Pharmacoeconomic analysis of topical treatments for tinea infections

Topical ketoconazole: a systematic review of current dermatological applications and future developments

Introduction: Although labeling changes and market withdrawal have been implemented for oral ketoconazole (KTZ) due to serious adverse effects (AEs), topical KTZ is generally thought to be effective and safe for the treatment of superficial fungal infections. New dermatologic indications for the use of topical KTZ have arisen such as onychomycosis, blepharitis, and hair loss. This article aims to review the literature on topical KTZ's efficacy and AEs, as well as provide an overview on current insights regarding its mechanism of action and upcoming developments. Methods: A PubMed search was done to include randomized controlled trials (RCTs) focusing on the use of topical KTZ in human subjects. Results: Forty studies with 4566 patients were included in this review. Topical KTZ is clinically effective for the treatment of Malassezia-related conditions such as seborrheic dermatitis (SD) and pityriasis versicolor (PV) with a reported efficacy of 63-90% and 71-89%, respectively. Conclusions: Topical KTZ demonstrates high clinical efficacy for Malassezia-related conditions. More efficacious alternatives are now available for Tinea and Candida. Although topical KTZ is safe, clinicians should be aware that allergic contact dermatitis may occur. Further studies should be completed to investigate the use of topical KTZ for hair loss and inflammatory dermatoses.

Transferability of economic evaluations: approaches and factors to consider when using results from one geographic area for another

BACKGROUND

Geographic transferability of economic evaluation data from one country to another has the potential to make a more efficient use of national and international evaluation resources. However, inappropriate transferability of economic data can provide misleading results and lead to an inefficient use of scarce health care resources.

OBJECTIVES

The objective of this study was to review, summarize and categorize the literature on: (i) factors affecting the geographic transferability of economic evaluation data; and (ii) approaches which have either been proposed or used for transferability.

METHODS

A systematic literature review on transferability was conducted. Electronic databases, hand searching and bibliographic searching techniques were utilized. Inclusion criteria for the review included conceptual or empirical papers with mention of factors affecting, or approaches for, transferability of economic evaluation data across geographic locations. Exclusion criteria included papers published prior to 1966, non-English language papers, pure science studies and animal studies. Three databases were involved in the primary search: Ovid MEDLINE, EMBASE, and CINAHL. In addition to the primary search, the Heath Economic Evaluation Database (OHE HEED), the NHS EED database and the EconLit databases were searched. Transferability factors were classified into major and minor categories, a classification of alternative transferability approaches was developed, and the number of empirical studies was catalogued according to this classification.

RESULTS

There is a substantial amount of literature on factors potentially affecting transferability. Based on these papers we identified 77 factors and subsequently developed a classification system which grouped these factors into five broad categories based on characteristics of the patient, the disease, the provider, the health care system and methodological conventions. Another 40 studies were identified which attempted to transfer economic evaluation data from one country to another and these were classified according to the sources for clinical efficacy, resource utilization and unit cost data.

CONCLUSIONS

There is strong evidence indicating that transferability of economic evaluation data is a difficult and complex task. Approaches which have been used for transferability suggest that, at a minimum, there is a need for country-specific substitution of practice pattern data as well as unit cost data. A limitation of this review relates to the lack of empirical studies which prevents stronger conclusions regarding which transferability factors are most important to consider and under which circumstances.

Variability of cost-effectiveness estimates for pharmaceuticals in Western Europe: lessons for inferring generalizability

OBJECTIVES

It has long been suggested that, whereas the results of clinical studies of pharmaceuticals are generalizable from one jurisdiction to another, the results of economic evaluations are location dependent. There has been, however, little study of the causes of variation, whether differences in study results among countries are systematic, or whether they are important for decision making.

METHODS

A literature search was conducted to identify economic evaluations of pharmaceuticals conducted in two or more European countries. The studies identified were then classified by methodological type and analyzed to assess their level of variability and to identify the main causes of variation. Assessments were also made of the extent to which differences in study results among countries were systematic and whether they would lead to a different decision, assuming a range of values of the threshold willingness-to-pay for a life-year or quality-adjusted life-year (QALY).

RESULTS

In total 46 intercountry drug comparisons were identified, 29 in multicountry studies and 17 in comparable single country studies that were considered to be sufficiently similar in terms of methodology. The type of study (i.e., trial-based or modeling study) had some impact on variability, but the most important factor was the extent of variation across countries in effectiveness, resource use or unit costs, allowed by the researcher's chosen methodology. There were few systematic differences in study results among countries, so a decision maker in country B, on seeing a recent economic evaluation of a new drug in country A, would have little basis on which to predict whether the drug, if evaluated, would be more or less cost-effective in his or her country. Given the extent of variation in cost-effectiveness estimates among countries, the importance of this for decision making depends on decision makers' thresholds in willingness-to-pay for a QALY or life-year. If a cost-effectiveness threshold (i.e., willingness-to-pay) for a life-year or QALY of dollar 50,000 were assumed, the same conclusion regarding cost-effectiveness would be reached in most cases.

CONCLUSION

This review shows that cost-effectiveness results for pharmaceuticals vary from country to country in Western Europe and that these variations are not systematic. In addition, constraints imposed by analysts may reduce apparent variability in the estimates. The lessons for inferring generalizability are not straightforward, although the implications of variation for decision making depend critically on the cost-effectiveness thresholds applying in Western Europe.

Tinea faciei, an often deceptive facial eruption

Tinea faciei is a relatively uncommon superficial dermatophyte infection limited to the glabrous skin of the face. It is usually seen in pediatric patients. This fungus can be found worldwide, but has a predilection for tropical humid climates. Although the infecting organisms and treatments are the same as for other superficial fungal infections, it is frequently misdiagnosed clinically and histologically.

Which antifungal agent for onychomycosis? A pharmacoeconomic analysis

The incidence of fungal nail infections is increasing and this is possibly because of several factors: better methods of detection, a growing population of immunocompromised patients who have a greater susceptibility to such infections, the increased use of immunosuppressive drugs, the increasing number of elderly people, worldwide travel, and the use of communal bathing facilities. Onychomycosis is a fungal infection of the fingernails and toenails that accounts for about 30% of all superficial fungal infections. It is characterised by nail discoloration, thickening and ultimately destruction of the nail plate. Management of this disease has improved significantly and treatment patterns have dramatically changed in recent years as a result of advances in new treatment options (e.g. oral antifungal agents) and changes in treatment regimens (e.g. pulse therapy). Also, newer drugs for onychomycosis have improved tolerability profiles compared with older agents. The overall costs of treating onychomycosis are substantial, and it has been estimated that direct cost for US Medicare patients with the disease is 43 million US dollars per year (year of costing not available). Pharmacoeconomic studies help in the decision-making process when selecting the most cost-effective antifungal agents to treat onychomycosis. To date there have been a number of national and international economic studies aimed at effectively assessing the efficacy and costs of the treatment options available to cure onychomycosis. The objectives of this paper are to (i) review the published findings regarding the epidemiology of onychomycosis; (ii) summarise the original pharmacoeconomic studies that describe the economic impact of the disease; and (iii) address the impact of the disease on patients' health-related quality of life.

Monetary and nonmonetary costs to patients attending an ambulatory dermatology clinic

BACKGROUND

Despite universal coverage under a provincial health plan, the residents of Ontario, Canada, still bear some costs for outpatient care, particularly for prescription drugs.

OBJECTIVE

To determine the financial and nonmonetary costs borne by patients presenting at a dermatology clinic in an academic centre, and to assess the extent to which these costs were problematic.

METHODS

Consecutive new patients in a 6-week period completed a self-administered questionnaire.

RESULTS

Eighty-six of 140 questionnaires (61%) were returned for analysis. The mean total cost to patients was C$28.92 (range $0 to $177.00). Medications were the largest expense (mean $35.66 for those receiving medication). Despite relatively prompt referrals (mean 12.4 days) and short in-office waiting time (mean 26.5 minutes), there was a trend for subjects to rate time costs as more problematic than monetary costs.

CONCLUSION

Patients attending a dermatology clinic bear variable monetary and nonmonetary costs. For some patients these costs may have the potential to impair access to care.