Tocilizumab in the treatment of rheumatoid arthritis: a cost-effectiveness analysis in the UK.

BACKGROUND: Since receiving a positive recommendation in England, Wales and Scotland, tocilizumab (TCZ) is one of the options available to clinicians for the treatment of rheumatoid arthritis (RA) patients in the UK. OBJECTIVE: The objective of this study was to evaluate the cost effectiveness of adding TCZ to the current treatment sequence of RA patients from a UK payer's perspective over a patient lifetime horizon. METHODS: An individual sampling model was developed to synthesise all clinical and economic inputs. Two scenarios were explored separately: patients contraindicated to methotrexate (MTX) and those MTX tolerant. For each scenario, the analysis compared three strategies. The standard of care (SoC) strategy included a sequence of the most commonly prescribed biologics; the other two comparator strategies considered the addition of TCZ to SoC at first line and second line. Patient characteristics were representative of UK patients. Treatment efficacy and quality-of-life evidence were synthesised from clinical trials and secondary sources. An analysis of a patient registry informed the model parameters regarding treatment discontinuation. The safety profile of all treatments in a given strategy was based on a network meta-analysis and literature review. Resource utilisation, treatment acquisition, administration, monitoring and adverse event treatment costs were considered. All costs reflect 2012 prices. Uncertainty in model parameters was explored by one-way and probabilistic sensitivity analysis. RESULTS: In the MTX-contraindicated population, if TCZ was added to the SoC in first line, the estimated incremental cost-effectiveness ratio (ICER) was £7,300 per quality-adjusted life-year (QALY) gained; if added in second line, the estimated ICER was £11,400 per QALY. In the MTX-tolerant population, the estimated costs and QALYs of the TCZ strategy were similar to those of the SoC strategy. Sensitivity analysis showed that parameters that affect the treatment cost (such as patient weight) can have a noticeable impact on the overall cost-effectiveness results. The majority of the other sensitivity analyses resulted in modest changes to the ICER. CONCLUSION: For the treatment of RA in MTX-tolerant and contraindicated patients, the addition of TCZ to the SoC was estimated to be a cost-effective strategy.

Topical therapies for the treatment of localized plaque psoriasis in primary care: a cost-effectiveness analysis.

BACKGROUND: Topical therapies are a mainstay of psoriasis treatment, but they vary substantially in terms of cost. OBJECTIVES: To determine the cost-effectiveness and optimal treatment sequence for psoriasis of the trunk, limbs and scalp. METHODS: Probabilities of response from a network meta-analysis were used to determine the short-term efficacy of topical therapies. Longer-term outcomes, including relapse, were informed by published evidence and clinical opinion. Benefits of treatment were measured as quality-adjusted life years (QALYs). Direct costs included topical agents, primary and secondary care visits and second-line therapies for treatment failures. RESULTS: For the trunk and limbs, initial treatment with a two-compound formulation (TCF) product containing vitamin D and potent corticosteroid provided the most QALYs, followed by separate morning and evening application of vitamin D and potent corticosteroid [two-compound application, TCA (am/pm)], and then twice-daily potent corticosteroids. The use of twice-daily potent corticosteroids was the most cost-effective first-line strategy (incremental cost-effectiveness ratio £ 20,000 per QALY), followed by TCA (am/pm) (£ 22,658 per QALY) and TCF product (£ 179,439 per QALY). For scalp psoriasis, initial treatment with very potent corticosteroids generated the most QALYs, followed by TCF product and then potent corticosteroids. Very potent corticosteroids were the most cost-effective treatment but, if too aggressive, potent corticosteroids were optimal followed by TCF product (£ 219,846 per QALY). The cost-effectiveness of second- and third-line topical agents varied with the assumptions made. CONCLUSIONS: Potent corticosteroids, used alone or in combination with vitamin D, are the most cost-effective treatment for patients with psoriasis of the trunk and limbs. Potent or very potent corticosteroids are the most cost-effective treatment for patients with scalp psoriasis.

International population and development: the United Nations' Cairo Action Plan for women's health.

The report of the International Conference on Population and Development (Cairo Action Document) was sponsored by 180 national governments and 1,200 nongovernmental organizations during the United Nations' conference on women, population, and development in Cairo, Egypt 1994. Many international conferences preceded the one in Cairo but it was there that women participated at an unprecedented level in shaping the debate. The resulting document represents a quantum leap for women's health. Nurses can play a major role in using the principles in the Cairo Action Document by empowering women and enhancing their health care. To invite dialogue, the authors provide an analysis of the Cairo Plan from a nursing perspective and identify three paradoxes that may hinder progress: Universal values and local cultures, global policy and local implementation, and national development and women's empowerment. Clinicians, scholars, and members of professional organizations are asked to consider the assumptions that underlie the recommendations for action and to propose ways to resolve the problems that may evolve during implementation.

PIP: Nurses can play a major role in promoting the principles outlined in the Cairo Action Document (issued at the 1994 International Conference on Population and Development). This document asserts a commitment to gender equality, educational and economic advancement for women, and a comprehensive reproductive health approach. The extent to which women's health is improved as a result of this and similar international gatherings depends, however, on resolution of three paradoxes. The first concerns potential conflicts between the principle of cultural sensitivity to local beliefs and the acceptance of universal ethical values (e.g., gender equality). Resolution of this paradox could be achieved by elevating the ethical imperative for universal women's rights above any local meanings or traditions. A second paradox relates to the assumption that solutions determined at the international level can be implemented in states and localities that may lack the requisite resources. The third paradox surrounds the emphasis on women's empowerment in less developed countries to stimulate economic growth, without regard for gender disparities in countries where economic progress has far outpaced advances in the status of women.

Matching versus cultural competence in research: methodological considerations.

Researcher/participant matching has been used in nursing research as a strategy for the development of culturally competent knowledge. In this manuscript, the complexities inherent in matching in nursing research are discussed. In raising and discussing issues and questions related to matching, we argue that although matching may be one of the strategies used to generate culturally competent knowledge, it is frequently too complex for operationalization. Therefore, we propose that researchers reflect on questions related to their knowledge of culture, their cultural sensitivity, and the nature of collaboration during every phase of the research. Reflecting on and responding to these questions in every research project may facilitate the development of more culturally competent knowledge.

The compensation of patients injured in clinical trials.

The problem of 'no fault' compensation for patients who suffer adverse effects as a result of their participation in clinical trials is discussed in the light of the guidelines issued by the Association of the British Pharmaceutical Industry (ABPI) and our recent experiences in reviewing protocols submitted to the local ethics of surgical research sub-committee. We have found a variety of qualifications being applied by pharmaceutical firms which are not in the spirit of the guidelines, let alone the interests of the patient, and we suggest a means whereby the patients can be assured of fair treatment in the event of 'no fault' injury.