Relationship between patient-reported disease severity and other clinical outcomes in osteoarthritis: a European perspective.

OBJECTIVE: To determine how patient-rated osteoarthritis (OA) severity correlates with other patient-reported and clinical outcomes in the European clinical setting. METHODS: We used the Adelphi Arthritis VII (2008) Disease Specific Program (DSP). OA severity was patient-rated using the question 'How bad would you say your arthritis is now?' with responses of 'mild,' 'moderate,' and 'severe.' Patient-reported outcomes included a 0-100 mm pain visual analogue scale (VAS); questions on daily functioning; Work Productivity and Activity Impairment (WPAI) scale; and EuroQoL (EQ-5D). Regression models and chi-square analyses evaluated relationships between self-rated OA severity and other outcomes. RESULTS: Patient-reported data were available from 1739 individuals (63.1% female, mean age 64.4 [standard deviation 11.9] years) from France, Germany, Italy, Spain, and the UK. With increasing OA severity; mild (24.5%), moderate (56.3%), severe (19.2%), statistically significant differences (p<0.05) were observed with higher pain VAS scores (28.3, 49.9, 69.2, respectively), reduced function, and greater overall work impairment due to OA (24.3%, 38.5%, 68.6%, respectively). Significant associations of patient-reported OA severity with function and health status were indicated, including the EQ-5D health state index; 0.77 (mild), 0.62 (moderate), 0.30 (severe) (p<0.0001). Physicians tended to overestimate patients who rated their OA as mild, and underrate patients who rated their OA as severe. CONCLUSIONS: In five European countries, patient-rated OA severity was associated with other patient-reported outcomes, and may be of benefit in the clinical setting when choosing treatment options aimed at improving pain, function and productivity, providing an accurate and tangible assessment of patient's perceptions of their disease.

Cost-effectiveness of salmeterol xinafoate/fluticasone propionate combination inhaler in chronic asthma.

OBJECTIVE: To determine where in the treatment steps recommended by the British Thoracic Society and Scottish Intercollegiate Guidelines Network (BTS/SIGN) Asthma Guideline it is cost-effective to use salmeterol xinafoate/fluticasone propionate combination inhaler (SFC) (Seretide) compared with other inhaled corticosteroid (ICS) containing regimens (with and without a long acting beta-2 agonist (LABA)) for chronic asthma in adults and children. RESEARCH DESIGN AND METHODS: Meta-analyses of percentage symptom-free days (%SFD) were used within a cost-effectiveness model. Time spent in two asthma control health states, 'symptom-free' and 'with-symptoms' was used as the measure of differential treatment effectiveness. SFC was compared with varying doses of fluticasone propionate (FP) and beclometasone dipropionate (BDP) with or without a separate salmeterol inhaler, and with the budesonide/formoterol combination inhaler (BUD/FORM) (Symbicort). Drug costs, non-drug costs and quality adjusted life years (QALY) were incorporated into the analyses. Results are presented as cost per QALY ratios and uncertainty explored using probabilistic sensitivity analysis. RESULTS: Compared with an increased dose of FP in adults, SFC either 'dominates' (i.e. cheaper and more effective) FP or the cost per QALY is 6852 pounds sterling. The cost per QALYs estimated in sensitivity analyses using BDP costs range from 5679 pounds sterling to 15,997 pounds sterling. For children the cost per QALY for SFC 50 Evohaler compared with an increased dose of FP is pound 15,739 pounds sterling. SFC is similarly clinically effective in improving %SFDs compared with FP plus salmeterol delivered in separate inhalers (mean differences for each dose comparison of -3.9 (low) (with a 95% confidence interval (CI): -12.96; 5.16); 4.10 (medium) (95% CI: -3.01; 11.21); -0.4 (high) (95% CI: -8.88; 8.08)) and BUD/FORM (mean difference of 0.40 (95% CI -3.69; 4.49)) in adults, and a cheaper SFC option is available at all doses (annual cost savings range from 18 pounds sterling-427 pounds sterling per patient). SFC was similarly effective compared with FP plus salmeterol in separate inhalers in children under 12 and also resulted in annual cost savings of between 47 pounds sterling and 77 pounds sterling. A number of other comparisons were also made and the results are available as electronic supplementary data. CONCLUSIONS: This is the first analysis to estimate the cost-effectiveness of SFC in chronic asthma compared with multiple comparators and based on a systematic identification of relevant trials and data on %SFDs. The findings suggest that for adults and children uncontrolled on BDP 400 microg/day or equivalent it is a cost-effective option to switch to SFC (at an equivalent ICS dose) compared with increasing the dose of ICS. For adults and children aged 12 years and over who have passed this point and are uncontrolled on BDP 800 microg/day or equivalent, switching to SFC remains a cost-effective approach. Where an adult or child requires an ICS and a LABA to be co-prescribed, SFC is a cost-effective option compared with FP or BDP plus salmeterol delivered in separate inhalers. In adults who require combination therapy, SFC is a cost-effective option compared with BUD/FORM.

Paying doctors by salary: a controlled study of general practitioner behaviour in England.

The study aim was to evaluate the impact of the experimental introduction of salaried contracts in England on general practitioner (GP) behaviour and the quality of care. A controlled before-and-after design was implemented involving ten practices of standard contract GPs, paid largely by capitation and fee-for-service, and ten salaried GP practices. Diaries and routinely available data were used to assess GP workload, and patient assessments of the quality of care were obtained by postal questionnaire. GPs in salaried practices spent less time on practice administration but more working out-of-hours and in direct patient care, allowing more patients to be seen. Total list sizes were smaller in salaried compared with standard contract practices, but lists per GP were higher because of staffing policies. Salaried GPs tended to provide shorter consultations compared with standard contract GPs, prescribe in fewer consultations, but referral rates were similar. Quality was rated as higher for seven out of thirteen aspects of care examined in salaried practices and two in standard contract practices. However, none of these differences were statistically significant. To conclude, salaried contracts did not adversely affect GP productivity and had little impact on other aspects of GP behaviour or the quality of care provided.

Salaried contracts in UK general practice: a study of job satisfaction and stress.

OBJECTIVES: To compare job satisfaction and stress levels of general practitioners (GPs) employed on salaried contracts with GPs on a 'standard' performance-related contract paid by fee-for-service and capitation. METHODS: Job satisfaction and stress levels were assessed using data from two postal surveys of GPs: a national survey of 'standard' contract GPs carried out in 1998; and a survey of salaried GPs and their non-salaried GP employers in 1999. Differences in satisfaction and stress scores were assessed by t-tests; regression analysis was used to control for confounding factors and possible selection bias. RESULTS: We achieved a response rate of 77% in the 1999 survey of salaried and non-salaried GPs; 48% of 'standard' contract GPs responded in the 1998 survey. We found that salaried GPs were as satisfied overall as both non-salaried GP employers and GPs on the 'standard' contract, even after controlling for confounding factors and selection bias. Salaried GPs were more satisfied with their remuneration, working hours and the recognition they got for their work. They experienced more stress with two factors but less stress with 19 factors compared with the 'standard' contract GPs. CONCLUSIONS: Overall job satisfaction levels among salaried doctors were similar to those of doctors on contracts paid by mixed fee-for-service and capitation. Future studies of job satisfaction levels under different doctor payment systems need to take account of the extent to which doctors have preferences for different types of contract if they are to derive unbiased results.