Therapeutic interchange of conjugated and esterified estrogens in a managed care organization

A program designed to curb increases in drug costs in an HMO by substituting esterified for conjugated estrogens was developed and studied. Patients were voluntarily switched from conjugated to esterified estrogens at an HMO in Washington State. Women were informed about the conversion through newsletters and during clinic and pharmacy visits and received physician and pharmacist counseling. Cost savings were estimated, and patient acceptance was evaluated by interviewing women in four groups, including women who were switched from conjugated to esterified estrogens and then switched back (C-E-C group), women who were not switched (C-C group), and women who were switched to esterified estrogens and not switched back (C-E group). During the first six months, 14,601 (89.2%) of 16,364 women taking conjugated estrogens were switched to esterified estrogens; of these, 13,654 (93.5%) continued taking esterified estrogens for at least six months. The HMO avoided $653,119 of an expected $750,000 cost increase for oral estrogen therapy during the first year of the program. A total of 754 women were interviewed; 65.8% in the C-E-C group and 78.4% in the C-E group reported being satisfied with the information they received. The conversion experience was rated as positive by 28.3% of women in the C-E-C group and 41.5% of women in the C-E group, negative by 25.1%, and 8.9%, and neutral by 46.6% and 49.6%. An HMO avoided a large increase in drug costs by substituting esterified for conjugated estrogens; only 6.5% of patients were switched back to conjugated estrogens at their physicians' or their own request; most patients thought the conversion was a neutral or positive experience.

Cost effectiveness of multi-therapy treatment strategies in the prevention of vertebral fractures in postmenopausal women with osteoporosis

OBJECTIVE

The aim of this study was to evaluate the cost effectiveness of multi-therapy treatment strategies in the prevention of vertebral fractures in postmenopausal women with osteoporosis.

DESIGN

A retrospective, incremental cost-effectiveness analysis was conducted from a societal perspective. It compared 9 treatment strategies over 3 years and incorporated the willingness of patients to initiate and continue each therapy.

MAIN OUTCOME MEASURES AND RESULTS

Four nondominated strategies formed the efficient frontier in the following order: (i) calcium-->no therapy; (ii) ovarian hormone therapy (OHT)-->calcium-->no therapy [166 Canadian dollars ($Can)]; (iii) OHT-->etidronate-->calcium-->no therapy ($Can2331); and (iv) OHT-->alendronate-->calcium-->no therapy ($Can40,965). The figures in parentheses are the incremental costs per vertebral fracture averted to move to that strategy from the previous strategy for patients who had undergone a hysterectomy.

CONCLUSIONS

We identified 4 efficient multi-therapy strategies for the treatment of vertebral osteoporosis in postmenopausal women, 2 of which were consistent with the practice guidelines of the Osteoporosis Society of Canada. Decision-makers may select from among these efficient strategies on the basis of incremental cost effectiveness.

[Analysis of subjective effect, acceptance and costs of conservative treatment of prolapse and incontinence in women]

A renaissance of conservative treatment for urinary incontinence and descensus is taking place presently in the German speaking area for pre-surgical improvement of tissue quality as well as for long-term-treatment replacing or postponing surgery. Modern pessaries (shape and material), a more intense and pathophysiological well-founded physiotherapy as well as the support of treatment by electrostimulation and its completion by adequate hormone substitution lead to a successful conservative treatment. "Gesundheitsstrukturreform" (reformatory measures of the German Public Health System), "Fallpauschalen" (flat-rate tariff of treatment by the case) and "Praxisbudgets" (budgets for out-clinic-treatment by the case, also a form of flat-rate tariff) lead to a restriction in prescribing necessary conservative treatment or preventive measures. Assigning the patient to surgical treatment is therefore in large parts favoured (treatment costs are then charged to clinic budgets). On the basis of the presented exemplary cost analysis completed by data on subjective effectiveness, acceptance and evaluation of efforts for patient and doctor we want to show that it is not either method that has to be considered in the treatment but both. Besides we have to treat the patient sequentially-conservative treatment in most cases first, especially in younger women. Conservative treatment thereby offers the possibility to delay or postpone surgery, a very meaningful option offered regarding the relatively poor results of surgery especially in cases of recurrent disease.

[Pharmacoeconomics of menopause treatments: epidemiological data and hormonal and non-hormonal prescription attitude of Belgian gynecologists]

In an economic analysis one has not only to consider costs induced by hormonal substitution therapy (HRT) but also its impact health. Different therapy costs will be considered and related to potential benefits on health. HRT decreases the incidence of symptoms of the menopause, the risk of osteoporosis and perhaps the incidence of coronary hearth disease and the risk of Alzheimer disease but probably increases the incidence of breast cancer. For a majority of women, the favorable impact seems to dominate, increasing their life expectancy.

[Cost of hormonal substitution treatment]

Hormone replacement therapy during menopause constitutes a long-lasting preventive treatment. The possibilities of prescriptions are varied. It is therefore important to individualise one's choice according to different criteria: simplicity, tolerance, effectiveness, comfort, cost. The latter--which currently varies between 34 BF and 681 BF for the patient per month--should no longer be an obstacle to begin or maintain hormone therapy during menopause.

Patient education programs and continuance with estrogen replacement therapy: evaluation of the women's health exchange

OBJECTIVE

This study examined the impact of the Women's Health Exchange (WHE), a program aimed at educating women about menopause and estrogen replacement therapy, on patient continuance with Estraderm, a transdermal estrogen replacement medication.

DESIGN

The prescription database of Express Scripts, Inc., a pharmacy benefits management company serving a large, nationwide insured population, was used for the study. All study subjects had one or more claims for Estraderm between 2/1/95 and 8/31/95. The intervention group consisted of 299 WHE enrollees, and the control group comprised a random sample of 1,513 patients who had not enrolled in WHE.

RESULTS

A multivariate Cox regression model found that older age, longer prior length of Estraderm use, progestin use, and patronage of a mail-order pharmacy were associated with increased continuance. Controlling for these factors and for HMO enrollment and copay amount, the likelihood of discontinuing Estraderm was significantly lower for WHE enrollees compared to non-WHE enrollees. Sensitivity analyses tested the effects of preexisting differences between the WHE and control group subjects on study findings. Even when WHE enrollees were compared with control subjects having similar medication costs, disease severity, or continuance with chronic medications, WHE enrollment was associated with an increased length of Estraderm therapy.

CONCLUSIONS

These findings suggest that patient education programs may improve continuance with transdermal hormone replacement therapy for patients with a prescription benefit.

Achieving long-term continuance of menopausal ERT/HRT: consensus opinion of the North American Menopause Society

OBJECTIVE

Estrogen replacement therapy (ERT, defined as estrogen alone) or hormone replacement therapy (HRT, defined as estrogen plus some form of progestogen) may be beneficial for many women as they approach menopause and beyond. If hormones are indicated for some women, optimal continuance is a clinical goal. The North American Menopause Society (NAMS) has developed a consensus opinion on how best to achieve this goal.

DESIGN

NAMS held a closed conference of experts in the field to determine why women who begin ERT/HRT stop taking the medication, to review what has been learned from continuance research in other therapeutic areas, to make recommendations about how to help women achieve long-term continuance of therapy, and to suggest areas for research. The proceedings of the conference were used to assist the NAMS Board of Trustees in developing this consensus opinion of the Society.

RESULTS

On the basis of current knowledge, the experts and NAMS established the following recommendations for helping women achieve long-term continuance of ERT/HRT: (1) involve the woman in the decision-making process, (2) explain benefits and risk with clarity and personalize them, (3) clarify and discuss the woman's preferences beginning early in decision making and use these preferences to modify a regimen to improve continuance, (4) provide educational information that the woman can understand, (5) help the woman systematize medication taking, and (6) follow up with the woman. Areas of needed research were identified.

CONCLUSIONS

As with all long-term prescription therapies, ERT/HRT for menopause-related effects is associated with suboptimal continuance. Many techniques can be used to help improve continuance. However, more research is needed to help women achieve optimal success.

Nonparametric willingness-to-pay measures and confidence statements

Willingness to pay (WTP) for a health care program can be estimated in contingent valuation (CV) studies by a nonparametric approach. The nonparametric approach is free from distributional assumptions, which is a strength compared with parametric regression-based approaches. However, using a nonparametric approach it is not clear how to obtain confidence statements for WTP estimates, for example, when testing hypotheses regarding differences in mean WTP for different subsamples. The authors propose a procedure that allows statistical testing and confidence interval estimation by employing bootstrap techniques. The method is easy to implement and has low computational costs with modern personal computers. The method is applied to data from a CV study where the WTP for hormone replacement therapy was investigated. The mean WTP was estimated for the full sample and separately for women with mild and severe menopausal symptoms. Using the proposed method, the mean WTP was significantly higher in the group with severe symptoms.

Cost effectiveness of coronary heart disease prevention strategies in adults

Although risk-factor modification has gained wide acceptance as an effective approach to the prevention of coronary heart disease (CHD), health planners, physicians and patients confront considerable uncertainty over the most appropriate and efficient preventive strategies. Some preventive approaches are both inexpensive and effective; others are expensive while their effectiveness is slight or unproven. Effectiveness varies with an individual's age, gender and other risk factors. Information provided by a cost-effectiveness analysis can clarify the value of alternative strategies for CHD prevention in specific populations, thereby helping to choose among them. It does so by producing a standard measure of value--the cost per year of life saved (YLS) or cost per quality-adjusted life-year (QALY) saved--that reveals which of several alternative interventions provides the greatest health benefit from a given expenditure. This article summarises the extensive literature on the cost effectiveness of CHD prevention with an emphasis on primary prevention. Published work indicates that smoking-cessation programmes, particularly those that rely on counselling with or without nicotine supplements, are highly cost effective in many settings. Although the evidence is limited, exercise programmes also appear to be cost effective. The detection and treatment of hypertension is highly cost effective, particularly when inexpensive drugs with proven effectiveness, such as diuretics or beta-blockers, are used. Hormone-replacement therapy is a cost-effective approach to CHD prevention in most postmenopausal women, although direct clinical trial data are lacking and it is uncertain which hormone preparation is best. Cholesterol reduction is a cost-effective strategy for the prevention of CHD in individuals without other treatable risk factors who are at very high risk of developing CHD. For individuals with multiple CHD risk factors, the choice of risk-modification strategies is complex and depends upon the interactions of risk and the relative costs of treating each risk.

[Risks, benefits and costs of hormone replacement therapy in menopause]

Hormone replacement therapy (HRT) acts both as an effective treatment of menopausal symptoms and genital atrophy, and as an effective prevention of osteoporosis. It is also probably cardioprotective and potentially preventing cerebrovascular disease. The risk of oestrogen-induced endometrial cancer is eliminated by the addition of a progestin. An increase in breast cancer risk is however possible after 10 years or more of HRT use. This multifactorial risk-benefit balance altogether with other variables (numerous and expensive hormonal therapies, low compliance of postmenopausal women, need for monitoring, therapy-related adverse events) explain why so few global pharmaco-economic appraisals have been devoted to HRT. Computer model studies have been set up to study hypothetical cohorts of menopausal women treated for 5-10 years or more, comprising hysterectomized women (receiving an estrogen alone) and non hysterectomized women (receiving an oestrogen-progestogen therapy) compared with untreated controls. Treatment of hysterectomized women as well as non hysterectomized symptomatic menopausal women appears relatively cost-effective. In terms of mortality and morbidity, a reduction in cardiovascular disease risk and, to a smaller extent, in osteoporosis has a strikingly greater impact than the small increase in breast cancer risk related to HRT use. A significant increase in life expectancy seems associated with long-term use and the quality-adjusted life years gain, is particularly impressive, as quality of life appears distinctly improved by HRT utilization. In the future, this beneficial cost-effectiveness equation will probably be optimized thanks to the introduction of alternative and innovative replacement therapies allowing longer treatment periods without increasing the risk of breast cancer.

Hormone replacement therapy: assessment of present use, costs, and trends

BACKGROUND

Hormone replacement therapy (HRT) is probably unprecedented as a drug in widespread preventive use by a predominantly well population, but there is little direct data on current trends in use.

AIM

To estimate trends in the use and cost of HRT in Britain.

METHOD

Government prescription data and therapy cost data were analysed to provide trends in costs and point prevalence of the use of HRT since 1980. Projections were estimated to the year 2000.

RESULTS

In 1987, HRT was used by an estimated 2.2% of women aged 40 to 64 years in England, and by 1.0% in Scotland. By 1994 this had risen to 21.7% in England, 20.4% in Scotland, and 21.3% in Wales. Between 1980 and 1986, costs remained steady at approximately 11 million Pounds per annum for England and 1 million Pounds for Scotland (1994 values). Between 1987 and 1994 they rose to 87 million Pounds for England, 10 million Pounds for Scotland, and 46 million Pounds for Wales (1994 values). Projections suggest that, by the year 2000, 25.4% of women aged 40 to 64 years (95% CI = 20.1-30.7%) will be taking HRT at any one time, at a cost of 150 million Pounds (95% CI = 142 m Pounds-157 m Pounds: 1994 values). This implies an 'ever' user prevalence of at least two-thirds of women in this age group.

CONCLUSION

Use of HRT for long-term therapy is widespread and rising. It is estimated that prevalence has increased tenfold since 1987. Average individual costs of therapy have fallen by one third. The level of reduced risk of osteoporosis and cardiovascular disease, and the balance with cost and potential increased risk of breast cancer, are not yet established and are in need of clarification.

Willingness to pay for hormone replacement therapy

This study addresses the question of willingness to pay (WTP) for hormone replacement therapy (HRT) in order to alleviate menopausal symptoms. The woman obtains utility from consumption of goods and health. The purchase of a treatment is represented as a shift in the health production function during the treatment period. The mean WTP for the HRT is estimated using a parametric and a non-parametric method. The mean WTP based on these two methods is similar in both cases and amounts to about SEK 40000 per year. Further, it is shown that the mean WTP is above the mean treatment cost of HRT. Finally, the implied WTP per gained quality adjusted life year (QALY) is estimated at about SEK 120000 and SEK 160000 based on the rating scale (RS) and time trade-off (TTO) methods, respectively.

Benefits of hormone replacement therapy--overview and update

Postmenopausal estrogen deficiency may result in a wide variety of physiologic disorders, including vasomotor symptoms, urogenital atrophy, an increase in the risk of coronary heart disease, osteoporotic fractures, and Alzheimer's disease. The growing body of evidence, including much that is newly published, demonstrating that hormone replacement therapy (HRT) can largely prevent or mitigate these sequelae, will be reviewed in this paper. The efficacy of HRT in alleviating vasomotor and urogenital discomfort, the most common symptoms of postmenopausal estrogen deficiency, is well established. Evidence from over 30 epidemiologic studies indicates that estrogen reduces the risk of coronary heart disease (CHD) by 50%. The risk of major CHD has been found to be markedly reduced in women who receive combined estrogen/progestogen therapy compared to nonusers (or estrogen-alone users). Estrogen is recommended as the modality of choice to prevent bone loss: data supporting a positive effect of estrogen on the risk of wrist and vertebral fracture are quite favorable. Similarly, outcomes of recent investigations have demonstrated a positive impact of HRT on both psychological function and the risk of osteoarthritis. In addition, HRT substantially reduces the risk of colon cancer. Moreover, the potential for HRT to delay the progression or reduce the risk for developing Alzheimer's disease is a new area of research that shows promise. Improvements in quality-of-life assessments have also been reported in conjunction with the relief of menopausal symptoms by HRT. Clinicians should be aware of the large amount of new evidence that strengthens the case for wider use of HRT. Based on these new data, physicians may conclude that HRT would benefit the majority of their postmenopausal patients and thus encourage HRT use in the absence of known risk factors.

[Women's hearts are hard to break. Coronary heart diseases--is the woman a special case!?]

1. Recommendations and decisions concerning treatment should primarily be based on the absolute evaluation of risk and risk reduction and not on calculation of a relative risk situation. 2. The therapeutic benefit in women at low risk should be balanced against possible physical and psychic side effects and submitted to a cost/benefit analysis. 3. The fact that coronary heart disease is rare in young women must not at all be reason for a less consequent treatment and prevention in women with established coronary heart disease.

The impact of hormone replacement therapy on quality of life and willingness to pay

OBJECTIVE

To measure the gain in quality of life due to hormone replacement therapy for women with mild and severe menopausal symptoms.

DESIGN

Prospective study where data on quality of life and willingness to pay were collected by interview.

SETTING

Department of Gynaecology at Södertälje Hospital near Stockholm.

PARTICIPANTS

One hundred and four women aged 45 to 65 years treated for menopausal symptoms for at least one month.

METHODS

Quality of life was measured by the time tradeoff and rating scale methods. The willingness to pay for hormone replacement therapy was investigated using the contingent valuation method.

MAIN OUTCOME MEASURES

The quality adjusted life year weight measured with the rating scale and time tradeoff methods, and willingness to pay.

RESULTS

The increase in the quality adjusted life year weight due to hormone replacement therapy for women with mild symptoms was 0.26 according to the rating scale method and 0.18 according to the time tradeoff method. For women with severe symptoms the quality adjusted life year weight increased by 0.50 according to the rating scale method and by 0.42 according to the time tradeoff method. The mean willingness to pay for hormone replacement therapy per month was 2300 Swedish krone for women with mild symptoms and 4800 Swedish krone for women with severe symptoms (Pounds 1 = 10.3 Swedish krone).

CONCLUSIONS

Hormone replacement therapy leads to a major improvement in quality of life for women with menopausal symptoms. Both for women with mild and severe menopausal symptoms the willingness to pay for the treatment also greatly exceeds the costs, indicating that hormone replacement therapy is economically beneficial for women with menopausal symptoms.

Managed care of hormone replacement therapy in the menopause

The principles of managed care are more difficult to apply to preventive medical treatments, such as hormone replacement therapy, than to the investigation and treatment of established disease. In addition to an ageing society with increased health demands, the use of hormone replacement therapy is increasing in most developed countries. Clinical guidelines for the counselling of post-menopausal women and the use of hormone replacement therapy have been prepared by the American College of Physicians. There is limited information about the benefits and risks of hormone replacement therapy from randomized prospective studies and these guidelines are based on the best available data from observational studies and meta-analysis. More secure data will become available within the next decade from long-term studies that are currently in progress. Managed care proposals for hormone replacement therapy must be flexible enough to adjust to new data as they become available while recognizing that, given current knowledge, hormone replacement is healthcare-cost-effective for the vast majority of menopausal women.

The marketing of estrogens for menopausal and postmenopausal women

Menopausal and postmenopausal women are a targeted consumer group in the promotion of hormone drugs. The marketing of these pharmaceutical products aims directly at prescribing medical professionals and indirectly at women. The promotion seems intended to creating a collective consciousness that women over 40 need medical and pharmacological treatment.

Estimating the cost per avoided hip fracture by osteoporosis treatment in Italy

OBJECTIVES

A cost-effectiveness analysis on osteoporosis treatment has been carried out as the basis for an estimate of the cost per avoided hip fracture (CPAHF) in Italy.

METHODS

We have assumed as correct, reported data on the efficacy of calcitonin in preventing hip fractures in European women over 50 (Mediterranean Osteoporosis Study). Health-care costs were calculated using Weinstein and Stason's equation.

RESULTS

Given the incidence of such fractures in Italy and their cost to the health service, we calculate that in order to prevent one hip fracture 1285 women need to be treated with calcitonin at a cost of over two million dollars. The introduction of an element of screening (bone mass measurement to select a high risk subpopulation) would reduce the CPAHF by 65%. Choice of a more effective treatment (as the hormone replacement therapy) would be cost-neutral.

CONCLUSIONS

Drug-related costs, selection of high risk subpopulations and drug efficacy have important implications in the estimation of optimal CPAHF.

Cost effectiveness scenario analysis for a proposed trial of hormone replacement therapy

Whereas evaluation of resource implications and quality of life are often incorporated into assessments of health technology, the decision to undertake the assessment is still mostly driven by interests in the clinical outcomes alone. A systematic approach to evaluating expected returns to health technology assessment has not been readily taken up by research funders or assessors. This paper sets out a specific methodology for ex ante evaluation or triage and proposes a decision procedure, using alternative outcome scenarios and the associated policy changes and costs and benefits, against a background of likely clinical practice in the absence of the assessment. The methodology is used to consider implications of a proposed major clinical trial to assess the long term costs and benefits of hormone replacement therapy.

Hormone replacement therapy: a review of the risk versus benefit--Part II

As the large ¿baby-boom¿ cohort of women enters the period of menopause, much attention is being focused on the potential public health benefits of hormone replacement therapy (HRT) and its relative safety. Increasingly, economic models derived from these studies define populations of women most likely to benefit from this treatment. This paper will review the clinical efficacy and safety of HRT and examine published pharmacoeconomic studies evaluating the use of HRT for post-menopausal women. Ultimately, the cost effectiveness of HRT is dependent on the extent of the cardioprotective effect of estrogen and estrogen-progestin combination therapy. Part II of this article describes the pharmacologic evidence that serves as a basis for evaluating HRT.