Treatment benefit and daily drug costs associated with treating Parkinson's disease in a Parkinson's disease clinic

Dynamics of Parkinson's Disease Multimodal Complex Treatment in Germany from 2010⁻2016: Patient Characteristics, Access to Treatment, and Formation of Regional Centers

Parkinson's disease (PD) is currently the world's fastest-growing neurological disorder. It is characterized by motor and non-motor symptoms which progressively lead to significant clinical impairment, causing a high burden of disease. In addition to pharmacological therapies, various non-pharmacological treatment options are available. A well established and frequently used multiprofessional inpatient treatment concept in Germany is "Parkinson's disease multimodal complex treatment" (PD-MCT) which involves physiotherapists, occupational therapists, speech therapists, and other specializations for the optimization of treatment in PD (ICD G20) and other Parkinsonian syndromes (ICD G21 and G23). In this study we analyze the PD-MCT characteristics of 55,141 PD inpatients who have been integrated into this therapy concept in Germany in the years 2010⁻2016. We demonstrate that PD-MCT is increasingly applied over this time period. Predominately, PD patients with advanced disease stage and motor fluctuations in age groups between 45 and 69 years were hospitalized. In terms of gender, more male than female patients were treated. PD-MCT is provided primarily in specialized hospitals with high patient numbers but a minor part of all therapies is performed in a rather large number of hospitals with each one treating only a few patients. Access to PD-MCT differs widely across regions, leading to significant migration of patients from underserved areas to PD-MCT centers ⁻ a development that should be considered when implementing such therapies in other countries. Furthermore, our data imply that despite the overall increase in PD-MCT treatments during the observational period, the restricted treatment accessibility may not adequately satisfy current patient´s need.

Benefit on motor and non-motor behavior in a specialized unit for Parkinson's disease

Treatment of patients with Parkinson's disease in specialized units is quite common in Germany. Data on the benefit of this hospitalization of patients with Parkinson's disease on motor and non-motor symptoms in conjunction with standardized tests are rare. Objective was to determine the efficacy of this therapeutic setting. We scored disease severity and performed clinical tests, respectively, instrumental procedures under standardized conditions in consecutively referred in-patients initially and at the end of their hospital stay. There was a decrease of motor and non-motor symptoms. The extent of improvement of non-motor and motor symptoms correlated to each other. Performance of complex movement sequences became better, whereas execution of simple movement series did not ameliorate. The interval for the timed up and go test went down. We demonstrate the effectiveness of an in-patient stay in a specialized unit for Parkinson's disease. Objective standardized testing supplements subjective clinical scoring with established rating scales.

Costs of Parkinson's disease in a privately insured population

BACKGROUND

This is the first analysis to estimate the costs of commercially insured patients with Parkinson's disease (PD) in the USA. Prior analyses of PD have not examined costs in patients aged under 65 years, a majority of whom are in the workforce.

OBJECTIVE

Our objective was to estimate direct and indirect costs associated with PD in patients under the age of 65 years who are newly diagnosed or have evidence of advanced PD.

METHODS

PD patients were selected from a commercially insured claims database (N > 12,000,000; 1999-2009); workloss data were available for a sub-sample of enrollees. Newly diagnosed patients with evidence of similar disorders were excluded. Patients with evidence of advanced PD disease, including ambulatory assistance device users (PDAAD) and institutionalized (PDINST) patients, as well as newly diagnosed PD patients, were analyzed. Each PD cohort was age-, gender- and region-matched to controls without PD. Direct (i.e. insurer payments to providers) and indirect (i.e. workloss) costs were reported in $US, year 2010 values, and were descriptively compared using Wilcoxon rank sum tests.

RESULTS

Patients had excess mean direct PD-related costs of $US4,072 (p < 0.001; N = 781) in the year after diagnosis. The PDAAD cohort (N = 214) had excess direct PD-related costs of $US26,467 (p < 0.001) and the PDINST cohort (N = 156) had excess direct PD-related costs of $US37,410 (p < 0.001) in the year after entering these states. Outpatient care was the most expensive cost source for newly diagnosed patients, while inpatient care was the most expensive for PDAAD and PDINST patients. Excess indirect costs were $US3,311 (p < 0.05; N = 173) in the year after initial diagnosis.

CONCLUSIONS

Direct costs for newly diagnosed PD patients exceeded costs for controls without PD, and increased with PD progression. Direct costs were approximately 6-7 times higher in patients with advanced PD than in matched controls. Indirect costs represented 45 % of total excess costs for newly diagnosed PD patients.

Do neurologists in Germany adhere to the national Parkinson's disease guideline?

Implementation of guidelines can improve clinical practice. The aim in this study was to investigate whether neurologists in Germany adhered to the national Parkinson's disease guideline. Data were obtained from a cross-sectional survey of 60 neurologists. Analyses were performed on 320 patients with idiopathic Parkinson's disease with either low grades of functional impairment (Hoehn and Yahr stage I) or higher grades of functional impairment (stage II-V) but without motor complications. The sample was divided into four groups depending on age and grade of functional impairment. For each group, a biometric parameter on the use of dopamine agonists and L-dopa was defined based on the guideline. In patients aged <70 years, the recommendation to use dopamine agonists without L-dopa (parameter 1) was observed in 53% of patients with lower grades of functional impairment, whilst recommended use of dopamine agonists in more functionally impaired patients (parameter 2) was followed to a greater extent (84%). In patients aged ≥70 years, recommendations to use L-dopa without dopamine agonists were adhered to in only 50% of less functionally impaired (parameter 3) and 52% of more functionally impaired (parameter 4) patients. In conclusion, our results indicated there was moderate but not full adherence to the guideline.

Quality of life, caregiver burden and insurance in patients with Parkinson's disease in Germany

BACKGROUND

German health politicians claim that maintenance and thus quality of life (QoL) of patients with chronic disease do not differ between the various healthcare insurance systems in Germany. Patient organizations i.e. the Deutsche Parkinson Vereinigung for patients with Parkinson's disease (PD), physicians, patients themselves and their carers controversially discuss this opinion making by politicians.

METHODS

We performed a survey to analyse the relations between QoL, insurance, disability and caregiver burden in 2603 patients with PD and their carers.

RESULTS

Insurance with private reimbursement provides a significant better self-reported patient disability and QoL according to the various employed rating instruments in patients with PD. Government employees with PD, who have additional private insurance, demand for significant shorter intervals of care giving by their carers. In general, caregiver burden did not significantly differ between patients with PD of the different healthcare insurance systems.

CONCLUSION

At least in Germany, obligatory medical insurance with associated state regulation of health care is inferior to private reimbursement insurance in various domains of QoL.

Treatment of advanced Parkinson's disease in the United States: a cost-utility model

BACKGROUND

As Parkinson's disease (PD) progresses, patients and their families experience substantial health and economic burdens. Because motor fluctuations (also called 'off-time') are linked to poor quality of life and higher healthcare costs, minimizing off-time is an effective strategy for reducing costs associated with PD.

OBJECTIVE

To assess the cost utility of rasagiline or entacapone as adjunctive therapies to levodopa versus levodopa/carbidopa/entacapone (LCE) versus standard levodopa monotherapy in patients with advanced PD and motor fluctuations in the US.

METHODS

A 2-year stochastic Markov model was utilized to examine the cost effectiveness of treatments of advanced PD. The model assumed that patients transition health status every 4 months. Transition probabilities, including uncertainties, were estimated from clinical trial data. Medical costs, daily drug costs and utility weights were obtained from published literature.

RESULTS

Over 2 years, all therapy options showed greater effectiveness than levodopa alone. Rasagiline+levodopa and LCE were cost saving from a payor perspective, while entacapone+levodopa was cost saving from a societal perspective. Mean benefits over 2 years were 0.12 (90% credibility interval [CI] 0.07, 0.18) additional quality-adjusted life-years (QALYs) for rasagiline+levodopa, entacapone+levodopa and LCE, 5.08 (90% CI 3.87, 6.28) additional months with <or=25% off-time for rasagiline+levodopa and 4.85 (90% CI 3.63, 6.06) additional months with <or=25% off-time for entacapone+levodopa and LCE versus levodopa alone.

CONCLUSION

From a payor perspective, rasagiline+levodopa and LCE were dominant therapies over levodopa monotherapy, while entacapone+levodopa was effective at a higher cost. With no additional cost over a 2-year period, rasagiline+levodopa presents a valuable alternative to entacapone+levodopa, LCE and levodopa monotherapy in the treatment of advanced PD patients. Results from this cost-utility model and prior adjunctive clinical data provide ongoing support for the adjunctive use of rasagiline in advanced PD patients with motor fluctuations.

Trends in resource utilization for Parkinson's disease in Germany

OBJECTIVE

The prevalence of Parkinson's disease (PD) and costs of healthcare resources for this disease have been increasing in recent years. The objective was to determine the trends in the resource utilization for PD in Germany.

METHODS AND PATIENTS

We compared resource utilization in two cohorts of PD patients recruited in 2000 (n=145) and 2004 (n=133) from two clinical departments, two office-based neurologists and several general practitioners. Direct and indirect costs were assessed based on a patient diary and structured personal interviews. Clinical status was classified in Hoehn and Yahr (HY) stages. Cost-driving factors were determined using multivariate regression analysis.

RESULTS

In 2004, total annual costs for PD ranged from EUR 18,660 for HY I-II to EUR 31,660 for HY II-V. As compared to costs in 2000, total costs increased in 2004 by 25-31%. Drug costs increased by 14-20% during this time. The largest increase in direct costs was observed in the early disease (HY I-II), primarily due to rising costs for inpatient care and drugs. Motor complications, age, HY stage and study year were independent cost-driving factors.

CONCLUSION

The resource utilization in PD increased rapidly over the four year study period. Increasing consumption of healthcare resources due to medical progress is a major factor of rising costs. Future studies should attend more to trends in the utilization of healthcare resources and identify factors which could slow down the expanding costs of healthcare.

The safety of dopamine agonists in the treatment of Parkinson's disease

Dopamine agonists are highly effective as adjunctive therapy to levodopa in advanced Parkinson's disease. These drugs have rapidly gained popularity as a monotherapy in the early stages of Parkinson's disease for patients < 65-70 years old, because they are about as effective as levodopa, but patients demonstrate a lower tendency to develop motor complications. However, dopamine agonists could have peripheral and central side effects, which are often the reason for the discontinuation of the treatment. This review focuses on the potential negative effects related to the use of dopamine agonists in the treatment of Parkinson's disease.

Entacapone improves complex movement performance in patients with Parkinson’s disease

BACKGROUND

A possible strategy to prolong plasma metabolism of Levodopa/Carbidopa (LD/CD) is Entacapone addition (EN), which improves impaired motor behaviour in patients with Parkinson's disease (PD).

AIMS OF THE STUDY

Objectives were to evaluate the clinical response to an increased dopaminergic substitution with EN by clinical rating and assessment of complex motions and to investigate the change of movement in PD patients during repeat drug administration during an eight hour interval.

METHODS

We used peg insertion with a computer based device and clinical rating for assessment of motor function in 20 treated PD patients. They received LD/CD and then the same LD/CD dosage plus EN in a standardised, open label fashion.

RESULTS

Motor scores and performance of the instrumental task were significantly better and the fluctuation of movement was less intense during the LD/CD/EN condition according to the motor test outcomes.

CONCLUSION

EN supplementation improves motor symptoms and provides a more continuous movement behaviour in PD patients.

Economic burden of Parkinson's disease in a developing country: a retrospective cost analysis in Shanghai, China

We investigated economic costs from patients with Parkinson's disease (PD) in Shanghai, China, which could be used as a baseline for future evaluations. Data were collected from 190 patients by interview during 1-year period. Direct medical care costs averaged approximately Chinese yuan, renminbi (RMB) 4,305 (USD 519, or EUR 410) per year per patient, of which drugs (RMB 2,677) accounted for the major costly component. Nonmedical direct costs were much less than direct health care costs, averaging approximately RMB 3,301 (USD 398, or EUR 314). Costs due to loss of productivity averaged approximately RMB 73 (USD 8.8, or EUR 7.0) per patient per year. Taken together, the overall mean annual cost for PD in our series was approximately RMB 7,679 (USD 925, or EUR 731), and these costs accounted for around half of the mean annual income. Total cost was significantly associated with the disease severity and the frequency of outpatient visits. In addition, levodopa equivalent dose (LED) and the number of drugs being taken were also closely related with the drug cost. The results indicate that the economic burden of Chinese PD patients is heavy.

Prospektive Erfassung der direkten und indirekten Kosten des idiopathischen Parkinson-Syndroms

Idiopathic Parkinson's disease is a chronic progressive neurodegenerative disorder that remains refractory to curative treatment. Most patients are afflicted for many years, and the disease frequently results in severe physical handicap. Statements on the considerable cost of treatment are largely based on estimates and retrospective studies. To obtain more substantial data, we conducted a 3-year study of the economic aspects. Direct and indirect costs incurred by 117 patients (78 male, mean age 67.5 years) at the Deutsche Klinik für Diagnostik in Wiesbaden, Germany, were prospectively followed. The average cost per patient and month ran to <euro> 1007.55. Of that, direct costs amounted to <euro> 603.33 (55.9%), with drugs taking up the major share at <euro> 480.23. Indirect costs were <euro> 404.22 per patient and month, with 76% thereof related to nursing care and the incapacity to earn a living. Cost increased in proportion to Hoehn and Yahr stage, declining again with stages 4 and 5. The data we gathered confirm that Parkinsonism is responsible for sizeable expenses for not only the treating unit but the national economy as a whole.

Pharmacokinetic behaviour of levodopa and 3-O-methyldopa after repeat administration of levodopa/carbidopa with and without entacapone in patients with Parkinson's disease

Addition of the catechol-O-methyltransferase (COMT) inhibitor entacapone (EN) prolongs plasma metabolism of levodopa (LD). Objectives were to determine the clinical response after EN addition and the plasma degradation of LD and 3-O-methyldopa [3-OMD]. Not optimum treated hospitalised patients with Parkinson's disease received the same LD dosage on the first day only with carbidopa (CD) and on the second day with CD and EN (t.i.d.) within a standardised setting. We scored motor symptoms and measured LD- and 3-OMD levels on both days at fixed moments. Motor impairment significant better improved probably due to significant higher maximum concentrations [C(max)] and computed area under the curve values of LD levels during the LD/CD/EN condition. Time to C(max) of LD was significantly delayed after the first two LD/CD/EN intakes. An impact of EN on 3-OMD levels appeared. A possibly augmented LD absorption and a prolonged LD metabolism after EN supplementation may contribute to a more continuous LD delivery to the brain.