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Ben-Zacharia AB, Smrtka J, Kalina JT, Vignos M, Smith S. Shared decision-making in underserved populations with multiple sclerosis: A systematic review. Mult Scler Relat Disord 2024; 90:105792. [PMID: 39121597 DOI: 10.1016/j.msard.2024.105792] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2024] [Revised: 07/23/2024] [Accepted: 07/27/2024] [Indexed: 08/12/2024]
Abstract
BACKGROUND The concept of shared decision-making (SDM) is valuable to ensure patients receive individualized care. SDM occurs when healthcare providers engage patients in making personal healthcare decisions that could contribute to better long-term outcomes. With the ever-increasing landscape of treatment options available, SDM can be challenging but valuable for patients. Patients from underserved populations are potentially less likely to engage in SDM, impacting their long-term care. This systematic literature review aimed to explore SDM in these patient populations. METHODS Relevant articles were retrieved from PubMed using key search terms, without any restriction on publication date. All searches and data retrieval were conducted between May 25, 2022, and August 17, 2022, and abstracts were reviewed by two independent reviewers. A thematic analysis was used to present the data. RESULTS All search terms yielded 418 articles; 89 were included (33 involving patients with multiple sclerosis [MS]). Reported mean percentage of patients with MS (including from underserved populations) who preferred SDM was 52 % (range: 37.5-71.5; n = 4). Differences in racial/ethnic assimilation of information communicated by clinicians were reported, impacted by the lower literacy level and certain cultural health beliefs in groups of underserved populations. Primary care clinicians play a key role in providing information to patients in underserved populations. CONCLUSIONS There is a clear benefit for SDM for patients with MS, and without it, patients report dissatisfaction, decisional regret, and lack of confidence in the medical system. However, there are several challenges, including the need for further examination of social determinants of health, for underserved patient populations which still need to be addressed.
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Affiliation(s)
- Aliza Bitton Ben-Zacharia
- Hunter Bellevue School of Nursing and Mount Sinai Hospital; Hunter Bellevue School of Nursing, 425 E 25th St, New York, NY 10010, USA; Mount Sinai, 146 East 126 Street, New York, NY 10035, USA.
| | - Jen Smrtka
- Biogen, 225 Binney St, Cambridge, MA 02142, USA
| | | | | | - Stacyann Smith
- Judith Jaffe Multiple Sclerosis Center, Weill Cornell Medicine, 1300 York Ave, New York, NY 10065, USA
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Balcom EF, Smyth P, Kate M, Vu K, Martins KJB, Aponte-Hao S, Luu H, Richer L, Williamson T, Klarenbach SW, McCombe JA. Disease-modifying therapy use and health resource utilisation associated with multiple sclerosis over time: A retrospective cohort study from Alberta, Canada. J Neurol Sci 2024; 458:122913. [PMID: 38335712 DOI: 10.1016/j.jns.2024.122913] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2023] [Revised: 12/21/2023] [Accepted: 02/01/2024] [Indexed: 02/12/2024]
Abstract
BACKGROUND Estimating multiple sclerosis (MS) prevalence and incidence, and assessing the utilisation of disease-modifying therapies (DMTs) and healthcare resources over time is critical to understanding the evolution of disease burden and impacts of therapies upon the healthcare system. METHODS A retrospective population-based study was used to determine MS prevalence and incidence (2003-2019), and describe utilisation of DMTs (2009-2019) and healthcare resources (1998-2019) among people living with MS (pwMS) using administrative data in Alberta. RESULTS Prevalence increased from 259 (95% confidence interval [CI]: 253-265) to 310 (95% CI: 304, 315) cases per 100,000 population, and incidence decreased from 21.2 (95% CI: 19.6-22.8) to 12.7 (95% CI: 11.7-13.8) cases per 100,000 population. The proportion of pwMS who received ≥1 DMT dispensation increased (24% to 31% annually); use of older platform injection therapies decreased, and newer oral-based, induction, and highly-effective therapies increased. The proportion of pwMS who had at least one MS-related physician, ambulatory, or tertiary clinic visits increased, and emergency department visits and hospitalizations decreased. CONCLUSIONS Alberta has one of the highest rates of MS globally. The proportion of pwMS who received DMTs and had outpatient visits increased, while acute care visits decreased over time. The landscape of MS care appears to be rapidly evolving in response to changes in disease burden and new highly-effective therapies.
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Affiliation(s)
- Erin F Balcom
- University of Alberta, Faculty of Medicine and Dentistry, Department of Medicine, Edmonton, Alberta T6G 2R3, Canada
| | - Penelope Smyth
- University of Alberta, Faculty of Medicine and Dentistry, Department of Medicine, Edmonton, Alberta T6G 2R3, Canada
| | - Mahesh Kate
- University of Alberta, Faculty of Medicine and Dentistry, Department of Medicine, Edmonton, Alberta T6G 2R3, Canada
| | - Khanh Vu
- University of Alberta, Faculty of Medicine and Dentistry, Real World Evidence Unit, Edmonton, Alberta T6G 2R3, Canada
| | - Karen J B Martins
- University of Alberta, Faculty of Medicine and Dentistry, Real World Evidence Unit, Edmonton, Alberta T6G 2R3, Canada
| | - Sylvia Aponte-Hao
- University of Calgary, Department of Community Health Sciences and the Centre for Health Informatics, Calgary, Alberta T2N 1N4, Canada
| | - Huong Luu
- University of Alberta, Faculty of Medicine and Dentistry, Real World Evidence Unit, Edmonton, Alberta T6G 2R3, Canada
| | - Lawrence Richer
- University of Alberta, Faculty of Medicine and Dentistry, Real World Evidence Unit, Edmonton, Alberta T6G 2R3, Canada; University of Alberta, Faculty of Medicine and Dentistry, Department of Pediatrics, Edmonton, Alberta T6G 2R3, Canada
| | - Tyler Williamson
- University of Calgary, Department of Community Health Sciences and the Centre for Health Informatics, Calgary, Alberta T2N 1N4, Canada
| | - Scott W Klarenbach
- University of Alberta, Faculty of Medicine and Dentistry, Department of Medicine, Edmonton, Alberta T6G 2R3, Canada; University of Alberta, Faculty of Medicine and Dentistry, Real World Evidence Unit, Edmonton, Alberta T6G 2R3, Canada.
| | - Jennifer A McCombe
- University of Alberta, Faculty of Medicine and Dentistry, Department of Medicine, Edmonton, Alberta T6G 2R3, Canada
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Keenan A, Le HH, Gandhi K, Adedokun L, Jones E, Unsworth M, Pike J, Trenholm E. Shared Decision-Making in the Treatment of Multiple Sclerosis: Results of a Cross-Sectional, Real-World Survey in Europe and the United States. Patient Prefer Adherence 2024; 18:137-149. [PMID: 38249686 PMCID: PMC10799568 DOI: 10.2147/ppa.s440410] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/12/2023] [Accepted: 12/21/2023] [Indexed: 01/23/2024] Open
Abstract
Introduction Multiple sclerosis (MS) is a neurodegenerative disease characterized by progressive deterioration of cognitive and physical functioning, reducing activities of daily living and quality of life (QoL). Several treatments are available that modify the course of the disease and reduce the frequency of relapses. Although effective, all treatment options are accompanied by adverse events, and this study aimed to assess the extent to which patients were involved in the choice of treatment. Methods Data were drawn from the Adelphi Multiple Sclerosis Disease Specific Program (DSP)™, a cross-sectional survey of healthcare practitioners (HCP) and their patients with MS in real-world clinical settings in Europe and the United States (US) between December 2020 and July 2021. HCPs reported patient demographics, clinical characteristics, current and previous treatment, and treatment outcomes. Patients voluntarily completed questionnaires reporting the physical and psychological impact of their MS and its treatment. Regression analysis with inverse probability of treatment weighting was used to compare treatment outcomes in patients actively involved in their current treatment choice with those who were not. Results Of a total of 692 patients, median age 40 years and 64% female, mostly diagnosed with relapsing-remitting MS, those who were involved in shared decision-making tended to choose oral therapies such as dimethyl fumarate more often than HCPs. MS had greater impact on physical and psychological functioning in patients whose HCP made treatment decisions solely. Patients involved in decision-making reported greater satisfaction with their treatment and a better QoL. Discussion Because no single optimal therapy exists for patients with MS, treatments should be individualized with consideration of patients' preferences. Our study shows that shared decision-making is under-utilized in the management of MS and supports the benefits of patient involvement. Conclusion Patients who have an active role in treatment decision-making show improved wellbeing and QoL, and overall treatment satisfaction.
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Affiliation(s)
- Alexander Keenan
- Scientific Affairs, Janssen Pharmaceuticals Inc., Titusville, NJ, USA
| | - Hoa H Le
- Scientific Affairs, Janssen Pharmaceuticals Inc., Titusville, NJ, USA
| | - Kavita Gandhi
- Research and Development, Janssen Pharmaceuticals Inc., Titusville, NJ, USA
| | - Lola Adedokun
- Research and Development, Janssen-Cilag Ltd, High Wycombe, UK
| | - Eddie Jones
- Central Nervous System, Adelphi Real World, Bollington, Cheshire, UK
| | - Mia Unsworth
- Central Nervous System, Adelphi Real World, Bollington, Cheshire, UK
| | - James Pike
- Statistics & Data Analytics, Adelphi Real World, Bollington, Cheshire, UK
| | - Emily Trenholm
- Central Nervous System, Adelphi Real World, Bollington, Cheshire, UK
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Zhao T, Taylor BV, Campbell JA, Palmer AJ. The disease-modifying therapy utilisation and cost trend for multiple sclerosis in Australia between 2013 and 2022. Mult Scler 2024; 30:80-88. [PMID: 38116594 DOI: 10.1177/13524585231213230] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2023]
Abstract
BACKGROUND The MS disease-modifying therapies (DMTs) prescribing landscape in Australia have changed over time. OBJECTIVES This study evaluated the utilisation and cost trends of MS-related DMTs in Australia over 10 years and investigated differences between States/Territories. METHODS The prescription and costs of 16 DMTs were extracted from the Pharmaceutical Benefits Scheme for 2013-2022. Descriptive approaches analysed the total number of people prescribed DMTs and total DMT costs per 10,000 population, proportions of prescriptions/costs by DMT groups and the number of people prescribed each individual DMT and costs of each DMT over the 10-year period. All estimates were for Australia and each State/Territory individually. RESULTS The number of people prescribed DMT and costs per 10,000 population had substantial growth between 2013 and 2022: 125%/164% for Australia, and 94%-251%/129%-373% for individual States/Territories. Higher efficacy group accounted for 54% of total people prescribed DMTs in 2013 and 75% in 2022. Fingolimod was the most popular DMT until 2020, then was dominated by ocrelizumab. The trends of individual DMT prescriptions and costs differed between states particularly in Western Australia (WA), Tasmania and Northern Territory (NT). CONCLUSION DMT prescriptions and costs continuously increased over the last decade, particularly for higher efficacy DMTs, and their trends differed between States/Territories.
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Affiliation(s)
- Ting Zhao
- Menzies Institute for Medical Research, University of Tasmania, Medical Science Precinct, Hobart, TAS, Australia
| | - Bruce V Taylor
- Menzies Institute for Medical Research, University of Tasmania, Medical Science Precinct, Hobart, TAS, Australia
| | - Julie A Campbell
- Menzies Institute for Medical Research, University of Tasmania, Medical Science Precinct, Hobart, TAS, Australia
| | - Andrew J Palmer
- Menzies Institute for Medical Research, University of Tasmania, Medical Science Precinct, Hobart, TAS, Australia
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Song Y, Wang Y, Wong SL, Yang D, Sundar M, Tundia N. Real-world treatment patterns and effectiveness of cladribine tablets in patients with relapsing forms of multiple sclerosis in the United States. Mult Scler Relat Disord 2023; 79:105052. [PMID: 37832254 DOI: 10.1016/j.msard.2023.105052] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2023] [Revised: 08/14/2023] [Accepted: 10/04/2023] [Indexed: 10/15/2023]
Abstract
BACKGROUND Real-world evidence on the use of cladribine tablets (CladT) for relapsing forms of multiple sclerosis (RMS) in the United States is emerging. The objective of this study was to assess the real-world treatment patterns and effectiveness of CladT in RMS. METHODS Adults with RMS initiating CladT were selected from the Symphony Integrated Dataverse. Baseline and follow-up periods were the 12 months before and 24 months after CladT initiation (index date). Switching to another disease-modifying therapy (DMT) and number of CladT courses were described during follow-up. Annualized relapse rate (ARR), MS disease severity, Expanded Disability Status Scale-Derived Disability Indicators (EDSS-DDI), corticosteroid use, and healthcare resource utilization (HRU) were described during Years 1 and 2 of follow-up and compared with baseline. RESULTS A total of 539 CladT-treated patients were included (mean age: 49.9 years; 77.6 % female). Over the 2-year follow-up, 91 % and 59 % of patients had one and two CladT courses, respectively, and 7 % of patients had evidence of switching to another DMT. ARR, MS disease severity score, and corticosteroid use decreased significantly during follow-up compared with baseline, while EDSS-DDI remained stable. All-cause and MS-related HRU decreased during follow-up. CONCLUSION CladT-treated patients with RMS had low switch rates, reduced ARR, disease severity, corticosteroid use, and HRU.
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Affiliation(s)
| | - Yan Wang
- Analysis Group, Los Angeles, CA, USA
| | - Schiffon L Wong
- EMD Serono Research & Development Institute, Inc., Billerica, MA, USA, an affiliate of Merck KGaA
| | | | | | - Namita Tundia
- EMD Serono Research & Development Institute, Inc., Billerica, MA, USA, an affiliate of Merck KGaA.
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Veldwijk J, DiSantostefano RL, Janssen E, Simons G, Englbrecht M, Schölin Bywall K, Radawski C, Raza K, Hauber B, Falahee M. Maximum Acceptable Risk Estimation Based on a Discrete Choice Experiment and a Probabilistic Threshold Technique. THE PATIENT 2023; 16:641-653. [PMID: 37647010 PMCID: PMC10570171 DOI: 10.1007/s40271-023-00643-w] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 07/19/2023] [Indexed: 09/01/2023]
Abstract
OBJECTIVE We aimed to empirically compare maximum acceptable risk results estimated using both a discrete choice experiment (DCE) and a probabilistic threshold technique (PTT). METHODS Members of the UK general public (n = 982) completed an online survey including a DCE and a PTT (in random order) measuring their preferences for preventative treatment for rheumatoid arthritis. For the DCE, a Bayesian D-efficient design consisting of four blocks of 15 choice tasks was constructed including six attributes with varying levels. The PTT used identical risk and benefit attributes. For the DCE, a panel mixed-logit model was conducted, both mean and individual estimates were used to calculate maximum acceptable risk. For the PTT, interval regression was used to calculate maximum acceptable risk. Perceived complexity of the choice tasks and preference heterogeneity were investigated for both methods. RESULTS Maximum acceptable risk confidence intervals of both methods overlapped for serious infection and serious side effects but not for mild side effects (maximum acceptable risk was 32.7 percent-points lower in the PTT). Although, both DCE and PTT tasks overall were considered easy or very easy to understand and answer, significantly more respondents rated the DCE choice tasks as easier to understand compared with those who rated the PTT as easier (7-percentage point difference; p < 0.05). CONCLUSIONS Maximum acceptable risk estimate confidence intervals based on a DCE and a PTT overlapped for two out of the three included risk attributes. More respondents rated the DCE as easier to understand. This may suggest that the DCE is better suited in studies estimating maximum acceptable risk for multiple risk attributes of differing severity, while the PTT may be better suited when measuring heterogeneity in maximum acceptable risk estimates or when investigating one or more serious adverse events.
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Affiliation(s)
- Jorien Veldwijk
- School of Health Policy and Management, Erasmus University Rotterdam, P.O. Box 1738, 3000, Rotterdam, The Netherlands.
- Erasmus Choice Modelling Centre, Erasmus University Rotterdam, Rotterdam, The Netherlands.
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands.
| | | | | | - Gwenda Simons
- Rheumatology Research Group, Institute of Inflammation and Ageing, University of Birmingham, Birmingham, UK
| | - Matthias Englbrecht
- Freelance Healthcare Data Scientist, Greven, Germany
- Department of Internal Medicine and Institute for Clinical Immunology, Friedrich-Alexander-Universität Erlangen-Nürnberg, Erlangen, Germany
| | | | | | - Karim Raza
- Rheumatology Research Group, Institute of Inflammation and Ageing, University of Birmingham, Birmingham, UK
- Department of Rheumatology, Sandwell and West Birmingham NHS Trust, Birmingham, UK
- MRC Versus Arthritis Centre for Musculoskeletal Ageing Research and Research into Inflammatory Arthritis Centre Versus Arthritis, College of Medical and Dental Sciences, University of Birmingham, Birmingham, UK
| | - Brett Hauber
- Pfizer, Inc., New York, NY, USA
- The Comparative Health Outcomes, Policy and Economics (CHOICE) Institute, University of Washington School or Pharmacy, Seattle, WA, USA
| | - Marie Falahee
- Rheumatology Research Group, Institute of Inflammation and Ageing, University of Birmingham, Birmingham, UK
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Jiang T, Ziemssen T, Wray S, Shen C, Söderbärg K, Lewin JB, Božin I, Freedman MS. Matching-Adjusted Indirect Comparisons of Diroximel Fumarate, Ponesimod, and Teriflunomide for Relapsing Multiple Sclerosis. CNS Drugs 2023; 37:441-452. [PMID: 37155132 DOI: 10.1007/s40263-023-01002-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 04/05/2023] [Indexed: 05/10/2023]
Abstract
INTRODUCTION Diroximel fumarate (DRF), ponesimod (PON), and teriflunomide (TERI) are oral disease-modifying therapies approved for the treatment of relapsing multiple sclerosis. No randomized trials have compared DRF versus PON or TERI. OBJECTIVES The objectives of this analysis were to compare DRF versus PON and DRF versus TERI for clinical and radiological outcomes. METHODS We used individual patient data from EVOLVE-MS-1, a 2-year, open-label, single-arm, phase III trial of DRF (n = 1057), and aggregated data from OPTIMUM, a 2-year, double-blind, phase III trial comparing PON (n = 567) and TERI (n = 566). To account for cross-trial differences, EVOLVE-MS-1 data were weighted to match OPTIMUM's average baseline characteristics using an unanchored matching-adjusted indirect comparison. We examined the outcomes of annualized relapse rate (ARR), 12-week confirmed disability progression (CDP), 24-week CDP, absence of gadolinium-enhancing (Gd+) T1 lesions, and absence of new/newly enlarging T2 lesions. RESULTS After weighting, we did not observe strong evidence of differences between DRF and PON for ARR [DRF versus PON incidence rate difference (IRD) -0.02; 95% confidence interval (CI) -0.08, 0.04; incidence rate ratio (IRR) 0.92; 95% CI 0.61, 1.2], 12-week CDP [risk difference (RD) -2.5%; 95% CI -6.3, 1.2; risk ratio (RR) 0.76; 95% CI 0.38, 1.1], 24-week CDP (RD -2.7%; 95% CI -6.0, 0.63; RR 0.68; 95% CI 0.28, 1.0), and absence of new/newly enlarging T2 lesions (RD -2.5%; 95% CI -13, 7.4; RR 0.94; 95% CI 0.70, 1.2). However, a higher proportion of DRF-treated patients were free of Gd+ T1 lesions than PON-treated patients (RD 11%; 95% CI 6.0, 16; RR 1.1; 95% CI 1.06, 1.2). Compared with TERI, DRF showed improved ARR (IRD -0.08; 95% CI -0.15, -0.01; IRR 0.74; 95% CI 0.50, 0.94), 12-week CDP (RD -4.2%; 95% CI -7.9, -0.48; RR 0.67; 95% CI 0.38, 0.90), 24-week CDP (RD -4.3%; 95% CI -7.7, -1.1; RR 0.57; 95% CI 0.26, 0.81), and absence of Gd+ T1 lesions (RD 25%; 95% CI 19, 30; RR 1.4; 95% CI 1.3, 1.5). However, DRF and TERI did not appear to differ significantly with respect to absence of new/newly enlarging T2 lesions when based on comparisons using the overall EVOLVE-MS-1 sample (RD 8.5%; 95% CI -0.93, 18; RR 1.3; 95% CI 0.94, 1.6), or in a sensitivity analysis restricted to newly enrolled EVOLVE-MS-1 patients (RD 2.7%; 95% CI -9.1, 14; RR 1.1; 95% CI 0.68, 1.5). CONCLUSIONS We did not observe differences between DRF and PON for ARR, CDP, and absence of new/newly enlarging T2 lesions, but there was a higher proportion of patients free of Gd+ T1 lesions among DRF-treated patients than PON-treated patients. DRF had improved efficacy versus TERI for all clinical and radiological outcomes, except for absence of new/newly enlarging T2 lesions. CLINICAL TRIALS REGISTRATION EVOLVE-MS-1 (ClinicalTrials.gov identifier: NCT02634307); OPTIMUM (ClinicalTrials.gov identifier: NCT02425644).
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Affiliation(s)
| | - Tjalf Ziemssen
- Center of Clinical Neuroscience, Carl Gustav Carus University Hospital, Dresden, Germany
| | - Sibyl Wray
- Hope Neurology MS Center, Knoxville, TN, USA
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Veldwijk J, de Bekker-Grob E, Juhaeri J, van Overbeeke E, Tcherny-Lessenot S, Pinto CA, DiSantostefano RL, Groothuis-Oudshoorn CGM. Suitability of Preference Methods Across the Medical Product Lifecycle: A Multicriteria Decision Analysis. VALUE IN HEALTH : THE JOURNAL OF THE INTERNATIONAL SOCIETY FOR PHARMACOECONOMICS AND OUTCOMES RESEARCH 2023; 26:579-588. [PMID: 36509368 DOI: 10.1016/j.jval.2022.11.019] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/14/2022] [Revised: 11/24/2022] [Accepted: 11/29/2022] [Indexed: 05/06/2023]
Abstract
OBJECTIVES This study aimed to understand the importance of criteria describing methods (eg, duration, costs, validity, and outcomes) according to decision makers for each decision point in the medical product lifecycle (MPLC) and to determine the suitability of a discrete choice experiment, swing weighting, probabilistic threshold technique, and best-worst scale cases 1 and 2 at each decision point in the MPLC. METHODS Applying multicriteria decision analysis, an online survey was sent to MPLC decision makers (ie, industry, regulatory, and health technology assessment representatives). They ranked and weighted 19 methods criteria from an existing performance matrix about their respective decisions across the MPLC. All criteria were given a relative weight based on the ranking and rating in the survey after which an overall suitability score was calculated for each preference elicitation method per decision point. Sensitivity analyses were conducted to reflect uncertainty in the performance matrix. RESULTS Fifty-nine industry, 29 regulatory, and 5 health technology assessment representatives completed the surveys. Overall, "estimating trade-offs between treatment characteristics" and "estimating weights for treatment characteristics" were highly important criteria throughout all MPLC decision points, whereas other criteria were most important only for specific MPLC stages. Swing weighting and probabilistic threshold technique received significantly higher suitability scores across decision points than other methods. Sensitivity analyses showed substantial impact of uncertainty in the performance matrix. CONCLUSION Although discrete choice experiment is the most applied preference elicitation method, other methods should also be considered to address the needs of decision makers. Development of evidence-based guidance documents for designing, conducting, and analyzing such methods could enhance their use.
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Affiliation(s)
- Jorien Veldwijk
- Erasmus School of Health Policy & Management, Erasmus University Rotterdam, Rotterdam, The Netherlands; Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands.
| | - Esther de Bekker-Grob
- Erasmus School of Health Policy & Management, Erasmus University Rotterdam, Rotterdam, The Netherlands
| | | | | | | | | | | | - Catharina G M Groothuis-Oudshoorn
- Health Technology and Services Research, Faculty of Behavioural and Management Science, University of Twente, Enschede, The Netherlands
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9
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Bandari D, Adamson M, Bowman M, Gutierrez A, Athavale A, Oak B, Hadker N, Branco F, Geremakis C, Lewin JB, Shankar SL. Real-world treatment preferences among health care providers in the United States in selecting disease modifying therapies for patients with multiple sclerosis: a discrete choice experiment. J Med Econ 2023; 26:1507-1518. [PMID: 37934412 DOI: 10.1080/13696998.2023.2279883] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/06/2023] [Accepted: 10/31/2023] [Indexed: 11/08/2023]
Abstract
AIMS Health care providers (HCPs) treating multiple sclerosis (MS) in clinical practice have numerous disease-modifying therapies (DMTs) to consider when evaluating treatment options. This study assessed the treatment preferences of HCPs in the United States, both direct (explicit) and derived (explicit and implicit), when selecting MS DMTs based on clinical and logistical treatment attributes. MATERIALS AND METHODS A 45-minute web-enabled questionnaire was administered to HCPs who manage patients with MS to assess the importance of treatment attributes. HCPs were recruited through an online panel. This study examined treatment attributes relevant to treatment decisions in MS, with a focus on the burden to HCPs and their staff, as well as HCP attitudes toward various aspects of MS care such as diagnosis, treatment prioritization, and ease of initiating or switching DMTs. The study also employed a discrete choice experiment (DCE) to assess direct and derived treatment preferences. RESULTS The study recruited 145 HCPs. Direct assessments (a score of greater than 7.0 was considered important) suggested that safety (mean importance rating = 7.8/9) and relative risk reduction in relapses (7.6/9) and disability progression (7.5/9) were most important when selecting DMTs. In contrast, derived importance from the DCE (higher points corresponding to greater importance) suggested that logistical attributes such as dose frequency (mean relative attribute importance = 17.5%), dose titration (10.3%), formulation (9.4%), and volume of calls (9.1%) were important considerations, along with efficacy (16.5%), safety (9.8%), and gastrointestinal tolerability (9.4%). LIMITATIONS This study may have been subject to selection bias due to the application of eligibility criteria, the convenient sampling recruitment methodology, and recruitment of HCPs with internet access. CONCLUSION In the direct assessment, clinical attributes were chosen as the most important treatment attributes by HCPs. However, in the DCE, derived treatment decisions rated logistical attributes as also being as important in treatment choice.
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Affiliation(s)
- Daniel Bandari
- Multiple Sclerosis Center of California & Research Group, Laguna Hills, CA, USA
| | | | | | - Amparo Gutierrez
- Orlando Health Multiple Sclerosis Comprehensive Care Center, Orlando, FL, USA
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10
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Jonker MF, Roudijk B, Maas M. The Sensitivity and Specificity of Repeated and Dominant Choice Tasks in Discrete Choice Experiments. VALUE IN HEALTH : THE JOURNAL OF THE INTERNATIONAL SOCIETY FOR PHARMACOECONOMICS AND OUTCOMES RESEARCH 2022; 25:1381-1389. [PMID: 35527163 DOI: 10.1016/j.jval.2022.01.015] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/11/2021] [Revised: 11/12/2021] [Accepted: 01/17/2022] [Indexed: 05/20/2023]
Abstract
OBJECTIVES This study aimed to identify the most commonly used internal validity tests in the discrete choice experiment (DCE) literature and establish their sensitivity and specificity. METHODS A structured literature review of recent DCE articles (2018-2020Q1) published in the health, marketing, transport economics, and environmental science literature was used to identify commonly used internal validity tests. The 2 most frequently used internal validity tests were incorporated in 4 new data collections. Respondent preferences in each application were summarized using a mixed logit model, which served as the benchmark for the subsequent sensitivity and specificity calculations. The performance of the internal validity tests was also compared with that of the root likelihood (RLH) test, which is a likelihood-based statistical validity test that is commonly used in marketing applications. RESULTS Dominant and repeated choice tasks were most commonly included in health-related DCE designs. Based on 4 applications, their specificity and sensitivity depend on the type of incorrect response pattern to be detected and on design characteristics such as the number of choice options per choice task and the number of internal validity tests as included in the experimental design. In all but one scenario, the performance of the dominant and repeated choice tasks was considerably worse than that of the RLH test. CONCLUSIONS Dominant and repeated choice tasks are unreliable screening tests and costly in terms of statistical power. The RLH test, which is a statistical test that does not require additional choice tasks to be included in the DCE design, provides a more reliable alternative.
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Affiliation(s)
- Marcel F Jonker
- Erasmus Choice Modelling Centre, Erasmus University Rotterdam, Rotterdam, The Netherlands; Erasmus School of Health Policy & Management, Erasmus University Rotterdam, Rotterdam, The Netherlands.
| | | | - Merit Maas
- Erasmus Choice Modelling Centre, Erasmus University Rotterdam, Rotterdam, The Netherlands
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11
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Alonso R, Rojas JI, Ramos J, Correa P, Pita C, Cohen L, Vanotti S, Garcea O, Silva B. Evaluation of adherence to treatment in patients with multiple sclerosis from Latin America. Mult Scler Relat Disord 2022; 63:103915. [DOI: 10.1016/j.msard.2022.103915] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2022] [Revised: 04/16/2022] [Accepted: 05/26/2022] [Indexed: 10/18/2022]
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12
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Versteegh MM, Huygens SA, Wokke BWH, Smolders J. Effectiveness and Cost-Effectiveness of 360 Disease-Modifying Treatment Escalation Sequences in Multiple Sclerosis. VALUE IN HEALTH : THE JOURNAL OF THE INTERNATIONAL SOCIETY FOR PHARMACOECONOMICS AND OUTCOMES RESEARCH 2022; 25:984-991. [PMID: 35667786 DOI: 10.1016/j.jval.2021.11.1363] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/14/2021] [Revised: 10/28/2021] [Accepted: 11/12/2021] [Indexed: 06/15/2023]
Abstract
OBJECTIVES The rapid expansion in treatment options for relapsing-remitting multiple sclerosis (RRMS) of the past decade requires clinical decision making on the sequential prescription of these treatments. Here, we compare 360 treatment escalation sequences for patients with RRMS in terms of health outcomes and societal costs in The Netherlands. METHODS We use a microsimulation model with a societal perspective, developed in collaboration with MS neurologists, to estimate the effectiveness and cost-effectiveness of 360 treatment sequences starting with first-line therapies in RRMS. This model integrated data on disease progression, disease-modifying treatment efficacy, clinical decision rules, age-dependent relapse rates, quality of life, healthcare, and societal costs. RESULTS Costs and health outcomes were overlapping among different treatment escalation sequences. In our model for RRMS treatment, optimal lifetime health outcomes (20.24 ± 1.43 quality-adjusted life-years [QALYs], 6.11 ± 0.30 relapses) were achieved with the sequence peginterferon-dimethyl fumarate-ocrelizumab-natalizumab-alemtuzumab. The most cost-effective sequence (peginterferon-glatiramer acetate-ocrelizumab-cladribine-alemtuzumab) yielded numerically worse health outcomes per patient (19.59 ± 1.43 QALYs, 6.64 ± 0.43 relapses), but resulted in €98 127 ± €19 134 less costs than the most effective treatment sequence. CONCLUSIONS Effectiveness estimates of treatments have overlapping confidence intervals but the treatment sequence that yields most QALYs is not the most cost-effective option, also when taking uncertainty into account. It is important that neurologists are aware of cost constraints and its relationship with prescription behavior, but treatment decisions should be individually tailored.
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Affiliation(s)
- Matthijs M Versteegh
- Institute for Medical Technology Assessment, Erasmus University Rotterdam, Rotterdam, The Netherlands.
| | - Simone A Huygens
- Institute for Medical Technology Assessment, Erasmus University Rotterdam, Rotterdam, The Netherlands
| | - Beatrijs W H Wokke
- MS Center ErasMS, Departments of Neurology and Immunology, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Joost Smolders
- MS Center ErasMS, Departments of Neurology and Immunology, Erasmus University Medical Center, Rotterdam, The Netherlands
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A Targeted Literature Search and Phenomenological Review of Perspectives of People with Multiple Sclerosis and Healthcare Professionals of the Immunology of Disease-Modifying Therapies. Neurol Ther 2022; 11:955-979. [PMID: 35608740 PMCID: PMC9127487 DOI: 10.1007/s40120-022-00349-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/17/2021] [Accepted: 03/25/2022] [Indexed: 11/29/2022] Open
Abstract
Introduction The mechanisms of action of disease-modifying therapies (DMTs) for multiple sclerosis (MS) are complex and involve an interplay of immune system components. People with MS (PwMS) may lack a clear understanding of the immunological pathways involved in MS and its treatment; effective communication between healthcare professionals (HCPs) and PwMS is needed to facilitate shared decision-making when discussing the disease and selecting DMTs and is particularly important in the coronavirus disease 2019 (COVID-19) era. Methods In this patient-authored two-part review, we performed a targeted literature search to assess the need for better communication between HCPs and PwMS regarding treatment selection, and also conducted a qualitative survey of four patient and care-partner authors to obtain insights regarding their understanding of and preferences for the treatment and management of MS. Results Following a search of the Embase and MEDLINE databases using Ovid in June 2020, an analysis of 40 journal articles and conference abstracts relating to patient empowerment and decision-making in DMT selection for MS showed a preference for safety and efficacy of treatments, followed by autonomy and convenience of administration. A need for better communication between HCPs and PwMS during treatment selection to improve patient satisfaction was also identified. The open survey responses from the patient authors revealed a need for greater involvement in decision-making processes and desire for improved communication and information tools. Conclusions This targeted literature search and phenomenological review confirms PwMS preferences for empowered decision-making in disease management and treatment selection, to optimize independence, safety, and efficacy. It also identifies an unmet need for improved communication and information tools that convey MS information in a relatable manner. Furthermore, this review seeks to address this unmet need by providing plain language figures and descriptions of MS immune mechanisms that can be used to facilitate discussions between HCPs and PwMS. Supplementary Information The online version contains supplementary material available at 10.1007/s40120-022-00349-5. In multiple sclerosis (MS), there are different cells in the immune system that contribute to the disease. The main cells in the immune system are T and B cells. People with MS (PwMS) might not be familiar with details about the immune system, and healthcare professionals might not always communicate details about how treatments work clearly to PwMS when choosing treatments with them. It is important for PwMS to have all the information they need to help make decisions about treatments. This information needs to be given in a way they can understand. This is especially important during the coronavirus disease 2019 (COVID-19) pandemic. In this paper, we first looked at what research has already been published about what is most important to PwMS when making treatment decisions. The existing research says that safety and effectiveness are the most important things and that PwMS prefer treatments that they can take themselves. PwMS also need better communication and information from doctors to make decisions and to help explain how MS treatments work in the body. Next, we gave a survey to the patients who are authors of this paper to ask about what is important to them when making treatment decisions. Their answers were very similar to the existing research. Overall, PwMS need better communication from healthcare professionals about the immune system. This paper also includes plain language descriptions and figures to help healthcare professionals explain and discuss the importance of the immune system in MS with PwMS.
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Simblett S, Pennington M, Quaife M, Theochari E, Burke P, Brichetto G, Devonshire J, Lees S, Little A, Pullen A, Stoneman A, Thorpe S, Weyer J, Polhemus A, Novak J, Dawe-Lane E, Morris D, Mutepua M, Odoi C, Wilson E, Wykes T. Key Drivers and Facilitators of the Choice to Use mHealth Technology in People With Neurological Conditions: Observational Study. JMIR Form Res 2022; 6:e29509. [PMID: 35604761 PMCID: PMC9171601 DOI: 10.2196/29509] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2021] [Revised: 05/21/2021] [Accepted: 01/04/2022] [Indexed: 11/16/2022] Open
Abstract
Background There is increasing interest in the potential uses of mobile health (mHealth) technologies, such as wearable biosensors, as supplements for the care of people with neurological conditions. However, adherence is low, especially over long periods. If people are to benefit from these resources, we need a better long-term understanding of what influences patient engagement. Previous research suggests that engagement is moderated by several barriers and facilitators, but their relative importance is unknown. Objective To determine preferences and the relative importance of user-generated factors influencing engagement with mHealth technologies for 2 common neurological conditions with a relapsing-remitting course: multiple sclerosis (MS) and epilepsy. Methods In a discrete choice experiment, people with a diagnosis of MS (n=141) or epilepsy (n=175) were asked to select their preferred technology from a series of 8 vignettes with 4 characteristics: privacy, clinical support, established benefit, and device accuracy; each of these characteristics was greater or lower in each vignette. These characteristics had previously been emphasized by people with MS and or epilepsy as influencing engagement with technology. Mixed multinomial logistic regression models were used to establish which characteristics were most likely to affect engagement. Subgroup analyses explored the effects of demographic factors (such as age, gender, and education), acceptance of and familiarity with mobile technology, neurological diagnosis (MS or epilepsy), and symptoms that could influence motivation (such as depression). Results Analysis of the responses to the discrete choice experiment validated previous qualitative findings that a higher level of privacy, greater clinical support, increased perceived benefit, and better device accuracy are important to people with a neurological condition. Accuracy was perceived as the most important factor, followed by privacy. Clinical support was the least valued of the attributes. People were prepared to trade a modest amount of accuracy to achieve an improvement in privacy, but less likely to make this compromise for other factors. The type of neurological condition (epilepsy or MS) did not influence these preferences, nor did the age, gender, or mental health status of the participants. Those who were less accepting of technology were the most concerned about privacy and those with a lower level of education were prepared to trade accuracy for more clinical support. Conclusions For people with neurological conditions such as epilepsy and MS, accuracy (ie, the ability to detect symptoms) is of the greatest interest. However, there are individual differences, and people who are less accepting of technology may need far greater reassurance about data privacy. People with lower levels of education value greater clinician involvement. These patient preferences should be considered when designing mHealth technologies.
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Affiliation(s)
- Sara Simblett
- Psychology Department, King's College London, London, United Kingdom
| | - Mark Pennington
- Psychology Department, King's College London, London, United Kingdom
| | - Matthew Quaife
- Health Economics Department, London School of Hygiene & Tropical Medicine, London, United Kingdom
| | | | - Patrick Burke
- Remote Assessment of Disease and Relapse in Central Nervous System Disorders Patient Advisory Board, King's College London, London, United Kingdom
| | - Giampaolo Brichetto
- Remote Assessment of Disease and Relapse in Central Nervous System Disorders Patient Advisory Board, King's College London, London, United Kingdom
- Italian Multiple Sclerosis Society and Foundation, Rome, Italy
| | - Julie Devonshire
- Remote Assessment of Disease and Relapse in Central Nervous System Disorders Patient Advisory Board, King's College London, London, United Kingdom
| | - Simon Lees
- Remote Assessment of Disease and Relapse in Central Nervous System Disorders Patient Advisory Board, King's College London, London, United Kingdom
| | - Ann Little
- Remote Assessment of Disease and Relapse in Central Nervous System Disorders Patient Advisory Board, King's College London, London, United Kingdom
- International Bureau for Epilepsy, Dublin, Ireland
| | - Angie Pullen
- Remote Assessment of Disease and Relapse in Central Nervous System Disorders Patient Advisory Board, King's College London, London, United Kingdom
- Epilepsy Action, Leeds, United Kingdom
| | - Amanda Stoneman
- Remote Assessment of Disease and Relapse in Central Nervous System Disorders Patient Advisory Board, King's College London, London, United Kingdom
- Epilepsy Action, Leeds, United Kingdom
| | - Sarah Thorpe
- Remote Assessment of Disease and Relapse in Central Nervous System Disorders Patient Advisory Board, King's College London, London, United Kingdom
| | - Janice Weyer
- Remote Assessment of Disease and Relapse in Central Nervous System Disorders Patient Advisory Board, King's College London, London, United Kingdom
| | - Ashley Polhemus
- Merck Sharp & Dohme Information Technology, Prague, Czech Republic
| | - Jan Novak
- Psychology Department, King's College London, London, United Kingdom
- Merck Sharp & Dohme Information Technology, Prague, Czech Republic
- Faculty of Science, Charles University, Prague, Czech Republic
| | - Erin Dawe-Lane
- Psychology Department, King's College London, London, United Kingdom
| | - Daniel Morris
- Psychology Department, King's College London, London, United Kingdom
| | - Magano Mutepua
- Psychology Department, King's College London, London, United Kingdom
| | - Clarissa Odoi
- Psychology Department, King's College London, London, United Kingdom
- South London and Maudsley Biomedical Research Centre, London, United Kingdom
| | - Emma Wilson
- Psychology Department, King's College London, London, United Kingdom
| | - Til Wykes
- Psychology Department, King's College London, London, United Kingdom
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Sabsabi S, Mikhael E, Jalkh G, Macaron G, Rensel M. Clinical Evaluation of Siponimod for the Treatment of Secondary Progressive Multiple Sclerosis: Pathophysiology, Efficacy, Safety, Patient Acceptability and Adherence. Patient Prefer Adherence 2022; 16:1307-1319. [PMID: 35637684 PMCID: PMC9148218 DOI: 10.2147/ppa.s221882] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/22/2022] [Accepted: 05/05/2022] [Indexed: 11/24/2022] Open
Abstract
INTRODUCTION A number of disease-modifying therapies have been approved for use in relapsing-remitting multiple sclerosis (MS) in the past two decades. However, only few treatment options are available for patients with secondary progressive multiple sclerosis (SPMS). Siponimod has recently been approved for use in patients with active forms of SPMS (who experience clinical relapses or new lesions on MRI superimposed on secondary progression independent of relapse activity). OBJECTIVE The aim of this article is to provide a comprehensive review on the mechanism of action, efficacy, safety, cost effectiveness and patient adherence with siponimod. METHODS We performed a PubMed search using the search terms: "siponimod", "secondary progressive multiple sclerosis", "sphingosine 1-phosphate modulators". Titles and abstract were screened and selected for relevance to the key section of this article. FINDINGS Siponimod is an oral sphingosine-1-phosphate receptor (S1PR) modulator with selectivity to S1PR-1 and 5. Modulation of this receptor on lymphocytes causes its internalization and degradation, preventing their egress from lymphoid tissues to the blood. In the pivotal Phase 3 randomized controlled trial EXPAND, siponimod was superior to placebo in reducing the risk of disability progression confirmed at 3 and 6 months, as well as the development of new MRI lesions and the rate of brain volume loss. Secondary analysis also showed a benefit on measures of cognitive functioning. The risk of lymphopenia and first-dose bradycardia appears to be lower with siponimod compared to non-selective S1P1R modulators. Different CYP2C9 genotypes affect the metabolism of siponimod; hence, genetic testing is required to adapt the titration and final dose accordingly. CONCLUSION Long-term extension and real-world studies will allow further evaluation of efficacy and safety in this population. Future research should focus on better defining SPMS, and identifying biomarkers of progression and outcome measures of treatment response in this category of patients.
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Affiliation(s)
- Sajida Sabsabi
- Department of Neurology, Hotel Dieu de France Hospital, Saint Joseph University, Beirut, Lebanon
| | - Elio Mikhael
- Department of Internal Medicine, Hotel Dieu de France Hospital, Saint Joseph University, Beirut, Lebanon
| | - Georges Jalkh
- Department of Neurology, Hotel Dieu de France Hospital, Saint Joseph University, Beirut, Lebanon
| | - Gabrielle Macaron
- Department of Neurology, Hotel Dieu de France Hospital, Saint Joseph University, Beirut, Lebanon
- Mellen Center for Multiple Sclerosis Treatment and Research, Cleveland Clinic, Cleveland, OH, USA
| | - Mary Rensel
- Mellen Center for Multiple Sclerosis Treatment and Research, Cleveland Clinic, Cleveland, OH, USA
- Correspondence: Mary Rensel, Email
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Jivraj F, Kang S, Reedie S, Kapadia S, Strzok S, Elliott E, Cano S, Rock M. The Patient and Clinician Assessment of Gastrointestinal (GI) Related Adverse Events Associated with Oral Disease-Modifying Therapies in Multiple Sclerosis: A Qualitative Study. Adv Ther 2022; 39:5072-5086. [PMID: 36053450 PMCID: PMC9438375 DOI: 10.1007/s12325-022-02250-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2022] [Accepted: 06/29/2022] [Indexed: 01/30/2023]
Abstract
INTRODUCTION Current guidelines for relapsing-remitting multiple sclerosis (RRMS) call for treatment with disease-modifying therapies (DMTs) early in the disease to prevent relapses and accumulation of neurologic impairment and disability. However, patients taking certain oral DMTs may experience gastrointestinal (GI)-related adverse events (AEs), particularly at dose titration. We conducted qualitative research with healthcare professionals (HCPs) and patients in Canada to contextualize their experiences with three oral DMTs: dimethyl fumarate (Tecfidera®), fingolimod (Gilenya®), and teriflunomide (Aubagio®). The objectives of this study were to (1) gather qualitative data to better understand the patient and HCP experience of GI AEs in oral MS DMT treatment in Canada and (2) determine to what extent two patient-reported outcome (PRO) instruments used in recent oral DMT trials capture what is important to patients regarding GI AEs in oral MS DMT treatment (content validity) and to provide qualitative data to help interpret PRO scores. METHODS This was a qualitative, non-interventional, descriptive, cross-sectional study comprising HCP and patient interviews conducted in English and French, using a 1:1 semi-structured interview approach. RESULTS Patients reported 16 unique GI AE concepts related to oral DMTs. The most commonly reported symptoms were diarrhea, indigestion, and nausea. While patients acknowledged the negative impact associated with GI-related AEs, most characterized the treatment experience as positive, focusing on preference for oral administration, perceived efficacy of DMTs in terms of lack of MS relapses, slowed progression of their disease, and improvement in MS symptoms. Results supported the content validity (relevance, comprehension, and comprehensiveness) of the two PROs assessed. HCP feedback reinforced patient perspectives on both GI concepts and the two PRO instruments. CONCLUSION Outcomes of these research activities include experiential data on the symptom and impact experience of oral DMTs in MS from both patients and HCPs that contribute to the process of determining therapeutic value.
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Affiliation(s)
- Farah Jivraj
- Biogen, 3250 Bloor St West, Suite #1200, Toronto, ON Canada
| | - Sha Kang
- Biogen, 3250 Bloor St West, Suite #1200, Toronto, ON Canada
| | - Scott Reedie
- Biogen, 3250 Bloor St West, Suite #1200, Toronto, ON Canada
| | | | - Sara Strzok
- Modus Outcomes, a Division of THREAD, Cambridge, MA USA
| | - Emma Elliott
- Modus Outcomes, a Division of THREAD, Cambridge, MA USA
| | - Stefan Cano
- Modus Outcomes, a Division of THREAD, Cambridge, MA USA
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Ziemssen T, Kurzeja A, Muresan B, Haas JS, Alexander J, Driessen MT. Real-world patient characteristics, treatment patterns and costs in relapsing multiple sclerosis patients treated with glatiramer acetate, dimethyl fumarate or teriflunomide in Germany. Neurodegener Dis Manag 2021; 12:93-107. [PMID: 34931528 DOI: 10.2217/nmt-2021-0031] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
Aim: To evaluate adherence, healthcare resource utilization (HRU) and costs for glatiramer acetate (GA; injectable), dimethyl fumarate (oral) and teriflunomide (oral) in relapsing multiple sclerosis. Patients & methods: Retrospective analyses of a claims database. Results: Teriflunomide patients were older with more co-morbidities and fewer relapses versus GA and dimethyl fumarate. GA patients were mostly disease-modifying therapies (DMTs)-treatment naive. Treatment adherence was 61-70%. All DMTs reduced HRU versus pre-index. Costs were comparable across cohorts. High adherence reduced hospitalizations and several costs versus low adherers. Conclusion: Adherence rates were high and comparable with all DMTs. Similar (and high) reductions in HRU and costs occurred with all DMTs. High adherence improved economic outcomes versus low adherence. Thus, investing in adherence improvement is beneficial to improve outcomes in relapsing multiple sclerosis.
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Affiliation(s)
- Tjalf Ziemssen
- MS Center Dresden, Center of Clinical Neuroscience, Neurological Clinic, University Hospital Carl Gustav Carus, Dresden University of Technology, Fetscherstr. 74, Dresden, 01307, Germany
| | - Anna Kurzeja
- European Medical Affairs, Teva Pharmaceuticals Europe B.V., Piet Heinkade 107, GM, 1019, Amsterdam, The Netherlands
| | - Bogdan Muresan
- Global Health Economics & Outcomes Research, Teva Pharmaceuticals Europe B.V., Piet Heinkade 107, GM, 1019, Amsterdam, The Netherlands
| | - Jennifer S Haas
- Real World Evidence, Xcenda GmbH, Lange Laube 31, Hanover, D-30159, Germany
| | - Jessica Alexander
- Global Medical Affairs, Teva Pharmaceutical Industries Ltd, 145 Brandywine Pkwy, West Chester, PA 19380, USA
| | - Maurice T Driessen
- Global Health Economics & Outcomes Research, Teva Pharmaceuticals Europe B.V., Piet Heinkade 107, GM, 1019, Amsterdam, The Netherlands
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Sippel A, Riemann-Lorenz K, Scheiderbauer J, Kleiter I, Morrison R, Kofahl C, Heesen C. Patients experiences with multiple sclerosis disease-modifying therapies in daily life - a qualitative interview study. BMC Health Serv Res 2021; 21:1141. [PMID: 34686166 PMCID: PMC8539738 DOI: 10.1186/s12913-021-07012-z] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2021] [Accepted: 09/07/2021] [Indexed: 01/26/2023] Open
Abstract
Background Besides coping with a disease with many uncertainties, people with relapsing-remitting multiple sclerosis face complex decisions concerning disease-modifying therapies (DMTs). In an interview study, we aimed to assess patients’ experiences with DMTs. Methods Problem-centred interviews were conducted with 50 people with relapsing-remitting multiple sclerosis in Germany using maximum variation sampling and covering all licensed DMTs. Data were analysed thematically using deductive and inductive categories. Results 47 of 50 patients had treatment with at least one of the approved DMTs. The main themes were: (1) starting a DMT, (2) switching to another DMT, (3) discontinuing a DMT, and (4) multiple sclerosis without starting a DMT. Different intercorrelated factors influenced the decision-making processes for or against a DMT. Individual experiences with DMTs in daily life contained the effort in administration, success, and failure of DMTs, coping strategies and well-being without DMTs. The decision-making process for or against a DMT and the use of those treatments can be understood as a constant, continually shifting process, complicated by different factors, which change over time. Experiences with DMTs were characterized by attempts to handle uncertainty and to (re)gain control and integrate adaptivity into one’s life. Conclusions The study provides a rich and nuanced amount of patients’ experiences with DMTs. The findings demonstrate the importance for practitioners to look at current life circumstances of patients with multiple sclerosis when recommending a DMT and to promote and enable patients to make informed decisions. Supplementary Information The online version contains supplementary material available at 10.1186/s12913-021-07012-z.
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Affiliation(s)
- Anna Sippel
- Institute of Neuroimmunology and Multiple Sclerosis (INIMS), University Medical Center Hamburg-Eppendorf (UKE), Martinistrasse 52, 20246, Hamburg, Germany.
| | - Karin Riemann-Lorenz
- Institute of Neuroimmunology and Multiple Sclerosis (INIMS), University Medical Center Hamburg-Eppendorf (UKE), Martinistrasse 52, 20246, Hamburg, Germany
| | | | - Ingo Kleiter
- Marianne-Strauß-Klinik, Behandlungszentrum Kempfenhausen für Multiple Sklerose Kranke gGmbH, Berg, Germany
| | | | - Christopher Kofahl
- Patient representative, Trier, Hamburg, Germany.,Institute of Medical Sociology, University Medical Center Hamburg-Eppendorf (UKE), Hamburg, Germany
| | - Christoph Heesen
- Institute of Neuroimmunology and Multiple Sclerosis (INIMS), University Medical Center Hamburg-Eppendorf (UKE), Martinistrasse 52, 20246, Hamburg, Germany.,Department of Neurology, University Medical Center Hamburg-Eppendorf (UKE), Hamburg, Germany
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Geng B, Craig TJ. Small molecule drugs for atopic dermatitis, rheumatoid arthritis, and hereditary angioedema. Ann Allergy Asthma Immunol 2021; 128:263-268. [PMID: 34673223 DOI: 10.1016/j.anai.2021.10.015] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2021] [Revised: 10/07/2021] [Accepted: 10/11/2021] [Indexed: 02/07/2023]
Abstract
OBJECTIVE To review recent trends in the development of targeted small molecule drugs (SMDs) for the treatment of immunologically driven disorders, including atopic dermatitis, rheumatoid arthritis, and hereditary angioedema. DATA SOURCES Data sources included peer-reviewed published literature from the PubMed database, published abstracts from scientific and medical meetings, and medication information from the Drugs@FDA database. STUDY SELECTIONS Articles with primary or retrospective trial results, articles with patient or physician survey results, articles providing expert perspectives, and commentary on chronic immunologic disorders, Food and Drug Administration package inserts, and abstracts from scientific meetings were selected. RESULTS Targeted biological therapies have greatly improved response rates and symptom relief for patients with long-term immunologically driven disorders over the past 2 decades. However, recent advances in the understanding of molecular pathways involved in the pathogenesis of these disorders have led to the development of novel targeted SMDs, such as tofacitinib and berotralstat, that can be delivered orally or topically. Few head-to-head studies that compare the safety and efficacy of biologics to SMDs in immunologically driven disorders exist, although some studies suggest that oral and topical modes of administration are preferred by patients and may improve patient quality of life over time. CONCLUSION Scientific advances have led to an increase in the development of targeted SMDs for the treatment of chronic immunologic disorders, which may revolutionize the management of these diseases. Head-to-head studies and real-world evidence are needed to fully compare treatment attributes between biologics and SMDs, including safety, efficacy, adherence, impact on quality of life, and cost-effectiveness.
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Affiliation(s)
- Bob Geng
- Division of Rheumatology, Allergy, and Immunology, Department of Medicine, University of California San Diego, La Jolla, California
| | - Timothy J Craig
- Department of Medicine, Pediatrics, and Biomedical Sciences, Penn State University, Hershey Medical Center, Hershey, Pennsylvania.
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Tencer T, Will O, Kumar J, Cambron-Mellott MJ, Mackie DS, Beusterien K. Patient and neurologist preferences in the UK for relapsing-remitting multiple sclerosis treatments: findings from a discrete choice experiment. Curr Med Res Opin 2021; 37:1589-1598. [PMID: 34129418 DOI: 10.1080/03007995.2021.1940911] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
OBJECTIVE To evaluate and compare patient and neurologist preferences for relapsing-remitting multiple sclerosis (RRMS) treatments with respect to benefits and risks associated with common and novel disease-modifying therapies, including brain volume loss (BVL). METHODS Patients with non-highly-active RRMS and neurologists in the United Kingdom completed an online cross-sectional survey. Patients completed one discrete choice experiment (DCE) exercise and providers completed two, one focusing on treatment for non-highly-active RRMS and another focused on highly active RRMS. Respondents chose between two treatment profiles that varied on seven attributes identified in qualitative research: 2 year disability progression; 1 year relapse rate; rate of BVL; and risks of gastrointestinal symptoms, flu-like symptoms, infection and life-threatening event. Bayesian modeling was used to estimate attribute-level weighted preferences. RESULTS Patients (n = 144) prioritized slowing the rate of BVL, followed by reducing risk of infection, rate of 2 year disability progression and 1 year relapse rate. For non-highly-active patients, neurologists (n = 101) prioritized slowing the rate of BVL, followed by reducing 2 year disability progression, risk of infection and 1 year relapse rate. For highly active patients, neurologists prioritized lowering the 1 year relapse rate, followed by slowing the rate of BVL and 2 year disability progression. In all three DCEs, rate of BVL was approximately twice as important as reducing the risks of flu-like symptoms, gastrointestinal symptoms and life-threatening event. CONCLUSIONS This study highlights similarities in treatment preferences for non-highly-active RRMS among patients and neurologists and differences in neurologists' preferences for treating non-highly-active vs. highly active RRMS. This research identifies BVL as a treatment outcome that should be discussed when physicians engage in shared decision-making with patients.
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Affiliation(s)
- Tom Tencer
- Bristol Myers Squibb, Princeton, NJ, USA
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21
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Manning ME, Kashkin JM. Berotralstat (BCX7353) is a novel oral prophylactic treatment for hereditary angioedema: Review of phase II and III studies. Allergy Asthma Proc 2021; 42:274-282. [PMID: 34127176 DOI: 10.2500/aap.2021.42.210034] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
Background: Hereditary angioedema (HAE) is a rare genetic disorder characterized by unpredictable and potentially life-threatening episodes of swelling in various parts of the body. These attacks can be painful and debilitating, and affect a patient's quality of life. Every patient who experiences an attack should be treated with on-demand medication to mitigate attack severity and duration. Many patients with HAE also receive long-term prophylaxis to reduce the frequency and severity of edema episodes. Although long-term prophylaxis reduces the disease burden for patients with HAE, available intravenous and subcutaneous treatments are accompanied by a significant treatment burden because of the logistical, emotional, and physical challenges posed by their long-term parenteral nature. Androgens are an effective oral prophylactic treatment; however, they are associated with significant adverse events and are not suitable for all patients. Thus, the HAE community has expressed interest in the development of alternative oral prophylactic therapies for preventing HAE attacks. Objective: Here, we review the phase II and III clinical data of berotralstat (BCX7353), which was approved by the U.S. Food and Drug Administration in December 2020. Results: Berotralstat is an oral, second-generation, synthetic, small-molecule plasma kallikrein inhibitor taken once daily for the prevention of HAE attacks in patients ages ≥ 12 years. Results from the APeX studies (APeX-1 NCT02870972, APeX-2 NCT03485911, APeX-S NCT03472040, APex-J NCT03873116) demonstrated the efficacy of berotralstat as long-term prophylaxis for patients with HAE, which showed a reduction in the attack rate and on-demand medication usage. Berotralstat was well tolerated, and gastrointestinal treatment-emergent adverse events were generally mild and self-limited. Conclusion: Oral berotralstat is an effective and safe long-term prophylactic treatment for patients with HAE that will provide patients unable to tolerate parenteral therapies with the option of disease control. Berotralstat may be associated with reduced treatment burden compared with injectable therapies, highlighting the importance of patient preference with regard to the administration route of their HAE prophylactic treatment.
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Affiliation(s)
- Michael E. Manning
- From the Allergy, Asthma and Immunology Associates, Ltd., Scottsdale, Arizona; and
| | - Jay M. Kashkin
- Kashkin Allergy, Asthma and Immunology Center, Fair Lawn, New Jersey
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Ngorsuraches S, Poudel N. Incorporating patients' preferences in the value assessment of disease-modifying therapies for multiple sclerosis: a narrative review. Expert Rev Pharmacoecon Outcomes Res 2021; 21:183-195. [PMID: 33472451 DOI: 10.1080/14737167.2021.1880321] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
Introduction: Despite the increasing role of patients in the US healthcare system, patients have yet been engaged in the value assessment of their treatments, including disease-modifying therapies (DMTs) for multiple sclerosis (MS). The objectives of this review were therefore to summarize existing studies on cost-effectiveness analysis (CEA) with quality-adjusted life years (QALYs) and patients' preferences of DMTs for MS, and to discuss how to incorporate patients' preferences into the value assessment of DMTs.Area covered: We reviewed previous systematic reviews and conducted further search until November 2020 for studies on CEA with QALYs and patients' preferences of DMTs for MS. We identified the outcomes that were assessed or valued in the CEA studies and the DMT attributes that were important to patients with MS.Expert opinion: Our literature review showed that the studies using CEA with QALYs failed to capture some important DMT attributes, e.g., route and frequency of administration, identified in the studies on the patients' preferences. Various approaches were available for incorporating the patients' preferences in the value assessment of DMTs for MS. We supported this incorporation, which subsequently would increase patient access to preferred DMTs.
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Affiliation(s)
- Surachat Ngorsuraches
- Department of Health Outcomes Research and Policy, Auburn University, Harrison School of Pharmacy, Auburn, AL, USA
| | - Nabin Poudel
- Department of Health Outcomes Research and Policy, Auburn University, Harrison School of Pharmacy, Auburn, AL, USA
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Thach A, Sutphin J, Coulter J, Leach C, Pappert E, Mansfield C. Patient Preferences for Treating "OFF" Episodes in Parkinson's Disease: A Discrete Choice Experiment. Patient Prefer Adherence 2021; 15:1187-1196. [PMID: 34103902 PMCID: PMC8179791 DOI: 10.2147/ppa.s301644] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/04/2021] [Accepted: 05/05/2021] [Indexed: 11/23/2022] Open
Abstract
INTRODUCTION Several on-demand treatments are available for management of "OFF" episodes in patients with Parkinson's disease (PD). We evaluated patients' preferences for features of theoretical on-demand treatment options. METHODS In a discrete choice experiment, US adults with self-reported PD of ≥5 years, or <5 years with "OFF" episodes, taking oral carbidopa/levodopa, selected between pairs of theoretical on-demand treatments that varied by mode of administration (with and without mode-specific adverse events [AEs]), time to FULL "ON," duration of "ON," and out-of-pocket cost for a 30-day supply. Data were analyzed with a random parameters logit model; results were used to calculate relative importance of treatment attributes, preference shares, and willingness to pay. RESULTS Among 300 respondents, 98% had "OFF" episodes. Across the range of attribute levels included in the survey, avoiding $90 cost was most important to respondents, followed by a preferable mode of administration with associated AEs and decreasing time to FULL "ON." Duration of "ON" was relatively less important. On average, respondents preferred a theoretical dissolvable sublingual film versus other theoretical treatments with alternative modes of administration. Respondents were willing to pay $28-$52 US dollars to switch from least- to more-preferred mode of administration with associated AEs, $58 to reach FULL "ON" in 15 versus 60 min, and $9 to increase duration of FULL "ON" from 1 to 2 h. CONCLUSION Respondents with PD valued lower out-of-pocket cost and a sublingual mode of administration with its associated AEs when choosing an on-demand treatment for "OFF" episodes.
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Affiliation(s)
- Andrew Thach
- Health Economics and Outcomes Research, Sunovion Pharmaceuticals Inc., Marlborough, MA, USA
- Correspondence: Andrew Thach Health Economics and Outcomes Research, Sunovion Pharmaceuticals Inc., 84 Waterford Dr, Marlborough, MA 01752, USATel +1 774-369-7123 Email
| | - Jessie Sutphin
- Health Preference Assessment, RTI Health Solutions, Research Triangle Park, NC, USA
| | - Joshua Coulter
- Health Preference Assessment, RTI Health Solutions, Research Triangle Park, NC, USA
| | - Colton Leach
- Health Preference Assessment, RTI Health Solutions, Research Triangle Park, NC, USA
| | - Eric Pappert
- Medical Affairs, Sunovion Pharmaceuticals Inc., Marlborough, MA, USA
| | - Carol Mansfield
- Health Preference Assessment, RTI Health Solutions, Research Triangle Park, NC, USA
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Kumar J, Cambron-Mellott MJ, Tencer T, Will O, Mackie DS, Beusterien K. Patient and Neurologist Preferences in the United States for Relapsing-Remitting Multiple Sclerosis Treatments: Findings from a Discrete Choice Experiment. Patient Prefer Adherence 2021; 15:1515-1527. [PMID: 34267507 PMCID: PMC8275192 DOI: 10.2147/ppa.s306498] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/13/2021] [Accepted: 05/28/2021] [Indexed: 12/02/2022] Open
Abstract
BACKGROUND AND OBJECTIVE Relapsing-remitting multiple sclerosis (RRMS) is a chronic inflammatory disease associated with central nervous system dysfunction and accelerated brain volume loss (BVL). There exists a paucity of research examining the importance of BVL to patients and neurologists and exploring whether such preferences may differ between these two groups. This study sought to evaluate the preferences of patients and neurologists for RRMS treatments by considering benefits and risks associated with novel and common disease-modifying therapies (DMTs). PATIENTS AND METHODS US patients diagnosed with non-highly active RRMS and US-based neurologists completed an online cross-sectional survey. A discrete choice experiment was used to assess patient and neurologist treatment preferences, with neurologists considering preferences for patients with non-highly active RRMS. Respondents chose between two treatment profiles with seven attributes identified in qualitative research: 2-year disability progression; 1-year relapse rate; rate of BVL; and risks of gastrointestinal symptoms, flu-like symptoms, infection, and life-threatening events. Attribute-level weighted preferences were estimated using a hierarchical Bayesian model. RESULTS Analyses included 150 patients with non-highly active RRMS (mean age: 54 years) and 150 neurologists (65% in private practice). Among patients, the most important treatment attribute was reducing the rate of BVL, followed by reducing the risk of infection and risk of flu-like symptoms. In contrast, the most important treatment attribute among neurologists was reducing the risk of a life-threatening event, followed by slowing the rate of 2-year disability progression and risk of infection. CONCLUSION The findings highlight differences in treatment preferences between US patients and neurologists for non-highly active RRMS. The importance placed by patients on slowing the rate of BVL makes this a key topic that should be covered in the shared decision-making process.
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Affiliation(s)
- Jinender Kumar
- Worldwide Health Economics and Outcomes Research, Bristol Myers Squibb, Princeton, NJ, USA
| | - M Janelle Cambron-Mellott
- RWE Data and Analytics, Kantar Health, New York, NY, USA
- Correspondence: M Janelle Cambron-Mellott Kantar Health, 3 World Trade Center, 175 Greenwich Street, 35th Floor, New York, NY, 10007, USATel +1 212 706 3961 Email
| | - Tom Tencer
- Worldwide Health Economics and Outcomes Research, Bristol Myers Squibb, Princeton, NJ, USA
| | - Oliver Will
- RWE Data and Analytics, Kantar Health, New York, NY, USA
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Tafazzoli A, Chavan A, Harty G, Moller J, Wong SL. Efficiency Model of Cladribine Tablets Versus Infusion-Based Disease-Modifying Drugs for Patients with Relapsing-Remitting Multiple Sclerosis. Adv Ther 2020; 37:3791-3806. [PMID: 32647909 DOI: 10.1007/s12325-020-01426-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2020] [Indexed: 11/25/2022]
Abstract
INTRODUCTION To develop a simulation model assessing the efficiency of using cladribine tablets versus infusion-based disease-modifying drugs (DMDs) for the treatment of relapsing-remitting multiple sclerosis (RRMS) from a facility perspective in the UK. METHODS A scheduling algorithm was developed to simulate day-case admissions and calculate the mean changes to resource use and time burden for patients in a facility that transitions from infusion-based treatments to cladribine tablets over 1 year. Model inputs and assumptions were based on previous research and expert opinion. Model validation and quality checks were performed and additional scenario analyses were also conducted. RESULTS The model successfully scheduled all infusion treatments in the base case and no patients were left off the schedule as a result of lack of capacity. Modeled base-case outcomes increased in future scenarios owing to a 35% increase in demand. The introduction of cladribine tablets reduced these impacts. Specifically, the difference in mean daily utilization was reduced in the future scenario from 13% to 3% as 8% of patients moved to cladribine tablets; annual administration costs decreased by 96% and annual time burden decreased by 90%. Results from additional scenarios showed the largest benefits from switching current infusion patients to cladribine tablets were realized in facilities having moderate to high resource utilization. CONCLUSIONS This model provides facility decision-makers the ability to assess the efficiency of using cladribine tablets rather than an infusion-based DMD. The simulation quantified the benefits gained from reducing the burden on facility resources by switching some patients with RRMS from infusion-based DMDs to cladribine tablets. Overall, modeled outcomes increased in future scenarios owing to an increase in demand, although the introduction of cladribine tablets reduced this impact.
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Affiliation(s)
- Ali Tafazzoli
- Evidence Synthesis, Modeling and Communication, Evidera, Bethesda, MD, USA
| | - Ameya Chavan
- Evidence Synthesis, Modeling and Communication, Evidera, Bethesda, MD, USA
| | - Gerard Harty
- Global Evidence and Value Development, Global Research and Development, EMD Serono, Inc, Billerica, MA, USA.
| | - Jorgen Moller
- Evidence Synthesis, Modeling and Communication, Evidera, London, UK
| | - Schiffon L Wong
- Global Evidence and Value Development, Global Research and Development, EMD Serono, Inc, Billerica, MA, USA
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