Cost-effectiveness of Coblation compared with cold steel tonsillectomies in the UK.

OBJECTIVE: This study aimed to estimate the cost-effectiveness of Coblation compared with cold steel tonsillectomy in adult and paediatric patients in the UK. METHOD: Decision analysis was undertaken by combining published clinical outcomes with resource utilisation estimates derived from a panel of clinicians. RESULTS: Using a cold steel procedure instead of Coblation is expected to generate an incremental cost of more than £2000 for each additional avoided haemorrhage, and the probability of cold steel being cost-effective was approximately 0.50. Therefore, the cost-effectiveness of the two techniques was comparable. When the published clinical outcomes were replaced with clinicians' estimates of current practice, Coblation was found to improve outcome for less cost, and the probability of Coblation being cost-effective was at least 0.70. CONCLUSION: A best-case scenario suggests Coblation affords the National Health Service a cost-effective intervention for tonsillectomy in adult and paediatric patients compared with cold steel procedures. A worst-case scenario suggests Coblation affords the National Health Service an equivalent cost-effective intervention for adult and paediatric patients.

The health economic burden that acute and chronic wounds impose on an average clinical commissioning group/health board in the UK.

OBJECTIVE: To estimate the patterns of care and related resource use attributable to managing acute and chronic wounds among a catchment population of a typical clinical commissioning group (CCG)/health board and corresponding National Health Service (NHS) costs in the UK. METHOD: This was a sub-analysis of a retrospective cohort analysis of the records of 2000 patients in The Health Improvement Network (THIN) database. Patients' characteristics, wound-related health outcomes and health-care resource use were quantified for an average CCG/health board with a catchment population of 250,000 adults ≥18 years of age, and the corresponding NHS cost of patient management was estimated at 2013/2014 prices. RESULTS: An average CCG/health board was estimated to be managing 11,200 wounds in 2012/2013. Of these, 40% were considered to be acute wounds, 48% chronic and 12% lacking any specific diagnosis. The prevalence of acute, chronic and unspecified wounds was estimated to be growing at the rate of 9%, 12% and 13% per annum respectively. Our analysis indicated that the current rate of wound healing must increase by an average of at least 1% per annum across all wound types in order to slow down the increasing prevalence. Otherwise, an average CCG/health board is predicted to manage ~23,200 wounds per annum by 2019/2020 and is predicted to spend a discounted (the process of determining the present value of a payment that is to be received in the future) £50 million on managing these wounds and associated comorbidities. CONCLUSION: Real-world evidence highlights the substantial burden that acute and chronic wounds impose on an average CCG/health board. Strategies are required to improve the accuracy of diagnosis and healing rates.

Clinical outcomes and cost-effectiveness of three different compression systems in newly-diagnosed venous leg ulcers in the UK.

OBJECTIVE: To assess clinical outcomes and cost-effectiveness of using a two-layer cohesive compression bandage (TLCCB; Coban 2) compared with a two-layer compression system (TLCS; KTwo) and a four-layer compression system (FLCS; Profore) in treating newly-diagnosed venous leg ulcers (VLUs) in clinical practice in the UK, from the perspective of the NHS. METHOD: This was a retrospective cohort analysis of the case records of patients with newly-diagnosed VLUs randomly extracted from The Health Improvement Network (THIN) database (a nationally representative database of clinical practice among patients registered with general practitioners in the UK) who were treated with either TLCCB (n=200), TLCS (n=200) or FLCS (n=200). The clinical outcomes and cost-effectiveness of the alternative compression systems were estimated over six months after starting treatment. RESULTS: Patients' mean age was 72 years and 58% were female. Time from wound onset to the start of compression was a mean of two months, and when starting compression the wound size was a mean of 45 cm2. The distribution of healing was significantly different between the three groups; 76% of wounds in the TLCCB group healed by six months compared with 70% and 64% in the TLCS and FLCS groups, respectively (p=0.006). Time to healing was significantly less in the TLCCB group compared with the two other groups (p=0.003). Patients in the TLCCB group experienced better health-related quality of life over six months (0.413 quality-adjusted life years (QALYs) per patient), compared with the TLCS and FLCS groups (0.404 and 0.396 QALYs per patient, respectively). The mean six-month NHS management cost was £3045, £3842 and £4480 per patient in the TLCCB, TLCS and FLCS groups, respectively. CONCLUSION: Real-world evidence demonstrates that treating newly-diagnosed VLUs with TLCCB, compared with the other two compression systems, affords a more cost-effective use of NHS-funded resources in clinical practice since it resulted in an increased healing rate, better health-related quality of life and a reduction in NHS management cost.

Cost-effectiveness of using adjunctive porcine small intestine submucosa tri-layer matrix compared with standard care in managing diabetic foot ulcers in the US.

OBJECTIVE: To estimate the cost-effectiveness of using tri-layer porcine small intestine submucosa (SIS; Oasis Ultra) as an adjunct to standard care compared with standard care alone in managing diabetic foot ulcers (DFUs) in the US, from the perspective of Medicare. METHOD: A Markov model was constructed to simulate the management of diabetic neuropathic lower extremity ulcers over a period of one year in the US. The model was used to estimate the cost-effectiveness of initially using adjunctive SIS compared with standard care alone to treat a DFU in the US at 2016 prices. RESULTS: At 12 months after the start of treatment, the use of adjunctive SIS instead of standard care alone is expected to lead to a 42 % increase in the number of ulcer-free months, 32 % increase in the probability of healing, a 3 % decrease in the probability of developing complicated ulcers and a 1 % decrease in the probability of undergoing an amputation. Health-care resource use is expected to be reduced by 11-14 % among patients who are initially managed with adjunctive SIS compared with those initially managed with standard care alone, with the exception of debridement, which is expected to be reduced by 35 %. Hence, the total health-care cost of starting treatment with adjunctive SIS instead of standard care alone was estimated to reduce payer costs by 1% (i.e. $105 per patient) over 12 months following the start of treatment. CONCLUSION: Within the study's limitations, the use of adjunctive SIS instead of standard care alone improves outcome for less cost and thereby affords a cost-effective use of Medicare-funded resources in the management of neuropathic foot ulcers among adult patients with type 1 or 2 diabetes mellitus in the US.

Clinical outcomes and cost-effectiveness of an externally applied electroceutical device in managing venous leg ulcers in clinical practice in the UK.

OBJECTIVE: To estimate the cost-effectiveness of treating patients with a venous leg ulcer (VLU) with an externally applied electroceutical (EAE) device, plus dressings and compression bandaging or continuing with their previous care plan, from the perspective of the National Health Service (NHS) in the UK. METHOD: This was a prospective, single-arm, non-blinded, clinical and economic evaluation of EAE therapy performed in 2013/14. Patients' VLUs were treated with six active units of EAE therapy (each unit for two days) plus dressings and compression bandaging over a period of 12 days. Afterwards, patients were managed with a combination of dressings and bandages. Each patient acted as their own control so that clinical outcomes, resource use and costs associated with the wound over 12 months before the start of EAE therapy were retrospectively compared with the first 12 months after the start of treatment. The relative cost-effectiveness of EAE therapy was estimated at 2013/14 prices. RESULTS: Within 12 months of starting EAE therapy 77% of all wounds healed and the other 23% improved. This difference in effectiveness between the 12-months period before and after EAE therapy was estimated to yield a 12% improvement in health gain of 0.09 QALYs (p<0.01), a 34% reduction in the requirement for nurse visits (from a mean 50.7 to 33.3 visits per patient) and a 26% reduction in the number of dressings. This resulted in an 11% reduction in the NHS cost of VLU management over 12 months after the start of treatment when compared with the previous 12 months (from £1,981 to £1,754 per patient). Hence, use of EAE therapy was found to be a dominant treatment (i.e. improved outcome for less cost). CONCLUSION: Within the study's limitations, use of the EAE device potentially affords the NHS a cost-effective treatment for managing VLUs when compared with patients remaining on their previous care plan.

Clinical outcomes and cost-effectiveness of three alternative compression systems used in the management of venous leg ulcers.

OBJECTIVE: To assess clinical outcomes and cost-effectiveness of using a two-layer cohesive compression bandage (TLCCB; Coban 2) compared with a two-layer compression system (TLCS; Ktwo) and a four-layer compression system (FLCS; Profore) in treating venous leg ulcers (VLUs) in clinical practice in the UK, from the perspective of the National Health Service (NHS). METHOD: This was a retrospective analysis of the case records of VLU patients, randomly extracted from The Health Improvement Network (THIN) database (a nationally representative database of clinical practice among patients registered with general practitioners in the UK), who were treated with either TLCCB (n=250), TLCS (n=250) or FLCS (n=175). Clinical outcomes and health-care resource use (and costs) over six months after starting treatment with each compression system were estimated. Differences in outcomes and resource use between treatments were adjusted for differences in baseline covariates. RESULTS: Patients' mean age was 75 years old and 57% were female. The mean time with a VLU was 6-7 months and the mean initial wound size was 77-85 cm2. The overall VLU healing rate, irrespective of bandage type, was 44% over the six months' study period. In the TLCCB group, 51% of wounds had healed by six months compared with 40% (p=0.03) and 28% (p=0.001) in the TLCS and FLCS groups, respectively. The mean time to healing was 2.5 months. Patients in the TLCCB group experienced better health-related quality of life (HRQoL) over six months (0.374 quality-adjusted life years (QALYs) per patient), compared with the TLCS (0.368 QALYs per patient) and FLCS (0.353 QALYs per patient). The mean six-monthly NHS management cost was £2,413, £2,707 and £2,648 per patient in the TLCCB, TLCS and FLCS groups, respectively. CONCLUSION: Despite the systems studied reporting similar compression levels when tested in controlled studies, real-world evidence demonstrates that initiating treatment with TLCCB, compared with the other two compression systems, affords a more cost-effective use of NHS-funded resources in clinical practice, since it resulted in an increased healing rate, better HRQoL and a reduction in NHS management cost. The evidence also highlighted the lack of continuity between clinicians managing a wound, the inconsistent nature of the administered treatments and the lack of specialist involvement, all of which may impact on healing. DECLARATION OF INTEREST: This study was supported by an unrestricted research grant from 3M Health Care, UK. 3M Health Care had no influence on the study design, the collection, analysis, and interpretation of data, or on the writing of, and decision to submit for publication, the manuscript.

Is it time to re-appraise the role of compression in non-healing venous leg ulcers?

OBJECTIVE: To evaluate the role of compression in non-healing venous leg ulcers (VLUs) of > 3 months' duration. METHOD: Patients' records from three independent data sets of non-healing VLUs of > 3 months'duration were re-analysed.Two data sets were separate audits of clinical practice and the third comprised patients' records from a randomised controlled trial. Some patients in each data set were never treated with compression. The effect of compression on healing at 6 months was tested with logistic regression. RESULTS: In each data set, patients in the compression and no-compression groups were matched according to ulcer size and duration; there were no differences in comorbidities. Comparing the no-compression with the compression groups, the healing rate at 6 months was 68% vs 48% in study 1, 12% vs 6% in study 2, and 26% vs 11% in study 3. Use of compression was found to be an independent predictor of not healing with an odds ratio of 0.422, 0.456 and 0.408 in studies 1, 2 and 3 respectively. CONCLUSION: The healing rate of non-healing VLUs of > 3 months' duration in the no-compression groups was double that of VLUs in the compression groups. These findings have the potential for treatment modification if confirmed in a prospective trial. DECLARATION OF INTEREST: There were no external sources of funding for this study. The authors have no conflicts of interest that are directly relevant to the content of this manuscript, which remains their sole responsibility.

Clinical and cost-effectiveness of absorbent dressings in the treatment of highly exuding VLUs.

OBJECTIVE: To estimate the clinical effectiveness and cost effectiveness of using a sodium carboxymethylcellulose dressing (CMC [Aquacel]) and four super absorbent dressings (DryMax Extra[DM], Flivasorb [F], Kerramax [K] and sachet S [S]) in the treatment of highly exuding chronic venous leg ulcers (VLUs) in the UK, from the perspective of the National Health Service (NHS). METHOD: A decision model was constructed depicting the patient pathways and associated management of a cohort of 439 patients with highly exuding chronic VLUs of;;: 3 months of age. The model was based on the case records of a cohort of matched patients from The Health Improvement Network (THIN)database (a nationally representative database of patients registered with general practitioners (GPs) in the UK) who were treated with one of the five dressings. The model estimated the costs and outcomes of patient management over 6 months and the relative cost-effectiveness of using each dressing. RESULTS: Patients' mean age was 73.1 years, and 46% were female. Between 39% and 56% ofVLUs healed by 6 months. CMC-treated wounds that remained unhealed increased in size by 43% over the study period, whereas unhealed wounds treated with the other dressings decreased in size by a mean 34%. Consequently, CMC was excluded from the cost-effectiveness analysis. The 6-monthly NHS cost of managing a VLU with S was £3700 per patient, which was 15-28% lower than the cost of managing patients with the other three super absorbents. Additionally, use of S improved patients' health status to a greater extent than the other three super absorbents, since S-treated patients accrued 0.3-3% more QALYs. Starting treatment with S was the preferred strategy followed by DM, K and Fin that order. CONCLUSION: Within the limitations of the data set,S affords the NHS a cost-effective treatment for managing highly exuding chronic VLUs of ≥3 months of age, compared with DM, F, K and CMC.

Costs and outcomes over 36 years of patients with phenylketonuria who do and do not remain on a phenylalanine-restricted diet.

BACKGROUND: To quantify the costs and consequences of managing phenylketonuria (PKU) in the UK and to estimate the potential implications to the UK's National Health Service (NHS) of keeping patients on a phenylalanine-restricted diet for life. METHOD: A computer-based model was constructed depicting the management of PKU patients over the first 36 years of their life, derived from patients suffering from this metabolic disorder in The Health Improvement Network database (a nationally representative database of patients registered with general practitioners in the UK). The model was used to estimate the incidence of co-morbidities and the levels of healthcare resource use and corresponding costs over the 36 years. RESULTS: Patients who remained on a phenylalanine-restricted diet accounted for 38% of the cohort. Forty-seven per cent of patients discontinued their phenylalanine-restricted diet between 15 and 25 years of age. Of these, 73% remained off diet and 27% restarted a restricted diet at a mean 30 years of age. Fifteen per cent of the cohort had untreated PKU. Eleven per cent of patients who remained on a phenylalanine-restricted diet for 36 years received the optimum amount of prescribed amino acid supplements. Patients had a mean 12 general practitioner visits per year and one hospital outpatient visit annually, but phenylalanine levels were only measured once every 18 to 24 months. The mean NHS cost (at 2007/08 prices) of managing a PKU sufferer over the first 36 years of their life was estimated to range between £21 000 and £149 000, depending on the amount of prescribed nutrition they received. CONCLUSION: The findings suggest that the majority of patients with PKU were under-treated. The NHS cost of patient management should not be an obstacle to encouraging patients to remain on a restricted diet until further information becomes available about the long-term clinical impact of stopping such a diet. Nevertheless, patients require counselling and managed follow up regardless of the choices they make about their diet.

Relative cost-effectiveness of a skin protectant in managing venous leg ulcers in the UK.

OBJECTIVE: To estimate the clinical and cost-effectiveness of using a skin protectant (Cavilon No Sting Barrier Film [NSBF] or Cavilon Durable Barrier Cream [DBC]; 3M) compared with not using a skin protectant in the management of venous leg ulcers (VLUs), in the UK. METHOD: A decision model was constructed depicting the patient pathways and associated management of a cohort of patients with and without a Cavilon formulation, plus dressings and compression. The model was based on the case records of a cohort of matched patients from The Health Improvement Network (THIN) database, who were first diagnosed with a VLU between 1 Jan 2008 and 31 Dec 2009. The model estimated the costs and outcomes of patient management over 6 months and the cost-effectiveness of using a Cavilon formulation relative to not using a skin protectant. RESULTS: Patients' mean age was 80.2 years and 61% were female. Sixty-five per cent (n=166) of Cavilon patients received NSBF, and 35% received DBC. Between 6% and 9% of VLUs were healed at 6 months and 53-66% became infected. Healing was affected by a patient's age (OR: 0.944 for each additional year), but not by gender, level of exudate or wound size. There was a significantly greater reduction in wound size among patients in the NSBF group than in the other two groups (p<0.001). Additionally, there was no significant difference in the initial wound size of those VLUs that did and did not heal in the two Cavilon groups; however, initial size of the VLUs that healed in the control group was significantly smaller than those that did not (p<0.001). Resource use was similar between the three groups. Patients were predominantly managed by practice nurses, with a mean 37-38 nurse visits over the study period. Patients' dressings were changed, on average, every 4-5 days, with a mean of 3 dressings under a compression bandage. The total 6-monthly NHS cost of managing a VLU was ~£2200. Practice nurse visits were the primary cost driver, accounting for up to 58% of the 6-monthly NHS cost, whereas dressings accounted for <10% of the cost. CONCLUSION: Use of NSBF leads to significantly greater wound size reduction than that observed in the other two groups and may facilitate the healing of larger wounds without increasing costs. Hence, use of NSBF for peri-wound skin protection in patients with exuding VLUs is the preferred treatment strategy. DECLARATION OF INTEREST: This study was sponsored by 3M Health Care, manufacturers of Cavillon NSBF and Cavillon DBC. However, the authors have no other conflicts of interest that are directly relevant to the content of this manuscript, which remains their sole responsibility.

Modelling the cost-effectiveness of electric stimulation therapy in non-healing venous leg ulcers.

OBJECTIVE: To estimate the cost-effectiveness of using electric stimulation (ES) therapy (Accel-Heal) plus dressings and compression bandaging compared with dressings and compression bandaging alone in treating chronic, non-healing venous leg ulcers (VLUs) of >6 months' duration from the perspective of the National Health Service (NHS) in the UK. METHOD: A 5-month Markov model was constructed, depicting the management of a chronic, non-healing VLU of >6 months' duration. The model considers the decision by a clinician to continue with a patient's previous care plan (comprising dressings and compression bandaging) or treating with ES therapy plus dressings and compression bandaging. The model was used to estimate the relative cost-effectiveness of ES therapy at 2008-2009 prices. RESULTS: According to the model, 38% of VLUs are expected to heal within 5 months after starting ES therapy, with a further 57% expected to improve. This improvement in clinical outcome is expected to lead to a 6% health gain of 0.017 QALYs (from 0.299 to 0.316 QALYs) over 5 months. The model also showed that using ES therapy instead of continuing with a patient's previous care plan is expected to reduce the NHS cost of managing them by 15%, from £880 to £749, due in part to a 27% reduction in the requirement for nurse visits (from mean 49.0 to 35.9 visits per patient) over the first 5 months after the start of treatment. Hence, use of ES therapy was found to be a dominant treatment (improved outcome for less cost). CONCLUSION: Within the model's limitations, use of ES therapy potentially affords the NHS a cost-effective treatment, compared with patients remaining on their previous care plan in managing chronic, non-healing VLUs of >6 months' duration. However, this is dependant on the number of ES therapy units per treatment, the unit cost of the device, and the number of nurse visits required to manage patients in clinical practice. DECLARATION OF INTEREST: This study was sponsored by Synapse Microcurrent Ltd., manufacturers of Accel-Heal. The authors have no other conflicts of interest that are directly relevant to the content of this manuscript. In particular, Synapse Microcurrent Ltd. had no role in the study design, in the collection, analysis and interpretation of data, or in writing the manuscript.

Clinical and economic evidence supporting a transparent barrier film dressing in incontinence-associated dermatitis and peri-wound skin protection.

OBJECTIVE: To summarise the clinical and economic literature relating to the effect of Cavilon No Sting Barrier Film on the incidence of incontinence-associated dermatitis, which is a risk factor for pressure ulceration and exudate-related peri-wound skin damage. METHOD: A systematic literature search was performed using available computerised databases for publications on Cavilon barrier film and other relevant terms. Six clinical studies were identified providing data on 1,563 patients treated with the barrier film or a comparator. The publications comprised prospective studies, randomised and non-randomised studies, multicentre trials, single-centre reports and a volunteer study. Due to the nature of the comparators, five studies were open-label. Differences in methodology and outcomes made a qualitative review the most appropriate analysis. RESULTS: The barrier film was at least as effective as petroleum ointments and more effective than zinc oxide formulations in preventing incontinence-associated dermatitis. The barrier film was also effective in peri-wound skin protection, although its clinical efficacy was not significantly different to that of petroleum ointments and zinc oxide formulations. Nevertheless, the barrier film was more cost-effective than either petroleum ointments or zinc oxide formulations in managing incontinence-associated dermatitis and peri-wound skin protection, largely due to savings in nursing time. CONCLUSION: The barrier film is at least as clinically effective and potentially more cost-effective in incontinence-associated dermatitis prophylaxis and peri-wound skin protection than petroleum ointments or zinc oxide formulations, releasing health care resources for alternative use. Further studies are required to quantify the relative efficacy and cost-effectiveness of the barrier film and other barrier formulations in different clinical settings and enhance the quality of the evidence base.

Resource implications and budget impact of managing cow milk allergy in the UK.

AIM: To determine current treatment patterns for infants with cow milk allergy (CMA) and the associated resource implications and budget impact, from the perspective of the UK's National Health Service (NHS). METHODS: A computer-based model was constructed depicting current management of newly-diagnosed infants with CMA derived from patients suffering from this allergy in The Health Improvement Network (THIN) Database. The model spanned a period of 12 months following initial presentation to a general practitioner (GP) and was used to estimate the 12-monthly healthcare cost (at 2006/07 prices) of treating an annual cohort of 18,350 infants from when they initially present to their GP. RESULTS: Patients presenting with a combination of gastrointestinal and atopic symptoms accounted for 59% of all patients. From the initial GP visit for CMA it took a mean 2.2 months to be put on diet, although treatment varied according to presenting symptoms. A total of 60% of all infants were initially treated with soy, 18% with an extensively hydrolysed formula and 3% with an amino acid formula. A mean 9% of patients remained symptomatic on soy and 29% on an extensively hydrolysed formula. The total cost of managing CMA over the first 12 months following initial presentation to a GP was estimated to be £1,381 per patient and £25.6 million for an annual cohort of 18,350 infants. LIMITATIONS: Patients were not randomised to treatment and resource use was not collected prospectively. Nevertheless, 1,000 eligible patients have been included in the analysis, which should be a sufficiently large sample to accurately assess treatment patterns and healthcare resource use in actual clinical practice. The diagnosis of CMA may not be secure in all cases. Nevertheless, patients were diagnosed as having CMA by a clinician and have been managed by their GP as if they had CMA. CONCLUSION: CMA imposes a substantial burden on the NHS. Any strategy that improves healthcare delivery and thereby shortens time to treatment, time to diagnosis and time to symptom resolution should potentially decrease the burden this allergy imposes on the health service and release resources for alternative use.

The cost-effectiveness of macrogol 3350 compared to lactulose in the treatment of adults suffering from chronic constipation in the UK.

BACKGROUND: It is unknown whether macrogol 3350 (Movicol) affords the UK's National Health Service (NHS) a cost-effective addition to the current range of laxatives. AIM: To estimate the cost-effectiveness of macrogol 3350 compared with lactulose in the treatment of chronic constipation, from the perspective of the UK's NHS. METHODS: A decision model depicting the management of chronic constipation was constructed using clinical outcomes and resource use values derived from patients suffering from chronic constipation in The Health Independent Network (THIN) database. The model was used to estimate the cost-effectiveness of a GP prescribing macrogol 3350 instead of lactulose to treat adults > or =18 years of age suffering from chronic constipation. RESULTS: Sixty-eight percent of patients given macrogol 3350 were successfully treated within 6 months after starting treatment compared to 60% of patients given lactulose.Patients' health status at 6 months was estimated to be 0.458 and 0.454 quality-adjusted life years (QALYs) in the macrogol 3350 and lactulose groups respectively. The total 6-monthly NHS cost of initially treating patients with macrogol 3350 or lactulose was estimated to be pound420 (US $688) and pound419 (US $686) respectively. Hence, the cost per QALY gained with macrogol 3350 was estimated to be pound250 (US $410). CONCLUSION: Macrogol 3350 affords the NHS a cost-effective addition to the range of laxatives available for this potentially resource-intensive condition.

Modelling the relative cost-effectiveness of amelogenin in non-healing venous leg ulcers.

OBJECTIVE: To assess the cost-effectiveness of using amelogenin plus compression bandaging versus compression bandaging alone in treating non-healing venous leg ulcers (VLUs) of over six months duration, from the perspective of the national health service in England. METHOD: A 12-month Markov model was constructed that depicted the management of a chronic, non-healing VLU of over six months duration. The model considers the decision by a clinician to treat a recalcitrant VLU with amelogenin plus compression bandaging or compression bandaging alone, and was used to estimate the relative cost-effectiveness of amelogenin plus compression bandaging at 20062007 prices. RESULTS: According to the model, 60% of all wounds treated with amelogenin plus compression bandaging are expected to heal within 12 months of the start of treatment compared with 41% of wounds treated with compression bandaging alone (p<0.01). Additionally, 23% of all amelogenin-treated wounds are expected to improve compared with 18% of wounds in the compression bandaging alone group. This difference in effectiveness between the two groups is expected to lead to a 7% improvement in health gain among amelogenin-treated patients when compared with those treated with compression bandaging alone (0.800 versus 0.746 QALYs; p<0.01) at 12 months after the start of treatment. Use of amelogenin is expected to lead a 10% reduction in NHS cost over 12 months from pound4,261 (95% CI: pound3,409; pound5,114) to pound3,816 (95% CI: pound3,227; pound4,405), due in part to a reduction in the requirement for nurse visits. Hence, amelogenin plus compression bandaging was found to be a dominant treatment. Moreover, use of amelogenin is expected to free-up NHS resources for alternative use within the system. CONCLUSION: Within the models limitations, amelogenin plus compression bandaging is expected to afford the NHS a cost-effective dressing compared with compression bandaging alone in the management of chronic non-healing VLUs of more than six months duration. DECLARATION OF INTEREST: This study was sponsored by Mölnlycke Heath Care. The authors have no other conflicts of interest that are directly relevant to the content of this manuscript.

Modelling the resource implications and budget impact of managing cow milk allergy in Australia.

OBJECTIVE: To estimate the resource implications and budget impact of current clinical practice for managing cow milk allergy (CMA) in Australia, from the perspective of the publicly funded healthcare system. METHODS: A decision model was constructed using published clinical outcomes and clinician-derived resource utilisation estimates. The model was used to estimate the expected 6-monthly levels of healthcare resource use and corresponding costs attributable to managing 6150 new CMA sufferers following referral to a specialist. RESULTS: The expected 6-monthly costs of managing 6150 newly-diagnosed infants with CMA following referral to a specialist was an estimated (Australian dollars, AU$) AU$6.5 million at 2006/07 prices. Clinical nutrition preparations were found to be the primary cost driver accounting for 62% of the total 6-monthly cost and clinician visits were the secondary cost driver accounting for up to a further 28% of the total 6-monthly cost. Sensitivity analysis showed there would be fewer visits to hospital-based paediatric gastroenterologists and paediatric immunologists/allergists if all newly-diagnosed patients were prescribed an amino acid formula (AAF) following referral to a specialist, instead of being managed according to current practice. CONCLUSION: CMA imposes a substantial burden on the publicly funded healthcare system in Australia. However, using an AAF as the initial treatment for CMA can potentially release limited hospital resources for alternative use within the paediatric healthcare system.

Cost-effectiveness of using continuous positive airway pressure in the treatment of severe obstructive sleep apnoea/hypopnoea syndrome in the UK.

OBJECTIVE: A study was undertaken to estimate the cost-effectiveness of using continuous positive airway pressure (CPAP) in the management of patients with severe obstructive sleep apnoea/hypopnoea syndrome (OSAHS) compared with no treatment from the perspective of the UK's National Health Service (NHS). METHODS: A Markov model was constructed to assess the cost-effectiveness of CPAP compared with no treatment. The model depicted the management of a 55-year-old patient with severe OSAHS as defined by an apnoea-hypopnoea index (AHI) >30 and daytime sleepiness (Epworth Sleepiness Scale score >or=12). The model spans a period of 14 years. RESULTS: According to the model, 57% of untreated patients are expected to be alive at the end of 14 years compared with 72% of patients treated with CPAP. Untreated patients are expected to cost the NHS pound10 645 (95% CI pound7988 to pound14,098) per patient over 14 years compared with pound9672 (95% CI pound8057 to pound12,860) per CPAP-treated patient. Treatment with CPAP for a period of 1 year was found not to be a cost-effective option since the cost per quality-adjusted life year (QALY) gained is expected to be > pound20,000, but after 2 years of treatment the cost per QALY gained is expected to be pound10,000 or less and, after 13 years of treatment, CPAP becomes a dominant treatment (ie, more effective than no treatment for less cost). CONCLUSION: Within the limitations of the model, CPAP was found to be clinically more effective than no treatment and, from the perspective of the UK's NHS, a cost-effective strategy after a minimum of 2 years of treatment.

Palliative care treatment patterns and associated costs of healthcare resource use for specific advanced cancer patients in the UK.

The purpose of this paper is to identify the treatment patterns and corresponding costs of healthcare resource use associated with palliative care for different types of advanced cancer patients, from the time they started strong opioid treatment until death. This was a modelling study performed from the perspective of the UK's National Health Service (NHS). A data set was created comprising 547 patients in the DIN-Link database who had a Read code for malignant neoplasms with a specific tumour-type diagnosis and who received their first strong opioid between 1 January 1998 and 30 September 2000 and died during that period. Palliative care-related resource utilization data were obtained from the DIN-Link database. Unit costs at 2000/2001 prices were applied to the resource use estimates to determine the mean cost of palliative care from the start of treatment until death. There were significant differences in age between patients with different cancer types and in patients' survival from diagnosis, time to the start of palliative care and duration of palliative care. The mean duration from cancer diagnosis to the start of strong opioid treatment ranged from 0.7 to 5.4 years in patients with lung and breast cancer respectively. Moreover, the length of palliative care ranged from 180 to 372 days in patients with these cancer types respectively. There were also statistically significant differences in resource use between patients with different cancer types, but this reflected, in part, the varying durations of palliative care. Nevertheless, there were also differences in the monthly number of primary care visits reflecting the different number of monthly prescriptions. There was no apparent relationship between the length and corresponding cost of palliative care which ranged from 1816 pounds sterling for colon cancer to 4789 pounds sterling for ovarian cancer. Additionally, on average, only a third of all patients also received 4-hourly morphine as part of their initial strong opioid treatment. The total cost of palliative care varied between cancer type and reflects, at least in part, the distinct clinical features associated with different tumours and the varying lengths of survival following the start of strong opioid treatment. Nevertheless, no apparent relationship was found between length of palliative care and corresponding costs. This analysis provides data on palliative care resource use for a variety of cancers and could provide useful input when planning local healthcare strategies and building service commissioning models.