Evaluation of the cost-utility of insulin degludec vs insulin glargine in Sweden.

OBJECTIVE: To evaluate the annual cost-utility of insulin degludec compared with glargine in patients with: type 1 diabetes (T1D), type 2 diabetes receiving basal-only therapy (T2D-BOT), and type 2 diabetes receiving basal-bolus therapy (T2B-BB) in Sweden. METHODS: A cost-utility model was programmed in Microsoft Excel to evaluate clinical and economic outcomes. The clinical trials were designed as treat-to-target, with insulin doses adjusted in order to achieve similar glycemic control between treatments, thus long-term modeling is not meaningful. Basal and bolus insulin doses, incidence of hypoglycemic events, frequency of self-monitoring of blood glucose, and possibility for flexibility in timing of dose administration were specified for each insulin in three diabetes populations, based on data collected in Swedish patients with diabetes and a meta-analysis of clinical trials with degludec. Using these characteristics, the model estimated costs from a societal perspective and quality-adjusted life years (QALYs) in the two scenarios. RESULTS: Use of degludec was associated with a QALY gain compared with glargine in T1D (0.31 vs 0.26 QALYs), T2D-BOT (0.76 vs 0.69 QALYs), and T2D-BB (0.56 vs 0.47 QALYs), driven by reduced incidence of hypoglycemia and possibility for flexibility around timing of dose administration. Therapy regimens containing degludec were associated with increased costs compared to glargine-based regimens, driven by the increased pharmacy cost of basal insulin, but partially offset by other cost savings. Based on estimates of cost and clinical outcomes, degludec was associated with incremental cost-effectiveness ratios of SEK 19,766 per QALY gained, SEK 10,082 per QALY gained, and SEK 36,074 per QALY gained in T1D, T2-BOT, and T2-BB, respectively. LIMITATIONS: The hypoglycemic event rates in the base case analysis were derived from a questionnaire-based study that relied on patient interpretation and recall of hypoglycemic symptoms. The relative rates of hypoglycemia with degludec compared to glargine were derived from a meta-analysis of phase III trials, which may not reflect the relative rates observed in real-world clinical practice. Both of these key limitations were explored in one-way sensitivity analyses. CONCLUSIONS: Based on reduced incidence of hypoglycemia and possibility for flexibility around timing of dose administration, use of degludec is likely to be cost-effective compared to glargine from a societal perspective in T1D, T2-BOT, and T2-BB in Sweden over a 1-year time horizon.

Willingness to pay for diabetes drug therapy in type 2 diabetes patients: based on LEAD clinical programme results.

OBJECTIVE: The purpose of this study was to investigate the preferences of people with diabetes for liraglutide vs other glucose lowering drugs, based on outcomes of clinical trials. METHODS: Willingness to pay (WTP) for diabetes drug treatment was assessed by combining results from a recent WTP study with analysis of results from the Liraglutide Effect and Action in Diabetes (LEAD) programme. The LEAD programme included six randomised clinical trials with 3967 participants analysing efficacy and safety of liraglutide 1.2 mg (LEAD 1-6 trials), rosiglitazone (LEAD 1 trial), glimepiride (LEAD 2-3 trials), insulin glargine (LEAD 5 trial), and exenatide (LEAD 6 trial). The WTP survey used discrete choice experimental (DCE) methodology to evaluate the convenience and clinical effects of glucose lowering treatments. RESULTS: People with type 2 diabetes were prepared to pay an extra €2.64/day for liraglutide compared with rosiglitazone, an extra €1.94/day compared with glimepiride, an extra €3.36/day compared with insulin glargine, and an extra €0.81/day compared with exenatide. Weight loss was the largest component of WTP for liraglutide compared with rosiglitazone, glimepiride, and insulin glargine. Differences in the administration of the two drugs was the largest component of WTP for liraglutide (once daily anytime) compared with exenatide (twice daily with meals). A limitation of the study was that it was based on six clinical trials where liraglutide was the test drug, but each trial had a different comparator, therefore the clinical effects of liraglutide were much better documented than the comparators. CONCLUSIONS: WTP analyses of the clinical results from the LEAD programme suggested that participants with type 2 diabetes were willing to pay appreciably more for liraglutide than other glucose lowering treatments. This was driven by the relative advantage of weight loss compared with rosiglitazone, glimepiride, and insulin glargine, and administration frequency compared with exenatide.

Long-term cost-effectiveness of insulin detemir versus NPH insulin in type 2 diabetes in Sweden.

AIM: To evaluate the cost-effectiveness of insulin detemir vs. NPH insulin once daily, in patients with type 2 diabetes in the Swedish setting based on clinical data from a published randomized controlled trial. METHODS: Projections of long-term outcomes were made using the IMS CORE Diabetes Model (CDM), based on clinical data from a 26-week randomized controlled trial that compared once daily insulin detemir and NPH insulin, when used to intensify insulin treatment in 271 patients with type 2 diabetes and body mass index (BMI) 25-40 kg/m(2). Trial results showed that insulin detemir was associated with a significantly lower incidence of hypoglycemic events and significantly less weight gain in comparison with NPH insulin. The analysis was conducted from a third party payer perspective and the base case analysis was performed over a time horizon of 40 years and future costs and clinical outcomes were discounted at a rate of 3% per year. RESULTS: Insulin detemir was associated with higher mean (SD) quality-adjusted life expectancy (5.42 [0.10] vs. 5.31 [0.10] quality-adjusted life years [QALYs]) and lower overall costs (SEK 378,539 [10,372] vs. SEK 384,216 [11,230]; EUR 33,794 and EUR 34,300, respectively, where 1 EUR=11.2015 SEK) compared with NPH insulin. Sensitivity analysis showed that the principal driver of the benefits associated with insulin detemir was the lower rate of hypoglycemic events (major and minor events) vs. NPH insulin, suggesting that detemir might also be cost-saving over a shorter time horizon. Limitations of the analysis include the use of data from a trial outside Sweden in the Swedish setting. CONCLUSIONS: Based on clinical input data derived from a previously published randomized controlled trial, it is likely that in the Swedish setting insulin detemir would be cost-saving in comparison with NPH insulin for the treatment of patients with type 2 diabetes.

Willingness-to-pay for benefits associated with basal insulin treatment of type 2 diabetes.

Data from a 20-week trial comparing insulin detemir and neutral protamine Hagedorn (NPH) insulin in insulin-naïve people with type 2 diabetes were analyzed using willingness-to-pay (WTP) data, a proxy for patient preference. The advantages of insulin detemir relative to NPH insulin with respect to a lower hypoglycemia rate and less weight gain were associated with a value of €27.87 per month.

Willingness to pay for health improvements associated with anti-diabetes treatments for people with type 2 diabetes.

OBJECTIVES: This study aimed to investigate the most important consequences of diabetes medication, as measured by the patients' willingness to pay (WTP). RESEARCH DESIGN AND METHODS: People in Sweden were recruited using existing nationwide e-mail panels if they were adults (>or=18 years) with type 2 diabetes and were receiving pharmacological anti-diabetes treatment(s). Data were collected electronically and results were analysed using a standard statistical model designed for choice games (conditional logit). Six characteristics relating to treatment of diabetes were examined: weight (gain or loss), mean glycated haemoglobin level (HbA(1c)), hypoglycaemic events, nausea, need for injections (with or independently of meals), and blood glucose testing. RESULTS: A total of 461 people with type 2 diabetes (291 males; 170 females) completed an internet questionnaire and were eligible for inclusion. Participants placed high value on weight loss and nausea avoidance; they would pay 176 Swedish Krona (SEK)/euro15.61 per month to lose 1 kg, and would pay SEK 560 (euro49.67) per month to avoid nausea completely. Patients wanting to reduce the number of hypoglycaemic events from three per month to none were willing to pay SEK 419 (euro37.17) per month. Patients valued a 1 percentage point reduction in HbA(1c) at SEK 414 (euro36.72) per month. Participants preferred taking tablets to injections and required a compensation of SEK 376 (euro33.35) to accept one injection/day. Injections independent of meals were preferred to injections with meals (WTP: SEK 140/euro12.42 per month). Potential limitations of this study are that the preferences expressed may not match preferences in real-life situations, and bias through the use of electronic questionnaire, which restricted participation to those with access to, and experience with, the internet. CONCLUSION: People with type 2 diabetes were willing to pay a considerable amount of money each month to lose weight, reduce or avoid hypoglycaemic events and reduce HbA(1C).

Hospitalization in Sweden of children born to immigrants.

AIM: To study whether excess hospitalization occurs among certain groups of children born in Sweden to immigrant parents. METHODS: The study was based on linkage of the Swedish Medical Birth Register 1987-1997 and the Swedish Hospital Discharge Register 1987-1998. RESULTS: Among children whose parents were of Swedish nationality excess hospitalization was found for children of young mothers, parity 3 or more, and if the mother smoked in early pregnancy. These factors were controlled for in the further analysis. Ten years after birth, a large percentage of children born to parents with foreign nationality could not be followed owing to death or emigration (19.9% vs 1.77% of children with Swedish parents). An excess hospitalization of immigrant children up to the age of about 5 y was seen but after that, if anything, these children were hospitalized less. For the whole group of children born to parents of non-Swedish nationality there was no difference in hospitalization rate after stratification for risk factors and age. When analysis was performed for specific nationalities significantly reduced rates were found for several western European countries while significantly increased rates were seen for the Middle East, north Africa and especially sub-Saharan Africa (odds ratio 1.57, 95% confidence interval 1.49-1.64). CONCLUSION: A moderately increased rate of child hospitalization was only observed for some selected immigrant groups.

The costs of exacerbations in chronic obstructive pulmonary disease (COPD).

Exacerbations are the key drivers in the costs of chronic obstructive pulmonary disease (COPD). The objective was to examine the costs of COPD exacerbations in relation to differing degrees of severity of exacerbations and of COPD. We identified 202 subjects with COPD, defined according to the BTS and ERS criteria. Exacerbations were divided into mild (self-managed), mild/moderate (telephone contact with a health-care centre and/or the use of antibiotics/systemic corticosteroids), moderate (health-care centre visits) and severe (emergency care visit or hospital admission). Exacerbations were identified by sending the subjects a letter inquiring whether they had any additional respiratory problems or influenza the previous winter. At least one exacerbation was reported by 61 subjects, who were then interviewed about resource use for these events. The average health-care costs per exacerbation were SEK 120 (95% C=39-246), SEK 354 (252-475), SEK 2111 (1673-2612) and SEK 21852 (14436-29825) for mild, mild/moderate, moderate and severe exacerbations, respectively. Subjects with impaired lung function experienced more severe exacerbations, which was also reflected in the cost of exacerbations per severity of the disease during the 4 1/2 month study period (ranging from SEK 224 for mild to SEK 13708 for severe cases, median SEK 940). Exacerbations account for 35-45% of the total per capita health-care costs for COPD. In conclusion, costs varied considerably with the severity of the exacerbation as well as with the severity of COPD. The prevention of moderate-to-severe exacerbations could be very cost-effective and improve the quality of life.

Consumer contributions in developing clinical practice guidelines.

Clinical practice guidelines are designed for use with consumers. However, consumers are rarely consulted about their development. This paper describes a research project to develop clinical practice guidelines for a community meeting to prevent and intervene with assaultive behavior. The research included consumer input from psychiatric inpatients. The two-phase approach with the consumers included a focus group, followed by survey research. Results, problems, and recommendations are presented.

The importance of lifestyle to self-assessed health.

Empirical research has revealed a causality between lifestyle and health, and lifestyle is seen as an important factor in explaining health differences among people. However, it is important to note the difference between the significance and the importance of a factor in explaining health differences, since the two concepts are commonly confused. Some research has suggested that lifestyle is not an important variable in explaining health differences, but just how important it is, is uncertain. This study measures the explanatory power of lifestyle for self-assessed health. It is found that lifestyle has only a limited effect; 3-5% of the differences in self-assessed health are explained by lifestyle variables.

[Scholarship report of a 1982 study trip in western and middle Turkey]. / Stipendiatrapport.

PIP: The cultural background of Islam and its religious practices as well as hospital administration and staff training, living conditions, the status of women, and child rearing were the topics of a study by 3 child care nurses in Turkey. The purpose of this study was to better understand the situation of Turkish immigrants and the possible conflicts they experience with Swedish society. Public school attendance is compulsory for a period of 5 years starting at age 7 (3 additional years may be required in the future). Since Ataturk's reforms in 1926, schools have been coeducational, and attendance is 80-90% even in remote rural areas governed by district registrars. The Red Crescent runs school health centers staffed by a doctor and a nurse. Illiterate women take a free 6-month course for 8 hours a day to learn reading and writing. There are state supported hospitals, workers' hospitals funded by unions, university clinics for the education of physicians, and small private clinics in Turkey. Most women marry at 14-18 years of age. The population is growing by 1 million annually. About 80% of urban women give birth in hospitals vs. only 20% of rural women. Women with high-risk pregnancies are placed in special birthing wards. Ultrasound is not used, nor is epidural anesthesia; only pethidine (Meperidine) injections are given to mitigate pain. Midwives play a central role in family planning, giving advice about contraceptives (IUDs are most prevalent, but the pill is gaining ground). Abortion is allowed for medical reasons, but a new law is being debated. Prostitutes get regular medical examinations to control venereal diseases. Pregnant women receive paid leave for 42 days before and after delivery. Education of nurses takes place in nursing schools of major cities like Istanbul, Ankara, and Izmir. Tuition, room, and board are free provided by the state. The course of study is 4 years and nurses can also work as midwives due to a shortage in their ranks. Elementary midwife training schools are mostly in the countryside, and their graduates visit newborn babies once a week for the first 40 days and once a month up to age 3. They also dispense vaccinations. Child care centers provide care for children between the ages of 3-6, at which point the schools take over.^ieng