Clinical practice of BOTOX® treatment for overactive bladder syndrome in Sweden: an assessment of resource use and external validity

OBJECTIVE

The objective of this study was to assess the resource use of treating overactive bladder (OAB) patients in real-world clinical practice and to evaluate whether there is external validity in the treatment of OAB in clinical practice.

MATERIALS AND METHODS

The study included 55 patients suffering from OAB and treated with BOTOX^® at two Swedish clinics. The study was conducted as an anonymized retrospective chart review study.

RESULTS

The estimated yearly direct cost of BOTOX treatment was €902. The mean age of patients in the study was 60 years, and 85% were women. The severity of OAB before BOTOX treatment, given by the mean number of daily leakages, equalled 4.8. The median interval between treatments was 210 days.

CONCLUSIONS

Patient characteristics in the real world were similar to those in the clinical trials, showing a high degree of external validity. Treatment intervals were longer in the real world than in clinical trials, indicating that treatment cost could be lower when patients are treated as observed in real-world clinical practice.

Regional Differences in the Prescription of Biologics for Psoriasis in Sweden: A Register-Based Study of 4168 Patients

BACKGROUND

Observational studies suggest an inequitable prescription of biologics in psoriasis care, which may be attributed to geographical differences in treatment access. Sweden regularly ranks high in international comparisons of equitable healthcare, and is, in connection with established national registries, an ideal country to investigate potential inequitable access.

OBJECTIVE

The aim was to determine whether the opportunity for patients to receive biologics depends on where they receive care.

METHODS

Biologic-naïve patients enrolled in the Swedish National Register for Systemic Treatment of Psoriasis (PsoReg) from 2008 to 2015 (n = 4168) were included. The association between the likelihood of initiating a biologic and the region where patients received care was analyzed. The strength of the association was adjusted for patient and clinical characteristics, as well as disease severity using logistic regression analysis. The proportion of patients that switched to a biologic (switch rate) and the probability of switch to a biologic was calculated in 2-year periods.

RESULTS

The national switch rate increased marginally over time from 9.7 to 11.0%, though the uptake varied across regions. Adjusted odds ratios for at least one region were significantly different from the reference region in every 2-year period. During the latest period (2014-2015), the average patient in the lowest prescribing region was nearly 2.5 times less likely to switch as a similar patient in the highest prescribing region.

CONCLUSIONS

Geographical differences in biologics prescription persist after adjusting for patient characteristics and disease severity. The Swedish example calls for further improvements in delivering equitable psoriasis care.

From concepts, theory, and evidence of heterogeneity of treatment effects to methodological approaches: a primer

Implicit in the growing interest in patient-centered outcomes research is a growing need for better evidence regarding how responses to a given intervention or treatment may vary across patients, referred to as heterogeneity of treatment effect (HTE). A variety of methods are available for exploring HTE, each associated with unique strengths and limitations. This paper reviews a selected set of methodological approaches to understanding HTE, focusing largely but not exclusively on their uses with randomized trial data. It is oriented for the “intermediate” outcomes researcher, who may already be familiar with some methods, but would value a systematic overview of both more and less familiar methods with attention to when and why they may be used. Drawing from the biomedical, statistical, epidemiological and econometrics literature, we describe the steps involved in choosing an HTE approach, focusing on whether the intent of the analysis is for exploratory, initial testing, or confirmatory testing purposes. We also map HTE methodological approaches to data considerations as well as the strengths and limitations of each approach. Methods reviewed include formal subgroup analysis, meta-analysis and meta-regression, various types of predictive risk modeling including classification and regression tree analysis, series of n-of-1 trials, latent growth and growth mixture models, quantile regression, and selected non-parametric methods. In addition to an overview of each HTE method, examples and references are provided for further reading.

By guiding the selection of the methods and analysis, this review is meant to better enable outcomes researchers to understand and explore aspects of HTE in the context of patient-centered outcomes research.

Considerations in developing model-based economic evaluations of glaucoma treatment

PURPOSE

To facilitate future glaucoma model development and to provide guidance for decision-makers evaluating them, we provide an overview of an innovative glaucoma model and highlight important modeling considerations.

CONSIDERATIONS

The considerations that were addressed include: disease outcome that is both relevant and meaningful to current clinical practice; diversity in treatment options and practices; incorporation of therapy discontinuation; and consideration of the variability in patient response to treatment.

MODEL SCOPE

A state-transition, Monte Carlo simulation model was developed to simulate the management and treatment of patients with glaucoma and/or ocular hypertension. The model examines strategies involving sequential use of up to 6 pharmacologic interventions. Transitions are based on the monthly probability that a patient is no longer "successfully maintained" on therapy, which can be a consequence of lack of intraocular pressure control, adverse events, lack of compliance, or lack of persistence. Outputs of the model include months on each treatment, frequency of therapy switches, days of intraocular pressure control, frequency of ophthalmologist visits, frequency of surgery, and glaucoma-related costs. The model allows the user to specify country-specific treatment strategies, survival on therapy, surgical rates, practice patterns, and costs.

CONCEPT APPLICATION

The model presented offers insights into accommodating patient and clinician variability through the use of persistence distributions. It will facilitate future glaucoma model development and provide insight for decision-makers who must evaluate model-based analyses of the economic value of glaucoma interventions.

Persistency and treatment failure in newly diagnosed open angle glaucoma patients in the United Kingdom

AIM

To determine utilisation patterns and calculate treatment failure and discontinuation rates in patients with open angle glaucoma treated in the United Kingdom with any of six groups of intraocular pressure (IOP) lowering agents.

METHODS

The UK General Practice Research Database was used to identify newly diagnosed (after 1 January 1997) open angle glaucoma patients who were naive to therapy with any of six index drug groups: carbonic anhydrase inhibitors, latanoprost, miotics, sympathomimetics, timolol, and other (non-timolol) beta blockers. Analyses included drug treatment data for 1 year following diagnosis. Outcomes were (1) time to therapy failure, defined as either change in index drug (replacement or addition of therapy) or patient referral for surgery, and (2) time to therapy discontinuation, defined as either therapy failure or no refill of the index drug in a period twice that covered by the first prescription fill. Cox proportional hazard regression and Kaplan-Meier and life table methods were used to compare groups.

RESULTS

Among the 2001 eligible patients, a beta blocker other than timolol was the most widely prescribed (42%), followed by timolol (32%), carbonic anhydrase inhibitors (10%), and latanoprost (7%). Compared to latanoprost, those treated with any alternative agent were significantly more likely to fail (p < or = 0.005 for each comparison) and to discontinue (p < or = 0.05 for each comparison) therapy. Failure rates ranged from 13% (latanoprost) to 45% (sympathomimetics), and discontinuation rates ranged from 30% (latanoprost) to 63% (miotics).

CONCLUSION

Latanoprost treated patients demonstrated lower rates of therapy failure and therapy discontinuation compared with patients treated with other widely used IOP lowering medications, including beta blockers.

Clinical and economic impacts of latanoprost 0.005% in first-line treatment of open-angle glaucoma and ocular hypertension in France

PURPOSE

To assess the cost-effectiveness of treatment strategies that utilize first-line latanoprost compared to those based on initial beta-blocker therapy in patients with open-angle glaucoma (OAG) or ocular hypertension (OH) in France.

METHODS

The study was based on a decision-analytic model that was populated with data from a retrospective chart review. A hypothetical cohort of patients newly diagnosed with OAG and/or OH was assessed over a period of 2 and 3 years. For each treatment strategy 10,000 patients were assumed.

RESULTS

First-line latanoprost therapy was significantly more effective than initial treatment with a beta-blocker, providing more days of intraocular pressure (IOP) control primarily due to its longer time until initial treatment failure. Latanoprost's higher acquisition cost was largely offset by reductions in costs associated with surgical procedures. The additional cost for latanoprost was estimated at approximately 41 Euro and 27 Euro over 2 and 3 years, respectively. The incremental cost per day of IOP control when latanoprost was used as first-line strategy compared to the first-line beta-blocker strategy was 0.82 Euro and 0.36 Euro over 2 and 3 years, respectively.

CONCLUSIONS

These results provide compelling evidence that first-line latanoprost therapy can provide superior clinical outcomes at a small additional cost in actual clinical practice.

A new index approach to measure lost benefits from progression to blindness

OBJECTIVES

An index approach for measuring the reduction in daily activities of patients suffering from an eye disease associated with progressive visual loss is proposed. The approach is illustrated using data collected from patients with cataract.

METHOD

The approach uses recently developed methods based on index theory together with measurements of daily activities. In a simulation based on observations of visual acuity and daily activities in patients with cataract, indexes of changes in benefits were estimated for varying levels of visual acuity.

RESULTS

Results show the development of loss in benefits resulting from a progressive deterioration in visual acuity. The results indicate a 40% loss in benefits at low levels of visual acuity, equivalent to a potential increase in benefits of 75% for these individuals following successful treatment.

CONCLUSIONS

The proposed index approach may prove useful for measuring reductions in daily activities resulting from the progressive loss of vision in eye disease. The approach has successfully measured the reduction in daily activities in patients with cataract and may be applicable in patients with other eye diseases, including age-related macular degeneration and open-angle glaucoma.