Direct healthcare costs of glaucoma treatment.

AIMS: To report the complete lifetime direct healthcare costs of glaucoma treatment in a database of 1136 patients attending the Glaucoma Clinic at Glasgow Royal Infirmary, Glasgow, UK. METHOD: The database was interrogated to identify all patients who had initiated treatment at the Glaucoma Clinic at Glasgow Royal Infirmary, and who had subsequently died of natural causes. The healthcare resource use based cost assessment was based on two aspects of the direct National Health Service cost: drug costs (prescribed medications) and non-drug costs (inpatient or outpatient/and surgical or procedure costs). RESULTS: 106 patients (53 men, 53 women) were identified for whom there were lifetime treatment data. The mean lifespan of the patients was 80.5 years, and the mean number of years attending the glaucoma clinic was 7.05 years (range 1-22 years). The mean cost of glaucoma treatment over the lifetime of the patients was £3001, with an annual mean cost per patient of £475. Non-drug and drug costs made up 66% and 34% respectively, of the lifetime costs. CONCLUSIONS: This is the only study to directly assess the lifetime treatment costs of glaucoma. Awareness of the costs of glaucoma treatment may be of increased importance in these financially challenging times.

Cost effectiveness of duloxetine in the treatment of fibromyalgia in the United States.

OBJECTIVE: To evaluate the cost effectiveness of duloxetine when considered as an alternative treatment for patients in the United States (US) being treated for fibromyalgia pain. RESEARCH DESIGN AND METHODS: A Markov model was used to evaluate the economic and clinical advantages of duloxetine in controlling fibromyalgia pain symptoms over a 2-year time horizon. A base-case treatment sequence was adopted from clinical guidelines, based on tricyclic antidepressants, serotonin-norepinephrine reuptake inhibitors, anticonvulsants, and opioids. Treatment response was modeled using changes from baseline in pain severity, and response thresholds: full response (at least a 50% change), response (30-49% change), and no response (less than a 30% change). Clinical efficacy and discontinuation data were taken from placebo- and active-controlled trials identified in a systematic literature review and mixed-treatment comparison. Utility data were based on EQ-5D data. MAIN OUTCOME MEASURES: Additional symptom-control months (SCMs), defined as the amount of time at a response level of 30% or less, and quality-adjusted life-years (QALYs) over a 2-year time horizon. RESULTS: For every 1000 patients, first-line duloxetine resulted in an additional 665 SCMs and 12.3 QALYs, at a cost of $582,911 (equivalent to incremental cost-effectiveness ratios [ICERs] of $877 per SCM and $47,560 per QALY). Second-line duloxetine resulted in an additional 460 SCMs and 8.7 QALYs, at a cost of $143,752 (equivalent to ICERs of $312 per SMC and $16,565 per QALY). LIMITATIONS: Response data for TCAs are limited to 30% improvement levels, reported trials are small, and have low placebo response rates. The model necessarily assumes that response rates are independent of placement in the treatment sequence. CONCLUSIONS: The results suggest that the introduction of duloxetine into the standard treatment sequence for fibromyalgia not only provides additional patient benefits, reflected by time spent in pain control, but also is cost effective when compared with commonly adopted thresholds.

Fracture liaison services for the evaluation and management of patients with osteoporotic fracture: a cost-effectiveness evaluation based on data collected over 8 years of service provision.

SUMMARY: The cost-effectiveness of Fracture Liaison Services (FLSs) for prevention of secondary fracture in osteoporosis patients in the United Kingdom (UK), and the cost associated with their widespread adoption, were evaluated. An estimated 18 fractures were prevented and £21,000 saved per 1,000 patients. Setup across the UK would cost an estimated £9.7 million. INTRODUCTION: Only 11% to 28% of patients with a fragility fracture receive osteoporosis treatment in the UK. FLSs provide an efficient means to identify patients and are endorsed by the Department of Health but have not been widely adopted. The objective of this study was to evaluate the cost-effectiveness of FLSs in the UK and the cost associated with their widespread adoption. METHODS: A cost-effectiveness and budget-impact model was developed, utilising detailed audit data collected by the West Glasgow FLS. RESULTS: For a hypothetical cohort of 1,000 fragility-fracture patients (740 requiring treatment), 686 received treatment in the FLS compared with 193 in usual care. Assessments and osteoporosis treatments cost an additional £83,598 and £206,544, respectively, in the FLS; 18 fractures (including 11 hip fractures) were prevented, giving an overall saving of £21,000. Setup costs for widespread adoption of FLSs across the UK were estimated at £9.7 million. CONCLUSIONS: FLSs are cost-effective for the prevention of further fractures in fragility-fracture patients. The cost of widespread adoption of FLS across the UK is small in comparison with other service provision and would be expected to result in important benefits in fractures avoided and reduced hospital bed occupancy.

Cost effectiveness of duloxetine in the treatment of diabetic peripheral neuropathic pain in the UK.

OBJECTIVE: The objective of this analysis was to evaluate the cost-effectiveness of duloxetine when considered as an additional treatment option for UK-based patients suffering from diabetic peripheral neuropathic pain. RESEARCH DESIGN AND METHODS: A decision-analytic model was used to represent the sequential management of patients with diabetic peripheral neuropathic pain. The standard UK treatment strategy was defined as first-line tricyclic antidepressants (amitriptyline), second-line anticonvulsants (gabapentin) and lastly an opioid-related treatment. The cost-effectiveness of duloxetine was evaluated as an additional first, second, third or fourth-line therapy over a 6-month treatment period for a cohort of 1000 patients. Treatment response was modelled based on changes from baseline pain severity using a standard 11-point pain scale (0-10); full response (>or= 50% change), partial response (30-49%) and no response (< 30%). The model was populated with efficacy and discontinuation data using indirect comparisons of treatment efficacy based on relative effects to a common placebo comparator. RESULTS: The second-line use of duloxetine resulted in cost savings of pound 77,071 for every 1000 treated patients, with an additional 29 patients achieving a full pain response when compared to standard UK treatment. Additional quality-adjusted life years (QALYs) were achieved at 1.88 QALYs per 1000 patients. CONCLUSIONS: This UK-based economic model suggests that second-line use of duloxetine is a beneficial and cost-effective treatment strategy for diabetic peripheral neuropathic pain.

Cost-effectiveness of high-dose chemotherapy in first-line treatment of advanced multiple myeloma.

The cost-effectiveness of high-dose chemotherapy in multiple myeloma was considered as part of a UK National Health Service Executive regional evidence-based appraisal process. The use of high-dose chemotherapy supported by autologous stem cell transplantation in patients under 65 years of age was shown to provide a marginal benefit of 0.7 life-years over conventional chemotherapy. This corresponded to an incremental cost 'per life-year gained' figure of approximately pound15 000, based upon initial treatment costs and trial-period data only. The use of high-dose chemotherapy in the first-line treatment of advanced multiple myeloma improves event-free and overall survival and appears to be a cost-effective treatment option.

Triaging patients with serious head injury: results of a simulation evaluating strategies to bypass hospitals without neurosurgical facilities.

OBJECTIVES: to inform the debate on whether seriously head-injured adult patients should be transported directly to the regional neurosurgical unit or indirectly after evaluation and stabilisation at the nearest hospital. DESIGN: a simulation model was constructed to compare triage strategies and to identify those that predicted the maximum survivors. In each strategy, an estimate of the patient's condition in the field was used to determine the receiving hospital. The model used data from previous publications and local ambulance service and hospital databases. In the absence of valid data, expert clinical estimates were made and subjected to sensitivity analyses. SETTING: an area in the North West Midlands of UK, covered by six acute hospitals including one with a regional neurosurgical unit. OUTCOME MEASURE: the number of survivors predicted by each triage strategy. RESULTS: five strategies were identified which consistently predicted the highest number of survivors. Compared with current policy it was predicted that in the North West Midlands, ten lives per year could be saved (6 per million total population per year). The results from sensitivity analyses did not alter these successful policies. CONCLUSION: the successful strategies should be considered as potential improvements to be introduced into clinical practice.

Hepatic resection for colorectal liver metastases: A cost-effectiveness analysis.

OBJECTIVE: To analyze the cost-effectiveness of resection for liver metastases compared with standard nonsurgical cytotoxic treatment. SUMMARY BACKGROUND DATA: The efficacy of hepatic resection for metastases from colorectal cancer has been debated, despite reported 5-year survival rates of 20% to 40%. Resection is confined to specialized centers and is not widely available, perhaps because of lack of appropriate expertise, resources, or awareness of its efficacy. The cost-effectiveness of resection is important from the perspective of managed care in the United States and for the commissioning of health services in the United Kingdom. METHODS: A simple decision-based model was developed to evaluate the marginal costs and health benefits of hepatic resection. Estimates of resectability for liver metastases were taken from UK-reported case series data. The results of 100 hepatic resections conducted in Sheffield from 1997 to 1999 were used for the cost calculation of liver resection. Survival data from published series of resections were compiled to estimate the incremental cost per life-year gained (LYG) because of the short period of follow-up in the Sheffield series. RESULTS: Hepatic resection for colorectal liver metastases provides an estimated marginal benefit of 1.6 life-years (undiscounted) at a marginal cost of 6,742 pound sterling++. If 17% of patients have only palliative resections, the overall cost per LYG is approximately 5,236 pound sterling (5,985 pound sterling with discounted benefits). If potential benefits are extended to include 20-year survival rates, these figures fall to approximately 1,821 pound sterling (2,793 pound sterling with discounted benefits). Further univariate sensitivity analysis of key model parameters showed the cost per LYG to be consistently less than 15,000 pound sterling. CONCLUSION: In this model, hepatic resection appears highly cost-effective compared with nonsurgical treatments for colorectal-related liver metastases.

Do we need to boost pertussis immunization within the existing UK vaccination schedule?

Pertussis infection is associated with significant morbidity in younger children (<4 years), which can include pneumonia, seizures and encephalopathy. Around one in 250 cases of pertussis in infants under the age of 6 months lead to death or severe brain damage. In the United Kingdom the control of pertussis infection has been based on a three-dose schedule of combined diphtheria, tetanus, whole-cell pertussis vaccine (DTPw) during the first 4 months of life. Coverage rates for primary vaccination are currently at high levels of over 90 per cent and infection rates are relatively low (approximately 1.2 per 100,000). However, there are concerns over the potential under-reporting of pertussis and clear shifts in the age pattern of notified cases are evident, with surveillance data suggesting a possible upward trend in the absolute numbers of infections in those at most risk (i.e. infants <3 months old). The addition of childhood booster dose(s) of pertussis vaccine to the standard schedule has potential clinical benefits and may be cost-effective. Selective adult booster immunization may also have a role to play in controlling the circulation of pertussis.

The cost-effectiveness of high dose chemotherapy in the treatment of relapsed Hodgkin's disease and non-Hodgkin's lymphoma.

As part of an NHS Executive Trent regional initiative we considered the role and cost-effectiveness of high dose chemotherapy in the treatment of relapsed Hodgkin's disease and non-Hodgkin's lymphoma. The key trials and case series show an additional patient benefit of 0.8-1.1 life years over standard chemotherapy. We estimate incremental cost per life year gained of 12 800 pound silver-17 600 pound silver, which reduces further if long-term benefits are considered. High dose chemotherapy in these conditions is both life-saving and cost-effective.