Services (NHS) Economic Evaluation database and EMBASE. ... CNS Drugs 2012; 26 (7): 581-600 ..... Service (PSS) among children and adolescents.
CNS Drugs 2012; 26 (7): 581-600 1172-7047/12/0007-0581/$49.95/0
SYSTEMATIC REVIEW
Adis ª 2012 Springer International Publishing AG. All rights reserved.
Cost Effectiveness of Pharmacotherapies for Attention-Deficit Hyperactivity Disorder A Systematic Literature Review Eric Q. Wu,1 Paul Hodgkins,2 Rym Ben-Hamadi,1 Juliana Setyawan,2 Jipan Xie,1 Vanja Sikirica,2 Ella X. Du,1 Sherry Y. Yan1 and M. Haim Erder 2 1 Analysis Group, Inc., Boston, MA, USA 2 Shire Development LLC., Wayne, PA, USA
Abstract
Background: Attention-deficit hyperactivity disorder (ADHD) is a common psychiatric disorder that impairs the quality of life for patients and their families and is associated with considerable direct and indirect costs. Pharmacotherapies for ADHD, including stimulants and non-stimulants, are often used to treat patients with ADHD. However, the costs, effectiveness and adverse effects of these agents vary. Therefore, information regarding the cost effectiveness of different pharmacological treatments is needed to better inform payers in the allocation of limited resources. Objectives: The objectives of this study were to conduct a systematic literature review of economic evaluations of pharmacotherapies for ADHD treatments and to assess the cost effectiveness of different interventions based on the existing studies. Methods: A systematic literature review of economic evaluations of pharmacotherapies for ADHD was conducted in MEDLINE, the National Health Services (NHS) Economic Evaluation database and EMBASE. For inclusion in this review, studies had to compare two or more ADHD interventions with at least one pharmacotherapy, assess both costs and outcomes, and be conducted between 1990 and 2011 in North America, Europe, Australia or New Zealand. Studies were excluded if they were not original research, were presented only as conference proceedings or abstracts or did not report costs associated with specific interventions. The study quality was assessed using the British Medical Journal (BMJ) health economics checklist. The literature search, data extraction and quality assessment were performed by one author and independently checked for accuracy by a second author. Discrepancies were resolved by consensus and referring to the original article. If necessary, a third reviewer was consulted.
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Results: The initial search returned 93 citations from MEDLINE, 10 from the NHS Economic Evaluation database and 377 from EMBASE. Thirteen papers met the inclusion/exclusion criteria and were included in the review. Based on the BMJ checklist, all these studies were considered to be of sufficient quality to be included in the literature review, but they varied substantially in target population, methodology and effectiveness measures. Identified pharmacotherapies were cost effective compared with no treatment, placebo, behavioural therapy or community care among children and adolescents with ADHD. Studies comparing non-stimulants with stimulants and amfetamine with methylphenidate stimulants showed inconsistent findings. A limited number of studies indicated that methylphenidate Osmotic-controlled Release Oral delivery System (OROS) was cost effective compared with short-acting methylphenidate. There were no published studies on the cost effectiveness of pharmacotherapy in the adult ADHD population, comparing stimulants, non-stimulants or adjuvant therapy. There is limited evidence on the longterm cost effectiveness of pharmacotherapies. Conclusions: Among children and adolescents with ADHD, there was consistent evidence that pharmacotherapies are cost effective compared with no treatment or behavioural therapy. Adequate data are lacking to draw conclusions regarding the relative cost effectiveness of different pharmacological agents. More economic evaluations with standardized methods, such as effectiveness measures and cost components, are warranted. To better inform payers about the economic value of existing medications, future studies should also consider identifying subgroups that may have heterogeneous responses to different treatments, including analyses of recently approved treatments (e.g. lisdexamfetamine, guanfacine extended-release and clonidine extended-release) and expanding the time horizon to incorporate long-term outcomes.
1. Introduction Attention-deficit hyperactivity disorder (ADHD) is a common psychiatric disorder in children and adolescents worldwide.[1,2] Symptoms can persist into adulthood.[3,4] Pharmacotherapies, including stimulants and non-stimulants, are widely used to treat ADHD and have been shown to be effective in reducing symptoms and impairments and in improving health-related quality of life (HRQoL).[5-8] With the increase of therapeutic options and substantial costs associated with ADHD,[9] economic evaluations assessing the cost effectiveness of different pharmacological treatments and identifying the most cost-effective treatments for ADHD would be of considerable value to payers Adis ª 2012 Springer International Publishing AG. All rights reserved.
in allocating limited resources. This review addresses these information needs. It provides an overview of ADHD and its economic burden, systematically summarizes the existing evidence on the economic value of pharmacotherapies for ADHD and identifies information gaps that future studies should address. 2. Overview of Attention-Deficit Hyperactivity Disorder (ADHD) 2.1 Prevalence of ADHD
Approximately 9.5% of school-aged children and adolescents (aged 4–17 years) in the US were identified by their parents in 2007 to have ever been CNS Drugs 2012; 26 (7)
Cost Effectiveness of Pharmacotherapies for ADHD
diagnosed with ADHD in their community.[10] The prevalence of ADHD has been increasing. Based on data from the National Health Interview Survey, the prevalence of ADHD in children and adolescents increased from 7% in 1990–2000 to 9% in 2007–9 in the US.[11] Among adults, the prevalence increased more than 3-fold, from 1.2 to 4 cases/1000 covered members during the past decade based on MarketScan commercial claims data.[12] Worldwide, the prevalence of ADHD is estimated as 6.4% in children (aged 6–11 years), 2.7% in adolescents (aged 12–18 years) and 2.5% of the adult population (aged >18 years).[1,2] Among children and adolescents (aged
