Cost-effectiveness analysis of atypical long-acting antipsychotics for treating chronic schizophrenia in Finland

Figures & data

Figure 1. Pharmacoeconomic decision tree model comparing PP-LAI (paliperidone palmitate; Xeplion®), OLZ-LAI (olanzapine pamoate; Zypadhera®), and RIS-LAI (risperidone; Risperdal Consta®) for chronic schizophrenia in Finland.

Table 1. Doses used to treat patients (source of data).

Drug	Stable disease	Relapsed (treated as out-patient)	Relapsed (treated as in-patient)
PP-LAI	69.3 mg monthly (Gopal et al.24, Fleischhacker et al.25)	84.9 mg every 4 weeks (Gopal et al.26, Pandina et al.27, Hough et al.28, Nasrallah et al.29, Pandina et al.30)	150 mg week 1, 100 mg week 2, then 82.8 mg every 4 weeks maintenance (Xeplion® Product monograph18, Hough et al.31)
RIS-LAI	40.3 mg every 2 weeks (Fleischhacker et al.25, Kissling et al.32, Lee et al.33, Lindenmayer et al.34, Olivares et al.35)	50 mg every 2 weeks (Risperdal Consta® Product monograph14 maximum dose*)	50 mg every 2 weeks (Risperdal Consta® Product monograph23 maximum dose*)
OLZ-LAI	432 mg every 4 weeks (Kane et al.36)	473 mg every 4 weeks (Lauriello et al.37)	300 mg every 2 weeks × 3 doses (as per Zypadhera® Product Monograph16), then 473 mg every 4 weeks maintenance (Lauriello et al.37)

LAI, long-acting injection; OLZ, olanzapine pamoate (Zypadhera®); PP, paliperidone palmitate (Xeplion®); RIS, risperidone microspheres (Risperdl Consta®).

*Three trials by Chue et al.38, Eerdekens et al.39, and Kane et al.13 had an average dose of 58.2 mg; however, those trials also included a dose of 75 mg, which is not commercially available and exceeds the maximum dose of 50 mg recommended in the Risperdal Consta® Product monograph23.

Table 2. Probability rates used in the model and sources of information.

Drug	Clinical rate or proportion	Rate—adherent (Source)	Rate—not adherent (Source)
PP-LAI	Adherence rate	0.872 (Assumption: RIS-LAI rate from Olivares et al.40, adjusted via Mehnert and Diels14)	0.128 (Calculation: 1 – adherence rate)
	Disease in remission	0.803 (Calculation [1 – sum of ER + hospital relapse rates])	0.148 (weighted average placebo rate from Hough et al.31 and Kane et al.36)
	Relapse treated in ER	0.059 (Calculation: hospitalization rate × ratio of ER visits: hospitalizations, per Ascher-Svanum et al.41)	0.299 (Calculation: 1 – [sum of ER + hospital relapse rates])
	Relapse–hospitalized	0.138 (Gopal et al.24, Hough et al.31, adjusted for adherence as per Weidenet al.42)	0.553 (Morken et al.43)
RIS-LAI	Adherence rate	0.823 (Olivares et al.40)	0.177 (Calculation: 1 – adherence rate)
	Disease in remission	0.763 (Calculation [1 – sum of (relapse rate + ER relapse rate)])	0.140 (Kane et al.36)
	Relapse treated in ER	0.071 (Ratio of ER visits: hospitalizations41)	0.274 (Calculation [1 – sum of relapse rates])
	Relapse–hospitalized	0.166 (Olivares et al.35)	0.586 (Assumption; PP rate was adjusted based on calculations by Mehnert and Diels14)
OLZ-LAI	Adherence rate	0.803 (Ascher-Svanum et al.41)	0.197 (Calculation: 1 – adherence rate)
	Disease in remission	0.793 (Kane et al.36)	0.148 (weighted average placebo rate from Hough et al.31 and Kane et al.36)
	Relapse treated in ER	0.062 (Kane et al.36)	0.299 (Calculation: 1 – [sum of ER relapse + hospital relapse rates])
	Relapse–hospitalized	0.145 (Calculation: 1 – [remission rate + ER relapse rate])	0.553 (Assume equal to PP-LAI)

ER, emergency room; LAI, long-acting injection; OLZ-LAI, olanzapine pamoate (Zypadhera®); PP-LAI, paliperdone palmitate (Xeplion®); RIS-LAI, risperidone microshperes (Risperdal Consta®).

Table 3. Costs (in 2011 euros) used in the model.

Resource	Item	Cost	Data source
Pharmacotherapy	Clozapine tablets	€0.004/mg	SLD Price list48
	OLZ-LAI	€0.89/mg	SLD Price list48
	PP-LAI	€4.31/mg	SLD Price list48
	RIS-LAI	€4.69/mg	SLD Price list48
Healthcare professionals	Psychiatrist: out-patient (per visit)	€144.96	Hujanen et al.49
	Psychiatrist: in-patient (per visit)	€260.00	Hus Palveluhinnasto50
	Primary care physician (per visit)	€100.80	Hujanen et al.49
	Psychiatric nurse (per visit)	€38.19	Hujanen et al.49
Institutional care	Hospital: emergency room (per visit)	€191.04	Hujanen et al.49
	Hospital: acute psychiatric (per day)	€623.57	Hujanen et al.49
	Hospital: psychiatric rehab (per day)	€283.63	Hujanen et al.49
	Hospital: long-term ward (per day)	€120.11	Hujanen et al.49
	General hospital ward (per day)	€150.61	Hujanen et al.49
	Day hospital (per day)	€197.65	Hujanen et al.49
	Day care centre visit	€120.32	Hujanen et al.49

LAI, long-acting injection; OLZ-LAI, olanzapine pamoate (Zypadhera®); PP-LAI, paliperdone palmitate (Xeplion®); RIS-LAI, risperidone microshperes (Risperdal Consta®).

Table 4. Results of the economic analysis.

	Clinical outcomes
Drug sequence	Relapse days	Emergency room visits	Hospitali-zations	Cost*/ patient	QALYs/ patient	Incremental cost†	Incremental QALYs†	Cost/ QALY	Economic outcome
PP-LAI―OLZ-LAI	34.5	0.127	0.252	€10,380	0.817			€12,701	dominant
OLZ-LAI―PP-LAI	39.4	0.142	0.291	€12,145	0.810	−€1765	−0.0071	€14,992	dominated
RIS-LAI―OLZ-LAI	39.3	0.134	0.298	€12,074	0.809	−€1694	−0.0085	€14,929	dominated

LAI, long acting injection; PP, paliperidone palmitate (Xeplion®); OLZ-LAI, olanzapine pamoate (Zypadhera®); RIS, risperidone microspheres (Risperdal Consta®); QALY, quality adjusted life years.

*All costs are in 2011 euros.

†Due to the dominance of PP-LAI, all increments are subtracted from those of PP-LAI.

Figure 2. Tornado diagram for incremental cost (PP-LAI vs OLZ-LAI), top 20 values.

Figure 3. Tornado diagram for incremental cost (PP-LAI vs RIS-LAI), top 20 values.

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