Initiating Self-Administration of Medicines for inpatients with cystic fibrosis.

INTRODUCTION: Children with cystic fibrosis (CF) take a multitude of therapies at home. Self-Administration of Medicines (SAM) is a scheme whereby the parent/carer and/or older child keep control of their own medicines in hospital. We initiated a scheme and assessed drug errors, cost implications, and parent and nurse satisfaction. METHODS: Following a pilot stage, the SAM protocol was initiated and amended as necessary. Drug errors were analysed from the Datix hospital electronic reporting system. Cost analysis of use of the patents own drugs was carried out. Questionnaires were given to parents and nursing staff. RESULTS: In the initial 10 months, 97 children had 159 admissions, and 60% were deemed suitable for SAM. Drug errors still occurred-33 in 5 years. Cost savings for the hospital over 1 year were £20 022 for 123 admissions. Patient/parent satisfaction was high, and all wished to partake in SAM for further admissions. CONCLUSIONS: The scheme was a success although it took 3 years to bring to fruition. Drug errors still occurred but we were able to amend the protocol appropriately to react to these. Cost savings are an incidental benefit from use of patient's own medication. The SAM scheme is applicable to all children with chronic disease on long term medications when they are in hospital.

The cost-effectiveness of requiring universal vs contextual self-injectable epinephrine autoinjector for allergen immunotherapy.

BACKGROUND: Aeroallergen immunotherapy (AIT) is a safe and effective disease-modifying treatment associated with rare therapy-associated fatality. Significant practice variation surrounds universal or contextual prescription of self-injectable epinephrine (SIE) for patients receiving AIT. OBJECTIVE: To characterize the cost-effectiveness of a universal vs contextual SIE requirement for patients receiving AIT. METHODS: An economic evaluation using cohort and microsimulation was performed from both the societal and health care sector perspectives for patients undergoing AIT, assessing a universal requirement to fill SIE prescriptions at the outset of therapy compared with requiring this only after a systemic reaction to immunotherapy (SRIT). RESULTS: A universal SIE requirement for AIT is not cost-effective, with the incremental cost-effectiveness ratio for this strategy estimated at $669,327,730 per quality-adjusted life-year (QALY). In the microsimulation (n = 10,000), the mean (SD) costs of a universal approach exceeded that of a more context-specific strategy where SIE was only prescribed for patients after an initial SRIT ($19,653.36 [$4296.66] vs $16,232.14 [$5204.32]), and given the effects on rates of AIT discontinuation, the universal approach was less effective (mean [SD], 25.555 [2.285] QALYs) compared with a contextualized approach (mean [SD], 25.579 [2.345] QALYs). Universal SIE prescription could be cost-effective if it provided a 1000 times protection against AIT fatality at a value-based cost of $24, and the annual AIT fatality rates unrealistically exceed 2.6 per 10,000 patients. CONCLUSION: In a simulation of potential SIE-prescribing strategies for patients receiving AIT, a universal approach to an epinephrine autoinjector requirement was not cost-effective when compared with an approach in which an SIE is prescribed only to patients with prior SRIT.

Patient-Administered Biologic and Biosimilar Filgrastim May Offer More Affordable Options for Patients with Nonmyeloid Malignancies Receiving Chemotherapy in the United States: A Budget Impact Analysis from the Payer Perspective.

BACKGROUND: Granulocyte colony-stimulating factors (G-CSFs) are often administered to reduce the incidence, severity, and duration of febrile neutropenia (FN) in chemotherapy patients. Tbo-filgrastim and filgrastim-sndz represent a follow-on biologic and a biosimilar version, respectively, of the short-acting G-CSF filgrastim with comparable efficacy and safety. OBJECTIVE: To estimate the budget impact of increasing use of patient-(home-) administered tbo-filgrastim and filgrastim-sndz from a U.S. payer perspective. METHODS: An interactive budget impact model was developed to estimate the changes in drug cost associated with projected increases in the market share of tbo-filgrastim from 5% to 10% and of filgrastim-sndz from 10% to 12% (with a corresponding decrease in filgrastim market share from 85% to 78%) for a 1 million-member health plan among patients with nonmyeloid malignancies receiving chemotherapy with a high risk of FN. Patient self-administration at home was assumed for 20% of patients receiving short-acting G-CSF treatment; all products were purchased through the patient's pharmacy benefit and were assumed to have tier 3 formulary status with a patient copay of $54 per prescription. Base-case data were derived from publicly available resources. The total plan budget impact was calculated using a 1-year time horizon, along with the differences in per member per month and per member per year (PMPY) costs between the current and future scenarios. RESULTS: The effective annual per-patient drug cost to the plan totaled between $16,961 and $27,199, depending on dosage and packaging, for tbo-filgrastim; between $16,216 and $26,015 for filgrastim-sndz; and between $19,134 and $30,663 for filgrastim. The estimated total annual plan cost associated with patient-administered short-acting G-CSFs was $53,298,217 (PMPY = $53.30) in the current scenario and $52,828,832 (PMPY = $52.82) in the future scenario. Cost savings totaled $469,385 (PMPY = $0.48). The model was most sensitive to changes in the percentage of patients self-administering G-CSF at home and to the wholesale acquisition cost for filgrastim. CONCLUSIONS: The effective annual plan per-patient drug costs for tbo-filgrastim and filgrastim-sndz were 11% and 15% lower than filgrastim, respectively. The present analysis estimated an annual U.S. health plan cost savings approaching $0.5 million following increases in market shares of approximately 5% for tbo-filgrastim and 2% for filgrastim-sndz. DISCLOSURES: This study was sponsored by Teva Branded Pharmaceutical Products R & D, which participated in the study design, data interpretation and analysis, the writing of the report, and the decision to submit. Aventine Consulting received consulting fees from Teva Pharmaceuticals and developed the cost model and provided data analysis support. Trautman and James are employed by Aventine Consulting. Szabo and Tang are employed by Teva Pharmaceuticals.

Is contraceptive self-injection cost-effective compared to contraceptive injections from facility-based health workers? Evidence from Uganda.

OBJECTIVE: To assess the cost-effectiveness of self-injected subcutaneous depot medroxyprogesterone acetate (DMPA-SC) compared to health-worker-administered intramuscular DMPA (DMPA-IM) in Uganda. STUDY DESIGN: We developed a decision-tree model with a 12-month time horizon for a hypothetical cohort of approximately 1 million injectable contraceptive users in Uganda to estimate the incremental costs per pregnancy averted and per disability-adjusted life year (DALY) averted. The study design derived model inputs from DMPA-SC self-injection continuation and costing research studies and peer-reviewed literature. We calculated incremental cost-effectiveness ratios from societal and health system perspectives and conducted one-way and probabilistic sensitivity analyses to test the robustness of results. RESULTS: Self-injected DMPA-SC could prevent 10,827 additional unintended pregnancies and 1620 maternal DALYs per year for this hypothetical cohort compared to DMPA-IM administered by facility-based health workers. Due to savings in women's time and travel costs, under a societal perspective, self-injection could save approximately US$1 million or $84,000 per year, depending on the self-injection training aid used. From a health system perspective, self-injection would avert more pregnancies but incur additional costs. A training approach using a one-page client instruction sheet would make self-injection cost-effective compared to DMPA-IM, with incremental costs per pregnancy averted of $15 and per maternal DALY averted of $98. Sensitivity analysis showed that the estimates were robust. The one-way and probabilistic sensitivity analyses showed that the costs of the first visit for self-injection (which include training costs) were an important variable impacting the cost-effectiveness estimates. CONCLUSIONS: Under a societal perspective, self-injected DMPA-SC averted more pregnancies and cost less compared to health-worker-administered DMPA-IM. Under a health system perspective, self-injected DMPA-SC can be cost-effective relative to DMPA-IM when a lower-cost visual aid for client training is used. IMPLICATIONS: Self-injection has economic benefits for women through savings in time and travel costs, and it averts additional pregnancies and maternal disability-adjusted life years compared to health-worker-administered injectable DMPA-IM. Implementing lower-cost approaches to client training can help ensure that self-injection is also cost-effective from a health system perspective.

Costs of administering injectable contraceptives through health workers and self-injection: evidence from Burkina Faso, Uganda, and Senegal.

OBJECTIVE: To evaluate the 12-month total direct costs (medical and nonmedical) of delivering subcutaneous depot medroxyprogesterone acetate (DMPA-SC) under three strategies - facility-based administration, community-based administration and self-injection - compared to the costs of delivering intramuscular DMPA (DMPA-IM) via facility- and community-based administration. STUDY DESIGN: We conducted four cross-sectional microcosting studies in three countries from December 2015 to January 2017. We estimated direct medical costs (i.e., costs to health systems) using primary data collected from 95 health facilities on the resources used for injectable contraceptive service delivery. For self-injection, we included both costs of the actual research intervention and adjusted programmatic costs reflecting a lower-cost training aid. Direct nonmedical costs (i.e., client travel and time costs) came from client interviews conducted during injectable continuation studies. All costs were estimated for one couple year of protection. One-way sensitivity analyses identified the largest cost drivers. RESULTS: Total costs were lowest for community-based distribution of DMPA-SC (US$7.69) and DMPA-IM ($7.71) in Uganda. Total costs for self-injection before adjustment of the training aid were $9.73 (Uganda) and $10.28 (Senegal). After adjustment, costs decreased to $7.83 (Uganda) and $8.38 (Senegal) and were lower than the costs of facility-based administration of DMPA-IM ($10.12 Uganda, $9.46 Senegal). Costs were highest for facility-based administration of DMPA-SC ($12.14) and DMPA-IM ($11.60) in Burkina Faso. Across all studies, direct nonmedical costs were lowest for self-injecting women. CONCLUSIONS: Community-based distribution and self-injection may be promising channels for reducing injectable contraception delivery costs. We observed no major differences in costs when administering DMPA-SC and DMPA-IM under the same strategy. IMPLICATIONS: Designing interventions to bring contraceptive service delivery closer to women may reduce barriers to contraceptive access. Community-based distribution of injectable contraception reduces direct costs of service delivery. Compared to facility-based health worker administration, self-injection brings economic benefits for women and health systems, especially with a lower-cost client training aid.

Does directly administered antiretroviral therapy represent good value for money in sub-Saharan Africa? A cost-utility and value of information analysis.

BACKGROUND: Successful antiretroviral therapy (ART) relies on the optimal level of ART adherence to achieve reliable viral suppression, avert HIV drug resistance, and prevent avoidable deaths. It has been shown that there are various groups of people living with HIV at high-risk of non-adherence to ART in sub-Saharan Africa. The objective of this study was to examine the cost effectiveness and value-of-information of directly administered antiretroviral therapy (DAART) versus self-administered ART among people living with HIV, at high risk of non-adherence to ART in sub-Saharan Africa. METHODS AND FINDINGS: A Markov model was developed that describes the transition between HIV stages based on the CD4 count, along with direct costs, quality of life and the mortality rate associated with DAART in comparison with self-administered ART. Data used in the model were derived from the published literature. A health system perspective was employed using a life-time time horizon. Probabilistic sensitivity analysis was performed to determine the impact of parameter uncertainty. Value of information analysis was also conducted. The expected cost of self-administered ART and DAART were $5,200 and $15,500 and the expected QALYs gained were 8.52 and 9.75 respectively, giving an incremental cost effectiveness ratio of $8,400 per QALY gained. The analysis demonstrated that the annual cost DAART needs to be priced below $200 per patient to be cost-effective. The probability that DAART was cost-effective was 1% for a willingness to pay threshold of $5,096 for sub-Saharan Africa. The value of information associated with the cost of DAART and its effectiveness was substantial. CONCLUSIONS: From the perspective of the health care payer in sub-Saharan Africa, DAART cannot be regarded as cost-effective based on current information. The value of information analysis showed that further research will be worthwhile and potentially cost-effective in resolving the uncertainty about whether or not to adopt DAART.

Association of Fatality Risk With Value-Based Drug Pricing of Epinephrine Autoinjectors for Children With Peanut Allergy: A Cost-effectiveness Analysis.

Importance: The high cost of self-injectable epinephrine autoinjectors may represent a barrier to community anaphylaxis management. Value-based pricing can provide a benchmark for rational epinephrine autoinjector costs. Objective: To define value-based pricing of community epinephrine autoinjectors. Design, Setting, and Participants: In an economic evaluation study using a cost-effectiveness birth cohort model over an extended 80-year time horizon, Markov simulations of children with peanut allergy evaluated cost ceilings for value-based epinephrine prices in peanut allergy. Simulation inputs included all-cause age-adjusted mortality (2013 US life tables), 2013 published food allergy fatality rates, 2017 rates of autoinjector device carriage, and 2016 published market costs of self-injectable epinephrine. All costs were expressed in 2018 US dollars and discounted at 3% per annum. Exposures: Cohorts of children with peanut allergy prescribed epinephrine autoinjectors were compared with those not receiving personal epinephrine prescriptions. Children without epinephrine autoinjectors assumed 10-fold to 100-fold fatality risk increases. Costs were evaluated from a societal perspective. Main Outcomes and Measures: Fatality risk, quality-adjusted life-years, and incremental cost-effectiveness ratio. Results: A total of 100 000 simulated infants with peanut allergy entered each strategy, with two-thirds of the group receiving annual personal epinephrine prescriptions and using those devices appropriately when indicated. Over the time horizon, the cost of anaphylaxis preparedness and treatment in those with personal epinephrine devices was $25 478 (95% CI, $25 399-$25 557) compared with $654 (95% CI, $645-$663) for those without personal epinephrine, resulting in an average food allergy fatality of 0.00056 (95% CI, 0.000414-0.000706) per patient prescribed self-injectable epinephrine and 0.00148 (95% CI, 0.001242-0.001718) in those not prescribed self-injectable epinephrine. The value-based price (incremental cost-effectiveness ratio, $100 000 per quality-adjusted life-year) for personal epinephrine based on 10-fold fatality risk difference was $24. At a market cost of $715 per twin pack, the autoinjector incremental cost-effectiveness ratio was $2 742 697 per quality-adjusted life-year. If a hypothetical fatality risk protection from personal epinephrine was modeled at 100-fold, the value-based price ceiling for a personal autoinjector was $264. Conclusions and Relevance: In a simulation of children with peanut allergy, a value-based epinephrine cost has a ceiling of $24 for a personal autoinjector, even at an exaggerated fatality risk.

Prevention of Anaphylaxis: The Role of the Epinephrine Auto-Injector.

Anaphylaxis is a life-threatening condition, with at-risk individuals remaining at chronic high risk of recurrence. Anaphylaxis is frequently underrecognized and undertreated by healthcare providers. The first-line pharmacologic intervention for anaphylaxis is epinephrine, and guidelines uniformly agree that its prompt administration is vital to prevent progression, improve patient outcomes, and reduce hospitalizations and fatalities. Healthcare costs potentially associated with failure to provide epinephrine (hospitalizations and emergency department visits) generally exceed those of its provision. At-risk patients are prescribed epinephrine auto-injectors to facilitate timely administration in the event of an anaphylactic episode. Despite guideline recommendations that patients carry 2 auto-injectors at all times, a significant proportion of patients fail to do so, with cost of medicine cited as one reason for this lack of adherence. With the increase of high-deductible healthcare plans, patient adherence to recommendations may be further affected by increased cost sharing. The recognition and classification of epinephrine as a preventive medicine by both the US Preventive Services Task Force and insurers could increase patient access, improve outcomes, and save lives.

Model-based evaluation of cost-effectiveness of nerve growth factor inhibitors in knee osteoarthritis: impact of drug cost, toxicity, and means of administration.

OBJECTIVE: Studies suggest nerve growth factor inhibitors (NGFi) relieve pain but may accelerate disease progression in some patients with osteoarthritis (OA). We sought cost and toxicity thresholds that would make NGFi a cost-effective treatment for moderate-to-severe knee OA. DESIGN: We used the Osteoarthritis Policy (OAPol) model to estimate the cost-effectiveness of NGFi compared to standard of care (SOC) in OA, using Tanezumab as an example. Efficacy and rates of accelerated OA progression were based on published studies. We varied the price/dose from $200 to $1000. We considered self-administered subcutaneous (SC) injections (no administration cost) vs provider-administered intravenous (IV) infusion ($69-$433/dose). Strategies were defined as cost-effective if their incremental cost-effectiveness ratio (ICER) was less than $100,000/quality-adjusted life year (QALY). In sensitivity analyses we varied efficacy, toxicity, and costs. RESULTS: SOC in patients with high levels of pain led to an average discounted quality-adjusted life expectancy of 11.15 QALYs, a lifetime risk of total knee replacement surgery (TKR) of 74%, and cumulative discounted direct medical costs of $148,700. Adding Tanezumab increased QALYs to 11.42, reduced primary TKR utilization to 63%, and increased costs to between $155,400 and $199,500. In the base-case analysis, Tanezumab at $600/dose was cost-effective when delivered outside of a hospital. At $1000/dose, Tanezumab was not cost-effective in all but the most optimistic scenario. Only at rates of accelerated OA progression of 10% or more (10-fold higher than reported values) did Tanezumab decrease QALYs and fail to represent a viable option. CONCLUSIONS: At $100,000/QALY, Tanezumab would be cost effective if priced ≤$400/dose in all settings except IV hospital delivery.

Community IntraVenous Antibiotic Study (CIVAS): protocol for an evaluation of patient preferences for and cost-effectiveness of community intravenous antibiotic services.

INTRODUCTION: Outpatient parenteral antimicrobial therapy (OPAT) is used to treat a wide range of infections, and is common practice in countries such as the USA and Australia. In the UK, national guidelines (standards of care) for OPAT services have been developed to act as a benchmark for clinical monitoring and quality. However, the availability of OPAT services in the UK is still patchy and until quite recently was available only in specialist centres. Over time, National Health Service (NHS) Trusts have developed OPAT services in response to local needs, which has resulted in different service configurations and models of care. However, there has been no robust examination comparing the cost-effectiveness of each service type, or any systematic examination of patient preferences for services on which to base any business case decision. METHODS AND ANALYSIS: The study will use a mixed methods approach, to evaluate patient preferences for and the cost-effectiveness of OPAT service models. The study includes seven NHS Trusts located in four counties. There are five inter-related work packages: a systematic review of the published research on the safety, efficacy and cost-effectiveness of intravenous antibiotic delivery services; a qualitative study to explore existing OPAT services and perceived barriers to future development; an economic model to estimate the comparative value of four different community intravenous antibiotic services; a discrete choice experiment to assess patient preferences for services, and an expert panel to agree which service models may constitute the optimal service model(s) of community intravenous antibiotics delivery. ETHICS AND DISSEMINATION: The study has been approved by the NRES Committee, South West-Frenchay using the Proportionate Review Service (ref 13/SW/0060). The results of the study will be disseminated at national and international conferences, and in international journals.

Economic impact of a novel naloxone autoinjector on third-party payers.

BACKGROUND: Patient overdoses on prescription opioid analgesics in the United States continue to rise, resulting in increased emergency department and hospitalization costs. Opioid overdose is readily reversible with naloxone, a fast-acting opioid antagonist. A new naloxone autoinjector (NAI), Evzio, which does not require medical training to use, was approved by the FDA in April 2014. Payers must decide on reimbursement policies for this product. PURPOSE: To demonstrate to payer decision makers the costs and potential medical resource cost offsets associated with the utilization of a new NAI. DESIGN: A deterministic model using matched controls. METHODOLOGY: An Excel-based cost model was developed for a hypothetical health plan with 1 million adult members. Costs of prescription opioid overdose events for patients appropriately dispensed NAI were compared with matched controls. RESULTS: NAI prescriptions increased from 218 in Year 1 to 2,527 in Year 3. In Year 3, 86 NAI patients (and their matched controls) experienced opioid overdose events. For this period, fatal overdoses in the NAI cohort totaled 11.1 vs. 14.7 for the control group. In Year 3, 2.5 deaths (10.1-7.6) were avoided. NAI acquisition costs rose from $125,000 in Year 1 (PMPM = $0.01) to nearly $1.5 million in Year 3 (PMPM = $0.12).This cost was offset by medical resource savings of approximately $84,000 in Year 1, increasing to $975,000 in Year 3. The total net cost (NAI less offsets) in Year 3, when NAI uptake was assumed to plateau, was $481,000 (PMPM = $0.04). CONCLUSION: A deterministic model demonstrated that NAI acquisition costs can be offset through medical cost reductions with improved timely access to naloxone.

Home Therapy with Plasma-Derived C1 Inhibitor: A Strategy to Improve Clinical Outcomes and Costs in Hereditary Angioedema.

BACKGROUND: Attacks of hereditary angioedema with C1 inhibitor deficiency (C1-INH-HAE) are commonly treated in the emergency department. Self-administration is emerging as an effective treatment option. In this study, we assessed the impact of home therapy with plasma-derived C1 esterase inhibitor (pdC1-INH) concentrate on treatment outcomes and costs. METHODS: This is an observational study in C1-INH-HAE patients who switched to home therapy with pdC1-INH (Berinert®) after learning intravenous self-infusion in a training course at a center in Southern Italy. Before starting home therapy and after the first year of home therapy, patients were interviewed about their treatment and outcomes during the prior 12 months. Annual costs were analyzed by cost minimization from the Italian health care payer perspective and the societal perspective. Outcomes and costs before and after the switch to home therapy were compared. RESULTS: The training course was attended by 36 participants, 17 (47.2%) of whom decided to switch to home therapy. This therapy was associated with a significant decrease in the mean annual number of hospitalizations (16.8 vs. 2.1, p = 0.003) and missed work/school days (20.3 vs. 7.1, p = 0.037) compared to conventional treatment. The times from symptom onset to treatment administration and from treatment administration to symptom improvement/resolution were not significantly different between the two strategies. The mean annual per-patient costs decreased with home therapy from EUR 30,010.57 to EUR 26,621.16 (11.3% saving) and from EUR 29,309.34 to EUR 26,522.04 (9.5% saving) from the societal and payer perspective, respectively. CONCLUSIONS: Home therapy with pdC1-INH is a feasible strategy for the management of C1-INH-HAE and may result in cost savings.

Internet video to support intravenous medication administration in the home: a cost minimisation study.

We compared the costs associated with three different methods of administering antibiotics to paediatric oncology patients. In scenario A, medicine was prepared in the home, checked in the home using a video link to a second nurse, and administered in the home. In scenario B, medicine was prepared by outsourcing the work to a commercial organisation, checked by pharmacists off-site and administered in the home. In scenario C, medicine was prepared in the hospital, checked by a second nurse and administered in the outpatient department. The staff time required for home administration was calculated from actual home visits. The cost of tablet computers and mobile Internet charges for double-checks in the home was based on an assumed useful life of 3 years for the equipment. The cost of outsourcing the preparation of medications was calculated from the actual cost of doing so during a four month period. Patient outcome was assumed to be the same in all three scenarios. The mean costs of a medication episode (i.e. one occasion of medication administration) was $129.91 in scenario A, $312.00 in scenario B and $355.91 in scenario C. Nurse preparation and administration in the home would save the oncology health service $124,899 per annum compared to outsourcing medication preparation. Nurse preparation and administration in the home would save the oncology health service $155,329 per annum compared to nurse preparation and administration in the outpatient department. Use of Internet-based video appears to produce savings compared to other methods of administering antibiotics and the technique may have wider application in supporting complex interventions in the home.

Balancing selected medication costs with total number of daily injections: a preference analysis of GnRH-agonist and antagonist protocols by IVF patients.

BACKGROUND: During in vitro fertilization (IVF), fertility patients are expected to self-administer many injections as part of this treatment. While newer medications have been developed to substantially reduce the number of these injections, such agents are typically much more expensive. Considering these differences in both cost and number of injections, this study compared patient preferences between GnRH-agonist and GnRH-antagonist based protocols in IVF. METHODS: Data were collected by voluntary, anonymous questionnaire at first consultation appointment. Patient opinion concerning total number of s.c. injections as a function of non-reimbursed patient cost associated with GnRH-agonist [A] and GnRH-antagonist [B] protocols in IVF was studied. RESULTS: Completed questionnaires (n = 71) revealed a mean +/- SD patient age of 34 +/- 4.1 yrs. Most (83.1%) had no prior IVF experience; 2.8% reported another medical condition requiring self-administration of subcutaneous medication(s). When out-of-pocket cost for [A] and [B] were identical, preference for [B] was registered by 50.7% patients. The tendency to favor protocol [B] was weaker among patients with a health occupation. Estimated patient costs for [A] and [B] were $259.82 +/- 11.75 and $654.55 +/- 106.34, respectively (p < 0.005). Measured patient preference for [B] diminished as the cost difference increased. CONCLUSIONS: This investigation found consistently higher non-reimbursed direct medication costs for GnRH-antagonist IVF vs. GnRH-agonist IVF protocols. A conditional preference to minimize downregulation (using GnRH-antagonist) was noted among some, but not all, IVF patient sub-groups. Compared to IVF patients with a health occupation, the preference for GnRH-antagonist was weaker than for other patients. While reducing total number of injections by using GnRH-antagonist is a desirable goal, it appears this advantage is not perceived equally by all IVF patients and its utility is likely discounted heavily by patients when nonreimbursed medication costs reach a critical level.

Hereditary angioedema treatment options: the availability of new therapies.

Hereditary angioedema (HAE) is a potentially life-threatening autosomal dominant disease characterized by recurrent episodes of oedema, commonly occurring in the skin, abdomen, and upper respiratory tract. After many years during which limited treatment options were available, a range of newer therapies with proven efficacy have been approved in Europe by the European Commission for the treatment of HAE attacks. However, due to differing legislation and financial restrictions, these treatment options are not available in all countries. Home therapy and self-administration of treatment are recommended in order to minimize the burden of disease upon the patient, with the ideal treatment option being effective, well-tolerated, and easy to prepare and administer. Recently, the Hereditary Angioedema International Working Group (HAWK) consensus recommended early, on-demand treatment for HAE. This article reviews the current treatment options available, and considers the need for treatment guidelines to recommend the appropriate therapy.

Economic evaluation of the use of point-of-care devices in patients with long term oral anticoagulation.

To examine the cost and cost-effectiveness of the use of point-of-care (POC) devices by the general practitioner (GP), in anticoagulation clinic or by the patient in self-testing (PST) and self-management (PSM), compared with standard laboratory testing to realize international normalized ratio tests for patients on long term anticoagulation therapy. An economic evaluation was performed from the Belgian health care payer's perspective using a Markov model. Outcomes data were derived from a meta-analysis and cost data were derived from claims databases. Several scenarios were tested based on number of tests and GP's contacts and probabilistic sensitivity analysis was used to handle uncertainty. Evidence on the impact of POC on mortality was only found for PSM. Therefore, a cost-effectiveness analysis was performed for PSM and for other strategies, only a cost comparison was done. With an unchanged number of tests, POC is cost-saving compared to laboratory testing (probability > 70%). In scenarios where POC induces more tests, results were different: with 52 tests/year, only PSM kept a probability of remaining cost-saving superior to 50%. Except in the case of 100% of GP consultations maintained and 52 tests/year performed, PSM resulted in significantly more "life years gained" (LYG) than usual care and was on average cost-saving. The organisation of long term oral anticoagulation monitoring should be directed towards PSM and, to a lesser extent, PST for selected and trained patients.

Public perception on the role of community pharmacists in self-medication and self-care in Hong Kong.

BACKGROUND: The choices for self-medication in Hong Kong are much diversified, including western and Chinese medicines and food supplements. This study was to examine Hong Kong public knowledge, attitudes and behaviours regarding self-medication, self-care and the role of pharmacists in self-care. METHODS: A cross-sectional phone survey was conducted, inviting people aged 18 or older to complete a 37-item questionnaire that was developed based on the Thematic Household surveys in Hong Kong, findings of the health prorfessional focus group discussions on pharmacist-led patient self management and literature. Telephone numbers were randomly selected from residential phone directories. Trained interviewers invited eligible persons to participate using the "last birthday method". Associations of demographic characteristics with knowledge, attitudes and beliefs on self-medication, self-care and role of pharmacists, and spending on over-the-counter (OTC) products were analysed statistically. RESULTS: A total of 1, 560 phone calls were successfully made and 1, 104 respondents completed the survey which indicated a response rate of 70.8%. 63.1% had adequate knowledge on using OTC products. Those who had no formal education/had attended primary education (OR = 3.19, 95%CI 1.78-5.72; p < 0.001), had attended secondary education (OR = 1.50, 95%CI 1.03-2.19; p = 0.035), and aged ≥ 60 years (OR = 1.82, 95% CI 1.02-3.26; p = 0.042) were more likely to have inadequate knowledge on self-medication. People with chronic disease also tended to spend more than HKD100 on western (OR = 3.58, 95%CI 1.58-8.09; p = 0.002) and Chinese OTC products (OR = 2.94, 95%CI 1.08-7.95; p = 0.034). 94.6% believed that patients with chronic illnesses should self-manage their diseases. 68% agreed that they would consult a pharmacist before using OTC product but only 45% agreed that pharmacists could play a leading role in self-care. Most common reasons against pharmacist consultation on self-medication and self-care were uncertainty over the role of pharmacists and low acceptance level of pharmacists. CONCLUSIONS: The majority of respondents supported patients with chronic illness to self-manage their diseases but less than half agreed to use a pharmacist-led approach in self-care. The government should consider developing doctors-pharmacists partnership programs in the community, enhancing the role of pharmacists in primary care and providing education to patients to improve their awareness on the role of pharmacists in self-medication and self-care.

Cost-effectiveness analysis of Chlamydia trachomatis screening via internet-based self-collected swabs compared with clinic-based sample collection.

BACKGROUND: Although the Centers for Disease Control and Prevention have recommended population-wide Chlamydia trachomatis screening of sexually active women less than 26 years of age, more than half of sexually active young women are not routinely screened. A Website (IWTK, www.iwantthekit.org), was developed in 2004 to promote home-based sample collection. METHODS: A decision tree was designed to model a hypothetical cohort of 10,000 women per year who order an internet-based C. trachomatis screening kit. We compared the incremental cost-effectiveness of 2 screening strategies: self-sampling via the IWTK website, and traditional, clinic-based screening by the same cohort of women who used IWTK. Probabilities and costs were estimated for each node in the decision tree. Estimates were derived from primary data, published data, and unpublished health data. RESULTS: The internet-based screening strategy prevented 35.5 more cases of pelvic inflammatory disease and saved an additional $41,000 in direct medical costs as compared with the clinic-based screening strategy. CONCLUSION: Our model estimates demonstrated that an internet-based, self-swab screening strategy was cost-effective compared with the traditional, clinic-based screening strategy. Assuming that the popularity of the use of the internet as a resource for information about healthcare and sexually transmitted infections leads to an increased use of IWTK, the public health benefit of this cost-effective strategy will be even greater.