine and generic venlafaxine as second-step treatment of major depressive disorder. METHODS: The analysis was based on a decision analytic model. Effectiveness outcomes were quality-adjusted life-years (QALYs) and remission rates; cost outcomes were direct medical costs, including impact of treating adverse events, and indirect costs associated with lost productivity. The analysis was performed from the societal perspective in Sweden over a 6-month timeframe. RESULTS: Estimated remission rates showed an incremental effectiveness in favour of escitalopram of 16.4 percentage points compared with both SNRI comparators. The escitalopram strategy was associated with a 0.025 increase in QALYs. Sensitivity analyses demonstrated that the model is robust and that escitalopram remains a cost-effective option when considering future predicted price reductions of generic venlafaxine. LIMITATIONS: The main limitation in this study was the lack of data available for second-step treatment. The remission rates, which are a key input to the model, were obtained from a relatively small sample of patients on second-step treatment and there are no published relapse rates for second-step treatment. The model also assumed that there was no difference in the adverse event (AE) rates between treatments after the first 8 weeks. CONCLUSIONS: This cost-effectiveness analysis indicates that, at a willingness-to-pay threshold of £30,000, escitalopram is the most cost-effective second-step treatment option for MDD in Sweden in over 85% cases compared with both venlafaxine and with duloxetine. Benefits for escitalopram included both increased effectiveness and reduced overall costs. The major contributing costs were those associated with productivity loss. The model was shown to have internal validity and robustness through the use of stochastic simulations and sensitivity analyses, which were conducted around the key efficacy parameters.

Escitalopram versus serotonin noradrenaline reuptake inhibitors as second step treatment for patients with major depressive disorder: a pooled analysis.

The objective of this study was to evaluate the efficacy and tolerability of escitalopram versus serotonin and noradrenaline reuptake inhibitors (SNRIs) as second step treatment (defined operationally as poor response or intolerability to an antidepressant) for major depressive disorder (MDD). Results from all eligible head-to-head clinical trials of MDD (which excluded patients who earlier failed two or more antidepressants) sponsored by Lundbeck or Forest comparing escitalopram and SNRIs (venlafaxine and duloxetine) were pooled. A second step treatment subgroup was identified, defined as patients treated earlier with any antidepressant in the 6-month period before baseline. Data from three clinical trials were included in the analysis; 132 patients were identified in the second step treatment subgroup (66 in each of the escitalopram and SNRI groups). The primary efficacy analysis showed that the patients subsequently treated with escitalopram had significantly lower Montgomery Asberg Depression Rating Scale total scores after 8 weeks compared with those subsequently treated with SNRIs (difference = -6.4, P<0.0001). Escitalopram treatment was also associated with higher clinical response (73 vs. 44%, P=0.0004) and remission rates (62 vs. 41%, P=0.0083) compared with subsequent treatment with SNRIs. Escitalopram showed a better tolerability profile with lower all-cause withdrawals from study (9 vs. 23%, P<0.04) and lower withdrawals because of adverse events (2 vs. 17%, P<0.003). In conclusion, escitalopram is associated with a better efficacy and tolerability profile than SNRIs (duloxetine and venlafaxine) when used as a second step treatment in patients with MDD. These results should be confirmed in prospective randomized clinical trials.

Healthcare expenditure in severely depressed patients treated with escitalopram, generic SSRIs or venlafaxine in the UK.

OBJECTIVE: To retrospectively compare the 12-month healthcare utilisation and direct medical costs associated with the use of escitalopram, generic SSRIs, and venlafaxine in patients with severe depression in the United Kingdom (UK). METHODS: Data for this retrospective cohort study were extracted from the GPRD, a large primary care database in the UK. Data from adults with an incident prescription of escitalopram, venlafaxine, or generic SSRI were extracted. The initial prescription had to fall within 3 months of a physician visit when severe depression according to the GPRD definition was mentioned. Frequency of antidepressant treatment, GP consultations, referrals, hospitalisations, and concomitant psychiatric medication was assessed on the 12-months after initial prescription and 2006 unit costs for healthcare services obtained from published literature were applied, and then compared between treatment cohorts using a propensity score-adjusted generalised linear model. RESULTS: The total annual healthcare expenditure per patient was similar with escitalopram and generic SSRIs (916 pounds vs. 974 pounds, adjusted p = 0.48) and significantly lower than venlafaxine (916 pounds vs. 1367 pounds, adjusted p < 0.0001), a pattern repeated when antidepressant costs were excluded from the analysis (escitalopram vs. SSRIs, 831 pounds vs. 957 pounds, adjusted p = 0.10; escitalopram vs. venlafaxine, 831 pounds vs. 1156 pounds, adjusted p = 0.006). Over the 12-month analysis period, there were significantly fewer hospitalisations per patient in the escitalopram vs. venlafaxine (0.12 vs. 0.27; adjusted p = 0.01) or generic SSRI (0.12 vs. 0.19; adjusted p = 0.046) groups. CONCLUSION: Despite some limitations associated with the system of data collection in the GPRD (need to apply proxies for severity assessment and external unit costs to resource consumption), the results of this real-life study brings additional evidence of escitalopram appearing to be a cost-effective treatment for patients suffering from severe depression as diagnosed in routine practice and could be considered for first-line treatment in these patients.

Anxiety disorders, major depressive disorder and the dynamic relationship between these conditions: treatment patterns and cost analysis.

OBJECTIVE: To determine the treatment pattern and impact on healthcare costs of anxiety disorders and major depressive disorder (MDD), and influence of their concomitance and subsequence. METHODS: A retrospective cohort study was conducted using a US reimbursement claims database. Adult patients with an incident diagnosis of anxiety or MDD (index date) were included. Their sociodemographic data, diagnoses, healthcare resource use and associated costs were collected over the 6 months preceding and 12 months following index date. RESULTS: A total of 599,624 patients were identified and included. Patients with phobia or post-traumatic stress disorder had the highest 12-month costs ($8,442 and $8,383, respectively). Patients with social anxiety disorder had the lowest costs ($3,772); generalized anxiety disorder ($6,472) incurred costs similar to MDD ($7,170). Costs were substantially increased with emergence of anxiety during follow-up in MDD patients ($10,031) or emergence of MDD in anxiety patients ($9,387). This was not observed in patients with both anxiety and MDD at index date ($6,148). CONCLUSION: This study confirms the high burden of costs of anxiety, which were within the same range as MDD. Interestingly, the emergence of anxiety or MDD in the year following a first diagnosis of MDD or anxiety, respectively, increased costs substantially. Major limitations were short follow-up and lack of absenteeism costs.

Cost effectiveness analysis of escitalopram compared to venlafaxine and fluvoxamine in treatment of major depressive disorder.

Objective. To compare the costs and effectiveness of escitalopram with venlafaxine and fluvoxamine for treatment of major depressive disorder (MDD) from the societal perspective in Singapore. Methods. The decision analytical model consisted of two pathways, one for primary care and the other for secondary care over a time horizon of 6 months. The parameters in the model were derived from clinical trials and results of a survey on local general practitioners and psychiatrists. The proportion of patients successfully treated was the main effectiveness measurement. Both direct and indirect costs were estimated and reported in 2007 Singapore dollars. Deterministic and probabilistic sensitivity analyses were performed. Results. The overall success rate for the 6-month treatment was 68.1% for escitalopram compared to 66.0% for venlafaxine. The total costs per patient treated were $2845 for escitalopram compared to $3176 for venlafaxine. The overall success rate was 64.7% for escitalopram and 60.0% for fluvoxamine. The total costs per patient treated were $3133 for escitalopram compared to $3297 for fluvoxamine. Probability sensitivity analysis demonstrated that escitalopram was dominant to venlafaxine and fluvoxamine in more than 95% of the random samples. Conclusion. Escitalopram is a cost-effective pharmacotherapy for MDD compared to venlafaxine and fluvoxamine.

Escitalopram and duloxetine in major depressive disorder: a pharmacoeconomic comparison using UK cost data.

BACKGROUND: Selective serotonin reuptake inhibitors (SSRIs) and serotonin-noradrenaline reuptake inhibitors (SNRIs) are approved for the treatment of major depressive disorder (MDD). The allosteric SSRI escitalopram has been shown to be at least as clinically effective as the SNRIs venlafaxine and duloxetine in MDD, with a better tolerability profile. In addition, escitalopram has been shown to be cost saving compared with venlafaxine. OBJECTIVE: To evaluate the cost effectiveness of escitalopram versus duloxetine in the treatment of MDD, and to identify key cost drivers. METHODS: The pharmacoeconomic evaluation was conducted alongside a 24-week, double-blind, multinational randomized study (escitalopram 20 mg/day and duloxetine 60 mg/day) in outpatients with MDD, aged 18-65 years, with Montgomery-Asberg Depression Rating Scale (MADRS) score >or=26 and Clinical Global Impression Severity (CGI-S) score >or=4, and baseline duration of the current depressive episode of 12 weeks to 1 year.The analysis was conducted on the full analysis set (FAS), which included all patients with >or=1 valid post-baseline health economic assessment. Effectiveness outcomes of the cost-effectiveness analyses (CEA) included the change in Sheehan Disability Scale (SDS) score (primary CEA), treatment response (MADRS score decrease >or=50%) and remission (MADRS score

Escitalopram in major depressive disorder: clinical benefits and cost effectiveness versus citalopram.

Objective. Escitalopram is the most selective of the serotonin reuptake inhibitors. Methods. We review all the clinical trials (three pivotal placebo-controlled trials with citalopram as an active reference, one long-term non-inferiority study and one head-to-head superiority study) that include citalopram as an active reference in major depressive disorder (MDD), and studies that evaluate the cost-effectiveness of the two drugs. Results. In two of the pivotal studies and in the long-term study, escitalopram was numerically better than citalopram in reducing Montgomery-Åsberg Depression Rating Scale (MADRS) scores from baseline, with comparative tolerability. Meta-analyses of these studies showed statistically significant differences in favour of escitalopram in terms of reducing MADRS and increasing response. This effect was particularly apparent in patients with higher baseline MADRS scores. These trends were confirmed in a head-to-head study, which clearly demonstrated the superiority of escitalopram compared with citalopram on primary and secondary endpoints. The difference between treatments was clinically relevant. Cost-effectiveness analyses demonstrated that although escitalopram has a slightly higher unit cost than generic citalopram, expected direct medical and productivity- related costs were lower with escitalopram than citalopram. Conclusion. On the basis of these results, escitalopram was concluded to be more clinically effective and more cost-effective than citalopram for the treatment of MDD, with a similar tolerability profile.

Can discrete event simulation be of use in modelling major depression?

BACKGROUND: Depression is among the major contributors to worldwide disease burden and adequate modelling requires a framework designed to depict real world disease progression as well as its economic implications as closely as possible. OBJECTIVES: In light of the specific characteristics associated with depression (multiple episodes at varying intervals, impact of disease history on course of illness, sociodemographic factors), our aim was to clarify to what extent "Discrete Event Simulation" (DES) models provide methodological benefits in depicting disease evolution. METHODS: We conducted a comprehensive review of published Markov models in depression and identified potential limits to their methodology. A model based on DES principles was developed to investigate the benefits and drawbacks of this simulation method compared with Markov modelling techniques. RESULTS: The major drawback to Markov models is that they may not be suitable to tracking patients' disease history properly, unless the analyst defines multiple health states, which may lead to intractable situations. They are also too rigid to take into consideration multiple patient-specific sociodemographic characteristics in a single model. To do so would also require defining multiple health states which would render the analysis entirely too complex. We show that DES resolve these weaknesses and that its flexibility allow patients with differing attributes to move from one event to another in sequential order while simultaneously taking into account important risk factors such as age, gender, disease history and patients attitude towards treatment, together with any disease-related events (adverse events, suicide attempt etc.). CONCLUSION: DES modelling appears to be an accurate, flexible and comprehensive means of depicting disease progression compared with conventional simulation methodologies. Its use in analysing recurrent and chronic diseases appears particularly useful compared with Markov processes.