Abstract
BACKGROUND: Patients with advanced Parkinson’s disease (PD) usually experience motor complications including dyskinesia and on-off fluctuations or off-state, defined as the amount of time spent with poor or absent motor function per waking hours, which substantially impact on the quality of life and cost of treatments. Current treatment guidelines included dopamine agonist or monoamine oxidase B (MAO-B) inhibitors or catechol-o-methyl transferase (COMT) inhibitors as adjunct treatment to Levodopa. The benefit of these treatments could affect to reduce the amount of time spent in off state and physical disabilities. Because of those treatments are still expensive and there was a limited cost-effectiveness study of anti-Parkinson drugs in advanced PD in Thailand, the cost–effective study is an important tool to inform policy decision making. Moreover, the results of this study will be used to support policy makers to determine whether the treatments should be included into the National list of essential medicines (NLEM). OBJECTIVES : The objectives of this analysis were to evaluate cost-utility of continuous subcutaneous apomorphine infusion (Apomorphine) + Levodopa tablet (tab.) and Rasagiline tab. + Levodopa tab. compared with Entacapone tab. + Levodopa tab in advanced PD patients and to estimate budget impact for providing drug treatment in next 5 years. METHODS: Markov model was used to estimate relevant costs and health outcomes using a lifetime horizon from societal and government perspectives. Direct medical and direct nonmedical costs were collected. Health outcomes were life years (LYs) and quality adjusted life years (QALYs). The results were presented as the incremental cost-effectiveness ratio (ICER) in Thai baht (THB) per LYs and QALYs. Costs and outcomes were discounted by 3% per year. Oneway and probabilistic sensitivity analyses were performed to investigate effects of model variable uncertainties on the results. RESULTS: Base on societal perspective, Apomorphine + Levodopa could reduce off-time and delay disability which resulted in increasing life years and quality of life compared with Entacapone tab. + Levodopa tab. The ICER value of lifetime treatment was 3,532,143 THB/QALY. In case that dropout rate was 55% and lifetime treatment was assumed, the ICER value was higher than that of providing 5-year treatment (3,426,000 and 2,997,588 THB/QALY, respectively). In those receiving treatment for 4, 3, 2 and 1 years, the ICER were 2,952,609, 2,944,111, 3,280,817 and 4,966,960 THB/QALY, respectively. Moreover, Rasagiline + Levodopa treatment could decrease off-time the same as Entacapone + Levodopa, whereas the cost of Rasagiline was higher than Entacapone (ICER value=1,551,447 THB/QALY). The additional budget required for providing Apomorphine for recent patients (18 cases) and new case (10 cases) was 6.9 million THB per year. Moreover, providing Rasagiline for recent patients (25,322 cases) and new case (595 cases) was 138 million THB per year. CONCLUSIONS: Based on the willingness to pay threshold 160,000 THB/QALY, Apomorphine + Levodopa and Rasagiline + Levodopa would not be cost-effective compared with Entacapone tab. in Advanced PD patients, in recent drug price. However, based on the cost-effective threshold, the price of Apomorphine and Rasagiline should be reduced by 90% and 25%, respectively.
