Background While clinical trial evidence has firmly established the efficacy of several atypical antipsychotics (AAPs) for treating bipolar depression, no randomized controlled trials (RCT’s) comparing AAPs have been conducted. This Bayesian network meta-analysis (NMA) compared the relative efficacy and tolerability of AAP monotherapy in adults with bipolar depression. Methods Efficacy measures included change in Montgomery Åsberg Depression Rating Scale (MADRS), Clinical Global Improvement – Bipolar Disorder (CGI-BP), response, and remission. Multiple tolerability outcomes were examined. Results from random effects models were reported as difference in change from baseline for continuous variables or odds ratios for dichotomous variables. Treatments were ranked using the surface under the curve cumulative ranking probabilities. Number needed to treat (NNT) and harm (NNH) were calculated. Results Eighteen RCT’s met inclusion criteria of the systematic literature review. On change in MADRS, lurasidone (− 4.71 [95% Crl − 6.98, − 2.41]), quetiapine (− 4.80 [− 5.93, − 3.72]), olanzapine (− 4.57 [− 5.92, − 3.20]), and cariprazine (− 2.29 [− 3.47, − 1.09]) were more efficacious than placebo. Lurasidone was associated with a significantly greater odds of response (≥50% improvement in MADRS) compared to cariprazine (1.78 [95% Crl 1.08, 2.77]), aripiprazole (2.38 [1.38, 3.85]), and ziprasidone (2.47 [1.41, 3.98]), but was similar to olanzapine (1.68 [0.99,2.65]) and quetiapine (1.25 [0.78, 1.90]). For change in CGI-BP-S-overall score, lurasidone was significantly better than cariprazine (− 0.38 [95% Crl − 0.66,-0.10]) and ziprasidone (− 0.58 [− 0.91,-0.26]), but similar to quetiapine (− 0.08 [− 0.36, 0.19])and olanzapine (− 0.04 [− 1.41, 1.46]). Lurasidone (0.34 kg [95% Crl − 0.22, 0.89]) and aripiprazole (0.20 kg [− 0.59, 1.00]) had a similar weight change compared to placebo, but olanzapine (2.88 kg [2.40, 3.36]), quetiapine (1.17 kg [0.84, 1.49]), and cariprazine (0.65 kg [0.34, 0.96]) were associated with greater weight gain. The NNT for response was the lowest for lurasidone (NNT = 5) followed by quetiapine (NNT = 6), olanzapine (NNT = 10) and cariprazine (NNT = 12). Conclusions In this NMA in adults with bipolar depression, which evaluated change in depressive symptoms (assessed by MADRS) across short-term trials, the largest improvement versus placebo was observed for lurasidone, olanzapine and quetiapine with cariprazine, showing a smaller treatment effect. Aripiprazole and ziprasidone were ineffective for the treatment of bipolar depression. Improvement in CGI-BP-S score for lurasidone was larger than cariprazine and ziprasidone but similar to quetiapine and olanzapine. Based on short term studies lurasidone and aripiprazole had similar weight gain compared to placebo.

ObjectivesTo examine healthcare resource use (HRU) and costs among heart failure (HF) patients using population data from Sweden.DesignRetrospective, non-interventional cohort study.SettingTwo cohorts were identified from linked national health registers (cohort 1, 2005–2014) and electronic medical records (cohort 2, 2010–2012; primary/secondary care patients from Uppsala and Västerbotten).ParticipantsPatients (aged ≥18 years) with primary or secondary diagnoses of HF (≥2 International Classification of Diseases and Related Health Problems, 10th revision classification) during the identification period of January 2005 to March 2015 were included.Outcome measuresHRU across the HF phenotypes was assessed with logistic regression. Costs were estimated based on diagnosis-related group codes and general price lists.ResultsTotal annual costs of secondary care of prevalent HF increased from SEK 6.23 (€0.60) to 8.86 (€0.85) billion between 2005 and 2014. Of 4648 incident patients, HF phenotype was known for 1715: reduced ejection fraction (HFrEF): 64.5%, preserved ejection fraction (HFpEF): 35.5%. Within 1 year of HF diagnosis, the proportion of patients hospitalised was only marginally higher for HFrEF versus HFpEF (all-cause (95% CI): 64.7% (60.8 to 68.4) vs 63.7% (60.8 to 66.5), HR 0.91, p=0.14; cardiovascular disease related (95% CI): 61.1% (57.1 to 64.8) vs 60.9% (58.0 to 63.7), HR 0.93, p=0.28). Frequency of hospitalisations and outpatient visits per patient declined after the first year. All-cause secondary care costs in the first year were SEK 122 758 (€12 890)/patient/year, with HF-specific care accounting for 69% of the costs. Overall, 10% of the most expensive population (younger; predominantly male; more likely to have comorbidities) incurred ~40% of total secondary care costs.ConclusionsHF-associated costs and HRU are high, especially during the first year of diagnosis. This is driven by high hospitalisations rates. Understanding the profile of resource-intensive patients being at younger age, male sex and high Charlson comorbidity index scores at the time of the HF diagnosis is most likely a sign of more severe disease.

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Objectives: Arteriovenous fistulas (AVF) are associated with lower morbidity and higher patency compared with other methods of hemodialysis (HD) vascular access. However, surgical fistula creation has important limitations including high failure rates and associated costs. This economic analysis examined the introduction of a less invasive, endovascular AVF creation option with the WavelinQ endoAVF System. Methods: A 1-year model was developed based on event rates from propensityscore matched analyses and observational data for HD vascular access procedures. From the payer perspective, the model compared the budget impact of a central venous catheter (CVC) and surgical AVF landscape to a treatment combination of CVC, surgical AVF, and WavelinQ. Procedure distribution and payment rates for index procedures and subsequent interventions (e.g., infection treatment, catheter placement, new AVF) were based on U.S. Medicare averages. From an outpatient provider perspective, costs rather than payments, were the unit of analysis. In addition to subsequent interventions, operating room location and time costs were assessed for providers. Results: Assuming a payer health plan size of 1 million patients, the model predicted cost savings with the introduction of WavelinQ of $3.6 million ($5,959 per patient) over 1 year. These cost savings were attributed to less subsequent interventions with WavelinQ (i.e., reduced by 0.92 per patient). From a provider perspective, the upfront cost of the WavelinQ procedure was predicted to be offset by avoided direct resources that may likely impact a provider's bottom line. This includes use of the angiography suite rather than operating room (i.e., $2,093 avoided per patient) and less infection-related costs (i.e., $5,355 avoided per patient) with WavelinQ. Conclusions: Use of an endovascular option for AVF access was associated with important cost savings for both the payer and provider compared with current HD access methods. Future study should examine longer term economic benefits of this new procedure.