Cost-Effectiveness of Device-Aided Therapies in Parkinson's Disease: A Structured Review.

BACKGROUND: Despite optimal dopaminergic treatment most patients in moderate to advanced stages of Parkinson's disease (PD) experience progressively increasing disabilities, necessitating a shift from oral medication to device-aided therapies, including deep brain stimulation (DBS), intrajejunal levodopa-carbidopa infusion (IJLI), and continuous subcutaneous apomorphine infusion (CSAI). However, these therapies are costly, limiting their implementation. OBJECTIVES: To perform a systematic review on cost-effectiveness analyses for device-aided therapies in PD. METHODS: References were identified by performing a systematic search in the PubMed and Web of Science databases in accordance with the PRISMA statement. In the absence of universal cost-effectiveness definitions, the gross domestic product per capita (GDP) in the country where a study was performed was used as a cut-off for cost-effectiveness based on cost per quality adjusted life year (QALY) gained. RESULTS: In total 30 studies were retrieved. All device-aided therapies improved quality of life compared to best medical treatment, with improvements in QALYs between 0.88 and 1.26 in the studies with long temporal horizons. For DBS, nearly all studies showed that cost per QALY was below the GDP threshold. For infusion therapies only three studies showed a cost per QALY below this threshold, with several studies with long temporal horizons showing costs below or near the GDP threshold. CONCLUSION: Of the device-aided therapies, DBS can be considered cost-effective, but the majority of infusion therapy studies showed that these were less cost-effective. However, long-term use of the infusion therapies appears to improve their cost-effectiveness and in addition, several strategies are underway to reduce these high costs.

[Pharmacoeconomic study of the treatment of advanced Parkinson's disease]. / Estudio farmacoeconomico del tratamiento de la enfermedad de Parkinson avanzada.

INTRODUCTION: When oral or transdermal drug therapy in Parkinson's disease becomes less effective, there are three therapies using assisted devices that can reduce motor and non-motor complications: subcutaneous apomorphine infusion pump (SAIP), continuous levodopa/carbidopa duodenal infusion (LDI) and deep brain stimulation (DBS). AIM: Conduct a comparative pharmacoeconomic analysis of the use of SAIP, with LDI and DBS. As a secondary objective arises discuss the profile of the ideal candidate for each of the technicals. PATIENTS AND METHODS: Information on life years gained and quality adjusted life years (QALY) according to Hoehn and Yahr scale was obtained, as well as data on costs and resource use for each of the alternatives. The perspective of the analysis was the National Health System and the time horizon was 5 years for costs and patient´s lifetime for utilities. Outcome measures used were life years gained and QALYs, and incremental cost/utility ratio for comparison. RESULTS: Cost/utility ratio was obtained for each option: 31,956 euros/QALY for DBS, 38,249 euros/QALY for SAIP, and 75,206 euros/QALY for LDI. CONCLUSIONS: Our results allow us to add information about effectiveness of different treatments, as these are presented in gain of years lived in full health (QALY). Data obtained contribute to decision making that determine planning and management of each case, without forgetting patient and neurologist preferences, as well as budgetary limitations.

TITLE: Estudio farmacoeconomico del tratamiento de la enfermedad de Parkinson avanzada.Introduccion. Cuando el tratamiento farmacologico oral o transdermico de la enfermedad de Parkinson pierde eficacia, se dispone de tres terapias mediante dispositivos asistidos que pueden reducir las complicaciones motoras y no motoras: la apomorfina en infusion subcutanea (ASBI), la bomba de infusion duodenal continua de levodopa/carbidopa (IDL) y la estimulacion cerebral profunda (ECP). Objetivo. Efectuar un analisis farmacoeconomico comparativo del uso de ASBI con IDL y ECP; como objetivo secundario, discutir el perfil del candidato ideal para cada una de las tecnicas. Pacientes y metodos. Se extrajo informacion sobre datos de años de vida ganados y años de vida ganados ajustados por calidad (AVAC) segun la escala de Hoehn y Yahr, e informacion sobre costes y consumo de recursos para cada alternativa. La perspectiva del analisis fue la del Sistema Nacional de Salud, y el horizonte temporal fue de cinco años para los costes y toda la vida del paciente para las utilidades. Las medidas de resultado utilizadas fueron los años de vida ganados y AVAC, y en su comparacion se uso la ratio coste-utilidad incremental. Resultados. El coste-utilidad obtenido para cada opcion fue: 31.956 euros/AVAC para la ECP, 38.249 euros/AVAC para la ASBI y 75.206 euros/AVAC para la IDL. Conclusiones. Los resultados permiten evaluar la efectividad y utilidad de los diferentes tratamientos para la enfermedad de Parkinson avanzada, pues se presentan en ganancias de años vividos en plena salud. Los datos obtenidos contribuyen a la toma de decisiones que determinen la planificacion y gestion de cada caso, sin olvidar las preferencias del paciente y del neurologo, asi como las limitaciones presupuestarias.

Cost-effectiveness of continuous subcutaneous apomorphine in the treatment of Parkinson's disease in the UK and Germany.

BACKGROUND: Parkinson's disease (PD) is the second most common neurodegenerative disease, affecting ∼ 5.2 million people worldwide. Continuous subcutaneous apomorphine (CSAI) represents an alternative treatment option for advanced PD with motor fluctuation. The purpose of this analysis was to estimate the cost-effectiveness of CSAI compared with Levodopa/carbidopa intestinal gel (LCIG), Deep-Brain-Stimulation (DBS) and Standard-of-care (SOC). METHODS: A multi-country Markov-Model to simulate the long-term consequences, disease progression (Hoehn & Yahr stages 3-5, percentage of waking-time in the OFF-state), complications, and adverse events was developed. Monte-Carlo simulation accounted for uncertainty. Probabilities were derived from RCT and open-label studies. Costs were estimated from the UK and German healthcare provider's perspective. QALYs, life-years (LYs), and costs were projected over a life-time horizon. RESULTS: UK lifetime costs associated with CSAI amounts to £78,251.49 and generates 2.85 QALYs and 6.28 LYs (€104,500.08, 2.92 QALYs and 6.49 LYs for Germany). Costs associated with LCIG are £130,011.34, achieves 3.06 QALYs and 6.93 LYs (€175,004.43, 3.18 QALYs and 7.18 LYs for Germany). The incremental-cost per QALY gained (ICER) was £244,684.69 (€272,914.58). Costs for DBS are £87,730.22, associated with 2.75 QALYs and 6.38 LYs (€105,737.08, 2.85 QALYs and 6.61 LYs for Germany). CSAI dominates DBS. SOC associated UK costs are £76,793.49; 2.62 QALYs and 5.76 LYs were reached (€90,011.91, 2.73 QALYs and 6 LYs for Germany). CONCLUSIONS: From a health economic perspective, CSAI is a cost-effective therapy and could be seen as an alternative treatment to LCIG or DBS for patients with advanced PD.

[Cost analysis in Italy of various strategies for the treatment of Parkinson disease in the advanced phase]. / Analisi dei costi, in Italia, di diverse strategie per il trattamento della malattia di Parkinson in fase avanzata.

OBJECTIVE: To perform a comparative economic evaluation of therapies--L-dopa drugs, subcutaneous infusion of apomorphine and surgical intervention of Deep Brain Stimulation (DBS)--for the treatment of advanced Parkinson's disease (APD) and to verify the level of assistance guaranteed in Italy to patients affected by APD. METHODS: Literature review and Delphi Panel to collect data about the efficacy of the therapies for the treatment of APD and the use of healthcare resources for such therapies. Field survey to investigate financing mechanisms of the therapeutical alternatives in the Italian regions; cost-analysis over five years (NHS perspective); cost-analysis (hospital perspective) for the initial administration of therapeutic alternatives. RESULTS: Literature review shows that the reduction of the "off-periods" is 62% for Apomorphine and 80-90% for DBS compared to traditional therapy. The 5-years economic analysis from the NHS perspective shows that the cost of a patients with APD is [symbol: see text] 58.065 if treated with traditional therapy, [symbol: see text] 36.423 (including infusional pump and the drug) with subcutaneous apomorphine and respectively [symbol: see text] 56.489 and [symbol: see text] 41.379 (depending on reimbursement of electrodes and neurostimulator on top of the DRG tariff) with DBS. The field survey, highlighted that Regions which currently reimburse the infusion pump for apomorphine and the electrodes and neurostimulator for DBS--on top of the DRG tariff--are a very limited number. CONCLUSIONS: Apomorphine and DBS in the treatment of APD show higher efficacy and lower costs compared to traditional therapy.

Economic aspects of medical erectile dysfunction therapies.

The introduction of safe and effective oral therapies has changed the significance of erectile dysfunction (ED) forever. Seldom has a new drug changed the landscape of pharmacotherapy in so many ways as sildenafil (Viagra, Pfizer). This article highlights the various oral, intracavernosal and intraurethral therapies currently available for ED and evaluates the socio-economic impact of each method.

[Apomorphine therapy versus deep rain stimulation. Clinical and economic aspects in patients with advanced Parkinson disease]. / Apomorphintherapie versus tiefe Hirnstimulation. Klinische und ökonomische Aspekte bei Patienten mit fortgeschrittenem Morbus Parkinson.

Long-term dopaminergic treatment of Parkinson's disease is complicated by the occurrence of dyskinesia and motor fluctuations and is responsible for increasing the costs of treatment. In these patients, continuous subcutaneous therapy with the dopamine agonist apomorphine or deep-brain stimulation represents a promising strategy. While the costs for the treatment with apomorphine are covered by health insurance, separate reimbursement for deep-brain stimulation does not exist in Germany. The case reports (n = 3) presented here emphasize that deep-brain stimulation is less cost-intensive than subcutaneous treatment with apomorphine in selected patients. Even in the first postoperative year costs for medication and hospital stays were reduced by approximately 60%. Moreover, in all three patients, motor complications improved after deep-brain stimulation in comparison to previous subcutaneous application of apomorphine. Thus, to further ensure deep-brain stimulation in parkinsonian patients it is mandatory to find a mode of reimbursement for the institutions concerned.