The cost effectiveness of stratified care in the management of migraine

Objective: To examine the cost effectivess of a stratified-care regimen for patients with migraine - in which patients are stratified by severity of i llness, and then prescribed differing treatments according to level of seve rity - compared with a conventional stepped-care approach. Design and methods: A decision analytic model was constructed to simulate a controlled clinical trial in which patients with migraine receiving primar y medical care were randomly assigned to treatment under a stepped-care or a stratified-care regimen. A health service payer perspective was adopted a nd the time horizon was I year. Data inputs were: (i) the frequency and dis ability of migraine, derived from population-based studies; (ii) disability level-specific treatment response rates for over-the-counter analgesics, a spirin/metoclopramide and zolmitriptan as the representative of high-end th erapy obtained from an international consensus opinion enquiry; and (iii) u nit costs of healthcare obtained from UK health service sources. Main outcome measures and results: The estimated 1-year direct healthcare c osts per primary care patient with migraine were pound sterling (pound) 156 .82 for stepped care and pound 151.57 for stratified care. Estimates of tre atment response rates were 40 and 71% for stepped and stratified care, resp ectively. The cost per successfully treated attack was pound 23.43 for step ped care and pound 12.60 for stratified care. Stratified care remained cost effective when tested in a wide range of one-way sensitivity analyses, and probabilistic sensitivity analysis showed the cost effectiveness of strati fied care to be significant at the 3% level. Conditional confidence analysi s showed that the level of confidence in the cost effectiveness of stratifi ed care varied positively with the case mix, i.e. in populations where the proportion of moderate and severely disabled patients with migraine was gre ater than 25%, the cost effectiveness of stratified care remained statistic ally significant. Conclusion: A stratified-care treatment strategy (including zolmitriptan as the representative of high-end therapy) is a highly cost-effective method of managing migraine in the primary care setting compared with stepped care , delivering improved clinical outcomes at no additional cost.