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72 Clinical effectiveness TABLE 61 Results for hyperactivity [MPH high dose (>30 mg/day) versus ATX high dose (≥ 1.5 mg/kg/day)] Study Scale MPH high dose: ATX high dose: Mean mean (SD) mean (SD) difference 7–15 years Kratochvil, 2002 70 ADHD-RS-IV Baseline/change from Baseline/change from MD (95% CI) (hyperactivity/impulsivity) baseline baseline CPRS-R (hyperactivity) 16.95 (7.07)/–8.48 (7.08) 17.77 (6.31)/–9.50 (6.99) 1.02 (–1.40 to 3.44) 10.05 (5.35)/–4.78 (4.49) 10.25 (4.39)/–5.56 (4.74) 0.78 (–0.82 to 2.38) Lower scores represent a better behavioural outcome. ADHD-RS-IV, ADHD Rating Scale–Parent Version (investigator administered and scored); CPRS-R, Conners’ Parent Rating Scale – Revised. Adverse events No significant differences in the incidence of headache, loss of appetite, stomach ache or insomnia were detected between the ATX and MPH treatment groups. In addition, no differences in participants’ mean change in weight were observed. Summary One study was included in this category. 70 No differences were reported between the two drugs for hyperactivity, CGI or adverse events (of interest). This study did not score very well in the quality assessment, and any results should be interpreted with caution. ER-MPH medium dose (20–40 mg/day) versus ATX low/medium dose (
Summary The one study in this category reported a significant improvement in favour of MPH compared with ATX for both hyperactivity and CGI. However, this study also reported a higher incidence of reduced appetite and insomnia in the MPH group, but no differences in headache or stomach ache. [Commercial information removed]. ATX versus DEX No studies directly compared ATX and DEX. The MTA trial (This section of the report was copied from the original NICE review: Lord J, Paisley S. The clinical effectiveness and cost-effectiveness of methylphenidate for hyperactivity in childhood. London: National Institute for Clinical Excellence, Version 2; August 2000. Results of recently published papers were added.) The Multimodal Treatment Study of Children with ADHD (MTA) trial does not strictly fall within the remit of this review, since ‘medical management’ included the option to use various drugs, not just methylphenidate. However, given the importance of this study and its relevance to practice, its key results are summarised below. Children between the ages of 7 and 9 years with a diagnosis of ADHD combined type (DSM-IV) were recruited through six centres. They had a range of co-morbid conditions, although children with conditions thought likely to prevent full participation in the treatments or assessments were excluded. Participants were randomised (n = 579) to one of four groups: 1. Medication management. Children had an initial 28-day double-blind, placebo-controlled dose titration of MPH (‘n of 1’ trial). This was followed by open titration of other medications for children with inadequate response to MPH. Children were maintained on optimal medication (including ‘no medication’ where appropriate) for 13 months, with half-hour monthly medication maintenance visits to a pharmaco-therapist, who offered ‘support encouragement, and practical advice (but not behavioural treatment)’. Further algorithmguided dose adjustments were allowed. 2. Behavioural treatment. This included three main components: first, a parent-training programme with 27 group and eight individual sessions per family; second, a child-focused treatment programme, which comprised an © Queen’s Printer and Controller of HMSO 2006. All rights reserved. Health Technology Assessment 2006; Vol. 10: No. 23 8-week, 5 days per week, 9 hours per day summer camp; third, a school-based programme, which included 10–16 sessions of biweekly teacher consultation and 12 weeks of a part-time, behaviourally trained classroom aide. Daily report cards were completed by teachers, to link school and home. These behavioural interventions were tapered, with intensive initial inputs fading to once-monthly contacts by the end of the 14-month treatment period. 3. Combined treatment. This included both of the above treatment programmes, but was not the simple addition of the other two strategies. To coordinate treatment, information was shared between the teacher, consultant and pharmaco-therapist. Average medication doses received also varied between the medication management and combined treatment groups. 4. Community care. Here children were provided with a report of their initial study assessments and a list of community mental health resources, then discharged to their own provider. In accordance with US practice, most of the children in this group received pharmaceutical therapy. The level of psychotherapeutic interventions in this group has not yet been reported. Outcomes were measured across six major domains: ADHD symptoms, oppositional/aggressive symptoms, social skills, internalising symptoms (anxiety and depression), parent–child relationships and academic achievement. Open parent and teacher ratings for these dimensions were augmented with blinded observational ratings of classroom behaviour. Assessments were conducted at baseline and 3, 9 and 14 months. Further follow-up assessments are planned. Analyses were conducted on an ITT basis using random-effects regression methods. The study was designed to assess the relative effectiveness of alternative treatment strategies. These strategies met ‘good practice’ ideals, although the children were intended to be representative of ‘real-world’ patients. 103 It is important to note that this trial did not include a placebo or ‘no treatment’ control group. Hence, the MTA trial cannot be used to assess the efficacy of the single treatment modalities (medication or behavioural therapy alone). Also, the community care group is of little direct relevance in the UK, because of the large differences between current practice in the USA and UK. 104 Most of the children in the community care group (97/146) received stimulant medication. 73
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A systematic review and economic mo
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A systematic review and economic mo
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Objectives: To assess the clinical
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Glossary and list of abbreviations
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Glossary Adverse effect An abnormal
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Glossary continued effects. Sometim
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Glossary continued point between tw
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Background Attention deficit hypera
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mean differences with 95% confidenc
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This review examines the clinical a
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4 Background E. Symptoms should not
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6 Background Concerta XL Concerta X
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8 Methods for reviewing effectivene
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10 Methods for reviewing effectiven
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Quantity and quality of research av
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TABLE 1 The quality of included stu
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TABLE 2 An overview of trials inclu
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TABLE 2 An overview of trials inclu
Page 39 and 40: TABLE 3 MPH low dose (≤15 mg/day)
Page 41 and 42: Quality of life Only one of the 12
Page 43 and 44: TABLE 5 MPH medium dose (15-30 mg/d
Page 45 and 46: Hyperactivity All nine studies that
Page 47 and 48: TABLE 6 Results for hyperactivity [
Page 49 and 50: Study Parallel trials Buitelaar 199
Page 51 and 52: TABLE 8 Results for hyperactivity [
Page 53 and 54: Study Parallel trials Gittelman-Kle
Page 55 and 56: TABLE 11 MPH high dose (>30 mg/day)
Page 57 and 58: TABLE 14 ER-MPH medium dose (20-40
Page 59 and 60: Study Crossover trials Stein 2003 S
Page 61 and 62: TABLE 19 Results for hyperactivity
Page 63 and 64: TABLE 22 MPH low dose (≤ 15 mg/da
Page 65 and 66: TABLE 24 MPH medium dose (15-30 mg/
Page 67 and 68: assessed by parents and teachers. I
Page 71 and 72: TABLE 30 DEX medium dose (10-20 mg/
Page 75 and 76: TABLE 38 DEX medium dose (10-20 mg/
Page 77 and 78: TABLE 41 DEX-SR plus non-drug inter
Page 79 and 80: Study Michelson 2001 [0.5] Michelso
Page 81 and 82: Hyperactivity Five trials (publishe
Page 83 and 84: TABLE 47 IR-MPH low-dose (≤ 15 mg
Page 85 and 86: STP. 77,78 Neither examined hyperac
Page 87 and 88: Adverse events No significant diffe
Page 89: did report that there were no signi
Page 93 and 94: showed persisting significant super
Page 95 and 96: easily rectified with dosage adjust
Page 97 and 98: Aim The aim of this chapter is to r
Page 99 and 100: only level of social disability tha
Page 101 and 102: did not include a ‘global’ HRQo
Page 103 and 104: might decrease but costs would be e
Page 105 and 106: 1st line pharmacotherapy Response,
Page 107 and 108: TABLE 70 Data for weighted average
Page 109 and 110: The probabilistic results were used
Page 111 and 112: The review also uncovered a mis-ref
Page 113 and 114: TABLE 77 Results of sensitivity ana
Page 115 and 116: TABLE 80 Response a rates (%) estim
Page 117 and 118: TABLE 82 Drug costs used in the cos
Page 119 and 120: The review of the economic evidence
Page 121 and 122: Extrapolation A secondary analysis
Page 123 and 124: economic model rests on the assumpt
Page 125 and 126: TABLE 87 Data used in calculating w
Page 127 and 128: not fully probabilistic. The averag
Page 129 and 130: Probability cost-effective 1.0 0.9
Page 131 and 132: TABLE 93 Results of sensitivity ana
Page 133 and 134: Base case model Responder to MPH Re
Page 135 and 136: TABLE 96 Results of the sensitivity
Page 137 and 138: The same method for synthesising th
Page 139 and 140: TABLE 103 Results of the economic m
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of the 64 identified in the clinica
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126 Discussion impact of active dru
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MPH, DEX and ATX improve hyperactiv
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1. National Institute for Clinical
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tutoring on the behavior and achiev
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91. Stein MA, Blondis TA, Schnitzle
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140. Hill P, Taylor E. An auditable
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189. Francis S, Fine J, Tannock R.
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235. Rhodes SM, Coghill DR, Matthew
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hyperactive boys: comparative and c
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This version of HTA monograph volum
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380 Health Technology Assessment Pr
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382 Health Technology Assessment Pr
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