Cost and Effectiveness of Select Treatments
- Based on clinical trial data, identify which one of the treatments listed in the following pairs presents the best value in terms of relative cost and effectiveness:
- Cefaly versus metroproprolol
- Botox versus placebo
- List 2 strategies used by insurance companies to manage the value of migraine therapies, and specifically Botox.
- Identify at least one resource for keeping up to date about the comparative effectiveness and cost-effectiveness of various migraine treatment options.
Cost-Effectiveness of Cefaly vs. Metroprolol
- Based in clinical trial data and gold-standard methods for economic evaluation,
- Cefaly is both more expensive and less effective than metropolol, a commonly used generic medication for episodic migraine:
|Treatment||Patients with >= 50% reduction in migraine frequency||Annual treatment cost||Incremental Cost-effectiveness ratio|
|Cephaly||382 per 1,000||$449 (2014 costs)||Dominated|
|Metroprolol||395 per 1,000||$49||Dominant|
- The difference is so large that for Cephaly to become dominant, it would have to have nearly double its effectiveness and cut its price by about 85% (to $76).
Cost-Effectiveness of BOTOX
Trials compared BOTOX to sham injections only. Among patients with very high baseline frequencies of migraine (20 days per month), BOTOX is cost-effective ($4 per migraine day averted). The placebo effect was powerful in studies, however, ad cost-effectiveness falls with reduced frequency.
|Trial||Treatment and Control Groups||N||Headache Days Per Month||Daily cost of chronic migraine management|
|Preempt 2 (Europe, N America 66 Centers)||Sham injections||358||13.4||0|
2 Insurance Strategies to Manage Value
- Migraine etiology and specific classification raise many questions, making precise targeting of treatment difficult.
- Botox: The high cost compared to other therapies and the strong placebo effect found in clinical trials have led many insurers to use:
- Step therapy (i.e., limiting Botox use to only patients who failed to have treatment success on other effective therapeutic options (e.g., triptans).)
- Stopping rules for lack of response to treatment
Example Coverage for BOTOX Prophylaxis
- Recommended for prophylaxis of:
- headache in adults with chronic migraine (defined as headaches on at least 15 days per month of which at least 8 days are with migraine):
- Requires Step Therapy: Use only for patients who have not responded ≥ 3 prior pharmacological prophylaxis therapies and
- whose condition is appropriately managed for medication overuse.
- Stopping Rules:
- < 30% reduction in headache days per month after two treatment cycles) or
- Changed to episodic migraine (defined as fewer than 15 headache days per month) for 3 consecutive months.
Limited evidence for the value of various medication options
- Medications not labelled for migraine are often covered to increase both affordability and management options.
- Studies of the outcomes and costs produced by medication are needed.
- To keep track of developments in the value of migraine treatments, see:
- Institute for Clinical and Economic Review (https://icer-review.org/)
- National Institute for Clinical Evaluation, United Kingdom.
- US Medicare:
Institute for Clinical and Economic Review. (2014) Action plan for the treatment of migraine: Payers and policymakers.