Exploring the Cost Effectiveness of Shared Decision Making for Choosing between Disease-Modifying Drugs for Relapsing-Remitting Multiple Sclerosis in the Netherlands: A State Transition Model

Abstract

Background Up to 31% of patients with relapsing-remitting multiple sclerosis (RRMS) discontinue treatment with disease-modifying drug (DMD) within the first year, and of the patients who do continue, about 40% are nonadherent. Shared decision making may decrease nonadherence and discontinuation rates, but evidence in the context of RRMS is limited. Shared decision making may, however, come at additional costs. This study aimed to explore the potential cost-effectiveness of shared decision making for RRMS in comparison with usual care, from a (limited) societal perspective over a lifetime. Methods An exploratory economic evaluation was conducted by adapting a previously developed state transition model that evaluates the cost-effectiveness of a range of DMDs for RRMS in comparison with the best supportive care. Three potential effects of shared decision making were explored: 1) a change in the initial DMD chosen, 2) a decrease in the patient’s discontinuation in using the DMD, and 3) an increase in adherence to the DMD. One-way and probabilistic sensitivity analyses of a scenario that combined the 3 effects were conducted. Results Each effect separately and the 3 effects combined resulted in higher quality-adjusted life years (QALYs) and costs due to the increased utilization of DMD. A decrease in discontinuation of DMDs influenced the incremental cost-effectiveness ratio (ICER) most. The combined scenario resulted in an ICER of €17,875 per QALY gained. The ICER was sensitive to changes in several parameters. Conclusion This study suggests that shared decision making for DMDs could potentially be cost-effective, especially if shared decision making would help to decrease treatment discontinuation. Our results, however, may depend on the assumed effects on treatment choice, persistence, and adherence, which are actually largely unknown.

How have Economic Evaluations in Relapsing Multiple Sclerosis Evolved Over Time? A Systematic Literature Review

“…In terms of the funding source, of the 81 studies reporting their funding source, only one study was funded by a university [ 42 ]. A majority of studies were funded by pharmaceutical companies ( n = 65), while seven studies were funded by government institutions ( n = 7) [ 40 , 62 – 67 ]; eight studies received no funding [ 43 , 68 – 74 ].…”

“…Thirteen studies in the UK [ 37 , 46 , 49 , 63 , 70 , 112 , 113 , 128 , 144 , 146 , 151 , 166 , 169 ], seven studies in the USA [ 40 , 41 , 71 – 73 , 114 , 137 ], and 11 studies in Europe [ 50 , 76 , 130 , 132 , 140 , 142 , 145 , 147 , 158 , 170 , 171 ] referred to published country-specific studies to derive utility inputs. Country-specific studies were used whenever available, while data from published studies from other countries were used in 12 studies [ 40 , 64 , 66 , 74 , 114 , 119 , 124 , 149 , 150 , 154 , 156 , 163 ] and five HTAs [ 98 – 100 , 102 , 161 ]. The most common publication referred to by the UK studies was that of Orme et al [ 172 ] ( n = 8) [ 46 , 49 , 70 , 112 , 113 , 128 , 144 , 166 ], while in the USA, the most common publication referred to was that of Prosser et al [ 173 ] ( n = 4) [ 71 – 73 , 137 ].…”

“…A complete list of the type of economic evaluation employed by the studies is available in the ESM In terms of the funding source, of the 81 studies reporting their funding source, only one study was funded by a university [42]. A majority of studies were funded by pharmaceutical companies (n = 65), while seven studies were funded by government institutions (n = 7) [40,[62][63][64][65][66][67]; eight studies received no funding [43, [68][69][70][71][72][73][74].…”

Modeling the Cost-Utility of Treatment Sequences for Multiple Sclerosis

“…4 Recent models incorporated second line treatments, but subsequent treatments were not uniquely identifiable because they were incorporated as a weighted average of alternatives. 5,18 In addition, 2 treatment lines likely do still not reflect the switching behavior in clinical practice: in The Netherlands, 5% of patients already switched to a third treatment line within 5 years. 6 Therefore, to our knowledge, this is the first publication on a complete treatment sequence cost-utility model for MS.…”

“…Cost-utility models in multiple sclerosis (MS) can be improved by incorporating treatment sequences to better reflect clinical practice. [1][2][3][4][5] Currently, cost-utility models for MS generally compare treatments under the assumption of lifetime usage, 2 while in reality, approximately half of patients switch to another MS drug within 5 years because of side effects or reduced treatment efficacy over time. 6 This study addresses treatment switching and other limitations in cost-utility models for MS using a microsimulation model.…”