Valuation of EQ-5D-5L in the Kingdom of Saudi Arabia: A National Representative Study.

OBJECTIVES: To estimate a Saudi-specific value set for the EQ-5D-5L questionnaire using the EuroQol Valuation Technology program and the EuroQol Group's standard protocol. METHODS: Participants were quota-sampled from the Saudi adult population based on residency location, age group, gender, education level, and employment status. The participants were guided through the completion of composite time trade-off (cTTO) and discrete choice experiment (DCE) tasks by trained interviewers using EuroQol Valuation Technology software. Quality control (QC) measures were used to ensure good data quality. Random intercept and Tobit models analyzed the cTTO data, as well as models correcting for heteroskedasticity. DCE data were analyzed using conditional logit models, whereas hybrid models were used to analyze the cTTO and DCE data jointly. To evaluate model performance, prediction accuracy, logical consistency, significance level, and goodness of fit were used. RESULTS: The valuation study included a representative sample of the Saudi population (N = 1000). The hybrid heteroskedastic model without a constant was chosen as the preferred model for generating the value set. The predicted values ranged from -0.683 for the worst health state ("55555") to 1 for the full health state ("11111"). Pain and discomfort had the largest impact on health-state preference values, whereas usual activities had the least. CONCLUSION: The value set for the Kingdom of Saudi Arabia is the first value set for the EQ-5D-5L for any country in the Middle East. The value set can be used in Saudi health system economic evaluations and decision making.

Informing a cost-effectiveness threshold for Saudi Arabia.

BACKGROUND: Saudi Arabia's Vision 2030 aims to reform health care across the Kingdom, with health technology assessment being adopted as one tool promising to improve the efficiency with which resources are used. An understanding of the opportunity costs of reimbursement decisions is key to fulfilling this promise and can be used to inform a cost-effectiveness threshold. This paper is the first to provide a range of estimates of this using existing evidence extrapolated to the context of Saudi Arabia. METHODS AND MATERIALS: We use four approaches to estimate the marginal cost per unit of health produced by the healthcare system; drawing from existing evidence provided by a cross-country analysis, two alternative estimates from the UK context, and based on extrapolating a UK estimate using evidence on the income elasticity of the value of health. Consequences of estimation error are explored. RESULTS: Based on the four approaches, we find a range of SAR 42,046 per QALY gained (48% of GDP per capita) to SAR 215,120 per QALY gained (246% of GDP per capita). Calculated potential central estimates from the average of estimated health gains based on each source gives a range of SAR 50,000-75,000. The results are in line with estimates from the emerging literature from across the world. CONCLUSION: A cost-effectiveness threshold reflecting health opportunity costs can aid decision-making. Applying a cost-effectiveness threshold based on the range SAR 50,000 to 75,000 per QALY gained would ensure that resource allocation decisions in healthcare can in be informed in a way that accounts for health opportunity costs. LIMITATIONS: A limitation is that it is not based on a within-country study for Saudi Arabia, which represents a promising line of future work.

Healthcare in Saudi Arabia is undergoing wide-ranging reform through Saudi Arabia's Vision 2030. One aim of these reforms is to ensure that money spent on healthcare generates the most improvement in population health possible. To do this requires understanding the trade-offs that exist: funding one pharmaceutical drug means that same money is not available to fund another pharmaceutical drug. This is relevant whether the new drug would be funded from within the existing budget for healthcare or from an expansion of it. If the drugs apply to the same patient population and have the same price, the question is simply, "which one generates more health?" In reality, we need to compare pharmaceutical drugs for different diseases, patient populations, and at a range of potential prices to understand whether the drug in question would generate more health per riyal spent than what is currently funded by the healthcare system. This paper provides the first estimates of the amount of health, measured in terms of quality adjusted life years (QALYs), generated by the Saudi Arabian healthcare system. We find that the healthcare system generates health at a rate of one QALY produced for every 50,000­75,000 riyals spent (58­86% of GDP per capita). Using the range we estimate to inform cost-effectiveness threshold can aid decision-making.

Analysis of IoT-Related Ergonomics-Based Healthcare Issues Using Analytic Hierarchy Process Methodology.

The objective of the present work is for assessing ergonomics-based IoT (Internet of Things) related healthcare issues with the use of a popular multi-criteria decision-making technique named the analytic hierarchy process (AHP). Multiple criteria decision making (MCDM) is a technique that combines alternative performance across numerous contradicting, qualitative, and/or quantitative criteria, resulting in a solution requiring a consensus. The AHP is a flexible strategy for organizing and simplifying complex MCDM concerns by disassembling a compound decision problem into an ordered array of relational decision components (evaluation criteria, sub-criteria, and substitutions). A total of twelve IoT-related ergonomics-based healthcare issues have been recognized as Lumbago (lower backache), Cervicalgia (neck ache), shoulder pain; digital eye strain, hearing impairment, carpal tunnel syndrome; distress, exhaustion, depression; obesity, high blood pressure, hyperglycemia. "Distress" has proven itself the most critical IoT-related ergonomics-based healthcare issue, followed by obesity, depression, and exhaustion. These IoT-related ergonomics-based healthcare issues in four categories (excruciating issues, eye-ear-nerve issues, psychosocial issues, and persistent issues) have been compared and ranked. Based on calculated mathematical values, "psychosocial issues" have been ranked in the first position followed by "persistent issues" and "eye-ear-nerve issues". In several industrial systems, the results may be of vital importance for increasing the efficiency of human force, particularly a human-computer interface for prolonged hours.

Restriction on antimicrobial dispensing without prescription on a national level: Impact on the overall antimicrobial utilization in the community pharmacies in Saudi Arabia.

BACKGROUND: High rates of non-prescription dispensing of antimicrobials have led to a significant increase in the antimicrobial overuse and misuse in Saudi Arabia (SA). The objective of this study was to evaluate the antimicrobial utilization following the enforcement of a new prescription-only antimicrobial dispensing policy in the community pharmacy setting in SA. METHODS: Data were extracted from the IQVIA database between May 2017 and May 2019. The antimicrobial utilization rates, based on sales, defined daily dose in grams (DDD), DDD/1000 inhabitants/day (DID), and antimicrobial-claims for the pre-policy (May 2017 to April 2018) and post-policy (June 2018 to May 2019) periods were assessed. RESULTS: Overall antimicrobial utilization declined slightly (~9-10%) in the post-policy versus pre-policy period (sales, 31,334 versus 34,492 thousand units; DDD, 183,134 versus 202,936), with higher claims (~16%) after policy implementation. There was a sudden drop in the utilization rate immediately after policy enforcement; however, the values increased subsequently, closely matching the pre-policy values. Utilization patterns were similar in both periods; penicillin was the most used antimicrobial (sales: 11,648-14,700-thousand units; DDD: 71,038-91,227; DID: 2.88-3.78). For both periods, the highest dip in utilization was observed in July (sales: 1,027-1,559 thousand units; DDD: 6,194-9,399), while the highest spike was in March/October (sales: 3,346-3,884 thousand units; DDD: 22,329-19,453). CONCLUSION: Non-prescription antimicrobial utilization reduced minimally following policy implementation in the community pharmacies across SA. Effective implementation of prescription-only regulations is necessary.

Real-world evaluation of costs of illness for pneumonia in adult patients in Dubai-A claims database study.

BACKGROUND: Pneumonia is a significant cause of morbidity and mortality among adults globally. This retrospective cohort analysis assessed the pneumonia burden and related healthcare resource utilization and costs in the at-risk (low, medium, and high-risk) adult patients in Dubai, United Arab Emirates (UAE). METHODS: The claims data from January 1, 2014 to June 30, 2019 were extracted from the Dubai Real-World Claims Database for patients, aged ≥18 year, having at least 1 pneumonia claim. Data for the inpatient, outpatient and emergency visits were assessed for 12-months, before (pre-index) and after (follow-up) a pneumonia episode. Healthcare costs were calculated based on dollar value of 2020. RESULTS: Total 48,562 records of eligible patients were analyzed (mean age = 39.9 years; low [62.1%], medium [36.2%] and high [1.7%] risk cohorts). Mean all-cause healthcare costs were approximately >45% higher in the follow-up period (1,947 USD/patient) versus pre-index period (1,327 USD/patient). During follow-up period, the mean annual pneumonia incidence rate was 1.3 episodes, with a similar pattern across all cohorts. Overall, mean claims and costs (USD) per patient (all-cause) were highest in the high-risk cohort in the follow-up period (claims: overall, 11.6; high-risk, 22.0; medium-risk, 13.9; low-risk, 9.9; costs: high-risk, 14,184; medium-risk, 2,240; low-risk, 1,388). Similarly, the mean pneumonia-related costs (USD) per patient were highest for the high-risk cohort (overall: 1,305; high-risk, 10,207; medium-risk, 1,283; low-risk, 882), however, the claims were similar across cohorts (claims/patient: overall: 2.0; high-risk, 1.9; medium-risk, 2.2; low-risk, 1.9). Most all-cause and pneumonia-related costs were due to inpatient visits (4,901 and 4,818 USD respectively), while outpatient (1,232 and 166 USD respectively) and emergency visits (347 and 206 USD respectively) contributed significantly lesser. CONCLUSIONS: Pneumonia imposes a significant healthcare burden in the UAE, especially in the high-risk patients with severe comorbidities. These findings would guide clinicians and policy makers to make informed decisions.

Patient characteristics, adherence, and costs of oral anticoagulation therapy in non-valvular atrial fibrillation using the Dubai Real-World Claims Database.

BACKGROUND: Non-vitamin K antagonist oral anticoagulants (NOACs) reduce the risk of stroke in patients with non-valvular atrial fibrillation (NVAF) and have better safety profile than vitamin K antagonists (VKAs). However, there is a dearth of quality, real-world, patient data on the use of these drugs to guide healthcare policies in United Arab Emirates (UAE). AIMS AND OBJECTIVES: The aim is to address the knowledge gap in demographic and clinical profiles of NVAF patients on NOACs (apixaban, rivaroxaban, and dabigatran) and warfarin in UAE. MATERIALS AND METHODS: This retrospective cohort analysis utilized the Dubai Real-World Claims Database to extract anonymized longitudinal data on NVAF patients with at least one NOAC or warfarin claim between January 2015 and March 2019. Data examined included comorbidities, healthcare resource utilization (HCRU), treatment adherence, and clinical events. RESULTS: From 11,086 NVAF patients in the database, 940 patients on oral anticoagulant treatment were selected with mean age of 58.6 ± 14.7 years and 73.7% men. At baseline, the mean CHA2DS2-VASc risk score was 2.4, and the mean Deyo-Charlson comorbidity index (CCI) score was 1.6. Most patients (71%) started oral anticoagulation treatment on a standard index dose. High medication possession ratio (MPR) and proportion of days covered (PDC) were observed in 86.8% and 43.1% of the overall cohort. The mean number of HCRU claims and cost during the 180-day follow-up period was 18.5 and 9,747 USD, respectively. Warfarin users accounted for both the highest number of claims and cost, whereas apixaban accounted for the lowest figures. Time to first major bleeding was shorter for warfarin users compared with patients on NOACs. Longer times to first stroke/systemic embolism (SE) were observed for rivaroxaban and warfarin. CONCLUSION: This study provides important comparative insights about comorbidities, adherence, HCRU, and outcome events among NOAC and warfarin users from real-world clinical practice settings.

Clinical and economic burden of nonalcoholic steatohepatitis in Saudi Arabia, United Arab Emirates and Kuwait.

BACKGROUND AND AIMS: The Middle East (ME) has a high prevalence of nonalcoholic fatty liver disease (NAFLD) and nonalcoholic steatohepatitis (NASH), driven by obesity and type-2 diabetes mellitus (T2DM). Studies in Saudi Arabia (KSA) and United Arab Emirates (UAE) predict an escalating impact of NAFLD/NASH, particularly advanced fibrosis due to NASH (AF-NASH), increasing cases of cirrhosis, liver cancer and death. The scale of this burden in other ME countries is unknown with no reports of NAFLD/NASH healthcare resource utilization (HCRU) or costs. We estimated the clinical and economic burden of NAFLD/NASH in KSA, UAE and Kuwait. METHODS: Markov models populated with country-specific obesity and T2DM prevalence data estimated numbers and progression of NAFLD/NASH patients from 2018 to 2030. Model inputs, assumptions and outputs were collected from literature, national statistics, and expert consensus. RESULTS: Over 13 years, the KSA model estimated cases increasing as follows: patients with fibrosis F0-3 doubled to 2.5 m, compensated and decompensated cirrhosis and hepatocellular carcinoma trebled to 212,000; liver failure or transplant patients increased four-fold to 4,086 and liver-related death escalated from < 10,000 to > 200,000. Similar trends occurred in UAE and Kuwait. Discounted lifetime costs of NASH standard-care increased totaling USD40.41 bn, 1.59 bn and 6.36 bn in KSA, UAE (Emiratis only) and Kuwait, respectively. NASH-related costs in 2019 comprised, respectively, 5.83%, 5.80% and 7.66% of national healthcare spending. CONCLUSIONS: NASH, especially AF-NASH, should be considered a higher priority in ME Public Health policy. Our analyses should inform health policy makers to mitigate the enormity of this escalating regional burden.

Cross-sectional study on Asthma Insights and Management in the Gulf and Russia.

Background: Asthma is a chronic and complex lung disease that is not completely understood. It involves airway inflammation, reversible airflow obstruction, and bronchial hyperresponsiveness. The most common symptoms are recurrent wheezing, chest tightness, shortness of breath, and coughing. Objective: The Asthma Insights and Management study gathered information on the burden of asthma in the Gulf region (United Arab Emirates, Kuwait, Saudi Arabia) and Russia. Methods: This was a cross-sectional, multinational, noninterventional, two-phase study that collected data from patients ages ≥ 12 years, through interviews and a survey questionnaire. Phase 1 consisted of survey questions focused on estimating the asthma prevalence in the community. Phase 2 was designed to assess the level of asthma control, asthma-related perceptions and behaviors, and presentation patterns. Data were summarized by using descriptive analyses. Results: Analysis of data of 711 patients revealed that the prevalence of asthma among patients who lived in the community was 7.9% and that 66% subjectively perceived their asthma as being controlled. However, 97% of the patients' asthma were partially controlled or uncontrolled based on the Global initiative for Asthma control classification. Troubling symptoms were daytime coughing (33.3%) and shortness of breath (20.3%). With respect to medications for asthma, 76.2% of the patients reported the use of quick relief medication and 80.8% of maintenance medication during the past 4 weeks. Asthma exacerbation in the past year was reported by 40% of adults and adolescents in the study. Conclusion: The results showed that a significant proportion of the patients experienced bothersome symptoms and that many had a lack of knowledge about asthma control and treatment recommendations, which indicated that there is a need for improvements in patient education and asthma care in the Gulf and Russia regions.

Imatinib mesylate (Gleevec) induced unilateral optic disc edema.

PURPOSE: Imatinib mesylate (Gleevec) is a chemotherapy medication developed to treat chronic myelogenous leukemia as well as gastrointestinal stromal tumors (Savage, N Engl J Med 2002;346:683-93). Ocular side effects are commonly reported with the use of imatinib mesylate, such as periorbital edema and epiphora. More serious ocular side effects, such as optic disc edema, are rarely reported. CASE REPORT: This case is of a patient who presented with monocular painless loss of vision in the left eye from a previously documented 20/20 to 20/70 shortly after starting treatment with imatinib mesylate. RESULTS: Every aspect of the ocular presentation and clinical history were addressed to unveil the cause of the disc edema. After ruling out all other causes, the patient was later diagnosed with unilateral optic disc edema as a related side effect of the toxicity from imatinib mesylate. CONCLUSIONS: The properties of imatinib mesylate and the possible etiology of secondary optic disc edema are discussed. This study aims to highlight the importance of systemic medications review for possible etiology of ocular disease as well as the multidisciplinary approach to managing oncology patients with ocular side effects.