Establishing Expert, Multi-Disciplinary, Peer-Reviewed Consensus to Lead a Paradigm Shift in Optimal Blood Glucose Management.

INTRODUCTION: The National Health Service (NHS) in the UK appears unclear on how blood glucose monitoring (BGM) should be used to support diabetes patient care and empowerment, and local interpretation of NICE guidance on the availability of devices varies widely. An expert group of clinicians and commissioners considered BGM in terms of access, guidance, resources, data integration, patient education, and patient choice. METHODS: The group generated a series of questions on BGM into a 38-statement questionnaire using Delphi methodology. This was circulated to clinicians involved in diabetes management across the UK, receiving 222 responses. RESULTS: From the questionnaire, 35 of the 38 statement responses showed > 66% consensus, with 26 of these achieving > 90% agreement. CONCLUSION: The expert group reviewed the responses and made recommendations based on the clear professional consensus demonstrated. These included the need to use new technology and data integration and that wider factors, including patient choice rather than cost alone, should inform formulary inclusion of BGM equipment. FUNDING: LifeScan U.K. Ltd.

Cost-effectiveness of alternative smoking cessation scenarios in Spain: results from the EQUIPTMOD.

AIMS: To assess the cost-effectiveness of alternative smoking cessation scenarios from the perspective of the Spanish National Health Service (NHS). DESIGN: We used the European study on Quantifying Utility of Investment in Protection from Tobacco model (EQUIPTMOD), a Markov-based state transition economic model, to estimate the return on investment (ROI) of: (a) the current provision of smoking cessation services (brief physician advice and printed self-helped material + smoking ban and tobacco duty at current levels); and (b) four alternative scenarios to complement the current provision: coverage of proactive telephone calls; nicotine replacement therapy (mono and combo) [prescription nicotine replacement therapy (Rx NRT)]; varenicline (standard duration); or bupropion. A rate of 3% was used to discount life-time costs and benefits. SETTING: Spain. PARTICIPANTS: Adult smoking population (16+ years). MEASUREMENTS: Health-care costs associated with treatment of smoking attributable diseases (lung cancer, coronary heart disease, chronic obstructive pulmonary infection and stroke); intervention costs; quality-adjusted life years (QALYs). Costs and outcomes were summarized using various ROI estimates. FINDINGS: The cost of implementing the current provision of smoking cessation services is approximately €61 million in the current year. This translates to 18 quitters per 1000 smokers and a life-time benefit-cost ratio of 5, compared with no such provision. All alternative scenarios were dominant (cost-saving: less expensive to run and generated more QALYs) from the life-time perspective, compared with the current provision. The life-time benefit-cost ratios were: 1.87 (proactive telephone calls); 1.17 (Rx NRT); 2.40 (varenicline-standard duration); and bupropion (2.18). The results remained robust in the sensitivity analysis. CONCLUSIONS: According to the EQUIPTMOD modelling tool it would be cost-effective for the Spanish authorities to expand the reach of existing GP brief interventions for smoking cessation, provide pro-active telephone support, and reimburse smoking cessation medication to smokers trying to stop. Such policies would more than pay for themselves in the long run.

OPTIMIZING USABILITY OF AN ECONOMIC DECISION SUPPORT TOOL: PROTOTYPE OF THE EQUIPT TOOL.

OBJECTIVES: Economic decision-support tools can provide valuable information for tobacco control stakeholders, but their usability may impact the adoption of such tools. This study aims to illustrate a mixed-method usability evaluation of an economic decision-support tool for tobacco control, using the EQUIPT ROI tool prototype as a case study. METHODS: A cross-sectional mixed methods design was used, including a heuristic evaluation, a thinking aloud approach, and a questionnaire testing and exploring the usability of the Return of Investment tool. RESULTS: A total of sixty-six users evaluated the tool (thinking aloud) and completed the questionnaire. For the heuristic evaluation, four experts evaluated the interface. In total twenty-one percent of the respondents perceived good usability. A total of 118 usability problems were identified, from which twenty-six problems were categorized as most severe, indicating high priority to fix them before implementation. CONCLUSIONS: Combining user-based and expert-based evaluation methods is recommended as these were shown to identify unique usability problems. The evaluation provides input to optimize usability of a decision-support tool, and may serve as a vantage point for other developers to conduct usability evaluations to refine similar tools before wide-scale implementation. Such studies could reduce implementation gaps by optimizing usability, enhancing in turn the research impact of such interventions.

A utility of model input uncertainty analysis in transferring tobacco control-related economic evidence to countries with scarce resources: results from the EQUIPT study.

AIMS: To inform the transferability of tobacco control-related economic evidence to resource-poor countries. METHODS: We ran a univariate sensitivity analysis on a return on investment (ROI) model, the European study on Quantifying Utility of Investment in Protection from Tobacco model (EQUIPTMOD), to identify key input values to which the ROI estimates were sensitive. The EQUIPTMOD used a Markov-based state transition model to estimate the ROI of several tobacco control interventions in five European countries (England, Germany, Spain, Hungary and the Netherlands). Base case ROI estimates were obtained through average values of model inputs (throughout the five countries), which were then replaced one at a time with country-specific values. Tornado diagrams were used to evaluate the significance of sensitivity, defined as a ≥ 10% difference in ROI estimates from the base case estimates. RESULTS: The ROI estimates were sensitive to 18 (of 46) input values. Examples of model inputs to which ROI estimates were sensitive included: smoking rate, costs of smoking-related diseases (e.g. lung cancer) and general population attributes. CONCLUSION: Countries that have limited research time and other resources can adapt EQUIPTMOD to their own settings by choosing to collect data on a small number of model inputs. EQUIPTMOD can therefore facilitate transfer of tobacco control related economic evidence to new jurisdictions.

Cost-effectiveness of possible future smoking cessation strategies in Hungary: results from the EQUIPTMOD.

AIMS: To evaluate potential health and economic returns from implementing smoking cessation interventions in Hungary. METHODS: The EQUIPTMOD, a Markov-based economic model, was used to assess the cost-effectiveness of three implementation scenarios: (a) introducing a social marketing campaign; (b) doubling the reach of existing group-based behavioural support therapies and proactive telephone support; and (c) a combination of the two scenarios. All three scenarios were compared with current practice. The scenarios were chosen as feasible options available for Hungary based on the outcome of interviews with local stakeholders. Life-time costs and quality-adjusted life years (QALYs) were calculated from a health-care perspective. The analyses used various return on investment (ROI) estimates, including incremental cost-effectiveness ratios (ICERs), to compare the scenarios. Probabilistic sensitivity analyses assessed the extent to which the estimated mean ICERs were sensitive to the model input values. RESULTS: Introducing a social marketing campaign resulted in an increase of 0.3014 additional quitters per 1 000 smokers, translating to health-care cost-savings of €0.6495 per smoker compared with current practice. When the value of QALY gains was considered, cost-savings increased to €14.1598 per smoker. Doubling the reach of existing group-based behavioural support therapies and proactive telephone support resulted in health-care savings of €0.2539 per smoker (€3.9620 with the value of QALY gains), compared with current practice. The respective figures for the combined scenario were €0.8960 and €18.0062. Results were sensitive to model input values. CONCLUSIONS: According to the EQUIPTMOD modelling tool, it would be cost-effective for the Hungarian authorities introduce a social marketing campaign and double the reach of existing group-based behavioural support therapies and proactive telephone support. Such policies would more than pay for themselves in the long term.

Development and application of an economic model (EQUIPTMOD) to assess the impact of smoking cessation.

BACKGROUND AND AIMS: Although clear benefits are associated with reducing smoking, there is increasing pressure on public health providers to justify investment in tobacco control measures. Decision-makers need tools to assess the Return on Investment (ROI)/cost-effectiveness of programmes. The EQUIPT project adapted an ROI tool for England to four European countries (Germany, the Netherlands, Spain and Hungary). EQUIPTMOD, the economic model at the core of the ROI tool, is designed to assess the efficiency of packages of smoking cessation interventions. The objective of this paper is to describe the methods for EQUIPTMOD and identify key outcomes associated with continued and cessation of smoking. METHODS: EQUIPTMOD uses a Markov model to estimate life-time costs, quality-adjusted life years (QALYs) and life years associated with a current and former smoker. It uses population data on smoking prevalence, disease prevalence, mortality and the impact of smoking combined with associated costs and utility effects of disease. To illustrate the tool's potential, costs, QALYs and life expectancy were estimated for the average current smoker for five countries based on the assumptions that they continue and that they cease smoking over the next 12 months. Costs and effects were discounted at country-specific rates. RESULTS: For illustration, over a life-time horizon, not quitting smoking within the next 12 months in England will reduce life expectancy by 0.66, reduce QALYs by 1.09 and result in £4961 higher disease-related health care costs than if the smoker ceased smoking in the next 12 months. For all age-sex categories, costs were lower and QALYs higher for those who quit smoking in the 12 months than those who continued. CONCLUSIONS: EQUIPTMOD facilitates assessment of the cost effectiveness of smoking cessation strategies. The demonstrated results indicate large potential benefits from smoking cessation at both an individual and population level.

Cost-effectiveness of increasing the reach of smoking cessation interventions in Germany: results from the EQUIPTMOD.

AIMS: To evaluate costs, effects and cost-effectiveness of increased reach of specific smoking cessation interventions in Germany. DESIGN: A Markov-based state transition return on investment model (EQUIPTMOD) was used to evaluate current smoking cessation interventions as well as two prospective investment scenarios. A health-care perspective (extended to include out-of-pocket payments) with life-time horizon was considered. A probabilistic analysis was used to assess uncertainty concerning predicted estimates. SETTING: Germany. PARTICIPANTS: Cohort of current smoking population (18+ years) in Germany. INTERVENTIONS: Interventions included group-based behavioural support, financial incentive programmes and varenicline. For prospective scenario 1 the reach of group-based behavioral support, financial incentive programme and varenicline was increased by 1% of yearly quit attempts (= 57 915 quit attempts), while prospective scenario 2 represented a higher reach, mirroring the levels observed in England. MEASUREMENTS: EQUIPTMOD considered reach, intervention cost, number of quitters, quality-of-life years (QALYs) gained, cost-effectiveness and return on investment. FINDINGS: The highest returns through reduction in smoking-related health-care costs were seen for the financial incentive programme (€2.71 per €1 invested), followed by that of group-based behavioural support (€1.63 per €1 invested), compared with no interventions. Varenicline had lower returns (€1.02 per €1 invested) than the other two interventions. At the population level, prospective scenario 1 led to 15 034 QALYs gained and €27 million cost-savings, compared with current investment. Intervention effects and reach contributed most to the uncertainty around the return-on-investment estimates. At a hypothetical willingness-to-pay threshold of only €5000, the probability of being cost-effective is approximately 75% for prospective scenario 1. CONCLUSIONS: Increasing the reach of group-based behavioural support, financial incentives and varenicline for smoking cessation by just 1% of current annual quit attempts provides a strategy to German policymakers that improves the population's health outcomes and that may be considered cost-effective.

Health-care interventions to promote and assist tobacco cessation: a review of efficacy, effectiveness and affordability for use in national guideline development.

AIMS: This paper provides a concise review of the efficacy, effectiveness and affordability of health-care interventions to promote and assist tobacco cessation, in order to inform national guideline development and assist countries in planning their provision of tobacco cessation support. METHODS: Cochrane reviews of randomized controlled trials (RCTs) of major health-care tobacco cessation interventions were used to derive efficacy estimates in terms of percentage-point increases relative to comparison conditions in 6-12-month continuous abstinence rates. This was combined with analysis and evidence from 'real world' studies to form a judgement on the probable effectiveness of each intervention in different settings. The affordability of each intervention was assessed for exemplar countries in each World Bank income category (low, lower middle, upper middle, high). Based on World Health Organization (WHO) criteria, an intervention was judged as affordable for a given income category if the estimated extra cost of saving a life-year was less than or equal to the per-capita gross domestic product for that category of country. RESULTS: Brief advice from a health-care worker given opportunistically to smokers attending health-care services can promote smoking cessation, and is affordable for countries in all World Bank income categories (i.e. globally). Proactive telephone support, automated text messaging programmes and printed self-help materials can assist smokers wanting help with a quit attempt and are affordable globally. Multi-session, face-to-face behavioural support can increase quit success for cigarettes and smokeless tobacco and is affordable in middle- and high-income countries. Nicotine replacement therapy, bupropion, nortriptyline, varenicline and cytisine can all aid quitting smoking when given with at least some behavioural support; of these, cytisine and nortriptyline are affordable globally. CONCLUSIONS: Brief advice from a health-care worker, telephone helplines, automated text messaging, printed self-help materials, cytisine and nortriptyline are globally affordable health-care interventions to promote and assist smoking cessation. Evidence on smokeless tobacco cessation suggests that face-to-face behavioural support and varenicline can promote cessation.

EQUIPT: protocol of a comparative effectiveness research study evaluating cross-context transferability of economic evidence on tobacco control.

INTRODUCTION: Tobacco smoking claims 700,000 lives every year in Europe and the cost of tobacco smoking in the EU is estimated between €98 and €130 billion annually; direct medical care costs and indirect costs such as workday losses each represent half of this amount. Policymakers all across Europe are in need of bespoke information on the economic and wider returns of investing in evidence-based tobacco control, including smoking cessation agendas. EQUIPT is designed to test the transferability of one such economic evidence base-the English Tobacco Return on Investment (ROI) tool-to other EU member states. METHODS AND ANALYSIS: EQUIPT is a multicentre, interdisciplinary comparative effectiveness research study in public health. The Tobacco ROI tool already developed in England by the National Institute for Health and Care Excellence (NICE) will be adapted to meet the needs of European decision-makers, following transferability criteria. Stakeholders' needs and intention to use ROI tools in sample countries (Germany, Hungary, Spain and the Netherlands) will be analysed through interviews and surveys and complemented by secondary analysis of the contextual and other factors. Informed by this contextual analysis, the next phase will develop country-specific ROI tools in sample countries using a mix of economic modelling and Visual Basic programming. The results from the country-specific ROI models will then be compared to derive policy proposals that are transferable to other EU states, from which a centralised web tool will be developed. This will then be made available to stakeholders to cater for different decision-making contexts across Europe. ETHICS AND DISSEMINATION: The Brunel University Ethics Committee and relevant authorities in each of the participating countries approved the protocol. EQUIPT has a dedicated work package on dissemination, focusing on stakeholders' communication needs. Results will be disseminated via peer-reviewed publications, e-learning resources and policy briefs.

Child uptake of smoking by area across the UK.

Smoking is a major public health problem. As smokers age and die prematurely, the tobacco industry must continue to recruit new, young smokers. Survey data indicate that currently in the UK around 207,000 children aged 11-15 start smoking every year. We used local data on adult smoking rates to apportion national data on child smoking uptake to specific areas. The presentation of data for individual local authorities, which now have responsibility for public health, can be used to focus attention locally. For example, this analysis demonstrates that each day, 67 children, more than two classrooms full, start smoking in London.