Economic evaluation alongside a randomised controlled trial to assess the effectiveness and cost-effectiveness of acupuncture in the management of chemotherapy-induced peripheral neuropathy.

OBJECTIVE: To assess the cost-effectiveness of acupuncture in the management of chemotherapy-induced peripheral neuropathy (CIPN) in Hong Kong. METHODS: A within trial cost-utility analysis with the primary endpoint for the economic evaluation being the Quality Adjusted Life Year (QALY) and associated Incremental Cost Effectiveness Ratio (ICER) over 14 weeks of treatment. A secondary cost-effectiveness analysis was undertaken with the endpoint being change in pain as measured on the Brief Pain Inventory (BPI). RESULTS: Eighty-seven patients were randomised to acupuncture or usual care. Acupuncture resulted in significant improvements in pain intensity (8- and 14-week mean changes compared to usual care of -1.8 and -1.8, respectively), pain interference (8- and 14-week mean changes compared to usual care of -1.5 and -0.9, respectively) and indicators of quality of life and neurotoxicity-related symptoms. However, in the economic evaluation there was little difference in QALYs between the two arms (mean change 0.209 and 0.200 in the acupuncture and usual care arms, respectively). Also, costs yielded deterministic ICERs of HK$616,965.62, HK$824,083.44 and HK$540,727.56 per QALY gained from the health care provider perspective, the societal perspective and the patient perspective, respectively. These costs are significantly higher than the cost-effectiveness threshold of HK$180,450 that was used for the base case analysis. CONCLUSION: While acupuncture can improve symptoms and quality of life indicators related to CIPN, it is unlikely to be a cost-effective treatment for CIPN-related pain in health care systems with limited resources. TRIAL REGISTRATION NUMBER: NCT02553863 (ClinicalTrials.gov) post-results.

Test Utilization and Value in the Evaluation of Peripheral Neuropathies.

Peripheral neuropathies can be classified as typical or atypical. Patients with atypical neuropathy have one or more of the following features: acute/subacute onset, non-length dependence, motor predominance, or asymmetry. This classification is important because it informs the appropriate diagnostic evaluation of this highly prevalent condition. The evaluation of a typical peripheral neuropathy, also known as distal symmetric polyneuropathy, requires a thorough history, neurologic examination, and focused laboratory testing. Electrodiagnostic testing and MRI account for the majority of costs but rarely lead to changes in diagnosis or management. These costs are increasingly being passed on to patients, especially those with high-deductible health plans. In contrast, patients with atypical neuropathy require more extensive testing, including electrodiagnostic tests. These tests are much more likely to lead to the use of disease-modifying therapies in these patients compared to in those with typical peripheral neuropathy. This article describes two cases to illustrate the appropriate diagnostic workup of those with typical or atypical neuropathy.

Cost-effectiveness analysis of dose-dense versus standard intravenous chemotherapy for ovarian cancer: An economic analysis of results from the Gynecologic Oncology Group protocol 262 randomized controlled trial.

OBJECTIVES: To determine the cost-effectiveness of dose-dense versus standard intravenous adjuvant chemotherapy for ovarian cancer using results from the no-bevacizumab cohort of the Gynecologic Oncology Group protocol 262 (GOG-262) randomized controlled trial, which reported a smaller absolute progression-free survival (PFS) benefit than the prior Japanese trial. METHODS: A three-state Markov decision model from a healthcare system perspective with a 21day cycle length and 28month time-horizon was used to calculate incremental cost-effectiveness ratio (ICER) values per progression-free life-year saved (PFLYS) using results from GOG-262. Costs of chemotherapy, complications, and surveillance were from Medicare or institutional data. PFS, discontinuation, and complication rates were from GOG-262. Time-dependent transition probabilities and within-cycle corrections were used. One-way and probabilistic sensitivity analyses were performed. RESULTS: The model produces standard and dose-dense cohorts with 84.3% and 68.3% progression event proportions at 28months, matching GOG-262 rates at the trial's median follow-up. With a median PFS of 10.3months after standard chemotherapy and a hazard ratio for progression of 0.62 after dose-dense therapy, the ICER for dose-dense chemotherapy is $8074.25 (95% confidence interval: $7615.97-$10,207.16) per PFLYS. ICER estimates are sensitive only to the hazard ratio estimate but do not exceed $100,000 per PFLYS. 99.8% of ICER estimates met a more stringent willingness-to-pay of $50,000 per PFLYS. The willingness-to-pay value at which there is a 90% probability of dose-dense treatment being cost-effective is $12,000 per PFLYS. CONCLUSIONS: Dose-dense adjuvant chemotherapy is robustly cost-effective for advanced ovarian cancer from a healthcare system perspective based on results from GOG-262.

[Capsaicin Cutaneous Patch: a Cost-consequences Study in a French University Hospital]. / Étude coût-conséquences sur la capsaïcine en patch cutané dans un CHU français.

INTRODUCTION: The capsaïcine 8% cutaneous patch (Qutenza®) was recently approved for the management of patients with peripheral neuropathic pain (PNP). Considering its limited clinical efficacy data, its improvement of medical benefit was determined to be 5 which was insufficient to support its reimbursement in addition to diagnosis related groups'tarifs. Nevertheless its commercialization was associated with a marked interest considering the unmet therapeutic needs for patients with PNP. OBJECTIVES: Our objectives were to assess the effectiveness, the safety, and the economic impact of Qutenza® in real-life conditions. METHODS: An observational cost-consequences study was launched under the aegis of the Drug Committee of our hospital. Medical charts and prescriptions of all patients who received at least one patch application were analyzed. Effectiveness and safety were assessed after 12-week and 24-week of follow-up. The economic impact was measured within the Hospital and Health Insurance perspective and with limitation to direct costs. RESULTS: From March 2012 to October 2013, 91 patients (54.3 ± 14.1 years; 52.7% of male) received at least one application. The average follow- up duration was 188.3 ± 86.4 days. The PNP etiologies were mainly post-surgery (42.9%) and post-traumatology (20.8%). A therapeutic response (decrease of ENS score of least 30%) after 12 weeks and 24 weeks was observed in 27.9% and 37.1% of patients respectively. The SF-36 mental score was significantly improved. The safety profile was good. The application of the patch resulted in incremental costs of 154 euros per hospital stay without impact on outpatient-prescription drug expenditures. CONCLUSION: This study confirms the interest of Qutenza® for heavily pretreated, refractory patients with PNP. The clinical profile of responders has to be further investigated in large observational studies.

[HEALTH INSURANCE ASPECTS OF PHYSIOTHERAPEUTIC CARE OF NEUROLOGY DISORDERS IN OUTPATIENT CARE]. / A NEUROLÓGIAI KÓRKÉPEK FIZIOTERÁPIÁS ELLÁTÁSÁNAK EGÉSZSÉGBIZTOSÍTÁSI VONATKOZÁSAI A JÁRÓBETEG-SZAKELLÁTÁSBAN.

BACKGROUND AND PURPOSE: The aim of our study is to analyse the ambulatory rehabilitation care of patients with neurological disorders in the field of physiotherapy. METHODS: Data derive from the database of the Hungarian National Health Insurance Fund Administration (year 2009). The analyses covered patients with diagnosis "G00-G99 Diseases of the nervous system" according to the International Classification of Diseases and underwent physiotherapy treatment. RESULTS: In 2009 altogether 190986 patients with neurological disorders received physiotherapy treatment in outpatient care, representing 1331675 cases and got 388.215 million Hungarian Forint health insurance reimbursement. The number of patients with nerve, nerve root and plexus disorders was 39 patients/10 000 population for males and 66 patients/10000 population for females. The number of patients with cerebral palsy and other paralytic syndromes was 49 patients/10000 population for males and 35 patients/10000 population for females. The number of patients with episodic and paroxysmal disorders was 33 patients/10000 population for males and 52 patients/10000 population for females. CONCLUSION: In the outpatient physiotherapy care the utilization indicators for female patients were higher in nerve, nerve root and plexus disorders and episodic and paroxysmal disorders, while in cerebral palsy and other paralytic syndromes the utilization by male patients was higher. There are important age and gender inequalities in the utilization of physiotherapy care of patients with neurological disorders.

Chemotherapy-induced peripheral neurotoxicity (CIPN): what we need and what we know.

Chemotherapy-induced peripheral neurotoxicity (CIPN) is one of the most frequent and severe long-term side effects of cancer chemotherapy. Preclinical and clinical studies have extensively investigated CIPN searching for effective strategies to limit its severity or to treat CIPN-related impairment, but the results have been disappointing. Among the reasons for this failure are methodological flaws in both preclinical and clinical investigations. Their successful resolution might provide a brighter perspective for future studies. Among the several neurotoxic chemotherapy drugs, oxaliplatin may offer a clear example of a methodological approach eventually leading to successful clinical trials. However, the same considerations apply to the other neurotoxic agents and, although frequently neglected, also to the new "targeted" agents.

The cost-effectiveness of mandatory folic acid fortification in Australia.

The Australian government recently introduced mandatory folic acid fortification of bread to reduce the incidence of neural tube defects (NTDs). The economic evaluation of this policy contained a number of limitations. This study aimed to address the limitations and to reconsider the findings. Cost-effectiveness analysis was used to assess the cost and benefits of mandatory versus voluntary folic acid fortification. Outcomes measures were quality-adjusted life-years (QALYs), life-years gained (LYG), avoided NTD cases, and additional severe neuropathy cases. Costs considered included industry costs and regulatory costs to the government. It was estimated that mandatory fortification would prevent 31 NTDs, whereas an additional 14 cases of severe neuropathy would be incurred. Overall, 539 LYG and 503 QALYs would be gained per year of mandatory compared with voluntary fortification. Mandatory fortification was cost-effective at A$10,723 per LYG and at A$11,485 per QALY. Probabilistic sensitivity analysis showed that at A$60,000 and A$151,000 per QALY, the probability that mandatory fortification was the most cost-effective strategy was 79% and 85%, respectively. Threshold analysis of loss of consumer choice indicated that with a compensation value above A$1.21 [assuming a willingness to pay (WTP) threshold of A$60,000 per QALY] or A$3.19 (assuming a WTP threshold of A$151,000 per statistical life-year) per capita per year mandatory fortification would not be cost-effective. Mandatory fortification was found to be cost-effective; however, inclusion of the loss of consumer choice can change this result. Even with mandatory fortification, mean folate intake will remain below the recommended NTD preventive level.

Tests and expenditures in the initial evaluation of peripheral neuropathy.

BACKGROUND: Peripheral neuropathy is a common disorder in which an extensive evaluation is often unrevealing. METHODS: We sought to define diagnostic practice patterns as an early step in identifying opportunities to improve efficiency of care. The 1996-2007 Health and Retirement Study Medicare claims-linked database was used to identify individuals with an incident diagnosis of peripheral neuropathy using International Classification of Diseases, Ninth Revision, codes and required no previous neuropathy diagnosis during the preceding 30 months. Focusing on 15 relevant tests, we examined the number and patterns of tests and specific test utilization 6 months before and after the incident neuropathy diagnosis. Medicare expenditures were assessed during the baseline, diagnostic, and follow-up periods. RESULTS: Of the 12, 673 patients, 1031 (8.1%) received a new International Classification of Diseases, Ninth Revision, diagnosis of neuropathy and met the study inclusion criteria. Of the 15 tests considered, a median of 4 (interquartile range, 2-5) tests were performed, with more than 400 patterns of testing. Magnetic resonance imaging of the brain or spine was ordered in 23.2% of patients, whereas a glucose tolerance test was rarely obtained (1.0%). Mean Medicare expenditures were significantly higher in the diagnostic period than in the baseline period ($14,362 vs $8067, P < .001). CONCLUSIONS: Patients diagnosed as having peripheral neuropathy typically undergo many tests, but testing patterns are highly variable. Almost one-quarter of patients receiving neuropathy diagnoses undergo high-cost, low-yield magnetic resonance imaging, whereas few receive low-cost, high-yield glucose tolerance tests. Expenditures increase substantially in the diagnostic period. More research is needed to define effective and efficient strategies for the diagnostic evaluation of peripheral neuropathy.

Pregabalin and gabapentin in matched patients with peripheral neuropathic pain in routine medical practice in a primary care setting: Findings from a cost-consequences analysis in a nested case-control study.

BACKGROUND: Pregabalin and gabapentin are marketed to treat peripheral neuropathic pain, but head-to-head comparison is lacking. OBJECTIVES: The aims of this work were to compare the effects of pregabalin and gabapentin on different patient-reported health outcomes and to analyze health care and nonhealth-care resource consumption and their related costs among patients treated for peripheral neuropathic pain in primary medical care. METHODS: A cost-consequences comparison in subjects with refractory (suboptimal response to > or =1 previous analgesic treatment for >6 months) chronic peripheral neuropathic pain was carried out using data extracted from two 12-week, observational, prospective studies in primary medical care. Patients were eligible if they were aged > or =18 years, had a score of > or =4 on the Douleur Neuropathique 4 questionnaire, and were able to complete health questionnaires written in Spanish. A nested-paired case-control design was chosen to perform the comparison with 2 controls (pregabalin) per case (gabapentin) matched by age, sex, peripheral neuropathic pain condition, time since diagnosis, number of previous treatments, pain intensity, depressive and anxiety symptom scores, and health state. Adult subjects with refractory chronic pain because of diabetic neuropathy, postherpetic or trigeminal neuralgias, or cervical or lumbosacral radiculopathies were included. Epidemiologic statistical methods were applied for comparing health effects (pain intensity, sleep, anxiety and depressive symptoms, disability, and health state), resources utilization, and related cost variations after 12 weeks. Indirect costs were measured by means of lost-workday equivalent calculations multiplied by the mean national daily salary. RESULTS: Analysis included 44 patients treated with gabapentin (cases) and 88 patients treated with pregabalin (controls) who were matched for age, sex, and other parameters. The mean (SD) gabapentin and pregabalin doses were 1263 (540) and 202 (119) mg/d, respectively. Although there was a greater reduction in last-week mean pain intensity with pregabalin (visual analog scale: 39.1 [22.5] vs 28.0 [22.2] mm; P = 0.008), as well as more patients with a > or =50% reduction in pain rate (60.9% vs 40.5%; P = 0.029), there were no significant differences between groups for sensory, affective, total, or present pain intensity. The significantly higher drug cost associated with pregabalin was offset by a greater reduction in productivity costs compared with gabapentin, yielding similar cost reduction (-euro1254 [1479] vs -euro1384 [2874], respectively; P = NS). CONCLUSION: Pregabalin appeared to be associated with greater reduction in mean weekly intensity of pain, but there were no significant differences in cost.

Trends in median, ulnar, radial, and brachioplexus nerve injuries in the United States.

UNLABELLED: significant constraints on an individual's quality of life. OBJECTIVE: To promote efforts to reduce exposure to injury risk factors and to utilize effective therapies when damage does occur, it is important to understand historical trends in both the demographics of peripheral nerve injury (PNI) patients and their treatment. We sought to examine some of these trends. METHODS: We searched the Nationwide Inpatient Sample for discharges classified with International Classification of Diseases, Ninth Revision diagnosis codes of median, ulnar, radial, or brachioplexus nerve injury between 1993 and 2006. We analyzed these data to obtain trend information for the number of discharges, hospital charges, treatment course, patient demographics, and other measures. RESULTS: Although aggregate discharges involving these injuries decreased slightly between 1993 and 2006, mean nominal hospital charges for their treatment increased significantly, in particular, for brachial plexus injuries. In 2006 30 to 40% of median, ulnar, and radial nerve injuries required acute repair by direct nerve suture. PNI patients in 2006 were more likely to be male, between the ages of 18 and 44 years, and from regions where the median income level is greater than $36 000. Approximately 75% of PNIs were treated in academic hospitals and 95% in metropolitan areas. CONCLUSION: PNIs are complex injuries that primarily affect males in key years of adulthood, frequently requiring high-cost acute surgical repair. Although there has been a slight decline in their incidence in the past decade, treatment cost has increased.

Modelling the prevalence and cost of back pain with neuropathic components in the general population.

BACKGROUND: Although there is increasing knowledge of the prevalence of neuropathic pain, little has been done to isolate the cost of neuropathic pain, especially with reference to the frequent complaint of back pain. AIMS: To estimate the prevalence of neuropathic components in back pain and associated costs. METHODS: We used available epidemiological data to model the prevalence of neuropathic back pain in the general adult population, combining three studies: painDETECT 1, painDETECT 2, and the German back pain research network (GBPRN) study, representing a total of 21,047 subjects. The painDETECT screening questionnaire was used in the former two surveys to assess neuropathic pain components. Costing data were obtained from 1718 participants in the GBPRN survey. RESULTS: According to our model, approximately 4% of the general adult population experienced back pain with a neuropathic component. Owing to the greater severity of neuropathic pain, its costs were found to be disproportionately high: among patients with persistent back pain, typical costs associated with a person suffering neuropathic back pain were higher than those of an average back pain patient, and as much as 67% higher than those of a patient with nociceptive back pain only. Approximately, 16% of the total costs associated with back pain were attributable to pain with a neuropathic component. CONCLUSIONS: Back pain with neuropathic components is likely to affect a relevant proportion of the general adult population and cause a disproportionately high share of back pain-related costs.

[Medical and economic reflections on Restore and Itrel neurostimulation systems for neuropathic pain treatment]. / Réflexion sur l'intérêt médicoéconomique des boîtiers de neurostimulation Restore et Itrel dans le traitement des douleurs neuropathiques chroniques.

In 2007, four patients where implanted with the Restore neurostimulation system for intractable chronic leg pain at the Poitiers Hospital. The potential for improving the patients' quality of life and medical-economic concerns motivated this choice for these highly selected patients. In this paper, we propose brief clinical case reports and discuss the reasons for choosing this new rechargeable system, even though it was initially more expensive than the standard neurostimulation system (Itrel 3). All patients receiving implants declared that they were very satisfied with the quality of stimulation provided by Restore and noted a significant improvement in their quality of life. If this solution becomes advantageous from an economic point of view, clinical data should lend support to the utility of this technological innovation for patients who have hitherto been in treatment failure.

A cost-utility analysis of pregabalin in the management of peripheral neuropathic pain.

OBJECTIVES: To assess the cost per QALY (quality-adjusted life years) of pregabalin in the management of peripheral neuropathic pain. METHODS: We compared pregabalin on top of "usual care" with "usual care" alone. In this study, usual care was defined as a mix of drug therapies, excluding anti-epileptic drugs (AEDs), because the latter represented only 9% of current use, and clinical evidence of pregabalin was demonstrated versus usual care without anti-epileptic drugs. A Markov model was developed to simulate the evolution of a patient cohort over 1 year, and applied cycles of 4 weeks. During each cycle, patients remained in 1 out of 4 possible states: severe, moderate or mild pain, and therapy withdrawal. The health care payers perspective was taken into account. Clinical data were obtained from a trial comparing usual care plus placebo to usual care plus pregabalin, at either 150, 300, or 300/600 mg/day (the latter depending on clearance of creatinin). Resulting effects on pain were transformed into transition-probabilities between different pain levels. Cost and SF36 utility data of pain levels were obtained from a 1-month observational study in 88 patients. RESULTS: Usual care resulted in a yearly cost of Euros 6,200 compared to Euros 5,984 for an all dose pregabalin-mix, meaning a cost saving of Euros 216 per patient. Utility increase was 0.01 for the pregabalin-mix (QALY 0.510 usual care; 0.520 pregabalin-mix). Monte Carlo analysis showed cost savings were not significant. However, the utility gain, albeit small, was statistically significant. CONCLUSIONS: Based on this analysis, it may be concluded, that in the considered patient population, at the specialist level, pregabalin is at least cost neutral to current usual care (without AEDs) and offers a slight but significant increase in quality of life.

Quality of life, resource consumption and costs of spinal cord stimulation versus conventional medical management in neuropathic pain patients with failed back surgery syndrome (PROCESS trial).

BACKGROUND: Chronic back and leg pain conditions result in patients' loss of function, reduced quality of life and increased costs to the society. AIMS: To assess health-related quality of life (HRQoL) and cost implications of spinal cord stimulation plus non-surgical conventional medical management (SCS group) versus non-surgical conventional medical management alone (CMM group) in the management of neuropathic pain in patients with failed back surgery syndrome. METHODS: A total of 100 patients were randomised to either the SCS or CMM group. Healthcare resource consumption data relating to screening, the use of the implantable generator in SCS patients, hospital stay, and drug and non-drug pain-related treatment were collected prospectively. Resource consumption was costed using UK and Canadian 2005-2006 national figures. HRQoL was assessed using the EuroQol-5D (EQ-5D) questionnaire. Costs and outcomes were assessed for each patient over their first 6-months of the trial. RESULTS: The 6-month mean total healthcare cost in the SCS group (CAN$19,486; 12,653 euros) was significantly higher than in the CMM group (CAN$3994; 2594 euros), with a mean adjusted difference of CAN$15,395 (9997 euros) (p<0.001). However, the gain in HRQoL with SCS over the same period of time was markedly greater in the SCS group, with a mean EQ-5D score difference of 0.25 [p<0.001] and 0.21 [p<0.001], respectively at 3- and 6-months after adjusting for baseline variables. CONCLUSIONS: The addition of SCS to CMM in patients with neuropathic leg and back pain results in higher costs to health systems but also generates important improvements in patients' EQ-5D over the same period.

[Cost of nucleoside analogue reverse transcriptase inhibitor-related toxicity in HIV-1-infected patients]. / Costes de la toxicidad asociada a los análogos de nucleósidos inhibidores de la transcriptasa inversa en pacientes con infección por el VIH-1.

OBJECTIVE: To estimate the impact of toxicity related to nucleoside analogue reverse transcriptase inhibitors (NRTI) on the total cost of medical care in HIV-1-infected patients. METHODS: . A pharmacoeconomic model was developed from the data obtained by a prospective, observational, multicenter study performed in Spain (Recover). The study patients had developed one NRTI-associated adverse event (AE) that justified discontinuation of treatment with the drug. All costs derived from NRTI-associated AEs in the HAART regimens of HIV-1-infected patients over a period of one year were assessed. The cost assessment (2005 values) included direct medical costs (drugs and AE management) and indirect costs (loss of productivity). The healthcare resources used in AE management were estimated by an expert panel of clinicians. RESULTS: The use and cost of resources rose with increasing severity of all the AE. The average total cost per patient was estimated to be 4012 euro, which included 1789 euro in drug costs (NRTI associated with therapy discontinuation due to AE), and 2223 euro in direct and indirect costs of AE management (45% and 55% of total cost, respectively). Seventy-three per cent of AE-associated costs per patient came from lipoatrophy (560 euro), lipodystropy (535 euro) and peripheral neuropathy (533 euro). CONCLUSION: Management of NRTI-related toxicities is more costly than NRTI acquisition and produces a significant increase in the overall healthcare expenditure for HIV-1-infected patients. This fact should be taken into account when designing the most efficient antiretroviral treatment strategies.

Costes de la toxicidad asociada a los análogos de nucleósidos inhibidores de la transcriptasa inversa en pacientes con infección por el VIH-1 / Cost of nucleoside analogue reverse transcriptase inhibitor-related toxicity in HIV-1-infected patients

Objetivo. Estimar el impacto de la toxicidad asociada a los inhibidores de la transcriptasa inversa análogos de nucleósidos (ITIAN) en el coste total del tratamiento de pacientes con infección por el virus de la inmunodeficiencia humana tipo 1 (VIH-1). Métodos. Se ha diseñado un modelo farmacoeconómico a partir de datos obtenidos de un estudio prospectivo, multicéntrico, observacional realizado en España (Estudio Recover). Los pacientes del estudio habían desarrollado un acontecimiento adverso (AA) asociado a un ITIAN que motivaba su suspensión. En el análisis se incluyen todos los costes derivados de la toxicidad inducida por los ITIAN en los tratamientos antirretrovirales durante un año. Los costes (valores del año 2005) incluidos han sido: médicos directos (fármacos y manejo de AA) e indirectos (pérdidas de productividad). La estimación de los recursos relacionados con el manejo de los AA se ha realizado a través de un panel de consenso de expertos clínicos. Resultados. El incremento en el uso y coste de recursos sanitarios se correlaciona con la gravedad de todos los AA evaluados. El coste promedio total estimado por paciente ha sido de 4.012 €: 1.789 € por costes farmacológicos (ITIAN asociados con la discontinuación de la terapia por AA) y 2.223 € por costes directos e indirectos del manejo de los AA (45 y 55%, respectivamente, de los costes totales). El 73% de los costes por paciente asociados a AA se deben a la lipoatrofia (560 €), lipodistrofia mixta (535 €) y neuropatía periférica (533 €). Conclusión. En pacientes que desarrollan toxicidades asociadas a ITIAN, el coste económico de su manejo es superior al coste de adquisición de los ITIAN y produce un incremento significativo en los costes totales del tratamiento de la infección por VIH-1. El coste del manejo de estas toxicidades debería tenerse en cuenta en el diseño de estrategias de tratamiento antirretroviral más eficientes (AU)

Objective. To estimate the impact of toxicity related to nucleoside analogue reverse transcriptase inhibitors (NRTI) on the total cost of medical care in HIV-1-infected patients. Methods. A pharmacoeconomic model was developed from the data obtained by a prospective, observational, multicenter study performed in Spain (Recover). The study patients had developed one NRTI-associated adverse event (AE) that justified discontinuation of treatment with the drug. All costs derived from NRTI-associated AEs in the HAART regimens of HIV-1-infected patients over a period of one year were assessed. The cost assessment (2005 values) included direct medical costs (drugs and AE management) and indirect costs (loss of productivity). The healthcare resources used in AE management were estimated by an expert panel of clinicians. Results. The use and cost of resources rose with increasing severity of all the AE. The average total cost per patient was estimated to be 4012 €, which included 1789 € in drug costs (NRTI associated with therapy discontinuation due to AE), and 2223 € in direct and indirect costs of AE management (45% and 55% of total cost, respectively). Seventy-three per cent of AE-associated costs per patient came from lipoatrophy (560 €), lipodystrophy (535 €) and peripheral neuropathy (533 €). Conclusion. Management of NRTI-related toxicities is more costly than NRTI acquisition and produces a significant increase in the overall healthcare expenditure for HIV-1-infected patients. This fact should be taken into account when designing the most efficient antiretroviral treatment strategies (AU)

The financial costs of healthcare treatment for people with Type 1 or Type 2 diabetes in the UK with particular reference to differing severity of peripheral neuropathy.

AIMS: To characterize symptom severity of diabetic peripheral neuropathy (DPN) in people with diabetes and to characterize its association with healthcare resource use. METHODS: The study was undertaken in Cardiff and the Vale of Glamorgan, UK. A postal survey was posted to subjects identified as having diabetes. Demography, quality of life (EQ-5D and SF-36) and symptoms of neuropathy (NTSS-6 and QOL-DN) data were collected. These data were linked to routine healthcare data coded into healthcare resource groups (HRGs) and subsequently costed according to UK National reference costs. RESULTS: Survey responses were received from 1298 patients, a 32% response rate. For patients with a clinically confirmed diagnosis of DPN, the mean NTSS-6-SA score was 6.16 vs. 3.19 (P < 0.001). Duration of diabetes did not change across groups defined by severity of neuropathy symptoms, but mean HbA(1c) and body mass index values did increase with symptom severity (range 7.6-8.1%, P = 0.023; and 28.0-30.9 kg/m(2), P < 0.001, respectively). General linear modelling showed that the NTSS-6-SA score was a significant predictor of both annual health resource costs and yearly prescribed drug costs. On average, each 1-point increase in NTSS-6-SA score predicted a 6% increase in primary and secondary care costs and a 3% increase in log transformed drug costs. CONCLUSION: This study demonstrated that severity of DPN symptoms was associated with increased healthcare resource use, thus costs.

Economic impact of shifting the locus of care for neuropathic pain from specialists to general practitioners.

We developed a decision-analytic model to examine the economic impact of shifting the locus of care for patients with painful neuropathies from specialists to GPs. The impetus for such a shift was assumed to be a formal education program, focusing on the recognition and treatment of neuropathic pain, conducted for GPs. In the model, all patients with neuropathic pain were assumed to initiate care with their GPs and then be referred to specialists and, ultimately, pain clinics as required for adequate pain control. Two alternative scenarios were examined--the "current" arrangement in which most patients were assumed to be referred for treatment by specialists and pain clinics and a "hypothetical" arrangement in which GPs were assumed to play an expanded role in the treatment of neuropathic pain and which, therefore, often precluded the need for referral. The model was populated with clinical, epidemiologic, and economic data from Norway. A total of 34,951 persons in Norway were estimated to seek care for painful neuropathies each year. The formal education program was assumed to cost 1.5 million Kroner (NOK). Shifting the locus of care from specialists to GPs would result in 4,715 additional GP visits, but 12,123 fewer specialist visits and 7,967 fewer visits to pain clinics. This change would result in estimated savings to the Norwegian health-care system in 2004 of 74.1 million NOK (approx. US $11.9 million). A partial shift in the locus of care of painful neuropathies from specialists to GPs may result in substantial cost savings to the Norwegian health-care system.