Our estimates of disease-modifying drug (DMD) relative treatment effect size, in the context of "real-world" clinical practice, are similar to DMD treatment efficacy estimates in pivotal trials, though our findings attained statistical significance. DMDs, as a class, are effective in delaying Expanded Disability Status Scale progression in patients with relapsing-onset definite multiple sclerosis (MS) (90%), although effectiveness is much better for relapsing-remitting MS than for secondary progressive MS groups.

Further research is required to examine the long-term clinical effectiveness and cost-effectiveness of these therapies. There is no definitive guidance in the United States concerning discontinuation of DMTs; this study suggests that the prudent use of a treatment discontinuation rule may considerably improve the cost-effectiveness of DMTs.

Background and Purpose-The construct of vascular cognitive impairment (VCI) includes many whose care is or will be costly. Nevertheless, estimates of these costs are not well described. We therefore set out to estimate the societal costs of VCI in elderly people. Methods-In a secondary analysis of the Canadian Study of Health and Aging, a representative cohort study, Canadian dollar costs using a societal perspective were estimated by standard methods. Results-The total annual per-patient societal costs for VCI by severity were $15 022 for those with mild disease, $14 468for those with mild to moderate disease, $20 063 for those with moderate disease, and $34 515 for those with severe disease. The most expensive component per individual was the cost of institutional long-term care. Although severe impairment was associated with higher costs, the extent of institutionalization at all levels of severity and less drug use among those more severely impaired mitigated a severity-cost gradient. Conclusions

Background: Despite the common association of psychiatric morbidity and multiple sclerosis (MS), population-based prevalence estimates of these disorders are limited. Such estimates are of particular importance to those conducting trials of interventions for the treatment of MS. This study examined the prevalence of bipolar disorder, depression, and attempted suicide among hospital service utilizers in Nova Scotia and compared these measures for the MS and non-MS population. Methods: Data regarding diagnosis and utilization were extracted from two linked databases which included all hospital separation records for Nova Scotia over a 3 year period (1992/93-1994/95). Results: The prevalence of bipolar disorder in hospitalized MS patients was 1.97% and depression was 4.27%. These rates were significantly higher than the 0.92% and 2.04%, respectively, for the non-MS hospital utilizers. These diagnoses also accounted for more than half of the primary diagnostic codes for psychiatric service separations by MS patients. The proportion of total hospital utilization which was accounted for by psychiatric services did not differ between MS and non-MS utilizers. While suicide attempts were rare, the estimated frequency of suicide attempts in the total MS population was more than three times that of the general population. Conclusions: Bipolar disorder and depression were twice as prevalent in hospitalized MS patients as in the general population of hospital utilizers while the estimated frequency of suicide attempts was at least three times greater. These results illustrate that psychiatric morbidity and service utilization are important considerations in the care of MS patients. RESUME: Utilisation des services psychiatriques hospitaliers et morbidite dans la sclerose en plaques. Introduction: En depit de l'association frequente de la morbidite psychiatrique et de la sclerose en plaques (SEP), il existe peu d'etudes evaluant la prevalence de ces affections dans la population. Ces donnees sont particulierement importantes pour ceux qui font des etudes d'intervention pour le traitement de la SEP Cette etude a examine' la prevalence de la maladie bipolaire, de la depression et des tentatives de suicide parmi les utilisateurs de services hospitaliers en Nouvelle-Ecosse et compart; ces donnees pour la SEP a celles de la population non atteinte de SEP. Methodes: Les donnees concernant le diagnostic et I'utilisation de soins ont 6te extraites de deux bases de donnees qui incluaient tous les dossiers concernant les conges hospitaliers pour la Nouvelle-Ecosse sur une periode de 3 ans (1992/93 -1994/95). Resultats: La prevalence de la maladie bipolaire chez les patients atteints de SEP hospitalises etait de 1.97% et celles de la depression de 4.27%. Ces taux etaient significativement plus eleves que les taux de 0.92% et 2.04% respectivement pour les utilisateurs hospitaliers n'6tant pas atteints de SEP. Ces diagnostics constituaient plus de la moiti£ des codes diagnostiques primaires pour les conges psychiatriques chez le...

Randomized controlled trials have demonstrated the efficacy of disease-modifying drugs (DMDs) in persons with relapsing-remitting multiple sclerosis (MS) and secondary progressive MS with superimposed relapses. However, these brief studies of selected patients have focused mainly on reducing attacks and must be complemented by evaluations in 'realworld' clinical settings to establish the effectiveness of DMD programs in slowing disease progression and to inform health policy and program decision-making. We assessed the effectiveness of DMDs as administered in a comprehensive publicly funded drug insurance program that provides DMDs to a geographically defined population of MS patients who meet specific eligibility criteria. Data from 1752 MS patients (10,312 assessments) seen between 1980 and 2004 at a regional MS Clinic serving the entire population of Nova Scotia, Canada were analysed. Using survival methods we observed a statistically significant reduction in disease progression to specific Expanded Disability Status Scale endpoints following the introduction of this program. Subgroup analyses of patients eligible for treatment using hierarchical linear regression methods also suggested that disease progression was slowed in patients treated with the first DMD prescribed. These findings provide evidence supporting DMD program effectiveness that can be used to inform the broader implementation of such programs.

Acute Guillain‐Barré syndrome is the most common cause of neuromuscular paralysis. Plasma exchange and intravenous immune globulin (IV IgG) are both effective treatments for this condition and the purpose of this report was to compare the cost‐effectiveness of these two modalities. A MEDLINE search was performed to identify randomized studies that compared the use of IV IgG and plasma exchange for treatment of acute Guillain‐Barré syndrome to determine if one modality was more effective and/or safer for the management of this condition. A decision analysis was structured around the alternatives facing neurologists who must choose a treatment regimen for patients diagnosed with acute Guillain‐Barré syndrome who require active therapy. Cost information was obtained directly from product manufacturers and hospital sources. Two head‐to‐head trials comparing the effectiveness of plasma exchange and IV IgG for treatment of acute Guillain‐Barré syndrome determined that there was insufficient evidence to suggest one therapy was more effective than the other; therefore, a cost minimization analysis was performed. The costs per patient of plasma exchange and IV IgG for the treatment of acute Guillain‐Barré syndrome were $6,204 and $10,165, respectively. A sensitivity analysis determined the model was sensitive to the cost of IV IgG. The cost savings per patient treatment for the use of plasma exchange varied from $304 to $6,625 depending on the IV IgG product selected. Plasma exchange and IV IgG are both effective treatments for Guillain‐Barré syndrome. However, our analysis determined plasma exchange on average was almost $4,000 less costly per patient than IV IgG. Further research is required to determine the impact of patient and physician preferences on the treatment of this disorder. J. Clin. Apheresis 14:107–113, 1999. © 1999 Wiley‐Liss, Inc.

Using the Expanded Disability Status Scale, cost per disability year avoided due to interferon beta-1b treatment in RRMS is quite high. Comparable CE estimates, using MS-specific or generic health-related quality-of-life outcome measures, are even higher. Further research is required to better measure treatment effects, modification of MS natural history, and net societal costs of IFN beta-1b in RRMS.

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