Cost-effectiveness of ticagrelor plus aspirin versus aspirin in acute ischaemic stroke or transient ischaemic attack: an economic evaluation of the THALES trial

Health economics; StrokeEconomía de la salud; IctusEconomia de la salut; IctusObjective THALES demonstrated that ticagrelor plus aspirin reduced the risk of stroke or death but increased bleeding versus aspirin during the 30 days following a mild-to-moderate acute non-cardioembolic ischaemic stroke (AIS) or high-risk transient ischaemic attack (TIA). There are no cost-effectiveness analyses supporting this combination in Europe. To address this, a cost-effectiveness analysis was performed. Methods Cost-effectiveness was evaluated using a decision tree and Markov model with a short-term and long-term (30-year) horizon. Stroke, mortality, bleeding and EuroQol-5 Dimension (EQ-5D) data from THALES were used to estimate short-term outcomes. Model transitions were based on stroke severity (disabling stroke was defined as modified Rankin Scale >2). Healthcare resource utilisation and EQ-5D data beyond 30 days were based on SOCRATES, another trial in AIS/TIA that compared ticagrelor with aspirin. Long-term costs, survival and disutilities were based on published literature. Unit costs were derived from national databases and discounted at 3% annually from a Swedish healthcare perspective. Results One-month treatment with ticagrelor plus aspirin resulted in 12 fewer strokes, 4 additional major bleeds and cost savings of €95 000 per 1000 patients versus aspirin from a Swedish healthcare perspective. This translated into increased quality-adjusted life-years (0.04) and reduced societal costs (−€1358) per patient over a lifetime horizon. Key drivers of cost-effectiveness were number of patients experiencing subsequent disabling stroke and degree of disability. Findings were robust over a range of input assumptions. Conclusion One month of treatment with ticagrelor plus aspirin is likely to improve outcomes and reduce costs versus aspirin in mild-to-moderate AIS or high-risk TIA.AstraZeneca funded the THALES trial and the cost-effectiveness analysis of this study

Sickness Insurance: Design and Behavior

The first essay presents the results from a questionnaire study of sickness insurance and sickness absence behavior in Sweden. In the first part, people’s preferences for the design of a sickness insurance are discussed. Three combinations of qualifying days and compensation rates, with approximately the same costs within the insurance system, are compared. From the questionnaire it is concluded that a system with one qualifying day is the most preferred, compared to no qualifying day at all (and lower compensation) or three qualifying days (and higher compensation). The second part of this paper focuses on factors that influence people’s decision whether or not to report sick. In the questionnaire individuals were asked whether they would go to work or not, presupposing that they actually feel ill. Respondents were asked the same questions under different hypothetical compensations. The results indicate strong effects of factors related to the financial loss of being absent on the propensity to report sick. The second essay analyzes to what extent Swedish employees choose to take a holiday instead of reporting sick, in an attempt to avoid the costs related to sickness absence. The data used comes both from a questionnaire survey and from the Labour Force Survey by Statistics Sweden. The data from the questionnaire shows that individuals sometimes actually choose a holiday instead of reporting sick, with the intention of avoiding costs. The Labour Force Survey study does not confirm that this type of behavior has a considerable effect on the overall sickness absence. The third essay focuses on the main differences between insurance with uniform premiums and insurance with experience-rated premiums. The purpose is to explore the complex interaction between, on the one hand, probability of failure, risk-aversion, discount rate and probability of changing risk group, and, on the other hand, people’s preferences for uniform premiums and experience-rated premiums. In the paper, both a theoretical model and a simulation model illustrate the differences. One important conclusion is that the complex nature of experience-rated insurance precludes simple and general conclusions about the preferences for this insurance. It is shown that an insurance with quite considerable redistribution between risk-groups might be preferred even by good risk individuals. This can be seen as support for social insurance. The fourth essay is a theoretical study of temporary sickness absence and insurance. The purpose is twofold; first to refine the theoretical model for temporary sickness absence and insurance, and second to analyze the optimal level of compensation in an employer-provided sickness insurance and a public sickness insurance, and to compare these two. It is found that full compensation, under some circumstances, could possibly be optimal in both employer-provided and public sickness insurance

What determines people's decisions whether or not to report sick?

Swedish employees who are temporarily absent from work are compensated for the loss of income from the governmentally regulated sickness insurance. During the 1990s, when the societal costs for covering sickness absence raised dramatically, the sickness insurance underwent several changes, which raised questions about how people reacted to the changes made. This article is based on a survey where individuals were asked several questions about whether they would go to work or report sick, given that they actually felt ill. Respondents were asked the same questions under different hypothetical compensations. The results indicated strong effects of factors related to the financial loss of being absent on the propensity to report sick.

Sick Leave Before and After Diagnosis of Rheumatoid Arthritis - A Report from the Swedish TIRA Project

Objective. Our study describes sick leave during 3 years before and 3 years after diagnosis of rheumatoid arthritis (RA) in relation to referents and identifies predictors for sick leave during the third year after diagnosis of RA. Methods. One hundred twenty patients (76% women) from the Swedish early RA study TIRA were included. Disease activity and disability were registered regularly during 3 years in TIRA. Referents were matched for sex, age, and home town. Sick leave data were obtained for patients 3 years before and 3 years after diagnosis and for the referents for the corresponding 6 years. Results. No differences were seen between patients and referents regarding sick leave during the first 2 years, whereas sick leave increased in patients 6 months before diagnosis, from 30% to 53%. During the 3 years after diagnosis, sick leave among patients was rather stable, varying between 50% and 60%, even though disability pension increased and sickness benefit decreased. Sick leave before diagnosis, disability I year after diagnosis, and type of work were identified as predictors for sick leave during the third year after diagnosis. Conclusion. Not surprisingly, sick leave in patients increased the year before diagnosis. Although disease activity and disability diminished after diagnosis, the patients' sick leave remained essentially unchanged. Sick leave 3 years after diagnosis was foremost predicted by earlier sick leave, disability, and type of work. (First Release May 1 2009; J Rheumatol 2009:36:1170-9; doi:10.3899/jrheum.080523

Dapagliflozin vs non-SGLT-2i treatment is associated with lower healthcare costs in type 2 diabetes patients similar to participants in the DECLARE-TIMI 58 trial : A nationwide observational study

Aims To investigate how the cardiovascular (CV) risk benefits of dapagliflozin translate into healthcare costs compared with other non-sodium-glucose cotransporter-2 inhibitor glucose-lowering drugs (oGLDs) in a real-world population with type 2 diabetes (T2D) that is similar to the population of the DECLARE-TIMI 58 trial. Methods Patients initiating dapagliflozin or oGLDs between 2013 and 2016 in Swedish nationwide healthcare registries were included if they fulfilled inclusion and exclusion criteria of the DECLARE-TIMI 58 trial (DECLARE-like population). Propensity scores for the likelihood of dapagliflozin initiation were calculated, followed by 1:3 matching with initiators of oGLDs. Per-patient cumulative costs for hospital healthcare (in- and outpatient) and for drugs were calculated from new initiation until end of follow-up. Results A total of 24 828 patients initiated a new GLD; 6207 initiated dapagliflozin and 18 621 initiated an oGLD. After matching based on 96 clinical and healthcare cost variables, groups were balanced at baseline. Mean cumulative 30-month healthcare cost per patient was similar in the dapagliflozin and oGLD groups ($11 807 and$11 906, respectively; difference, -$99; 95$629, $483; P = 0.644). Initiation of dapagliflozin rather than an oGLD was associated with significantly lower hospital costs (-$658; 95% CI, -$1169, -$108; P = 0.024) and significantly higher drug costs ($559; 95$471, 648; P < 0.001). Hospital cost difference was related mainly to fewer CV- and T2D-associated complications with use of dapagliflozin compared with use of an oGLD (-363; 95% CI, -$665, -$61; P = 0.008). Conclusion In a nationwide, real-world, DECLARE-like population, dapagliflozin was associated with lower hospital costs compared with an oGLD, mainly as a result of reduced rates of CV- and T2D-associated complications

Cost-effectiveness of ticagrelor plus aspirin versus aspirin in acute ischaemic stroke or transient ischaemic attack : an economic evaluation of the THALES trial

Objective THALES demonstrated that ticagrelor plus aspirin reduced the risk of stroke or death but increased bleeding versus aspirin during the 30 days following a mild-to-moderate acute non-cardioembolic ischaemic stroke (AIS) or high-risk transient ischaemic attack (TIA). There are no cost-effectiveness analyses supporting this combination in Europe. To address this, a cost-effectiveness analysis was performed. Methods Cost-effectiveness was evaluated using a decision tree and Markov model with a short-term and long-term (30-year) horizon. Stroke, mortality, bleeding and EuroQol-5 Dimension (EQ-5D) data from THALES were used to estimate short-term outcomes. Model transitions were based on stroke severity (disabling stroke was defined as modified Rankin Scale &gt;2). Healthcare resource utilisation and EQ-5D data beyond 30 days were based on SOCRATES, another trial in AIS/TIA that compared ticagrelor with aspirin. Long-term costs, survival and disutilities were based on published literature. Unit costs were derived from national databases and discounted at 3% annually from a Swedish healthcare perspective. Results One-month treatment with ticagrelor plus aspirin resulted in 12 fewer strokes, 4 additional major bleeds and cost savings of euro95 000 per 1000 patients versus aspirin from a Swedish healthcare perspective. This translated into increased quality-adjusted life-years (0.04) and reduced societal costs (-euro1358) per patient over a lifetime horizon. Key drivers of cost-effectiveness were number of patients experiencing subsequent disabling stroke and degree of disability. Findings were robust over a range of input assumptions. Conclusion One month of treatment with ticagrelor plus aspirin is likely to improve outcomes and reduce costs versus aspirin in mild-to-moderate AIS or high-risk TIA.Trial registration number NCT03354429