Patient-reported outcomes in topical field treatment of actinic keratosis in Swedish and Danish patients

Topical treatments in dermatology can be long, complex and lead to nonadherence and nonpersistence to prescribed treatment. Clinical efficacy observed in randomized clinical trials (RCT) may therefore be reduced in real-world clinical practice. The objective of this study was to analyze patient-reported treatment adherence, treatment satisfaction and health-related quality of life (HRQoL) with topical treatments of actinic keratosis (AK) in routine clinical practice in Denmark and Sweden. Adult patients prescribed field-directed topical AK treatments with diclofenac gel, imiquimod or ingenol mebutate per routine clinical practice were eligible for the observational RAPID-ACT study. Data were collected through physician and patient questionnaires that included validated instruments to measure treatment satisfaction (TSQM-9), treatment adherence (MMAS) and HRQoL (EQ-5D-5L, EQ-VAS, AKQoL). In total, 446 patients from Denmark and Sweden were included. Ingenol mebutate patients reported a higher satisfaction with treatment effectiveness compared to patients treated with diclofenac (p = .006) while no other differences in treatment satisfaction could be determined. Treatment adherence was generally high, but higher for ingenol mebutate compared to both diclofenac (p < .001) and imiquimod (p = .007), possibly due to shorter treatment duration. No differences in improved HRQoL were found. More research is needed about the link between treatment adherence and real-world effectiveness.

Treatment of Severe Pain and Opioid-induced Constipation: An Observational Study of Quality of Life, Resource Use, and Costs in Sweden

INTRODUCTION

Opioid-induced constipation (OIC) is a common and costly side effect of opioid treatment affecting patients' quality of life (QoL). The combination oxycodone/naloxone reduces OIC while providing effective analgesia in patients with moderate to severe pain. The objective of this observational study was to compare health-related quality of life (HRQoL), healthcare resource use, and costs in patients with severe pain who were initially treated with oxycodone and laxatives and then subsequently switched to treatment with oxycodone/naloxone.

METHODS

Data were collected by means of questionnaires completed by patients with OIC before and after the initiation of oxycodone/naloxone treatment at different clinical centers in Sweden. The questionnaires included questions on healthcare resource use and absence from work and also consisted of the Patient Assessment of Constipation-QoL (PAC-QoL) instrument, the EuroQol five dimensions questionnaire (EQ-5D), the Patient Assessment of Constipation Symptoms (PAC-SYM) instrument, and the Bowel Function Index (BFI).

RESULTS

The analysis included 37 patients. Resource utilization was lower after treatment with oxycodone/naloxone, in terms of both the number of healthcare contacts and the purchases of medicine for the treatment of constipation. According to the BFI score, patients had fewer problems with OIC after the initiation of oxycodone/naloxone. The PAC-QoL score showed a positive change for patients in both the 96-point dissatisfaction index and the 16-point satisfaction index. PAC-SYM scores was lower after the initiation of oxycodone/naloxone treatment, indicating fewer constipation-related problems.

CONCLUSION

Treatment with oxycodone/naloxone had an overall positive effect on patients, consisting mainly of decreasing the severity of the constipation problems, increasing HRQoL, and decreasing the use of healthcare resources.

FUNDING

Mundipharma AB, Gothenburg, Sweden.

Societal cost of subcutaneous and intravenous trastuzumab for HER2-positive breast cancer - An observational study prospectively recording resource utilization in a Swedish healthcare setting

INTRODUCTION

Trastuzumab is part of the standard treatment for HER2-positive breast cancer. The aim of this study was to estimate the societal value of trastuzumab administered through subcutaneous (SC) injection compared to intravenous (IV) infusion.

METHODS

Female patients with HER2-positive breast cancer receiving SC or IV trastuzumab were consecutively enrolled from five Swedish oncology clinics from 2013 to 2015. Data on time and resource utilization was collected prospectively using patient and nurse questionnaires. Societal costs were calculated by multiplying the resource use by its corresponding unit price, including direct medical costs (pharmaceuticals, materials, nurse time, etc.), direct non-medical costs (transportation) and indirect costs (production loss, lost leisure time). Costs were reported separately for patients receiving trastuzumab for the first time and non-first time ("subsequent treatment").

RESULTS

In total, 101 IV and 94 SC patients were included in the study. The societal costs were lower with SC administration. For subsequent treatments the cost difference was €117 (IV €2099; SC €1983), partly explained by a higher time consumption both for nurses (14 min) and patients (23 min) with IV administration. Four IV and 16 SC patients received trastuzumab for the first time and were analysed separately, resulting in a difference in societal costs of €897 per treatment. A majority of patients preferred SC to IV administration.

CONCLUSION

SC administration resulted in both less direct medical costs and indirect costs, and was consequently less costly than IV administration from a societal perspective in a Swedish setting.

A cost analysis of introducing an infectious disease specialist-guided antimicrobial stewardship in an area with relatively low prevalence of antimicrobial resistance

BACKGROUND

Antimicrobial stewardship programs have been widely introduced in hospitals as a response to increasing antimicrobial resistance. Although such programs are commonly used, the long-term effects on antimicrobial resistance as well as societal economics are uncertain.

METHODS

We performed a cost analysis of an antimicrobial stewardship program introduced in Malmö, Sweden in 20 weeks 2013 compared with a corresponding control period in 2012. All direct costs and opportunity costs related to the stewardship intervention were calculated for both periods. Costs during the stewardship period were directly compared to costs in the control period and extrapolated to a yearly cost. Two main analyses were performed, one including only comparable direct costs (analysis one) and one including comparable direct and opportunity costs (analysis two). An extra analysis including all comparable direct costs including costs related to length of hospital stay (analysis three) was performed, but deemed as unrepresentative.

RESULTS

According to analysis one, the cost per year was SEK 161 990 and in analysis two the cost per year was SEK 5 113. Since the two cohorts were skewed in terms of size and of infection severity as a consequence of the program, and since short-term patient outcomes have been demonstrated to be unchanged by the intervention, the costs pertaining to patient outcomes were not included in the analysis, and we suggest that analysis two provides the most correct cost calculation. In this analysis, the main cost drivers were the physician time and nursing time. A sensitivity analysis of analysis two suggested relatively modest variation under changing assumptions.

CONCLUSION

The total yearly cost of introducing an infectious disease specialist-guided, audit-based antimicrobial stewardship in a department of internal medicine, including direct costs and opportunity costs, was calculated to be as low as SEK 5 113.

TOTALL: high cost of allergic rhinitis-a national Swedish population-based questionnaire study

Allergic rhinitis is a global illness with a well-recognised impact on quality of life and work performance. Comparatively little is known about the extent of its economic impact on society. The TOTALL study estimates the total cost of allergic rhinitis using a sample representing the entire Swedish population of working age. A questionnaire focused on allergic rhinitis was mailed out to a random population of Swedish residents, aged 18–65 years. Health-care contacts, medications, absenteeism (absence from work) and presenteeism (reduced working capacity at work) were assessed, and the direct and indirect costs of allergic rhinitis were calculated. Medication use was evaluated in relation to the ARIA guidelines. In all, 3,501 of 8,001 (44%) answered the questionnaire, and 855 (24%) of these reported allergic rhinitis. The mean annual direct and indirect costs because of allergic rhinitis were €210.3 and €750.8, respectively, resulting in a total cost of €961.1 per individual/year. Presenteeism represented 70% of the total cost. Antihistamines appear to be used in excess in relation to topical steroids, and the use of nasal decongestants was alarmingly high. The total cost of allergic rhinitis in Sweden, with a population of 9.5 million, was estimated at €1.3 billion annually. These unexpectedly high costs could be related to the high prevalence of disease, in combination with the previously often underestimated indirect costs. Improved adherence to guidelines might ease the economic burden on society.

Cost-effectiveness of Maintenance Treatment with a Barrier-strengthening Moisturizing Cream in Patients with Atopic Dermatitis in Finland, Norway and Sweden

Atopic dermatitis is a chronic skin disorder with high prevalence, especially in the Nordic countries. Effective maintenance therapy during symptom-free episodes may prolong the time to eczema relapse according to a previously published clinical trial. The present study evaluates the cost-effectiveness of a barrier-strengthening moisturizer containing 5% urea, compared with a moisturizer with no active ingredients during eczema-free periods. A health economic microsimulation model, based on efficacy data from the randomized clinical trial, analysed the cost-effectiveness of the barrier-strengthening treatment in Finland, Norway and Sweden. The barrier-strengthening moisturizer was cost-saving compared with the moisturizer with no active ingredients in all 3 countries. The result was confirmed in all but one sensitivity analysis. In conclusion, the barrier-strengthening moisturizer is cost-effective as maintenance therapy for patients with atopic dermatitis compared with a moisturizer with no active ingredients.

Health related quality of life in patients with actinic keratosis--an observational study of patients treated in dermatology specialist care in Denmark

Background

Actinic keratosis (AK) is a common skin condition that may progress to non-melanoma skin cancer (NMSC). The disease may influence Health Related Quality of Life (HRQoL), but studies of HRQoL in patients with AK are limited.

The purpose of the study was to analyze HRQoL in patients with different severity levels of AK treated in dermatology specialist care using generic and disease-specific HRQoL instruments and to analyze their relationship.

Methods

AK patients who visited dermatological clinics in Denmark were included in an observational, cross-sectional, study in a multi-center setting. Dermatologists assessed AK severity and patients completed: Actinic Keratosis Quality of Life Questionnaire (AKQoL), Dermatology Life Quality Index (DLQI), and EQ-5D-5 L including EQ-VAS. Differences between categorical subgroups were tested with Wilcoxon rank-sum test. The relationship between instruments was analyzed with the Spearman correlation test.

Results

A total of 312 patients were included in the analyses. Patients reported impairment in the disease specific HRQoL instrument AKQoL (mean AKQoL 6.7, DLQI 2, EQ-5D-5 L 0.88, and EQ-VAS 79). HRQoL was least affected in patients with mild actinic disease, whereas patients with severe actinic damage suffered from further impaired HRQoL (mean AKQoL 10.1 and DLQI 4.6). Correlations between DLQI and AKQoL were moderate, whereas the correlations between DLQI and EQ-5D-5 L and between AKQoL and EQ-5D-5 L were weak.

Conclusions

Patients with severe actinic damage showed more impairment in HRQoL than those with mild disease. Correlations between instruments suggest that they are complementary as they measure different aspects of HRQoL and are used for different purposes.

Cost consequences due to reduced ulcer healing times - analyses based on the Swedish Registry of Ulcer Treatment

Resource use and costs for topical treatment of hard-to-heal ulcers based on data from the Swedish Registry of Ulcer Treatment (RUT) were analysed in patients recorded in RUT as having healed between 2009 and 2012, in order to estimate potential cost savings from reductions in frequency of dressing changes and healing times. RUT is used to capture areas of improvement in ulcer care and to enable structured wound management by registering patients with hard-to-heal leg, foot and pressure ulcers. Patients included in the registry are treated in primary care, community care, private care, and inpatient hospital care. Cost calculations were based on resource use data on healing time and frequency of dressing changes in Swedish patients with hard-to-heal ulcers who healed between 2009 and 2012. Per-patient treatment costs decreased from SEK38 223 in 2009 to SEK20 496 in 2012, mainly because of shorter healing times. Frequency of dressing changes was essentially the same during these years, varying from 1·4 to 1·6 per week. The total healing time was reduced by 38%. Treatment costs for the management of hard-to-heal ulcers can be reduced with well-developed treatment strategies resulting in shortened healing times as shown in RUT.

Predictors of lower-extremity amputation in patients with an infected diabetic foot ulcer

OBJECTIVE

Infection commonly complicates diabetic foot ulcers and is associated with a poor outcome. In a cohort of individuals with an infected diabetic foot ulcer, we aimed to determine independent predictors of lower-extremity amputation and the predictive value for amputation of the International Working Group on the Diabetic Foot (IWGDF) classification system and to develop a risk score for predicting amputation.

RESEARCH DESIGN AND METHODS

We prospectively studied 575 patients with an infected diabetic foot ulcer presenting to 1 of 14 diabetic foot clinics in 10 European countries.

RESULTS

Among these patients, 159 (28%) underwent an amputation. Independent risk factors for amputation were as follows: periwound edema, foul smell, (non)purulent exudate, deep ulcer, positive probe-to-bone test, pretibial edema, fever, and elevated C-reactive protein. Increasing IWGDF severity of infection also independently predicted amputation. We developed a risk score for any amputation and for amputations excluding the lesser toes (including the variables sex, pain on palpation, periwound edema, ulcer size, ulcer depth, and peripheral arterial disease) that predicted amputation better than the IWGDF system (area under the ROC curves 0.80, 0.78, and 0.67, respectively).

CONCLUSIONS

For individuals with an infected diabetic foot ulcer, we identified independent predictors of amputation, validated the prognostic value of the IWGDF classification system, and developed a new risk score for amputation that can be readily used in daily clinical practice. Our risk score may have better prognostic accuracy than the IWGDF system, the only currently available system, but our findings need to be validated in other cohorts.

Evaluation of the cost-effectiveness of buprenorphine in treatment of chronic pain using competing EQ-5D weights

Background and aims

Chronic pain is a life altering condition and common among elderly persons. The 7-day buprenorphine patch could be a suitable treatment for managing chronic pain of moderate severity in elderly patients in Sweden.

The objective of this analysis was to investigate the cost-effectiveness of the 7-day buprenorphine patch, versus no treatment, in patients >50 years old who suffer from moderate pain in a health economic perspective. An additional aim was to evaluate how the cost-effectiveness is affected by the choice of EQ-5D weights.

Methods

The annual treatment cost and the potential gains in health-related quality of life (HRQoL) of buprenorphine, compared to no treatment, were evaluated. Original EQ-5D data were collected from four clinical reference studies at baseline and at the final visit. Treatment effects on HRQoL were then assessed using both UK and Swedish EQ-5D weights. Annual treatment costs were calculated based on costs of physician visits and pharmaceuticals.

The optimal treatment dose was 10-15 μg/h and the analysis was hence performed on both a 10- and a 15 μg/h buprenorphine patch.

Results

The analysis of buprenorphine treatment resulted in improved HRQoL in all reference studies, irrespective of choice of EQ-5D weight set. The change in quality adjusted life years (QALYs) varied with a gain of 0.042-0.118 using the UK weights and 0.020-0.051 with the Swedish weights. The average annual treatment cost was SEK14454 for the 10μg/h patch and SEK17 017 for the 15 μg/h patch, while cost for the no-treatment alternative was SEK 9 960. The base case incremental cost-effectiveness ratios (ICER) with the UK weights were SEK 40000-SEK 170000 and SEK 90000-SEK 350000 when applying the Swedish weights. The corresponding ICER-span in the sensitivity analysis was SEK 15 000-SEK 400 000 when applying the UK weights and SEK 30 000-SEK 840 000 with the Swedish weights (SEK 100 is about €11).

Conclusions

The results imply that the 7-day buprenorphine patch may be a cost-effective treatment of moderate chronic pain in patients over 50 years of age. The UK and the Swedish EQ-5D weights generated vastly different HRQoL estimates but buprenorphine remains cost-effective regardless choice of weight set.

Health-related quality of life predicts major amputation and death, but not healing, in people with diabetes presenting with foot ulcers: the Eurodiale study

OBJECTIVE

Low health-related quality of life (HRQoL) has been consistently reported to be associated with poor prognosis for a variety of health outcomes in various settings. We aimed to evaluate whether HRQoL in patients presenting with new diabetic foot ulcers (DFUs) has prognostic significance for ulcer healing, major amputation, and death.

RESEARCH DESIGN AND METHODS

We followed 1,088 patients with new DFUs presenting for treatment at one of the 14 centers in 10 European countries participating in the Eurodiale (European Study Group on Diabetes and the Lower Extremity) study, prospectively until healing (76.9%), major amputation (4.6%), or death (6.4%) up to a maximum of 1 year. At baseline, patient and ulcer characteristics were recorded as well as EQ-5D, a standardized instrument consisting of five domains and a visual analog scale for use as a measure of HRQoL. The prognostic influence of the EQ-5D domains was evaluated in multivariable Cox regression analyses on the time-to-event data, adjusting for baseline clinical characteristics of the ulcer and comorbidities.

RESULTS

While predictive effects of HRQoL, adjusted for possible confounders, were absent for healing, decreased HRQoL, especially in the physical domains, was statistically significant for major amputation (mobility, self-care, usual activities) and death (self-care, usual activities, pain/discomfort).

CONCLUSIONS

Low HRQoL appears to be predictive for major amputation and death, but high HRQoL does not increase healing. Future studies into the influence of HRQoL on ulcer outcome are important in attempts to decrease treatment failure and mortality.

Treatment patterns, treatment satisfaction, severity of disease problems, and quality of life in patients with psoriasis in three Nordic countries

Biological drugs are expensive, but can reduce symptoms and increase quality of life for patients with psoriasis. The aim of this study was to examine quality of life, disease severity and treatment satisfaction in Danish, Finnish and Swedish patients with psoriasis. Based on 12 months' data from patient surveys and chart reviews, 3 treatment groups were identified: topical, systemic and/or biological <12 months, and biological for 12 months. Regression analyses were performed to investigate influence on treatment satisfaction, disease problems and quality of life. Patients treated with biological drugs for 12 months showed the highest treatment satisfaction and the lowest Dermatology Life Quality Index score. A number of patients with topical treatment reported low quality of life, severe or very severe disease problems, and low treatment satisfaction. Some patients with psoriasis may be under-treated and might benefit from a more aggressive treatment strategy. It is important, however, that resource utilization is optimized and patients are not treated with more advanced agents than necessary.

Cost-effectiveness of mometasone furoate nasal spray in the treatment of acute rhinosinusitis

BACKGROUND

Acute rhinosinusitis is a common disease with an increasing incidence rate. It causes substantial costs to the individual and to society through healthcare consumption and absence from work. The use of antibiotics is widespread in the treatment of acute rhinosinusitis, but increasing bacterial resistance is an argument for restricting excessive use of antibiotics.

AIMS

The aim of this study was to analyse the cost-effectiveness of mometasone furoate nasal spray (MFNS) compared with amoxicillin or non-active treatment of mild to moderate acute rhinosinusitis in a Swedish setting.

METHODS

A cost-effectiveness model was developed to capture the costs and health-related quality of life (HRQoL) over a 15-day period. Acute rhinosinusitis was modelled as changes in the Major Symptom Score. The model takes on a societal perspective in a Swedish setting. Efficacy data were taken from a randomised clinical study. The model has three treatment arms: (A) MFNS 200 μg twice daily, (B) amoxicillin 500 mg three times daily, and (C) placebo. Information about resource utilisation and HRQoL was taken from a recent observational study.

RESULTS

Costs were reduced and quality-adjusted life years were increased with MFNS 200 μg twice daily compared with amoxicillin 500 mg three times daily. MFNS was cost-saving or cost-effective compared with amoxicillin or non-active treatment in the sensitivity analyses regardless of the HRQoL measurement used.

CONCLUSIONS

This study shows that treatment with MFNS 200 μg twice daily results in lower costs and improved HRQoL in acute rhinosinusitis compared with amoxicillin or self-medication.

Are treatment satisfaction, quality of life, and self-assessed disease severity relevant parameters for patient registries? Experiences from Finnish and Swedish patients with psoriasis

Patient registries often lack indicators of the disease as experienced by patients, e.g. treatment satisfaction and self-assessed disease severity. There is scarce information about the relationship between these assessments and currently existing instruments used in treatment evaluation. Our objective was to explore the importance of these indicators among patients with psoriasis in Finland and Sweden, in relation to treatment patterns and current measures of health-related quality of life. Data were collected from a patient survey and a retrospective chart review for 273 patients over 12 months. To assess psoriasis treatment completely, it is necessary to consider the impact of the disease on the patient in terms of treatment satisfaction, disease severity and health-related quality of life. The individual disease burden on patients should play a central role in formulating treatment goals. Clinician- and patient-based perspectives of the overall impact of psoriasis can assist clinical decision-making and evaluations of treatments.

Delivery of care to diabetic patients with foot ulcers in daily practice: results of the Eurodiale Study, a prospective cohort study

AIMS

To determine current management and to identify patient-related factors and barriers that influence management strategies in diabetic foot disease.

METHODS

The Eurodiale Study is a prospective cohort study of 1232 consecutive individuals presenting with a new diabetic foot ulcer in 14 centres across Europe. We determined the use of management strategies: referral, use of offloading, vascular imaging and revascularization.

RESULTS

Twenty-seven percent of the patients had been treated for > 3 months before referral to a foot clinic. This varied considerably between countries (6-55%). At study entry, 77% of the patients had no or inadequate offloading. During follow-up, casting was used in 35% (0-68%) of the plantar fore- or midfoot ulcers. Predictors of use of casting were male gender, large ulcer size and being employed. Vascular imaging was performed in 56% (14-86%) of patients with severe limb ischaemia; revascularization was performed in 43%. Predictors of use of vascular imaging were the presence of infection and ischaemic rest pain.

CONCLUSION

Treatment of many patients is not in line with current guidelines and there are large differences between countries and centres. Our data suggest that current guidelines are too general and that healthcare organizational barriers and personal beliefs result in underuse of recommended therapies. Action should be undertaken to overcome these barriers and to guarantee the delivery of optimal care for the many individuals with diabetic foot disease.

Optimal organization of health care in diabetic foot disease: introduction to the Eurodiale study

This article describes the rationale and protocol of a large data collection study in patients with new diabetic foot ulcers by the Eurodiale study group, a consortium of centers of expertise in the field of diabetic foot disease within Europe. This study is a multicenter, observational, prospective data collection study. Its main aim is to determine the major factors determining clinical outcome and outcome in terms of health-related quality of life and health care consumption. Between September 1, 2003, and October 1, 2004, in 14 European centers, all consecutive patients with diabetes and a new foot ulcer were included in the study and followed until the end point or for a maximum of 1 year. End points were healing of the foot, major amputation, or death. Data were collected on patient, foot, and ulcer characteristics and on diagnostic and management procedures. Furthermore, data were collected on health care organization, quality of life, and resource use. A total of 1232 patients were included in the study. Sixty-three percent of the patients were referred by their general practitioner or were self-referrals. Twenty-seven percent of the patients were admitted at the time of inclusion; 1088 patients were followed until the end point. "Optimal Organization of Health Care in Diabetic Foot Disease" is one of the first large multicenter studies in the field of diabetic foot disease on clinical presentation, clinical outcome, quality of life, resource utilization, and health care organization and their interrelationships. These data will provide us with new insights that enable us to improve care for these patients and guide the development of new studies in this area. The results of this study are the subject of a separate presentation.

Under what conditions is feedback microwave thermotherapy (ProstaLund Feedback Treatment) cost-effective in comparison with alpha-blockade in the treatment of benign prostatic hyperplasia and lower urinary tract symptoms?

OBJECTIVE

Lower urinary tract symptoms (LUTS) due to benign prostatic hyperplasia (BPH) are a common condition in men, and their incidence increases with age. The objective of this study was to evaluate the potential cost-utility of microwave thermotherapy, specifically the ProstaLund Feedback Treatment (PLFT), versus alpha-blockade in Swedish patients with LUTS due to BPH.

MATERIAL AND METHODS

A health-economic simulation model, based on long-term disease progression and costs, was developed to analyse the cost-utility of PLFT in comparison with alpha-blockade over a 3-year period based on data from published literature, treatment programmes and official price lists. Outcome measures used in the analysis were quality of life, survival and reduction in International Prostate Symptom Score. Sensitivity analyses were performed for a number of essential variables. The perspective of the study is the healthcare sector. All costs are expressed as 2003 prices.

RESULTS

Three years after an intervention with PLFT or initiation of drug treatment the cost-utility of PLFT was estimated at approximately euro 6600-9500 per quality-adjusted life-year gained. The cost-utility was further improved over a longer time period, and PLFT appears to be cost-saving after 5 years. One important finding from the model simulation was that PLFT also seems to be favourable in patients with less pronounced symptoms. This result may be further validated when additional results from controlled clinical trials become available.

CONCLUSIONS

The present model simulation indicates that treatment with PLFT seems to be cost-effective compared with drug therapy with alpha-blockade. The result shows that the time-frame of the analysis has a great impact on the cost-effectiveness ratio.

Local treatment pattern versus trial-based data: a cost-effectiveness analysis of drotrecogin alfa (activated) in the treatment of severe sepsis in Sweden

Three methodological approaches were applied to analyze whether the cost-effectiveness of drotrecogin alfa (activated) (Xigris) as an adjunct to standard care compared with standard care alone is a cost-effective alternative for the treatment of Swedish patients with severe sepsis and organ dysfunction. Health-economic model simulations were applied to (1) Swedish treatment pattern data, (2) international trial data and local unit prices, and (3) Swedish local patient data combined with trial age structure to adjust for differences in the age structure between the trial and the Swedish patient sample. The methodological approach had no effect on the overall conclusion that the intervention was cost-effective in the treatment of Swedish patients with severe sepsis and organ dysfunction. However, the cost-effectiveness ratios were sensitive to the approach applied. The results indicate the importance of collecting not only information on local prices but also information about treatment pattern and patient characteristics when conducting country-specific health-economic model applications.

[Treatment of venous leg ulcers is costly for the health care and the society. The value of preventive measures should be further investigated according to a study]

Annual costs for the treatment of venous leg ulcers in Sweden have been estimated at between SEK 17,000 and SEK 26,500 per patient in 2002 prices. The calculation was based on a model simulation including data from a follow-up of patients in clinical practice, an expert panel, and published literature. The variation in costs depends on ulcer size and ulcer duration when treatment is initiated. The highest costs were estimated for a group of patients with ulcers 10 cm2 or larger and ulcer duration of 6 months or longer. About 50 per cent of the total annual costs were related to staff costs for dressing changes.

Annual costs of treatment for venous leg ulcers in Sweden and the United Kingdom

The aim of this study was to estimate costs of treating venous leg ulcers in Sweden and the United Kingdom during 1 year and to quantify costs in different health states. The costs of treating four different types of venous leg ulcers were estimated for 52 weeks by a stochastic health economic model, which simulated resource use data obtained from prospectively collected patient data, expert panels in the two countries, and published scientific literature. The average cost of treating an ulcer varied between 1332 Euro and 2585 Euro in Sweden and from 814 Euro to 1994 Euro in the United Kingdom. Cost of treating large ulcers (>/= 10 cm(2)) of long duration (>/= 6 months) was highest in both countries. Frequency of dressing changes and duration of time for each dressing change were higher in Sweden than in the United Kingdom, resulting in higher total cost per patient in Sweden. An important factor for the total costs was time to heal. Other important variables influencing treatment costs were frequency and duration of dressing changes. Actions to reduce time used for dressing changes and the total time to healing are thus very important in reducing costs spent on treatment of venous leg ulcers in both countries.

Health-Economic Consequences of Diabetic Foot Lesions

Diabetic foot complications result in huge costs for both society and the individual patients. Few reports on the health-economic consequences of diabetic foot infections have been published. In studies considering a wide societal perspective, costs of antibiotics were relatively low, whereas total costs for topical treatment were high relative to the total costs of foot infections. Total direct costs for healing of infected ulcers not requiring amputation are approximately 17,500 dollars (in 1998 US dollars), whereas the costs for lower-extremity amputations are approximately 30,000 dollars-33,500 dollars depending on the level of amputation. Prevention of foot ulcers and amputations by various methods, including patient education, proper footwear, and foot care, in patients at risk is cost effective or even cost saving. Awareness of the potential influence of reimbursement systems on prevention, management, and outcomes of diabetic foot lesions has increased. Despite methodological obstacles, modeling studies are needed in future health-economic evaluations to determine the cost effectiveness of various strategies.

[Treatment of venous leg ulcers can be better and cheaper. Annual costs calculation based on an inquiry study]

Weekly resource use data for local wound treatment was collected from a clinical survey (138 patients). Annual costs were calculated from the weekly resource usage multiplied by unit costs and published epidemiological prevalence data for Sweden. The average weekly cost was 101 euro, though it differed depending by ulcer size. The total direct annual cost of venous leg ulcers in Sweden could be estimated at 73 million euro (2002 prices, 1 euro = SEK 9.16) based on a point prevalence of 0.3 percent and 45 percent venous ulcers. Treatment of leg ulcers seems to have improved compared with previous reports, resulting in slightly decreased costs. Nevertheless, the costs are still substantial and the management of these patients requires large resources. A more structured management, more careful selection of dressing products and decreased frequency of dressing changes imply further improvements in wound healing and quality of life for patients and decreased costs for the health care system and for society.

Costs of deep foot infections in patients with diabetes mellitus

OBJECTIVE

To calculate costs for the management of deep foot infections and to identify the most important factors related to treatment costs.

DESIGN

Costs for in-hospital care, surgery, investigations, antibacterials, visits to the foot-care team, orthopaedic appliances and topical treatment were calculated retrospectively from diagnosis until healing or death. Multiple regression analysis was used to identify factors that independently affect costs.

SETTING

A multidisciplinary foot-care team.

PATIENTS

220 prospectively followed patients with diabetes mellitus and deep foot infections who were referred to the team from 1986 to 1995.

MAIN OUTCOME MEASURES AND RESULTS

Total cost for healing without amputation was Swedish kronor (SEK)136,600 per patient, while the corresponding cost for healing with minor amputation was SEK260,000 and with major amputation was SEK234,500. All costs were quoted in SEK at 1997 price levels (1 Pound sterling and $US1 equalled approximately SEK12.50 and SEK7.64, respectively). The cost of antibacterials was 4% of total costs. The cost of topical treatment was 51% of total costs and related to wound healing time. Number of weeks between diagnosis of deep foot infection and healing, and number of surgical procedures were variables that explained 95% of costs in the multiple regression analysis. It was not possible to find any parameters present at diagnosis that could contribute to an explanation of total treatment costs.

CONCLUSIONS

Topical treatment accounted for the largest proportion of total costs and the most important cost driving factors were wound healing duration and repeated surgery. Costs of antibacterials should not be used as an argument in the choice between early amputation and conservative treatment.

Cost effectiveness of Helicobacter pylori eradication therapies in patients with duodenal ulcer. An analysis of triple therapy versus two dual therapy alternatives

OBJECTIVE

Recent research has focused on eradication therapy as the principal treatment of patients with duodenal ulcers and Helicobacter pylori infection. The aim of this study was to analyse the cost effectiveness of triple therapy versus 2 dual therapies.

DESIGN

A health economic evaluation of triple therapy with lansoprazole, amoxicillin and clarithromycin versus 2 dual therapies (lansoprazole or omeprazole, each with amoxicillin) in the eradication of Helicobacter pylori in patients with duodenal ulcers was performed in parallel with a randomised clinical trial. Direct and indirect costs were estimated for 1 year using data elicited from patient questionnaires and from the clinical trial.

MAIN OUTCOME MEASURES AND RESULTS

Despite the initial drug cost for triple therapy being 650 Swedish kronor (SEK; 1996 values) higher, the average total direct cost in this group was only SEK150 to SEK200 higher than in the dual therapy groups. This was a result of fewer outpatient visits and lower drug use after treatment failure in the triple therapy group. Triple therapy had a more favourable cost-effectiveness ratio than the dual therapies.

CONCLUSION

In spite of higher initial antimicrobial costs, triple therapy with lansoprazole, amoxicillin and clarithromycin is more cost effective than dual therapy because of a higher eradication rate and greater symptom relief.

Economic evaluation of gemcitabine single agent therapy compared with standard treatment in stage IIIB and IV non-small cell lung cancer

Chemotherapy treatment of patients with advanced non-small cell lung cancer (NSCLC) has been characterised by low cure rates, serious side effects, and expensive inpatient care. The aim of the present report was to perform an economic evaluation of gemcitabine monotherapy compared with standard chemotherapy treatment for NSCLC stages IIIB and IV. Standard chemotherapy treatment was identified as cisplatin/etoposide and ifosfamide/etoposide. Effectiveness expressed as survival and tumour response rates was assumed to be broadly equivalent for the alternatives. A cost-minimisation analysis was therefore performed. Total costs per patient per first treatment cycle of chemotherapy for the alternatives cisplatin/etoposide, ifosfamide/etoposide and gemcitabine were Skr 15,131, Skr 25,226, and Skr 13,266, respectively. The results are sensitive to whether chemotherapy could be given in inpatient or in outpatient care. Monotherapy with gemcitabine outpatient treatment in patients with stage IIIB and IV NSCLC was found to be a cost saving alternative when compared with currently used inpatient combination regimens. The treatment alternative with gemcitabine appears to be associated with higher costs for drugs and outpatient care, but lower costs for inpatient care and treatment of adverse events.

The economic costs of acute myeloid leukemia in Sweden

The direct and indirect costs of acute myeloid leukemia were estimated for Sweden in 1989. The calculated total cost was SEK 460 million. Nearly half of the costs, or 1.7 million per patient diagnosed, were indirect costs due to premature mortality. Direct costs of relapses and indirect costs of mortality represent costs due to the absence of completely curable therapy. They also represent potential cost savings that could be obtained after introduction of new treatment options in the future.

Cost-effectiveness analysis of treatment with liposomal amphotericin B versus conventional amphotericin B in organ or bone marrow transplant recipients with systemic mycoses

Economic appraisal of pharmaceuticals is becoming increasingly important. In a retrospective study of patient records from 58 organ or bone marrow-transplanted patients with systemic mycoses, the cost-effectiveness of treatment with a liposomal amphotericin B formulation was compared with that of conventional amphotericin B. Treatment with liposomal amphotericin B results in fewer adverse reactions, increased life expectancy and higher costs than treatment with conventional amphotericin B. Pricing liposomal amphotericin B at about SKE6000 per patient treatment day will result in an additional cost per life-year gained of about SEK150 000 relative to that using conventional amphotericin B for patients receiving kidney, kidney and pancreas, or pancreas transplants. For liver and bone marrow transplant (BMT) recipients the marginal cost-effectiveness ratio was about SEK195 000 and SEK150 000 per life-year gained. Compared with alternative use of resources in society and health care, use of liposomal amphotericin B rather than conventional amphotericin treatment can be considered cost-effective at the price assumed.