Comparative cost-effectiveness of 11 oral antipsychotics for relapse prevention in schizophrenia within Singapore using effectiveness estimates from a network meta-analysis

Cost-utility analysis of lurasidone for the first-line treatment of schizophrenia in China

Objective

To evaluate the cost-effectiveness of lurasidone compared with olanzapine and risperidone in the first-line treatment of patients with schizophrenia from a Chinese healthcare system perspective.

Methods

A Markov model with 6-week cycle was constructed to reflect the disease progression of schizophrenia patients in the acute and maintenance phase. Probabilities of treatment discontinuation and adverse events in the acute phase were derived from the 6-week lurasidone clinical trial and a published network meta-analysis; long-term risks of relapse and discontinuation were estimated based on the 12-month lurasidone clinical trial and other treatment comparison studies. Cost inputs were derived from published literature and Chinese official documents, supplemented by expert opinions when necessary. Utility values were taken from published literature. Costs and quality-adjusted life-years (QALYs) were assessed over 15 years with a discount rate of 5% per year.

Results

Over a 15-year time horizon, lurasidone yielded an improvement of 0.197 QALYs with a cost saving of CN¥12,093 (US$1,753) vs. olanzapine and an improvement of 0.116 QALYs with a cost saving of CN¥6,781 (US$983) vs. risperidone. One-way sensitivity analyses demonstrated robust base-case results since all analyses yielded net monetary benefits >0 at a willingness-to-pay threshold of CN¥72,447.00 (US$10,499.57)/QALY. Probabilistic sensitivity analyses suggested that lurasidone had 99.7, 99.9, and 100% probability of being cost-effective vs. olanzapine and risperidone at the conventional decision thresholds of 1, 2, and 3 times the Chinese per capita gross domestic product [namely CN¥72,447.00 (US$10,499.57)/QALY, CN¥1,44,894.00 (US$20,999.13)/QALY, and CN¥2,17,341.00 (US$31,498.70)/QALY in 2020], respectively.

Conclusion

Treatment with lurasidone was predicted to improve health outcomes and be a dominant strategy for patients with schizophrenia, compared with olanzapine and risperidone, in China.

A Systematic Review of Methods and Study Quality of Economic Evaluations for the Treatment of Schizophrenia

Background: Schizophrenia is a severe and complex disease with substantial economic and social burdens. Despite multiple treatment choices, adverse events, and impaired social functions are still challenges in clinical therapy. Pharmacoeconomic evaluations could provide evidence to help decision makers improve the utilization of scarce resources. However, there remains some challenges especially in modeling due to uncertainties in progression of schizophrenia. There are limited summaries about the overall methodologies of schizophrenia economic evaluations.

Objective: The aim of this study is to review the existing economic evaluations of antipsychotics for the treatment of schizophrenia and summarize the evidence and methods applied.

Methods: An electronic literature search was performed in PubMed, Web of Science, EBSCO host, The Cochrane Library and ScienceDirect from January 2014 to December 2020. Search terms included “schizophrenia,” “schizophrenic,” “pharmacoeconomic,” “economic evaluation,” “cost-effectiveness,” and “cost-utility.” The Literature was screened and extracted by two researchers independently and assessed with the Quality of Health Economic Studies (QHES) List and Consolidated Health Economic Evaluation Reporting Standards (CHEERS) Statement.

Results: A total of 25 studies were included in the review. The regions included Europe, North America, Asia and Africa. Most of the studies chose second-generation antipsychotics as comparators and integrated treatment sequences. Time horizons varied from 1 year to lifetime. The healthcare sector was the most common perspective, accordingly, most of the evaluations considered only direct medical costs. The Markov model and decision tree model were the most common choices. Adverse events, compliance and persistence were considered important parameters. Quality-adjusted life-years were the major outcomes applied to the economic evaluations. All utilities for health states and adverse events were collected from published literature. All of the studies applied uncertainty analysis to explore the robustness of the results. The quality of the studies was generally satisfactory. However, improvements were needed in the choice of time horizons, the measurements of outcomes and the descriptions of assumptions.

Conclusions: This study highlights the methodology of economic evaluation of schizophrenia. Recommendations for modeling method and future study are provided.

Evaluating the utility of digital phenotyping to predict health outcomes in schizophrenia: protocol for the HOPE-S observational study

INTRODUCTION

The course of schizophrenia illness is characterised by recurrent relapses which are associated with adverse clinical outcomes such as treatment-resistance, functional and cognitive decline. Early identification is essential and relapse prevention remains a primary treatment goal for long-term management of schizophrenia. With the ubiquity of devices such as smartphones, objective digital biomarkers can be harnessed and may offer alternative means for symptom monitoring and relapse prediction. The acceptability of digital sensors (smartphone and wrist-wearable device) and the association between the captured digital data with clinical and health outcomes in individuals with schizophrenia will be examined.

METHODS AND ANALYSIS

In this study, we aim to recruit 100 individuals with schizophrenia spectrum disorders who are recently discharged from the Institute of Mental Health (IMH), Singapore. Participants are followed up for 6 months, where digital, clinical, cognitive and functioning data are collected while health utilisation data are obtained at the 6 month and 1 year timepoint from study enrolment. Associations between digital, clinical and health outcomes data will be examined. A data-driven machine learning approach will be used to develop prediction algorithms to detect clinically significant outcomes. Study findings will inform the design, data collection procedures and protocol of future interventional randomised controlled trial, testing the effectiveness of digital phenotyping in clinical management of individuals with schizophrenia spectrum disorders.

ETHICS AND DISSEMINATION

Ethics approval has been granted by the National Healthcare Group (NHG) Domain Specific Review Board (DSRB Reference no.: 2019/00720). The results will be published in peer-reviewed journals and presented at conferences.

TRIAL REGISTRATION NUMBER

NCT04230590.

From predictions to evidence: Treatment compliance, disease progression and social compliance of patients with schizophrenia in the COVID-19 pandemic

PURPOSE

This study explored how patients with schizophrenia were provided with social support and treatment compliance during the pandemic.

DESIGN AND METHODS

A total of 396 patients with schizophrenia and their relatives were interviewed by telephone calls.

FINDINGS

Multiple antipsychotic use and depot antipsychotics were not superior in preventing relapse. A total of 70.2% of the patients wanted to meet with their psychiatrist online but only 7.1% of them were reached online. A total of 59% of patients were able to take their medication thanks to the extension of their drug prescriptions.

PRACTICE IMPLICATIONS

Active inclusion of telepsychiatry applications in clinical practice is necessary for patients with schizophrenia. Government policies developed for treatment compliance seem important.

Systematic review of the methods of health economic models assessing antipsychotic medication for schizophrenia

BACKGROUND

Numerous economic models have assessed the cost-effectiveness of antipsychotic medications in schizophrenia. It is important to understand what key impacts of antipsychotic medications were considered in the existing models and limitations of existing models in order to inform the development of future models.

OBJECTIVES

This systematic review aims to identify which clinical benefits, clinical harms, costs and cost savings of antipsychotic medication have been considered by existing models, to assess quality of existing models and to suggest good practice recommendations for future economic models of antipsychotic medications.

METHODS

An electronic search was performed on multiple databases (MEDLINE, EMBASE, PsycInfo, Cochrane database of systematic reviews, The NHS Economic Evaluation Database and Health Technology Assessment database) to identify economic models of schizophrenia published between 2005-2020. Two independent reviewers selected studies for inclusion. Study quality was assessed using the National Institute for Health and Care Excellence (NICE) checklist and the Cooper hierarchy. Key impacts of antipsychotic medications considered by exiting models were descriptively summarised.

RESULTS

Sixty models were included. Existing models varied greatly in key impacts of antipsychotic medication included in the model, especially in clinical outcomes used for assessing reduction in psychotic symptoms and types of adverse events considered in the model. Quality of existing models was generally low due to failure to capture the health and cost impact of adverse events of antipsychotic medications and input data not obtained from best available source. Good practices for modelling antipsychotic medications are suggested.

DISCUSSIONS

This review highlights inconsistency in key impacts considered by different models, and limitations of the existing models. Recommendations on future research are provided.

A Systematic Review of Economic Models Across the Entire Schizophrenia Pathway

BACKGROUND

Schizophrenia is associated with a high economic burden. Economic models can help to inform resource allocation decisions to maximise benefits to patients.

OBJECTIVES

This systematic review aims to assess the availability, quality and consistency of conclusions of health economic models evaluating the cost effectiveness of interventions for schizophrenia.

METHODS

An electronic search was performed on multiple databases (MEDLINE, EMBASE, PsycINFO, Cochrane database of systematic reviews, NHS Economic Evaluation Database and Health Technology Assessment database) to identify economic models of interventions for schizophrenia published between 2005 and 2020. Two independent reviewers selected studies for inclusion. Study quality was assessed using the National Institute for Health and Care Excellence (NICE) checklist and the Cooper hierarchy. Model characteristics and conclusions were descriptively summarised.

RESULTS

Seventy-three models met inclusion criteria. Seventy-eight percent of existing models assessed antipsychotics; however, due to inconsistent conclusions reported by different studies, no antipsychotic can be considered clearly cost effective compared with the others. A very limited number of models suggest that the following non-pharmacological interventions might be cost effective: psychosocial interventions, stratified tests, employment intervention and intensive intervention to improve liaison between primary and secondary care. The quality of included models is generally low due to use of a short time horizon, omission of adverse events of interventions, poor data quality and potential conflicts of interest.

CONCLUSIONS

This review highlights a lack of models for non-pharmacological interventions, and limitations of the existing models, including low quality and inconsistency in conclusions. Recommendations on future modelling approaches for schizophrenia are provided.

Comparative cost-effectiveness of amisulpride and olanzapine in the treatment of schizophrenia in China

BACKGROUND

Both amisulpride and olanzapine are leading treatments for schizophrenia in China. This study aimed to investigate the long-term cost-effectiveness of amisulpride and olanzapine in the treatment of schizophrenia in China.

METHODS

A decision-analytic Markov model was developed to simulate the lifetime clinical and economic outcomes of schizophrenia treatment from the healthcare payer perspective. The long-term costs and QALYs were estimated. Sensitivity analyses were performed to explore the impact of variance of parameters on the results.

RESULTS

Treatment with amisulpride provided an effectiveness gain of 16.59 QALYs at an average cost of USD 25,884 whereas olanzapine resulted in 16.38 QALYs at a cost of USD 34,839 over a lifetime horizon. One-way sensitivity analysis suggested that the most sensitive variable was the unit cost of olanzapine. In a probabilistic sensitivity analysis based on a Monte Carlo simulation with a lifetime horizon, the probability of amisulpride being cost-effective was 99.8% at a willingness-to-pay threshold of USD 9,322, the GDP per capita in China 2018. A scenario analysis with updated olanzapine unit cost suggested an ICER of 7,857 USD/QALY.

CONCLUSIONS

Amisulpride is likely to be a cost-effective option with increased effectiveness compared with olanzapine in the treatment of schizophrenia patients in China.

A cost-utility analysis of Amisulpride and Paliperidone in the treatment of Schizophrenia

Background

Schizophrenia is a severe, long-term neurodevelopmental disorder that results in increased morbidity and mortality. Amisulpride and Paliperidone are two antipsychotics used to treat schizophrenia in the UK. This evaluation compares the cost-utility of each drug; no similar research has been conducted in the UK.

Methods

A cost utility analysis was performed looking at the benefits in terms of Quality Adjusted Life Years within one year of the treatment, and the costs in pound sterling, discounted to the 2016/2017 value. This evaluation was from the perspective of the National Health Service, the biggest provider of health within the United Kingdom.

Outcomes

The cost utility analysis found an incremental cost effectiveness ratio of £10,941 per added Quality Adjusted Life Year for using Paliperidone, instead of the more widely used Amisulpride.

Interpretation

This is below the NICE threshold of £20–30,000 per QALY. Hence, it is within reason to suggest shifting diagnostic practices to Paliperidone.

Economic evaluations on the use of aripiprazole for patients with schizophrenia: A systematic review

WHAT IS KNOWN AND OBJECTIVES

Schizophrenia is a serious mental disorder and is associated with substantial economic and social burden. Cost-effectiveness analysis is important to assess the costs of different therapeutic options. However, there is a lack of information on the reporting quality of economic evaluations, cost drivers, as well as updated data focused on aripiprazole, an antipsychotic drug commonly prescribed in schizophrenia. This study evaluates and summarizes the evidence of economic evaluations of the use of aripiprazole in schizophrenia. In addition, we aimed to identify cost drivers and critically assess the reporting qualities of these studies.

METHODS

A comprehensive literature research was conducted using PubMed, NHS Economic Evaluation Database, CEA Registry and LILACS databases dated until March 2018. Full economic analyses of aripiprazole in schizophrenia that were based on decision analytical models and published in English, Portuguese or Spanish languages were included. Two independent authors identified the studies and performed data extraction and quality assessment using 24 items from the Consolidated Health Economic Evaluation Reporting Standards (CHEERS) statement.

RESULTS AND DISCUSSION

A total of 79 potential studies were identified, of which 17 studies performing model-based economic evaluations fully met the eligibility criteria. Of these, 15 were industry-funded studies. A trend favouring olanzapine, lurasidone and paliperidone could be observed, whereas aripiprazole was extensively described as a dominated alternative. However, notably, 93% of the industry-funded studies presented results favouring their sponsors, only two of them being the manufacturer of aripiprazole. Cost drivers were usually related to the relapse rates/probabilities regardless of the funding source. The overall quality of reporting of the economic analyses was poor, with most studies scoring around 12-13 points. The most frequent problems were the lack of description of relevance of the outcome measures, characteristics of the base case population and report of precision measures for all the parameters of the model.

WHAT IS NEW AND CONCLUSION

No consistent conclusion on the cost-effectiveness of aripiprazole could be drawn due to the context-specific costs, conflicting parameters of effectiveness and safety, and bias related to industry sponsorship. Cost drivers, though, were usually related to the relapse rates/probabilities. In addition, poor reporting quality of the studies performing full economic analysis requires further improvement to ensure greater transparency of the findings.

Systematic review of utility values used in the pharmacoeconomic evaluations for schizophrenia: implications on cost-effectiveness results

Background and Objectives: Utility elicitation studies for schizophrenia generate different utility values for the same health states. We reviewed utility values used in schizophrenia pharmacoeconomic evaluations and evaluated the impact of their selection on the incremental cost-effectiveness ratio (ICER). Methods: A systematic search was performed in Medline and Embase. Health state definitions, associated utility values, elicitation studies, and value selection processes were extracted. Sets of utility values for all schizophrenia health states were used in a cost-effectiveness model to evaluate the ICER. Results: Thirty-five cost-utility analyses (CUAs) referring to 11 utility elicitation studies were included. The most frequent health states were 'stable' (28 CUAs, 7 utility elicitation studies, 10 values, value range 0.650-0.919), 'relapse requiring hospitalisation' (18, 5, 7, 0.270-0.604), 'relapse not requiring hospitalisation' (18, 5, 10, 0.460-0.762), and 'relapse only' (10, 5, 6, 0.498-0.700). Seventeen sets of utility values were identified with difference in utility values between relapse and stable ranging from -0.358 to -0.050, resulting in ICERs ranging from -56.2% to +222.6% from average. Conclusion: The use of utility values for schizophrenia health states differs among CUAs and impacts on the ICER. More rigorous and transparent use of utility values and sensitivity analysis with different sets of utility values are suggested for future CUAs.

Cost-effectiveness of olanzapine in the first-line treatment of schizophrenia in China

OBJECTIVES

This study aimed to analyze (1) the cost-effectiveness of olanzapine orally disintegrating tablet (ODT) compared to olanzapine standard oral tablet (SOT) and (2) the cost-effectiveness of olanzapine-SOT compared to aripiprazole-SOT for patients with schizophrenia in China.

METHODS

A microsimulation model was adapted from a healthcare payers' perspective. The model ran over a 1-year time horizon, using quarterly cycles. The costs of adverse events were acquired through a clinical expert panel. The average bidding prices in China of olanzapine-ODT, olanzapine-SOT, aripiprazole-SOT, and other switch alternatives were used. Inpatient and outpatient medical costs were sourced from the Urban Employee Basic Medical Insurance database in Tianjin. Additionally, adherence, efficacy, safety, and utility data were taken from the literature. Uncertainty of parameters were assessed through one-way and probabilistic sensitivity analyses.

RESULTS

The total annual costs per patient in aripiprazole-SOT arm, olanzapine-SOT arm, and olanzapine-ODT arm are USD 2,296.05, USD 1,940.05, and USD 2,292.81, respectively. The average number of relapses per patient in 1 year in the aripiprazole-SOT arm, olanzapine-SOT arm, and olanzapine-ODT arm, are 0.734, 0.325, and 0.198, respectively. The quality-adjusted life years (QALYs) gained per patient in 1 year in the aripiprazole-SOT arm, olanzapine-SOT arm, and olanzapine-ODT arm are 0.714, 0.737, and 0.758, respectively. Consequently, (1) the incremental cost-effectiveness ratios (ICERs) of administrating olanzapine-ODT over olanzapine-SOT are USD 2,791.96 per relapse avoided and USD 16,798.39 per QALY gained; and (2) the ICERs of using olanzapine-SOT over aripiprazole-SOT are USD -870.39 per relapse avoided and USD -15,477.93 per QALY gained. All ICERs are under the willingness-to-pay threshold in China of USD 25,772.67. The sensitivity analyses confirmed the robustness of the results.

CONCLUSION

As the first-line treatment for schizophrenia in China, olanzapine-ODT is cost-effective compared to olanzapine-SOT and olanzapine-SOT is cost-effective compared to aripiprazole-SOT.

Comparative efficacy and safety between amisulpride and olanzapine in schizophrenia treatment and a cost analysis in China: a systematic review, meta-analysis, and cost-minimization analysis

BACKGROUND

Amisulpride was introduced into China in 2010 as a second-generation atypical antipsychotic, while olanzapine has been on the market since 1999 as one of the leading treatments for schizophrenia in China. Since more Chinese patients are gaining access to amisulpride, the study aims to compare the efficacy, safety, and costs between amisulpride and olanzapine for schizophrenia treatment in China.

METHODS

PubMed, Embase, the Cochrane library, China National Knowledge Infrastructure (CNKI) and WanFang database were systematically searched for randomized controlled trials (RCTs) up to July 2018. The Cochrane Risk of Bias tool was utilized to assess the quality of included studies. A meta-analysis was performed to compare the efficacy and safety of amisulpride and olanzapine, followed by a cost-minimization analysis using local drug and medical costs reported in China.

RESULTS

Twenty RCTs with 2000 patients were included in the systematic review. There were no significant differences between amisulpride and olanzapine on efficacy measures based on scores from the Positive and Negative Syndrome Scale, the Scale for the Assessment of Negative Symptoms, the Brief Psychiatric Rating Scale and the Clinical Global Impressions-Severity or Improvement. For safety outcomes, amisulpride was associated with lower fasting blood glucose and less abnormal liver functions as well as significantly lower risks of weight gain, constipation, and somnolence; olanzapine was associated with significantly lower risks of insomnia and lactation/amenorrhea/sexual hormone disorder. No significant differences were found in risks of extrapyramidal symptoms (EPS), tremor, akathisia, abnormal corrected QT interval. Cost-minimization analysis showed that amisulpride was likely to be a cost-saving alternative in China, with potential savings of 1358 Chinese Yuan (CNY) per patient for a three-month schizophrenia treatment compared with olanzapine.

CONCLUSION

As the first meta-analysis and cost-minimization analysis comparing the efficacy, safety and cost of amisulpride and olanzapine within a Chinese setting, the study suggests that amisulpride may be an effective, well-tolerated, and cost-saving antipsychotic drug alternative in China.

Systematic review of pharmacoeconomic models for schizophrenia

Background: Economic models are broadly used in the economic evaluation of antipsychotics in schizophrenia. Our objective was to summarize the structure of these models. Methods: Model-based economic evaluations of antipsychotics in schizophrenia were identified through Medline and Embase. General information was extracted including analysis type, model type, perspective, population, comparator, outcome, and timeframe. Model-specific structures for decision tree (DT), cohort- and patient-level Markov model (CLMM, PLMM), and discrete-event simulation (DES) models were extracted. Results: A screen of 1870 records identified 79 studies. These were mostly cost-utility analyses (n = 48) with CLMM (n = 32) or DT models (n = 29). They mostly applied payer perspective (n = 68), focused on general schizophrenia for relapse prevention (n = 73), compared pharmacotherapies as first-line (n = 71), and evaluated incremental cost per quality-adjusted life year (QALY) gained (n = 40) with a 1-year (n = 32) or 5-year (n = 26) projection. DT models progressed with the branching points of response, relapse, discontinuation, and adherence. CLMM models transitioned between disease states, whereas PLMM models transitioned between adverse event states with/without disease state. DES models moved forward with times to remission, relapse, psychiatrist visit, and death. Conclusions: A pattern of pharmacoeconomic models for schizophrenia was identified. More subtle structures and patient-level models are suggested for a future modelling exercise.

A systematic review of health economic models and utility estimation methods in schizophrenia

INTRODUCTION

There is a growing need for economic evaluations describing the disease course, as well as the costs and clinical outcomes related to the treatment of schizophrenia.

AREAS COVERED

A systematic review on studies describing health economic models in schizophrenia and a targeted literature review on utility mapping algorithms in schizophrenia were carried out. Models found in the review were collated and assessed in detail according to their type and various other attributes. Fifty-nine studies were included in the review. Modeling techniques varied from simple decision trees to complex simulation models. The models used various clinical endpoints as value drivers, 47% of the models used quality-adjusted life years, and eight percent used disability-adjusted life years to measure benefits, while others applied various clinical outcomes. Most models considered patients switching between therapies, and therapeutic adherence, compliance or persistence. The targeted literature review identified four main approaches to map PANSS scores to utility values.

EXPERT COMMENTARY

Health economic models developed for schizophrenia showed great variability, with simulation models becoming more frequently used in the last decade. Using PANSS scores as the basis of utility estimations is justifiable.

The Cost of Relapse in Schizophrenia

INTRODUCTION

Schizophrenia is a chronic and debilitating mental illness characterised by periods of relapse that require resource intensive management. Quantifying the cost of relapse is central to the evaluation of the cost effectiveness of treating schizophrenia.

OBJECTIVES

We aimed to undertake a comprehensive search of the available literature on the cost of relapse.

METHODS

We performed a search on multiple databases (MEDLINE, Embase, PsycINFO and Health Management Information Consortium) for any study reporting a cost of relapse or data from which such a cost could be calculated. Costs are reported in 2015 international dollars.

RESULTS

We found 16 studies reporting costs associated with relapse over a defined period of time and identified a cost associated with hospitalisation for relapse in 43 studies. Eight clinical decision analyses also provided cost estimates. Studies from the US report excess costs of relapse of $6033-$32,753 (2015 Purchasing Power Parity dollars [PPP$]) over periods of 12-15 months. European studies report excess costs of $8665-$18,676 (2015 PPP$) over periods of 6-12 months. Estimates of the cost of hospitalisation for relapse are more diverse, and associated with marked differences in typical length of stay across jurisdictions.

CONCLUSIONS

Wide ranges in the estimated cost of relapse may reflect differences in sample section and relapse definition as well as practice styles and differences in resource costs. Selection of the most appropriate cost estimate should be guided by the definition of relapse and the analysis setting.