A systematic review of the cost and cost-effectiveness of immunoglobulin treatment in patients with hematological malignancies.

OBJECTIVES: Patients with hematological malignancies are likely to develop hypogammaglobulinemia. Immunoglobulin (Ig) is commonly given to prevent infections, but its overall costs and cost-effectiveness are unknown. METHODS: A systematic review was conducted following the PRISMA guidelines to assess the evidence on the costs and cost-effectiveness of Ig, administered intravenously (IVIg) or subcutaneously (SCIg), in adults with hematological malignancies. RESULTS: Six studies met the inclusion criteria, and only two economic evaluations were identified; one cost-utility analysis (CUA) of IVIg versus no Ig, and another comparing IVIg with SCIg. The quality of the evidence was low. Compared to no treatment, Ig reduced hospitalization rates. One study reported no significant change in hospitalizations following a program to reduce IVIg use, and an observational study comparing IVIg with SCIg suggested that there were more hospitalizations with SCIg but lower overall costs per patient. The CUA comparing IVIg versus no Ig suggested that IVIg treatment was not cost-effective, and the other CUA comparing IVIg to SCIg found that home-based SCIg was more cost-effective than IVIg, but both studies had serious limitations. CONCLUSIONS: Our review highlighted key gaps in the literature: the cost-effectiveness of Ig in patients with hematological malignancies is very uncertain. Despite increasing Ig use worldwide, there are limited data regarding the total direct and indirect costs of treatment, and the optimal use of Ig and downstream implications for healthcare resource use and costs remain unclear. Given the paucity of evidence on the costs and cost-effectiveness of Ig treatment in this population, further health economic research is warranted.

Health shocks, health and labor market dynamics, and the socioeconomic-health gradient in older Singaporeans.

Health disparities by socioeconomic status (SES) are potentially shaped by how an individual's health status and work capacity are affected by the incidence of illness, and how these effects vary across SES groups. We examine the impact of illness on the dynamics of health status, work activity and income in older Singaporeans to gain new insights on how ill health shapes the socioeconomic health gradient. Our data comprise of 60 monthly waves (2015-2019) of panel survey data containing 445,464 person-observations from 11,827 unique respondents from Singapore. We apply a matched event-study difference-in-differences research design to track how older adults' health and work changes following the diagnosis of heart disease and cancer. Our focus is how the dynamics of health and work differ for different SES groups, which we measure by post-secondary education attainment. We find that the dynamics of how self-assessed health recovers following the diagnosis of a new heart disease or cancer do not vary significantly across SES groups. Work activity however varies significantly, with less well-educated males and females being significantly less likely to be in active employment and have income from work, and are marginally more likely to be in retirement following the onset of ill health. By contrast, more well-educated males work more, and earn more a year after the health shock than they did before they fell ill. Occupational differences likely played a role in how work activity of less well-educated men decline more after an acute health event compared with more well-educated men. Understanding the drivers of the socioeconomic health gradient necessitates a focus on individual-level factors, as well as system-level influences, that affect health and work.

Economic evaluation: immunoglobulin vs prophylactic antibiotics in hypogammaglobulinemia and hematological malignancies.

ABSTRACT: Patients with hematological malignancies are at high risk of developing hypogammaglobulinemia (HGG) and infections. Immunoglobulin (Ig) is one recommended option to prevent these infections, but it is expensive, and its cost-effectiveness compared with other prevention strategies remains unknown. We conducted a trial-based economic evaluation from the Australian health care system perspective to estimate the 12-month cost-effectiveness of prophylactic Ig vs prophylactic antibiotics in 63 adults with HGG and hematological malignancies participating in the RATIONAL feasibility trial. Two analyses were conducted: (1) cost-utility analysis to assess the incremental cost per quality-adjusted life year (QALY) gained; and (2) cost-effectiveness analysis to assess the incremental cost per serious infection prevented (grade ≥3) and per any infection (any grade) prevented. Over 12 months, the total cost per patient was significantly higher in the Ig group than in the antibiotic group (mean difference, AU$29 140; P < .001). Most patients received IVIg, which was the main cost driver; only 2 patients in the intervention arm received subcutaneous Ig. There were nonsignificant differences in health outcomes. Results showed Ig was more costly than antibiotics and associated with fewer QALYs. The incremental cost-effectiveness ratio of Ig vs antibiotics was AU$111 262 per serious infection prevented, but Ig was more costly and associated with more infections when all infections were included. On average and for this patient population, Ig prophylaxis may not be cost-effective compared with prophylactic antibiotics. Further research is needed to confirm these findings in a larger population and considering longer-term outcomes. The trial was registered at the Australian and New Zealand Clinical Trials Registry as #ACTRN12616001723471.

A randomised controlled trial of motivational interview for relapse prevention after release from smoke-free prisons in Australia.

PURPOSE: This paper aims to determine whether a single session of a motivational interview (MI) reduces smoking relapse amongst people released from smoke-free prisons. DESIGN/METHODOLOGY/APPROACH: This study sought to recruit 824 ex-smokers from 2 smoke-free prisons in the Northern Territory, Australia. Participants were randomised to receive either one session (45-60 min) face-to-face MI intervention 4-6 weeks prior to release or usual care (UC) without smoking advice. The primary outcome was continuous smoking abstinence verified by exhaled carbon monoxide test (<5 ppm) at three months post-release. Secondary outcomes included seven-day point-prevalence, time to the first cigarette and the daily number of cigarettes smoked after release. FINDINGS: From April 2017 to March 2018, a total of 557 participants were randomised to receive the MI (n = 266) or UC (n = 291), with 75% and 77% being followed up, respectively. There was no significant between-group difference in continuous abstinence (MI 8.6% vs UC 7.4%, risk ratio = 1.16, 95%CI 0.67∼2.03). Of all participants, 66.9% relapsed on the day of release and 90.2% relapsed within three months. On average, participants in the MI group smoked one less cigarette daily than those in the UC within the three months after release (p < 0.01). RESEARCH LIMITATIONS/IMPLICATIONS: A single-session of MI is insufficient to reduce relapse after release from a smoke-free prison. However, prison release remains an appealing time window to build on the public health benefit of smoke-free prisons. Further research is needed to develop both pre- and post-release interventions that provide continuity of care for relapse prevention. ORIGINALITY/VALUE: This study is the first Australian randomised controlled trial to evaluate a pre-release MI intervention on smoking relapse prevention amongst people released from smoke-free prisons.