Economic evaluation of interventions for the treatment of asthma in children: A systematic review

OBJECTIVES

This systematic review aimed to identify and critique full economic evaluations (EEs) of childhood asthma treatments with the intention to guide researchers and commissioners of pediatric asthma services toward potentially cost-effective strategies.

METHODS

"MEDLINE," "Embase," "EconLit," "NHS EED," and "CEA" databases were searched to identify relevant EEs published between 2005 and May 2017. Quality of included studies was assessed with a published checklist.

RESULTS

Eighteen studies were identified and comprised one cost-benefit analysis, 11 cost-effectiveness analyses, one cost-minimization analysis, and six cost-utility analyses. Treatments included pharmaceutical (n = 11) and non-pharmaceutical (n = 7) interventions. Fourteen studies identified cost-effective strategies. The quality of the studies varied and there were uncertainties due to the methods and relevance of data used.

CONCLUSION

Good-quality economic evaluation studies of pediatric asthma treatments are lacking. EE of new technologies adapted to local settings is recommended and can result in cost savings.

Reducing Asthma Attacks in Children using Exhaled Nitric Oxide as a biomarker to inform treatment strategy: a randomised trial (RAACENO)

Background

Childhood asthma is a common condition. Currently there is no validated objective test which can be used to guide asthma treatment in children. This study tests the hypothesis that the addition of fractional exhaled nitric oxide (F_ENO) monitoring in addition to standard care reduces the number of exacerbations (or attacks) in children with asthma.

Methods

This is a multi-centre, randomised controlled study. Children will be included of age 6–16 years who have a diagnosis of asthma, currently use inhaled corticosteroids (ICSs) and have had an exacerbation in the previous 12 months. Exclusion criteria include being unable to provide F_ENO measurement at baseline assessment, having another chronic respiratory condition and being currently treated with maintenance oral steroids. Participants will be recruited in both primary and secondary care settings and will be randomised to either receive asthma treatment guided by F_ENO plus symptoms (F_ENO group) or asthma treatment guided by symptoms only (standard care group). Within the F_ENO group, different treatment decisions will be made dependent on changes in F_ENO. Participants will attend assessments 3, 6, 9 and 12 months post randomisation. The primary outcome is asthma exacerbation requiring prescription and/or use of an oral corticosteroid over 12 months as recorded by the participant/parent or in general practitioner records. Secondary outcomes include time to first attack, number of attacks, asthma control score and quality of life. Adherence to ICS treatment is objectively measured by an electronic logging device. Participants are invited to participate in a “phenotyping” assessment where skin prick reactivity and bronchodilator response are determined and a saliva sample is collected for DNA extraction. Qualitative interviews will be held with participants and research nurses. A health economic evaluation will take place.

Discussion

This study will evaluate whether F_ENO can provide an objective index to guide and stratify asthma treatment in children.

Trial registration

ISRCTN, ISRCTN67875351. Registered on 12 April 2017. Prospectively registered.

Randomised controlled trial to assess the impact of a lifestyle intervention (ActWELL) in women invited to NHS breast screening

INTRODUCTION

In Scotland, the incidence of breast cancer is predicted to rise significantly in the next few decades and while there are measures to support reductions in morbidity and mortality, the breast cancer community is currently exploring preventative opportunities including supporting weight management programmes in postmenopausal women. This study aims to assess the effectiveness and cost-effectiveness of a theory-based, community delivered, minimal contact, weight management (diet, physical activity and behaviour change techniques) programme (ActWELL) in women with a body mass index (BMI) >25 kg/m² attending routine breast cancer screening appointments.

METHODS AND ANALYSIS

The study will be a four-centre, 1:1 parallel group randomised controlled trial of a 12-month weight management intervention initiated in breast cancer screening centres, delivered by trained Breast Cancer Now lifestyle coaches in community settings. The intervention programme involves two intervention meetings with coaches plus (up to) nine telephone contacts over 12 months. The programme will focus on personalised diet (including alcoholic and sugary drinks) and physical activity habits. Behaviour change techniques include self-monitoring, goal setting, implementation intentions, action and coping plans. The study has a sample size of 414 women with a BMI >25 kg/m² attending routine National Health Service breast cancer screening appointments. Measures will be taken at baseline, 12 weeks and at 12-month follow-up, complemented by qualitative interviews exploring perceived acceptability and impact on habitual behaviours. The two co-primary outcomes are mean change in measured body weight and change in physical activity between groups to 12 months. Secondary outcomes are changes in eating habits, alcohol intake, sedentary time, quality of life, waist circumference, lipid, haemoglobin A1c and insulin profiles, blood pressure and cost-effectiveness of the intervention.

ETHICS AND DISSEMINATION

The protocol has been approved by East of Scotland Research Ethics Committee (17/ES/0073). All participants provide written informed consent. Dissemination will be through peer-reviewed publication and conference presentations.

TRIAL REGISTRATION NUMBER

ISRCTN11057518; Pre-results.

Ruxolitinib for the treatment of myelofibrosis: a NICE single technology appraisal

The National Institute for Health and Care Excellence (NICE) invited the manufacturer of ruxolitinib (Novartis) to submit clinical and cost-effectiveness evidence for ruxolitinib within its licensed indication (the treatment of disease-related splenomegaly or symptoms in adult patients with myelofibrosis), according to the Institute's Single Technology Appraisal process. The Centre for Reviews and Dissemination and Centre for Health Economics at the University of York were commissioned to act as the independent Evidence Review Group (ERG). This article provides a description of the company submission, the ERG review and the resulting NICE guidance TA289 issued in June 2013. The ERG critically reviewed the evidence presented in the manufacturer's submission and identified areas requiring clarification, for which the manufacturer provided additional evidence. The main clinical effectiveness data were derived from two phase III, multicentre, randomised controlled trials (RCTs): Controlled myelofibrosis study with oral JAK inhibitor treatment (COMFORT)-II compared ruxolitinib with best available therapy (BAT), and COMFORT-I compared ruxolitinib with placebo. These RCTs demonstrated that ruxolitinib confers significant benefits in terms of spleen size reduction and improvement in symptom burden. In the COMFORT-II trial, a reduction in spleen volume of ≥35 % was achieved in 28 % of ruxolitinib-treated patients compared with 0 % of patients in the BAT group (p < 0.001) at 48 weeks, and there was a mean change in spleen volume of -30.1 versus +7.3 % (p < 0.001). Ruxolitinib also provided significant improvements in myelofibrosis-associated symptoms and health-related quality-of-life compared with BAT and placebo. The ERG concluded that ruxolitinib appears to reduce splenomegaly and its associated symptoms, but that there was considerable uncertainty surrounding the manufacturer's cost-effectiveness estimates due to limitations in the manufacturer's model. The manufacturer's model did not allow for disease progression, did not accurately capture symptomatic relief, had several implausible or unjustified assumptions, and there were several parameter choices that the ERG found sub-optimal. ERG sensitivity analyses found that nearly all plausible adjustments to the model reduced the cost effectiveness of ruxolitinib. It is very likely that the base-case incremental cost-effectiveness ratio of £73,980/quality-adjusted life-year presented by the manufacturer represents a best-case scenario. The NICE Appraisal Committee concluded that ruxolitinib was clinically effective, but could not be considered a cost effective use of National Health Service (NHS) resources for treating disease-related splenomegaly or symptoms in adults with myelofibrosis. Ruxolitinib is not recommended for the treatment of disease-related splenomegaly or symptoms in adult patients with primary myelofibrosis (also known as chronic idiopathic myelofibrosis), post-polycythaemia vera myelofibrosis and post-essential thrombocythaemia myelofibrosis in NICE TA289.

Modeling the impact of screening policy and screening compliance on incidence and mortality of cervical cancer in the post-HPV vaccination era

BACKGROUND

In Norway, pap smear screening target women aged 25-69 years on a triennial basis. The introduction of human papillomavirus (HPV) mass immunization in 2009 raises questions regarding the cost-saving future changes to current screening strategies.

METHODS

We calibrated a dynamic HPV transmission model to Norwegian data and assessed the impact of changing screening 20 or 30 years after vaccine introduction, assuming 60 or 90% vaccination coverage. Screening compliance among vaccinated women was assumed at 80 or 50%. Strategies considered: (i) 5-yearly screening of women of 25-69 years, (ii) 3-yearly screening of women of 30-69 years and (iii) 3-yearly screening of women of 25-59 years.

RESULTS

Greatest health gains were accomplished by ensuring a high vaccine uptake. In 2060, cervical cancer incidence was reduced by an estimated 36-57% compared with that of no vaccination. Stopping screening at the age of 60 years, excluding opportunistic screening, increased cervical cancer incidence by 3% (2060) compared with maintaining the current screening strategy, resulting in 1.0-2.4% extra cancers (2010-2060). The 5-yearly screening strategy elevated cervical cancer incidence by 30% resulting in 4.7-11.3% additional cancers.

CONCLUSION

High vaccine uptake in the years to come is of primary concern. Screening of young women <30 years remains important, even under the conditions of high vaccine coverage.

Cost comparison of insulin glargine with insulin detemir in a basal-bolus regime with mealtime insulin aspart in type 2 diabetes in Germany

OBJECTIVE

To compare the treatment costs of insulin glargine (IG; Lantus) to detemir (ID; Levemir), both combined with bolus insulin aspart (NovoRapid) in type 2 diabetes (T2D) in Germany.

METHODS

Cost comparison was based on data of a 1-year randomised controlled trial. IG was administered once daily and ID once (57% of patients) or twice daily (43%) according to treatment response. At the end of the trial, mean daily basal insulin doses were 0.59 U/kg (IG) and 0.82 U/kg (ID). Aspart doses were 0.32 U/kg (IG) and 0.36 U/kg (ID). Costs were calculated from the German statutory health insurance (SHI) perspective using official 2008 prices. Sensitivity analyses were performed to test robustness of the results.

RESULTS

Annual basal and bolus insulin costs per patient were euro 1,473 (IG) and euro 1,940 (ID). The cost of lancets and blood glucose test strips were euro 1,125 (IG) and euro 1,286 (ID). Annual costs for needles were euro 393 (IG) and euro 449 (ID). The total annual cost per patient of administering IG was euro 2,991 compared with euro 3,675 for ID, translating into a 19% annual cost difference of euro 684/patient. Base case results were robust to varying assumptions for insulin dose, insulin price, change in weight and proportion of ID once daily administrations.

CONCLUSION

IG and ID basal-bolus regimes have comparative safety and efficacy, based on the Hollander study, IG however may represent a significantly more cost saving option for T2D patients in Germany requiring basal-bolus insulin analogue therapy with potential annual cost savings of euro 684/patient compared to ID.

Comparison of treatment costs in inadequately controlled type 2 diabetes in Germany based on the APOLLO trial with insulin glargine

OBJECTIVE

A cost analysis of once-daily insulin glargine versus three-times daily insulin lispro in combination with oral antidiabetic drugs (OADs) for insulin-naive type 2 diabetes patients in Germany based on the APOLLO trial (A Parallel design comparing an Oral antidiabetic drug combination therapy with either Lantus once daily or Lispro at mealtime in type 2 diabetes patients failing Oral treatment).

METHODS

Annual direct treatment costs were estimated from the perspective of the German statutory health insurance (SHI). Costs accounted for included insulin medication, disposable pens and consumable items (needles, blood glucose test strips and lancets). Sensitivity analyses (on resource use and unit costs) were performed to reflect current German practice.

RESULTS

Average treatment costs per patient per year in the base case were 1,073 euro for glargine and 1,794 euro for lispro. Insulin costs represented 65% vs. 37% of total costs respectively. Acquisition costs of glargine were offset by the lower costs of consumable items (380 euro vs. 1,139 euro). Sensitivity analyses confirmed the robustness of the results in favour of glargine. All scenarios yielded cost savings in total treatment costs ranging from 84 euro to 727 euro.

CONCLUSIONS

Combination therapy of once-daily insulin glargine versus three-times daily insulin lispro both with OADs, in the management of insulin-dependent type 2 diabetes offers the potential for substantial cost savings from the German SHI perspective.

Measuring the effects of seating on people with profound and multiple disabilities--a preliminary study

This paper describes a preliminary study to investigate a range of approaches that might be used for measuring the effects of special seating on people with profound and multiple disabilities and their carers. A number of tools are proposed for measuring the effects on quality of life, function and carer satisfaction. The results of applying these tools to measure the effects of intervention with customized molded seating on nine people with multiple disabilities are described. The results suggest that these tools are sensitive to this intervention, showing a general beneficial effect with good carer satisfaction. The study points the way towards application of these tools to people with a wider range of disabilities and to different interventions.

Interpreting reported health-care benefits

When reading published reports on the benefits of different treatments or health-care programmes, readers are generally interested in judging the applicability of the results to their own settings. Thus they need to be able to identify what consequences (and costs) were included in the evaluation. This short paper describes the different categories of 'benefit' that may arise from health-care interventions and explains some of the methodological considerations in their measurement. It provides simple advice on avoiding the common pitfalls when interpreting the value offered by a particular treatment or configuration of health services.

Interpreting reported health-care costs

This short paper describes the different categories of health-care costs and methodological considerations in cost measurement. It provides simple advice on avoiding some of the common pitfalls in cost interpretation and should help readers in assessing the usefulness of reported costs.

Faecal occult blood screening for colorectal cancer: is it cost-effective?

Recently published evidence from two large-scale clinical trials conducted in England and in Denmark suggests that faecal occult blood screening for colorectal cancer significantly reduces mortality. However, before screening can be advocated as part of national health policy, its cost-effectiveness must be demonstrated. The English screening trial has been the subject of a detailed economic evaluation over the past 10 years In this paper, cost-effectiveness estimates of screening are presented, based on cost and outcome data combined in a mathematical model developed from the trial's clinical findings The estimates of cost per quality-adjusted life-year gained from colorectal cancer screening show the procedure to be of similar cost-effectiveness to breast cancer screening in the short term. Over the longer term, however, the estimates for colorectal cancer screening appear superior.

Symptoms before and after surgery for colorectal cancer

Questionnaires were completed by a sample (n = 53) of patients at two points in time, prior to surgery for colorectal cancer and three months thereafter. The questionnaires comprised the Nottingham Health Profile, as a general health status measure, and a specific checklist of 30 symptoms. Of the physical symptoms, loss of appetite, rectal bleeding and urgency of bowel movement appeared to decline after treatment, whilst other potential symptoms, such as vomiting, appeared to occur only rarely, both before and after surgery. Pre-treatment symptoms of psychological distress appeared to have dissipated by three months, suggesting that they were more likely to have resulted from the anticipation of treatment rather from the disease itself. A logistic regression model suggests that the presence of certain symptoms, such as rectal bleeding and heartburn, is more likely to be associated with the presence of late- as opposed to early-stage cancer.

Cost-effectiveness of screening for colorectal cancer: a simulation model

Colorectal cancer is a major cause of mortality in Western countries, although early detection of the disease is known to improve survival. Recent developments in medical technology have made mass population screening a practicable proposition and a number of randomized controlled trials of screening are currently being conducted. This paper reports on the construction of a computer simulation model of the cost-effectiveness of colorectal cancer screening, being developed in conjunction with a major UK trial. Based on accumulated trial data and semi-Markov descriptions of the disease process, the model will facilitate the assessment of the cost-effectiveness of a variety of screening modalities, with a view to informing policy in the future.

Determinants of persistent compliance with screening for colorectal cancer

Mass population screening for colorectal cancer is currently being evaluated by means of randomized controlled trials. These trials point to the likelihood that, if implemented, the level of both initial and sustained compliance will prevent the full potential of screening being realised. The paper opens by reviewing the evidence on determinants of compliance, both initial and longer term, although little empirical evidence on adherence to repeated screening is currently available. The paper then presents the results of a survey of persistent compliers and non-compliers within the English screening trial, in order to identify those characteristics most closely associated with persistent compliance behaviour. Persistent compliers are found, inter alia, to be of higher socio-economic classes than persistent non-compliers, to have more personal and family experiences of illness and to visit their dentists more regularly. The results suggest that generalized attempts at compliance enhancement would be ineffectual against the prevailing background characteristics of the non-compliant population, and that the more overt targeting of efforts in this respect is to be preferred.

Colorectal cancer screening and quality of life

To evaluate the quality of life of patients following surgery for colorectal cancer, and to compare the quality of life between patients whose cancer was detected as a result of faecal occult blood screening with that of patients whose cancer presented symptomatically, an analysis was conducted within the context of the randomized controlled trial of colorectal cancer screening, University Hospital, Nottingham, UK. A total of 418 survivors of the trial's test and control groups and 33 randomly selected cancer patients completed quality of life questionnaires (Nottingham Health Profile and Health Measurement Questionnaire). The mode of entry to diagnosis and treatment (screening vs. non-screening) appeared to exert no major impact on post-intervention quality of life. The stage of cancer progression was not closely related to outcome life quality. A quality of life coefficient for surviving patients based on the Rosser classification was estimated to lie within the range 0.948-0.981. This figure accords well with the estimates of other studies of interventions in populations of similar age. Overall, there are no grounds for believing that faecal occult blood screening for colorectal cancer per se significantly influences patients' post-intervention quality of life.

Convergent validity of two measures of the quality of life

In the paper, a test of convergent validity is undertaken for two methods of quality of life assessment, one based on a shortened version of the Health Measurement Questionnaire and the other based on professional clinical judgement. The Nottingham Health Profile is used as the comparator, and the data derive from a sample of colorectal cancer patients. Criteria for convergent validity are established and both methods yield outcomes broadly consistent with such criteria.