Cost of illness in multiple sclerosis by disease characteristics - A review of reviews

Introduction: In light of the increasing number of economic burden studies and heterogeneity in methodology and reporting standards, there is a need for robust evidence synthesis on an umbrella review level.Areas covered: We performed the first review of reviews of cost-of-illness studies in multiple sclerosis. Focusing on disaggregated costs by disease characteristics (disability level, relapse, disease course), we also characterized the underlying methodological evidence base of individual (primary) studies.Expert Commentary: We identified 17 reviews encompassing 111 unique primary studies, and a high degree of overlap across reviews. Costs were substantial, rising with disability level, relapse episodes, and disease progression. Disability was the key cost driver. Compared to mild disability, total costs for moderate disability were 1.4-2.3-fold higher and 1.8-2.9-fold higher for severe disability. With escalating disability, the share of costs outside the health system (indirect costs, informal care) increasingly outweighed the share of direct medical costs. Of all 111 primary studies, 72% gathered resource use/loss data by patient self-report. Associated costs were mostly reported by disability level (75%), followed by relapse (48%) and disease course (21%). In conclusion, although heterogeneity can make in-depth comparisons of costs across studies impossible, important patterns are broadly apparent.

Secondary progressive multiple sclerosis: a systematic review of costs and health state utilities

Objective: To identify evidence in the literature presenting the economic and humanistic (based on health state utility values [HSUVs]) burden of multiple sclerosis (MS) and report the incremental burden of secondary progressive MS (SPMS) compared with relapsing-remitting MS (RRMS).Methods: Electronic databases (Embase, MEDLINE, MEDLINE In-Process, Cochrane Library) and other relevant repositories were systematically searched from the date of inception until November 2019 for evidence on the economic burden of MS, or HSUVs in patients with MS. Data were extracted from studies investigating cost data or HSUVs for patients with SPMS compared with RRMS.Results: In total, 25 studies were identified that reported data on the economic and HSUV burden of SPMS versus RRMS: 18 studies reported cost data and nine presented HSUVs. Overall, costs associated with SPMS were consistently higher than those for RRMS. Major cost drivers appeared to shift following transition from RRMS to SPMS, with higher direct medical costs associated with RRMS than with SPMS, while the opposite was true for direct non-medical costs and indirect costs. In all studies presenting HSUVs specifically in patients with SPMS, the disease burden was greater (indicated by lower HSUV scores or a negative regression coefficient vs RRMS) for patients with SPMS than for those with RRMS. Fatigue and psychological stress (including depression) were identified as key drivers of this reduced health-related quality of life (HRQoL).Conclusions: Our findings indicate that SPMS is associated with higher costs and more substantial HRQoL decrements than RRMS. These results highlight the substantial unmet need for effective treatments that can slow disease progression in patients with SPMS, which, in turn, would reduce the rate of HRQoL deterioration and increasing healthcare costs.

Cost-effectiveness of Cladribine Tablets and fingolimod in the treatment of relapsing multiple sclerosis with high disease activity in Spain

OBJECTIVE

To estimate the cost-effectiveness of Cladribine Tablets in the treatment of relapsing multiple sclerosis (RMS) with high disease activity compared with fingolimod, from the perspective of the National Health System (NHS) in Spain.

METHODS

A Markov model was developed. The annual transition probabilities, were adjusted to patients with RMS with high disease activity. The effect of the treatments compared on the Expanded Disability Status Scale (EDSS) was modeled by hazard ratios for the confirmed progression of disability. The annual relapse rate and the probability of suffering adverse reactions were obtained from a meta-analysis and the literature. The derived costs were calculated from Spanish unit costs. The utilities were obtained from the CLARITY clinical trial and the literature. Deterministic and probabilistic sensitivity analyzes were performed.

RESULTS

Cladribine tablets was the dominant treatment: lower costs (-86,536 €) and more effective (+1.11 quality-adjusted life years - QALYs) compared to fingolimod. The probability that Cladribine Tablets was cost-effective compared to fingolimod ranged between 94.6% and 96.1% for willingness to pay from € 20,000 to € 30,000 per QALY gained.

CONCLUSIONS

Cladribine Tablets is a cost-effective treatment, compared to fingolimod, for the treatment of RMS with high disease activity.

EXPERT OPINION

According to the present study, compared to fingolimod, treatment with Cladribine Tablets of relapsing multiple sclerosis with high disease activity is an option that could generate savings for the Spanish National Health System, with a considerable gain in QALYs. Cladribine Tablets is considered cost-effective and dominant (less costs and more effectiveness) than fingolimod treatment option in this population.

Economic burden of multiple sclerosis in a population with low physical disability

BACKGROUND

In multiple sclerosis (MS), half of affected people are unemployed within 10 years of diagnosis. The aim of this study was to assess the economic impact of MS in adult subjects with relapsing-remitting MS (RRMS) and primary progressive MS (PPMS).

METHODS

A multicenter, non-interventional, cross-sectional study was conducted. The Expanded Disability Status Scale (EDSS) and the 23-item Multiple Sclerosis Work Difficulties Questionnaire (MSWDQ-23) were used to assess disability and work performance, respectively. Only indirect costs were considered using the human capital method, including work costs. Professional support costs and informal caregivers' costs were also estimated.

RESULTS

A total of 199 subjects were studied (mean age: 43.9 ± 10.5 years, 60.8% female, 86.4% with RRMS). Median EDSS score was 2.0 (interquartile range: 1.0-3.5) and median MSWDQ-23 total score was 31.5 (15.2, 50.0). The number of employed subjects decreased after MS diagnosis from 70.6 to 47.2%, and the number of retired people increased (23.6%). Mean age of retirement was 43.6 ± 10.5 years. Ten percent of the population had sick leaves (absenteeism was seen in 90.9% of the student population and 30.9% of the employed population). Professional support in their daily life activities was needed in 28.1% of subjects. Costs for sick leave, work absenteeism, premature retirement and premature work disability/pensioner were €416.6 ± 2030.2, €763.4 ± 3161.8, €5810.1 ± 13,159.0 and €1816.8 ± 9630.7, respectively. Costs for professional support and informal caregiving activities were €1026.93 ± 4622.0 and €1328.72, respectively.

CONCLUSIONS

MS is responsible for a substantial economic burden due to indirect and informal care costs, even in a population with low physical disability.

New insights into the burden and costs of multiple sclerosis in Europe: Results for Spain

INTRODUCTION

In order to estimate the value of interventions in multiple sclerosis (MS) where lifetime costs and outcomes cannot be observed, outcome data have to be combined with costs. This requires that cost data be regularly updated.

OBJECTIVES AND METHODS

This study is part of a cross-sectional retrospective study in 16 countries collecting data on resource consumption, work capacity, health-related quality of life (HRQoL) and prevalent symptoms for patients with MS. Descriptive analyses are presented by level of severity, from the societal perspective, in EUR 2015.

RESULTS

A total of 462 patients (mean age 43 years) participated in Spain; 96% were below retirement age and of these, 45% were employed. Employment was related to disability, and MS affected productivity at work for 72% of those working. Overall, 92% and 64% of patients experienced fatigue and cognitive difficulties as a problem, respectively. Mean utility and total annual costs were estimated at 0.772 and €20,600 at Expanded Disability Status Scale (EDSS) 0-3, 0.486 and €48,500 at EDSS 4-6.5 and 0.182 and €68,700 at EDSS 7-9, respectively. The mean cost of a relapse was €2050.

CONCLUSION

This study illustrates the burden of MS on Spanish patients and provides current data that are important for development of health policies.

Impact on healthcare resource utilization of multiple sclerosis in Spain

BACKGROUND

Multiple sclerosis (MS) is a chronic disease with a high socioeconomic impact. The aim of this study was to assess healthcare resources utilization and costs in a sample of patients with MS.

METHODS

A retrospective, cohort study was conducted using electronic medical records from 19 primary care centres in Asturias and Catalonia, Spain. Adult patients diagnosed with MS were distributed into two groups according to the Expanded Disability Status Scale (EDSS) score: 0-3.5 (no-moderate disability) and 4-9.5 (severe disability). Healthcare (direct cost) and non-healthcare costs (work productivity losses) were analysed. An analysis of covariance (ANCOVA) was used for correction, p < 0.05. A multiple regression model was performed to obtain the variables associated with costs.

RESULTS

A total of 222 patients were analyzed; mean (SD) age: 45.5 (12.5) years, 64.4% female, and 62.2% presented a diagnosis of relapsing-remitting MS. Median EDSS score was 2.5, with 68.5% of the patients with no to moderate disability. The mean annual cost per MS patient was €25,103. For no-moderate and severe disability, the ANCOVA-adjusted mean annual cost was €23,157 and €29,242, respectively (p = 0.013). Direct costs and MS disease-modifying therapy accounted for 39.4% and 31.7% of the total costs, respectively. The total costs were associated with number of relapses (β = 0.135, p = 0.001), time since diagnosis (β = 0.281, p = 0.023), and age (β = 0.198, p = 0.037).

CONCLUSIONS

Multiple sclerosis imposes a substantial economic burden on the Spanish National Health System, patients and society as a whole. Costs significantly correlated with disease progression.

Estimate of the cost of multiple sclerosis in Spain by literature review

INTRODUCTION

Multiple Sclerosis (MS) is a progressive disease leading to increasing disability and costs. A literature review was carried out to identify MS costs and to estimate its economic burden in Spain. Areas Covered: The public electronic databases PubMed, ScienceDirect and IBECS were consulted and a manual review of communications presented at related congresses was carried out. A total of 225 references were obtained, of which 43 were finally included in the study. Expert Commentary: Three major cost groups were identified: direct healthcare costs, direct non-healthcare costs and indirect costs. There is a direct relationship between disease progression and increased costs, mainly direct non-healthcare costs (greater need for informal care) and indirect costs (greater loss of productivity). The total cost associated with MS in Spain is €1,395 million per year, and that the mean annual cost per patient is €30,050. Beyond costs, a large impact on the quality of life of patients, with an annual loss of up to 13,000 quality-adjusted life years was also estimated. MS has a large economic impact on Spanish society and a significant impact on the quality of life of patients.

Cost of Illness of Multiple Sclerosis - A Systematic Review

BACKGROUND

Cost-of-illness (COI) studies of Multiple Sclerosis (MS) are vital components for describing the economic burden of MS, and are frequently used in model studies of interventions of MS. We conducted a systematic review of studies estimating the COI of MS, to compare costs between studies and examine cost drivers, emphasizing generalizability and methodological choices.

MATERIAL AND METHOD

A literature search on studies published in English on COI of MS was performed in PubMed for the period January 1969 to January 2014, resulting in 1,326 publications. A mapping of studies using a bottom-up approach or top-down approach, respectively, was conducted for the 48 studies assessed as relevant. In a second analysis, the cost estimates were compared between the 29 studies that used a societal perspective on costs, human capital approach for indirect costs, presenting number of patients included, time-period studied, and year of price level used.

RESULTS

The mapping showed that bottom-up studies and prevalence approaches were most common. The cost ratios between different severity levels within studies were relatively stable, to the ratio of 1 to 2 to 3 for disability level categories. Drugs were the main cost drivers for MS-patients with low disease severity, representing 29% to 82% of all costs in this patient group, while the main cost components for groups with more advanced MS symptoms were production losses due to MS and informal care, together representing 17% to 67% of costs in those groups.

CONCLUSION

The bottom-up method and prevalence approach dominated in studies of COI of MS. Our findings show that there are difficulties in comparing absolute costs across studies, nevertheless, the relative costs expressed as cost ratios, comparing different severity levels, showed higher resemblance. Costs of drugs were main cost drivers for less severe MS and informal care and production losses for the most severe MS.

Brain health: time matters in multiple sclerosis

INTRODUCTION

We present international consensus recommendations for improving diagnosis, management and treatment access in multiple sclerosis (MS). Our vision is that these will be used widely among those committed to creating a better future for people with MS and their families.

METHODS

Structured discussions and literature searches conducted in 2015 examined the personal and economic impact of MS, current practice in diagnosis, treatment and management, definitions of disease activity and barriers to accessing disease-modifying therapies (DMTs).

RESULTS

Delays often occur before a person with symptoms suggestive of MS sees a neurologist. Campaigns to raise awareness of MS are needed, as are initiatives to improve access to MS healthcare professionals and services. We recommend a clear treatment goal: to maximize neurological reserve, cognitive function and physical function by reducing disease activity. Treatment should start early, with DMT and lifestyle measures. All parameters that predict relapses and disability progression should be included in the definition of disease activity and monitored regularly when practical. On suboptimal control of disease activity, switching to a DMT with a different mechanism of action should be considered. A shared decision-making process that embodies dialogue and considers all appropriate DMTs should be implemented. Monitoring data should be recorded formally in registries to generate real-world evidence. In many jurisdictions, access to DMTs is limited. To improve treatment access the relevant bodies should consider all costs to all parties when conducting economic evaluations and encourage the continuing investigation, development and use of cost-effective therapeutic strategies and alternative financing models.

CONCLUSIONS

The consensus findings of an international author group recommend a therapeutic strategy based on proactive monitoring and shared decision-making in MS. Early diagnosis and improved treatment access are also key components.

ENCOMS: Argentinian survey in cost of illness and unmet needs in multiple sclerosis

The objective of the study was to assess the cost of multiple sclerosis (MS) patients in Argentina categorized by disease severity using a societal perspective.

METHOD

Cross-sectional study including MS patients from 21 MS centers in 12 cities of Argentina. Patients were stratified by disease severity using the expanded disability status scale (EDSS) (group 1 with EDSS score between 0 and 3; group 2 with EDSS >3 and <7; group 3 with EDSS ≥7). Direct and indirect costs were analyzed for the second quarter of 2012 from public sources and converted to US Dollars.

RESULTS

266 patients were included. Mean annual cost per MS patient was USD 36,025 (95%CI 31,985-38,068) for patients with an EDSS between 0-3; USD 40,705 (95%CI 37,199-46,300) for patients with EDSS >3 and <7, and USD 50,712 (95%CI 47,825-62,104) for patients with EDSS ≥7.

CONCLUSIONS

This is the first Argentine study evaluating the costs of MS considering disease severity.

Cost of disorders of the brain in Spain

Background

Brain disorders represent a high burden in Europe and worldwide. The objective of this study was to provide specific estimates of the economic costs of brain disorders in Spain, based on published epidemiological and economic evidence.

Methods

A cost-of-illness study with a societal perspective of 19 brain disorders was carried out. Cost data published between 2004 and 2012 was obtained from a systematic literature review. Direct healthcare, direct non-medical and indirect costs were considered, prioritizing bottom-up information. All costs were converted to Euro and to year 2010. The missing values were imputed with European estimates. Sensitivity analyses based on qualitative assessment of the literature and on a Monte Carlo simulation were performed.

Results

The review identified 33 articles with information on costs for 11 disorders (8 neurological, 3 mental). The average per–patient cost ranged from 36,946 € for multiple sclerosis to 402 € for headache. The societal cost of the 19 brain disorders in Spain in 2010 was estimated in 84 € billion. Societal costs ranged from 15 € billion for dementia to 65 € million for eating disorders. Mental disorders societal cost were 46 € billions (55% of the total), while neurological disorder added up to 38 € billion. Healthcare costs represented 37% of the societal costs of brain disorders, whereas direct non-medical constituted 29% and indirect costs 33%.

Conclusion

Brain disorders have a substantial economic impact in Spain (equivalent to almost 8% of the country's GDP). Economic data on several important brain disorders, specially mental disorders, is still sparse.

Treatment experience, burden, and unmet needs (TRIBUNE) in Multiple Sclerosis study: the costs and utilities of MS patients in The Netherlands

BACKGROUND

Multiple sclerosis (MS) is an important, highly disabling neurological disease, common among young adults in The Netherlands. Nevertheless, only a few studies to date have measured the burden imposed by MS on society in The Netherlands.

OBJECTIVES

To estimate the cost and quality-of-life associated with MS in The Netherlands, while focusing on the burden of relapses and increasing disease severity.

METHODS

MS patients in The Netherlands (n = 263) completed a web-based questionnaire which captured information on demographics, disease characteristics and severity (Expanded Disability Status Scale [EDSS]), co-morbidities, relapses, resource consumption, utilities, fatigue and activities of daily living (ADL).

RESULTS

Most patients included in the study were receiving treatment for MS (76% of the sample). The mean cost per patient per year increased with worsening disability and was estimated at €30,938, €51,056, and €100,469 for patients with mild (EDSS 0-3), moderate (EDSS 4-6.5), and severe (EDSS 7-9) disability, respectively. The excess cost of relapses was estimated at €8195 among relapsing-remitting patients with EDSS score ≤5. The quality-of-life of patients decreased with disease progression and existence of relapses.

CONCLUSIONS

The cost of MS in The Netherlands was higher compared to the results of previous studies. The TRIBUNE study provides an important update on the economic burden of MS in The Netherlands in an era of more widespread use of disease-modifying therapies. It explores the cost of MS linked to relapses and disease severity and examines the impact of MS on additional health outcomes beyond utilities such as ADL and fatigue.

STUDY LIMITATIONS

Patients were selected from specialized treatment centers, therefore this sample may not be representative of the entire MS population in The Netherlands, i.e., few patients not receiving MS therapies were included. In addition, only a few patients with severe disability were included in the study sample; therefore, results for this disease severity sub-group should be interpreted with caution.