Economic impact of generic substitution of lamotrigine: projected costs in the US using findings in a Canadian setting

BACKGROUND

Generic substitution may not always save health care costs for antiepileptic drugs (AED).

OBJECTIVE

(1) To examine the economic impacts of generic substitution of lamotrigine in Canada; and (2) to convert observed Canadian costs to a United States (US) setting.

METHODS

Health claims from Québec's health plan (RAMQ) between 08/2002 and 07/2006 were analyzed. Patients with > or = 1 epilepsy claim and treated with branded lamotrigine (Lamictal) before generic entry were selected. Health care costs ($/person-year) were compared during periods of branded and generic use of lamotrigine. Two cost-conversion methods were employed; one using purchasing power parities, US/Canada service use ratios, and exchange rate, and another employing Canadian health care utilization and US unit costs.

RESULTS

671 patients were observed during 1650.9 and 291.2 person-years of branded and generic use of lamotrigine, respectively. The generic-use period was associated with an increase in overall costs (2006 constant Canadian dollars) relative to brand use (C$7902 vs. C$6419/person-year; cost ratio (CR) = 1.22; p = 0.05), despite the lower cost of generic lamotrigine. Non-lamotrigine costs were 33% higher in the generic period (p = 0.013). Both conversion methods yielded increases in total projected health care costs excluding lamotrigine (2006 constant US dollars) during the generic period (Method 1: cost difference: US$1758/person-year, CR = 1.33, p = 0.01); Method 2: cost difference: US$2516, CR = 1.39, p = 0.004).

LIMITATIONS

Study limitations pertain to treatment differences, indicators used for conversion and possible claim inaccuracies.

CONCLUSION

Use of generic lamotrigine in Canada was significantly associated with increased overall medical costs compared to brand use. Projected overall US health care costs would likely increase as well.

Cost of epilepsy: a systematic review

The objective of this review was to overview published cost-of-illness (COI) studies of epilepsy and their methodological approaches. Epilepsy imposes a substantial burden on individuals and society as a whole. The mean prevalence of epilepsy is estimated at 0.52% in Europe, 0.68% in the US, and peaks up to 1.5% in developing countries. Estimation of the economic burden of epilepsy is of pivotal relevance to enable a rational distribution of healthcare resources. This is especially so with the introduction of the newer antiepileptic drugs (AEDs), the marketing of vagal-nerve stimulators and the resurgence of new surgical treatment options, which have the potential to considerably increase the costs of treating epilepsy.A systematic literature review was performed to identify studies that evaluated direct and indirect costs of epilepsy. Using a standardized assessment form, information on the study design, methodological framework and data sources were extracted from each publication and systematically reported. We identified 22 studies worldwide on costs of epilepsy. The majority of the studies reflected the costs of epilepsy in Europe (three studies each for the UK and Italy, one study each for Germany, the Netherlands, Switzerland, France and the EU) and the US (four studies), but studies were also available from India (two), Hong Kong, Oman, Burundi, Chile and Mexico. The studies utilized different frameworks to evaluate costs. All used a bottom-up approach; however, only 12 studies (55%) evaluated direct as well as indirect costs. The range for the mean annual direct costs lay between 40 International Dollar purchasing power parities (PPP-$) in rural Burundi and PPP-$4748 (adjusted to 2006 values) in a German epilepsy centre. Recent studies suggest AEDs are becoming the main contributor to direct costs. The mean indirect costs ranged between 12% and 85% of the total annual costs. Epilepsy is a cost-intensive disorder. A reliable comparison of the different COI studies in epilepsy is not easily feasible, as the evaluated studies show substantial methodological differences with respect to their patient selection criteria, diagnostic stratifications and evaluated costs. Therefore, there is an urgent need for studies that evaluate direct and indirect costs in a standardized fashion.

The economic consequences of generic substitution for antiepileptic drugs in a public payer setting: the case of lamotrigine

Generic substitution of antiepileptic drugs (AEDs) may increase pharmacy utilization, thus counterbalancing per-pill savings. The purpose of our study was to analyze the economic impact of government-mandated switching from branded to generic lamotrigine. Patients in a Canadian public pharmacy claims database using branded lamotrigine (Lamictal GlaxoSmithKline, UK) in 2002 converted to generic lamotrigine in 2003 and were observed from July 2002 to March 2006. Patients used branded lamotrigine for >or=90 days pre-generic entry and had >or=1 claim for generic lamotrigine post-generic entry. For the generic period, observed per-patient monthly drug costs were calculated as the sum of costs for lamotrigine, other AEDs, and non-AEDs. Expected per-patient drug costs were estimated assuming lamotrigine dose and other prescription drug utilization in the generic period were identical to those observed during the brand period. Differences between observed and expected costs were compared. Among 1,142 branded lamotrigine users, overall average monthly drug costs per person were expected to decrease by $30.55 due to lower pill costs. Instead, they fell by $11.98 from the brand to the generic periods (p < 0.001). Because of dosage changes, lamotrigine costs decreased by $29.92 instead of the anticipated $33.87 (p < 0.001). Increased pharmacy utilization caused other AED costs to rise by $6.29 versus the expected $0.36 (p < 0.001), while non-AED drug cost increased by $11.64 rather than by $2.95 (p < 0.001). We concluded that conversion to generic lamotrigine resulted in lower than expected cost savings. Further research is necessary to determine whether this is due to reduced effectiveness and/or tolerability. Payers may weigh smaller-than-expected cost reductions against a possible decrease in effectiveness to assess the relevance of mandatory generic switching of lamotrigine.

Evaluation of socio-economic factors causing discontinuation of epilepsy treatment resulting in seizure recurrence: A study in an urban epilepsy clinic in India

BACKGROUND AND PURPOSE

The prevalence rate of epilepsy in India ranges between 4.15 and 7.03 per 1000 population. In the developing countries, the major problems of epilepsy are lying in the treatment gap and discontinuation of treatment due to various adverse socio-economic factors. The objective of this study was to evaluate the rate of discontinuation of epilepsy treatment and its related socio-economic factors responsible for discontinuation.

MATERIAL AND METHODS

Among 1450 patients with epilepsy who were recurrently followed up at an intervals of 2 months from 05 January to 06 January; 620 patients discontinued their treatment. Among them 88.7% patient had breakthrough seizures for more than in two occasions. Socio-economic factors in respect to the treatment were evaluated during the follow-up period vis-a-vis income and expenditure, unemployment status, negative attitude towards medical treatment, non-availability of drugs locally, co-morbid psychiatric and other illnesses, polytherapy and socialillusional thoughts about epilepsy.

RESULTS

Discontinuation of epilepsy treatment was detected in 42.75% (n = 620) of total patients resulting in recurrence of seizures. Reasons for discontinuation were multiple in most of the cases. The discontinued group had an average annual cost of treatment and income of Rs. 5500 ($110) and Rs. 12,800 ($256), respectively, amounting to 40% of their total income being expended for the cost of the treatment, while in continued group annual cost of treatment and income were Rs. 4500 ($ = 90) and Rs. 24,400 ($ = 580) respectively amounting to only 18% of the total income (p < 0.001) for the cost of treatment. Among the discontinued group, 90% of the patients reported the cost factors, 29.09% due to the unemployment, 20% from the frustration and despair, 20.09% due to non-availability of medicines locally, 17.27% spiritual illusional thoughts about epilepsy, 10% for marital disharmony were the causes for discontinuation of treatment. In the discontinued group, 10% got polytherapy against 9.03% in the continued group (p > 0.01), co-morbid psychiatric illnesses were observed in 4.54% against 3.25% in the continued group (p > 0.10).

CONCLUSION

The study showed a significant number of patients (42.75%) discontinued epilepsy treatment within 1 year due to poor knowledge regarding the problem of discontinuation, cost and income disparity, unemployment, spiritual illusional thoughts about epilepsy, frustration and mental impairment, lack of uniform availability of drugs in local market. To tide these shortcomings, uniform availability of cheaper antiepileptic drugs with adequate information and communication regarding the disease and upliftment of socio-economic status are to be ensured.

A randomised controlled trial examining the longer-term outcomes of standard versus new antiepileptic drugs. The SANAD trial

OBJECTIVES

To compare clinicians' choice of one of the standard epilepsy drug treatments (carbamazepine or valproate) versus appropriate comparator new drugs.

DESIGN

A clinical trial comprising two arms, one comparing new drugs in carbamazepine and the other with valproate.

SETTING

A multicentre study recruiting patients with epilepsy from hospital outpatient clinics.

PARTICIPANTS

Patients with an adequately documented history of two or more clinically definite unprovoked epileptic seizures within the last year for whom treatment with a single antiepileptic drug represented the best therapeutic option.

INTERVENTIONS

Arm A was carbamazepine (CBZ) versus gabapentin (GBP) versus lamotrigine (LTG) versus oxcarbazepine (OXC) versus topiramate (TPM). Arm B valproate (VPS) versus LTG versus TPM.

MAIN OUTCOME MEASURES

Time to treatment failure (withdrawal of the randomised drug for reasons of unacceptable adverse events or inadequate seizure control or a combination of the two) and time to achieve a 12-month remission of seizures. Time from randomisation to first seizure, 24-month remission of seizures, incidence of clinically important adverse events, quality of life (QoL) outcomes and health economic outcomes were also considered.

RESULTS

Arm A recruited 1721 patients (88% with symptomatic or cryptogenic partial epilepsy and 10% with unclassified epilepsy). Arm B recruited 716 patients (63% with idiopathic generalised epilepsy and 25% with unclassified epilepsy). In Arm A LTG had the lowest incidence of treatment failure and was statistically superior to all drugs for this outcome with the exception of OXC. Some 12% and 8% fewer patients experienced treatment failure on LTG than CBZ, the standard drug, at 1 and 2 years after randomisation, respectively. The superiority of LTG over CBZ was due to its better tolerability but there is satisfactory evidence indicating that LTG is not clinically inferior to CBZ for measures of its efficacy. No consistent differences in QoL outcomes were found between treatment groups. Health economic analysis supported LTG being preferred to CBZ for both cost per seizure avoided and cost per quality-adjusted life-year gained. In Arm B for time to treatment failure, VPS, the standard drug, was preferred to both TPM and LTG, as it was the drug least likely to be associated with treatment failure for inadequate seizure control and was the preferred drug for time to achieving a 12-month remission. QoL assessments did not show any between-treatment differences. The health economic assessment supported the conclusion that VPS should remain the drug of first choice for idiopathic generalised or unclassified epilepsy, although there is a suggestion that TPM is a cost-effective alternative to VPS.

CONCLUSIONS

The evidence suggests that LTG may be a clinical and cost-effective alternative to the existing standard drug treatment, CBZ, for patients diagnosed as having partial seizures. For patients with idiopathic generalised epilepsy or difficult to classify epilepsy, VPS remains the clinically most effective drug, although TPM may be a cost-effective alternative for some patients. Three new antiepileptic drugs have recently been licensed in the UK for the treatment of epilepsy (levetiracetam, zonisamide and pregabalin), therefore these drugs should be compared in a similarly designed trial.

Costs of NHS maternity care for women with multiple pregnancy compared with high-risk and low-risk singleton pregnancy

OBJECTIVE

To compare antenatal and obstetric costs for multiple pregnancy versus singleton pregnancy risk groups and to identify factors driving cost differentials.

DESIGN

Observational study over 15 months (2001-02).

SETTING

Four district hospitals in southeast England.

POPULATION

Consecutive women with multiple pregnancy and singleton women with risk factors for fetal congenital heart disease (CHD) (pregestational diabetes, epilepsy, or family history of CHD) or Down syndrome, and a sample of low-risk singleton women.

METHODS

Clinical care was audited from the second trimester anomaly scan until postnatal discharge, and the resource items were costed. Multiple regression analysis determined predictors of costs.

MAIN OUTCOME MEASURES

NHS mean costs of antenatal and obstetric care for different types of pregnancy.

RESULTS

A total of 959 pregnancies were studied. Three percent of 243 women with multiple pregnancy reached 40 weeks of gestation compared with 54-55% of 163 low-risk and 322 Down syndrome risk women and 36% of 231 cardiac risk women. Antenatal costs for cardiac risk (1,153 pounds sterling) and multiple pregnancy (1,048 pounds sterling) were nearly double the costs for other two groups (P < 0.001). As 63% of multiple births were delivered by caesarean section, the obstetric cost for multiple pregnancy (3,393 pounds sterling) was 1,000 pounds sterling greater overall. Pregestational diabetes was the most influential factor driving singleton costs, resulting in similar total costs for multiple pregnancy women (4,442 pounds sterling) and for women with diabetes (4,877 pounds sterling).

CONCLUSIONS

Our analyses confirm that multiple pregnancies are substantially more costly than most singleton pregnancies. Identifying women with diabetes as equally costly is pertinent because of the findings of the Confidential Enquiry into Maternal and Child Health that standards of maternal care for diabetics often are inadequate.

[The direct costs of epilepsy in a Chilean population]

INTRODUCTION

Epilepsy Chilean prevalence is 17-21/1,000 inhabitants. In past years, there is concern for the high costs involved in its handling. AIM. To estimate the direct costs of treatment and handling in specific population with epilepsy.

PATIENTS AND METHODS

It is a retrospective study, in 6 groups of people with epilepsy: recent diagnosis (RD), remission (R), occasional seizures (OS), active without resistance to drugs (AWRD), resistance to pharmacological treatment (RPT), and epilepsy surgery (S). Data and characteristics tabulation and economical study of each group were made, considering 1 year of treatment. A comparison was made between them and their average in relation to international data.

RESULTS

293 patients. 52% male. 76% adults. 25% students. 55% focal seizures. Costs per group: (USD/patient/year): RD, 443; R, 316; OS, 430; AWRD, 711; RPT, 946; S, 4,262. Direct average cost of treatment for epilepsy in this population: 615 USD/patient/year.

CONCLUSIONS

When differentiating in groups of individuals with epilepsy, the highest average annual cost is in surgery and the lowest in remission. In all the groups, except for surgery one, the highest expense is in drugs (average 81%). In relation to other countries, our direct costs are 5 times lower than in some developed countries and 3.5 times higher than in other developing countries. This data is of interest to governmental and financial spheres, so to provide a better quality of life for people with epilepsy, lowering costs and fees for their treatment and contributing to epilepsy and surgery national programs.

Availability and Costs of Antiepileptic Drugs and Quality of Phenobarbital in Vientiane Municipality, Lao PDR

PURPOSE

In developing countries, availability and quality of drugs are critical factors for effective management and control of epilepsy. This study investigated the availability and costs of antiepileptic drugs (AEDs), and the quality of phenobarbital in Vientiane Municipality, Lao PDR.

METHODS

In March 2004, we enrolled all pharmacies (categories I and II) of four central districts of Vientiane eligible to sell AEDs. Two hundred and eight pharmacies of category III (75.1% of all registered pharmacies) were excluded as the sale of AEDs was not authorized. All pharmacists were interviewed with a standard questionnaire. Whenever phenobarbital was available, a sample was purchased and assayed by liquid chromatography. Phenobarbital was defined as being of correct quality if the active substance average content corresponded to +/-15% of the indicated amount.

RESULTS

66 pharmacies were enrolled (13 and 45 of categories I and II, respectively, and 8 hospital pharmacies). Six generics of AEDs were found (phenobarbital, phenytoin, valproic acid, clonazepam, carbamazepine, diazepam) and all pharmacies sold at least 1 AED. The 2 most widely available drugs were diazepam (5 mg) and phenobarbital (100 mg), present in 87.9 and 53.0% of the pharmacies, respectively. All 34 phenobarbital samples examined showed a correct concentration of the active compound. However, the concentration of phenobarbital 100 mg tablets produced in Lao PDR (mean concentration 94.7 mg) was significantly lower (p = 0.005) than the imported equivalent (mean concentration 99.7 mg). The direct drug costs of a yearly treatment with phenobarbital were estimated to be at least 25.2 USD.

CONCLUSIONS

A variety of AEDs are present. Their availability, particularly of phenobarbital, is restricted to higher-category pharmacies and within those it is rather limited. To meet the costs of AEDs in this setting is a major challenge for people with epilepsy. However, the quality of the available phenobarbital was rather satisfactory.

A cost-effectiveness decision model for antiepileptic drug treatment in newly diagnosed epilepsy patients

OBJECTIVE

To establish cost-effectiveness of antiepileptic drug (AED) treatment strategies of newly diagnosed patients with epilepsy.

METHODS

A decision analysis was carried out comparing effectiveness and treatment cost of six treatment strategies comprising carbamazepine (CBZ), lamotrigine (LTG), and valproate (VPA) as first-line and second-line drugs. Three outcome groups were defined: complete success, partial success, and failure. Data on seizure control and failure due to adverse effects were derived from the literature. Data on resource use and costs were collected for each outcome group by means of a patient survey.

RESULTS

Cost data were obtained from 71 patients. Cost increased from complete success to failure outcome groups. The probability of obtaining complete success varied from 64% (VPA-CBZ strategy) to 74% (LTG-VPA strategy). The strategy LTG-VPA was more effective than the least expensive strategy CBZ-VPA, but at higher costs per additional effectively treated patient. Probabilistic sensitivity analysis confirmed these findings to be robust. Subsequent analysis showed that changing inclusion criteria used in the selection of the studies from the literature had a major effect on cost-effectiveness ratios of the various strategies. The probability that LTG first-line therapy is the most cost-effective option remains small, even defining a high cost-effectiveness threshold. Nevertheless, LTG second-line strategies can be cost-effective depending on the willingness to pay for patient improvement.

CONCLUSIONS

Only a few studies satisfied our inclusion criteria for employment in our decision model. Our model supports the use of conventional AEDs as first-line options for patients with newly diagnosed epilepsy. LTG second-line therapy is likely to be the most cost-effective option in case society is willing to pay more than Euro 6000 for an additional successfully treated patient. This study also illustrates that, with the data presently available, the outcome of decision analysis for AED treatment choice depends on the inclusion criteria used to select trials. Prospective real-life studies are needed in which first- and second-line treatment strategies are compared with respect to both effectiveness and costs.

The personal and financial impact of repetitive or prolonged seizures on the patient and family

Individuals with epilepsy consistently report diminished quality of life. The clinical characteristics of seizures and the unpredictable nature of seizure occurrences are some factors that affect quality of life. Prolonged or repetitive seizures can impose psychologic comorbidities, social issues, and lifestyle restrictions that can affect quality of life of patients and their caregivers and family members, who also bear the considerable indirect costs of seizures, including time away from work or school, and even loss of employment. The availability and use of an at-home medication to terminate prolonged or repetitive seizures or in seizure emergencies improves quality of life for patients and their families. Fewer visits to the emergency department are associated with a reduction in the financial burden to families and the health care system. This article discusses factors that contribute to the personal and financial impact of prolonged seizures on adult and pediatric patients, their families, and caregivers.

Epilepsy and employment: literature review

OBJECTIVE

The aim of this review is to increase understanding of the factors that affect the regular employment positions of people with epilepsy by means of the World Health Organization International Classification of Functioning, Disability, and Health (ICF) model.

METHOD

Thirty-four primary research articles describing factors associated with employment for people with epilepsy are reviewed.

RESULTS

People with epilepsy may face a number of complex and interacting problems in finding and maintaining employment. Stigma, seizure severity, and psychosocial variables such as low self-esteem, passive coping style, and low self-efficacy have been implicated as factors that play an important role in predicting employment. Findings demonstrate the need for specific employment training programs.

CONCLUSION

We recommend specific training interventions that focus on increasing the self-efficacy and coping skills of people with epilepsy so that these individuals will be able to accept their disorder and make personal and health-related choices that help them to achieve better employment positions in society.

Guidelines--are they useful?

Antiepileptic drug (AED) guidelines are developed to improve medical decision making, to provide guidance and recommendation for patient management, to develop standards to judge or assess clinical practice, and to keep the cost-benefit ratio at an acceptable level. These guidelines are derived from evidence-based medicine (EBM), a four-tiered grading system that is used to analyze clinical trials and published experiments independent of clinical bias and experience. Although guidelines may not answer all questions it is critical that clinicians using them consider the available evidence, as well as the quality of the evidence, when incorporating the information in their decision making.

The social and economic impact of epilepsy in Zambia: a cross-sectional study

BACKGROUND

Among the 40 million people with epilepsy worldwide, 80% reside in low-income regions where human and technological resources for care are extremely limited. Qualitative and experiential reports indicate that people with epilepsy in Africa are also disadvantaged socially and economically, but few quantitative systematic data are available. We sought to assess the social and economic effect of living with epilepsy in sub-Saharan Africa.

METHODS

We did a cross-sectional study of people with epilepsy concurrently matched for age, sex, and site of care to individuals with a non-stigmatised chronic medical condition. Verbally administered questionnaires provided comparison data for demographic characteristics, education, employment status, housing and environment quality, food security, healthcare use, personal safety, and perceived stigma.

FINDINGS

People with epilepsy had higher mean perceived stigma scores (1.8 vs 0.4; p<0.0001), poorer employment status (p=0.0001), and less education (7.1 vs 9.4 years; p<0.0001) than did the comparison group. People with epilepsy also had less education than their nearest-age same sex sibling (7.1 vs 9.1 years; p<0.0001), whereas the comparison group did not (9.4 vs 9.6 years; p=0.42). Housing and environmental quality were poorer for people with epilepsy, who had little access to water, were unlikely to have electricity in their home (19%vs 51%; p<0.0001), and who had greater food insecurity than did the control group. During pregnancy, women with epilepsy were more likely to deliver at home rather than in a hospital or clinic (40%vs 15%; p=0.0007). Personal safety for people with epilepsy was also more problematic; rape rates were 20% among women with epilepsy vs 3% in the control group (p=0.004).

INTERPRETATION

People with epilepsy in Zambia have substantially poorer social and economic status than do their peers with non-stigmatised chronic medical conditions. Suboptimum housing quality differentially exposes these individuals to the risk of burns and drowning during a seizure. Vulnerability to physical violence is extreme, especially for women with epilepsy.

[The use of topamax in the treatment of epilepsy: clinical and pharmacoeconomic aspects]

The results of an open prospective naturalistic study on the use of topiramate (topamax) in 92 patients with focal epilepsy are presented. The pharmacological remission with duration over one year was achieved in 47,8% of patients. In total, the percentage of remission and clinical improvement made up 68,5%. The positive changes were observed in drug-naive patients (during first monotherapy) and in patients who previously received ineffective therapy. In some cases of patients with resistant forms of epilepsy, pharmacological remission or significant improvement of the control over seizures was found. The topamax therapy substantially increased the quality of life of the patients. The cost of therapy was 3100-5200 rubles per month, mean costs for a one patient during one year--416,000 rubles. The marginal utility 237,000 rubles per each additional QALY was significantly lower than $20,000, the minimal threshold of cost-effectiveness for European countries.

Economic evaluation of seizures associated with solitary cysticercus granuloma

BACKGROUND

Patients with solitary cysticercus granuloma (SCG) develop acute symptomatic seizures because of the inflammatory response of the brain and the seizures are self-limiting. Thus seizure disorder associated with SCG provides a good model to study the total cost of illness (COI).

MATERIALS AND METHODS

COI of new-onset seizures associated with SCG was studied in 59 consecutive patients registered at the epilepsy clinic. Direct treatment-related costs and indirect costs, man-days lost and wages lost were evaluated. The relative cost was calculated as the percentage of per capita gross national product (GNP) at current prices for the year 1997-1998.

RESULTS

The total COI, for treating seizure disorder associated with SCG per the period of CT resolution of the lesion per patient was INR 7273.7 (US$ 174.66, I$ 943.16) and he/she would be spending 50.9% of per capita GNP The direct cost per patient was INR 5916 (US$ 137.14, 41.4% of per capita GNP). If the patient had received only AEDs for the period of resolution of CT lesion, the cost would be INR 5702.48 (US$132.2, 40% of per capita GNP). The extra expenditure on albendazole and steroid was INR 213.72 (US$ 4.95), 3.6% of the total direct cost and 20.7% of the medication cost. Indirect cost (average wage loss) per patient was INR 1312.7 (US$ 30.42) and it accounted for 9% of per capita GNP. The one-time expenditure at present costs (adjusted for inflation) to the nation to treat all the prevalence cases is to the tune of INR 1.184 billion (US$ 2.605) and 0.0037% of GNP.

CONCLUSIONS

This study suggests that seizure disorder associated with SCG, a potentially preventable disorder, is a good model to study the total COI. The one-time expenditure at present costs to the nation to treat all the prevalence cases of seizure disorder associated with SCG is to the tune of INR 1.184 billion (US$ 2.605 million) and 0.0037% of GNP.

Direct and Indirect Costs of Refractory Epilepsy in a Tertiary Epilepsy Center in Germany

PURPOSE

There are only few studies on the costs of epilepsy in Germany. Therefore, we performed a pilot study to estimate the direct and indirect costs of refractory epilepsy in a German epilepsy center.

METHODS

A "prevalence-based," cross-sectional convenience sample of adults with active epilepsy attending the outpatient clinic of our tertiary epilepsy center was evaluated. Seizure-free patients and patients presenting with their first seizure were excluded. Direct and indirect costs were prospectively recorded over a three-month period using questionnaires and a patient diary. Cost driving factors were identified.

RESULTS

One hundred one patients were included (40.7+/-15.2 years; disease duration: 18.1+/-15.3 years; 6 patients had focal epilepsy with simple partial seizures only, 28 with complex partial seizures, 43 with secondarily generalized tonic-clonic seizures; 20 had idiopathic generalized epilepsy with generalized tonic-clonic seizures). The total costs of epilepsy per patient were in average euro 2610+/-4200 over the three-month period. Direct cost contributed 39% to the total costs. Costs of anticonvulsant medication were the main contributor to the direct costs while indirect costs were caused mainly by losses due to early retirement. Cost driving factors included higher seizure frequency, longer disease duration, ictal falls, and situationally inappropriate complex behavior during or after the seizure.

CONCLUSIONS

Indirect costs were higher than direct costs in adult patients with active epilepsy attending a German epilepsy center. Medication contributed the most to the direct costs and early retirement was the main factor for the indirect costs. The costs of poorly controlled epilepsy in this German study were above average of the European costs of epilepsy.

The costs of epilepsy misdiagnosis in England and Wales

BACKGROUND

The management of epilepsy incurs significant costs to the United Kingdom (UK) National Health Service (NHS). Making a diagnosis of epilepsy can, however, be difficult and misdiagnosis frequently occurs when patients are seen by non-specialists. This study estimates the financial costs of epilepsy misdiagnosis in the NHS in England and Wales.

METHODS

Standard costing methods were applied to estimate the costs attributable to epilepsy misdiagnosis. The primary data were published in UK studies on the prevalence of epilepsy, epilepsy misdiagnosis and costs identified from Medline, Cinahl and Embase (1996-May 2006).

RESULTS

An estimated total of 92,000 people were misdiagnosed with epilepsy in England and Wales in 2002. The average medical cost per patient per year of misdiagnosis was 316 pounds sterling, with the chief economic burdens being inpatient admissions (45%), inappropriate prescribing of antiepileptic drugs (AEDs) (26%), outpatient attendances (16%) and general practitioner (GP) care (8%). The estimated annual medical costs in England and Wales were 29,000,000 pounds sterling, while total costs could reach up to 138,000,000 pounds sterling a year.

CONCLUSIONS

Allowing for uncertainty, and considering the analysis exclusively from the NHS/CBS (community based services) perspective the opportunity costs of misdiagnosis are substantial. There is a need for health care commissioners to ensure that misdiagnosis is kept to a minimum by ensuring that individuals with a recent onset suspected seizure are seen as soon as possible by a specialist medical practitioner with training and expertise in epilepsy.

How to Replace Lamotrigine with Valproate

If lamotrigine (LTG) has to be replaced with valproate (VPA), this exchange may be complicated by adverse events that result from the complex interaction of both drugs. We report on two cases in which such problems occurred in spite of a cautious switch considering the VPA induced LTG serum increase. The satisfying outcome after a sudden and complete withdrawal of LTG in both cases encouraged us to perform the switch from LTG to VPA systematically by discontinuing LTG abruptly and building up the VPA maintenance dosage very rapidly in the following five consecutive patients who required this exchange. We recommend our abrupt dosage change-over strategy as an easy, safe and cost-effective option.

Clinical and Economic Outcomes of Pharmacist-Managed Antiepileptic Drug Therapy

This study explores the associations between pharmacist-managed antiepileptic drug therapy in hospitalized Medicare patients and diagnoses indicating the need for these drugs. It also explores the following major heath care outcomes: death rate, hospital length of stay (LOS), Medicare charges, drug charges, laboratory charges, complications, and adverse drug reactions. Data were drawn from the 1998 MedPAR and 1998 National Clinical Pharmacy Services databases. Pharmacist-managed antiepileptic drug therapy was evaluated in a study population of 9380 Medicare patients with diagnosed epilepsy or seizure disorders treated in 794 United States hospitals. This population was derived from the 38,311 hospitalized Medicare patients with epilepsy or seizure disorders (MedPAR). In hospitals without pharmacist-managed antiepileptic drug therapy, death rates were 120.61% higher, with 374 excess deaths (chi(2)=5.983, df=1, p=0.014, odds ratio [OR]=1.553, 95% confidence interval [CI] 1.102-2.189). Hospital LOS was 14.68% higher, with 8069 patient-days (Mann-Whitney U test [U]=3833132, p=0.0009); total Medicare charges were 11.19% higher, with 14,372,550 dollars in excess total charges (U=3644199, p=0.0003); per-patient drug charges were $115 +/- $92 higher (p=NS); laboratory charges were 32.24% higher, with 5,664,970 dollars in excess charges; and aspiration pneumonia rate was 54.61% higher (chi(2)=5.848, df=1, p=0.015, OR=1.233, 95% CI 1.081-1.901). Although the frequencies of other complications and adverse effects were higher, these differences were not statistically significant compared with hospitals with pharmacist-managed antiepileptic drug therapy. Clinical and economic outcomes were improved among hospitalized Medicare patients whose antiepileptic drug therapy was managed by pharmacists.

Estimation of the cost of Taenia solium cysticercosis in Eastern Cape Province, South Africa

OBJECTIVES

To provide a comprehensive estimate of the societal costs of Taenia solium cysticercosis for the Eastern Cape Province (ECP), South Africa, as an objective measure of its impact in this endemic area.

METHODS

Epidemiological data on the prevalence of epilepsy, proportion of epilepsy cases due to neurocysticercosis (NCC) and consequences of cysticercosis were gathered from published and unpublished sources. Economical data were mostly obtained from governmental sources. Three methods were used for estimating productivity losses. Monte Carlo sampling was used to represent the uncertainty of the estimates with 95% Credible Intervals (95% CI). The estimation is for 1 year using a societal approach. All costs are reported in 2004 US Dollars.

RESULTS

Overall, there were an estimated 34 662 (95% CI: 17 167-54 068) NCC-associated cases of epilepsy in ECP in 2004. The overall monetary burden (in million of US Dollars) was estimated to vary from US Dollars 18.6 (95% CI: US Dollars 9.0-32.9) to US Dollars 34.2 (95% CI: US Dollars 12.8-70.0) depending on the method used to estimate productivity losses. The agricultural sector contributed an average of Dollars 5.0 million. The prevalence of epilepsy, proportion of productivity reduction and the proportion of epilepsy cases attributable to NCC had the largest impact on the overall estimates.

CONCLUSION

This preliminary estimate suggests that T. solium cysticercosis results in considerable monetary costs to a region that is already economically constrained. Because this infection is preventable, these results could guide stakeholders in deciding where to invest scarce health and agricultural resources in their countries.