Needs with Regard to Decision Support Systems for Treating Patients with Incurable Non-small Cell Lung Cancer.

Treatment decision-making for patients with incurable non-small cell lung cancer (NSCLC) is complex due to the rapidly increasing number of treatments and discovery of new biomarkers. Decision support systems (DSS) could assist thoracic oncologists (TO) weighing of the pros and cons of treatments in order to arrive at an evidence-based and personalized treatment advice. Our aim is to inventory (1) TO's needs with regard to DSS in the treatment of incurable (stage IIIB/IV) NSCLC patients, and (2) preferences regarding the development of future tools in this field. We disseminated an online inventory questionnaire among all members of the Section of Oncology within the Society of Physicians in Chest Medicine and Tuberculosis. Telephone interviews were conducted to better contextualize the findings from the questionnaire. In total, 58 TO completed the questionnaire and expressed a need for new DSS. They reported that it is important for tools to include genetic and immune markers, to be sufficiently validated, regularly updated, and time-efficient. Also, future DSS should incorporate multiple treatment options, integrate estimates of toxicity, quality of life and cost-effectiveness of treatments, enhance communication between caregivers and patients, and use IT solutions for a clear interface and continuous updating of tools. With this inventory among Dutch TO, we summarized the need for new DSS to aid treatment decision-making for patients with incurable NSCLC. To meet the expressed needs, substantial additional efforts will be required by DSS developers, above already existing tools.

Cost-effectiveness analysis of various pertussis vaccination strategies primarily aimed at protecting infants in the Netherlands.

BACKGROUND: Pertussis is a highly contagious respiratory disease. Despite a high rate of vaccine coverage through the Dutch national immunization program, the incidence of pertussis remains high in the Netherlands and the risk of infection continues. Because pertussis is most severe in unimmunized infants and infants who have only received some of the recommended doses, new pertussis immunization strategies should be considered to protect this vulnerable population. OBJECTIVE: This study was designed to estimate the cost-effectiveness of 3 new immunization strategies for possible addition to the current Dutch national immunization program: immunization of the infant at birth, immunization of the parents immediately after birth of the child (cocooning), and maternal immunization during the third trimester of pregnancy. METHODS: A literature search was performed in the PubMed database for articles published in English, German, and Dutch using the following terms: pertussis, whooping cough, vaccination strategies, maternal immunization, cocooning, at birth, vaccine efficacy, mortality, underreporting, prevalence, incidence, and cost-effectiveness. A decision-tree model was developed for this analysis, and data on pertussis morbidity and costs were collected consistently for different age groups (infants <1 year of age and adults 25 to 34 years of age). The size of the infant cohort was set at 200,000 to approximate previous Dutch birth cohorts. The size of the adult cohort was set at 401,380 parents for the cocooning strategy and 201,380 mothers for the maternal immunization strategy. Health benefits (quality-adjusted life-years [QALYs]) and costs were estimated in both cohorts for each of the 3 immunization strate- gies. Incremental cost-effectiveness ratios were calculated from both a payer's and a societal perspective. The robustness of the results was determined through sensitivity analysis. RESULTS: In the base-case analysis, cocooning and maternal immunization were found to be effective in reducing the incidence of pertussis among infants (123 and 174 infant cases were expected to be prevented, respectively). Furthermore, cocooning and maternal immunization were estimated to be cost-effective from a payer's perspective (euro4600 [US $6400]/QALY and euro3500 [$4900]/QALY, respectively) and even cost-saving from a societal perspective (savings of up to euro7200 [$10,100] and euro5000 [$7000], respectively). Sensitivity analyses revealed that favorable cost-effectiveness was generally robust. In the sensitivity analysis, the cost-effectiveness of cocooning and maternal immunization was mostly sensitive for changes in assumptions on underreporting (200-fold increase in reported number of symptomatic cases) of pertussis disease and infection. With no underreporting, the ICER was estimated at euro211,900 ($296,700)/QALY for cocooning and euro81,600 ($114,200)/QALY for maternal immunization from a payer's perspective. However, even at much lower levels of underreporting (20- to 30-fold increase in incidence), cost-effectiveness remained favorable. The cost-effectiveness of the third strategy, at-birth immunization, was highly unfavorable (euro329,900 [$461,900]/QALY from a payer's perspective and euro330,100 [$462,100]/ QALY from a societal perspective). CONCLUSIONS: This study estimated that the addition of cocooning or maternal immunization to the current Dutch national immunization program likely would be cost-effective or even cost-saving. These estimates were mainly due to reduction in the number of cases among parents, which are likely to be mild and therefore would largely remain unreported. Immunization at birth was not a cost-effective strategy. Cocooning was the most expensive intervention to implement; however, it resulted in the highest number of QALYs gained (mainly in adults). Maternal immunization would offer better protection of infants, due to maternally acquired antibodies.

Salmeterol/fluticasone propionate versus fluticasone propionate plus montelukast: a cost-effective comparison for asthma.

INTRODUCTION AND OBJECTIVE: Asthma, owing to its chronic nature, is associated with a substantial economic burden. Healthcare providers need to compare the cost effectiveness of alternative asthma treatment options to ensure that they obtain the best value for money from the resources they control. The objective of the current study was to compare the cost effectiveness of salmeterol/fluticasone propionate in combination with fluticasone propionate plus montelukast in patients with symptomatic asthma uncontrolled with inhaled corticosteroid (ICS) monotherapy. STUDY DESIGN AND METHODS: Direct healthcare resource data were prospectively collected during a double-blind, randomized, 12-week clinical study of inhaled salmeterol/fluticasone propionate 50/100 microg twice daily (n = 356) and inhaled fluticasone propionate 100 microg twice daily plus oral montelukast 10mg daily (n = 369). Resources were costed in Dutch guilders (NLG) from the perspective of The Netherlands healthcare system using 1999/2000 prices, but have been presented in US dollars and euros. The primary effectiveness measure was the proportion of successfully treated weeks (based on mean morning PEF values). Secondary measures were episode-free days, symptom-free days, and symptom-free nights. RESULTS: Salmeterol/fluticasone propionate was more effective than fluticasone propionate plus montelukast as measured by the proportion of successfully treated weeks mean 63.3% vs 39.0%; median difference 25%; p < 0.001). Salmeterol/fluticasone propionate was also more effective than fluticasone propionate plus montelukast according to the secondary effectiveness measures. The mean total direct daily healthcare costs per patient were 16% higher with fluticasone propionate plus montelukast than with salmeterol/fluticasone propionate mainly due to higher drug costs in the former group (2.25 US dollars vs 1.94; 1.92 euro vs 1.66, respectively; the NLG was fixed against the euro at a rate of 1 euro = NLG2.2 on 31 December 1998; 1 US dollars = NLG1.883, June 2003; 1 US dollars= 0.848 euro, June 2003). Incremental cost-effectiveness analyses showed that salmeterol/fluticasone propionate was dominant over fluticasone propionate plus montelukast and sensitivity analyses showed these results to be robust. CONCLUSION: Salmeterol/fluticasone propionate is a more cost-effective treatment option than fluticasone propionate plus montelukast for patients with symptomatic asthma uncontrolled by ICS.