Cost-Effectiveness of Pain Management Strategies in Advanced Cancer.

OBJECTIVES: Uncontrolled pain in advanced cancer is a common problem and has significant impact on individuals' quality of life and use of healthcare resources. Interventions to help manage pain at the end of life are available, but there is limited economic evidence to support their wider implementation. We conducted a case study economic evaluation of two pain self-management interventions (PainCheck and Tackling Cancer Pain Toolkit [TCPT]) compared with usual care. METHODS: We generated a decision-analytic model to facilitate the evaluation. This modelled the survival of individuals at the end of life as they moved through pain severity categories. Intervention effectiveness was based on published meta-analyses results. The evaluation was conducted from the perspective of the U.K. health service provider and reported cost per quality-adjusted life-year (QALY). RESULTS: PainCheck and TCPT were cheaper (respective incremental costs -GBP148 [-EUR168.53] and -GBP474 [-EUR539.74]) and more effective (respective incremental QALYs of 0.010 and 0.013) than usual care. There was a 65 percent and 99.5 percent chance of cost-effectiveness for PainCheck and TCPT, respectively. Results were relatively robust to sensitivity analyses. The most important driver of cost-effectiveness was level of pain reduction (intervention effectiveness). Although cost savings were modest per patient, these were considerable when accounting for the number of potential intervention beneficiaries. CONCLUSIONS: Educational and monitoring/feedback interventions have the potential to be cost-effective. Economic evaluations based on estimates of effectiveness from published meta-analyses and using a decision modeling approach can support commissioning decisions and implementation of pain management strategies.

Sensitivity of chest X-ray for detecting lung cancer in people presenting with symptoms: a systematic review.

BACKGROUND: Despite increasing use of computed tomography (CT), chest X-ray remains the first-line investigation for suspected lung cancer in primary care in the UK. No systematic review evidence exists as to the sensitivity of chest X-ray for detecting lung cancer in people presenting with symptoms. AIM: To estimate the sensitivity of chest X-ray for detecting lung cancer in symptomatic people. DESIGN AND SETTING: A systematic review was conducted to determine the sensitivity of chest X-ray for the detection of lung cancer. METHOD: Databases including MEDLINE, EMBASE, and the Cochrane Library were searched; a grey literature search was also performed. RESULTS: A total of 21 studies met the eligibility criteria. Almost all were of poor quality. Only one study had the diagnostic accuracy of chest X-ray as its primary objective. Most articles were case studies with a high risk of bias. Several were drawn from non-representative groups, for example, specific presentations, histological subtypes, or comorbidities. Only three studies had a low risk of bias. Two primary care studies reported sensitivities of 76.8% (95% confidence interval [CI] = 64.5 to 84.2%) and 79.3% (95% CI = 67.6 to 91.0%). One secondary care study reported a sensitivity of 79.7% (95% CI = 72.7 to 86.8%). CONCLUSION: Though there is a paucity of evidence, the highest-quality studies suggest that the sensitivity of chest X-ray for symptomatic lung cancer is only 77% to 80%. GPs should consider if further investigation is necessary in high-risk patients who have had a negative chest X-ray.

Salvage of Failed Achilles Tendon Interposition Arthroplasty for DRUJ Instability After Ulnar Head Resection With Aptis Prosthesis.

BACKGROUND: Historically, failed conservative treatment for irreparably damaged distal radioulnar joints (DRUJs) is treated via distal ulnar resection or DRUJ fusion; complications include disabling painful convergence of the radius and ulnar stump during lifting Various treatments for radioulnar impingement include distal radioulnar Achilles tendon allograft interpositional arthroplasty. This technique does not adequately prevent radioulnar impingement and we explore an alternative treatment. METHODS: We report 7 adult patients who failed Achilles tendon interposition, subsequently treated with Aptis total DRUJ prostheses (mean follow-up, 26 months; range, 7-40). RESULTS: Revision to Aptis prosthesis produced clinically stable DRUJ, improved grip strength and painless lifting capabilities, high patient satisfaction, and no major complications. All returned to daily activities and even recreational sports. CONCLUSIONS: Tendon lacks biomechanical features key to the shock-absorbing function of cartilage-features it cannot deliver when used to prevent radioulnar convergence. We report Aptis DRUJ prosthesis as an alternative to the tendon allograft technique.

The Clinical and Cost Effectiveness of Ustekinumab for the Treatment of Psoriatic Arthritis: A Critique of the Evidence.

The National Institute for Health and Care Excellence (NICE) invited the manufacturer of ustekinumab (Janssen) to submit evidence for the clinical and cost effectiveness of ustekinumab for the treatment of active psoriatic arthritis (PsA) as part of the Institute's single technology appraisal (STA) process. The Centre for Reviews and Dissemination and the Centre for Health Economics Technology Appraisal Group at the University of York were commissioned to act as the independent Evidence Review Group (ERG). This article provides a description of the ERG review of the manufacturer's evidence submission, and summarises the NICE Appraisal Committee's final guidance (TA340) issued in June 2015. The manufacturer presented evidence on ustekinumab for two patient populations: (1) a tumour necrosis factor-α (TNFα)-inhibitor-naïve population who had not previously received any TNFα inhibitors (biologics); and (2) a TNFα-inhibitor-exposed population who had previously received at least one TNFα inhibitor. The clinical evidence for ustekinumab was derived from two randomised controlled trials (PSUMMIT 1 and 2), in which a total of 927 patients who had not responded to previous disease-modifying antirheumatic drug therapies received ustekinumab 45 mg, ustekinumab 90 mg, or placebo. These data suggested that ustekinumab is more effective than placebo over 16-24 weeks in terms of both joint and skin response. In the absence of head-to-head comparisons between different biologics (ustekinumab, golimumab, etanercept, adalimumab and infliximab), the manufacturer conducted a network meta-analysis to estimate the relative efficacy of treatments for the TNFα-inhibitor-naïve population. Results of this analysis were marked as academic in confidence and are therefore not reported. For the TNFα-inhibitor-exposed population, the clinical analysis was limited to ustekinumab versus conventional management only, and was based on a subgroup of 180 patients from the PSUMMIT 2 trial. The ERG raised concerns relating to the lack of data on the long-term efficacy of ustekinumab, the limited data available for the exposed population, and the lack of consideration of the sequential use of treatments. Based on the manufacturer's original model, the ERG found ustekinumab to be dominated by golimumab in the anti-TNF-inhibitor-naïve population, and had an incremental cost-effectiveness ratio (ICER) of £29,843/quality-adjusted life-years versus conventional management in the exposed population. The ERG's analyses highlighted the fact that there is significant uncertainty around the model results. In addition, the ERG's exploratory cost-effectiveness analysis, which incorporated the sequential use of TNFα inhibitors, suggested that ustekinumab would not be cost effective if it were used as second-line treatment. The initial NICE recommendations asserted that ustekinumab was not recommended for treating active PsA. However, the manufacturer submitted a post-consultation model that included a Patient Access Scheme (PAS), halving the unit cost of ustekinumab 90 mg to £2147 (the same as a 45 mg dose). The NICE final recommendations were that, dependent on the inclusion of the PAS, ustekinumab is recommended as an option, along or in combination with methotrexate, for treating active PsA in adults only when treatment with TNFα inhibitors is contraindicated but would otherwise be considered, or the person has previously had treatment with one or more TNFα inhibitors, which has failed.