Cost-effectiveness analysis of low versus high dose colistin in the treatment of multi-drug resistant pneumonia in Saudi Arabia

Decision-Analytical Modelling of Medicines in the Middle East: A Systematic Review of Economic Evaluation Studies

BACKGROUND

Economic evaluations through decision-analytical models have played a limited role in shaping healthcare resource optimisation and reimbursement decisions in the Middle East.

OBJECTIVE

This review aims to systematically examine economic evaluation studies focusing on decision-analytical models of medicines in the Middle East, defining methodological characteristics and appraising the quality of the identified models.

METHODS

A systematic review approach was employed to identify published decision-analytical models of medicines in the Middle East. Six databases were searched (MEDLINE, EMBASE, Econlit, Web of Science, Global Health Cost-Effectiveness Analysis Registry and the Global Index Medicus) from 1998 to July 2024. Studies meeting the inclusion criteria-full economic evaluations of medicines using decision-analytical models in the Middle East-were considered. Data were extracted and tabulated to include study characteristics and methodological specifications, and data were narratively analysed. The Philips checklist was used to assess the quality of studies.

RESULTS

Sixty-three decision-analytical modelling studies of medicines were identified and reviewed, from eight Middle Eastern countries, with the majority (90%) conducted in Iran, Saudi Arabia, Qatar and Egypt. The cost-effectiveness of medications for non-communicable diseases was explored in 77% of the models. Gross domestic product-based cost-effectiveness thresholds were commonly used, and international sources provided data on intervention effectiveness and health outcomes, while national sources were mainly used for the costs of resource use. Most models incorporated an assessment of parameter uncertainty, whereas other types of uncertainty were not explored. Studies from high-income countries were generally of higher quality than those from middle-income countries.

CONCLUSIONS

The number of published decision-analytical models in the Middle East was low, considering the available medicinal products and disease burden. Key elements related to the quality of decision-analytical models, including analysis of the model structure, appropriateness of model inputs and uncertainty assessment, were not consistently fulfilled. Recommendations are provided to enhance the quality of future economic evaluation studies. This includes strengthening the existing health economics capacities, establishing country-specific health technology assessment systems (where possible), and initiating collaborations to generate national cost and outcome data. PROSPERO registration: CRD42021283904.

A Systematic Review of the Costs of Drug-Associated Acute Kidney Injury and Potential Cost Savings With Nephrotoxin Stewardship Prevention Strategies

There is a scarcity of information related to the financial impact of acute kidney injury (AKI), and even more so the economics of drug-associated AKI (D-AKI). Our goal was to provide a comprehensive summary of the economic burden of D-AKI by evaluating the costs of D-AKI compared to not developing AKI and cost savings associated with nephrotoxin stewardship approaches. Following the PRISMA guidelines, a literature search was conducted using PubMed to identify articles from database inception through November 2023. The main outcomes included AKI incidence, resource use, and cost of nephrotoxin stewardship programs/D-AKI event or no event. Key findings were summarized based on whether the study compared the cost of D-AKI vs. no AKI or identified potential cost savings associated with a nephrotoxin stewardship method to prevent D-AKI or worsening D-AKI. All costs were adjusted to USD2023. Twenty-five studies met the inclusion criteria. Eight studies compared the cost of D-AKI to no AKI. Total admission costs of patients who developed D-AKI ranged from $47,696 to $173,569. Nineteen studies implemented nephrotoxin stewardship with 12 substituting a less nephrotoxic drug; five using therapeutic drug monitoring and two altering drug dosing to limit exposure. Overall, these prevention strategies ranged from $5,171 to $364,973 in total medical cost savings and $17 to $942 in total cost savings per patient-day. The in-hospital economic impact of D-AKI is substantial. Implementing nephrotoxin stewardship strategies to reduce D-AKI is associated with cost savings. Institutions should adopt strategic and efficient nephrotoxin stewardship programs to optimize patient care and reduce costs.

An Update on Colistin in Clinical Healthcare Unit in the Kingdom of Saudi Arabia: A Narrative Review

Globally, gram-negative bacteria are a significant cause of morbidity. Multi-drug resistance bacteria are responsible for an increasing surge in infections that place a high cost on healthcare systems around the world. Recently, colistin, an antibiotic belonging to the polymyxin family, was reintroduced to combat multidrug- resistant gram-negative bacteria. Excessive and persistent use of colistin has led to the development and spread of colistin-resistant gram-negative bacteria throughout the globe. Healthcare units in various countries, including Saudi Arabia, are currently battling colistin-resistant gram-negative bacteria. Recently, colistin-resistant gram-negative bacteria have become a major health concern in Saudi Arabia. Hence, extensive epidemiological surveys and studies are required to understand the current status of the colistin antibiotic. Examining the knowledge currently available to the medical community on the molecular mechanism, clinical effectiveness, molecular epidemiology, and bacterial resistance to colistin in Saudi Arabia is the aim of this review.

Evaluating the effectiveness of the Ministry of Health restriction policy on seasonal antibiotic consumption trends in Saudi Arabia, 2016-2020

Background: Understanding antibiotic consumption patterns over time is essential to optimize prescribing practices and minimizing antimicrobial resistance. This study aimed to determine whether the antibiotics restriction policy launched by the Saudi Ministry of Health in April 2018 has impacted antibiotic use by assessing changes and seasonal variations following policy enforcement. Methods: Quarterly sales data of J01 antibacterial for systemic use in standard units were obtained from the IQVIA-MIDAS database, spanning from the first quarter of 2016 to the last quarter of 2020. Antibiotics consumption was measured in defined daily doses per 1,000 inhabitant per day- in a quarter (DDDdq). A comparative analysis of antibiotic consumption pre- and post-policy periods introduction was conducted by computing the average consumption values for each period. Statistical comparison of the mean differences between the two periods were then made using independent samples t-test, Mann-Whitney U Test where needed. Time series analysis was employed to estimate the projected antibiotic consumption in the post-policy period if the restriction policy had not been implemented, which was then compared to actual consumption values to evaluate the effectiveness of the restriction policy. Results: During the pre-policy, there were seasonal trends of the total and oral antibiotic consumption through quarters, with higher consumption observed in the first and fourth quarters. In contrast, parenteral antibiotic consumption did not appear to follow a clear seasonal pattern. Following the restriction policy, there was a significant reduction in total and oral antibiotic use, with mean reductions of -96.9 DDDdq (p-value = 0.002) and -98 DDDdq (p-value = 0.002), respectively. Conversely, a significant increase in parenteral antibiotic consumption was observed with a mean increase of +1.4 DDDdq (p-value < 0.0001). The comparison between the forecasted and actual models showed that the actual antibiotics consumption for total, oral, and parenteral were lower than the corresponding forecasted values by 30%, 31%, and 34%, respectively. Conclusion: Overall, our analysis of antibiotics consumption from 2016 to 2020 displays great success for the policy implemented by the Saudi Ministry of Health in significantly reducing the total and oral use of antibiotics. However, future studies are needed to explore the increased consumption of the parenteral antibiotics as well as the persistent high consumption patterns during the fall and winter months even after the implementation of the restriction policy.

Pham S, P.M. Vo T, X. Duong C, A. Perwitasari D, H.K. Truong N, T.H. Quach D, N.P. Nguyen T, T.T. Duong V, M. Nguyen P, H. Nguyen T, Taxis K, Nguyen T. Pneumonia: Drug-Related Problems and Hospital Readmissions

Pneumonia is one of the most common infectious diseases and the fourth leading cause of death globally. According to US statistics in 2019, pneumonia is the most common cause of sepsis and septic shock. In the US, inpatient pneumonia hospitalizations account for the top 10 highest medical costs, totaling $9.5 billion for 960,000 hospital stays. The emergence of antibiotic resistance in the treatment of infectious diseases, including the treatment of pneumonia, is a globally alarming problem. Antibiotic resistance increases the risk of death and re-hospitalization, prolongs hospital stays, and increases treatment costs, and is one of the greatest threats in modern medicine. Drug-related problems (DRPs) in pneumonia - such as suboptimal antibiotic indications, prolonged treatment duration, and drug interactions - increase the rate of antibiotic resistance and adverse effects, thereby leading to an increased burden in treatment. In a context in which novel and effective antibiotics are scarce, mitigating DRPs in order to reduce antibiotic resistance is currently a prime concern. A variety of interventions proven useful in reducing DRPs are antibiotic stewardship programs, the use of biomarkers, computerized physician order entries and clinical decision support systems, and community-acquired pneumonia scores.

Methodological Approaches to Cost-Effectiveness Analysis in Saudi Arabia: What Can We Learn? A Systematic Review

OBJECTIVE

The recent establishment of the health technology assessment (HTA) entity in the Kingdom of Saudi Arabia (KSA) has resulted in increased interest in economic evaluation. The aim of this study is to evaluate the technical approaches used in published economic evaluations and the limitations reported by the authors of the respective studies that could affect the ability to perform economic evaluations in the KSA.

METHODS

We conducted a systematic literature review of published economic evaluations performed for the KSA over the past 10 years. An electronic literature search of the PubMed, EMBASE, and Cochrane databases was performed. A CHEERS checklist was used to assess the quality of reporting. Reported limitations were classified into domains including the definition of perspectives, identification of comparators, estimation of costs and resources, and use of the incremental cost-effectiveness ratio threshold.

RESULTS

Twelve evaluations were identified; most involved cost-effectiveness analysis (92%). Missing and unclear data were found within the CHEERS criteria. Regardless of the perspective used, most described the perspective as an "institutional" perspective (70%) and almost half were reclassified by the current reviewer (42%). Most did not clearly state the comparator (83%), and published model comparators were commonly used (50%). Resource estimation was mostly performed by the authors of the respective studies (67%), and costs were mostly obtained from hospital institutional data (75%). The lack of an established threshold for the country-specific willingness to pay was observed in 50% of the analyses.

CONCLUSIONS

Economic evaluations from the KSA are limited. Capacity building and country-specific HTA guidelines could improve the quality of evaluations to better inform decision making.

HIGHLIGHTS

Economic analysis of health technology should follow standard guidelines. Unfortunately, these guides are often underutilized, and our findings identify considerable missing, not clearly stated, or incomplete data within the analyses, which can weaken the impact of the recommendations.The limitations reported by the authors of the respective studies emphasize the suboptimal quality of the reporting. A lack of data was frequently identified and resulted in using "institutional" practice as a major source of data input for the analyses.In light of the call for the establishment of an HTA entity in the KSA, framing a standard analytic approach when conducting economic evaluations will support HTA in informing resource allocation decisions. We hope that our findings highlight the need for country-specific guidance to improve practice and enhance future research.

Reporting Quality of Cost-Effectiveness Analyses Conducted in Saudi Arabia: A Systematic Review

OBJECTIVES

Pharmacoeconomics and health economics in general is a new field that is still developing and emerging, not only in Saudi Arabia but all over the world. The objective of this study is to collect all published cost-effectiveness analysis (CEA) studies conducted based on Saudi settings and to evaluate their reporting quality.

METHODS

We used PRISMA guidelines to search for all English-language CEAs conducted in Saudi Arabia in 3 databases: Medline, Embase, and Scopus. Keywords used in the search were: cost-effectiveness, cost-benefit, cost-utility, economic evaluation, Saudi Arabia. The data extracted were analyzed to assess reporting quality based on Consolidated Health Economic Evaluation Reporting Guidelines (CHEERS) and the second panel recommendations.

RESULTS

The 3 databases yielded 859 articles after removing duplicates. Only 7 articles included as final results following PRISMA guidelines. These 7 studies were published between 2015 and 2020. The CEA studies varied in their reporting quality; however, there were common missing required items among all of them, such as justifying choosing of a specific model and time horizon and reporting the ethical implications of the studied interventions.

CONCLUSION

Seven published CEA studies were conducted based on Saudi settings as revealed by this review. The included studies reported the more important aspects of CEA studies. However, there were missed reporting items based on the checklists we used to assess CEAs in this review. Although perfect and complete adherence to CHEERS or the second panel guidelines is a high standard, future CEAs should adhere to such standards. Transparency and good reporting are cornerstones in CEAs, and future CEAs should report their methods, findings, and results in a more transparent and efficient way.

A Systematic Review of Sources of Outcomes and Cost Data Utilized in Economic Evaluation Research Conducted in the Gulf Cooperation Council

Background

Transparency and clarity in reporting of methods used to identify, measure, and value outcomes and resources in published economic evaluations is crucial.

Objective

The aims of this review were to identify and assess the quality of published economic evaluation studies in the Gulf Cooperation Council (GCC) region, with a specific focus on methods used to identify, measure, and value cost and outcomes data.

Methods

An electronic search of publications from 2009 to October 2019 was performed in three clinical (Medline, Scopus, and EMBASE) and one economic (NHS EED) databases. Full economic evaluations undertaken in GCC countries from any perspective were included. Reference lists of three reviews on the same topic and area were also searched for further eligible articles. The Consolidated Health Economic Evaluation Reporting Standards (CHEERS) checklist was used for methodological quality assessment. Data on type and source of cost and outcomes data were collected.

Results

Out of 1857 studies identified, 14 relevant studies were eligible and included. Eleven studies were based in Saudi Arabia, and the remaining studies were published in the United Arab of Emirates (UAE), Qatar, and Oman. Majority of the evaluations were based on the Markov modelling (n=8). None of the studies fully fulfilled the CHEERS quality criteria. Quality-adjusted life years (QALYs) was the main outcome (n=10). The EQ-5D was valued using the UK value set tariff (n=6). Published literature was the source of outcomes data in seven studies. Hospital-based data were used as a source of healthcare resource use data in four studies, whereas hospital-based costs (n = 7) combined with other sources such as local/national data were the sources of unit cost data in the majority of the studies.

Conclusion

Rigorous economic evaluations are lacking in the region leading to inaccurate information being given to decision-makers.

Systematic review on estimated rates of nephrotoxicity and neurotoxicity in patients treated with polymyxins

BACKGROUND

Nephrotoxicity and neurotoxicity are commonly associated with polymyxin treatment; however, the emergence of multidrug-resistant Gram-negative bacteria with limited therapeutic options has resulted in increased use of polymyxins.

OBJECTIVES

To determine the rates of nephrotoxicity and neurotoxicity during polymyxin treatment and whether any factors influence these.

DATA SOURCES

Medline, Embase and Cochrane Library databases were searched on 2 January 2020.

STUDY ELIGIBILITY CRITERIA

Studies reporting nephrotoxicity and/or neurotoxicity rates in patients with infections treated with polymyxins were included. Reviews, meta-analyses and reports not in English were excluded.

PARTICIPANTS

Patients hospitalized with infections treated with systemic or inhaled polymyxins were included. For comparative analyses, patients treated with non-polymyxin-based regimens were also included.

METHODS

Meta-analyses were performed using a random-effects model; subgroup meta-analyses were conducted where data permitted using a mixed-effects model.

RESULTS

In total, 237 reports of randomized controlled trials, cohort and case-control studies were eligible for inclusion; most were single-arm observational studies. Nephrotoxic events in 35,569 patients receiving polymyxins were analysed. Overall nephrotoxicity rate was 0.282 (95% confidence interval (CI) 0.259-0.307). When excluding studies where >50% of patients received inhaled-only polymyxin treatment or nephrotoxicity assessment was by methods other than internationally recognized criteria (RIFLE, KDIGO or AKIN), the nephrotoxicity rate was 0.391 (95% CI 0.364-0.419). The odds of nephrotoxicity were greater with polymyxin therapies compared to non-polymyxin-based regimens (odds ratio 2.23 (95% CI 1.58-3.15); p < 0.001). Meta-analyses showed a significant effect of polymyxin type, dose, patient age, number of concomitant nephrotoxins and use of diuretics, glycopeptides or vasopressors on the rate of nephrotoxicity. Polymyxin therapies were not associated with a significantly different rate of neurotoxicity than non-polymyxin-based regimens (p 0.051). The overall rate of neurotoxicity during polymyxin therapy was 0.030 (95% CI 0.020-0.043).

CONCLUSIONS

Polymyxins are associated with a higher risk of nephrotoxicity than non-polymyxin-based regimens.