Analysis Group, Inc., Boston, MA, USA.
CNS Drugs. 2012 Jul 1;26(7):581-600. doi: 10.2165/11633900-000000000-00000.
Attention-deficit hyperactivity disorder (ADHD) is a common psychiatric disorder that impairs the quality of life for patients and their families and is associated with considerable direct and indirect costs. Pharmacotherapies for ADHD, including stimulants and non-stimulants, are often used to treat patients with ADHD. However, the costs, effectiveness and adverse effects of these agents vary. Therefore, information regarding the cost effectiveness of different pharmacological treatments is needed to better inform payers in the allocation of limited resources.
The objectives of this study were to conduct a systematic literature review of economic evaluations of pharmacotherapies for ADHD treatments and to assess the cost effectiveness of different interventions based on the existing studies.
A systematic literature review of economic evaluations of pharmacotherapies for ADHD was conducted in MEDLINE, the National Health Services (NHS) Economic Evaluation database and EMBASE. For inclusion in this review, studies had to compare two or more ADHD interventions with at least one pharmacotherapy, assess both costs and outcomes, and be conducted between 1990 and 2011 in North America, Europe, Australia or New Zealand. Studies were excluded if they were not original research, were presented only as conference proceedings or abstracts or did not report costs associated with specific interventions. The study quality was assessed using the British Medical Journal (BMJ) health economics checklist. The literature search, data extraction and quality assessment were performed by one author and independently checked for accuracy by a second author. Discrepancies were resolved by consensus and referring to the original article. If necessary, a third reviewer was consulted.
The initial search returned 93 citations from MEDLINE, 10 from the NHS Economic Evaluation database and 377 from EMBASE. Thirteen papers met the inclusion/exclusion criteria and were included in the review. Based on the BMJ checklist, all these studies were considered to be of sufficient quality to be included in the literature review, but they varied substantially in target population, methodology and effectiveness measures. Identified pharmacotherapies were cost effective compared with no treatment, placebo, behavioural therapy or community care among children and adolescents with ADHD. Studies comparing non-stimulants with stimulants and amfetamine with methylphenidate stimulants showed inconsistent findings. A limited number of studies indicated that methylphenidate Osmotic-controlled Release Oral delivery System (OROS) was cost effective compared with short-acting methylphenidate. There were no published studies on the cost effectiveness of pharmacotherapy in the adult ADHD population, comparing stimulants, non-stimulants or adjuvant therapy. There is limited evidence on the long-term cost effectiveness of pharmacotherapies.
Among children and adolescents with ADHD, there was consistent evidence that pharmacotherapies are cost effective compared with no treatment or behavioural therapy. Adequate data are lacking to draw conclusions regarding the relative cost effectiveness of different pharmacological agents. More economic evaluations with standardized methods, such as effectiveness measures and cost components, are warranted. To better inform payers about the economic value of existing medications, future studies should also consider identifying subgroups that may have heterogeneous responses to different treatments, including analyses of recently approved treatments (e.g. lisdexamfetamine, guanfacine extended-release and clonidine extended-release) and expanding the time horizon to incorporate long-term outcomes.
注意力缺陷多动障碍（ADHD）是一种常见的精神疾病，会降低患者及其家庭的生活质量，并导致相当大的直接和间接成本。ADHD 的药物治疗，包括兴奋剂和非兴奋剂，通常用于治疗 ADHD 患者。然而，这些药物的成本、疗效和不良反应各不相同。因此，需要了解不同药物治疗的成本效益，以便更好地为支付方在有限资源的分配提供信息。
本研究旨在对 ADHD 药物治疗的经济学评价进行系统文献回顾，并根据现有研究评估不同干预措施的成本效益。
在 MEDLINE、英国国家卫生服务（NHS）经济评价数据库和 EMBASE 中对 ADHD 药物治疗的经济学评价进行了系统文献检索。本综述纳入的研究必须比较两种或两种以上 ADHD 干预措施与至少一种药物治疗，评估成本和结果，并在北美、欧洲、澳大利亚或新西兰进行，时间为 1990 年至 2011 年。如果研究不是原始研究，仅作为会议报告或摘要呈现，或者未报告特定干预措施的相关成本，则将其排除在外。使用英国医学杂志（BMJ）卫生经济学清单评估研究质量。文献检索、数据提取和质量评估由一名作者进行，并由第二名作者独立检查准确性。如有分歧，通过共识解决，并参考原始文章。必要时咨询第三位审稿人。
最初的搜索从 MEDLINE 返回了 93 条引用，从 NHS 经济评价数据库返回了 10 条引用，从 EMBASE 返回了 377 条引用。13 篇论文符合纳入/排除标准，并纳入综述。根据 BMJ 清单，所有这些研究都被认为具有足够的质量，可以纳入文献综述，但它们在目标人群、方法和有效性测量方面存在很大差异。在儿童和青少年 ADHD 患者中，与不治疗、安慰剂、行为疗法或社区护理相比，确定的药物治疗具有成本效益。比较非兴奋剂与兴奋剂和苯丙胺与哌醋甲酯兴奋剂的研究结果不一致。有限的研究表明，哌醋甲酯控释口服混悬液（OROS）与速释哌醋甲酯相比具有成本效益。目前尚无关于成人 ADHD 人群药物治疗成本效益的研究，比较兴奋剂、非兴奋剂或辅助治疗。关于药物治疗的长期成本效益的证据有限。
在儿童和青少年 ADHD 患者中，有一致的证据表明药物治疗具有成本效益，优于不治疗或行为疗法。缺乏充分的数据来得出关于不同药物制剂相对成本效益的结论。需要更多使用标准化方法（如有效性测量和成本组成）的经济评价。为了让支付方更好地了解现有药物的经济价值，未来的研究还应考虑确定可能对不同治疗有不同反应的亚组，包括最近批准的治疗方法（例如，利右苯丙胺、胍法辛缓释和可乐定缓释）的分析，并延长时间范围以纳入长期结果。
