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PHARMACOECONOMIC ANALYSIS OF OUTPATIENT COMBINED THERAPY OF ARTERIAL HYPERTENSION AND HYPERCHOLESTEROLEMIA
E.S.Egorova, L.B.Okonenko, O.S.Bondarenko
Yaroslav-the-Wise Novgorod State University, [email protected]
Pharmacoeconomic analysis of outpatient therapy for patients with diagnosis of arterial hypertension (AH) and hypercholesterolemia has been carried out. Result of treatment is estimated by reducing risk of cardiovascular death.
Keywords: pharmacoeconomics, arterial hypertension, hypercholesterolemia
Проведен фармакоэкономический анализ амбулаторной терапии пациентов с диагнозом артериальная гипертония (АГ) и гиперхолестеринемия. Результат лечения оценен по снижению риска сердечно-сосудистой смерти.
Ключевые слова: фармакоэкономика, артериальная гипертензия, гиперхолестеринемия
In economically advanced countries cardiovascular diseases take the first place among causes of disability and mortality of adult population. The rhythm of modern life causes rejuvenation of cardiovascular disease. According to the World Health Organization life expectancy in the western and the eastern countries is defined in 50% by diseases of the circulatory system. The highest mortality from cardiovascular disease among all European countries is in Russia. According to
digest of medical information-analytical center «Basic indicators of public health and health care organizations of Novgorod region for 2009» diseases of circulatory system is leading in appealability and among causes of mortality in hospitals.
Despite significant progress in creating of new and effective drugs for treatment of hypertension and hypercholesterolemia mortality rate remains high. There are many reasons: small availability of modern
diagnostic techniques and equipment in practical public health, lack of information awareness of physicians in diagnosis and treatment, time-lag in detection of disease, etc.
The main goal of treatment of hypercholesterolemia and hypertension is increasing of life expectancy, reducing of risk of cardiovascular death, improving of quality of patients’ life (in prospect, for complications of this pathology). However, the drugs used in cardiovascular disease are costly, so commitment of patients to their health is low in Russia. According to some authors less than 6% of patients have taken statins for 3 years (from among those who were prescribed statins) [1]. Therefore it is particularly important to determine the most clinically effective and less financially costly treatment regimen.
In order to identify optimal treatment regimen we used method of pharmacoeconomic analysis of «cost-effectiveness». The study was based on Polyclinic №3 of Municipal Medical Institution, Central City Clinical Hospital (MMI CCCH), Velikiy Novgorod. Criteria basing on which we include patients in the research are: presence of hypertension of I-II degree and hypercholesterolemia, age up to 68 years. 70 people participated in the study. Drug therapy in this group of patients has been carried out usually for a long time; for analysis we used data of two months of therapy after the first patients’ visit to doctor and achieving significant result of direct clinical effects (physical characteristics — decreasing of blood pressure and reduce of total cholesterol).
We identified seven treatment regimens which doctors use for combined therapy of hypertension and hypercholesterolemia. Treatment regimens were assigned with number in order of decreasing of frequency of use (Table 1).
Table 1
Regimens of combined therapy of hypertension and hypercholesterolemia
№ Treatment regimen Frequency of prescribing, %
1 Enalapril 5 mg, 2 times a day Atoris 20 mg for night 25,6
2 Renitek 10 mg, 2 times a day Atoris 20 mg for night 19,7
3 Renitek 5 mg, 2 times a day Simgal 20 mg for night 10,1
4 Renitek 5 mg, 2 times a day Crestor 10 mg for night 9,5
5 Amlotop 2.5 mg, once a day Atoris 20 mg for night 16,9
6 Amlotop 5 mg, once a day Simgal 20 mg for night 9,4
7 Betaloc Zok 12.5 mg, 2 times a day Atoris 20 mg for night 8,8
We calculated direct medical and nonmedical costs for eight-week therapy. Indirect costs are assessed difficult, so they remained outside of the analysis.
The direct medical costs included: cost of drugs, cost of visiting doctor (147 rubles x 2 doses = 294 rub.), and cost of test of total cholesterol in blood (60 rubles x 2 = 120 rub.). Cost of patient’s travel to clinics were direct nonmedical costs.
The average price of 1 package of drug in retail sales in Velikiy Novgorod was determined by taking into account the dosage and filling. Prices were taken as at 10.01.2011 in five major pharmacy networks, located in the city. Calculating of cost of each treatment regimen has been performed according to average cost of package in retail pharmaceutical market of Velikiy Novgorod and regime of medication. Direct costs of treatment are presented in Table 2.
Table 2
Direct costs of combined therapy of hypertension and hypercholesterolemia for 8 weeks
Medical costs Non-medical costs Total, rubles
№ Treatment regimen Costs of medication for 8 weeks, rubles Cost of clinical tests, rubles Cost of visiting doctor, rubles Cost of travel to clinics, rubles
1 Enalapril 5 mg, 2 times a day Atoris 20 mg for night 859,6 120 294 112 1385,6
2 Renitek 10 mg, 2 times a day Atoris 20 mg for night 934,6 120 294 112 1460,6
3 Renitek 5 mg, 2 times a day Simgal 20 mg for night 959,3 120 294 112 1485,3
4 Renitek 5 mg, 2 times a day Crestor 10 mg for night 3257,5 120 294 112 3783,5
5 Amlotop 2.5 mg, once a day Atoris 20 mg for night 1599,9 120 294 112 2125,9
6 Amlotop 5 mg, once a day Simgal 20 mg for night 1633,0 120 294 112 2159,0
7 Betaloc Zok 12.5 mg, 2 times a day Atoris 20 mg for night 1127,3 120 294 112 1653,3
100%
80%
60%
40%
20%
0%
□ Travel cost
□ Cost of visiting dctor
□ Cost of clinical tests
□ Drug cost
13 5 7
regimen regimen regimen regimen
Fig.1. The structure of direct costs of combined therapy of hypertension and hypercholesterolemia
Depending on the treatment regimen 60-80% of all direct costs are accounted for the cost of drugs (Fig. 1). This cost structure is typical for outpatient therapy.
Effectiveness of therapy was estimated by reducing of 10-year risk of cardiovascular death on a scale of SCORE. Such factors as age, sex, smoking status, total cholesterol and systolic blood pressure has been taken into account in defining of risk of cardiovascular death by SCORE scale. The resulting figure represents the probability of death from cardiovascular disease over the next 10 years expressed as percentage (Table 3). The greatest value and efficiency has combination of drugs Renitec and Crestor (Table 3).
Coefficients «cost/effectiveness» have been calculated for each alternative treatment regimens with formula 1.
DCj + DC2
CEA =-
Ef
(1)
CEA — coefficient «cost-effectiveness»; DC1 — direct medical costs (the cost of medications, clinical tests, vis-
iting doctor), rub.; DC2 — direct non-medical costs (cost of travel to clinics, laboratories), rub.; Ef — reducing of 10-year risk of cardiovascular death, difference between risk before and after treatment, %.
Coefficient «cost/effectiveness» shows the number of monetary units (rubles) to be spent on therapy to reduce 10-year risk of cardiovascular death by 1%. Lowest cost per unit of effectiveness belongs to Renitec and Simgala (Scheme 3), but as result of using this regimen for 8 weeks risk reduced only on 4.65%. Costs of regimens 4 and 5 are more significant, but with higher efficiency. Regimens 1 and 2 have the opposite situation — low cost and low efficiency. 6 and 7 treatment regimens do not guarantee greater efficiency at lower cost, so at this stage we can say that they will not be optimal.
Regimens 1, 2, 3, 4 and 5 were exposed to incremental analysis. This analysis allows determining cost effectiveness in terms of money using more expensive or cheaper options. Cost effectiveness is evaluated in com-
Table 3
Cost effectiveness of combined therapy of hypertension and hypercholesterolemia
№ Treatment regimen Direct costs, rub. Reducing of 10-year risk of death (effectiveness), % CEA, rub. CEAN/3, rub.
1 Enalapril 5 mg, 2 times a day Atoris 20 mg for night 1385,6 2,94 471,3 61,9
2 Renitek 10 mg, 2 times a day Atoris 20 mg for night 1460,6 4,55 321,0 247,0
3 Renitek 5 mg, 2 times a day Simgal 20 mg for night 1485,3 4,65 319,4 Basis regimen
4 Renitek 5 mg, 2 times a day Crestor 10 mg for night 3783,5 8,37 452,0 617,8
5 Amlotop 2.5 mg, once a day Atoris 20 mg for night 2125,9 4,80 442,9 4270,7
6 Amlotop 5 mg, once a day Simgal 20 mg for night 2159,0 4,03 535,7 Not dominant
7 Betaloc Zok 12.5 mg, 2 times a day Atoris 20 mg for night 1653,3 2,73 605,6 Not dominant
parison with the basic treatment regimen for which we took regimen 3 as it has the lowest coefficient of cost-effectiveness. Cost-effectiveness calculated by the formula 2 is presented in Table 3.
CEA = dcn - DC3
N3 EfN - Ef ■
(2)
CEAn/3 — cost effectiveness using more expensive or
cheaper options of regimen N compared with the basic regimen 3, rub.; DCN — direct costs when using scheme N, rub.; DC3 — direct costs when using basic regimen 3, rub. (DC3 = 1485.3 rubles.); EfN — reducing of 10-year risk of cardiovascular death when using regimen N, %; Ef3 — reducing 10-year risk of cardiovascular death when using basic regimen 3, % (Ef3 = 4,65%).
When using regimens 1 and 2, you can save 61.9 and 247 rubles per unit of effectiveness correspondingly. Application of regimens 4 and 5 will require spending additional 617.8 and 4270.7 rubles per efficiency unit respectively.
Thus, optimal treatment regimen for combination therapy of hypertension and hypercholesterolemia according to coefficient «cost/effectiveness» is the 3rd regimen: Renitec 5 mg 2 times a day + Simgal 20 mg for night. In case of money deficit patient can be prescribed treatment regimen 1 and 2. If it is necessary to reduce significantly risk of cardiovascular death we recommend Renitec 5 mg 2 times a day + Crestor 10 mg for night, since this regimen of all the above has very high productivity and reasonable cost-effectiveness.
1. Shalnova S.A., Balanova Y.A., Konstantinov V.V. and others. Arterial hypertension: prevalence, awareness, using of antihypertensive drugs and treatment efficacy among population of Russian Federation. // Russian Journal of Cardiology. 2006. №4. P.45-50.
2. Diagnosis and correction of dyslipidemia to prevent and treat of atherosclerosis. Russian recommendations (IV revision). Cardiovascular therapy and prevention. 2009. №8(6). 58 p.
