Acceptability of 'as needed' biologic therapy in psoriasis: insights from a multi-stakeholder mixed methods study

OBJECTIVES

Biologic therapies have led to increasing numbers of patients with psoriasis who have clear or nearly clear skin. Current practice is that biologic therapy is continued indefinitely in these patients, contributing to a substantial long-term drug and healthcare burden. 'As needed' biologic therapy in psoriasis may address this, however our understanding of patient and clinician perceptions of this strategy is limited.

METHODS

We first conducted UK-wide online scoping surveys of patients with psoriasis and dermatology clinicians to explore their views on 'as needed' biologic therapy. Using topic guides informed by these survey findings, we then carried out qualitative focus groups with patients and clinicians. Themes were identified using reflexive thematic analysis.

RESULTS

Of 67 patients and 27 clinicians completing the scoping surveys, 67% (43/64) and 78% (21/27), respectively, supported the use of 'as needed' biologic therapy. Respondents highlighted advantages such as a reduction in healthcare burden and greater ownership of care. Challenges included logistics of 'as needed' drug provision and potential risks of disease flare and drug immunogenicity. Focus groups comprised 15 patients with psoriasis (9 female [60%], average disease duration 32 years [range 9-64 years]) and 9 dermatology clinicians (8 female [89%], average dermatology experience 20 years [range 8-33 years]). Both patients and clinicians felt that an 'as needed' treatment approach will deliver a reduction in treatment burden and present an opportunity for patient-led ownership of care. Both groups highlighted the importance of ensuring ongoing access to medication and discussing the potential impact of psoriasis recurrence. Patient preferences were influenced by their lived experiences, particularly previous difficulties with medication delivery logistics and establishing disease control. Clinician perspectives were informed by personal experience of their patients adapting their own dosing schedules. Clinicians highlighted the importance of targeted patient selection for an 'as needed' approach, ongoing disease monitoring, and prompt re-access to medications upon psoriasis recurrence.

CONCLUSION

These data indicate that 'as needed' biologic therapy in psoriasis is acceptable for both patients and clinicians. Formal assessment of clinical effectiveness and cost effectiveness is warranted, to enable the real-world potential of this approach to be realised.

British Association of Dermatologists guidelines for biologic therapy for psoriasis 2023: a pragmatic update

The article provides a pragmatic update of the British Association of Dermatologists guidelines for biologic therapy for psoriasis.

Real-World Implementation and Outcomes of Adalimumab Therapeutic Drug Monitoring in Psoriasis: A National Specialized Center Experience

Serum adalimumab concentration is a biomarker of treatment response but therapeutic drug monitoring (TDM) is yet to be implemented in routine psoriasis care. We incorporated adalimumab TDM in a national specialized psoriasis service and evaluated it using the RE-AIM (Reach, Effectiveness, Adoption, Implementation, and Maintenance) implementation science framework. We undertook pre-implementation planning (validating local assays) and implementation interventions targeted to patients (pragmatic sampling at routine reviews), clinicians (introduction of a TDM protocol), and healthcare systems (adalimumab TDM as a key performance indicator). Over 5 months, 170 of 229 (74%) individuals treated with adalimumab received TDM. Clinical improvement after TDM-guided dose escalation occurred in 13 of 15 (87%) nonresponders with serum drug concentrations <8.3 μg/ml (median PASI reduction of 3.2 [interquartile range = 2.2-8.2] after 23.4 weeks) and in all nonresponders who had TDM-guided switch in biologic due to supratherapeutic drug concentrations (>8.3 μg/ml; n = 2) or positive antidrug antibody (n = 2) (PASI reduction of 7.8 [interquartile range = 7.5-12.9] after 20.0 weeks). Proactive TDM led to dose reduction in five individuals with clear skin and subtherapeutic or supratherapeutic drug concentrations; four (80%) sustained clear skin after 50 weeks (range = 42-52). Adalimumab TDM based on pragmatic serum sampling is clinically viable and may lead to patient benefit. Context-specific implementation interventions and systematic implementation assessment may bridge the biomarker research-to-practice gap.

Comparing the efficacy and tolerability of biologic therapies in psoriasis: an updated network meta-analysis

BACKGROUND

The rapid expansion of psoriasis biologics has led to an urgent need to understand their relative efficacy and tolerability to inform treatment decisions better and, specifically, to inform guideline development.

OBJECTIVES

To update a 2017 meta-analysis on the comparative efficacy and tolerability of biologic treatments for psoriasis.

METHODS

We searched the MEDLINE, PubMed, Embase and Cochrane databases for randomized controlled trials (RCTs), published up to 7 September 2018, of 11 licensed, NICE-approved biologics targeting tumour necrosis factor (adalimumab, etanercept, infliximab, certolizumab pegol), interleukin (IL)-12/IL-23p40 (ustekinumab), IL-17A (secukinumab, ixekizumab), IL-17RA (brodalumab) and IL-23p19 (guselkumab, tildrakizumab, risankizumab). A frequentist network meta-analysis ascertained direct or indirect evidence comparing biologics with one another, methotrexate or placebo. This was combined with hierarchical cluster analyses to consider efficacy (≥ 90% improvement in Psoriasis Area and Severity Index (PASI 90) or Physician's Global Assessment 0 or 1; PASI 75; Dermatology Life Quality Index improvement) and tolerability (drug withdrawal due to adverse events) outcomes at 10-16 weeks, followed by assessments of study quality, heterogeneity and inconsistency.

RESULTS

We identified 62 RCTs presenting data on direct comparisons (31 899 participants). All biologics were efficacious compared with placebo or methotrexate at 10-16 weeks. Hierarchical cluster analyses revealed that adalimumab, brodalumab, certolizumab pegol, guselkumab, risankizumab, secukinumab, tildrakizumab and ustekinumab were comparable with respect to high short-term efficacy and tolerability. Infliximab and ixekizumab clustered together, with high short-term efficacy but relatively lower tolerability than the other agents, although the number of drug withdrawal events across the network was low, so these findings should be treated with caution.

CONCLUSIONS

Using our methodology we found that most biologics cluster together with respect to short-term efficacy and tolerability, and we did not identify any single agent as 'best'. These data need to be interpreted in the context of longer-term efficacy, effectiveness data, safety, posology and drug acquisition costs when making treatment decisions.

Quantifying Argonaute 2 (Ago2) expression to stratify breast cancer

BACKGROUND

Argonaute-2 (Ago2) is an essential component of microRNA biogenesis implicated in tumourigenesis. However Ago2 expression and localisation in breast cancer remains undetermined. The aim was to define Ago2 expression (mRNA and protein) and localisation in breast cancer, and investigate associations with clinicopathological details.

METHODS

Ago2 protein was stained in breast cancer cell lines and tissue microarrays (TMAs), with intensity and localization assessed. Staining intensity was correlated with clinicopathological details. Using independent databases, Ago2 mRNA expression and gene alterations in breast cancer were investigated.

RESULTS

In the breast cancer TMAs, 4 distinct staining intensities were observed (Negative, Weak, Moderate, Strong), with 64.2% of samples stained weak or negatively for Ago2 protein. An association was found between strong Ago2 staining and, the Her2 positive or basal subtypes, and between Ago2 intensity and receptor status (Estrogen or Progesterone). In tumours Ago2 mRNA expression correlated with reduced relapse free survival. Conversely, Ago2 mRNA was expressed significantly lower in SK-BR-3 (HER2 positive) and BT-20 (Basal/Triple negative) cell lines. Interestingly, high levels of Ago2 gene amplification (10-27%) were observed in breast cancer across multiple patient datasets. Importantly, knowledge of Ago2 expression improves predictions of breast cancer subtype by 20%, ER status by 15.7% and PR status by 17.5%.

CONCLUSIONS

Quantification of Ago2 improves the stratification of breast cancer and suggests a differential role for Ago2 in breast cancer subtypes, based on levels and cellular localisation. Further investigation of the mechanisms affecting Ago2 dysregulation will reveal insights into the molecular differences underpinning breast cancer subtypes.

Treatment cost of non-small cell lung cancer in three European countries: comparisons across France, Germany, and England using administrative databases

INTRODUCTION

Lung cancer is a highly prevalent condition with non-small cell lung cancer (NSCLC), representing ∼ 80%. Given its high prevalence and poor survival rates, it is important to understand costs associated with NSCLC treatment.

OBJECTIVES

To carry out an incidence-based study in three European countries: France, Germany, and the UK, to estimate the cost of NSCLC treatment.

METHODS

Three similar administrative databases were accessed; Hospital Episode Statistics (England), Gesundheitsforen Leipzig (Germany), French Hospital Discharge system (France), using ICD-9/10 codes and treatment/surgery algorithms to identify NSCLC patients. An incidence population of NSCLC patients was obtained using an index year (ranging from 2007-2008), ensuring the absence of prior lung cancer (12-months). Data were extracted on treatment information, patient characteristics, and disease staging. Average NSCLC treatment costs were estimated by age and severity. For England, 20,081 patients were identified, for France, 15,061, and for Germany, 1038.

RESULTS

In-patient length of stay was 8.9, 8.7, and 10.1 days for France, England, and Germany, respectively, for the first year. Average total costs for the 2-year follow-up period for France, England, and Germany were €25,063, €17,777, and €32,500, respectively. Sub-group analyses showed higher costs for younger patients and those with metastatic disease.

CONCLUSION

Considerable differences in average treatment costs were observed. In-patient costs dominate in the first year of treatment in all countries. The study highlights the costly nature of NSCLC.

Smoking and periodontal disease: discrimination of antibody responses to pathogenic and commensal oral bacteria

Smoking is an independent risk factor for the initiation, extent and severity of periodontal disease. This study examined the ability of the host immune system to discriminate commensal oral bacteria from pathogens at mucosal surfaces, i.e. oral cavity. Serum immunoglobulin (Ig)G antibody reactive with three pathogenic and five commensal oral bacteria in 301 current smokers (age range 21-66 years) were examined by enzyme-linked immunosorbent assay. Clinical features of periodontal health were used as measures of periodontitis. Antibody to the pathogens and salivary cotinine levels were related positively to disease severity; however, the antibody levels were best described by the clinical disease unrelated to the amount of smoking. The data showed a greater immune response to pathogens than commensals that was related specifically to disease extent, and most noted in black males. Significant correlations in individual patient responses to the pathogens and commensals were lost with an increasing extent of periodontitis and serum antibody to the pathogens. Antibody to Porphyromonas gingivalis was particularly distinct with respect to the discriminatory nature of the immune responses in recognizing the pathogens. Antibody responses to selected pathogenic and commensal oral microorganisms differed among racial groups and genders. The antibody response to the pathogens was related to disease severity. The level of antibody to the pathogens, and in particular P. gingivalis, was correlated with disease severity in black and male subsets of patients. The amount of smoking did not appear to impact directly serum antibody levels to these oral bacteria.

Economic evaluation of sacral nerve stimulation for faecal incontinence

BACKGROUND

Sacral nerve stimulation (SNS) is an established treatment for faecal incontinence in patients who have failed conservative management. This study established the cost-effectiveness of treating patients with SNS compared with non-surgical treatment.

METHODS

A decision analysis model was performed. Data from 70 patients were obtained from medical records, bowel habit diaries and Short Form 36 quality of life questionnaires. Direct medical and non-medical costs were ascertained using the 2005/2006 national tariff, national statistics, and medication, pad and device costs. Indirect non-medical costs were also estimated.

RESULTS

Incontinence episodes were reduced from a median of 12 per fortnight at baseline to one per fortnight with SNS. Based on direct medical and non-medical costs, the incremental cost-effectiveness ratio (ICER) for SNS was pound25 070 per QALY gained. It cost pound1038 more per year to treat patients with SNS for a median reduction of 286 incontinence episodes, equating to pound3.63 per episode reduced. When indirect non-medical costs were included the ICER was reduced to pound12 959 per QALY gained.

CONCLUSION

The ICER of pound25 070 is within the pound30 000 per QALY threshold recommended by the National Institute for Health and Clinical Excellence as an effective use of National Health Service resources with proper justification.

Cost-effectiveness of primary prevention of cardiovascular disease with atorvastatin in type 2 diabetes: results from the Collaborative Atorvastatin Diabetes Study (CARDS)

AIMS/HYPOTHESIS

We estimated the cost-effectiveness of atorvastatin treatment in the primary prevention of cardiovascular disease in patients with type 2 diabetes using data from the Collaborative Atorvastatin Diabetes Study (CARDS).

SUBJECTS AND METHODS

A total of 2,838 patients, who were aged 40 to 75 years and had type 2 diabetes without a documented history of cardiovascular disease and without elevated LDL-cholesterol, were recruited from 32 centres in the UK and Ireland and randomly allocated to atorvastatin 10 mg daily (n = 1,428) or placebo (n = 1,410). These subjects were followed-up for a median period of 3.9 years. Direct treatment costs and effectiveness were analysed to provide estimates of cost per endpoint-free year over the trial period for alternative definitions of endpoint, and of cost per life-year gained and cost per quality-adjusted life-year (QALY) gained over a patient's lifetime.

RESULTS

Over the trial period, the incremental cost-effectiveness ratio (ICER) was estimated to be 7,608 pounds per year free of any CARDS primary endpoint; the ICER was calculated to be 4,896 pounds per year free of any cardiovascular endpoint and 4,120 pounds per year free of any study endpoint. Over lifetime, the incremental cost per life-year gained was 5,107 pounds and the cost per QALY was 6,471 pounds (costs and benefits both discounted at 3.5%).

CONCLUSIONS/INTERPRETATION

Primary prevention of cardiovascular disease with atorvastatin is a cost-effective intervention in patients with type 2 diabetes, with the ICER for this intervention falling within the current acceptance threshold ( 20,000 pounds per QALY) specified by the National Institute for Health and Clinical Excellence (NICE).

A cost-effectiveness analysis of n-3 PUFA (Omacor) treatment in post-MI patients

This study evaluates the cost-effectiveness of Omacor treatment as a standard prevention measure post-MI in the UK. A cost-effectiveness model was developed based on the GISSI-P trial, combining a survival and a Markov model, over a lifetime period. The base case results for Omacor, at 4 years and over a lifetime, respectively, were: cost [corrected] per QALY gained: pound15,189 and 3,723; [corrected] cost per life years gained (LYG): pound12,011 and pound2,812 [corrected] The cost per death avoided at 4 years was pound31,786. Deterministic and probabilistic sensitivity analyses did not change the base case results substantially. The use of Omacor as a standard post-MI prevention treatment seems warranted in the UK, both on the basis of its efficacy, which is in addition to other prophylactic treatments as evidenced by the results of the GISSI-P trial, and on cost-effectiveness grounds - both at 4 years and over a lifetime's time-horizon, using the current cost-effectiveness thresholds.

Systematic review on urine albumin testing for early detection of diabetic complications

OBJECTIVES

To determine whether microalbuminuria is an independent prognostic factor for the development of diabetic complications and whether improved glycaemic or blood pressure control has a greater influence on the development of diabetic complications in those with microalbuminuria than in those with normoalbuminuria.

DATA SOURCES

Electronic databases up until January 2002.

REVIEW METHODS

A protocol for peer review by an external expert panel was prepared that included selection criteria for data extraction and required two independent reviewers to undertake article selection and review. Completeness was assessed using hand-searching of major journals. Random effects meta-analysis was used to obtain combined estimates of relative risk (RR). Funnel plots, trim and fill methods and meta-regression were used to assess publication bias and sources of heterogeneity.

RESULTS

In patients with type 1 or type 2 DM and microalbuminuria there is a RR of all-cause mortality of 1.8 [95% confidence interval (CI) 1.5 to 2.1] and 1.9 (95% CI 1.7 to 2.1) respectively. Similar RRs were found for other mortality end-points, with age of cohort being inversely related to the RR in type 2 DM. In patients with type 1 DM, there is evidence that microalbuminuria or raised albumin excretion rate has only weak, if any, independent prognostic significance for the incidence of retinopathy and no evidence that it predicts progression of retinopathy, although strong evidence exists for the independent prognostic significance of microalbuminuria or raised albumin excretion rate for the development of proliferative retinopathy (crude RR of 4.1, 95% CI 1.8 to 9.4). For type 2 DM, there is no evidence of any independent prognostic significance for the incidence of retinopathy and little, if any, prognostic relationship between microalbuminuria and the progression of retinopathy or development of proliferative retinopathy. In patients with type 1 DM and microalbuminuria there is an RR of developing end-stage renal disease (ESRD) of 4.8 (95% CI 3.0 to 7.5) and a higher RR (7.5, 95% CI 5.4 to 10.5) of developing clinical proteinuria, with a significantly greater fall in glomerular filtration rate (GFR) in patients with microalbuminuria. In patients with type 2 DM, similar RRs were observed: 3.6 (95% CI 1.6 to 8.4) for developing ESRD and 7.5 (95% CI 5.2 to 10.9) for developing clinical proteinuria, with a significantly greater decline in GFR in the microalbuminuria group of 1.7 (95% CI 0.1 to 3.2) ml per minute per year compared with those who were normoalbuminuric. In adults with type 1 or type 2 DM and microalbuminuria at baseline, the numbers progressing to clinical proteinuria (19% and 24%, respectively) and those regressing to normoalbuminuria (26% and 18%, respectively) did not differ significantly. In children with type 1 DM, regression (44%) was significantly more frequent than progression (15%). In patients with type 1 or type 2 DM and microalbuminuria, there is scarce evidence as to whether improved glycaemic control has any effect on the incidence of cardiovascular disease (CVD), the incidence or progression of retinopathy, or the development of renal complications. However, among patients not stratified by albuminuria, improved glycaemic control benefits retinal and renal complications and may benefit CVD. In the effects of angiotensin-converting enzyme (ACE) inhibitors on GFR in normotensive microalbuminuric patients with type 1 DM, there was no evidence of a consistent treatment effect. There is strong evidence from 11 trials in normotensive type 1 patients with microalbuminuria of a beneficial effect of ACE inhibitor treatment on the risk of developing clinical proteinuria and on the risk of regression to normoalbuminuria. Patients with type 2 DM and microalbuminuria, whether hypertensive or not, may obtain additional cardiovascular benefit from an ACE inhibitor and there may be a beneficial effect on the development of retinopathy in normotensive patients irrespective of albuminuria. There is limited evidence that treatment of hypertensive microalbuminuric type 2 diabetic patients with blockers of the renin--angiotensin system is associated with preserved GFR, but also evidence of no differences in GFR in comparisons with other antihypertensive agents. The data on GFR in normotensive cohorts are inconclusive. In normotensive type 2 patients with microalbuminuria there is evidence from three trials (all enalapril) of a reduction in risk of developing clinical proteinuria; in hypertensive patients there is evidence from one placebo-controlled trial (irbesartan) of a reduction in this risk. Intensive compared with moderate blood pressure control did not affect the rate of progression of microalbuminuria to clinical proteinuria in the one available study. There is inconclusive evidence from four trials of any difference in the proportions of hypertensive patients progressing from microalbuminuria to clinical proteinuria when ACE inhibitors are compared with other antihypertensive agents, and in one trial regression was two-fold higher with lisinopril than with nifedipine.

CONCLUSIONS

The most pronounced benefits of glycaemic control identified in this review are on retinal and renal complications in both normoalbuminuric and microalbuminuric patients considered together, with little or no evidence of any greater benefit in those with microalbuminuria. Hence, microalbuminuric status may be a false boundary when considering the benefits of glycaemic control. Classification of a person as normoalbuminuric must not serve to suggest that they will derive less benefit from optimal glycaemic control than a person who is microalbuminuric. All hypertensive patients benefit from blood pressure lowering and there is little evidence of additional benefit in those with microalbuminuria. Antihypertensive therapy with an ACE inhibitor in normotensive patients with microalbuminuria is beneficial. Monitoring microalbuminuria does not have a proven role in modulating antihypertensive therapy while the patient remains hypertensive. Recommendations for microalbuminuria research include: determining rate and predictors of development and factors involved in regression; carrying out economic evaluations of different screening strategies; investigating the effects of screening on patients; standardising screening tests to enable use of common reference ranges; evaluating the effects of lipid-lowering therapy; and using to modulate antihypertensive therapy.

Cost-effectiveness of acarbose for the management of impaired glucose tolerance in Sweden

We assessed the cost-effectiveness of acarbose in the management of patients with impaired glucose tolerance (IGT) in Sweden, based on progression to type 2 diabetes (T2D) and cardiovascular (CV) events reported in the STOP-NIDDM trial population, including high-risk subgroups. The cost per patient free from T2D was SEK28,000 or SEK1260 per diabetes free month prior to progression to T2D. The cost per patient free from CV events was SEK101,000 or SEK5000 per CV event free month. For the high CV risk subgroups, acarbose treatment dominated placebo (i.e. acarbose was more effective, less costly). Acarbose significantly reduces the incidence of diabetes and CV events in IGT patients. We predict this may translate into healthcare cost savings that partially or, in patients at high CV risk, fully offset the cost of acarbose. We conclude that acarbose is likely to be cost-effective in the management of impaired glucose tolerance.

In vivo antimicrobial effectiveness of an essential oil-containing mouth rinse 12 h after a single use and 14 days' use

OBJECTIVES

Two studies were conducted to determine the antimicrobial effect of rinsing with an essential oil-containing mouth rinse 12 h after a single rinse and 12 h after 2 weeks of twice daily rinsing, during the daytime and overnight.

MATERIALS AND METHODS

These studies utilized a randomized, double-blind, controlled crossover design. Following baseline sampling of bacteria from supragingival plaque and the dorsum of the tongue, subjects began twice-daily rinsing with either an essential oil mouth rinse containing 0.09% zinc chloride (Tartar Control Listerine Antiseptic) or a negative control rinse. Bacterial sampling was repeated 12 h after the first rinse, and again 12 h after the final rinse 14 days later. The sampling schedule was adjusted according to whether the study was investigating daytime or overnight activity. Samples were plated on Schaedlers medium (total anaerobes), Schaedlers Nalidixic/Vancomycin medium (Gram-negative anaerobes), and OOPS medium (volatile sulphur compound (VSC)-producing organisms). Inter-group log10 transformed colony-forming units/ml counts from samples of supragingival plaque and tongue swabs on each of the three media were compared by analysis of covariance.

RESULTS

The mean bacterial counts in subjects using the essential oil mouth rinse were significantly lower (p< or =0.005) than mean counts in subjects using the control rinse in all the comparisons, i.e., tongue and supragingival plaque samples on each of three media at two sampling periods in the daytime and overnight study, respectively. Mean bacterial count percent reductions for plaque samples ranged from 56.3 to 95.3; percent reductions for tongue samples ranged from 61.1 to 96.1. There was a trend to higher reductions after 14 days' rinsing than after the initial rinse.

CONCLUSION

Rinsing with the essential oil mouth rinse can have long-lasting effects in reducing anaerobic bacteria overall as well as Gram-negative anaerobes and VSC-producing bacteria. The significant reductions in numbers of these bacteria produced by the essential oil mouth rinse, both in plaque and on the dorsum of the tongue, can play a key role in explaining the essential oil mouth rinse's effectiveness in reducing supragingival plaque and gingivitis as well as its effectiveness in controlling intrinsic oral malodor over prolonged periods.

Estimating medical care costs under conditions of censoring

A number of non-parametric estimators have been proposed to calculate average medical care costs in the presence of censoring. This paper assesses their performance both in terms of bias and efficiency under extreme conditions using a medical dataset which exhibits heavy censoring. The estimators are further investigated using artificially generated data. Their variances are derived from analytic formulae based on the estimators' asymptotic properties and these are compared to empirically derived bootstrap estimates. The analysis revealed various performance patterns ranging from generally stable estimators under all conditions considered to estimators which become increasingly unstable with increasing levels of censoring. The bootstrap estimates of variance were consistent with the analytically derived asymptotic variance estimates. Of the two estimators that performed best, one imposes restrictions on the censoring distribution while the other is not restricted by the censoring pattern and on this basis the second may be preferred.

Cost of an emerging epidemic: an economic analysis of atrial fibrillation in the UK

OBJECTIVE

To evaluate the cost of atrial fibrillation (AF) to health and social services in the UK in 1995 and, based on epidemiological trends, to project this estimate to 2000. DESIGN, SETTING, AND MAIN OUTCOME MEASURES: Contemporary estimates of health care activity related to AF were applied to the whole population of the UK on an age and sex specific basis for the year 1995. The activities considered (and costs calculated) were hospital admissions, outpatient consultations, general practice consultations, and drug treatment (including the cost of monitoring anticoagulant treatment). By adjusting for the progressive aging of the British population and related increases in hospital admissions, the cost of AF was also projected to the year 2000.

RESULTS

There were 534 000 people with AF in the UK during 1995. The "direct" cost of health care for these patients was 244 million pounds sterling (approximately 350 million euros) or 0.62% of total National Health Service (NHS) expenditure. Hospitalisations and drug prescriptions accounted for 50% and 20% of this expenditure, respectively. Long term nursing home care after hospital admission cost an additional 46.4 million pounds sterling (approximately 66 million euros). The direct cost of AF rose to 459 million pounds sterling (approximately 655 million euros) in 2000, equivalent to 0.97% of total NHS expenditure based on 1995 figures. Nursing home costs rose to 111 million pounds sterling (approximately 160 million euros).

CONCLUSIONS

AF is an extremely costly public health problem.

The current cost of angina pectoris to the National Health Service in the UK

OBJECTIVE

To calculate the cost of angina pectoris to the UK National Health Service (NHS) in the year 2000.

METHODS

Calculation of the cost of hospital admissions, revascularisation procedures, hospital outpatient consultations, general practice (GP) consultations, and prescribed drug treatment.

RESULTS

634 000 individuals (1.1% of the UK population) consulted GPs 2.35 million times, costing pound 60.5 million. They required 16.0 million prescriptions (cost pound 80.7 million) and 254 000 hospital outpatient referrals (cost pound 30.4 million). There were 149 000 hospital admissions, 117 000 coronary angiograms, 21 400 coronary artery bypass operations, 17 700 percutaneous coronary interventions, and 516 000 outpatient visits, at a cost of pound 208.4 million, pound 69.9 million, pound 106.2 million, pound 60.7 million, and pound 52.2 million, respectively. The direct cost of angina was therefore pound 669 million (1.3% of total NHS expenditure), with hospital bed occupancy and procedures accounting for 32% and 35% of this total, respectively.

CONCLUSIONS

Angina is a common and costly public health problem. It consumed over 1% of all NHS expenditure in the year 2000, mainly because of hospital bed occupancy and revascularisation procedures. This is likely to be a conservative estimate of its true cost.

UK budgetary systems and new health-care technologies

OBJECTIVES

This article outlines the budgetary setting within the UK health-care system.

METHODS

It is argued that while prospective budgets can give rise to efficient resource allocation outcomes, this relies on the budget being set at an appropriate level and the accompanying incentive structures being efficient. The organizational structures and the interrelationships are critical. The recent history of UK National Health Service reforms and expenditure is outlined. It is suggested that until recently, although the budget system has the potential to promote efficiency, the aggregate budget allocated to the NHS has probably been too low given public expectations, technology advances, and preferences for health care.

RESULTS

The aggregate budget is due to rise considerably over the next 5 years. While some incentive and regulatory provisions will move the budget toward an efficient allocation many microlevel incentive issues remain.

CONCLUSION

Whether efficient patterns of health-care allocation emerge remains open to debate, however, because the existing incentive mechanisms are not optimal.

Surgical impact of adhesions following surgery in the upper abdomen

Background

The Surgical and Clinical Adhesions Research (SCAR) study set out to determine the long-term morbidity associated with postoperative adhesions following open abdominal and pelvic surgery, including the burden associated with adhesions after surgery in the upper abdomen.

Methods

Scotland's National Health Service hospital admissions are recorded by the Scottish Medical Record Linkage system. This system allows detailed analysis of hospital activity throughout Scotland including follow-through of individual patients, with sophisticated accuracy checks to ensure the quality and totality of the data set. Within the SCAR study, the total number of individuals who underwent an open abdominal or pelvic procedure in 1986 was defined, a subset of whom underwent surgery in the anatomical area of the upper abdomen (fore gut and related organs). Disease (International Classification of Diseases version 9) and procedure (Office of Population Censuses and Surveys 3/4) codes for adhesion-related problems or reoperations that might be complicated by the presence of adhesions were identified. For the purposes of the study only readmissions for directly related adhesion complications during the following 10 years were considered (e.g. small bowel obstruction and adhesiolysis). The study was steered by a multidisciplinary panel of surgeons, gynaecologists and health economists.

Results

In 1986 in Scotland, a total cohort of 8714 patients had open surgery in the upper abdomen which was considered likely to cause adhesions. This compared to 12 585 undergoing open surgery in the lower abdomen (mid hindgut) and 8489 in the female reproductive tract. The majority of patients in this cohort underwent open surgery on the gallbladder (44·4 per cent) or stomach (20·6 per cent). During the 10-year study 3293 individuals (37·8 per cent) required one or more readmissions for surgical or medical treatment for conditions either related to adhesions or involving a reoperation which could be complicated by adhesions. In total, 7048 surgical or medical readmissions were identified, with a mean of 2·1 readmissions per patient. At least 321 (4·6 per cent) of these readmissions were a direct result of abdominal or pelvic adhesions, constituting a large clinical burden. Analysis of readmissions over time showed that this burden continued steadily over the 10-year study period. As well as this workload burden, there was a risk for the patient associated with open surgery on the foregut with a mean of 3·7 readmissions for direct adhesion complications for every 100 initial procedures. This rate varied according to the site of initial surgery: 3·0 per 100 procedures for open surgery of the gallbladder, 3·5 per 100 for the stomach and 7·3 per 100 for open surgery on the pancreas.

Conclusion

The SCAR study provides the first epidemiological assessment of postoperative adhesions. Using an extremely conservative view, the medical and surgical impact following open surgery in the upper abdomen is considerable with 4·6 per cent of readmissions over a 10-year period directly attributable to adhesions. The full impact of adhesions, including their effect on subsequent surgery, is likely to be considerably greater and extensive research is being progressed with the SCAR data set to investigate further the burden and associated costs, and optimum strategies to reduce the problem.

The case for fire safe cigarettes made through industry documents

OBJECTIVES

To examine the extensive research undertaken by the tobacco industry over the past 25 years toward development of a fire safe cigarette.

METHODS

Research was conducted through a web based search of internal tobacco industry documents made publicly available through the 1998 Master Settlement Agreement.

RESULTS

The documents reveal that the tobacco industry produced a fire safe cigarette years ago, but failed to put it on the market. These findings contradict public industry claims that denied the technical feasibility and commercial acceptability of fire safe cigarettes. Internal documents also reveal a decades long, coordinated political strategy used to block proposed legislation and obfuscate the fire safe issue.

CONCLUSIONS

Federal legislation mandating fire safe cigarettes is needed.

A cost-effectiveness evaluation of amlodipine usage in patients with coronary artery disease in Sweden

The objective of this analysis was to calculate the cost-effectiveness of amlodipine therapy in patients with coronary artery disease in Sweden. It is hypothesised that treatment with amlodipine will have an impact on overall cardiovascular disease treatment costs, resulting in a positive cost-effectiveness profile. A Markov cohort simulation model was constructed to simulate event-related and procedure-related health economic outcomes of coronary artery disease populations on amlodipine versus those on placebo. Patient level data from the Prospective Evaluation of the Vascular Effects of Norvasc Trial was used to populate the model. The total number of adverse cardiovascular clinical outcomes experienced over a three-year period was lower for patient on amlodipine than for those on placebo. The rate of hospitalisation per patient due to angina, coronary artery bypass graft, percutaneous transluminal coronary angioplasty, congestive heart failure, and myocardial infarction in the placebo cohort was 64.7%, while the rate in the amlodipine cohort was 46.9%. The cost per patient was Swedish kroner (SEK)26,600 for amlodipine patients and SEK27,400 for placebo patients. The use of amlodipine resulted in improved clinical outcomes as well as a slight savings in cost over a three-year period.

The excess cost of acute exacerbations of chronic bronchitis in patients aged 45 and older in England and Wales

INTRODUCTION

Chronic Bronchitis is a serious and costly health problem. Prevalence is estimated at 45 per 10,000 persons in the United Kingdom. Approximately 120,000 Pounds would be saved for every 100 hospital admissions avoided. A reduction in acute exacerbations of chronic bronchitis (AECB), treatment failures, and subsequent hospital admission could have a significant impact on the burden of AECB borne by secondary care facilities in the UK National Health Service (NHS).

OBJECTIVE

The aim of this study is to provide an economic assessment of the direct cost to the health care system associated with the management of chronic bronchitis and its acute exacerbations.

DESIGN

A prevalence-based, excess-cost-of-illness analysis is undertaken from the perspective of the UK NHS. Disease prevalence data, primary health care resource utilization, hospital inpatient and outpatient resource utilization, and costs of health care were taken from a variety of data sources, including a large UK national survey of general practice (GP) consultations, the General Practice Research Database, a survey from a single NHS hospital trust, and the national health-care resource and cost statistics.

RESULTS

From 1994 to 1995, approximately 233,000 cases of chronic bronchitis were detected in the persons aged 45 and older in the United Kingdom. Prevalence peaked at 204 per 10,000 in the group of subjects aged 75 to 84 years. During that same period, the total excess cost of primary care associated with AECB was calculated at 35.7 million Pounds. The largest component of primary care costs was the excess cost of all prescription medicines, which totaled 27.8 million Pounds. The excess cost attributed to antibacterial and respiratory prescription medications alone was estimated at 9 million Pounds. Excess costs attributed to GP consultations and hospital emergency room visits were 6.5 million Pounds and 1.3 million Pounds, respectively. The excess costs arising from inpatient hospital episodes included 8.3 million Pounds for hospital admissions, 660,000 Pounds for outpatient costs, and 225,000 Pounds for day care.

CONCLUSIONS

These results suggest that improving the management of AECB with the objective of reducing the number of AECB treatment failures and the associated hospital admissions could significantly reduce expenditures by the UK NHS.

Postoperative adhesions: ten-year follow-up of 12,584 patients undergoing lower abdominal surgery

PURPOSE

Postoperative adhesions are a significant problem after colorectal surgery. However, the basic epidemiology and clinical burden are unknown. The Surgical and Clinical Adhesions Research Study has investigated the scale of the problem in a population of 5 million.

METHODS

Validated data from the Scottish National Health Service Medical Record Linkage Database were used to define a cohort of 12,584 patients undergoing open lower abdominal surgery in 1986. Readmissions for potential adhesion-related disease in the subsequent ten years were analyzed. The methodology was conservative in interpreting adhesion-related disease.

RESULTS

In the study cohort 32.6 percent of patients were readmitted a mean of 2.2 times in the subsequent ten years for a potential adhesion-related problem. Although 25.4 percent of readmissions were in the first postoperative year, they continued steadily throughout the study period. After open lower abdominal surgery 7.3 percent (643) of readmissions (8,861) were directly related to adhesions. This varied according to operation site: colon (7.1 percent), rectum (8.8 percent), and small intestine (7.6 percent). The readmission rate was assessed to provide an indicator of relative risk of adhesion-related problems after initial surgery. The overall average rate of readmissions was 70.4 per 100 initial operations, with 5.1 directly related to adhesions. This rose to 116.4 and 116.5, respectively, after colonic or rectal surgery-with 8.2 and 10.3 directly related to adhesions.

CONCLUSIONS

There is a high relative risk of adhesion-related problems after open lower abdominal surgery and a correspondingly high workload associated with these readmissions. This is influenced by the initial site of surgery, colon and rectum having both the greatest impact on workload and highest relative risk of directly adhesion-related problems. The study provides sound justification for improved adhesion prevention strategies.

Where are the economic guidelines coming from?

Economic guidelines recommend methods that should be employed in conducting economic evaluations of healthcare programs. The nature of the efficiency or equity goal underpinning economic guidelines is unclear. What is also unclear is how the methods recommended in the guidelines are linked to the underlying efficiency or equity goal being targeted. If it is unclear what efficiency/equity objectives are being pursued, then it is unlikely that even full implementation of economic guidelines will improve resource allocation.

Assessment of quality of life in lung transplantation using a simple generic tool

BACKGROUND

The EuroQol is a generic questionnaire developed to provide a simple method for assigning utility values to health. This study examines the applicability of the EuroQol to the measurement of quality of life in single, bilateral, and heart-lung transplantation.

METHODS

A cross sectional study was performed in 87 patients awaiting lung transplantation and in 255 transplant recipients attending follow up clinics in four transplant units.

RESULTS

In the waiting list group 61% reported extreme problems in at least one of the five EuroQol quality of life domains compared with 20% single lung recipients, 4% bilateral lung recipients, and 2% heart-lung recipients at 3 or more years after transplantation. The mean utility value of patients on the waiting list was 0.31. In comparison, utility values for recipients 3 years after transplantation were 0.61 for single, 0.82 for bilateral, and 0.87 for heart-lung transplants. The utility scores and health profiles of bilateral and heart-lung recipients were consistently superior to those of single lung recipients. Problems in all five domains were more frequent in single lung recipients. Subjective assessment with a visual analogue scale showed a similar trend.

CONCLUSIONS

The EuroQol is a simple method of deriving a single utility value for quality of life and is responsive to changes after lung transplantation. It is worth considering as a means of monitoring quality of life after transplantation and as an index of quality of survival in research studies in solid organ transplantation. These data suggest that quality of life after transplantation of one lung is inferior to that after transplantation of two lungs.

Overview of the arthritis Cost Consequence Evaluation System (ACCES): a pharmacoeconomic model for celecoxib

Pharmacoeconomic analyses have become useful and essential tools for health care decision makers who increasingly require such analyses prior to placing a drug on a national, regional or hospital formulary. Previous health economic models of non-steroidal anti-inflammatory drugs (NSAIDs) have been restricted to evaluating a narrow range of agents within specific health care delivery systems using medical information derived from homogeneous clinical trial data. This paper summarizes the Arthritis Cost Consequence Evaluation System (ACCES)--a pharmacoeconomic model that has been developed to predict and evaluate the costs and consequences associated with the use of celecoxib in patients with arthritis, compared with other NSAIDs and NSAIDs plus gastroprotective agents. The advantage of this model is that it can be customized to reflect local practice patterns, resource utilization and costs, as well as provide context-specific health economic information to a variety of providers and/or decision makers.

Cost effectiveness of an intensive blood glucose control policy in patients with type 2 diabetes: economic analysis alongside randomised controlled trial (UKPDS 41). United Kingdom Prospective Diabetes Study Group

OBJECTIVE

To estimate the cost effectiveness of conventional versus intensive blood glucose control in patients with type 2 diabetes.

DESIGN

Incremental cost effectiveness analysis alongside randomised controlled trial.

SETTING

23 UK hospital clinic based study centres.

PARTICIPANTS

3867 patients with newly diagnosed type 2 diabetes (mean age 53 years).

INTERVENTIONS

Conventional (primarily diet) glucose control policy versus intensive control policy with a sulphonylurea or insulin.

MAIN OUTCOME MEASURES

Incremental cost per event-free year gained within the trial period.

RESULTS

Intensive glucose control increased trial treatment costs by pound 695 (95% confidence interval pound 555 to pound 836) per patient but reduced the cost of complications by pound 957 (pound 233 to pound 1681) compared with conventional management. If standard practice visit patterns were assumed rather than trial conditions, the incremental cost of intensive management was pound 478 (-pound 275 to pound 1232) per patient. The within trial event-free time gained in the intensive group was 0.60 (0.12 to 1.10) years and the lifetime gain 1.14 (0.69 to 1.61) years. The incremental cost per event-free year gained was pound 1166 (costs and effects discounted at 6% a year) and pound 563 (costs discounted at 6% a year and effects not discounted).

CONCLUSIONS

Intensive blood glucose control in patients with type 2 diabetes significantly increased treatment costs but substantially reduced the cost of complications and increased the time free of complications.

Centre-specific or average unit costs in multi-centre studies? Some theory and simulation

Costing issues are increasingly being addressed in multi-centre studies. In this paper, two methods for collecting costing information are compared within a simulated clinical trial setting. One method estimates average treatment costs by applying unit costs averaged across treatment centres to centre-specific volumes of resource use. The second uses centre-specific information for both the unit costs and the resource volumes, and then averages across centres. Using a pre-specified production relation between the different volumes of resource use, and simulating changes in unit costs, it is shown that these two methods result in statistically different estimates of average treatment costs. This finding holds, regardless of the degree of substitutability between the resource volumes, except when considerable uncertainty surrounds treatment centre responses to relative changes in unit costs. The findings suggest that a more cautious approach should be adopted in the collection, calculation and interpretation of treatment costs in multi-centre studies.

Establishing health state valuations for disease specific states: an example from heart disease

This study considers the feasibility of defining a QALY from disease-specific data using the New York Heart Association (NYHA) classification of heart failure. The study derives health state values for the four different NYHA classifications of disease progression using the time trade-off (TTO) instrument associated with the five dimensional (EQ-5D) health state valuation method. Consistent mappings between the disease classification and the chosen QALY instrument are found. With this being the case, the assumption of constant proportionality, which is necessary to define the QALY as an acceptable measure of health related preferences, is considered. It is found that constant proportionality does not hold across the more severe health states, thus questioning the use of QALYs as representing cardinal preference structures.

Adhesion-related hospital readmissions after abdominal and pelvic surgery: a retrospective cohort study

BACKGROUND

Adhesions after abdominal and pelvic surgery are important complications, although their basic epidemiology is unclear. We investigated the frequency of such complications in the general population to provide a basis for the targeting and assessment of new adhesion-prevention measures.

METHODS

We used validated data from the Scottish National Health Service medical record linkage database to identify patients undergoing open abdominal or pelvic surgery in 1986, who had no record of such surgery in the preceding 5 years. Patients were followed up for 10 years and subsequent readmissions were reviewed and outcomes classified by the degree of adhesion. We also assessed the rate of adhesion-related admissions in 1994 for the population of 5 million people.

FINDINGS

1209 (5.7%) of all readmissions (21,347) were classified as being directly related to adhesions, with 1169 (3.8%) managed operatively. Overall, 34.6% of the 29,790 patients who underwent open abdominal or pelvic surgery in 1986 were readmitted a mean of 2.1 times over 10 years for a disorder directly or possibly related to adhesions, or for abdominal or pelvic surgery that could be potentially complicated by adhesions. 22.1% of all outcome readmissions occurred in the first year after initial surgery, but readmissions continued steadily throughout the 10-year period. In 1994, 4199 admissions were directly related to adhesions.

INTERPRETATION

Postoperative adhesions have important consequences to patients, surgeons, and the health system. Surgical procedures with a high risk of adhesion-related complications need to be identified and adhesion prevention carefully assessed.

Knowledge, attitudes and behaviour towards HIV infection among family planning clinic attendees: changes between 1991 and 1997

AIM

To detect changes in knowledge, attitudes and behaviour towards HIV infection amongst Family Planning Clinic attendees in Christchurch, New Zealand, between 1991 and 1997.

METHODS

A voluntary, anonymous, self-administered questionnaire was applied to consecutive subjects attending the Montreal Centre of the Family Planning Association in Christchurch, in 1991 and repeated in 1997. Results were compared to assess changes in demographic features, knowledge, attitudes and behaviour pertaining to HIV infection between these times.

RESULTS

A 99% response rate was obtained in 1991 and 98% in 1997. Two hundred people in 1991 and 353 people in 1997 responded. These predominantly female heterosexual groups were demographically similar. Levels of knowledge pertaining to HIV infection were high and did not change significantly between 1991 and 1997, except for a rise in the proportion who felt donating blood was a high risk behaviour from 12.0% to 25.7% (p<0.001). HIV testing and discussion about HIV testing amongst couples was more common in 1997. However, the use of recreational intravenous drugs rose from 5.0% to 10.6% (p=0.025), condom use with every new partner fell from 65.1% to 42.1% (p=0.001) and the perceived risk of acquiring HIV in New Zealand and several Western Hemisphere countries fell, with 40.0% perceiving the South Island as a high-risk place in 1991 to 24.1% in 1997(p<0.001). This was paralleled by an apparent rise in known HIV testing.

CONCLUSIONS

This predominantly heterosexual population appears to have maintained good levels of knowledge about HIV infection. However, this does not seem to be being translated into safer behaviour. This study detects alarming changes in behaviour in the face of adequate knowledge levels and increased testing for HIV which may provide pathways for entry of HIV into, and transmission within, the heterosexual population of New Zealand. Several aims of the New Zealand Strategy on HIV/AIDS 1990 need to be revisited in light of the evidence and resources directed appropriately.

International economic analysis of primary prevention of cardiovascular disease with pravastatin in WOSCOPS. West of Scotland Coronary Prevention Study

AIMS

The results of the West of Scotland Coronary Prevention Study (WOSCOPS) demonstrated the clinical benefit of using pravastatin for the primary prevention of cardiovascular disease in hypercholesterolaemic men. To inform decision makers, who must also consider costs, this study assesses the economic efficiency of such an intervention in a broad range of countries.

METHODS AND RESULTS

A generalized model of cardiovascular disease prevention was used to estimate the cost-effectiveness of primary prevention with pravastatin compared to diet alone. This model follows a cohort of hypercholesterolaemic men over a given period quantifying the effect in terms of the avoidance of cardiovascular disease based on treatment-specific risks derived from WOSCOPS data and extensive record-linkage data on disease-specific survival. Country-specific costs are accounted for by expressing all such parameters in terms of the ratio of monthly treatment to that of managing a myocardial infarction. Over a broad range of inputs the cost-effectiveness ratios remain below $25,000 per life years gained, regardless of country. Subgroups with even better economic efficacy can be defined on the basis of higher baseline risk.

CONCLUSIONS

In contrast to some previous reports, this analysis based on trial data demonstrates that pravastatin provides not only an effective means of primary cardiovascular disease prevention, but also an efficient one.