Examining patient preferences in the treatment of rheumatoid arthritis using a discrete-choice approach

Background: Biological disease-modifying antirheumatic drugs (bDMARDs) used in second-line treatment of rheumatoid arthritis (RA) are administered parenterally. However, so-called targeted synthetic DMARDs (tsDMARDs) – developed more recently – offer alternative (ie, oral) administration forms in second-line treatment. Since bDMARDs and tsDMARDs can be regarded as equal in terms of efficacy, the present study examines whether such characteristics as route of administration drive RA patients’ treatment choice. This may ultimately suggest superiority of some second-line DMARDs over equally effective options, at least according to RA-patient preferences. Objective: The current study assessed the importance of oral administration among other treatment characteristics differing between available second-line DMARDs for RA patients’ preferences using a discrete-choice experiment (DCE). Materials and methods: The DCE involved scenarios of three hypothetical treatment options in a d-efficient design with varying levels of key attributes (route and frequency of administration, time till onset of drug effect, combination therapy, possible side effects), as defined by focus groups. Further patient characteristics were recorded by an accompanying questionnaire. In the DCE, patients were asked to choose best and worst options (best–worst scaling). Results were analyzed by count analysis and adjusted regression analysis. Results: A total of 1,588 subjects completed the DCE and were eligible for final analyses. Across all characteristics included in the DCE, “oral administration” was most desired and “intravenous infusion” was most strongly rejected. This was followed by “no combination with methotrexate” being strongly preferred and “intake every 1–2 weeks” being strongly rejected. On average, levels of route of administration showed strongest influences on patients’ decisions in post hoc bootstrapping analysis. Conclusion: According to the results, an oral DMARD that does not have to be combined with methotrexate and is not administered (only) every 1–2 weeks appears a highly favorable treatment option for patients with RA. DMARDs meeting these preferences may increase compliance and adherence in RA treatment

Treatment of Atopic Dermatitis and Impact on Quality of Life: A Review with Emphasis on Topical Non-Corticosteroids

Atopic dermatitis (AD) is a chronic skin disease with increasing prevalence and rising costs. Stigmatisation and pruritus are only some aspects of potential quality-of-life (QOL) impairments. AD is not curable and repeated treatments are often necessary. At present, treatment with topically-applied corticosteroids is state-of-the-art for mild to moderate flare-ups. However, many patients are worried about the use of corticosteroids due to the widespread fear of adverse effects. In this review the present literature is analysed concerning impact on quality of life for topically-applicable alternatives to the state-of-the-art treatment. For comparison reasons, data from other treatment modalities are additionally given. Characteristics of studies were analysed using `general' (year and mode of publication, type and aim of study, number of patients, and clinical measurement) and `QOL specific' criteria (type and number of QOL measurements including relevance for study aim and age group, validation in used language, sensitivity to change, and improvement at end of study). QOL data are published only in the minority of studies evaluating treatment efficacy and do not cover the variety of possible therapies. Data are available for tacrolimus, pimecrolimus, UVA/UVB combination and UVB narrowband (topical non-corticosteroidal treatments), as well as for topical corticosteroids, cyclosporin, and inpatient treatment. All studies provided a marked improvement in quality of life after therapy. One study assessed quality of life after a treatment-free follow-up period obtaining a clear increase in impact on quality of life. Since studies used different QOL measurements and vary in inclusion criteria, treatment schedules and presentation of results, a comparison of QOL improvement is not recommended. A single randomised study compared topically applied non-corticosteroidal treatment (UVA/UVB combination) with another treatment modality (cyclosporin) and found no difference in QOL improvement. At present, there is a clear lack of controlled randomised studies evaluating different active treatment modalities and their impact on quality of life. Consensus meetings are desirable to formulate guidelines for the selection and correct use of QOL measurements. Patients' fear of side effects (e.g. concerning corticosteroids) should be integrated in QOL questionnaires for evaluation of possible compliance problems and real costs. Since relapse after treatment is frequent in AD, QOL measurements should also be performed after a treatment-free follow-up period. At present, we can not answer the question `which treatment best improves quality of life in AD?'.Antihistamines, Atopic dermatitis, Azathioprine, Corticosteroids, Cyclosporin, Herbal medicines, Interferon gamma, Methotrexate, Pharmacoeconomics, Phototherapy, Psoralens, Quality of life

Estimating the cost-effectiveness of a sequential pneumococcal vaccination program for adults in Germany

<div><p>Introduction</p><p>In Germany, a 23-valent polysaccharide pneumococcal vaccine (PPSV23) is recommended for elderly (60+) and patients 16+ with chronic diseases not associated with immune suppression. For all other patients at risk, sequential immunization with a 13-valent pneumococcal conjugate vaccine (PCV13) first, followed by PPSV23 is recommended. Repeated vaccination with PPSV23 is recommended every 6 years after individual assessment by the physician. This was adopted into the vaccination directive with binding reimbursement and funding. However, additional voluntary services allow statutory health insurances to differentiate from each other. Aim of this study is to estimate the cost-effectiveness of voluntary service scenarios compared to the strategy in place to support informed decision making.</p><p>Methods</p><p>A microsimulation framework with Markov-type process of a population susceptible to pneumococcal disease over a lifetime horizon was developed to compare effectiveness and cost-effectiveness of different vaccination strategies. We simulated 1,000 iterations for seven scenarios. Assumptions were derived from published literature and probabilistic sensitivity analysis was run to show the robustness of the model.</p><p>Results</p><p>Our study indicates that all voluntary service strategies could prevent further clinical cases compared to the existing policy. Depending on the scenario, 48–142 invasive pneumococcal disease (IPD), 24,000–45,000 hospitalized all-cause nonbacteremic pneumonia (NBP), 15,000–45,000 outpatient NBP cases, and 4,000–8,000 deaths could be avoided on average. This refers to potential savings of €115 Mio. - €187 Mio. for medical and non-medical costs. Additional costs per patient for the payer are €2.48 to €7.13 and for the society €2.20 to €6.85. The ICER per LYG ranged from €3,662 to €23,061 (payer) and €3,258 to €29,617 (societal). All but one scenario was cost-effective in ≥60% of the generated 1,000 simulations.</p><p>Conclusion</p><p>Compared to the vaccination strategy in place, the different hypothetical scenarios can be considered cost-effective and suitable as additional voluntary services.</p></div

Model structure.

<p>Model structure.</p

Age and risk level specific demographic and epidemiological parameters.

<p>Age and risk level specific demographic and epidemiological parameters.</p

Age and risk level specific medical and non-medical costs^b.

<p>Age and risk level specific medical and non-medical costs<a href="http://www.plosone.org/article/info:doi/10.1371/journal.pone.0197905#t004fn003" target="_blank">^b</a>.</p

Effectiveness of PCV13 and PPSV23^a.

<p>Effectiveness of PCV13 and PPSV23<a href="http://www.plosone.org/article/info:doi/10.1371/journal.pone.0197905#t002fn002" target="_blank">^a</a>.</p

Proportion of simulations (%) in the quadrants of the ICER scatterplot.

<p>Proportion of simulations (%) in the quadrants of the ICER scatterplot.</p

Maximum herd effect in year 5 of modelling (absolute in %).

<p>Maximum herd effect in year 5 of modelling (absolute in %).</p