Findings from three methods to identify falls in hospitals: Results from the Ambient Intelligent Geriatric Management system fall prevention trial

OBJECTIVE

To (a) compare characteristics of patients who fall with those of patients who did not fall; and (b) characterise falls (time, injury severity and location) through three fall reporting methods (incident system reports, medical notes and clinician reports).

METHODS

A substudy design within a stepped-wedge clinical trial was used: 3239 trial participants were recruited from two inpatient Geriatric Evaluation and Management Units and one general medicine ward in two Australian states. To compare the characteristics of patients who had fallen with those who had not, descriptive tests were used. To characterise falls through three reporting methods, bivariate logistic regressions were used.

RESULTS

Patients who had fallen were more likely than patients who had not fallen to be cognitively impaired (51% vs. 29%, p < 0.01), admitted with falls (38% vs. 28%, p = 0.01) and have poor health outcomes such as prolonged length of stay (24 [16-34] vs. 12 [8-19] days [IQR], p < 0.01) and less likely to be discharged directly to the community (62% vs. 47%, p < 0.01). Most falls were captured from medical notes (93%), with clinician (71%) and incident reports (68%) missing 21%-25% of falls. The proportion of injurious falls identified through incident reports was higher than medical records or clinician reports (40% vs. 34% vs. 37%).

CONCLUSIONS

This study reaffirms the need to improve reporting falls in incident systems and at clinical handover to the team leader. Research should continue to use more than one method of identifying falls, but include data from medical records. Many falls cause injury, resulting in poor health outcomes.

Pragmatic review of interventions to prevent catheter-associated urinary tract infections (CAUTIs) in adult inpatients

BACKGROUND

Urinary tract infections (UTIs) are one of the most common hospital-acquired complications. Insertion of a urinary catheter and the duration of catheterization are the main risk factors, with catheter-associated UTIs (CAUTIs) accounting for 70-80% of hospital-acquired UTIs. Guidance is available regarding the prevention of hospital-acquired CAUTIs; however, how best to operationalize this guidance remains a challenge.

AIM

To map and summarize the peer-reviewed literature on model-of-care interventions for the prevention of CAUTIs in adult inpatients.

METHODS

PubMed, CINAHL and SCOPUS were searched for articles that reported UTI, CAUTI or urinary catheter outcomes. Articles were screened systematically, data were extracted systematically, and interventions were classified by intervention type.

FINDINGS

This review included 70 articles. Interventions were classified as single component (N=19) or multi-component (N=51). Single component interventions included: daily rounds or activities (N=4), protocols and procedure changes (N=6), reminders and order sets (N=5), audit and feedback interventions (N=3), and education with simulation (N=1). Overall, daily catheter reviews and protocol and procedure changes demonstrated the most consistent effects on catheter and CAUTI outcomes. The components of multi-component interventions were categorized to map common elements and identify novel ideas.

CONCLUSION

A range of potential intervention options with evidence of a positive effect on catheter and CAUTI outcomes was identified. This is intended to provide a 'menu' of intervention options for local decision makers, enabling them to identify interventions that are relevant and feasible in their local setting.

Predictors of short-term hospitalization and emergency department presentations in aged care

OBJECTIVES

To examine individual, medication, system, and healthcare related predictors of hospitalization and emergency department (ED) presentation within 90 days of entering the aged care sector, and to create risk-profiles associated with these outcomes.

DESIGN AND SETTING

Retrospective population-based cohort study using data from the Registry of Senior Australians.

PARTICIPANTS

Older people (aged 65 and older) with an aged care eligibility assessment in South Australia between January 1, 2013 and May 31, 2016 (N = 22,130).

MEASUREMENTS

Primary outcomes were unplanned hospitalization and ED presentation within 90 days of assessment. Individual, medication, system, and healthcare related predictors of the outcomes at the time of assessment, within 90 days or 1-year prior. Fine-Gray models were used to calculate subdistribution hazard ratios (sHR) and 95% confidence intervals (CI). Harrell's C-index assessed predictive ability.

RESULTS

Four thousand nine-hundred and six (22.2%) individuals were hospitalized and 5028 (22.7%) had an ED presentation within 90 days. Predictors of hospitalization included: being a man (hospitalization sHR = 1.33, 95% CI 1.26-1.42), ≥3 urgent after-hours attendances (hospitalization sHR = 1.21, 95% CI 1.06-1.39), increasing frailty index score (hospitalization sHR = 1.19, 95% CI 1.11-1.28), individuals using glucocorticoids (hospitalization sHR = 1.11, 95% CI 1.02-1.20), sulfonamides (hospitalization sHR = 1.18, 95% CI 1.10-1.27), trimethoprim antibiotics (hospitalization sHR = 1.15, 95% CI 1.03-1.29), unplanned hospitalizations 30 days prior (hospitalization sHR = 1.13, 95% CI 1.04-1.23), and ED presentations 1 year prior (hospitalization sHR = 1.07, 95% CI 1.04-1.10). Similar predictors and hazard estimates were also observed for ED presentations. The hospitalization models out-of-sample predictive ability (C-index = 0.653, 95% CI 0.635-0.670) and ED presentations (C-index = 0.647, 95% CI 0.630-0.663) were moderate.

CONCLUSIONS

One in five individuals with aged care eligibility assessments had unplanned hospitalizations and/or ED presentation within 90 days with several predictors identified at the time of aged care eligibility assessment. This is an actionable period for targeting at-risk individuals to reduce hospitalizations.

Older People Who Are Frequent Users of Acute Care: A Symptom of Fragmented Care? A Case Series Report on Patients' Pathways of Care

Older frequent users of acute care can experience fragmented care. There is a need to understand the issues in a local context before attempting to address fragmented care. 0.5% (n=61) of the population in a defined local government area were identified as having ≥4 unplanned emergency department (ED) presentations/ admissions to an acute-care hospital over 13 months. A retrospective case-series study was conducted to examine detailed pathways of care for 17 patients within the identified population. The two dominant presentation reasons were clinical symptoms associated with a declining/significant loss of capacity in fundamental self-care activities and chronic cardiac/respiratory conditions. Of patients discharged home, 21% of discharge letters were delayed >7 days and only 19% received a written discharge plan. Half of community dwelling patients received home nursing and/or assistance. Frequent users of acute care can experience untimely hospital communication and may require more coordinated care provided in the community to assist self-care and manage chronic conditions.

Measuring the financial and productivity burden of paediatric hospitalisation on the wider family network

AIM

To estimate the non-medical out-of-pocket costs for families with a child in hospital.

METHODS

This study was a survey of 225 parents of paediatric inpatients on nine wards of an Australian public paediatric teaching hospital on two separate days. Our primary outcomes were the costs associated with: (i) time taken off work to care for the child in hospital; (ii) time off work or contributed by family and friends to care for other dependents; and (iii) travel, meals, accommodation and incidental expenses during the child's stay. Demographic data included postcode (to assess distance, socio-economic status and remoteness), child's age, ward and whether this was their child's first admission.

RESULTS

Mean patient age was 6.5 years (standard deviation 5.2). On an average per patient day basis, parents took 1.12 days off work and spent 0.61 (standard deviation 0.53) nights away from home, with 83.8% of nights away at the child's bedside. Parents spent Australian dollars (AUD)89 per day on travel and AUD36 on meals and accommodation. Total costs (including productivity costs) were AUD589 per patient day. Higher costs per patient day were correlated with living in a more remote area (0.48) and a greater travel distance to the hospital (0.41). A higher number of days off work was correlated (0.69) with number of school days missed.

CONCLUSION

These results demonstrate the considerable time and financial resources expended by families caring for a child in hospital and are important inputs in evaluating health-care interventions that affect risk of hospitalisation and length of stay in paediatric care.

Mortality reductions from marginal increases in public spending on health

There is limited empirical evidence of the nature of any relationship between health spending and health outcomes in Australia. We address this by estimating the elasticity of health outcomes with respect to public healthcare spending using an instrumental variable (IV) approach to account for endogeneity of healthcare spending to health outcomes. Results suggest that, based on the conditional mean, a 1% increase in public health spending was associated with a 2.2% (p < 0.05) reduction in the number of standardised Years of Life Lost (YLL). Sensitivity analyses and robustness checks supported this conclusion. Further exploration using IV quantile regression indicated that marginal returns on public health spending were significantly greater for areas with poorer health outcomes compared to areas with better health outcomes. On average, marginal increases in public health spending reduce YLL, but areas with poorer health outcomes have the greatest potential to benefit from the same marginal increase in public health spending compared to areas with better health outcomes. Understanding the relationship between health spending and outcomes and how this differs according to baseline health outcomes can help meet dual policy objectives to improve the productivity of the healthcare system and reduce inequity.

Frailty prevalence in Australia: Findings from four pooled Australian cohort studies

OBJECTIVE

To examine frailty prevalence in Australian older adults.

METHODS

Frailty was measured using a modified Fried Frailty Phenotype (FFP) in a combined cohort of 8804 Australian adults aged ≥65 years (female 86%, median age 80 (79-82) years) from the Dynamic Analyses to Optimise Ageing Project and the North West Adelaide Health Study.

RESULTS

Using the FFP, 21% of participants were frail while a further 48% were prefrail. Chi-squared testing of frailty among four age groups (65-69, 70-74, 75-79 and 80-84 years) for sex, and marital status revealed that frailty was significantly higher for women (approximately double that of men), increased significantly with advancing age for both sexes, and was significantly higher for women who were widowed, divorced or never married.

CONCLUSION

If frailty could be prevented or reversed, it would have an impact on a larger number of older people.

OLDER PEOPLE WHO ARE FREQUENT USERS OF ACUTE CARE: A SYMPTOM OF FRAGMENTED CARE? A CASE SERIES REPORT ON PATIENTS’ PATHWAYS OF CARE

Older frequent users of acute care can experience fragmented care. There is a need to understand the issues in a local context before attempting to address fragmented care. 0.5% (n=61) of the population in a defined local government area were identified as having ≥4 unplanned emergency department (ED) presentations/admissions to an acute-care hospital over 13 months. A retrospective case-series study was conducted to examine detailed pathways of care for 17 patients within the identified population. The two dominant presentation reasons were clinical symptoms associated with a declining/significant loss of capacity in fundamental self-care activities and chronic cardiac/respiratory conditions. Of patients discharged home, 21% of discharge letters were delayed >7 days and only 19% received a written discharge plan. Half of community dwelling patients received home nursing and/or assistance. Frequent users of acute care can experience untimely hospital communication and may require more coordinated care provided in the community to assist self-care and manage chronic conditions.

Management of Musculoskeletal Conditions in Rural South Australia: A Randomised Controlled Trial

With age, the prevalence of musculoskeletal conditions increases markedly. This rural-based study determined the benefits of two approaches for managing musculoskeletal conditions: a multiple-component 'Self-management Plus' intervention, and usual care. The intervention combined self-management education with physical activity and health professional support. 6-month outcomes included: Clinical Global Impression-Improvement Scale (CGI-IS) and Quality of Life (QoL). A total of 145 people were recruited; mean (SD) age was 66.1 (11.1) and 63.3 (10.9) years for intervention and control groups respectively. The intervention resulted in greater improvements in global functioning (CGI-IS mean (SD) = 3.2 (1.3)) than usual care (CGI-IS mean (SD) = 4.2 (1.5)). There was no difference in QoL improvement between study groups. A multiple-component 'Self-management Plus' intervention had a positive effect on physical functioning for older adults with musculoskeletal conditions. However, recruitment and retention of participants was problematic, which raises questions about the intervention's feasibility in its current form.

Building multidisciplinary health workforce capacity to support the implementation of integrated, people-centred Models of Care for musculoskeletal health

To address the burden of musculoskeletal (MSK) conditions, a competent health workforce is required to support the implementation of MSK models of care. Funding is required to create employment positions with resources for service delivery and training a fit-for-purpose workforce. Training should be aligned to define "entrustable professional activities", and include collaborative skills appropriate to integrated and people-centred care and supported by shared education resources. Greater emphasis on educating MSK healthcare workers as effective trainers of peers, students and patients is required. For quality, efficiency and sustainability of service delivery, education and research capabilities must be integrated across disciplines and within the workforce, with funding models developed based on measured performance indicators from all three domains. Greater awareness of the societal and economic burden of MSK conditions is required to ensure that solutions are prioritised and integrated within healthcare policies from local to regional to international levels. These healthcare policies require consumer engagement and alignment to social, economic, educational and infrastructure policies to optimise effectiveness and efficiency of implementation.

Feasibility, acceptability and diagnostic test accuracy of frailty screening instruments in community-dwelling older people within the Australian general practice setting: a study protocol for a cross-sectional study

INTRODUCTION

Frailty is one of the most challenging aspects of population ageing due to its association with increased risk of poor health outcomes and quality of life. General practice provides an ideal setting for the prevention and management of frailty via the implementation of preventive measures such as early identification through screening.

METHODS AND ANALYSIS

Our study will evaluate the feasibility, acceptability and diagnostic test accuracy of several screening instruments in diagnosing frailty among community-dwelling Australians aged 75+ years who have recently made an appointment to see their general practitioner (GP). We will recruit 240 participants across 2 general practice sites within South Australia. We will invite eligible patients to participate and consent to the study via mail. Consenting participants will attend a screening appointment to undertake the index tests: 2 self-reported (Reported Edmonton Frail Scale and Kihon Checklist) and 5 (Frail Scale, Groningen Frailty Index, Program on Research for Integrating Services for the Maintenance of Autonomy (PRISMA-7), Edmonton Frail Scale and Gait Speed Test) administered by a practice nurse (a Registered Nurse working in general practice). We will randomise test order to reduce bias. Psychosocial measures will also be collected via questionnaire at the appointment. A blinded researcher will then administer two reference standards (the Frailty Phenotype and Adelaide Frailty Index). We will determine frailty by a cut-point of 3 of 5 criteria for the Phenotype and 9 of 42 items for the AFI. We will determine accuracy by analysis of sensitivity, specificity, predictive values and likelihood ratios. We will assess feasibility and acceptability by: 1) collecting data about the instruments prior to collection; 2) interviewing screeners after data collection; 3) conducting a pilot survey with a 10% sample of participants.

ETHICS AND DISSEMINATION

The Torrens University Higher Research Ethics Committee has approved this study. We will disseminate findings via publication in peer-reviewed journals and presentation at relevant conferences.

Stepped-wedge cluster randomised controlled trial to assess the effectiveness of an electronic medication management system to reduce medication errors, adverse drug events and average length of stay at two paediatric hospitals: a study protocol

INTRODUCTION

Medication errors are the most frequent cause of preventable harm in hospitals. Medication management in paediatric patients is particularly complex and consequently potential for harms are greater than in adults. Electronic medication management (eMM) systems are heralded as a highly effective intervention to reduce adverse drug events (ADEs), yet internationally evidence of their effectiveness in paediatric populations is limited. This study will assess the effectiveness of an eMM system to reduce medication errors, ADEs and length of stay (LOS). The study will also investigate system impact on clinical work processes.

METHODS AND ANALYSIS

A stepped-wedge cluster randomised controlled trial (SWCRCT) will measure changes pre-eMM and post-eMM system implementation in prescribing and medication administration error (MAE) rates, potential and actual ADEs, and average LOS. In stage 1, 8 wards within the first paediatric hospital will be randomised to receive the eMM system 1 week apart. In stage 2, the second paediatric hospital will randomise implementation of a modified eMM and outcomes will be assessed. Prescribing errors will be identified through record reviews, and MAEs through direct observation of nurses and record reviews. Actual and potential severity will be assigned. Outcomes will be assessed at the patient-level using mixed models, taking into account correlation of admissions within wards and multiple admissions for the same patient, with adjustment for potential confounders. Interviews and direct observation of clinicians will investigate the effects of the system on workflow. Data from site 1 will be used to develop improvements in the eMM and implemented at site 2, where the SWCRCT design will be repeated (stage 2).

ETHICS AND DISSEMINATION

The research has been approved by the Human Research Ethics Committee of the Sydney Children's Hospitals Network and Macquarie University. Results will be reported through academic journals and seminar and conference presentations.

TRIAL REGISTRATION NUMBER

Australian New Zealand Clinical Trials Registry (ANZCTR) 370325.

Better informing decision making with multiple outcomes cost-effectiveness analysis under uncertainty in cost-disutility space

INTRODUCTION

Comparing multiple, diverse outcomes with cost-effectiveness analysis (CEA) is important, yet challenging in areas like palliative care where domains are unamenable to integration with survival. Generic multi-attribute utility values exclude important domains and non-health outcomes, while partial analyses-where outcomes are considered separately, with their joint relationship under uncertainty ignored-lead to incorrect inference regarding preferred strategies.

OBJECTIVE

The objective of this paper is to consider whether such decision making can be better informed with alternative presentation and summary measures, extending methods previously shown to have advantages in multiple strategy comparison.

METHODS

Multiple outcomes CEA of a home-based palliative care model (PEACH) relative to usual care is undertaken in cost disutility (CDU) space and compared with analysis on the cost-effectiveness plane. Summary measures developed for comparing strategies across potential threshold values for multiple outcomes include: expected net loss (ENL) planes quantifying differences in expected net benefit; the ENL contour identifying preferred strategies minimising ENL and their expected value of perfect information; and cost-effectiveness acceptability planes showing probability of strategies minimising ENL.

RESULTS

Conventional analysis suggests PEACH is cost-effective when the threshold value per additional day at home (𝕜1) exceeds $1,068 or dominated by usual care when only the proportion of home deaths is considered. In contrast, neither alternative dominate in CDU space where cost and outcomes are jointly considered, with the optimal strategy depending on threshold values. For example, PEACH minimises ENL when 𝕜1=$2,000 and 𝕜2=$2,000 (threshold value for dying at home), with a 51.6% chance of PEACH being cost-effective.

CONCLUSION

Comparison in CDU space and associated summary measures have distinct advantages to multiple domain comparisons, aiding transparent and robust joint comparison of costs and multiple effects under uncertainty across potential threshold values for effect, better informing net benefit assessment and related reimbursement and research decisions.

A risk-adjusted economic evaluation of alternative models of involvement of practice nurses in management of type 2 diabetes

AIMS

To determine the cost-effectiveness of alternative models of practice nurse involvement in the management of type 2 diabetes within the primary care setting.

METHODS

Linked routinely collected clinical data and resource use (general practitioner visits, hospital services and pharmaceuticals) were used to undertake a risk-adjusted cost-effectiveness analysis of alternative models of care for the management of diabetes patients. These models were based on the reported level of involvement of practice nurses in the provision of clinical-based activities. Potential confounders were controlled for by using propensity score-weighted regression analyses. The impact of alternative models of care on outcomes and costs was measured and incremental cost-effectiveness estimated. The uncertainty around the estimates of cost-effectiveness was illustrated through bootstrapping.

RESULTS

Although the difference in total cost between two models of care was not statistically significant, the high-level model was associated with better outcomes (larger mean reductions in HbA(1c)). The upper 95% confidence intervals showed that the incremental cost per 1% decrease in HbA(1c) is only $454, and per one additional patient to achieve an HbA(1c) value of less than 53 mmol/mol (7.0%) is $323. Further analyses showed little uncertainty surrounding the decision to adopt the high-level model.

CONCLUSIONS

The results provide a strong indication that the high-level model is a cost-effective way of managing diabetes patients. Our findings highlight the need for effective incentives to encourage general practices to better integrate practice nurses in the provision of clinical services.

A risk adjusted cost-effectiveness analysis of alternative models of nurse involvement in obesity management in primary care

OBJECTIVE

Controlled evaluations are subject to uncertainty regarding their replication in the real world, particularly around systems of service provision. Using routinely collected data, we undertook a risk adjusted cost-effectiveness (RAC-E) analysis of alternative applied models of primary health care for the management of obese adult patients. Models were based on the reported level of involvement of practice nurses (registered or enrolled nurses working in general practice) in the provision of clinical-based activities.

DESIGN AND METHODS

Linked, routinely collected clinical data describing clinical outcomes (weight, BMI, and obesity-related complications) and resource use (primary care, pharmaceutical, and hospital resource use) were collected. Potential confounders were controlled for using propensity weighted regression analyses.

RESULTS

Relative to low level involvement of practice nurses in the provision of clinical-based activities to obese patients, high level involvement was associated with lower costs and better outcomes (more patients losing weight, and larger mean reductions in BMI). Excluding hospital costs, high level practice nurse involvement was associated with slightly higher costs. Incrementally, the high level model gets one additional obese patient to lose weight at an additional cost of $6,741, and reduces mean BMI by an additional one point at an additional cost of $563 (upper 95% confidence interval $1,547).

CONCLUSION

Converted to quality adjusted life year (QALY) gains, the results provide a strong indication that increased involvement of practice nurses in clinical activities is associated with additional health benefits that are achieved at reasonable additional cost. Dissemination activities and incentives are required to encourage general practices to better integrate practice nurses in the active provision of clinical services.

Cost-effectiveness of screening high-risk HIV-positive men who have sex with men (MSM) and HIV-positive women for anal cancer

BACKGROUND

Anal cancer is uncommon and predominantly a disease of the elderly. The human papillomavirus (HPV) has been implicated as a causal agent, and HPV infection is usually transmitted sexually. Individuals who are human immunodeficiency virus (HIV)-positive are particularly vulnerable to HPV infections, and increasing numbers from this population present with anal cancer.

OBJECTIVE

To estimate the cost-effectiveness of screening for anal cancer in the high-risk HIV-positive population [in particular, men who have sex with men (MSM), who have been identified as being at greater risk of the disease] by developing a model that incorporates the national screening guidelines criteria.

DATA SOURCES

A comprehensive literature search was undertaken in January 2006 (updated in November 2006). The following electronic bibliographic databases were searched: Applied Social Sciences Index and Abstracts (ASSIA), BIOSIS previews (Biological Abstracts), British Nursing Index (BNI), Cumulative Index to Nursing and Allied Health Literature (CINAHL), Cochrane Database of Systematic Reviews (CDSR), Cochrane Central Register of Controlled Trials (CENTRAL), EMBASE, MEDLINE, MEDLINE In-Process & Other Non-Indexed Citations, NHS Database of Abstracts of Reviews of Effects (DARE), NHS Health Technology Assessment (HTA) Database, PsycINFO, Science Citation Index (SCI), and Social Sciences Citation Index (SSCI).

STUDY SELECTION

Published literature identified by the search strategy was assessed by four reviewers. Papers that met the inclusion criteria contained the following: data on population incidence, effectiveness of screening, health outcomes or screening and/or treatment costs; defined suitable screening technologies; prospectively evaluated tests to detect anal cancer. Foreign-language papers were excluded. Searches identified 2102 potential papers; 1403 were rejected at title and a further 493 at abstract. From 206 papers retrieved, 81 met the inclusion criteria. A further treatment paper was added, giving a total of 82 papers included.

DATA EXTRACTION

Data from included studies were extracted into data extraction forms by the clinical effectiveness reviewer. To analyse the cost-effectiveness of screening, two decision-analytical models were developed and populated.

RESULTS

The reference case cost-effectiveness model for MSM found that screening for anal cancer is very unlikely to be cost-effective. The negative aspects of screening included utility decrements associated with false-positive results and with treatment for high-grade anal intraepithelial neoplasia (HG-AIN). Sensitivity analyses showed that removing these utility decrements improved the cost-effectiveness of screening. However, combined with higher regression rates from low-grade anal intraepithelial neoplasia (LG-AIN), the lowest expected incremental cost-effectiveness ratio remained at over 44,000 pounds per quality-adjusted life-year (QALY) gained. Probabilistic sensitivity analysis showed that no screening retained over 50% probability of cost-effectiveness to a QALY value of 50,000 pounds. The screening model for HIV-positive women showed an even lower likelihood of cost-effectiveness, with the most favourable sensitivity analyses reporting an incremental cost per QALY of 88,000 pounds.

LIMITATIONS

Limited knowledge is available about the epidemiology and natural history of anal cancer, along with a paucity of good-quality evidence concerning the effectiveness of screening.

CONCLUSIONS

Many of the criteria for assessing the need for a screening programme were not met and the cost-effectiveness analyses showed little likelihood that screening any of the identified high-risk groups would generate health improvements at a reasonable cost. Further studies could assess whether the screening model has underestimated the impact of anal cancer, the results of which may justify an evaluative study of the effects of treatment for HG-AIN.

A survival-based cost-effectiveness analysis of 5 years of letrozole versus tamoxifen as adjuvant therapy in postmenopausal women with early breast cancer: 76-month update of BIG-1–98

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Background: The latest update of the BIG 1–98 study reports a hazard ratio for overall survival (OS) of 0.81 (95% CI 0.69 = 0.94) (censoring TAM patients who crossed over to LET). Previous economic analyses of the aromatase inhibitors extrapolated observed differences in time to recurrence. This study uses observed differences in OS to estimate the incremental cost per life year (LY), and per quality adjusted LY (QALY) gained of 5 years LET versus 5 years TAM in ER+ postmenopausal women, from a UK NHS perspective. Methods: Annual survival probabilities over the first 7 years post-surgery were extracted from updated BIG 1–98 results. Survival was extrapolated to 20 years using data reported by the Early Breast Cancer Trialists’ Group for women receiving 5 years TAM. Equivalent annual survival probabilities were assumed for the LET and TAM groups post-7 years (likely to be a conservative assumption given diverging OS between 5 and 7 years). Costs included those of the interventions and and a wide range of adverse events (AEs). Published five year costs for locoregional recurrence (LR) and metastases (METS) were applied to reported recurrence rates over 9 years. A Markov model applied published utility weights for DFS with AEs, LR, and METS. All costs and health benefits were discounted at 3.5% annually. Results: The reference case results show that over a 20 year period, the discounted additional treatment costs of LET'are £4,427, and AEs incur an additional £88 per patient, while the reduced frequency decreases the cost difference by £807. The total cost difference between LET and TAM is £3,707. The discounted gain in LYs is 0.286. The incremental cost per LY gained for LET over TAM is £12,970. The Markov model estimated a difference in discounted QALYs of 0.297, with an incremental cost per QALY gained of £12,500. Conclusions: The economic analysis of 5 years LET compared to 5 years TAM based on observed differences in OS produces similar results to earlier modelled extrapolations based on differences in time to recurrence. However, the 20 year time horizon used in this analysis is shorter than previous analyses, and so the results may be considered conservative, i.e. LET may be more cost-effective than previously estimated.

[Table: see text]

A preliminary model-based assessment of the cost-utility of a screening programme for early age-related macular degeneration

OBJECTIVES

To estimate the cost-effectiveness of screening for age-related macular degeneration (AMD) by developing a decision analytic model that incorporated and assessed all of the National Screening Committee criteria. A further objective was to identify the major areas of uncertainty in the model, and so inform future research priorities in this disease area.

DATA SOURCES

Major databases were searched in March 2004 and updated in January 2005.

REVIEW METHODS

Systematic literature reviews covered the epidemiology and natural history of AMD, the screening and treatment effectiveness and health-related quality of life relating to AMD. A hybrid cohort-individual sampling model was implemented to describe the range of pathways between the incidence of age-related maculopathy (ARM) and death via clinical presentation and treatment at different stages of the disease. As significant shortfalls in the data available from the literature were apparent, so a range of primary data sources were also used to populate the model. To obtain estimates for the value of parameters deemed to be within an expert's remit, data describing some parameters were elicited from relevant experts. The data identified informed probability distributions describing the uncertainty around the model parameters. To incorporate joint parameter uncertainty (i.e. correlations between parameters), the AMD natural history model was calibrated probabilistically. Randomly sampled sets of input parameters were assigned weights representing the accuracy of their predictions of a set of observed model outputs. The analysis of the AMD screening model estimated the costs, numbers of quality-adjusted life-years (QALYs) and cases of blindness in a general population sample of 50-year-olds over the remainder of their lifetime, for 16 alternative screening options (including no screening). The reference case analysis incorporated current treatment options of laser photocoagulation and photodynamic therapy. Sensitivity analyses describing six alternative sets of intervention strategies, based on horizon scanning of potential future treatments for AMD, were also undertaken.

RESULTS

There remains significant uncertainty about whether any form of screening for AMD is cost-effective. However, annual screening from age 60 years seems to provide the highest mean net benefits, but this is based on a cost-effectiveness estimate that has very poor precision (high levels of uncertainty). The probabilistic sensitivity analysis shows that the 95% credible interval for annual screening from age 60 years ranges from this option dominating the previous option to an incremental cost per QALY of over 0.5 million pounds sterling. Plotting a cost-effectiveness acceptability frontier shows that although annual screening from age 60 years has the highest net benefits at a value of QALY of 30,000 pounds sterling, the associated probability of this option being the most cost-effective option is only around 20%. The sensitivity analyses around potential future treatment options indicate that screening may become more cost-effective with the new treatments.

CONCLUSIONS

The conclusions focus on the interpretation of the results from the perspective of defining the major areas of uncertainty, which were defined as disease progression, rates of clinical presentation, screening test and optician effectiveness, treatment effectiveness, and costs of blindness. Future research may be best targeted at assessing how routine data may be used to describe clinical presentation rates of ARM. Other potential studies include a pilot study of the effectiveness of screening and opticians' referral patterns for AMD and a costing study of blindness as a continuum of association with deterioration in vision.

Cost-utility analysis of deferasirox compared to standard therapy with desferrioxamine for patients requiring iron chelation therapy in the United Kingdom

OBJECTIVE

The primary objective of the study was to evaluate the cost-utility of deferasirox (Exjade) compared to standard therapy using desferrioxamine (Desferal) for the control of iron overload in patients receiving frequent blood transfusions. The perspective adopted was that of the National Health Service in the UK.

METHODS

Phase II/III clinical trials have shown deferasirox in the recommended doses of 20-30 mg/kg per day to have similar efficacy to desferrioxamine at equivalent doses in the control of chronic iron overload. The main difference between them is in the mode of administration. Desferrioxamine is administered parenterally as a slow subcutaneous infusion typically infused 8-12 hours a day for 5-7 days a week. In comparison, deferasirox provides 24 hour chelation via a once daily oral tablet dispersed in water or juice. An excel based economic model was developed to evaluate the annual healthcare costs and quality of life, or utility, benefits associated with differences in mode of administration, using beta-thalassaemia as the reference case. A community utility study using time trade-off methods was performed to determine utility outcomes associated with iron chelation therapy (ICT) mode of administration.

RESULTS

In the reference case (patient mean weight 42 kg), deferasirox 'dominated' desferrioxamine, i.e. resulted in lower net costs and higher quality adjusted life years (QALYs). Drug dose and cost is patient weight related. Incremental cost per QALY gained was pound 7775 for patients with a mean weight of 62 kg.

CONCLUSIONS

The cost-utility analysis did not take drug compliance into account. However, Deferasirox is cost-effective compared to standard iron chelation therapy with desferrioxamine, due to the cost and quality of life benefits derived from a simpler and more convenient oral mode of administration.

A review and critique of modelling in prioritising and designing screening programmes

OBJECTIVES

To undertake a structured review and critical appraisal of methods for the model-based cost-utility analysis of screening programmes. Also to develop guidelines and an assessment checklist of good practice in the development of screening models.

DATA SOURCES

Major electronic databases of healthcare and operational research literatures were searched up to June 2003.

REVIEW METHODS

Searches of the literature were undertaken to identify applied and methodological studies of economic evaluations of healthcare screening programmes. All applied screening models were also reviewed in three broad disease areas (cancer, cardiovascular disease and diabetes), as well as antenatal screening. A second-level review focused on particular aspects of the modelling process through case study assessments of screening models for three specific disease areas (colorectal cancer, abdominal aortic aneurysms and antenatal screening for haemoglobinopathies). A separate literature review of studies reporting the utility effects of screening was also undertaken. Guidelines and an assessment checklist for good practice for screening modelling were developed.

RESULTS

Few relevant methodological studies were identified, and no studies reporting direct empirical comparisons of alternative methodologies were retrieved. From the review of disease-based screening models, it was apparent that many alternative modelling methods had been applied, including some relatively new approaches that had not been widely disseminated. Natural history modelling is the preferred approach. Alternative modelling approaches were generally only used to extrapolate the observed effects of screening and were unsuitable for evaluating unobserved screening options. More complex model structures may incorporate important additional aspects of the disease natural history, although any benefits should outweigh the consequences of additional unobservable input parameters and increased complexity in implementing the model. No direct comparisons of more detailed and less detailed screening model structures informed areas in which more realistic representations of the disease process may be most beneficial, so only general aspects of good practice could be defined. Two structural aspects that were not well handled by existing screening models included post-diagnosis disease progression and screening uptake. Most models described the former using historical mortality rates, rather than treatment models that are representative of current treatment patterns for different stages of the disease. Constant screening uptake rates were applied to all screening programmes and attendance was not linked to disease incidence or progression. Evidence exists to inform a more detailed representation of screening uptake. The most commonly applied modelling techniques were cohort Markov models and individual sampling simulation models. Individual sampling simulation models may provide more flexibility in their representation of a screening decision problem, but any benefits should outweigh the consequences of the need to assess both variability and uncertainty. Complex mathematical models describing input parameters as continuous variables have analysed the cost-effectiveness of screening; these require further development to estimate the cost-utility of screening directly, or to inform a more detailed representation of the preclinical section of a natural history model (with a traditional state-based model describing pathways' post-clinical presentation). Calibration is a common aspect of screening models, whereby models are fitted to observed data describing outputs of the model in order to populate unobserved input parameters. The review concluded that the estimation of a reference case input parameter set is not recommended.

CONCLUSIONS

The review of methods for the model-based cost-utility analysis of screening programmes identified the natural history modelling approach as the preferred general method of evaluation for screening programmes. State transition models have generally been used to represent disease natural histories, with individual sampling models more prevalent than in treatment intervention evaluations. No comparative methodological studies were identified, so no empirical data were available to inform the relative merits of alternative methodologies. The defined guidelines and assessment checklist are informed, therefore, by theoretical interpretations of the impact of alternative approaches to different components of the modelling process when applied to the cost-utility analysis of screening programmes. Further research is needed into methods with the potential to improve the accuracy of screening models, and to respond to the needs of model users.

Health care costs for the treatment of breast cancer recurrent events: estimates from a UK-based patient-level analysis

Cost pressures and the need to demonstrate cost-effectiveness of new interventions require consideration of the costs of treating disease. This study presents analyses of resource use data covering 199 postmenopausal women who experienced a breast cancer recurrent event between 1991 and 2004 and were treated at the Western General Hospital, Edinburgh. Aggregate (5-year) treatment costs for alternative recurrent events were estimated, as well as the annual costs incurred by patients experiencing contralateral, locoregional, or distant recurrence, who remained alive without further recurrence for a year. The 95% confidence intervals for the 5-year costs of recurrence ranged from pounds 10,000 to pounds 37,000 for locoregional recurrence, and pounds 14,500- pounds 20,000 for distant recurrence. No evidence of significant variations in these costs across time periods between 1991 and 2004 was identified. Annual costs for patients remaining in the same health state showed high initial costs for contralateral and locoregional recurrence, with low costs in subsequent years, while costs associated with distant recurrence declined at a slower rate and plateaued at 4-5 years post-diagnosis. The cost estimates presented in this paper not only inform the magnitude of the resource consequences of breast cancer recurrences, but they are also better suited to informing cost-effectiveness analyses, which have a far greater role in allocating health-care resources.

Comparison of the cost per distant disease-free year gained for upfront letrozole or anastrozole, or switched exemestane compared to tamoxifen for early breast cancer in hormone receptor-positive postmenopausal women: The UK perspective

557

Background: Due to subsequent poor prognosis, prevention of distant recurrence (DR) is a primary aim of adjuvant hormonal therapy for early breast cancer. Compared to 5 years TAM in hormone receptor positive (HR+) postmenopausal women, DR relative risks are 0.73 (95% CI 0.6 - 0.88) for 5 years letrozole (LET), 0.84 (95% CI 0.7 - 1.0) for 5 years anastrozole (ANA), 0.73 (95% CI 0.59 - 0.9) for 2–3yrs exemestane after 2–3 years (EXE/TAM). This analysis evaluates the incremental cost per distant disease free year gained from a UK NHS perspective of LET, ANA, EXE/TAM versus 5 years TAM using the same health economic model. Methods: A Markov model described pathways through relevant health states over the remaining lifetime of a cohort of HR+ women aged 61 yrs. Probabilities of breast cancer events (contralateral; locoregional; soft tissue, bone, and visceral metastases) adverse events (endometrial cancer, hip and other fractures, cardiovascular disease, thromboembolic events, and arthralgia) were based on the latest early breast cancer overview, published results of the BIG 1–98, ATAC, and IES trials, and UK population-based studies as appropriate. Conservatively, no carry-over effect was assumed for the AIs after therapy discontinuation. Costs (2005 UK£) of breast-cancer care were obtained from a primary costing study in Scotland, and treatment costs for AEs were obtained from published studies. Costs and DR-free years were discounted at 3.5% annually. Results: The mean durations of DDFS were estimated to be 12.81, 12.66, 12.57, and 12.35 years for LET, ANA, TAM/EXE, and TAM, respectively. The incremental cost per distant disease free year gained of LET vs TAM is £10,379 (95% CI £5,286-£17,818), of ANA vs TAM is £11,428 (95% CI £5,071- £48,856), and of TAM/EXE vs TAM alone is £11,020 (95% CI £4,820-£36,947). Conclusion: Compared to 5 years TAM, adjuvant treatment of postmenopausal HR+ women with an AI is a cost-effective use of UK NHS resources. Based on the mean results, LET appears to be the most cost-effective of the three AIs, despite its higher acquisition cost compared to ANA in the UK, though the confidence intervals are wide.

[Table: see text]

International comparison of the cost-effectiveness of 5 years letrozole or anastrozole compared to 5 years tamoxifen for early breast cancer in hormone receptor-positive postmenopausal women: Belgium, Canada, UK, and US analyses

556

Background: The BIG1–98 and ATAC trials have proven the effectiveness of 5 years letrozole (LET) and anastrozole (ANA), respectively, compared to 5 years tamoxifen (TAM) for the treatment of postmenopausal women with hormone receptor positive (HR+) early stage breast cancer. This analysis uses similar assumptions to those used in the NICE appraisal in the UK, and country specific input data to estimate the cost-effectiveness of LET vs TAM and ANA vs. TAM from the Belgian, Canadian, UK, and US health care perspective (8 analyses). Methods: The same Markov model was used to estimate the incremental cost per quality-adjusted life year (QALY) gained (ICQ) across the 8 analyses in postmenopausal women with HR+ early stage breast cancer. Model events and assumptions were based on the analysis undertaken by the NICE appraisal team in the UK. Probabilities of breast cancer events (contralateral; locoregional; and metastases) were based on the latest early breast cancer (Lancet) overview. Country-specific cost, utility, and adverse event parameter values were informed by relevant population-based studies. LET and ANA effects were informed by published results of the BIG 1–98 and ATAC trials, which were assumed to cease after therapy discontinuation (other than fracture risk that continued for 5 further years). Costs and QALYs were estimated over the remaining lifetime of a cohort of HR+ women aged 60 yrs, discounted at 3.5% annually. Conclusion: Compared to TAM, adjuvant treatment of postmenopausal HR+ women with LET or ANA for 5 years is a cost-effective use of resources in all of the countries included in this analysis. Based on the model assumptions used by the NICE appraisal team in the UK, the mean results indicate that LET is more cost-effective than ANA, though the confidence intervals are wide.

[Table: see text]

No significant financial relationships to disclose.

Option appraisal of population-based colorectal cancer screening programmes in England

OBJECTIVES

To estimate the effectiveness, cost-effectiveness and resource impact of faecal occult blood testing (FOBT) and flexible sigmoidoscopy (FSIG) screening options for colorectal cancer to inform the Department of Health's policy on bowel cancer screening in England.

METHODS

We developed a state transition model to simulate the life experience of a cohort of individuals without polyps or cancer through to the development of adenomatous polyps and malignant carcinoma and subsequent death in the general population of England. The costs, effects and resource impact of five screening options were evaluated: (a) FOBT for individuals aged 50-69 (biennial screening); (b) FOBT for individuals aged 60-69 (biennial screening); (c) once-only FSIG for individuals aged 55; (d) once-only FSIG for individuals aged 60; and (e) once-only FSIG for individuals aged 60, followed by FOBT for individuals aged 61-70 (biennial screening).

RESULTS

The model suggests that screening using FSIG with or without FOBT may be cost-saving and may produce additional benefits compared with a policy of no screening. The marginal cost-effectiveness of FOBT options compared to a policy of no screening is estimated to be below pound3000 per quality adjusted life year gained.

CONCLUSIONS

Screening using FOBT and/or FSIG is potentially a cost-effective strategy for the early detection of colorectal cancer. However, the practical feasibility of alternative screening programmes is inevitably limited by current pressures on endoscopy services.

Cost-effectiveness of letrozole and anastrozole as adjuvant therapy for hormone receptor positive early breast cancer in postmenopausal women

10577

Background: The BIG 1–98 and ATAC studies demonstrated that, in postmenopausal women with hormone receptor positive (HR+) early breast cancer, 5 years of initial adjuvant therapy with the aromatase inhibitors (AIs) letrozole (LET) or anastrozole (ANA) is superior to tamoxifen (TAM). The cost-effectiveness TAM, LET, and ANA have not been previously evaluated using a consistent methodology. Methods: A Markov model was used to estimate the incremental cost per quality-adjusted life year (QALY) gained with initial adjuvant therapy with LET vs TAM, ANA vs TAM, and LET vs ANA in postmenopausal women with HR+ early stage breast cancer from the US healthcare system perspective. Probabilities of recurrence (including contralateral tumor) and adverse events (endometrial cancer, thromboembolism, fractures, hypercholesterolemia, MI, and stroke) for TAM were based primarily on published US population-based studies and trials of prophylactic TAM vs placebo. Corresponding probabilities for LET and ANA were calculated by multiplying probabilities for TAM by estimated relative risks of LET vs TAM and ANA vs TAM from the BIG 1–98 and ATAC trials respectively. Other probabilities, costs, and health-state utilities were obtained from published studies. Expected lifetime costs and QALYs were estimated for a cohort of HR+ postmenopausal women with early breast cancer, aged 61 years at therapy initiation and discounted at 3% annually. Probabilistic sensitivity analyses were conducted to assess precision of results. Results: Incremental cost per QALY gained for LET vs TAM is $33,536 (95% CI $20,409 to $70,566) and for ANA vs TAM is $38,967 (95% CI $23,826 to $81,904). Compared with ANA, LET is less costly ($9,647 vs $10,190) and gains more QALYs (0.29 vs 0.26), although differences in costs (95% CI -$1,669 to $671) and QALYs (95% CI -0.16 to 0.22) are not statistically significant. Conclusions: In postmenopausal women with HR+ early breast cancer, adjuvant therapy with either LET or ANA is cost-effective from a US healthcare system perspective. Although LET dominates ANA in our base-case analysis, definitive conclusions regarding the cost-effectiveness of LET vs ANA must await results of comparative clinical studies.

[Table: see text]

A cost-utility analysis of clopidogrel in patients with non-ST-segment-elevation acute coronary syndromes in the UK

OBJECTIVE

To assess the long-term cost effectiveness of 1 year's treatment with clopidogrel on top of standard therapy (including aspirin; ASA) compared with standard therapy alone, in patients diagnosed with non-ST-segment-elevation acute coronary syndromes (ACS) in the UK.

DESIGN

Cost utility analysis using a Markov model, incorporating clinical data from CURE (a multicentre randomised controlled trial, involving 12,562 patients) and data from UK observational studies.

SETTING

Health economic evaluation carried out from the perspective of the UK NHS.

PATIENTS

A representative cohort of 1000 UK patients aged 66 years, diagnosed with non-ST-segment-elevation ACS.

INTERVENTIONS

Either a combination of 75 mg/day clopidogrel (300 mg loading dose, within 24 h prior to hospital admission) and standard therapy (including ASA, 75-325 mg/day) for 1 year followed by standard therapy alone for their remaining lifetime, or standard therapy alone (including ASA, 75-325 mg/day) for life.

MAIN OUTCOME MEASURES

Incremental cost per life-year gained and incremental cost per quality-adjusted life-year (QALY) gained.

RESULTS

In the base case, the incremental cost effectiveness of the clopidogrel combination vs standard therapy alone is estimated as pounds 6991 per life-year gained and pounds 7365 per QALY gained. The probability that clopidogrel remains cost effective within the generally accepted pounds 30,000 per QALY threshold is more than 80%. The confidence interval around the relative risk for vascular death was identified as the main parameter affecting the estimated cost effectiveness.

CONCLUSIONS

One year's treatment with clopidogrel is a cost effective intervention compared with standard therapy that should be considered as a routine treatment for patients with non-ST-segment-elevation ACS.

Liquid-based cytology in cervical screening: an updated rapid and systematic review and economic analysis

OBJECTIVES

To update an earlier published report reviewing the effectiveness and cost-effectiveness of liquid-based cytology (LBC).

DATA SOURCES

Electronic bibliographic databases, relevant articles, sponsor submissions and various health services research-related resources.

REVIEW METHODS

The selected data were reviewed and assessed with respect to the quality of the evidence. Pooled estimates of the parameters of interest were derived from the original and the updated studies. Meta-analyses were undertaken where appropriate. The mathematical model developed for the original rapid review of LBC was adapted to synthesise the updated data to estimate costs, survival and quality-adjusted survival of patients tested using LBC and using Papanicolaou (Pap) smear testing. Cost data from published sources were incorporated into the above model to allow economic, as well as clinical, implications of treatment to be assessed. The primary incremental cost-effectiveness ratio is the cost per life year gained (LYG), although estimates of the cost per quality-adjusted life-year (QALY) gained are also presented. A sensitivity analysis was undertaken to identify the key parameters that determine the cost-effectiveness of the treatments, with the objective of identifying how robust the results of the economic analysis are, given the current level of evidence.

RESULTS

From the evidence available, it is likely that the LBC technique will reduce the number of false-negative test results. Modelling analyses undertaken as part of this study indicate that this would reduce the incidence of invasive cancer. There is now more evidence to support improvements emanating from the use of LBC screening in terms of a reduced number of unsatisfactory specimens and a decrease in the time needed to obtain the smear samples. The estimated annual gross cost of consumables and operating equipment, and other one-off conversion costs associated with introducing the new technique, will be between 17 British pounds and 38 British pounds million in England and Wales, depending on the LBC system and the configuration of the service. Analyses based on models of disease natural history, conducted in this study, showed that conventional Pap smear screening was extendedly dominated by LBC (LBC was always more cost-effective than conventional Pap smear testing over the same screening interval). Comparing LBC across alternative screening intervals gave a cost-effectiveness of under 10,000 British pounds per LYG when screening was undertaken every 3 years. The cost-effectiveness results were relatively stable under most conditions, although if screening outcomes such as borderline results and colposcopy are assumed to induce even small amounts of disutility then LBC screening at 5-yearly intervals may be the most cost-effective option.

CONCLUSIONS

This updated analysis provides more certainty with regard to the potential cost-effectiveness of LBC compared with conventional Pap smear testing. However, there is uncertainty regarding the relative effectiveness (and cost-effectiveness) of the two main LBC techniques. Further research in the area of utility assessment may be worthwhile and possibly a full cost-effectiveness study of LBC based on a trial of its introduction in a low-prevalence population, although the results of the modelling analysis provide a robust argument that LBC is a cost-effective alternative to conventional cervical cancer screening. A randomised comparison of the two main techniques may also be useful.

A trial-based cost-effectiveness analysis of letrozole followed by tamoxifen versus tamoxifen followed by letrozole for postmenopausal advanced breast cancer

BACKGROUND

Third-generation aromatase inhibitors are being considered as an alternative to tamoxifen as first-line therapy for advanced breast cancer. These newer therapies are more expensive, and will gain greater acceptance if they can demonstrate cost-effectiveness.

METHODS

Life table analyses are used to compare the costs and benefits [life years gained and quality-adjusted life years (QALYs) gained] of treating postmenopausal women with advanced breast cancer with first-line letrozole (with the option of second-line tamoxifen) compared with first-line tamoxifen (with the option of second-line letrozole). Patient-level data from a large clinical trial describes the effectiveness of the therapy options, clinicians estimate resource usage and utility values are obtained from the literature.

RESULTS

The mean cost of providing first- and second-line hormonal therapy is pound 4765 if letrozole is the first-line therapy and pound 3418 if tamoxifen is provided first (a difference of pound 1347). However, patients receiving letrozole as first-line therapy gain an additional 0.228 life years, or 0.158 QALYs. The cost-effectiveness analysis found that first-line hormonal therapy with letrozole gains additional life years at a cost of pound 5917, whilst the cost per additional QALY gained is pound 8514.

CONCLUSION

The strategy of letrozole as first-line hormonal therapy not only provides an opportunity for extending and improving patient's quality of life, but also is highly cost-effective compared with other generally accepted medical treatments.

Efficiency of alternative policy options for screening for developmental dysplasia of the hip in the United Kingdom

AIMS

To assess, using a decision model, the efficiency of ultrasound based and clinical screening strategies for developmental dysplasia of the hip.

METHODS

The additional cost per additional favourable outcome was compared for the following strategies: clinical screening alone using the Ortolani and Barlow tests; addition of static and dynamic ultrasound examination of the hips of all infants (universal ultrasound) or restricted to infants with defined risk factors (selective ultrasound); "no screening" (that is, clinical diagnosis only).

RESULTS

Ultrasound based screening strategies are predicted to be more effective but more costly than clinical screening or no screening. Estimated total costs per 100,000 live births are approximately pound 4 million for universal ultrasound, pound 3 million for selective ultrasound, pound 1 million for clinical screening alone, and pound 0.4 million for no screening. The relative efficiency of selective ultrasound and clinical screening is poorly differentiated, and depends on how infants are selected for ultrasound as well as the expertise of clinical screening examiners. If training costs less than pound 20 per child screened, clinical screening alone would be more efficient than selective ultrasound. Relative to no screening, each of the 16 additional favourable outcomes achieved as a result of selective ultrasound costs approximately pound 0.2 million, while each of the five favourable outcomes achieved through universal ultrasound screening, over and above selective ultrasound, costs approximately pound 0.3 million.

CONCLUSIONS

Policy choice depends on values attached to the different outcomes, willingness to pay to achieve these and total budget.

Performance, treatment pathways, and effects of alternative policy options for screening for developmental dysplasia of the hip in the United Kingdom

AIMS

To compare, using a decision model, performance, treatment pathways and effects of different newborn screening strategies for developmental hip dysplasia with no screening.

METHODS

Detection rate, radiological absence of subluxation at skeletal maturity and avascular necrosis of the femoral head, as favourable and unfavourable treatment outcomes respectively, were compared for the following strategies: clinical screening alone using the Ortolani and Barlow tests; the addition of static and dynamic ultrasound examination of the hips of all infants (universal ultrasound) or restricted to infants with defined risk factors (selective ultrasound); "no screening" (that is, clinical diagnosis only).

RESULTS

Universal or selective ultrasound detects more more affected children (76% and 60% respectively) than clinical screening alone (35%), results in a higher proportion of affected children with favourable treatment outcomes (92% and 88% respectively) than clinical screening alone (78%) or no screening (75%), and the highest proportion of these achieved without recourse to surgery (64% and 79% respectively) compared with clinical screening alone (18%). However, ultrasound based strategies are also associated with the highest number of unfavourable treatment outcomes arising in unaffected children treated following a false positive screening result. The detection rate of clinical screening alone becomes similar to that reported for universal ultrasound when based on studies using experienced examiners (80%) rather than junior medical staff (35%).

CONCLUSION

From the largely observational data available, ultrasound based screening strategies appear to be most sensitive and effective but are associated with the greatest risk of potential adverse iatrogenic effects arising in unaffected children.