Cost-effectiveness of pretomanid-based regimen for highly drugresistant TB in a low-burden setting.

BACKGROUND: Recent clinical findings reported improvement in the treatment outcomes of highly resistant TB (HDR-TB) with the pretomanid (Pa) based regimen. This study aimed to evaluate the cost-effectiveness of the Pa-based regimen for HDR-TB treatment from the perspective of the healthcare sector in the United States.METHODS: A lifelong decision-analytic model was constructed to simulate potential treatment outcomes of 1) the bedaquiline-Pa-linezolid (BPaL) regimen, and 2) the bedaquiline-linezolid (B-L) based regimen in a hypothetical cohort of adult patients with HDR-TB. Primary model outputs were TB-related direct medical costs, qualityadjusted life-years (QALYs) and incremental cost per QALY gained (ICER).RESULTS: In the base-case analysis, the BPaL regimen gained 3.0054 QALYs and saved costs by USD60,433 when compared to the B-L-based regimen. In the probabilistic sensitivity analysis, the BPaL regimen gained higher QALYs at a lower cost in 80.3% of the time, and gained higher QALYs at a higher cost with ICER less than the willingness-to-pay (WTP) threshold (100,000 USD/QALY) in 19.0% of the simulations. The probability of the BPaL regimen being cost-effective was higher than the B-L-based regimen throughout the variation of WTP.CONCLUSION: BPaL therapy is likely the cost-effective option for HDR-TB treatment from the US healthcare sector perspective.

Antibiotic management of acute pharyngitis in primary care.

The Centre for Health Protection of the Department of Health has convened the Advisory Group on Antibiotic Stewardship Programme in Primary Care (the Advisory Group) to formulate guidance notes and strategies for optimising judicious use of antibiotics and enhancing the Antibiotic Stewardship Programme in Primary Care. Acute pharyngitis is one of the most common conditions among out-patients in primary care in Hong Kong. Practical recommendations on the diagnosis and antibiotic treatment of acute streptococcal pharyngitis are made by the Advisory Group based on the best available clinical evidence, local prevalence of pathogens and associated antibiotic susceptibility profiles, and common local practice.

Potential clinical and economic outcomes of active beta-D-glucan surveillance with preemptive therapy for invasive candidiasis at intensive care units: a decision model analysis.

Early initiation of antifungal treatment for invasive candidiasis is associated with change in mortality. Beta-D-glucan (BDG) is a fungal cell wall component and a serum diagnostic biomarker of fungal infection. Clinical findings suggested an association between reduced invasive candidiasis incidence in intensive care units (ICUs) and BDG-guided preemptive antifungal therapy. We evaluated the potential cost-effectiveness of active BDG surveillance with preemptive antifungal therapy in patients admitted to adult ICUs from the perspective of Hong Kong healthcare providers. A Markov model was designed to simulate the outcomes of active BDG surveillance with preemptive therapy (surveillance group) and no surveillance (standard care group). Candidiasis-associated outcome measures included mortality rate, quality-adjusted life year (QALY) loss, and direct medical cost. Model inputs were derived from the literature. Sensitivity analyses were conducted to evaluate the robustness of model results. In base-case analysis, the surveillance group was more costly (1387 USD versus 664 USD) (1 USD = 7.8 HKD), with lower candidiasis-associated mortality rate (0.653 versus 1.426 per 100 ICU admissions) and QALY loss (0.116 versus 0.254) than the standard care group. The incremental cost per QALY saved by the surveillance group was 5239 USD/QALY. One-way sensitivity analyses found base-case results to be robust to variations of all model inputs. In probabilistic sensitivity analysis, the surveillance group was cost-effective in 50 % and 100 % of 10,000 Monte Carlo simulations at willingness-to-pay (WTP) thresholds of 7200 USD/QALY and ≥27,800 USD/QALY, respectively. Active BDG surveillance with preemptive therapy appears to be highly cost-effective to reduce the candidiasis-associated mortality rate and save QALYs in the ICU setting.

Potential clinical and economic outcomes of CYP2C9 and VKORC1 genotype-guided dosing in patients starting warfarin therapy.

The US Food and Drug Administration has updated the label information for warfarin to encourage the use of genetic information before initiating treatment with the drug. We used decision-tree modeling to simulate the outcomes of CYP2C9 and vitamin K epoxide reductase complex 1 (VKORC1) genotype-guided dosing in patients in whom warfarin therapy is to be initiated. The inputs for the model were derived from the literature. The incremental costs per unit outcome improved (ICERs) were US$347,059 per quality-adjusted life-year (QALY) gained, $170,192 per adverse event averted, and $1,106,250 per life saved. The outcomes of 10,000 Monte Carlo simulations demonstrate that the ICER per QALY gained was >$50,000 62.1% of the time. ICER was sensitive to baseline international normalized ratio (INR) control, reduction in out-of-range INRs by genotype-guided dosing, and genotyping cost. In conclusion, genotype-guided dosing for warfarin therapy does not appear to be cost-effective, with the potential ICER per QALY being >$50,000. Lowering the genotyping cost, improving effectiveness of INR control of the genotype-guided dosing algorithm, and applying the algorithm in practice sites with high out-of-range INRs would improve the cost-effectiveness of the dosing algorithm.

Cost-effectiveness analysis of influenza and pneumococcal vaccination for Hong Kong elderly in long-term care facilities.

BACKGROUND: To compare cost and quality-adjusted life-years (QALYs) gained by influenza vaccination with or without pneumococcal vaccination in the elderly living in long-term care facilities (LTCFs). METHODS: Cost-effectiveness analysis based on Markov modelling over 5 years, from a Hong Kong public health provider's perspective, on a hypothetical cohort of LTCF residents aged > or = 65 years. Benefit-cost ratio (BCR) and net present value (NPV) of two vaccination strategies versus no vaccination were estimated. The cost and QALYs gained by two vaccination strategies were compared by Student's t-test in probabilistic sensitivity analysis (10,000 Monte Carlo simulations). RESULTS: Both vaccination strategies had high BCRs and NPVs (6.39 and US$334 for influenza vaccination; 5.10 and US$332 for influenza plus pneumococcal vaccination). In base case analysis, the two vaccination strategies were expected to cost less and gain higher QALYs than no vaccination. In probabilistic sensitivity analysis, the cost of combined vaccination and influenza vaccination was significantly lower (p<0.001) than the cost of no vaccination. Both vaccination strategies gained significantly higher (p<0.001) QALYs than no vaccination. The QALYs gained by combined vaccination were significantly higher (p = 0.030) than those gained by influenza vaccination alone. The total cost of combined vaccination was significantly lower (p = 0.011) than that of influenza vaccination. CONCLUSION: Influenza vaccination with or without pneumococcal vaccination appears to be less costly with higher QALYs gained than no vaccination, over a 5-year period, for elderly people living in LTCFs from the perspective of a Hong Kong public health organisation. Combined vaccination was more likely to gain higher QALYs with lower total cost than influenza vaccination alone.

Public knowledge, attitudes and behavior on antibiotic use: a telephone survey in Hong Kong.

BACKGROUND: This study aimed to examine public knowledge, attitudes and behaviors regarding antibiotic use in the community of Hong Kong. METHODS: A cross-sectional phone survey was conducted in 2006 on people aged 18 or older who were uninstitutionalized Hong Kong residents regarding antibiotic use for upper respiratory tract infections (URTIs). RESULTS: A total of 1,002 respondents participated in the survey and 77%, 72% and 85% of the respondents had adequate knowledge, appropriate attitude/belief and behavior on antibiotic use, respectively. Some respondents (26%) believed that antibiotic was needed for symptoms of URTIs if they felt sick enough to seek medical care and 8% would share antibiotic with family members. Eighty-nine (9%) respondents had acquired antibiotic without a prescription. During the most recent episode of URTI, 78% had completed the antibiotic treatment course. Stepwise multiple logistic showed that higher education level and family income were associated with adequate patient knowledge. Male gender was a predictor of poor behavior on antibiotic use. Appropriate belief was associated with tertiary level of education or above. CONCLUSIONS: Over 70% of the present cohort showed adequate knowledge, appropriate attitudes/beliefs and behavior on antibiotic use. Despite a small percent (8%-9%) of respondents reportedly shared and/or self-prescribed antibiotics, this would translate into the practice of half a million people in Hong Kong. Public education programmes should therefore be developed, targeting specific areas of misconceptions, misuse of antibiotic and vulnerable groups at risk of improper use of antibiotics.

Linezolid versus vancomycin for prosthetic joint infections: a cost analysis.

BACKGROUND: Prosthetic joint infections (PJIs) caused by methicillin-resistant gram-positive bacteria are primarily treated by intravenous vancomycin. Linezolid, active against methicillin-resistant strains and available in oral and intravenous dosage forms, is a potential alternative to vancomycin for the treatment of PJIs. OBJECTIVE: To analyze the cost of linezolid therapy (outpatient setting) and vancomycin therapy (inpatient and outpatient settings) for PJIs caused by methicillin-resistant gram-positive bacteria. METHODS: A decision tree was designed to simulate the clinical outcome and healthcare resource utilization of linezolid, vancomycin by outpatient and home parenteral antimicrobial therapies (OHPAT) and vancomycin administered in inpatient setting (rehabilitation facility) for patients with PJIs caused by methicillin-resistant strains. Clinical inputs were estimated from literature and the cost analysis was conducted from the perspective of the public healthcare provider in Hong Kong. RESULTS: The base-case analysis showed that the vancomycin (OHPAT) group (USD14,470 per patient) was the least costly alternative, followed by the linezolid group (USD17,877 per patient) and the vancomycin (rehabilitation) group (USD19,980 per patient) (1USD = 7.8HKD). The clinical treatment success rates of vancomycin and linezolid were influential factors. Monte Carlo 10,000 simulations showed that the vancomycin (OHPAT) group was less costly than the arms of linezolid and vancomycin (rehabilitation) 64% and 100% of the time, respectively. The linezolid group was less costly than the vancomycin (rehabilitation) group in 65%of the times. CONCLUSION: Home-infusion of vancomycin therapy appears to be the least costly treatment approach for PJIs caused by methicillin-resistant gram-positive bacteria from the perspective of a Hong Kong public health organization.

Atypical antipsychotic therapy for treatment of schizophrenia in Hong Kong Chinese patients--a cost analysis.

OBJECTIVE: To evaluate the direct medical cost of atypical antipsychotic therapy for schizophrenia among Hong Kong Chinese patients and to identify factors affecting the cost of treatment. METHODS: In this retrospective database analysis, patient data were retrieved from three Hong Kong public hospitals. Patients aged 2 18 years who received an initial prescription for olanzapine, risperidone, quetiapine or amisulpride between April 1 and September 30, 2003; and had an ICD-10-coded diagnosis of schizophrenia were included. Patient data were collected for a maximum duration of 1 year before and after treatment initiation. Primary outcome measures were the schizophrenia-related direct medical costs. Demographic and clinical factors were analyzed by multiple regression analysis to identify influential factors for the cost of atypical antipsychotic therapy. RESULTS: A total of 325 patient records were reviewed and 82 patients were included in the analysis. Cost per patient per month for clinic visits (US$ 67 +/- 41 versus US$ 78 +/- 41), medications (US$ 8 +/- 12 versus US$ 97 +/- 83), and the total cost per patient per month (US$ 314 +/- 898 versus US$ 431 +/- 914) increased significantly after treatment initiation (US$ 1 = HK$ 7.8). Previous duration of hospitalization (RR = 1.00, 95% CI = 1.00 1.01), history of substance abuse (RR = 1.26, 95% CI = 1.05 1.52) and use of depot antipsychotics (RR = 1.22, 95% CI = 1.05 - 1.42) were associated with higher cost of atypical antipsychotic therapy. CONCLUSION: The total direct medical cost increased significantly after initiation of atypical antipsychotic therapy in a cohort of Chinese patients with schizophrenia. History of drug abuse, use of depot antipsychotics and prior duration of hospitalization were positive predictors of cost of therapy.

Clinical and economic analyses of antimicrobial therapy in fever wards of a Hong Kong teaching hospital.

OBJECTIVE: The aims of this study were to evaluate the use of antimicrobial agents in the fever wards of a Hong Kong teaching hospital and to identify those factors associated with treatment failure and having an influence on the total direct medical costs of antimicrobial therapy. METHODS: This was a retrospective observational study. Demographic and clinical data were collected on 123 patients admitted to the fever wards in a local teaching hospital between July 2004 and August 2004. Multivariate analyses were performed to identify factors associated with treatment failure and the total direct medical treatment cost. RESULTS: The rate of treatment failure was 30.1% (37 out of 123 patients). The mean total direct medical cost was HK$ 26,442 +/- 17,153 (US$ 1 = HK$ 7.8). The empirical therapy in 90 (73.2%) patients complied with the institutional guidelines. 25 (20.3%) patients were eligible for renal dosage adjustment and in 7 (28%) of these patients the dosage of antimicrobial agents was renally adjusted. Of the 27 patients in whom pathogens were identified, 9 (33.3%) patients were eligible for antimicrobial streamlining (changing to an antibiotic with a narrower spectrum) but streamlining was only done in 2 (22.2%) patients. Multivariate analysis showed that the history of malignant diseases (RR = 5.07; 95% CI = 1.06 - 24.22) and non-compliance with the institutional treatment guidelines for selection of empirical antimicrobial therapy (RR = 3.58; 95% CI = 1.35 - 9.54) were risk factors associated with treatment failure. Duration of intravenous antimicrobial therapy was associated with the total cost of treatment (RR = 1.60; 95% CI = 1.35 - 2.10). CONCLUSION: Non-compliance with treatment guidelines in empirical antimicrobial treatment and the duration of intravenous antimicrobial therapy were modifiable risk factors for treatment failure and total treatment cost, respectively.

Factors associated with healthcare utilization costs for statin therapy--a pilot study in Hong Kong.

BACKGROUND: Socio-economic status, comorbidities and adherence to statin therapy might affect the cost-effectiveness of statin therapy in hyperlipidemia. OBJECTIVE: To examine the effects size of demographic factors, clinical factors and adherence to statin therapy on the direct medical costs for Chinese patients at high risk of coronary heart disease (CHD). METHODS: This was a prospective, observational cohort study conducted in the outpatient departments of a public teaching hospital in Hong Kong. Patients at high risk of CHD who had been on statin monotherapy for < 12 months were recruited. Baseline demographic and clinical data were obtained. Statin adherence was monitored prospectively over 6 months using the Medication Event Monitoring System. Total direct medical costs per member per month (cPMPM), including cost for clinic visits, statin medication, laboratory tests on lipids and management of CHD events if any, were calculated from the perspective of a public healthcare organization. RESULTS: 83 patients completed the study. Median cPMPM in 80 patients (96% of 83 patients) without a new CHD event (USD 42) and for 3 (4%) patients who experienced CHD events (USD 444) were significantly different (p = 0.003). History of congestive heart failure (beta = 1,957, 95% CI = 1,006 - 2,909), male gender (beta = 584, 95% CI = 215 - 952), coronary atherosclerosis (beta = 1,436, 95% CI = 538 - 2,334) and diabetes mellitus (beta = 604, 95% CI = 136 - 1,07 1) were positive predictors for cPMPM. CONCLUSION: In this pilot study male gender, diabetes mellitus, congestive heart failure and coronary atherosclerosis appear to be significantly associated with higher costs for Chinese patients at high risk of CHD.

Helicobacter pylori eradication prior to initiation of long-term non-steroidal anti-inflammatory drug therapy in Chinese patients-a cost-effectiveness analysis.

BACKGROUND: Recent randomized clinical trials suggested that eradication of Helicobacter pylori prior to initiation of non-steroidal anti-inflammatory drug (NSAID) therapy would reduce the rate of peptic ulcer disease (PUD). OBJECTIVE: To analyze the cost-effectiveness of H. pylori eradication prior to initiation of long-term NSAID therapy for prevention of NSAID-induced PUD in a cohort of Chinese patients at high risk for PUD. METHODS: Clinical and economic data of 100 participants from a previously reported clinical trial conducted in Hong Kong were analyzed. Patients with a history of peptic ulcers were randomized to 1-week omeprazole 20 mg, amoxicillin 1 g and clarithromycin 500 mg twice daily (eradication group; n = 51) or 1-week omeprazole 20 mg twice daily (omeprazole group; n = 49) before initiation of diclofenac 100 mg daily for 6 months. The rates of PUD and healthcare utilization for routine follow-up as well as for management of symptomatic PUD of the 2 groups were retrieved from medical records. RESULTS: The rate of symptomatic ulcers in eradication group and omeprazole group were 3.9% and 18%, respectively. The mean direct medical cost of the eradication group was significantly lower than that of the omeprazole group by 30% (US dollar 797 (95% CI = 685 - 909) versus US dollar 1,128 (95% CI = 879 - 1,377)) (p = 0.018). The results were robust to variation of all the cost items. CONCLUSIONS: H. pylori eradication prior to initiation of NSAID therapy appeared to reduce the ulcer rate and mean direct medical cost when compared to no eradication for Chinese H. pylori-infected NSAID users at high risk for PUD.

The all-powerful and 'happy' drug: the use of steroids among primary care doctors in Hong Kong.

BACKGROUND: Steroids are commonly used, but their prescribing pattern and factors associated with their use in the primary care setting are largely unknown. METHODS: Using diagnosis and drug data obtained from logbooks submitted by participants in the Diploma in Family Medicine course between 1999 and 2004, we selected and analysed all patients with a prescription of steroid as well as conditions in which it was prescribed. Factors, relating to patients or doctors, which could be associated with steroid prescription were recorded for both the prescribed and the non-prescribed groups. The results were compared using chi-square tests. RESULTS: Steroids were prescribed in 7.1% of all patient encounters, of which dermatological and respiratory diseases were the most two common conditions. Upper respiratory tract infections accounted for a third of all respiratory diseases in which steroid was prescribed. Female or 'minor' patients (OR 1.16, 95% CI 1.01-1.32 and 1.16, 1.00-1.36 respectively) were more likely to be given a steroid and younger doctors (1.52, 1.25-1.86) were more likely to prescribe them. CONCLUSION: Some patterns of poor prescribing practice were demonstrated in this study. Campaigns by professional bodies may improve prescribing among our community doctors and effective public education programmes are needed to modify the health beliefs and expectations of the general public.

Is INR between 2.0 and 3.0 the optimal level for Chinese patients on warfarin therapy for moderate-intensity anticoagulation?

AIM: To examine the optimal range of International Normalized Ratio (INR) for Chinese patients receiving warfarin for moderate-intensity anticoagulation. METHODS: This was a retrospective cohort study conducted at the ambulatory setting of a 1400-bed public teaching hospital in Hong Kong. The INR measurements and occurrence of serious or life-threatening haemorrhagic and thromboembolic events among patients newly started on warfarin from 1 January 1999 to 30 June 2001 for indications with target INR 2-3 were analysed. The INR-specific incidence of bleeding and thromboembolism were calculated. RESULTS: A total of 491 patients were included, contributing to 453 patient-years of observation period. Forty-seven of the 491 patients experienced 25 haemorrhagic events (5.5 per 100 patient-years) and 27 thromboembolic events (6.0 per 100 patient-years). The percentage of patient-time spent within therapeutic INR range (2-3), INR <2 and INR >3 were 50, 44 and 6%, respectively. The incidence of either haemorrhagic or thromboembolic events was lowest (< or =4 events per 100 patient-years) at INR values between 1.8 and 2.4. CONCLUSIONS: An INR of 1.8-2.4 appeared to be associated with the lowest incidence rate of major bleeding or thromboembolic events in a cohort of Hong Kong Chinese patients receiving warfarin therapy for moderate-intensity anticoagulation.