Comparing treatments in the new health care environment What works and who benefits?

1. Comparing treatments in the new health care environmentWhat works and who benefits? Tim Carey MD MPH Jan 2009

2. Support • NIAMS- National Institute of Arthritis and Musculoskeletal Disease • NIH CTSA award to UNC • NCMHD-National Center for Minority Health and Health Disparities • AHRQ-Agency for Healthcare Research and Quality • Health Resources and Services Administration • GSK Foundation • RWJ Foundation • DERP- Drug Effectiveness Review Project • Dissemination grant supported by the Neurontin Special Committee

3. Nothing new • Clinicians have always compared one treatment with another • Most conditions have therapeutic options • Meds vs PCI vs CABG for CAD • Surgery vs radiation for prostate CA • Decompression vs fusion vs exercise for spine disease • Lovastatin vs simvastatin for hyperlipidemia • Fluoxetine vs. paroxetine for depression • Increase in efficacious treatments, and especially expensive efficacious rx • Rise in healthcare costs has led to renewed emphasis on comparative effectiveness and cost-effectiveness • Increased emphasis on comparing treatments • Medications with each other • Procedures with each other • Procedures compared with medications or physical treatments (exercise, PT, etc)

4. Efficacy and effectiveness • Efficacy: Does the treatment work in an ideal situation? • Generally addressed in relatively small RCT’s, often sited at tertiary care settings • Effectiveness: Does the treatment work for the average patient in the average practice? • Populations in primary care (or setting where most pts treated) • Less stringent eligibility criteria • Health outcomes assessed • Long study duration; clinically relevant treatment modalities • Assessment of adverse events • Adequate sample size to assess a minimally important difference from a patient perspective • Intention to treat analysis Gartlehner et al J Clin Epid 2006

5. Applicability • Does the evidence from the clinical literature apply to most patients, or groups of patients, with the condition of interest? • Does the evidence from the clinical literature apply to the next patient I am going to see in my practice? • PICOTS approach • Population; Intervention; Comparator; Outcome; Timeframe; Setting

6. What is being compared? • Similar treatments? • Appropriate outcomes • Are harms being searched for? • Is the comparison treatment the current state of the art treatment? • Patient preferences taken into account?

7. Coke vs Pepsi • Risk of losing perspective- how well does treatment work at all for the condition? • Is it an interesting question to compare two similar medications (or procedures)? • Two statins • Patent vs generic (Kesselheim JAMA Dec 3, 2008) • Harm profiles • Drug vs procedure; invasive vs non-invasive • Potential audiences for comparative effectiveness • Payers and regulators • Practice community, hospital P+T committees • Patients • Research investment • Secondary analysis vs primary data collection • Large, simple trials (ALLHAT, CATIE)

8. Strength of Evidence • When is sufficient evidence present to say ‘case closed.” • Relationship between strength of evidence assessment and ‘guideline’ • Guidelines take into account additional information including cost, convenience, acceptability, cultural and policy issues • Strength systems take into account: number of studies, size of studies, quality of research, reproducibility (coherence), etc • GRADE system seems to be center of emerging consensus • Transparent, plain English • Global qualitative assessment • What is the likelihood that an additional study would lead to a different conclusion?

9. GRADE Rating Grade Definition • High Further research is very unlikely to change our confidence in the estimate of effect • Moderate Further research is likely to have an important Impact on our confidence in the estimate of effect and may change the estimate • Low Further research is very likely to have an important impact on our confidence in the estimate of effect and is likely to change the estimate • Very low Any estimate of effect is very uncertain Guyatt, ACP J Club 2006

10. Comparative effectiveness reviews: Subset of Systematic Review • Within a class of treatments (often meds), is there a difference in efficacy, effectiveness or adverse events among agents? • Optimally requires head-to-head trials between agents at equivalent doses • CATIE (antipsychotics), ALLHAT (antihypertensives), STAR-D (antidepressants) • Comparing placebo-controlled trials of different agents possible, but should be viewed with caution • Reviews underway through DERP and AHRQ at UNC: • Non-drug treatment s for refractory depression • Antiepileptic drugs for bipolar disorder • Disease modifying drug for arthritis • Controller drugs for asthma

11. Methods • Prior systematic review methods often highly variable • Cochrane methods manual provides consistency, but questions often very narrow • In the past, little funding for methods work • Europeans (British, Dutch) often leaders • Role of NICE • EPC methods manual substantial advance, now in 2nd revision • New chapters on dx test methods, use of prior systematic reviews • Risk of consistent methods leading to lack of innovation • Peer reviewed, chapters published in J Clin Epid, Annals of Internal Medicine

12. COMPARATIVE EFFECTIVENESS OF SECOND-GENERATION ANTIDEPRESSANTS IN THE PHARMACOLOGIC TREATMENT OF ADULT DEPRESSIONFinal ReportDecember 2006 Prepared for: Agency for Healthcare Research and QualityU.S. Department of Health and Human ServicesPrepared by:RTI International-University of North CarolinaResearch Triangle Park, North Carolina

13. Key Question 1 Do antidepressants differ in efficacy and effectiveness for the treatment of major depressive disorder, dysthymia, and subsyndromal depression?

14. Included Medications Other Bupropion Duloxetine Mirtazapine Nefazodone Venlafaxine Trazodone SSRIs Citalopram Escitalopram Fluoxetine Fluvoxamine Paroxetine Sertraline

15. Results: Excluded Studies 62 studies excluded because of poor internal validity • High loss to followup • Single blinding • No intention-to-treat analysis • No systematic literature search for systematic reviews

16. Major Depressive Disorder:Body of Evidence • 72 head-to-head trials (including 3 effectiveness trials) on 16,780 patients • 18 studies assessed quality of life • We conducted 4 meta-analyses and 62 adjusted indirect comparisons • Outcome of interest: response to treatment

17. Major Depressive Disorder:Evidence of Comparative Efficacy • Overall, no substantial differences in efficacy • Statistically significant results from meta-analyses: modest and likely not clinically important • No differences in quality of life Strength of evidence: moderate

18. Major Depressive Disorder: Evidence of Comparative Efficacy • Although efficacy is similar, second-generation antidepressants are not identical • Mirtazapine has a significantly faster onset of action than SSRIs • Bupropion has less effect on sexual functioning than SSRIs Strength of evidence: moderate

19. Major Depressive Disorder: Evidence of Comparative Effectiveness • 3 effectiveness trials: studies conducted under “real world” conditions • No differences in effectiveness among examined drugs • No differences in quality of life Strength of evidence: moderate

20. Summary of Results of Direct and Indirect Comparisons • Results are summarized in 3 forest plots • One comparing SSRIs and SSRIs • One comparing • SSRIs and SSNRI (duloxetine) • SSRIs and SNRIs (mirtazapine; venlafaxine) • SSNRI/SNRI and SNRI • One comparing • SSRIs, SSNRI, and SNRIs vs. other second-generation antidepressants • other second-generation antidepressants with each other

21. Indirect comparisons • Attractive option when no or limited head to head RCT data • Statistics opaque • Loss of much of the benefit of randomization • Limited statistical power • Need 4x the subjects to achieve same power as head to head trial • Overlapping confidence intervals does not mean that treatments are the same

22. Unadjusted Indirect Comparison A P A P A P A P A D A D A E A F B P B P B P B C B C B D B E B F

23. Adjusted Indirect Comparison A P A P A P A P A D A D A E A F B P B P B P B C B C B D B E B F

24. SSRIs vs. SSRIs 1.14 (1.04, 1.26) *Citalopram vs. Escitalopram Citalopram vs. Fluoxetine 0.89 (0.47, 1.71) 0.48 (0.08, 2.82) Citalopram vs. Fluvoxamine Citalopram vs. Paroxetine 0.72 (0.38, 1.39) Citalopram vs. Sertraline 0.85 (0.45, 1.63) Escitalopram vs. Fluoxetine 1.15 (0.90, 1.47) Fluvoxamine Escitalopram vs. 0.61 (0.11, 3.29) 0.93 (0.71, 1.22) Escitalopram vs. Paroxetine 1.10 (0.85, 1.42) Escitalopram vs. Sertraline Fluoxetine vs. Fluvoxamine 0.53 (0.10, 2.81) *Fluoxetine vs. Paroxetine 1.09 (0.99, 1.21) *Fluoxetine vs. Sertraline 1.11 (1.01, 1.21) Fluvoxamine vs. Paroxetine 1.52 (0.29, 8.05) Fluvoxamine vs. Sertraline 1.79 (0.34, 9.45) 1.20 (0.88, 1.64) Paroxetine vs. Sertraline 0.01 0.1 0.2 0.5 1 2 5 10 Favors first SSRI Favors second SSRI * Based on meta-analysis of head-to-head trials

25. SSRI vs. SSNRI Citalopram vs. Duloxetine 0.76 (0.39, 1.47) Escitalopram vs. Duloxetine 0.97 (0.71, 1.33) Fluoxetine vs. Duloxetine 1.12 (0.84, 1.50) Fluvoxamine vs. Duloxetine 1.59 (0.30, 8.45) Paroxetine vs. Duloxetine 1.50 (0.88, 2.53) Sertraline vs. Duloxetine 1.27 (0.99, 1.64) SSRI vs. SNRI Citalopram vs. Mirtazapine 0.78 (0.40, 1.53) Escitalopram vs. Mirtazapine 1.01 (0.74, 1.37) Fluoxetine vs. Mirtazapine 0.87 (0.72, 1.06) Fluvoxamine vs. Mirtazapine 1.64 (0.31, 8.76) Paroxetine vs. Mirtazapine 1.08 (0.88, 1.33) Sertraline vs. Mirtazapine 0.92 (0.74, 1.14) Citalopram vs. Venlafaxine 0.79 (0.41, 1.52) Escitalopram vs. Venlafaxine 1.02 (0.82, 1.26) *Fluoxetine vs. Venlafaxine 1.21 (1.01, 1.24) Fluvoxamine vs. Venlafaxine 1.66 (0.31, 8.81) Paroxetine vs. Venlafaxine 1.05 (0.75, 1.49) Sertraline vs. Venlafaxine 0.88 (0.72, 1.07) SSNRI & SNRI vs. SNRI Duloxetine vs. Venlafaxine 1.28 (0.86, 1.91) Duloxetine vs. Mirtazapine 1.03 (0.79, 1.35) Mirtazapine vs. Venlafaxine 1.01 (0.81, 1.27) 0.2 0.5 1 2 5 10 Favors SSRI Favors SSNRI Favors SSRI Favors SNRI Favors SSNRI & SNRI Favors SNRI * Based on meta-analysis of head-to-head trials

26. How certain can we be that the treatments are the same? • Overlapping confidence intervals is not the same as therapeutic equivalence • Indirect comparisons of limited power to detect differences • Non-inferiority trials lead to plethora of small, underpowered studies.

27. What about harms? • Limited data from RCT’s • Better data collection than in observational studies, but patient population young, fewer co-morbidities • Inconsistent definitions of harms from study to study • Secondary data and cohort studies may complement RCT information • Need for better data- EMR’s, pt reports? • Assessment of benefits and harms may require qualitative, patient-centered judgments • Function vs longevity; short vs long-term effects; etc.

28. Remaining Issues for Clinicians and Patients in treatment of depression • Multiple treatment options may be necessary for many patients: • 40% of patients do not achieve clinical response with initial treatment • 10% - 15% discontinue treatment because of adverse events • Antidepressants differ significantly in dosing regimens • Need for rx of med-refractory patients

29. Quality of studies • Good studies should get more attention than bad • Quality ratings to date lack transparency, • ? Susceptible to gaming? • Many good studies should have more impact • >40 ‘scales’ for rating quality of randomized trials • Some commonalities across scales • Randomization • Similarity of groups at baseline • Allocation concealment • Blinded assessors • Intention to treat analysis • Adequate and non-differential drop-out rate

30. What’s left out of systematic reviews? • Case series, other types of observational studies • Can be helpful for emerging treatments, harms identification, ?procedures • Role of case series influencing clinical practice. • Neurontin case series in the late 90’s • Small size • Modest duration • Often unclear setting • High dropout • Stereotyped conclusions

31. Number of case series studies on neurontin in bipolar disorder

32. Publication bias • We know it occurs….. • Statistical tests • Funnel plots • “Fill and trim” • Low statistical power • FDA site • Efficacy and harms issues • Trial registries

33. The Weight of the Evidence

34. Deriving Key Concepts from a Systematic Review • Read it, read it again, include source materials • Multi-disciplinary “Science Panel” • EPC faculty, psychiatry, PharmD, primary author of evidence report • 8 versions of 10 key concepts • Iterative process • Start general, become successively more specific, then back off to more general (‘granularity’) • Lots of discussion on language

35. Key Concept 1 • Current evidence supports the conclusion that three AEDs (carbamazepine, valproic acid/valproate and lamotrigine) are efficacious in achieving and maintaining remission for outpatient adults with primary diagnoses of bipolar I disorder with recent mania or mixed episodes. • The overall magnitude of benefit obtained with AEDs in bipolar I disorder with recent mania or mixed episodes was an absolute improvement of the probability of attaining remission ranging from 7-28%; the relative rate of attaining remission was between 1.17-2.87, compared to placebo. The strength of evidence for this indication is low (GRADE criteria). • Carbamazepine is the only AED that has been shown in fair-quality published trials to be significantly better than placebo in reducing mania scores in acute therapy of outpatient adults. • There was no acceptable evidence to support choice of one agent over another based on speed of onset in attaining remission

36. Key Concept 2 • The rates of achieving and maintaining remission during treatment with the three AED’s mentioned above are similar to those obtained with lithium treatment for bipolar I disorder. For outpatient adults with acute mania, carbamazepine and valproate were similar, relative to lithium, in terms of response rates. a. The incidence of recurrence in the studies examined ranged between 16% and 70% with placebo, and between 6% and 65% with medication treatment. The broad range of these estimates is due to the variable definitions of recurrence used and variable duration of follow-up. Recurrence is a significant problem for these patients even with treatment with AED’s.

37. Key Messages v6.1 • There remains no scientifically acceptable clinical trial evidence which supports use of either gabapentin or topiramate in bipolar mood disorder, either as monotherapy or as an adjunct to other therapies. • Research supports the use of three antiepileptic drugs—(1) carbamazepine, (2) valproic acid/valproate and (3) lamotrigine in achieving and maintaining remission for outpatient adults with primary diagnoses of bipolar I disorder. Evidence of efficacy is less clear for these treatments for type II bipolar disorder. • 3. Carbamazepine, valproic acid/valproate, and lamotrigine work as well as lithium in achieving and maintaining remission in bipolar I disorder.   • 4. The types of adverse events vary among anti-epileptic drugs and lithium. There is insufficient evidence to determine if the overall risk of adverse events differs among AEDs. Unlike the AED’s, lithium poses significant risk when taken in an overdose.

42. Current comparative effectiveness activities • Head to head trials • Comparative effectiveness reports • Meta-analyses • Secondary data analyses • Administrative claims data • Re-analyses of existing RCT data • Use of data derived from electronic medical records • Large effectiveness trials

43. Why not more large effectiveness trials? • CATIE, ALLHAT, Women’s Health Initiative, Endarterectomy trials all substantially changed practice • But did they change practice enough? • Expense • Difficulty determining the appropriate comparison treatment • Risk (SPORT trials for back pain) • Problems with non-inferiority trials • Marketing issues

44. Funding sources • FDA • Regulatory role, not research • ?regulatory capture in PADUFA • NIH • Historically not involved with comparative effectiveness • ALLHAT, CATIE, STAR*D, SPORT. More to come? • CTSA and ‘Type II’ (bench to bedside) translational research • AHRQ • Effective Health Care Program • EPC’s and DEcIDE • Discussion of increase in funding by several hundred million dollars • Rapid response secondary data analyses • EMR analyses • Selected head-to-head trials • Industry • Limited incentive • “Do you feel lucky”- some potential to game comparisons

45. Current UNC activities • Evidence-based Practice Center • Multiple comparative effectiveness reviews • DEcIDE Center • Secondary database analyses • Depression treatment strategies • Effectiveness of cancer treatments • Moderate RCT activities • CATIE study • Substantial expertise in trial coordination • Only modest activity comparing procedures with treatments or in assessing devices • Methods work on propensity score analysis (EPID), more efficient methods of conducting literature searches using text recognition (SILS)

46. Public good, public guardian • Widespread recognition that current system is dysfunctional • FDA role likely to change • Avandia, Vioxx, stents, etc • Concern regarding FDA funding stream • CMS taking increasing role • State Medicaid programs form consortium

47. Schematic for Bedside to Clinic Translational Research

48. Current proposals • Substantial budgetary allocations of $100m to $1B • Secondary data analyses • Systematic reviews and meta-analyses • Head to head real world effectiveness trials • FDA • Established, decades of experience, diminished credibility • AHRQ • Established, good methods, hx of political vulnerability • Institute of Medicine (IOM) • Universal respect, not a research entity, often slow • “Public-private Partnership” • Potentially nimble, risk of regulatory capture • Federal Reserve model • National health board favored by Sen Daschle • Political independence

49. Stimulus package • $1.1 billion over 2 yr for comparative effectiveness research (currently ~$50 million/year) • Probable administration by AHRQ and NIH, mixture of RCT’s, secondary data analyses, reviews. • How ‘shovel ready’ is CER work? • Career development awards http://grants.nih.gov/grants/guide/pa-files/PAR-09-085.html

50. Resources • Agency for Healthcare Research and Quality www.ahrq.gov • Cochrane collaboration • Drug Effectiveness Review Project DERP • http://www.ohsu.edu/drugeffectiveness/