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

Treatment Status and Healthcare Cost Trends for Patients with Multiple Sclerosis in Japan: A Claims Database Analysis

Introduction

The healthcare situation of multiple sclerosis (MS) and its course are not being thoroughly investigated in Japan. We aimed to examine the current healthcare situation, including treatment and healthcare costs, of MS according to duration since its first diagnosis using Japanese real-world data to determine unidentified healthcare issues at each disease stage.

Methods

This retrospective, non-comparative, non-interventional study used a Japanese nationwide claims database (April 2008–August 2018) comprising 20 million patients from 329 acute care hospitals (as of June 2018). Treatment patterns, comorbidities, healthcare resource utilization, and healthcare costs were analyzed using longitudinal analyses of patients with MS according to duration since the first diagnosis. The time from diagnosis to first treatment was examined using Kaplan–Meier analysis.

Results

We identified 7067 patients with MS [mean (standard deviation) age at first diagnosis 45.0 (16.2) years]. About 70% of the patients did not receive disease-modifying therapy (DMT) within the first year of diagnosis. The frequency of DMT use decreased in patients with a longer duration since the first diagnosis. MS treatment costs tended to increase with a longer duration from the first diagnosis until 9 years, followed by a tendency to decrease; contrastingly, other healthcare costs tended to increase with duration after decreasing from the year of the first diagnosis to the next year. The frequencies of hospitalizations and hospital visits, healthcare costs—excluding those for MS treatment and tests—and prevalence of comorbidities tended to be higher in patients with a longer duration since the first diagnosis.

Conclusion

A considerable proportion of patients did not receive DMT, suggesting that patients with early-stage MS may lose the opportunity to improve their prognosis through early intervention with DMT. Among patients with a longer duration since the first diagnosis, fewer treatment choices may be available despite the larger clinical and treatment burden.

Supplementary Information

The online version contains supplementary material available at 10.1007/s40120-022-00374-4.

A Principal Component Analysis Approach to Estimate the Disability Status for Patients with Multiple Sclerosis Using Japanese Claims Data

INTRODUCTION

Claims databases are preferred for research on multiple sclerosis (MS) as this condition is characterized by low prevalence and long disease course. However, Japanese claims databases contain no information on disease severity or disability status of MS. Here, we aimed to explore the possibility of utilizing a principal component analysis (PCA) to estimate MS severity using a Japanese claims database.

METHODS

An MS severity score was developed using a PCA. Factors related to functional systems for Expanded Disability Status Scale (EDSS) and higher disease severity (74 diagnoses, 68 drug prescriptions, and 77 procedures) were extracted from the claims database (April 2008-August 2018). The score (PC1 score) was developed for each patient-year-each year from the first diagnosis (excluding the year of the first diagnosis), based on the first principal component of the included factors. Finally, the patient-years were classified into quartiles based on the PC1 score, and demographic information and medical status were analyzed.

RESULTS

The database contained 7067 patients with MS. The highest score group had a higher mean age (55.4 ± 0.2 [mean ± standard error] years), lower percentage of women (64.4 ± 0.7%), and longer mean disease duration from first diagnosis (8.1 ± 0.1 years) than the lowest score group (43.3 ± 0.2 years, 68.4 ± 0.8%, and 6.0 ± 0.1 years, respectively). In addition, the PC1 score of each patient positively correlated with disease duration from diagnosis.

CONCLUSION

We developed a PC1 score to indicate MS severity using information from a Japanese claims database. Since changes in demographic features we observed are consistent with findings of previous research, this score might represent MS severity to some extent. Further research is necessary to validate this score with clinical measurement of disability such as the EDSS.

The Economic and societal burden of multiple sclerosis on lebanese society: a cost-of-illness and quality of life study protocol

This protocol describes the estimation of the societal costs and quality-of-life (QOL) burden of multiple sclerosis (MS) in Lebanon. This cross-sectional, prevalence-based burden-of-illness study was carried out in a premier MS center in Lebanon. We enrolled Lebanese patients aged 18 years and older who had been diagnosed with MS more than 6 months. The study uses a bottom-up approach to estimate the cost-of-illness (COI) and QOL using a retrospective face-to-face interview questionnaire. This resource utilization questionnaire was adapted to the Lebanese context by clinical and health economics experts. The methodologies used to estimate the consumption of healthcare resources, informal care, and productivity losses are well-defined and aligned with the Lebanese healthcare system. Costs are presented overall and by MS severity levels. QOL is measured using the EuroQOL (EQ-5D-5 L) and Multiple Sclerosis International Quality of Life (MusiQoL) instrument. This protocol pioneers in informing the design of future COI and QOL studies in low - and middle-income countries (LMICs), as the methods used could be applied in similar LMICs. Furthermore, we provide recommendations and discuss the challenges of conducting a high-quality burden-of-illness study in LMICs and the steps taken to meet them, using the case of Lebanon.

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.

Exploring the Cost Effectiveness of Shared Decision Making for Choosing between Disease-Modifying Drugs for Relapsing-Remitting Multiple Sclerosis in the Netherlands: A State Transition Model

Background

Up to 31% of patients with relapsing-remitting multiple sclerosis (RRMS) discontinue treatment with disease-modifying drug (DMD) within the first year, and of the patients who do continue, about 40% are nonadherent. Shared decision making may decrease nonadherence and discontinuation rates, but evidence in the context of RRMS is limited. Shared decision making may, however, come at additional costs. This study aimed to explore the potential cost-effectiveness of shared decision making for RRMS in comparison with usual care, from a (limited) societal perspective over a lifetime.

Methods

An exploratory economic evaluation was conducted by adapting a previously developed state transition model that evaluates the cost-effectiveness of a range of DMDs for RRMS in comparison with the best supportive care. Three potential effects of shared decision making were explored: 1) a change in the initial DMD chosen, 2) a decrease in the patient’s discontinuation in using the DMD, and 3) an increase in adherence to the DMD. One-way and probabilistic sensitivity analyses of a scenario that combined the 3 effects were conducted.

Results

Each effect separately and the 3 effects combined resulted in higher quality-adjusted life years (QALYs) and costs due to the increased utilization of DMD. A decrease in discontinuation of DMDs influenced the incremental cost-effectiveness ratio (ICER) most. The combined scenario resulted in an ICER of €17,875 per QALY gained. The ICER was sensitive to changes in several parameters.

Conclusion

This study suggests that shared decision making for DMDs could potentially be cost-effective, especially if shared decision making would help to decrease treatment discontinuation. Our results, however, may depend on the assumed effects on treatment choice, persistence, and adherence, which are actually largely unknown.

Does health-related quality of life differ between people with relapse onset and progressive onset Multiple Sclerosis?

BACKGROUND

Multiple Sclerosis (MS) can be categorised as relapse onset MS (ROMS) and progressive onset MS (PROMS). We aimed to examine if health-related quality of life (in terms of health state utilities [HSUs] and dimensional scores) differed by onset type, in which health dimensions the differences were most pronounced, and whether these differences remained when stratified by disability severity.

METHODS

We estimated HSUs and the unique composite 'super-dimension' and 'individual dimension' scores (crude, age, sex, disease duration and disease modifying therapies use adjusted; and stratified by onset type and disability severity) for a sample of 1577 participants in the Australian MS Longitudinal Study, using the Assessment of Quality of Life (AQoL)-8D.

RESULTS

Adjusted mean overall HSU of PROMS was 0.55, 0.07 lower than ROMS. Adjusted mean physical and psychosocial super-dimension scores for PROMS were 0.51 and 0.28, 0.07 and 0.06 lower than for ROMS, respectively. For the individual health dimensions, the largest difference was seen in independent living (-0.12), followed by relationships (-0.07), and self-worth (-0.07). Whilst HSUs and dimensional scores were negatively associated with increasing disability severity in both onset types, estimates by disability severity did not differ between the two cohorts.

CONCLUSIONS

Our study provides a comprehensive assessment of the effects of MS onset type on the overall and disability-severity specific HRQoL scores using a detailed preferentially sensitive AQoL-8D instrument. While overall HRQoL was substantially lower in PROMS than in ROMS, the mean HRQoL values for each disability level did not differ by onset type, indicating that future health economic models can use the same HSU inputs for both onset types.

Economic Burden of Multiple Sclerosis in Low- and Middle-Income Countries: A Systematic Review

BACKGROUND

Although the economic burden of multiple sclerosis (MS) in high-income countries (HICs) has been extensively studied, information on the costs of MS in low- and middle-income countries (LMICs) remains scarce. Moreover, no review synthesizing and assessing the costs of MS in LMICs has yet been undertaken.

OBJECTIVE

Our objective was to systematically identify and review the cost of illness (COI) of MS in LMICs to critically appraise the methodologies used, compare cost estimates across countries and by level of disease severity, and examine cost drivers.

METHODS

We conducted a systematic literature search for original studies in English, French, and Dutch containing prevalence or incidence-based cost data of MS in LMICs. The search was conducted in MEDLINE (Ovid), PubMed, Embase (Ovid), Cochrane Library, National Health Service Economic Evaluation Database (NHS EED), Econlit, and CINAHL (EBSCO) on July 2020 without restrictions on publication date. Recommended and validated methods were used for data extraction and analysis to make the results of the COI studies comparable. Costs were adjusted to $US, year 2019 values, using the World Bank purchasing power parity and inflated using the consumer price index.

RESULTS

A total of 14 studies were identified, all of which were conducted in upper-middle-income economies. Eight studies used a bottom-up approach for costing, and six used a top-down approach. Four studies used a societal perspective. The total annual cost per patient ranged between $US463 and 58,616. Costs varied across studies and countries, mainly because of differences regarding the inclusion of costs of disease-modifying therapies (DMTs), the range of cost items included, the methodological choices such as approaches used to estimate healthcare resource consumption, and the inclusion of informal care and productivity losses. Characteristics and methodologies of the included studies varied considerably, especially regarding the perspective adopted, cost data specification, and reporting of costs per severity levels. The total costs increased with greater disease severity. The cost ratios between different levels of MS severity within studies were relatively stable; costs were around 1-1.5 times higher for moderate versus mild MS and about two times higher for severe versus mild MS. MS drug costs were the main cost driver for less severe MS, whereas the proportion of direct non-medical costs and indirect costs increased with greater disease severity.

CONCLUSION

MS places a huge economic burden on healthcare systems and societies in LMICs. Methodological differences and substantial variations in terms of absolute costs were found between studies, which made comparison of studies challenging. However, the cost ratios across different levels of MS severity were similar, making comparisons between studies by disease severity feasible. Cost drivers were mainly DMTs and relapse treatments, and this was consistent across studies. Yet, the distribution of cost components varied with disease severity.

Annual Cost Burden by Level of Relapse Severity in Patients with Multiple Sclerosis

Introduction

The severity of relapses varies in multiple sclerosis (MS) and may lead to a differential cost burden. This study aimed to characterize the direct healthcare costs associated with relapses in patients with MS by the level of relapse severity.

Methods

This retrospective analysis used claims data extracted from the MarketScan^® Databases from January 1, 2013 to March 31, 2017 (study period January 1, 2012 to March 31, 2018). Adult patients with at least one diagnosis of MS and 12 months of continuous enrollment prior to the first MS diagnosis to 12 months after the index date were included. On the basis of the severity of the relapse, patients were stratified into three cohorts: severe relapse (SR), mild/moderate relapse (MMR), and no relapse (NR). All-cause and MS-related costs were analyzed during the 12-month follow-up period. Group differences were assessed using descriptive and multivariate statistical analyses.

Results

In total, 8775 patients with MS were analyzed: 6341 (72%) in the NR cohort, 1929 (22%) in the MMR cohort, and 505 (6%) in the SR cohort. Overall, patients were mostly female (76%), mean age was 50 years, and 25% were on a disease-modifying therapy. Mean (standard deviation [SD]) all-cause and MS-related costs among patients with a relapse were higher vs patients without a relapse (all-cause $66,489 [$56,264] vs $41,494 [$48,417]; MS-related $48,700 [$43,364] vs $24,730 [$33,821]). Among patients with a relapse, the mean (SD) all-cause costs were $87,979 [$65,991] vs $60,863 [$51,998] and MS-related costs were $69,586 ($51,187) vs $43,233 [$39,292] for patients in the SR vs MMR cohorts, respectively. A similar trend for increase in cost by relapse severity was observed in the adjusted analysis.

Conclusion

Total annual all-cause and MS-related costs increased with severity of the relapses. High-efficacy treatments might reduce the severity of the relapses, thereby reducing the cost of care in patients with MS.

Factors associated with the healthcare expenditures of patients with multiple sclerosis in urban areas of China estimated by a generalized estimating equation

Background: Multiple sclerosis (MS) has a significant healthcare burden. This study examined the medical cost and out-of-pocket (OOP) expenses, and quantified the impact factors contributing to the costs. Methods: This is a retrospective study in 77 Chinese urban cites from 2013 to 2015. The data included the details of the utilization of medical resources, cost, and reimbursement ratio of all patients with a diagnosis of MS. A generalized estimating equation model was used to estimate the factors influencing the direct medical cost and OOP expenses for in- and outpatients. Results: A total of 267 patients with MS were identified. The mean cost per in- and outpatient was respectively 16996.2 and 2294.2 renminbi ($2768.12 and $373.65, €2087.16 and €281.73). Approximately 27% of the expenses were paid by the patients OOP. Factors contributing to high cost and high OOP expenses for inpatients were tertiary hospital admission, length of stay and residence in the east regions of China. Females and outpatients with resident insurance paid more OOP. Conclusion: This study illustrates the medical costs and burden of MS in Chinese patients and provides real-world data on MS that are essential for the improvement of health policies.

Impact of multiple sclerosis phenotypes on burden of disease in Finland

Aims: The aim of this study was to quantify how multiple sclerosis (MS) phenotypes differ from each other in respect of costs and quality-of-life.Materials and methods: The study is based on survey data from Finnish patients with MS (n = 553). The information contained disease type, disease severity according to self-reported Expanded Disease Severity Scale (EDSS), healthcare resource use, and medication use. In addition, information related to employment and early retirement was collected. EQ-5D-VAS and Multiple Sclerosis Impact Scale-29 (MSIS-29) instruments were used to collect quality-of-life data, and Fatigue Severity Scale (FSS) instrument for evaluating fatigue. Patients were stratified based on their disease type (relapsing-remitting MS (RRMS), secondary progressive MS (SPMS), primary progressive MS (PPMS)) and disease severity. The data were primarily analyzed using summary statistics.Results: SPMS had the highest annual total cost (71,177€) followed by PPMS (51,082€) and RRMS (36,492€). Early retirement covered the greatest share of costs in RRMS (39%) and SPMS (43%). In PPMS, early retirement and professional care were the two most equally important cost drivers, contributing together 56% of the total costs. Direct healthcare costs were responsible for 33%, 19%, and 18% of total costs in RRMS, SPMS, and PPMS. The mean EDSS in RRMS, SPMS, and PPMS were 2.5, 5.5, and 5.9, respectively. Differences in the quality-of-life were observed with both disease specific (MSIS-29) and generic (EQ-5D-VAS) instruments. The mean utility value from EQ-5D among patients with RRMS, SPMS, and PPMS was 0.76, 0.52, and 0.49, respectively. In addition, patients with SPMS and PPMS were more likely to report fatigue than patients with RRMS.Conclusions: MS phenotype has an impact on costs and quality-of-life of the patients. Early retirement seems to be one of the most important contributors to MS-related costs.

Cost Effectiveness of Cladribine Tablets for the Treatment of Relapsing-Remitting Multiple Sclerosis in The Netherlands

BACKGROUND

Cladribine tablets have recently become available in The Netherlands for patients with relapsing-remitting multiple sclerosis (RRMS) as a disease-modifying agent that reduces the frequency and severity of relapses and delays disability progression.

OBJECTIVE

The aim of this study was to evaluate the cost effectiveness of cladribine tablets, compared with alternative options, in the treatment of RRMS patients with high disease activity (HDA) and patients with rapidly evolving severe (RES) MS in The Netherlands.

METHODS

A Markov model was developed simulating the costs and effects of RRMS treatment. For HDA, alemtuzumab and fingolimod were used as comparators; natalizumab was used for the RES subpopulation. The analysis included a societal perspective and a value-of-information (VOI) analysis.

RESULTS

For the HDA subpopulation, treatment with cladribine tablets was the cost-effective (dominant) strategy compared with alemtuzumab and fingolimod, with 50.9% and 98.2%, respectively, probability of being cost effective at a threshold of €50,000/QALY gained and a net monetary benefit (NMB) of €10,866 and €151,115, respectively. For the RES subpopulation, treatment with cladribine tablets dominated treatment with natalizumab, with 94.1% probability of being cost effective at a threshold of €50,000/QALY gained and an NMB of €122,986. Note that these outcomes are driven by the lower costs of cladribine tablets. Efficacy differences were small, very uncertain, and likely not clinically meaningful. The probabilistic sensitivity analyses showed significant overlap in the credible intervals for total lifetime QALY outcomes and costs of cladribine tablets and all relevant comparators. The population-level VOI amounted to €19,295,441.

CONCLUSIONS

The base-case analysis shows that treatment of RRMS with cladribine tablets is cost effective versus alemtuzumab and fingolimod in HDA patients, and cost effective versus natalizumab in RES patients, at a threshold of €50,000. Driven by the lower costs, cladribine tablets were cost effective (dominant) in all base-case analyses. However, given that outcomes are based on indirect comparisons and post hoc subgroup analysis, as well as the uncertainty surrounding the outcomes, the results presented in this paper should be interpreted with caution.

Burden of relapsing-remitting multiple sclerosis on workers in the US: a cross-sectional analysis of survey data

Background

Multiple sclerosis (MS) is prevalent among working age individuals (20–60 years), leading to high burden on work productivity. Few data are available about the absenteeism and presenteeism in employed individuals with MS in comparison to non-MS personnel. This study aimed to quantify the burden of illness of employed US adults with relapsing-remitting multiple sclerosis (RRMS) and examine burden by levels of work impairment.

Methods

A retrospective cross-sectional analysis was conducted using patient-reported responses from the US National Health and Wellness Survey (NHWS). Data from NHWS 2015–2016 were analyzed from 196 employed RRMS respondents who were matched 1:4 to employed respondents without MS based on demographic and general health characteristics. Demographic and general health characteristics for employed RRMS individuals were analyzed by levels of work impairment (none, 1–30%; 31–68%; 69–100%). Work productivity (absenteeism, presenteeism, and work impairment), decrements in health-related quality of life (HRQoL) (short form-36, EQ-5D), and healthcare resource utilization (HCRU) were compared to determine the burden of RRMS.

Results

After propensity score matching, the levels of absenteeism and presenteeism were 2 and 1.8 times higher in the employed RRMS population than the employed non-MS population, respectively (P < 0.001 for both). HRQoL was significantly lower in employed respondents with RRMS than those without MS (P < 0.001 for all). Employed respondents with RRMS had significantly more HCRU over 6 months compared to those without MS (P < 0.001). Furthermore, among employed RRMS respondents, greater levels of impairment were associated with increasing disease severity, greater healthcare resource use, fatigue, and cognitive impairment and inversely associated with mental and physical HRQoL (P < 0.0001 for all).

Conclusions

Among employed individuals, respondents with RRMS had lower, work productivity, HRQoL, and higher HCRU as compared with those without MS. Given the large impact RRMS has on work impairment, a need exists to manage individuals on therapies that improve HRQoL, reduce symptoms, and improve their ability to perform in the workforce.

Cost-minimization analysis of alemtuzumab compared to fingolimod and natalizumab for the treatment of active relapsing-remitting multiple sclerosis in the Netherlands

AIM

In active relapsing remitting multiple sclerosis (RRMS) patients requiring second-line treatment, the Dutch National Health Care Institute (ZiN) has not stated a preference for either alemtuzumab, fingolimod, or natalizumab. The aim was to give healthcare decision-makers insight into the differences in cost accumulation over time between alemtuzumab-with a unique, non-continuous treatment schedule-and fingolimod and natalizumab for second-line treatment of active RRMS patients in the Netherlands.

METHODS

In line with ZiN's assessment, a cost-minimization analysis was performed from a Dutch healthcare perspective over a 5-year time horizon. Resource use was derived from hospital protocols and summaries of product characteristics, and validated by two MS specialists. Unit costs were based on national tariffs and guidelines. Robustness of the base case results was verified with multiple sensitivity and scenario analyses.

RESULTS

Alemtuzumab results in cost savings compared to fingolimod and natalizumab from, respectively, 3.3 and 2.8 years since treatment initiation onwards. At 5 years, total discounted costs per patient of alemtuzumab were €79,717, followed by fingolimod with €110,044 and natalizumab with €122,238, resulting in cost savings of €30,327 and €42,522 for alemtuzumab compared to fingolimod and natalizumab, respectively. Key drivers of the model are drug acquisition costs and the proportions of patients that do not require further alemtuzumab treatment after either two, three, or four courses.

LIMITATIONS

No treatment discontinuation and associated switching between treatments were incorporated. Consequences of JC virus seropositivity while continuing natalizumab treatment (e.g. additional monitoring) were omitted from the base case.

CONCLUSION

The current cost-minimization analysis demonstrates that, from the Dutch healthcare perspective, treating active RRMS patients with alemtuzumab results in cost savings compared to second-line alternatives fingolimod and natalizumab from ∼3 years since treatment initiation onwards. After 5 years, alemtuzumab's cost savings are estimated at €30k compared to fingolimod and €43k compared to natalizumab.

Healthcare utilization and costs of multiple sclerosis patients in the Netherlands: a healthcare claims database study

AIM

To investigate the incidence and prevalence and healthcare costs of multiple sclerosis (MS) in the Netherlands by using healthcare claims data.

MATERIALS & METHODS

A claims database was analyzed including 26% of the Dutch population.

RESULTS

Average prevalence of MS in the Netherlands was 88 per 100,000 inhabitants (males 48, 127 females) and incidence nine per 100,000. Yearly per patient medication costs were highest in the year after the first MS claim and then decreased. Hospital costs were 30% higher in the first year of MS claims than after 3 years of MS claims. The patients often used co-medication, such as antidepressants and antibiotics.

CONCLUSION

Dutch incidence and cost estimates based on claims were consistent with previous estimates. Prevalence estimates were somewhat higher. Drug and hospital costs were highest shortly after the diagnosis. Healthcare consumption related to comorbidities was in-line with the previously reported comorbidity estimates.

Predictors of the 10-year direct costs for treating multiple sclerosis

OBJECTIVES

Disease-modifying treatments (DMTs) constitute the largest direct medical cost for multiple sclerosis (MS). This study aims at investigating predictors of the 10-year economic burden for DMT administration and management.

MATERIALS AND METHODS

This study included 537 newly diagnosed, drug naïve relapsing-remitting MS (RRMS) patients, followed up for 10.1±3.3 years. Costs for DMT administration and management were calculated, and referred to each year of observation (annual costs). Possible predictors of disease evolution were categorized into early predictors (age, gender, disease duration, baseline expanded disability status scale (EDSS), 1-point EDSS progression within 2 years, and annualized relapse rate -ARR- within 2 years), and long-term predictors (reaching of EDSS 4.0, conversion to secondary progressive -SP-, ARR, number of DMTs, follow-up duration). Association between predictors and study outcome was explored using mixed-effects log-linear regression models.

RESULTS

A 1-point higher EDSS at diagnosis was associated with 13.21% increase in the annual costs (95%CI=4.16-23.04%). Each additional year of age at diagnosis was associated with a 0.74% decrease in the annual costs (95%CI=-1.43 to-0.04%). Female gender was associated with a 12.43% decrease in the annual costs (95%CI=-22.61 to-0.93%). Converting to SP was associated with a 14.26% decrease in the annual costs (95%CI=-14.26 to-2.94%). Each additional year of follow-up was associated with a 3.05% decrease in the annual costs (95%CI=-4.51 to-1.57%).

CONCLUSIONS

An estimate of the 10-year costs associated with DMT administration and management can be calculated by analyzing different factors, and might be of particular interest for planning resources needed for treating people with MS.

Cost-utility of First-line Disease-modifying Treatments for Relapsing-Remitting Multiple Sclerosis

PURPOSE

This study evaluated the cost-effectiveness of first-line treatments of relapsing-remitting multiple sclerosis (RRMS) (dimethyl fumarate [DMF] 240 mg PO BID, teriflunomide 14 mg once daily, glatiramer acetate 20 mg SC once daily, interferon [IFN]-β1a 44 µg TIW, IFN-β1b 250 µg EOD, and IFN-β1a 30 µg IM QW) and best supportive care (BSC) in the health care payer setting in Finland.

METHODS

The primary outcome was the modeled incremental cost-effectiveness ratio (ICER; €/quality-adjusted life-year [QALY] gained, 3%/y discounting). Markov cohort modeling with a 15-year time horizon was employed. During each 1-year modeling cycle, patients either maintained the Expanded Disability Status Scale (EDSS) score or experienced progression, developed secondary progressive MS (SPMS) or showed EDSS progression in SPMS, experienced relapse with/without hospitalization, experienced an adverse event (AE), or died. Patients׳ characteristics, RRMS progression probabilities, and standardized mortality ratios were derived from a registry of patients with MS in Finland. A mixed-treatment comparison (MTC) informed the treatment effects. Finnish EuroQol Five-Dimensional Questionnaire, Three-Level Version quality-of-life and direct-cost estimates associated with EDSS scores, relapses, and AEs were applied. Four approaches were used to assess the outcomes: cost-effectiveness plane and efficiency frontiers (relative value of efficient treatments); cost-effectiveness acceptability frontier, which demonstrated optimal treatment to maximize net benefit; Bayesian treatment ranking (BTR); and an impact investment assessment (IIA; a cost-benefit assessment), which increased the clinical interpretation and appeal of modeled outcomes in terms of absolute benefit gained with fixed drug-related budget. Robustness of results was tested extensively with sensitivity analyses.

FINDINGS

Based on the modeled results, teriflunomide was less costly, with greater QALYs, versus glatiramer acetate and the IFNs. Teriflunomide had the lowest ICER (24,081) versus BSC. DMF brought marginally more QALYs (0.089) than did teriflunomide, with greater costs over the 15 years. The ICER for DMF versus teriflunomide was 75,431. Teriflunomide had >50% cost-effectiveness probabilities with a willingness-to-pay threshold of <€77,416/QALY gained. According to BTR, teriflunomide was first-best among the disease-modifying therapies, with potential willingness-to-pay thresholds of up to €68,000/QALY gained. In the IIA, teriflunomide was associated with the longest incremental quality-adjusted survival and time without cane use. Generally, primary outcomes results were robust, based on the sensitivity analyses. The results were sensitive only to large changes in analysis perspective or mixed-treatment comparison.

IMPLICATIONS

The results were sensitive only to large changes in analysis perspective or MTC. Based on the analyses, teriflunomide was cost-effective versus BSC or DMF with the common threshold values, was dominant versus other first-line RRMS treatments, and provided the greatest impact on investment. Teriflunomide is potentially the most cost-effective option among first-line treatments of RRMS in Finland.

Healthcare Costs for Treating Relapsing Multiple Sclerosis and the Risk of Progression: A Retrospective Italian Cohort Study from 2001 to 2015

BACKGROUND

Disease modifying treatments (DMTs) are the main responsible for direct medical costs in multiple sclerosis (MS). The current investigation aims at evaluating possible associations between healthcare costs for treating relapsing remitting MS (RRMS) and disease evolution.

METHODS

The present cohort study retrospectively included 544 newly diagnosed RRMS patients, prospectively followed up for 10.1±3.3 years. Costs for DMT administration and management were calculated for each year of observation. Following clinical endpoints were recorded: time to first relapse, 1-point EDSS progression, reaching of EDSS 4.0, reaching of EDSS 6.0, and conversion to secondary progressive MS (SP). Covariates for statistical analyses were age, gender, disease duration and EDSS at diagnosis.

RESULTS

At time varying Cox regression models, 10% increase in annual healthcare costs was associated with 1.1% reduction in 1-point EDSS progression (HR = 0.897; p = 0.018), with 0.7% reduction in reaching EDSS 6.0 (HR = 0.925; p = 0.030), and with 1.0% reduction in SP conversion (HR = 0.902; p = 0.006).

CONCLUSION

Higher healthcare costs for treating MS have been associated with a milder disease evolution after 10 years, with possible reduction of long-term non-medical direct and indirect costs.

The impact of multiple sclerosis severity on health state utility values: Evidence from Australia

Background:

The measurement of health state utility values (HSUVs) for a representative sample of Australian people with multiple sclerosis (MS) has not previously been performed.

Objectives:

Our main aim was to quantify the HSUVs for different levels of disease severities in Australian people with MS.

Method:

HSUVs were calculated by employing a ‘judgement-based’ method that essentially creates EQ-5D-3L profiles based on WHOQOL-100 responses and then applying utility weights to each level in each dimension. A stepwise linear regression was used to evaluate the relationship between HSUVs and disease severity, classified as mild (Expanded Disability Status Scale (EDSS) levels: 0–3.5), moderate (EDSS levels: 4–6) and severe (EDSS levels: 6.5–9.5).

Results:

Mean HSUV for all people with MS was 0.53 (95% confidence interval (CI): 0.52–0.54). Utility decreased with increasing disease severity: 0.61 (95% CI: 0.60–0.62), 0.51 (95% CI: 0.50–0.52) and 0.40 (95% CI: 0.38–0.43) for mild, moderate and severe disease, respectively. Adjusted differences in mean HSUV between the three severity groups were statistically significant.

Conclusion:

For the first time in Australia, we have quantified the impact of increasing severity of MS on health utility of people with MS. The HSUVs we have generated will be useful in further health economic analyses of interventions that slow progression of MS.

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.

Burden of illness in multiple sclerosis (DEFENSE) study: the costs and quality-of-life of Finnish patients with multiple sclerosis

OBJECTIVE

Although multiple sclerosis (MS) is one of the most common causes of non-traumatic disability among young adults, no published data on its economic and health-related quality-of-life (HRQoL) burden is available from Finland. The DEFENSE study aimed to estimate the costs and HRQoL of patients with MS (PwMS) in Finland and explore how these variables are influenced by disease severity and relapses.

METHODS

Overall, 553 PwMS registered with the Finnish Neuro Society, a national patient association in Finland, completed a self-administered questionnaire capturing information on demographics, disease characteristics and severity (Expanded Disease Severity Scale [EDSS]), relapses, resource consumption and HRQoL.

RESULTS

The PwMS had a mean EDSS score of 4.0. Overall, 44.1% had relapsing-remitting form of the disease (RRMS). The mean age was 53.8 years and 55.7% had retired prematurely due to MS. Disease-modifying therapies (DMTs) were used by 42.7% of the study population, and 21.5% across all disease types and severities had experienced relapses during the previous year. The mean total annual cost of MS was €46,994, which increased with advancing disease from €10,835 (EDSS score = 0) to €109,901 (EDSS score = 8-9). The mean utility was 0.644. HRQoL decreased with increasing disease severity. Relapses imposed an additional utility decrement among the PwMS with RRMS and EDSS ≤5 and had a trend-like effect on total costs.

LIMITATIONS

The cross-sectional setting did not allow assessment of the significance of relapses in early MS or the use of DMTs on the prognosis of the disease.

CONCLUSION

The study confirms previous findings from other countries regarding a significant disease burden associated with MS and provides, for the first time, published numerical estimates from Finland. Treatments that slow disease progression and help PwMS retain employment for a longer duration have the highest potential to reduce the disease burden associated with MS.

Determinants of physical activity in minimally impaired people with multiple sclerosis

OBJECTIVE

Despite the commonly known benefits of physical activity, evidence shows that people with multiple sclerosis (pwMS) are relatively inactive. There are several studies about factors affecting physical activity in pwMS. However, these factors have not investigated in minimally impaired pwMS who do not have remarkable symptoms and walking disturbance. The objective was to determine factors affecting physical activity in minimally impaired pwMS.

PATIENTS AND METHODS

We recruited 52 minimally impaired pwMS and measured physical activity with Godin Leisure-Time Exercise Questionnaire (GLTEQ) and an accelerometer used for the 7-day period. Demographic data were recorded. Walking (speed, endurance, dexterity, and quality), fatigue, depression, and quality of life were measured.

METHODS

We recruited 52 minimally impaired pwMS and measured physical activity with Godin Leisure-Time Exercise Questionnaire (GLTEQ) and an accelerometer used for the 7-day period. Demographic data were recorded. Walking (speed, endurance, dexterity, and quality), fatigue, depression, and quality of life were measured.

RESULTS

The walking speed assessed by the Timed 25-Foot Walk and gender were found the determinants of physical activity level assessed by the GLTEQ and accelerometer, respectively. Walking (speed, endurance, and dexterity), gender, employment status, and quality of life were associated with physical activity. Either female or unemployed participants had significantly less physical activity. There were no significant difference between physical activity levels and the other subgroups.

CONCLUSION

Either to be a female or to have slower walking speed was associated with less physical activity. Strategies to improve walking should be focused on female pwMS with minimal impairment.

Dimethyl fumarate for multiple sclerosis

BACKGROUND

Multiple sclerosis (MS) often leads to severe neurological disability and a serious decline in quality of life. The ideal target of disease-modifying therapy for MS is to prevent disability worsening and improve quality of life. Dimethyl fumarate is considered to have an immunomodulatory activity and neuroprotective effect. It has been approved by the U.S. Food and Drug Administration (FDA) and the European Medicines Agency as a first-line therapy for adult patients with relapsing-remitting MS (RMSS).

OBJECTIVES

To assess the benefit and safety of dimethyl fumarate as monotherapy or combination therapy versus placebo or other approved disease-modifying drugs (interferon beta, glatiramer acetate, natalizumab, mitoxantrone, fingolimod, teriflunomide, alemtuzumab) for patients with MS. 

SEARCH METHODS

The Trials Search Co-ordinator searched the Trials Specialised Register of the Cochrane Multiple Sclerosis and Rare Diseases of the Central Nervous System Group (4 June 2014). We checked reference lists of published reviews and retrieved articles and searched reports (2004 to June 2014) from the MS societies in Europe and America. We also communicated with investigators participating in trials of dimethyl fumarate and the Biogen Idec Medical Information.

SELECTION CRITERIA

We included randomised, controlled, parallel-group clinical trials (RCTs) with a length of follow-up equal to or greater than one year evaluating dimethyl fumarate, as monotherapy or combination therapy, versus placebo or other approved disease-modifying drugs for patients with MS without restrictions regarding dosage, administration frequency and duration of treatment.

DATA COLLECTION AND ANALYSIS

We used the standard methodological procedures of The Cochrane Collaboration. Two review authors independently assessed trial quality and extracted data. Disagreements were discussed and resolved by consensus among the review authors. We contacted the principal investigators of included studies for additional data or confirmation of data.

MAIN RESULTS

Two RCTs were included, involving 2667 adult patients with RRMS to evaluate the efficacy and safety of two dosages of dimethyl fumarate (240 mg orally three times daily or twice daily) by direct comparison with placebo for two years. Among them, a subsample of 1221 (45.8%) patients were selected to participate in MRI evaluations by each study site with MRI capabilities itself. No powered head-to-head study with an active treatment comparator has been found. Meta-analyses showed that dimethyl fumarate both three times daily and twice daily reduced the number of patients with a relapse (risk ratio (RR) 0.57, 95% confidence interval (CI) 0.50 to 0.66, P < 0.00001 and 0.64, 95% CI 0.54 to 0.77, P < 0.00001, respectively) or disability worsening (RR 0.70, 95% CI 0.57 to 0.87, P = 0.0009 and 0.65, 95% CI 0.53 to 0.81, P = 0.0001, respectively) over two years, compared to placebo. The treatment effects were decreased in the likely-case scenario analyses taking the effect of dropouts into consideration. Both dosages also reduced the annualised relapse rate. Data of active lesions on MRI scans were not combined because there was a high risk of selection bias for MRI outcomes and imprecision of MRI data in both studies, as well as an obvious heterogeneity between the studies. In terms of safety profile, both dosages increased the risk for adverse events and the risk for drug discontinuation due to adverse events. The most common adverse events included flushing and gastrointestinal events (upper abdominal pain, nausea and diarrhoea). Uncommon adverse events included lymphopenia and leukopenia, but they were more likely to happen with dimethyl fumarate than with placebo (high dosage: RR 5.25, 95% CI 2.20 to 12.51, P = 0.0002 and 5.23, 95% CI 2.47 to 11.07, P < 0.0001, respectively; low dosage: RR 5.69, 95% CI 2.40 to 13.46, P < 0.0001 and 6.53, 95% CI 3.13 to 13.64, P < 0.00001, respectively). Both studies had a high attrition bias resulting from the unbalanced reasons for dropouts among groups. Quality of evidence for relapse outcome was moderate, but for disability worsening was low.

AUTHORS' CONCLUSIONS

There is moderate-quality evidence to support that dimethyl fumarate at a dose of 240 mg orally three times daily or twice daily reduces both the number of patients with a relapse and the annualised relapse rate over two years of treatment in comparison with placebo. However, the quality of the evidence to support the benefit in reducing the number of patients with disability worsening is low. There is no high-quality data available to evaluate the benefit on MRI outcomes. The common adverse effects such as flushing and gastrointestinal events are mild-to-moderate for most patients. Lymphopenia and leukopenia are uncommon adverse events but significantly associated with dimethyl fumarate. Both dosages of dimethyl fumarate have similar benefit and safety profile, which supports the option of low-dose administration. New studies of high quality and long-term follow-up are needed to evaluate the benefit of dimethyl fumarate on prevention of disability worsening and to observe the long-term adverse effects including progressive multifocal leukoencephalopathy.

Unmet education, psychological and peer support needs of people with multiple sclerosis

OBJECTIVE

Multiple sclerosis is a complex neurological disease which can cause impairment in a range of aspects of an individual's life. It often requires a degree of adjustment and peer support. The aim of the present study was to examine satisfaction with educational, psychological and peer support services of people with MS across gender, age and symptom severity.

METHOD

Participants completed a needs analysis questionnaire using Likert scales to determine the level of satisfaction with the support services. The questionnaire was sent to participants (n=3502) throughout Australia as paper copy with reply paid envelope, or made available to them online via email links. A total of 2805 responded and completed the questionnaire (80% response rate). Of those, 79% were female and 21% were male. The participants ranged in age from 19 to 92 years, (M=52.10; SD=11.82).

RESULTS

In terms of psychological services, females were less satisfied with their access to relationship and family counseling. There was also a clear need for more varieties in peer support groups, times, as well as modes of communication, especially among young people and mildly affected groups. Symptom severity was associated with a greater need for almost all education and psychological support services.

CONCLUSION

The findings of this study highlight current areas of unmet needs and may be used to inform the design and development of future education, psychological and social support services to ensure they are relevant and useful, as well as providing direction for future research.

Direct and indirect economic consequences of multiple sclerosis in Ireland

INTRODUCTION

Multiple sclerosis (MS) has significant financial consequences for healthcare systems, individual patients and households, and the wider society. This study examines the distribution of MS costs and resource utilisation across cost categories and from various perspectives, as MS disability increases.

METHODS

Two hundred and fourteen patients with MS were recruited from a specialist MS outpatient clinic in Ireland and included in an interview-based study on MS-related healthcare resource consumption and costs. Patients were grouped into three categories based on disability: mild [Expanded Disability Status Scale (EDSS) score 0-3.5, n = 114], moderate (EDSS 4.0-6.5, n = 72) and severe (EDSS 7.0-9.5, n = 27). The mean annual direct and indirect costs (in year 2012 values) were estimated using non-parametric bootstrapping.

RESULTS

Participants were 66.4 % female, with a mean age of 47.6 years and a mean EDSS score of 3.6. The majority had relapsing-remitting MS (RRMS) (53 %). The mean annual direct (indirect) costs per person were €10,249 (€9,447), €13,045 (€31,806) and €56,528 (€39,440) in mild, moderate and severe MS, respectively. Direct costs are driven by the cost of disease-modifying therapies and professional home help in mild and severe MS, respectively. Between 74 % (severe MS) and 96 % (mild MS) of all direct costs are borne by the healthcare payer, the remainder being incurred by patients, their families or other non-healthcare organisations.

CONCLUSIONS

MS is associated with high levels of healthcare resource consumption and costs, and these costs increase with increasing disability. There is potential to significantly reduce the economic burden of MS through interventions that prevent progression from mild or moderate MS to severe MS, help support independent living at home and keep people with MS in the work force.