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Antimuscarinics – health economics

StudyPopulation
Study method
Intervention detailsCosts
Outcomes
ResultsAdditional commentsStudy type
Hughes 2004405
UK
Funding:
Janssen Pharmaceutical
A hypothetical cohort with urge incontinence associated with OAB
Empirical models of drug effects and persistence used to derive clinical effectiveness estimates. This was combined with cost data to derive an estimate of cost effectiveness
3 pharmaceutical treatments for OAB: oxybutynin ER (Oxy-ER), immediate-release oxybutynin (Oxy-IR), tolterodine immediate-release (Tol-IR), tolterodine extended-release (Tol-ER) (IR) tolterodineTotal annual cost (base case):
Oxy-IR £40, Oxy-ER £79, Tol-IR £74, Tol-ER £63
Total annual cost (discontinuers adopt baseline values):
Oxy-IR £42, Oxy-ER £82, Tol-IR £78, Tol-ER £68
Total annual cost (discontinuers adopt placebo values):
Oxy-IR £37, Oxy-ER £77, Tol-IR £73, Tol-ER £63
Total annual cost (full persistence):
Oxy-IR £129, Oxy-ER £241, Tol-IR £383, Tol-ER £362
Annual number of incontinent-free weeks (base case):
Oxy-IR: 7.5, Oxy-ER: 11.1, Tol-IR: 9.6, Tol-ER 10.9
Annual number of incontinent-free weeks (discontinuers adopt baseline values):
Oxy-IR: 2.5, Oxy-ER: 3.0, Tol-IR: 1.3, Tol-ER 1.4
Annual number of incontinent-free weeks (discontinuers adopt placebo values):
Oxy-IR: 14.3, Oxy-ER: 14.3, Tol-IR: 13.4, Tol-ER 13.8
Annual number of incontinent-free weeks (full persistence):
Oxy-IR: 22.1, Oxy-ER: 20.1, Tol-IR: 14.0, Tol-ER 19.4
Incremental cost per incontinent-free week (Base case):
Oxy-IR: £5.25a, Oxy-ER: £84.82b, Tol-IR: Dominated, Tol-ER: £7.14c
Incremental cost per incontinent-free week (Discontinuers adopting baseline values):
Oxy-IR: £16.59a, Oxy-ER: £87.43c, Tol-IR: Dominated, Tol-ER: Dominated
Incremental cost per incontinent-free week (Discontinuers adopting placebo values):
Oxy-IR: £2.58a, Oxy-ER: £1375.50c, Tol-IR: Dominated, Tol-ER: Dominated
Incremental cost per incontinent-free week (Full persistence):
Oxy-IR: £5.81a, Oxy-ER: Dominated, Tol-IR: Dominated, Tol-ER: Dominated
a versus no treatment
b versus Tol-ER
c versus Oxy-IR
Model
Direct medical costs – dugs, appliances, containment products, staff costs and direct overheads, surgical procedures.
NHS perspective, 1998 prices inflated to 2001 values.
Time horizon one year.
Model results were robust to parameter uncertainty but were affected by assumptions made about early discontinuation.
Cost effectiveness analysis
Kobelt 1998410
Sweden
Funding:
Pharmacia and Upjohn
Hypothetical patient cohort with overactive bladder
A Markov model was used to estimate the cost, utility and months of cure over one-year
QALYs were calculated by a regression analysis of the correlation between urinary symptoms and EQ-5D scores
Costs were based on drug costs and pad usage
Tolterodine; no treatmentAverage Total costs per patient over one year:
tolterodine SEK8,595, no treatment SEK3,286
Average Total QALYs per patient per year:
tolterodine 0.6977, no treatment 0.6728
Average cured months per patient per year:
tolterodine 3.6709, no treatment 0.816
Incremental cost per QALY of tolterodine vs no treatment:
SEK213,000 (USD 28,000)
Incremental cost per cured month of tolterodine vs no treatment:
SEK1,860 (USD215)
Model
Swedish context.
Exchange rate: USD1 = SEK7.6.
The authors report that the ICER of SEK213,000 per QALY is within the range usually considered cost effective.
Markov model utilizes 5 severity states.
Model assumed no further treatment effect after 3 months.
Cost–utility analysis and cost effectiveness analysis
O’Brien 2001409
Canada
Funding:
Pharmacia Corporation
Hypothetical patient cohort with urge incontinence
A Markov model was used to estimate the effects of two treatment strategies on cost, utility, and time in “normal” health state over one-year
Discontinuation rates were obtained from Quebec prescription claims data
Utility estimates were obtained from a previous Swedish study
generic oxybutynin with no further treatment in patients who discontinue initial therapy; generic oxybutynin with switch to tolterodine in patients who discontinue initial therapyTotal average costs to health care payer per patient over one year:
oxybutynin to no therapy CAD82, oxybutynin to tolterodine CAD294
Total average costs to patient over one year::
oxybutynin to no therapy CAD285, oxybutynin to tolterodine CAD236
Total costs per patient over one year:
oxybutynin to no therapy CAD367, oxybutynin to tolterodine CAD530
Average Total QALYs per patient over one year:
oxybutynin to no therapy 0.67, oxybutynin to tolterodine 0.69
Average months in normal health state over one year:
oxybutynin to no therapy 0.50, oxybutynin to tolterodine 1.15
Incremental cost per QALY of tolterodine vs no further therapy:
CAD9,982
Incremental cost per additional month in a normal health state of tolterodine vs no further therapy:
CAD251
Model
Canadian context.
Patient and health care payer perspective.
One-way sensitivity analysis produced did not produce large variations from base rates.
Cost–utility analysis and cost effectiveness analysis
Guest 2004406
Austria, France and UK
Funding:
Sanofi-Synthelabo
Hypothetical patient cohort of patients with OAB > = 18 years of age, and urge or mixed incontinence with a primary-urge component
A decision analytic model to estimate costs and incontinence outcomes of three treatment strategies over a six-month period
Data was obtained from a systematic literature review and information about resource utilization were derived from interviews with clinicians
Controlled-release oxybutynin; immediate-release oxybutynin;
tolterodine
Total average costs per patient over 6 months (UK):
Controlled-release oxybutynin Euro1078.05, immediate-release oxybutynin Euro1097.30, tolterodine Euro1359.20
Total average costs per patient over 6 months (France):
Controlled-release oxybutynin Euro872.91, immediate-release oxybutynin Euro834.25, tolterodine Euro861.90
Total average costs per patient over 6 months (Austria):
Controlled-release oxybutynin Euro912.84, immediate-release oxybutynin Euro986.64, tolterodine Euro1108.71
Average percentage reduction in frequency of incontinence at 6 months (UK):
CR oxybutynin 72.3, IR oxybutynin 62.3, tolterodine 56.3
Average percentage reduction in frequency of incontinence at 6 months (France):
CR oxybutynin 72.2, IR oxybutynin 54.7, tolterodine 48.4
Average percentage reduction in frequency of incontinence at 6 months (Austria):
CR oxybutynin 76.4, IR oxybutynin 62.1, tolterodine 63.8
Average change in daily no. of incontinence episodes per patient at 6 months (UK):
CR oxybutynin 3.6 to 1.0, IR oxybutynin 3.6 to 1.4, tolterodine 3.6 to 1.6
Average change in daily no. of incontinence episodes per patient at 6 months (France):
CR oxybutynin 3.6 to 1.0, IR oxybutynin 3.6 to 1.6, tolterodine 3.6 to 1.9
Average change in daily no. of incontinence episodes per patient at 6 months (Austria):
CR oxybutynin 3.6 to 0.9, IR oxybutynin 3.6 to 1.4, tolterodine 3.6 to 1.3
Average percentage reduction in micturition frequency at 6 months (UK):
CR Oxybutynin 24.1, IR Oxybutynin 17.4, tolterodine 20.1
Average percentage reduction in micturition frequency at 6 months (France):
CR Oxybutynin 24.2, IR Oxybutynin 15.4, tolterodine 17.0
Average percentage reduction in micturition frequency at 6 months (Austria):
CR Oxybutynin 25.4, IR Oxybutynin 19.2, tolterodine 21.2
Average change in the daily number of micturitions per patient at 6 months (UK):
CR Oxybutynin 11.5 to 8.7, IR Oxybutynin 11.5 to 9.5, tolterodine 11.5 to 9.2
Average change in the daily number of micturitions per patient at 6 months (France):
CR Oxybutynin 11.5 to 8.7, IR Oxybutynin 11.5 to 9.7, tolterodine 11.5 to 9.5
Average change in the dail number of micturitions per patient at 6 months (Austria):
CR Oxybutynin 11.5 to 8.6, IR Oxybutynin 11.5 to 9.3, tolterodine 11.5 to 9.1
Incremental cost effectiveness in reducing the frequency of incontinence (UK):
CR oxybutynin dominates other treatments, IR oxybutynin dominates tolterodine
Incremental cost effectiveness in reducing the frequency of incontinence (France):
CR oxybutynin vs IR oxybutynin; Euro64 per additional reduction in the no. of daily incontinence episodes, CR oxybutynin vs tolterodine; Euro12 per additional reduction in the no. of daily incontinence episodes, IR oxybutynin dominates tolterodine
Incremental cost effectiveness in reducing the frequency of incontinence (Austria):
CR oxybutynin dominates other treatments, IR oxybutynin vs tolterodine; Euro1,219
Incremental cost effectiveness in reducing the frequency of micturition (UK):
CR oxybutynin dominates other treatments, IR oxybutynin vs tolterodine; Euro1,455 per additional reduction in no. of daily micturitions
Incremental cost effectiveness in reducing the frequency of micturition (France):
CR oxybutynin vs IR oxybutynin; Euro39 per additional reduction in the no. of daily micturitions, CR oxybutynin vs tolterodine; Euro14 per additional reduction in the no. of daily micturitions, , IR oxybutynin vs tolterodine; Euro138 per additional reduction in the no. of daily micturitions
Incremental cost effectiveness in reducing the frequency of micturition (Austria):
CR oxybutynin dominates other treatments, IR oxybutynin vs tolterodine; Euro610 per additional reduction in no. of daily micturitions
Model
Conducted from perspective of payers (Sick Funds in Austria, Social Security in France and NHS) and patients, 2000/01 prices (Euros).
Costs to patients and societal costs arising from lost productivity were also estimated.
Cost effectiveness analysis
Getsios 2004407
Canada
Funding:
This work was supported in part by a grant from Janssen-Ortho Canada
Hypothetical patient cohort: baseline characteristics; 83.3% female, 59.1 years mean age, 45% had 7–21 incontinent episodes per week, 34% had 22–42 incontinent episodes per week, 21% > 42 episodes per week
A Markov model was used to estimate the costs and outcomes resulting from each treatment over one-year
2 pharmaceutical treatments for overactive bladder: extended-release (ER) oxybutynin; immediate-release (IR) tolterodineTotal costs per patient at one year:
Tolterodine IR CAD688, Oxybutynin ER CAD656
Completely continent at week 52:
Tolterodine IR 17.2%, Oxybutynin ER 20.4%
No or minimal incontinence at week 52:
Tolterodine IR 48.7%, oxybutynin ER 54.3%
Days per year with no incontinent episodes:
Tolterodine IR 146.0, oxybutynin ER 162.5
Total annual incontinent episodes:
Tolterodine IR 679.8, oxybutynin ER 584.6
Patients receiving drug at week 52:
Tolterodine IR 81.5%, oxybutynin ER 79.1%
Oxybutynin ER dominates Tolterodine IRModel
Direct costs only – drugs, doctor visits, pads and laundry.
Canadian context; health care payer perspective; 2002 costs.
Time horizon one year.
5 severity states.
Transition probabilities into different states was calculated from the OBJECT clinical trial.
Clinical data comparing oxybutynin ER and tolterodine IR only available for 3 months and it was assumed that there would be no change in severity among patients who were compliant with treatment.
Treatment persistence rates over 3 months were based on OBJECT study, a common dropout rate was assumed for all patients after this.
Sensitivity analysis showed that net savings would be eliminated if oxybutynin cost CAD0.11 more than tolterodine.
Cost effectiveness analysis
Getsios et al., 2004
UK404
Funding:
This work was in part supported by a grant from Janssen Pharmaceutica
Hypothetical patient cohort: baseline characteristics; 83.3% female, 59.1 years mean age, 45% had 7–21 incontinent episodes per week, 34% had 22–42 incontinent episodes per week, 21% > 42 episodes per week
A Markov model was used to estimate the costs and outcomes resulting from each treatment
2 pharmaceutical treatments for overactive bladder: extended-release (ER) oxybutynin, immediate-release (IR) tolterodineTotal costs per patient at one year:
Tolterodine IR £418, Oxybutynin ER £332
Completely continent at week 52:
Tolterodine IR 17.2%, Oxybutynin ER 20.4%
No or minimal incontinence at week 52:
Tolterodine IR 48.7%, oxybutynin ER 54.3%
Days per year with no incontinent episodes:
Tolterodine IR 146.0, oxybutynin ER 162.5
Total annual incontinent episodes:
Tolterodine IR 679.8, oxybutynin ER 584.6
QALYs:
Tolterodine IR 0.686, oxybutynin ER 0.690
Patients receiving drug at week 52:
Tolterodine IR 81.5%, oxybutynin ER 79.1%
Oxybutynin ER dominates Tolterodine IRModel
Direct costs only – drugs, doctor visits, pads and laundry.
UK context, perspective of a comprehensive healthcare payer; 2002 costs.
Time horizon one year.
5 severity states.
Transition probabilities into different states was calculated from the OBJECT clinical trial.
Clinical data comparing oxybutynin ER and tolterodine IR only available for 3 months and it was assumed that there would be no change in severity among patients who remained compliant after this date.
Health utilities derived from study by Kobelt et al., 1998.
Treatment persistence rates over 3 months were based on OBJECT study, a common dropout rate was assumed for all patients after this.
Sensitivity analysis suggested that the results were quite stable to different assumptions. Increasing discontinuation rates reduced the cost effectiveness of oxybutynin ER relative to tolterodine IR. The dominance of oxybutynin ER was also sensitive to the costs of treatment.
Only examined a fixed dose for each drug.
Data to estimate the effect of lower compliance were not available.
Cost–utility and cost effectiveness analysis
Arikian 2000408
US
Funding:
This research was supported by a grant from the Alza Corporation
Hypothetical patient cohort of patients with OAB
A decision analytic model to determine the costs, weekly incontinence episodes and expected number of continent days of three treatment strategies over a six-month period
Data was derived from a review of RCT data combined with expert opinion
Drug costs were based on the January 1999 wholesaler acquisition cost and average daily dosage was based on clinical opinion
3 pharmaceutical treatments for overactive bladder: once-daily contolled-release oxybutynin, twice daily tolterodine, immediate-release oxybutyninTreatment success*:
oxybutynin controlled-release 52.30%; immediate-release oxybutynin 46.15%; tolterodine 31.89%
Continent days:
oxybutynin controlled-release 75; immediate-release oxybutynin 65; tolterodine 44
Surgery (second-line treatment)
Cost:
oxybutynin controlled-release USD 1,403; immediate-release oxybutynin USD 1,395; tolterodine USD 1,650
Surgery (third-line treatment)
Cost:
oxybutynin controlled-release USD 894; immediate-release oxybutynin USD 819; tolterodine USD 918
*Treatment success defined as patients with zero incontinence episodes per week at the end of six months
Surgery (second-line treatment)
Cost per success:
oxybutynin controlled-release USD 2,682; immediate-release oxybutynin USD 3,022; tolterodine USD 5,177
Cost per continent day:
oxybutynin controlled-release USD 18.70; immediate-release oxybutynin USD 21.60; tolterodine USD 37.20
Surgery (third-line treatment)
Cost per success:
oxybutynin controlled-release USD 1,708; immediate-release oxybutynin USD 1,774; tolterodine USD 2,882
Cost per continent day:
oxybutynin controlled-release USD 11.90; immediate-release oxybutynin USD 12.60; tolterodine USD 20.70
Model
US context.
Authors report that sensitivity analysis shows that results are robust to model assumptions.
Baseline results suggest that tolterodine is dominated.
Cost effectiveness analysis

From: Evidence tables for included studies

Cover of Urinary Incontinence
Urinary Incontinence: The Management of Urinary Incontinence in Women.
NICE Clinical Guidelines, No. 40.
National Collaborating Centre for Women's and Children's Health (UK).
London: RCOG Press; 2006 Oct.
Copyright © 2006, National Collaborating Centre for Women’s and Children’s Health.

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