Cost-Effectiveness Analysis of Stratified Versus Stepped Care Strategies for Acute Treatment of Migraine
- 85 Downloads
Background: The Disability in Strategies for Care (DISC) study was the first large randomised controlled trial to compare alternative treatment strategies in the acute treatment of migraine. With 835 patients in its intention-to-treat efficacy analysis, DISC compared a stratified care strategy, where initial therapy was based on clinical need as determined by the Migraine Disability Assessment Scale (MIDAS) and two stepped care strategies (across attacks and within attacks), where first-line therapy with a simple combination analgesic was escalated, if response had been inadequate, to zolmitriptan, a migraine-specific therapy.
Objective: To report on the cost effectiveness of these three strategies from a societal perspective.
Study design and methods: A cost-effectiveness analysis was undertaken using data from the DISC study, and including both health service and productivity costs. Data were collected prospectively on drug usage (main therapy and rescue medication); resource use associated with adverse events was estimated by a clinician blinded to treatment strategy. Health service resource use was costed using UK unit costs (1999 to 2000 values). Data were collected using diary cards on the amount of time patients lost from work, and on reduced effectiveness at work, due to a migraine attack. This facilitated an estimate of the productivity costs associated with the treatment strategies. To assess cost effectiveness, the differences in costs between the strategies were related to the two primary outcome measures in the trial: headache response 2 hours after initial therapy and disability-adjusted time during the first 4 hours after initial therapy.
Results: Although the mean health service cost was higher in the stratified care group (mean over 6 attacks of £28.25 versus £11.74 and £23.15 in the stepped care across attacks group and within attacks group, respectively), mean productivity costs over 6 attacks were lower in the stratified group (£112.22 versus £144.70 and £127.53). The total mean cost over six attacks was, therefore, lowest in the stratified care group (£138.95 compared with £157.19 in the stepped care across attacks group and £148.53 in the stepped care within attacks group), although these differences did not reach statistical significance. In terms of headache response, stratified care was statistically significantly more effective than both forms of stepped care. Using disability-adjusted time, stratified care was statistically significantly more effective than stepped care across attacks, but not against stepped care within attacks.
Conclusion: Given its lower mean costs and higher mean effectiveness, a stratified care strategy, which included zolmitriptan, was the dominant strategy and was unequivocally more cost effective from a societal perspective than either stepped care strategy. When the uncertainty around these means was considered, stratified care had the highest probability of being cost effective.
- 1.Saper JR, Silberstein S, Gordon CD, et al., editors. Handbook of headache management: a practical guide to diagnosis and treatment of head, neck and facial pain. Baltimore (MD): Williams and Wilkins, 1993Google Scholar
- 3.Pryse-Phillips WE, Dodick DW, Edmeads JG. Guidelines for the diagnosis and management of migraine in clinical practice. Canadian Headache Society. CMAJ 1997; 156: 1273–87Google Scholar
- 5.Lipton RB, Stewart WF. Clinical applications of zolmitriptan (Zomig, 311C90). Cephalalgia 1997; 18: 530–9Google Scholar
- 10.Stewart WF, Lipton RB, Kolodner KB. Validity of the Migraine Disability Assessment (MIDAS) score in comparison to a diary-based measure in a population sample of migraine sufferers. Pain. In pressGoogle Scholar
- 11.British Medical Association, Royal Pharmaceutical Society of Great Britain. British National Formulary. London: British Medical Association and the Royal Pharmaceutical Society of Great Britain, no. 39, 2000 MarGoogle Scholar
- 12.Netten A, Dennett J, Knight J. Unit costs of health and social care. Canterbury: Personal Social Services Research Unit, University of Kent, 1999Google Scholar
- 13.Chartered Institute of Public Finance and Accountancy (CIPFA). The Health Service Database 1999. Croydon: CIPFA, 1999Google Scholar
- 14.MEDTAP International. Database of International Unit Costs for Economic Evaluation in Health Care. London: MEDTAP International Inc, 1999Google Scholar
- 15.Gold MR, Siegel JE, Russell LB, et al., editors. Cost-effectiveness in health and medicine. New York (NY): Oxford University Press, 1996Google Scholar
- 17.Office for National Statistics. Monthly digest of statistics, April. London: The Stationary Office, 2000Google Scholar
- 19.Efron B, Tibshirani R. An introduction to the bootstrap. New York (NY): Chapman & Hall, 1993Google Scholar
- 28.Canadian Coordinating Centre for Health Technology Assessment (CCHOTA). Guidelines for Economic Evaluation of Pharmaceuticals: Canada. Ottawa: 1997Google Scholar
- 29.Commonwealth of Australia. Guidelines for the Pharmaceutical Industry on Preparation of Submissions to the Pharmaceutical Benefits Advisory Committee: Including Major Submissions Involving Economic Analyses. Canberra: Australian Government Publication Service, 1995Google Scholar
- 30.Health Insurance Council. Dutch guidelines for pharmacoeconomic research. Amsterdam: Health Insurance Council, 1999Google Scholar