title: A cost-effectiveness analysis of off-label atypical antipsychotic treatment in children and adolescents with ADHD who have failed stimulant therapy.
abstract: The objectives of this study are: (1) to estimate the expected health outcomes of atypical antipsychotics (AAPs) and other non-stimulant attention-deficit/hyperactivity disorder (ADHD) medications and (2) to evaluate the cost-effectiveness of AAPs compared to other non-stimulant ADHD medications. We used decision analysis to compare three alternatives for treating children and adolescents with ADHD who failed initial stimulant treatment: (1) AAPs, (2) a selective norepinephrine reuptake inhibitor (atomoxetine), and (3) selective α2-adrenergic agonists (clonidine and guanfacine). Probability estimates and quality-adjusted life year (QALY) weights were derived from a literature review. Cost-effectiveness was estimated using the expected health outcomes derived from the decision analysis and expected costs from the literature. The study was conducted from the third-party payer perspective, and the study period was 1 year. One-way deterministic sensitivity analysis and a Monte Carlo simulation were performed. Over the course of 1 year of ADHD pharmacotherapy, the highest QALY was for clonidine/guanfacine (expected QALY = 0.95) followed by atomoxetine (expected QALY = 0.94). Atypical antipsychotics yielded the lowest health outcome with an expected QALY of 0.84. In the cost-effectiveness analysis, the AAP strategy was dominated as it was less effective and more costly than other two strategies. Compared to clonidine/guanfacine, AAPs provided lower QALYs (0.11 QALY lost) at an additional cost of $2186 on average. Compared to atomoxetine, AAPs resulted in 0.10 QALYs lost at an additional cost of $2186. In this decision analysis model, AAPs provide lower expected health outcomes than other ADHD medications in children and adolescents who failed prior stimulant therapy. Furthermore, AAPs were not a cost-effective option.
authors.affiliation: College of Pharmacy, University of Kentucky, 789 South Limestone Street, Lexington, KY, 40536, USA. minjisohn@ferris.edu.|Department of Pharmaceutical Sciences, College of Pharmacy, Ferris State University, 220 Ferris Drive, Big Rapids, MI, 49307, USA. minjisohn@ferris.edu.
authors.forename: Minji
authors.initials: M
authors.lastname: Sohn
authors.affiliation: College of Pharmacy, University of Kentucky, 789 South Limestone Street, Lexington, KY, 40536, USA.
authors.forename: Jeffery
authors.initials: J
authors.lastname: Talbert
authors.affiliation: College of Pharmacy, University of Kentucky, 789 South Limestone Street, Lexington, KY, 40536, USA.|Department of Epidemiology, College of Public Health, University of Kentucky, 111 Washington Avenue, Lexington, KY, 40536, USA.
authors.forename: Daniela C
authors.initials: DC
authors.lastname: Moga
authors.affiliation: College of Pharmacy, University of Kentucky, 789 South Limestone Street, Lexington, KY, 40536, USA.
authors.forename: Karen
authors.initials: K
authors.lastname: Blumenschein
mesh_terms: D000293:Adolescent; D014150:Antipsychotic Agents / Q000191:economics* / Q000627:therapeutic use*; D000069445:Atomoxetine Hydrochloride / Q000191:economics / Q000627:therapeutic use; D001289:Attention Deficit Disorder with Hyperactivity / Q000188:drug therapy* / Q000191:economics*; D000697:Central Nervous System Stimulants / Q000627:therapeutic use*; D002648:Child; D003000:Clonidine / Q000191:economics / Q000627:therapeutic use; D003362:Cost-Benefit Analysis; D003661:Decision Support Techniques; D016316:Guanfacine / Q000191:economics / Q000627:therapeutic use; D017048:Health Care Costs; D006801:Humans; D009010:Monte Carlo Method; D019057:Quality-Adjusted Life Years; D017211:Treatment Failure
chemical_list: D014150:Antipsychotic Agents; D000697:Central Nervous System Stimulants; D016316:Guanfacine; D000069445:Atomoxetine Hydrochloride; D003000:Clonidine
keywords: Adolescents; Antipsychotics; Children; Cost-effectiveness; Decision tree; Stimulant