Cost Effectiveness Analysis of Different Treatment Alternatives in Children with Attention Deficit Hyperactivity Disorder

Abstract

Patients and methods Children in psychiatric out patients clinic at Abasseya Mental Hospital (AMH) Cairo, Egypt, who are 6 to 12 years of age (boys or girls) , and had a clinical diagnoses of ADHD as defined in the Diagnostic and statistical Manual fourth edition (DSM_IV) (American Psychiatric Association,2000;2011) , confirmed by structured interview v , and had an IQ of > 70 assessed by the Stanford-Binet Intelligence Scale: Fourth Edition for children (SB:FE) (Grunau et al.,2000; Caruso, 2001). Exclusion criteria included Serious or chronic medical illness such as (diabetes mellitus ,TB, Cardiovascular or cerbrovascular diseases),Co morbid psychosis or bipolar disorder, history of seizure disorder,Ongoing use of psychoactive medications other than the study drug. This study was conducted in accordance with the ethical standards of the investigative site institutional review board 1. Sixty four child (84.37% boys) enrolled in this study were subjected to the following: a. History: patient's personal, family, and medical history were taken. b. Clinical, and Psychiatric assessment to obtain the exact diagnosis, severity , intelligent quotient IQ-test was done for each patient. 2. Patient's parent or primary care givers were asked to: a. Fill in a socioeconomic sheet (El-Shakhs , 2013). b. Rate in Swanson , Nolan, and Pelham questionnaire (SNAP) Rating Scale (Canadian ADHD Resource Alliance, 2013). c. Rate in The Revised Conners' Parent Rating Scale (CPRS-R) (Conners , et al., 1998, 2001). 3. Patients were classified according to the type of treatment they received into three groups (depended on psychiatric recommendation and parents preferences): A. Group 1: medication only group (20 child); was defined as intake of Atomoxetine daily with average dose of 0.5 mg/kg /day for titration period , then a target dose of 1.2mg/kg/day ( maximum 100 mg/day) taken once daily . B. Group 2: behavioral therapy only group (21 child); sessions by psychologists or specially trained facilitator for 45 to 75 minutes were delivered for children and parents (between eight and 12 sessions for each) . Summary and Conclusion 66 C. Group 3: combined medication and behavioral therapy group (23 child); that is, behavioral therapy is delivered concurrently with medication. 4. Patients had been followed up monthly for 12 weeks to report compliance, adverse effects, tolerability, and discontinuation. Resources and Costs: The analysis adopted the perspective of the Egyptian Ministry Of Health (payer perspective), thus only direct medical cost were estimated. Health service costs included consisted of; Treatment medication (Atomoxetine), psychotherapy sessions costs, and Psychiatrist and mental nurse costs (professional staff costs). Outputs: Outputs included cost and effectiveness outcomes for each treatment arm, and Average Cost-Effectiveness Ratio (ACER) comparing medication versus behavioural therapy versus combined therapy. Average Cost Effectiveness Ratio (ACER) = health care cost ($) clinical outcome (not in $) Results The present study included 64 child (84.375% boys) ranging in age between 6 and 12 years (mean 8.159,SD 1.3978) these participants had an IQ ≥70. ANOVA showed no statistically significant difference between base line characteristics among the three groups of patients thus 3 groups were comparable before treatment. The use of health service resources and costs during the three months of the study. Total costs of care per patient for medication group versus behavioral versus combined group at 3 months was 620.49 LE, 532.41 LE , 1033.95 LE. Combined therapy was associated with the highest Average Cost Effective Ratio with ACER of 6158.25 LE per QALY, medication therapy was 3734.97 LE per QALY .While ACER of behavioral therapy was 3476.83 LE per QALY. This means that, according to base case results, Behavioral therapy is the most cost effective treatment option among those assessed, followed by medication treatment as second choice, combined therapy comes as third choice. According to base-case analysis, combined therapy was associated with the greatest health benefits and highest costs. While behavioral therapy was associated with the least health benefits and lowest costs. Both are trade off options depends on the decision maker choices .