Cost-effectiveness of rimegepant oral lyophilisate compared to best supportive care for the acute treatment of migraine in the UK

AIMS

Migraine is the most common disabling headache disorder and is characterized by recurrent throbbing head pain and symptoms of photophobia, phonophobia, nausea, and vomiting. Rimegepant 75 mg, an oral lyophilisate calcitonin gene-related peptide antagonist, is the first treatment approved for both the acute and preventative treatment of migraine, and the first acute therapy approved in over 20-years. The objective was to assess the cost-utility of rimegepant compared with best supportive care (BSC) in the UK, for the acute treatment of migraine in the adults with inadequate symptom relief after taking at least 2 triptans, or for whom triptans are contraindicated or not tolerated.

MATERIALS AND METHODS

A de novo model was developed to estimate incremental costs and quality-adjusted life years (QALYs), structured as a decision tree followed by Markov model. Patients received rimegepant or BSC for a migraine attack and were assessed for response (pain relief at 2-h). Responders and non-responders followed different pain trajectories over 48-h cycles. Non-responders discontinued treatment while responders continued treatment for subsequent attacks, with a proportion discontinuing over time. Data sources included a post-hoc pooled analysis of the phase 3 acute rimegepant trials (NCT03235479, NCT03237845, NCT03461757), and a long-term safety study (NCT03266588). The analysis was conducted from the perspective of the UK National Health Service and Personal Social Services over a 20-year time horizon.

RESULTS

Rimegepant resulted in an incremental cost-utility ratio (ICUR) of £10,309 per QALY gained vs BSC, which is cost-effectiveness at a willingness to pay threshold of £30,000/QALY. Rimegepant generated +0.44 incremental QALYs and higher incremental lifetime costs (£4,492). Improved QALYs for rimegepant were a result of less time spent with severe and moderate headache pain.

CONCLUSION

This study highlights the economic value of rimegepant which was found to be cost-effective for the acute treatment of migraine in adults unsuitable for triptans.

86 STAFF EXPERIENCES OF COVID-19 MANAGEMENT IN A LONG-TERM CARE FACILITY FOR OLDER PEOPLE IN IRELAND

Background

Long term care (LTC) facilities for older people have been challenged by COVID-19 in an unprecedented manner. The impact of COVID-19 on health care professionals working in LTC facilities for older people is emerging as a crucial topic. Healthcare workers in LTC for older people were already pre COVID-19 experiencing high levels of stress and compassionate fatigue. The aim of the study was to capture the experiences of staff working during COVID-19 pandemic in a LTC facility for older people in Ireland.

Methods

Semi-structured interviews were conducted with 28 participants who were staff members, both clinical and non-clinical, in a LTC facility for older people in Ireland. Informed consent was obtained from all participants in accordance with the principles of the Helsinki Declaration. Data were interpreted using thematic analysis which allows for patterns of meaning to emerge by creating themes.

Results

21 clinical and 7 non-clinical staff members participated in interviews conducted between June and September 2021. Through analysis four main themes were identified: ‘Fear of COVID-19’, ‘Coping’, ‘Crisis and communication’ and ‘Teamwork’. Themes were interlinked with each other and mainly highlights the high level of adaption by staff in various roles during a time of uncertainty.

Conclusion

The findings are supported by previous studies into staff experiences of COVID-19 in which the level of uncertainty and stress caused by COVID-19 impacted staff on both professional and personal levels. Although positive examples of strong teamwork and a sense of working together were found, there was also fatigue as the pandemic continues. Future studies into staff stress levels and coping with COVID-19 should include the voices of healthcare professionals in LTC facilities for older people.

91 MONITORING FOR CLINICAL DETERIORATION; NURSES EXPERIENCE USING MODIFIED IRISH NATIONAL EARLY WARNING SYSTEM IN AN OLDER PERSON RESIDENTIAL CARE SERVICE

Background

We are a 140-bed Care of the Older Person facility. Approximately 50% of Sepsis cases occur in this demographic. The Irish National Early Warning System (INEWS) is an early warning system to assist staff recognise and respond appropriately to clinical deterioration. Currently there is no INEWS for Older Person Residential Services. Challenges for treatment relating to deterioration in our service are; detecting ‘new confusion’, access to doctors, treatment options available and the necessity to transfer a resident to the Acute Care sector if intravenous antibiotics were required. We used the National Clinical Guideline INEWS Version 2 (2020) to develop a clinical monitoring and escalation protocol. This was rolled out December 2021.

Methods

A Nurses Opinion survey was carried out to determine Nurses experience with using the locally modified Early Warning System.

Results

There was a 63% (n=35) response rate. 100% reported improvement in identifying clinical deterioration in a timely manner and effective monitoring for deteriorating residents. 96% reported improvement in confidence with monitoring unwell residents, confidence with transfer out decisions and referring the resident to the doctor for review. 91% noted improvement in communicating residents’ condition to doctors. 87% improvement in clinical practice when monitoring vital signs. 82% improved communication using the ISBAR. On reviewing clinical documentation for all residents who had deteriorated post implementation there was a significant improvement in monitoring and documentation. 23% stated increased time and staffing levels were required for monitoring of residents. 9% stated doctors didn’t always understand the INEWS.

Conclusion

Implementation of the modified INEWS has resulted in considerably improved clinical monitoring, documentation, & Nurses confidence. Significant challenges remain including ethical issues with decision to transfer out a resident for treatment. Recommendations are upskilling of Health Care Assistants to carry out vital signs monitoring, robust advanced healthcare decision making and implementation of an INEWS for Older Person Services.

270 ENHANCING CAPACITY TO CONSENT IN AN OLDER PERSON RESIDENTIAL CARE FACILITY; USING SPEECH AND LANGUAGE THERAPY TO MAXIMISE COMMUNICATION

Background

For consent to be valid the resident must be able understand the information and communicate their choice. People with dementia can have a number of communication deficits; difficulty word finding, tendency to digress and repeat themselves, understanding the spoken word, maintaining a conversation topic without losing track, using semantically empty words (e.g. ‘thing’, ‘stuff’) in place of content words. This can limit their ability to express wishes and preferences. Out of 100 residents in our Older Person Residential Care facility 48% require some supports with communication; 25 diagnosed with dementia, 8 suspected (33%) and 15 with cognitive impairment. As per the HSE National Consent policy 2022 we have a duty to maximise capacity for our residents to consent to treatment and interventions. Insight into the factors involved in the communication process between nursing staff and people with dementia is limited. Speech and Language Therapists (SALT) identify the specific nature of communication deficits for a person with dementia.

Methods

Our SALT reviewed our residents and advised on actions required to reduce the impact of communication deficits. We implemented a Communication care plan for our residents to include all identified communication abilities and disabilities for both speech and language across all modalities (reading, writing, gesture, symbols). To evidence understanding of consent, all staff interacting with residents were requested to undertake the HSELand National Consent policy module. All staff attended training which involved enhancing communication abilities.

Results

In February 2022, 95% of care plans audited had actions to address communication deficits in place. Ad hoc discussion with staff evidenced improved understanding of each resident’s communication deficits and necessity to use SALT reviews to enhance capacity to consent.

Conclusion

We have demonstrated that the use of SALT to enhance ability to communicate has enhanced capacity to consent for our residents. Staff also demonstrated improved communication practices.

Heterogeneity in the onwards transmission risk between local and imported cases affects practical estimates of the time-dependent reproduction number

During infectious disease outbreaks, inference of summary statistics characterizing transmission is essential for planning interventions. An important metric is the time-dependent reproduction number (Rt), which represents the expected number of secondary cases generated by each infected individual over the course of their infectious period. The value of Rt varies during an outbreak due to factors such as varying population immunity and changes to interventions, including those that affect individuals' contact networks. While it is possible to estimate a single population-wide Rt, this may belie differences in transmission between subgroups within the population. Here, we explore the effects of this heterogeneity on Rt estimates. Specifically, we consider two groups of infected hosts: those infected outside the local population (imported cases), and those infected locally (local cases). We use a Bayesian approach to estimate Rt, made available for others to use via an online tool, that accounts for differences in the onwards transmission risk from individuals in these groups. Using COVID-19 data from different regions worldwide, we show that different assumptions about the relative transmission risk between imported and local cases affect Rt estimates significantly, with implications for interventions. This highlights the need to collect data during outbreaks describing heterogeneities in transmission between different infected hosts, and to account for these heterogeneities in methods used to estimate Rt. This article is part of the theme issue 'Technical challenges of modelling real-life epidemics and examples of overcoming these'.

Real-world impact of rotavirus vaccination in European healthcare settings: a systematic literature review

INTRODUCTION

Rotavirus is one of the most common pathogens causing diarrhea in children <5 years and has a major impact on childhood morbidity and mortality. Since the implementation of rotavirus vaccines into childhood immunization programs across Europe, there has been a reduction in rotavirus burden, including hospitalizations, outpatient cases, costs, and deaths.

AREAS COVERED

A systematic literature review identified publications describing the clinical and economic impact of rotavirus vaccinations across Europe, from their introduction in 2006 to the end of 2020. A total of 3,137 articles were identified, of which 46 were included in the review. Included articles reported the impact of rotavirus vaccination on disease in any age group.

EXPERT OPINION

Rotavirus vaccination has resulted in substantial reductions in hospitalizations and rotavirus-associated costs across Europe, particularly in children <5 years. There is some evidence of herd protection afforded to older age groups where vaccine uptake is high among infants, highlighting the potential for vaccination to confer a greater societal benefit as programs become more established. Increasing vaccination coverage and continuing investment in widespread rotavirus vaccination programs across countries will likely increase the substantial public health benefits associated with vaccination and further reduce the clinical and economic burden of disease.

177 REDUCTION OF RESTRICTIVE PRACTICES IN AN OLDER PERSON RESIDENTIAL CARE FACILITY; THE IMPACT ON HUMAN RIGHTS AND RESIDENT SAFETY

Background

We are a 140 bed long term care residential care facility for older people. We strive to achieve a ‘Restraint Free Environment’ in accordance with Article 40.4 of the Irish Constitution and Articles 14 (liberty and security) and 15 (freedom from torture or cruel, inhuman or degrading treatment) of the UN Convention on Rights of Persons with Disabilities(1). Health Act 2007, Regulations 2013 defines restrictive practice as ‘the intentional restriction of a person’s voluntary movement or behaviour’. Use of restrictive practices is warranted when there is a real and substantial risk to a person and this risk cannot be addressed by non-restrictive means’ (HIQA, 2019) (2).

Methods

An extensive review of non pharmacological restrictive practices in the Organisation was undertaken. This included One to One supervision, use of bedrails, Exit Alarm mats and Electronic Monitoring bracelets. Bedrails were replaced for some residents with Safety Wedges and Ultra Low beds.

Results

Review of restraint interventions showed no clear link to prevention of falls or injuries as a result of restraint. Contrary there was evidence of breach of dignity and privacy for the residents. Based on the review, bedrail use was reduced radically between 2016 and 2021 by 79% (42–9). Falls rate remained consistent approximately 3.6–3.2 per 1,000 Occupied Bed Days.

Exit Alarm mats, Electronic Monitoring bracelets and One to One supervision was discontinued. These were replaced with direct observation and two hourly anticipation of needs. Cost saving on One to One estimated to have been €25,000 in 2016 alone. Clear care planning of the resident’s needs are core.

Conclusion

We have demonstrated that we could successfully reduce restrictive practices, thus respecting Human Rights, with no compromise to resident safety.

References

1. United Nations Convention on Rights for Persons with Disabilities (2007)

2. H.I.Q.A 2019 Guidance on promoting a Care Environment that is Free of Restrictive Practice.

Anaesthetic-analgesic ear drops to reduce antibiotic consumption in children with acute otitis media: the CEDAR RCT

BACKGROUND

Acute otitis media (AOM) is a common reason for primary care consultations and antibiotic prescribing in children. Options for improved pain control may influence antibiotic prescribing and consumption.

OBJECTIVE

The Children's Ear Pain Study (CEDAR) investigated whether or not providing anaesthetic-analgesic ear drops reduced antibiotic consumption in children with AOM. Secondary objectives included pain control and cost-effectiveness.

DESIGN

A multicentre, randomised, parallel-group (two-group initially, then three-group) trial.

SETTING

Primary care practices in England and Wales.

PARTICIPANTS

1- to 10-year-old children presenting within 1 week of suspected AOM onset with ear pain during the preceding 24 hours and not requiring immediate antibiotics. Participating children were logged into the study and allocated using a remote randomisation service.

INTERVENTIONS

Two-group trial - unblinded comparison of anaesthetic-analgesic ear drops versus usual care. Three-group trial - blinded comparison of anaesthetic-analgesic ear drops versus placebo ear drops and unblinded comparison with usual care.

MAIN OUTCOME MEASURES

The primary outcome measure was parent-reported antibiotic use by the child over 8 days following enrolment. Secondary measures included ear pain at day 2 and NHS and societal costs over 8 days.

RESULTS

Owing to a delay in provision of the placebo drops, the recruitment period was shortened and most participants were randomly allocated to the two-group study (n = 74) rather than the three-group study (n = 32). Comparing active drops with usual care in the combined two-group and three-group studies, 1 out of 39 (3%) children allocated to the active drops group and 11 out of 38 (29%) children allocated to the usual-care group consumed antibiotics in the 8 days following enrolment [unadjusted odds ratio 0.09, 95% confidence interval (CI) 0.02 to 0.55; p = 0.009; adjusted for delayed prescribing odds ratio 0.15, 95% CI 0.03 to 0.87; p = 0.035]. A total of 43% (3/7) of patients in the placebo drops group consumed antibiotics by day 8, compared with 0% (0/10) of the three-group study active drops groups (p = 0.051). The economic analysis of NHS costs (£12.66 for active drops and £11.36 for usual care) leads to an estimated cost of £5.19 per antibiotic prescription avoided, but with a high degree of uncertainty. A reduction in ear pain at day 2 in the placebo group (n = 7) compared with the active drops group (n = 10) (adjusted difference in means 0.67, 95% CI -1.44 to 2.79; p = 0.51) is consistent with chance. No adverse events were reported in children receiving active drops.

LIMITATIONS

Estimated treatment effects are imprecise because the sample size target was not met. It is not clear if delayed prescriptions of an antibiotic were written prior to randomisation. Few children received placebo drops, which hindered the investigation of ear pain.

CONCLUSIONS

This study suggests that reduced antibiotic use can be achieved in children with AOM by combining a no or delayed antibiotic prescribing strategy with anaesthetic-analgesic ear drops. Whether or not the active drops relieved ear pain was not established.

FUTURE WORK

The observed reduction in antibiotic consumption following the prescription of ear drops requires replication in a larger study. Future work should establish if the effect of ear drops is due to pain relief.

TRIAL REGISTRATION

Current Controlled Trials ISRCTN09599764.

FUNDING

This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 23, No. 34. See the NIHR Journals Library website for further project information. Alastair D Hay was funded by a NIHR Research Professorship (funding identifier NIHR-RP-02-12-012).

Thulium laser transurethral vaporesection versus transurethral resection of the prostate for benign prostatic obstruction: the UNBLOCS RCT

BACKGROUND

Transurethral resection of the prostate (TURP) is the standard operation for benign prostatic obstruction (BPO). Thulium laser transurethral vaporesection of the prostate (ThuVARP) vaporises and resects the prostate using a technique similar to TURP. The small amount of existing literature suggests that there may be potential advantages of ThuVARP over TURP.

OBJECTIVE

To determine whether or not the outcomes from ThuVARP are equivalent to the outcomes from TURP in men with BPO treated in the NHS.

DESIGN

A multicentre, pragmatic, randomised controlled parallel-group trial, with an embedded qualitative study and economic evaluation.

SETTING

Seven UK centres - four university teaching hospitals and three district general hospitals.

PARTICIPANTS

Men aged ≥ 18 years who were suitable to undergo TURP, presenting with bothersome lower urinary tract symptoms (LUTS) or urinary retention secondary to BPO.

INTERVENTIONS

Patients were randomised 1 : 1 to receive TURP or ThuVARP and remained blinded.

MAIN OUTCOME MEASURES

Two co-primary outcomes - patient-reported International Prostate Symptom Score (IPSS) and clinical measure of maximum urine flow rate (Qmax) at 12 months post surgery.

RESULTS

In total, 410 men were randomised, 205 to each arm. The two procedures were equivalent in terms of IPSS [adjusted mean difference 0.28 points higher for ThuVARP (favouring TURP), 95% confidence interval (CI) -0.92 to 1.49 points]. The two procedures were not equivalent in terms of Qmax (adjusted mean difference 3.12 ml/second in favour of TURP, 95% CI 0.45 to 5.79 ml/second), with TURP deemed superior. Surgical outcomes, such as complications and blood transfusion rates, and hospital stay were similar for both procedures. Patient-reported urinary and sexual symptoms were also similar between the arms. Qualitative interviews indicated similar patient experiences with both procedures. However, 25% of participants in the ThuVARP arm did not undergo their randomised allocation, compared with 2% of participants in the TURP arm. Prostate cancer was also detected less frequently from routine histology after ThuVARP (65% lower odds of detection) in an exploratory analysis. The adjusted mean differences between the arms were similar for secondary care NHS costs (£9 higher for ThuVARP, 95% CI -£359 to £376) and quality-adjusted life-years (0.01 favouring TURP, 95% CI -0.04 to 0.01).

LIMITATIONS

Complications were recorded in prespecified categories; those not prespecified were excluded owing to variable reporting. Preoperative Qmax and IPSS data could not be collected for participants with indwelling catheters, making adjustment for baseline status difficult.

CONCLUSIONS

TURP was superior to ThuVARP in terms of Qmax, although both operations resulted in a Qmax considered clinically successful. ThuVARP also potentially resulted in lower detection rates of prostate cancer as a result of the smaller volume of tissue available for histology. Length of hospital stay after ThuVARP, anticipated to be a key benefit, was equal to that after TURP in this trial. Overall, both ThuVARP and TURP were effective procedures for BPO, with minor benefits in favour of TURP. Therefore, the results suggest that it may be appropriate that new treatment alternatives continue to be compared with TURP.

FUTURE WORK

Longer-term follow-up to assess reoperation rates over time, and research into the comparative effectiveness of ThuVARP and TURP in large prostates.

TRIAL REGISTRATION

Current Controlled Trials ISRCTN00788389.

FUNDING

This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 24, No. 41. See the NIHR Journals Library website for further project information.

The effects of iPod and text-messaging use on driver distraction: a bio-behavioral analysis

This study was designed to empirically examine the effects of iPod device and text-messaging activities on driver distraction. Sixty participants were asked to perform a driving simulation task while searching for songs using an iPod device or text messaging. Driving errors as measured by lane deviations were recorded and analyzed as a function of the distracters. Physiological measures (EEG) were also recorded during the driving phases in order to measure participant levels of cortical arousal. It was hypothesized that iPod use and text messaging would result in a profound effect on driving ability. The results showed a significant effect of iPod use and text-messaging on driving performance. Increased numbers of driving errors were recorded during the iPod and text-messaging phases than the pre- and post-allocation phases. Higher levels of Theta activity were also observed during the iPod and Text-messaging phase than the pre- and post-allocation phases. Implications for in-vehicle systems design, training, and safety are also discussed.

Dose-dependent effects of alcohol on appetite and food intake

To examine the potential dose-response effect of alcohol on appetite and food intake, 12 males attended the laboratory on three occasions. On each occasion, they were given a standard breakfast, then lunch 3 h later, and dinner, 4 h after that. Thirty minutes before lunch, Ss received 330 ml of no-alcohol lager (263 kJ: no-alcohol condition), the same amount of lager spiked with 1 unit (1 UA: 8 g ethyl alcohol, 498.2 kJ) or 4 units of alcohol (4 UA: 32 g ethyl alcohol, 1203.8 kJ). Visual analogue scale (VAS) ratings of appetite and mood were recorded before and after preloads and lunch, then hourly across the day. Intake at lunch (excluding energy from the preload) was significantly higher following 4 UA (5786+/-991 kJ) compared to 1 UA (4928+/-1245 kJ). Participants consumed more high-fat salty food items at lunch following 4 UA compared to the other preloads. Hunger was rated higher following 4 UA across the day in comparison to the other preloads, but fullness ratings failed to reflect any difference by condition. Energy intake at dinner was similar in all conditions and total energy intake across the day was significantly higher after 4 UA (14,615+/-1540 kJ) than after 1 UA (13,204+/-2156 kJ). In conclusion, above a certain threshold, alcohol appears to stimulate appetite in part, due to elevated levels of subjective hunger. When this occurs, energy intake is not reduced at subsequent meals. Thus, alcohol may contribute to positive energy balance via its additive effects to total energy intake and by short-term appetite stimulation.