Pharmacoeconomics of long-acting atypical antipsychotics for acutely relapsed chronic schizophrenia in Finland

Figures & data

Figure 1. Decision tree used in this analysis.

Table 1. Model inputs and their sources.

Patient state	Drug	Item	Value	Source
Hospitalized	All	Utility	0.490	Average of Lenert et al.19 and Revicki et al.20
	ARI-LAI	Regimen	2 weeks of oral aripiprazole 12.8 mg + 400 mg ARI-LAI, then every 4 weeks	Abilify Maintena Product Summary21, Kane et al.22
		Response @ 13 weeks	0.429	Kane et al.23, placebo adjusted using Bucher et al.’s24 method
		Response @ 26 weeks	0.167	Calculation based on 26-week rate from Kane et al.23 and 13-week response rate
	OLZ-LAI	Regimen	300 mg every 2 weeks ×3, then 473 mg every 4 weeks	Zypadhera Product Summary25, Lauriello et al.26
		Response @ 13 weeks	0.427	Lauriello et al.26, placebo adjusted using Bucher et al.’s24 method
	PP-LAI	Regimen	150 mg week 1, 100 mg week 2, then 82.8 mg monthly maintenance	Xeplion Summary of Product Characteristics27, Hough et al.28
		Response @ 13 weeks	0.360	Average of Gopal et al.29, Kramer et al.30, Nasrallah et al.31, Pandina et al.32, Takahashi et al.33, placebo adjusted using Bucher et al.’s24 method
		Response @ 26 weeks	0.455	Calculation based 13-week response rate and assume 26-week rate equals OLZ-LAI
	RIS-LAI	Regimen	50 mg every 2 weeks	Maximum dose as per Risperdal Consta EMA Product Summary34; Pandina et al.35; Meltzer et al.36
		Response @ 13 weeks	0.337	Pro-rated from PP-LAI using the average from head-to-head trials by Fu et al.37, Li et al.38, Pandina et al.35
		Response @ 26 weeks	0.412	Calculation based on pro-rated PP-LAI rate and 13-week response rate
Relapsed, treated in ER	All	Utility	0.659	Briggs et al.39, Cummins et al.40, Lenert et al.19
	ARI-LAI	Regimen	2 weeks of oral aripiprazole 12.8 mg + 400 mg ARI-LAI, then every 4 weeks	Abilify Maintena Product Summary21, Kane et al.22
	OLZ-LAI	Regimen	473 mg every 4 weeks	Lauriello et al.26
	PP-LAI	Regimen	84.9 mg monthly	Average of Gopal et al.29, Hough et al.41, Nasrallah et al.31, Pandina et al.32^,35
	RIS-LAI	Regimen	50 mg every 2 weeks	Maintenance dose pro-rated as per PP-LAI
Stable disease	All	Utility	0.890	Average of Briggs et al.34, Cummins et al.35, Lenert et al.19, Oh et al.42, Revicki et al.20
	ARI-LAI	Adherence rate	0.730	Average of other three drugs
		Rate of stable disease	0.887	Kane et al.43; placebo adjusted as per Bucher et al.24
		Hospitalization rate	0.079	Relapse rate from Kane et al.43 adjusted using Ascher-Svanum et al.44 ratio of Hospitalizations:ER visits
		ER visit rate	0.034	Relapse rate from Kane48 adjusted using Ascher Svanum44 ratio of ER visits:Hospitalizations
		Dropout rate (LoE + AEs)	0.204	Average from all placebo-controlled trials of acute treatment (Kane et al.22, Potkin et al.45, McEvoy et al.46, Kane et al.47); placebo adjusted as per Bucher et al.24
		Regimen	396.3 mg every 4 weeks	Kane et al.43 (96.3% received 400 mg, 3.7% received 300 mg); Fleischhacker et al.48
	OLZ-LAI	Adherence rate	0.731	Detke et al.49
		Rate of stable disease	0.826	Kane et al.50
		Hospitalization rate	0.122	Kane et al.50; adjusted for adherence51
		ER visit rate	0.052	Calculation: 1 – (other rates)
		Dropout rate (LoE + AEs)	0.212	Lauriello et al.26 rate, placebo adjusted
		Regimen	432 mg every 4 weeks Adjunct: oral 10.8 mg/day for 31 days (21% of patients)	Kane et al.50; Ascher-Svanum et al.52
	PP-LAI	Adherence rate	0.749	Asseburg et al.53 rate for RIS-LAI adjusted via Mehnert and Diels54
		Rate of stable disease	0.836	Calculation: 1 - Relapse rate from Hough et al.28, adjusted for placebo using Bucher et al.’s24 method
		Hospitalization rate	0.115	Relapse rate from Hough et al.28 adjusted using Ascher Svanum et al.44 ratio of Hospitalizations:ER visits
		ER visit rate	0.049	Relapse rate from Hough et al.28 adjusted using Ascher Svanum et al.44 ratio of ER visits: Hospitalizations
		Dropout rate (LoE + AEs)	0.202	Rates from placebo controlled acute treatment: Gopal et al.29, Pandina et al.35, placebo adjusted24
		Regimen	69.3 mg monthly	Gopal et al.55, Fleischhacker et al.56
	RIS-LAI	Adherence rate	0.709	Asseburg et al.53
		Rate of stable disease	0.763	Calculation: 1 – (Hospitalization rate + ER visit rate) adjusted for adherence via Weiden et al.51
		Hospitalization rate	0.166	Olivares et al.57 adjusted for adherence via Weiden et al.51
		ER visit rate	0.071	Calculation: 1 – (Hospitalization + Stable rates)
		Dropout rate (LoE + AEs)	0.117	OLZ-LAI rate x ratio from Ascher-Svanum et al.58
		Regimen	40.3 mg every 2 weeks + adjunct: 3.2 mg/day for 43 days (22% of patients)	Average of Fleischhacker et al.56, Kissling et al.59, Lee et al.60, Lindenmayer et al.61, Möller et al.62, and Olivares et al.63
Non-adherent	All drugs	Stable disease	0.234	Average of Hough et al.28 and Kane et al.43 placebo non-relapse rates at 1 year
		Relapses (hospitalized)	0.556	Adjust relapse rate via Ascher-Svanum et al.44 Hospitalization:ER ratio for non-adherent patients
		Relapses treated in ER	0.209	Adjust relapse rate via Ascher-Svanum et al.44 ER: Hospitalization ratio for non-adherent patients

AE, adverse event; ARI, aripiprazole; ER, emergency room; LAI, long-acting injectable; LoE, lack of efficacy; OLZ, olanzapine; PP, paliperidone; RIS, risperidone.

Table 2. Cost inputs used in the model (2015 euros).

Cost centre	Resource	Cost/unit	Data source
Drugs*	PP-LAI	4.25	SLD price list64
	RIS-LAI	4.63	SLD price list64
	OLZ-LAI	0.887	SLD price list64
	ARI-LAI	0.824	SLD price list64
	Risperidone	0.2674	SLD price list64
	Olanzapine	0.024	SLD price list64
	Aripiprazole	0.2291	SLD price list64
	Clozapine	0.0064	SLD price list64
	Lorazepam	0.0646	SLD price list64
	Clozapine level	12.64	Kliinisen Kemian Laboratoriotutkimusten65
	Blood count	7.00	Kliinisen Kemian Laboratoriotutkimusten65
Health professionals	Psychiatrist-outpatient visit	171.25	Kapiainen et al.66
	Primary care physician	116.28	Kapiainen et al.66
	Psychiatric nurse	50.74	Kapiainen et al.66
Hospitals/facilities	Emergency room visit	256.87	Kapiainen et al.66
	Acute psychiatric ward	731.50	Kapiainen et al.66
	Psychiatric rehab ward	431.29	Kapiainen et al.66
	Long-term ward	201.90	Kapiainen et al.66
	General medical ward	225.16	Kapiainen et al.66
	Day hospital	206	HUS Palveluhinnasto 201467
	Day care centre visit	162	HUS Palveluhinnasto 201467

*All drugs are costed using the average price per milligram across all strengths.

ARI, aripiprazole; LAI, long acting injectable; OLZ, olanzapine; PP, paliperidone palmitate; RIS, risperidone.

Table 3. Clinical and economic outcomes.

Long acting antipsychotic	Cost/patient*	QALY	Economic outcome	Days with stable disease	ER visits	Hospital re-admissions
Paliperidone	€41,148	0.683	Dominant	132.0	0.039	0.236
Aripiprazole	€41,543	0.671	Dominated	122.6	0.041	0.285
Risperidone	€42,067	0.666	Dominated	114.4	0.050	0.288
Olanzapine	€45,406	0.672	Dominated	125.5	0.052	0.283

ER, emergency room; QALY, quality adjusted life-year.

*All costs are in 2015 euros.

Results of the one-way (break-even) sensitivity analyses.

Parameter	Drug rate changed	Base case	Comparison drug	Value where PP-LAI cost not lowest	% difference	Value where PP-LAI QALYs not highest	% difference
Adherence	PP-LAI	74.9%	ARI-LAI	66.6%	−8.3%	44.7%	−30.2%
			RIS-LAI	55.5%	−11%	31.8%	−43.1%
			OLZ-LAI	resistant	n/a	46.3%	−28.6%
	ARI-LAI	73.0%	PP-LAI	78.0%	+5.0%	99.5%	+26.5%
	RIS-LAI	70.9%	PP-LAI	88.5%	+17.6%	resistant	n/a
	OLZ-LAI	73.1%	PP-LAI	resistant	n/a	98.3%	+25.2%
Dropout rate (LoE + AEs)	PP-LAI	20.2%	ARI-LAI	26.2%	+6.0%	42.6%	+22.4%
			RIS-LAI	34.2%	+14.0%	52.2%	+32.0%
			OLZ-LAI	84.8%	+64.6	41.4%	+21.2%
	ARI-LAI	20.4%	PP-LAI	14.3%	−6.1%	resistant	n/a
	RIS-LAI	30.4%	PP-LAI	14.3%	−16.1%	resistant	n/a
	OLZ-LAI	21.2%	PP-LAI	resistant	n/a	resistant	n/a
Stable disease/relapse	PP-LAI	83.6%	ARI-LAI	80.9%	−2.7%	63.0%	−23.6%
			RIS-LAI	77.4%	−6.2%	54.2%	−29.4%
			OLZ-LAI	55.1%	−28.5%	67.1%	−19.5%
	ARI-LAI	88.7%	PP-LAI	93.5%	+4.8%	resistant	n/a
	RIS-LAI	76.3%	PP-LAI	92.1%	+15.8%	resistant	n/a
	OLZ-LAI	82.6%	PP-LAI	resistant	n/a	resistant	n/a
Drug price (per mg)	PP-LAI	4.251€	ARI-LAI	4.73€	+11.3%	n/a*	n/a
			RIS-LAI	5.35€	+25.9%	n/a*	n/a
			OLZ-LAI	9.33€	+113%	n/a*	n/a
	ARI-LAI	0.824€	PP-LAI	0.705€	−14.4%	n/a*	n/a
	RIS-LAI	4.632€	PP-LAI	2.60€	−43.9%	n/a*	n/a
	OLZ-LAI	0.887€	PP-LAI	resistant	n/a	n/a*	n/a
Institutional costs	All costs		ARI-LAI		−56%†	n/a*	n/a
			RIS-LAI	resistant	n/a
			OLZ-LAI	resistant	n/a
Adherence (2nd line)	all	40.0%	ARI-LAI	all resistant	n/a	all resistant	n/a
			RIS-LAI
			OLZ-LAI
Clozapine success	clozapine	40.2%	ARI-LAI	53.2%	+13.0%	all resistant	n/a
			RIS-LAI	resistant	n/a
			OLZ-LAI	resistant	n/a
Drug maintenance dose	PP-LAI	69.3 mg	ARI-LAI	99 mg	+42.4%	n/a	n/a
			RIS-LAI	138 mg	+99.1%	n/a	n/a
			OLZ-LAI	386 mg	+457%	n/a	n/a
	ARI-LAI	396.3 mg	PP-LAI	228 mg	−42.5%	n/a	n/a
	RIS-LAI	40.3 mg	PP-LAI	2.6 mg	−93.5%	n/a	n/a
	OLZ-LAI	432 mg	PP-LAI	resistant	n/a	n/a	n/a

*Costs have no impact on outcomes.

†All costs resistant to increases; all hospital and related costs would have to be reduced by that percentage for comparison drug costs to be lower than PP-LAI.

AEs, adverse events; ARI, aripiprazole; LAI, long acting injectable; LoE, lack of efficacy; n/a, not applicable; OLZ, olanzapine pamoate; PP, paliperidone palmitate; QALY, quality adjusted life year; RIS, risperidone.

Lenert LA, Sturley AP, Rapaport MH, et al. Public preferences for health states with schizophrenia and a mapping function to estimate utilities from positive and negative symptom scale scores. Schiz Res 2004;71:155-75

 PubMed Web of Science ®Google Scholar

Revicki DA, Shakespeare A, Kind P. Preferences for schizophrenia-related health states: a comparison of patients, caregivers and psychiatrists. Int Clin Psychopharmacol 1996;11:101-8

 PubMed Web of Science ®Google Scholar

Abilify Maintena® summary of product characteristics. London, UK: European Medicines Agency, http://www.ema.europa.eu/docs/en_GB/document_library/EPAR_-_Product_Information/human/002755/WC500156111.pdf. Accessed May 3, 2015

 Google Scholar

Kane JM, Peters-Strickland T, Baker RA, et al. Aripiprazole once-monthly in the acute treatment of schizophrenia: findings from a 12-week, randomized, double-blind, placebo-controlled study. J Clin Psychiatry. J Clin Psychiatry 2014;75:1254-60

 PubMed Web of Science ®Google Scholar

Kane JM, Osuntokun O, Kryzhanovskaya LA, et al. A 28-week, randomized, double-blind study of olanzapine versus aripiprazole in the treatment of schizophrenia. J Clin Psychiatry 2009;70:572-81

 PubMed Web of Science ®Google Scholar

Bucher HC, Guyatt GH, Griffith LE, et al. The results of direct and indirect treatment comparisons in meta-analysis of randomized controlled trials. J Clin Epidemiol 1997;50:683-91

 PubMed Web of Science ®Google Scholar

Zypadhera Summary of product characteristics. London, UK: European Medicines Agency, 2013. http://www.ema.europa.eu/docs/en_GB/document_library/EPAR_-_Product_Information/human/000890/WC500054429.pdf. Accessed May 5, 2015

 Google Scholar

Lauriello J, Lambert T, Andersen S, et al. An 8-week, double-blind, randomized, placebo controlled study of olanzapine long-acting injection in acutely ill patients with schizophrenia. J Clin Psychiatry 2008;69:790-9

 PubMed Web of Science ®Google Scholar

Xeplion Summary of product characteristics. London, UK: European Medicines Agency, 2013. http://www.ema.europa.eu/docs/en_GB/document_library/EPAR_-_Product_Information/human/002105/WC500103317.pdf. Accessed May 6, 2015

 Google Scholar

Hough D, Gopal S, Vijapurkar U, et al. Paliperidone palmitate maintenance treatment in delaying the time-to-relapse in patients with schizophrenia: a randomized, double-blind, placebo-controlled study. Schizophr Res 2010;116:107-17

 PubMed Web of Science ®Google Scholar

Gopal S, Hough DW, Xu H, et al. Efficacy and safety of paliperidone palmitate in adult patients with acutely symptomatic schizophrenia: a randomized, double-blind, placebo-controlled, dose-response study. Int Clin Psychopharmacol 2010;25:247-56

 PubMed Web of Science ®Google Scholar

Kramer M, Litman R, Hough D, et al. Paliperidone palmitate, a potential long-acting treatment for patients with schizophrenia. Results of a randomized, double-blind, placebo-controlled efficacy and safety study. Int J Neuropsychopharmacol 2010;13:635-47

 PubMed Web of Science ®Google Scholar

Nasrallah HA, Gopal S, Gassmann-Mayer C, et al. A controlled, evidence-based trial of paliperidone palmitate, a long-acting injectable antipsychotic, in schizophrenia. Neuropsychopharmacology 2010;35:2072-82

 PubMed Web of Science ®Google Scholar

Pandina GJ, Lindenmayer J-P, Lull JM, et al. A randomized, placebo-controlled study to assess the efficacy and safety of 3 doses of paliperidone palmitate in adults with acutely exacerbated schizophrenia. J Clin Psychopharmacol 2010;30:235-44

 PubMed Web of Science ®Google Scholar

Takahashi N, Takahashi M, Saito T, et al. Randomized, placebo-controlled, double-blind study assessing the efficacy and safety of paliperidone palmitate in Asian patients with schizophrenia. Neuropsychiatr Dis Treat 2013;8:1889-98

 PubMed Web of Science ®Google Scholar

European Medicines Agency. Risperdal Consta_ summary of product characteristics. London, UK, 2008. characteristics. http://www.ema.europa.eu/docs/en_GB/document_library/Referrals_document/Risperdal_Consta_30/WC500008170.pdf. Accessed May 5, 2015

 Google Scholar

Pandina G, Lane R, Gopal S, Gassmann-Mayer C, Hough D, Remmerie B, Simpson G. A double-blind study of paliperidone palmitate and risperidone long-acting injectable in adults with schizophrenia. Prog Neuropsychopharmacol Biol Psychiatry 2011;35:218-26

 PubMed Web of Science ®Google Scholar

Meltzer HY, Lindenmayer JP, Kwentus J, et al. A six month randomized controlled trial of long acting injectable risperidone 50 and 100mg in treatment resistant schizophrenia. Schizophr Res 2014;154:14-22

 PubMed Web of Science ®Google Scholar

Fu DJ, Bossie CA, Sliwa JK, et al. Paliperidone palmitate versus oral risperidone and risperidone long-acting injection in patients with recently diagnosed schizophrenia: a tolerability and efficacy comparison. Int Clin Psychopharmacol 2014;29:45-55

 PubMed Web of Science ®Google Scholar

Li H, Rui Q, Ning X, et al. A comparative study of paliperidone palmitate and risperidone long-acting injectable therapy in schizophrenia. Prog Neuropsychopharmacol Biol Psychiatry 2011;35:1002-8

 PubMed Web of Science ®Google Scholar

Briggs A, Wild D, Lees M, et al. Impact of schizophrenia and schizophrenia treatment-related adverse events on quality of life: direct utility elicitation. Health Qual Life Outcomes 2008;6:105

 PubMed Web of Science ®Google Scholar

Cummins C, Stevens A, Kisely S. The use of olanzapine as a first and second choice treatment in schizophrenia. A West Midlands Development and Evaluation Committee Report. Birmingham, UK: Department of Public Health & Epidemiology, University of Birmingham, 1998

 Google Scholar

Hough D, Lindenmayer J-P, Gopal S, et al. Safety and tolerability of deltoid and gluteal injections of paliperidone palmitate in schizophrenia. Prog Neuropsychopharmacol Biol Psychiatry 2009;33:1022-31

 PubMed Web of Science ®Google Scholar

Oh PI, Lanctôt KL, Mittmann N, et al. Cost-utility of risperidone compared with standard conventional antipsychotics in chronic schizophrenia. J Med Econ 2001;4:137-56

 Google Scholar

Kane JM, Sanchez R, Perry PP, et al. Aripiprazole intramuscular depot as maintenance treatment in patients with schizophrenia: a 52-week, multicenter, randomized, double-blind, placebo-controlled study. J Clin Psychiatry 2012;73:617-24

 PubMed Web of Science ®Google Scholar

Ascher-Svanum H, Faries D, Zhu B, et al. Medication adherence and long-term functional outcomes in the treatment of schizophrenia in usual care. J Clin Psychiatry 2006;67:453-60

 PubMed Web of Science ®Google Scholar

Fleischhacker WW1, Sanchez R, Johnson B, et al. Long-term safety and tolerability of aripiprazole once-monthly in maintenance treatment of patients with schizophrenia. Int Clin Psychopharmacol 2013;28:171-6

 PubMed Web of Science ®Google Scholar

Potkin SG, Saha AR, Kujawa MJ, et al. Aripiprazole, an antipsychotic with a novel mechanism of action, and risperidone vs placebo in patients with schizophrenia and schizoaffective disorder. Arch Gen Psychiatry 2003;60:681-90

 PubMed Web of Science ®Google Scholar

McEvoy JP, Daniel DG, Carson WH, et al. A randomized, double-blind, placebo-controlled, study of the efficacy and safety of aripiprazole 10, 15 or 20 mg/day for the treatment of patients with acute exacerbations of schizophrenia. J Psychiatr Res 2007;41:895-905

 PubMed Web of Science ®Google Scholar

Kane JM, Carson WH, Saha AR, et al. Efficacy and safety of aripiprazole and haloperidol versus placebo in patients with schizophrenia and schizoaffective disorder. J Clin Psychiatry. 2002;63:763-71

 PubMed Web of Science ®Google Scholar

Detke HC, Lauriello J, Landry J, McDonnell DP. Within-drug benefit-risk evaluation of olanzapine long-acting injection at one and two years of treatment. Int J Methods Psychiatr Res 2014;23:439-50

 PubMed Web of Science ®Google Scholar

Kane J, Detke H, Naber D, et al. Olanzapine long-acting injection: a 24-week, randomized, double-blind trial of maintenance treatment in patients with schizophrenia. Am J Psychiatry 2010;167:181-9

 PubMed Web of Science ®Google Scholar

Weiden PJ, Kozma C, Grogg A, et al. Partial compliance and risk of rehospitalization among California Medicaid patients with schizophrenia. Psychiatr Serv 2004;55:886-91

 PubMed Web of Science ®Google Scholar

Ascher-Svanum H, Peng X, Montgomery W, et al. Assessing the infrequent oral supplementation of olanzapine long-acting injection in the treatment of schizophrenia. Eur Psychiatry 2011;26:313-19

 PubMed Web of Science ®Google Scholar

Asseburg C, Willis M, Löthgren M, et al. Hospitalisation utilisation and costs in schizophrenia patients in Finland before and after initiation of risperidone long-acting injection. Schizophr Res Treatment 2012;2012:791468

 PubMedGoogle Scholar

Mehnert A, Diels J. Impact of administration interval on treatment retention with long-acting antipsychotics in schizophrenia. Presented at the Tenth Workshop on Costs and Assessment in Psychiatry -Mental Health Policy and Economics; Venice, Italy, 25-27 March 2011

 Google Scholar

Gopal S, Vijapurkar U, Lim P, et al. A 52-week open-label study of the safety and tolerability of paliperidone palmitate in patients with schizophrenia. J Psychopharmacol 2010;25:685-97

 PubMed Web of Science ®Google Scholar

Fleischhacker WW, Gopal S, Lane R, et al. A randomized trial of paliperidone palmitate and risperidone long-acting injectable in schizophrenia. Int J Neuropsychopharmacol 2012;15:107-18

 PubMed Web of Science ®Google Scholar

Olivares J, Peuskens J, Pecanek J, et al. Clinical and resource-use outcomes of risperidone long-acting injection in recent and long-term diagnosed schizophrenia patients: results from a multinational electronic registry. Curr Med Res Opin 2009;25:2197-206

 PubMed Web of Science ®Google Scholar

Ascher-Svanum H, Montgomery WS, McDonnell DP, et al. Treatment-completion rates with olanzapine long-acting injection versus risperidone long-acting injection in a 12-month, open-label treatment of schizophrenia: indirect, exploratory comparisons. Int J Gen Med 2012;5:391-8

 PubMedGoogle Scholar

Kissling W, Heres S, Lloyd K, et al. Direct transition to long-acting risperidone - analysis of long-term efficacy. J Psychopharmacol 2005;19:15-21

 PubMed Web of Science ®Google Scholar

Lee M, Ko Y, Lee S, et al. Long-term treatment with long-acting risperidone in Korean patients with schizophrenia. Hum Psychopharmacol 2006;21:399-407

 PubMed Web of Science ®Google Scholar

Lindenmayer J-P, Khan A, Eerdekens M, et al. Long-term safety and tolerability of long-acting injectable risperidone in patients with schizophrenia or schizoaffective disorder. Eur Neuropsychopharmacol 2007;17:138-44

 PubMed Web of Science ®Google Scholar

Möller H-J, Llorca P-M, Sacchetti E, et al. Efficacy and safety of direct transition to risperidone long-acting injectable in patients treated with various antipsychotic therapies. Int Clin Psychopharmacol 2005;20:121-30

 PubMed Web of Science ®Google Scholar

Olivares JM, Rodrigues-Morales A, Diels J, et al. Long-term outcomes in patients with schizophrenia treated with risperidone long-acting injection or oral antipsychotics in Spain: Results from the electronic Schizophrenia Treatment Adherence Registry (e-STAR). Eur Psychiatry 2009;24:287-96

 PubMed Web of Science ®Google Scholar

IMS Health Oy SLD price. Finland: Suomen LääkeData Oy. http://www.sld.fi/finland.html. Accessed April 22, 2014

 Google Scholar

Price list: Kliinisen Kemian Laboratoriotutkimusten Ja Verivalmisteiden. Hinnasto 2015. Seinäjoki, Finland: Etelä-Pohjanmaan sairaanhoitopiiri, January 1, 2015

 Google Scholar

Kapiainen S, Väisänen A, Haula T. Terveyden- ja sosiaalihuolloin yksikkökustannukset Suomessa vuonna 2011. Raportti 3/2014. Terveyden ja hyvinvoinnin laitos. https://www.julkari.fi/bitstream/handle/10024/114683/THL_RAPO3_2014_web.pdf?sequence=1. Tampere, Finland 2014. Accessed May 3, 2015

 Google Scholar

HUS Palveluhinnasto 2014. Osa 2 Suoriteperusteiset sairaanhoidolliset palvelut. http://www.hus.fi/hus-tietoa/talous/Hinnoittelu/Documents/HUS%20Palveluhinnasto%202014%20OSA%202.pdf. Helsinki, Finland 2014 Accessed May 3, 2015

 Google Scholar