Cost-Effectiveness of Decision Support Strategies in Acute Bronchitis.

BACKGROUND: A recent clinical trial suggests that printed (PDS) and computer decision support (CDS) interventions are safe and effective in reducing antibiotic use in acute bronchitis relative to usual care (UC). OBJECTIVE: Our aim was to evaluate the cost-effectiveness of decision support interventions in reducing antibiotic use in acute bronchitis. DESIGN: We conducted a clinical trial-based cost-effectiveness analysis comparing UC, PDS and CDS for management of acute bronchitis. We assumed a societal perspective, 5-year program duration and 30-day time horizon. PATIENTS: The U.S. population aged 13-64 years presenting with acute bronchitis in the ambulatory setting. INTERVENTIONS: Printed and computer decision support interventions relative to usual care. MAIN MEASURES: Cost per antibiotic prescription safely avoided. KEY RESULTS: In the base case, PDS dominated UC and CDS, with lesser total costs (PDS: $2,574, UC: $2,768, CDS: $2,805) and fewer antibiotic prescriptions (PDS: 3.79, UC: 4.60, CDS: 3.95) per patient over 5 years. In one-way sensitivity analyses, PDS dominated UC across all parameter values, except when antibiotics reduced work loss by ≥ 1.9 days or the probability of hospitalization within 30 days was ≥ 0.9 % in PDS (base case: 0.2 %) or ≤ 0.4 % in UC (base case: 1.0 %). The dominance of PDS over CDS was sensitive both to probability of hospitalization and plausible variation in the adjusted odds of antibiotic use in both strategies. CONCLUSIONS: A PDS strategy to reduce antibiotic use in acute bronchitis is less costly and more effective than both UC and CDS strategies, although results were sensitive to variation in probability of hospitalization and the adjusted odds of antibiotic use. This simple, low-cost, safe, and effective intervention would be an economically reasonable component of a multi-component approach to address antibiotic overuse in acute bronchitis.

Antibiotic therapy for ventilator-associated tracheobronchitis: a standard of care to reduce pneumonia, morbidity and costs?

PURPOSE OF REVIEW: The present review draws our attention to ventilator-associated tracheobronchitis (VAT) as a distinct clinical entity that has been associated with progression to ventilator-associated pneumonia (VAP) and worse patient outcomes. In contrast to VAP, which has been extensively investigated for over the past 30 years, most VAT studies have been conducted in the past decade. There are ample data which demonstrate that VAT may progress to VAP, have more ventilator days, and have longer ICU stay that may translate into higher healthcare costs. RECENT FINDINGS: The article focuses on the diagnostic criteria for VAT, causative agents, and studies analyzing associations between VAT and patient outcomes in relation to early, appropriate intravenous, and/or aerosolized antibiotic therapy. Aerosolized antibiotic treatment delivered by improved device technology is a novel approach that has proved to be effective for the treatment and eradication of multidrug-resistant bacterial pathogens. Aerosolized antibiotics are effective in decreasing the use of systemic antibiotics, reducing bacterial resistance, and may also facilitate clinical resolution of infection. SUMMARY: Evidence presented in this review supports treatment of VAT with early and appropriate antibiotic therapy as a standard of care to reduce VAP, ventilator days, and duration of ICU stay in high-risk patient population.

A Case-Control Study on the Impact of Ventilator-Associated Tracheobronchitis in the PICU.

OBJECTIVES: Hospital-acquired infections increase morbidity, mortality, and charges in the PICU. We implemented a quality improvement bundle directed at ventilator-associated pneumonia in our PICU in 2005. We observed an increase in ventilator-associated tracheobronchitis coincident with the near-elimination of ventilator-associated pneumonia. The impact of ventilator-associated tracheobronchitis on critically ill children has not been previously described. Accordingly, we hypothesized that ventilator-associated tracheobronchitisis associated with increased length of stay, mortality, and hospital charge. DESIGN: Retrospective case-control study. PATIENTS: Critically ill children admitted to a quaternary PICU at a free-standing academic children's hospital in the United States. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: We conducted a retrospective case control study, with institutional review board approval, of 77 consecutive cases of ventilator-associated tracheobronchitis admitted to our PICU from 2004-2010. We matched each case with a control based on the following criteria (in rank order): age range (< 30 d, 30 d to 24 mo, 24 mo to 12 yr, > 12 yr), admission Pediatric Risk of Mortality III score ± 10, number of ventilator days of control group (> 75% of days until development of ventilator-associated tracheobronchitis), primary diagnosis, underlying organ system dysfunction, surgical procedure, and gender. The primary outcome measured was PICU length of stay. Secondary outcomes included ventilator days, hospital length of stay, mortality, and PICU and hospital charges. Data was analyzed using chi square analysis and p less than 0.05 was considered significant. We successfully matched 45 of 77 ventilator-associated tracheobronchitis patients with controls. There were no significant differences in age, gender, diagnosis, or Pediatric Risk of Mortality III score between groups. Ventilator-associated tracheobronchitis patients had a longer PICU length of stay (median, 21.5 d, interquartile range, 24 d) compared to controls (median, 18 d; interquartile range, 17 d), although not statistically significant (p = 0.13). Ventilator days were also longer in the ventilator-associated tracheobronchitis patients (median, 17 d; IQR, 22 d) versus control (median, 10.5 d; interquartile range, 13 d) (p = 0.01). There was no significant difference in total hospital length of stay (54 d vs 36 d; p = 0.69). PICU mortality was higher in the ventilator-associated tracheobronchitis group (15% vs 5%; p = 0.14), although not statistically significant. There was an increase in both median PICU charges ($197,393 vs $172,344; p < 0.05) and hospital charges ($421,576 vs $350,649; p < 0.05) for ventilator-associated tracheobronchitis patients compared with controls. CONCLUSIONS: Ventilator-associated tracheobronchitis is a clinically significant hospital-acquired infection in the PICU and is associated with longer duration of mechanical ventilation and healthcare costs, possibly through causing a longer PICU length of stay. Quality improvement efforts should be directed at reducing the incidence of ventilator-associated tracheobronchitis in the PICU.

Costs of childhood asthma due to traffic-related pollution in two California communities.

Recent research suggests the burden of childhood asthma that is attributable to air pollution has been underestimated in traditional risk assessments, and there are no estimates of these associated costs. We aimed to estimate the yearly childhood asthma-related costs attributable to air pollution for Riverside and Long Beach, CA, USA, including: 1) the indirect and direct costs of healthcare utilisation due to asthma exacerbations linked with traffic-related pollution (TRP); and 2) the costs of health care for asthma cases attributable to local TRP exposure. We calculated costs using estimates from peer-reviewed literature and the authors' analysis of surveys (Medical Expenditure Panel Survey, California Health Interview Survey, National Household Travel Survey, and Health Care Utilization Project). A lower-bound estimate of the asthma burden attributable to air pollution was US$18 million yearly. Asthma cases attributable to TRP exposure accounted for almost half of this cost. The cost of bronchitic episodes was a major proportion of both the annual cost of asthma cases attributable to TRP and of pollution-linked exacerbations. Traditional risk assessment methods underestimate both the burden of disease and cost of asthma associated with air pollution, and these costs are borne disproportionately by communities with higher than average TRP.

Power Outage: An Ignored Risk Factor for COPD Exacerbations.

BACKGROUND: COPD is the third leading cause of death in the United States, with 16 million Americans currently experiencing difficulty with breathing. Power outages could be life-threatening for those relying on electricity. However, significant gaps remain in understanding the potential impact of power outages on COPD exacerbations. RESEARCH QUESTION: The goal of this study was to determine how power outages affect COPD exacerbations. STUDY DESIGN AND METHODS: Using distributed lag nonlinear models controlling for time-varying confounders, the hospitalization rate during a power outage was compared vs non-outage periods to determine the rate ratio (RR) for COPD and its subtypes at each of 0 to 6 lag days in New York State from 2001 to 2013. Stratified analyses were conducted according to sociodemographic characteristics, season, and clinical severity; changes were investigated in numerous critical medical indicators, including length of stay, hospital cost, the number of comorbidities, and therapeutic procedures between the two periods. RESULTS: The RR of COPD hospitalization following power outages ranged from 1.03 to 1.39 across lag days. The risk was strongest at lag0 and lag1 days and lasted significantly for 7 days. Associations were stronger for the subgroup with acute bronchitis (RR, 1.08-1.69) than for cases of acute exacerbation (RR, 1.03-1.40). Compared with non-outage periods, the outage period was observed to be $4.67 thousand greater in hospital cost and 1.38 greater in the number of comorbidities per case. The average cost (or number of comorbidities) was elevated in all groups stratified according to cost (or number of comorbidities). In contrast, changes in the average length of stay (-0.43 day) and the average number of therapeutic procedures (-0.09) were subtle. INTERPRETATION: Power outages were associated with a significantly elevated rate of COPD hospitalization, as well as greater costs and number of comorbidities. The average cost and number of comorbidities were elevated in all clinical severity groups.

Cost and clinical consequence of antibiotic non-adherence in acute exacerbations of chronic bronchitis.

OBJECTIVE: To quantify the impact of non-adherence on the clinical effectiveness of antibiotics for acute exacerbations of chronic bronchitis (AECB) and to estimate the economic consequences for Spain, Italy and the United States. METHODS: Standard systematic reviewing procedures were followed to identify randomised controlled clinical trials of antibiotic treatment for acute respiratory tract infection for which adherence was reported. A decision-analytic model was then constructed to evaluate the impact of non-adherence to antibiotic treatment on clinical effectiveness and costs per AECB episode. The model compared the total treatment costs, cure rates and incremental costs per cure for a poor compliance group (PCG) against a good compliance group (GCG). Clinical and resource use estimates were from the published literature and physician surveys. RESULTS: Twenty-five articles met the criteria of the systematic review, although only one reported treatment success by adherence status. The relative risk of clinical effectiveness if non-adherent was 0.75 (95%CI 0.73-0.78). Based on this single study, the model predicted that 16-29% more patients would be cured in the GCG vs. the PCG, and payers would save up to euro122, euro179 and US$141 per AECB episode in Spain, Italy and the United States, respectively. CONCLUSIONS: Non-adherence to antibiotics for AECB may have an impact on clinical effectiveness, which is associated with increased costs.

Smoking in the home and children's health.

OBJECTIVES: We estimate for young children the annual excess health service use, healthcare expenditures, and disability bed days for respiratory conditions associated with exposure to smoking in the home in the United States. METHODS: Health service use, healthcare expenditures and disability bed days data come from the 1999 and 2001 Medical Expenditure Panel Survey (MEPS). Reported smoking in the home comes from the linked National Health Interview Survey, from which the MEPS sample is drawn. Multivariate statistical analysis controls for potential confounding factors. The sample is 2759 children aged 0-4. RESULTS: Smoking in the home is associated with an increase in the probability of emergency department visits for respiratory conditions by five percentage points and the probability of inpatient use for these conditions by three percentage points. There is no relation between indoor smoking by adults and either ambulatory visits or prescription drug expenditures. Overall, indoor smoking is associated with $117 in additional healthcare expenditures for respiratory conditions for each exposed child aged 0-4. Indoor smoking is also associated with an eight percentage point increase in the probability of having a bed day because of respiratory illness for children aged 1-4. CONCLUSIONS: Despite the significant progress made in tobacco control, many children are still exposed to secondhand smoke in their home. Reducing exposure to smoking in the home would probably reduce healthcare expenditures for respiratory conditions and improve children's health.

[Risk factors for increased cost of exacerbations of chronic bronchitis and chronic obstructive pulmonary disease]. / Factores de riesgo de elevado coste de las agudizaciones de la bronquitis crónica y la EPOC.

OBJECTIVE: To identify what variables characterizing the patients, exacerbations, and treatment of chronic bronchitis and chronic obstructive pulmonary disease (COPD) are associated with a higher direct health cost. METHOD: Observational pharmacoeconomic study of exacerbations of chronic bronchitis and COPD (of probable bacterial etiology, defined as Anthonisen types I or II). Direct health costs were assessed during 30 days of follow-up. Logistic regression was employed for statistical analysis, with calculation of the adjusted odds ratios (OR). An exacerbation cost greater than 150 euros was defined as the dependent variable. RESULTS: Data on 1164 patients were collected by 252 physicians. Pharmacoeconomic data were complete in 947 patients (82.6%). In the first 30 days, 206 sought medical attention because of unsatisfactory response to treatment (21.8%), 69 (7.3%) attended the emergency room, and 22 (2.3%) were admitted to hospital. Overall, 101 exacerbations (10.7%) were classified as high cost (> 150 euros). Continuous oxygen therapy (OR = 7.58) and previous hospitalization (OR = 2.6) were associated with high-cost exacerbations, whereas diagnosis of chronic bronchitis (OR = 0.41) and treatment of the exacerbation with moxifloxacin or amoxicillin-clavulanic acid as opposed to clarithromycin (OR = 0.38) were associated with low-cost exacerbations. CONCLUSION: Treatment failure was reported for 21.8% of the patients with exacerbations of chronic bronchitis and COPD. Repeated medical visits and requests for complementary tests were the main factors responsible for increased cost. Variables associated with high-cost exacerbations were continuous oxygen therapy, previous hospitalization, and treatment with clarithromycin as opposed to moxifloxacin or amoxicillin-clavulanic acid.

Valuing the Economic Costs of Allergic Rhinitis, Acute Bronchitis, and Asthma from Exposure to Indoor Dampness and Mold in the US.

Two foundational methods for estimating the total economic burden of disease are cost of illness (COI) and willingness to pay (WTP). WTP measures the full cost to society, but WTP estimates are difficult to compute and rarely available. COI methods are more often used but less likely to reflect full costs. This paper attempts to estimate the full economic cost (2014$) of illnesses resulting from exposure to dampness and mold using COI methods and WTP where the data is available. A limited sensitivity analysis of alternative methods and assumptions demonstrates a wide potential range of estimates. In the final estimates, the total annual cost to society attributable to dampness and mold is estimated to be $3.7 (2.3-4.7) billion for allergic rhinitis, $1.9 (1.1-2.3) billion for acute bronchitis, $15.1 (9.4-20.6) billion for asthma morbidity, and $1.7 (0.4-4.5) billion for asthma mortality. The corresponding costs from all causes, not limited to dampness and mold, using the same approach would be $24.8 billion for allergic rhinitis, $13.5 billion for acute bronchitis, $94.5 billion for asthma morbidity, and $10.8 billion for asthma mortality.

The impact and cost of influenza in the elderly.

BACKGROUND: Traditional methods of measuring the impact and cost of influenza virus have focused on epidemic years and morbidity and mortality due to pneumonia and influenza. METHODS: Annualized age-sex-race adjusted rates of hospitalization for pneumonia and influenza and other diagnoses among elderly Medicare beneficiaries during the epidemic influenza season of 1989 to 1990 and the nonepidemic season of 1990 to 1991 were compared with an interim period in 1990 without influenza virus circulation. RESULTS: The rates of hospitalization for pneumonia and influenza, acute bronchitis, chronic respiratory disease, and congestive heart failure were significantly greater during each influenza period compared with the interim period. The highest rates were found in the epidemic season of 1989 to 1990. The amount reimbursed by Medicare to hospitals to 1990. The amount reimbursed by Medicare to hospitals for the treatment of excess hospitalizations during periods of influenza activity was more than $1 billion in 1989 to 1990 and almost $750 million in 1990 to 1991. CONCLUSIONS: Measures of the impact and cost of influenza in elderly Americans should include all of the diagnoses listed above and should recognize that the impact of influenza virus is significant even in nonepidemic years. There are great opportunities for cost savings if effective control programs are implemented.

How do we achieve cost-effective options in lower respiratory tract infection therapy?

Acute bronchitis and acute exacerbations of chronic bronchitis, common illnesses encountered by general and family physicians, account for approximately 14 million physician visits per year. The pattern of antibiotic prescribing for these infections varies from country to country, but there is no clear rationale for these antimicrobial choices. A recent meta-analysis of all randomized, placebo-controlled trials of patients treated with antibiotics for acute exacerbations of chronic bronchitis concluded that a small but statistically significant improvement could be expected in antibiotic-treated patients. Haemophilus influenzae is the most commonly isolated organism from sputum in patients with acute exacerbations of chronic obstructive lung disease but other Haemophilus species, Streptococcus pneumoniae, and Moraxella catarrhalis may also be found. High-risk patients can be defined as being elderly, with significant impairment of lung function, having poor performance status with other comorbid conditions, having frequent exacerbations, and often requiring oral corticosteroid medication. Well-defined clinical trials measure efficacy of a drug but not the effectiveness in a real world situation. Future studies of new antimicrobials should examine their efficacy in patients with an increased risk of true bacterial infection.

Pharmacoeconomic evaluation of acute exacerbations of chronic bronchitis and COPD.

BACKGROUND: Although exacerbations are the main cause of medical visits and hospitalizations of patients with chronic bronchitis and COPD, little information is available on the costs of their management. OBJECTIVE: This study attempted to determine the total direct costs derived from the management of exacerbations of chronic bronchitis and COPD in an ambulatory setting. METHOD: A total of 2,414 patients with exacerbated chronic bronchitis and COPD were recruited from 268 general practices located throughout Spain. Patients were followed up for 1 month. RESULTS: A total of 507 patients (21%) relapsed; of these, 161 patients (31.7%) required attention in emergency departments and 84 patients (16.5%) were admitted to the hospital. The total direct mean cost of all exacerbations was $159; patients who were hospitalized generated 58% of the total cost. Cost per failure was $477.50, and failures were responsible for an added mean cost of $100.30/exacerbation. Exacerbations of the 1,130 patients with COPD had a mean cost of $141. Sensitivity analysis showed that a 50% reduction in the failure rate (from 21 to 10.5%) would result in a total cost of exacerbation of $107 (33% reduction). CONCLUSION: Exacerbations of chronic bronchitis and COPD are costly, but the greatest part of costs derives from therapeutic failures, particularly those that end in hospitalization.

A 1-year community-based health economic study of ciprofloxacin vs usual antibiotic treatment in acute exacerbations of chronic bronchitis: the Canadian Ciprofloxacin Health Economic Study Group.

OBJECTIVE: To evaluate the costs, consequences, effectiveness, and safety of ciprofloxacin vs standard antibiotic care in patients with an initial acute exacerbation of chronic bronchitis (AECB) as well as recurrent AECBs over a 1-year period. DESIGN: Randomized, multicenter, parallel-group, open-label study. SETTING: Outpatient general practice. PATIENTS: A total of 240 patients, 18 years or older with chronic bronchitis, with a history of frequent exacerbations (three or more in the past year) presenting with a type 1 or 2 AECB (two or more of increased dyspnea, increased sputum volume, or sputum purulence). MAIN OUTCOME MEASURES: The assessment included AECB symptoms, antibiotics prescribed, concomitant medications, adverse events, hospitalizations, emergency department visits, outpatient resources such as diagnostic tests, procedures, and patient and caregiver out-of-pocket expenses. Patients completed the Nottingham Health Profile, St. George's Respiratory Questionnaire, and the Health Utilities Index. The parameters were recorded with each AECB and at regular quarterly intervals for 1 year. These variables were compared between the ciprofloxacin-treated group and the usual-care-treated group. RESULTS: Patients receiving ciprofloxacin experienced a median of two AECBs per patient compared to a median of three AECBs per patient receiving usual care. The mean annualized total number of AECB-symptom days was 42.9+/-2.8 in the ciprofloxacin arm compared to 45.6+/-3.0 days in the usual-care arm (p=0.50). The overall duration of the average AECB was 15.2+/-0.6 days for the ciprofloxacin arm compared to 16.3+/-0.6 days for the usual-care arm. Treatment with ciprofloxacin tended to accelerate the resolution of all AECBs compared to usual care (relative risk=1.20; 95% confidence interval [CI], 0.91 to 1.58; p=0.19). Treatment assignment did not affect the interexacerbation period but a history of severe bronchitis, prolonged chronic bronchitis, and an increased number of AECBs in the past year were associated with shorter exacerbations-free periods. There was a slight, but not statistically significant, improvement in all quality of life measures with ciprofloxacin over usual care. The only factors predictive of hospitalization were duration of chronic bronchitis (odds ratio=4.6; 95% CI, 1.6, 13.0) and severity of chronic bronchitis (odds ratio=4.3; 95% CI, 0.8, 24.6). The incremental cost difference of $578 Canadian in favor of usual care was not significant (95% CI, -$778, $1,932). The cost for the ciprofloxacin arm over the usual care arm was $18,588 Canadian per quality-adjusted life year gained. When the simple base case analysis was expanded to examine the effect of risk stratification, the presence of moderate or severe bronchitis and at least four AECBs in the previous year changed the economic and clinical analysis to one favorable to ciprofloxacin with the ciprofloxacin-treated group having a better clinical outcome at lower cost ("win-win" scenario). CONCLUSIONS: Treatment with ciprofloxacin tended to accelerate the resolution of all AECBs compared to usual care; however, the difference was not statistically significant. Further, usual care was found to be more reflective of best available care rather than usual first-line agents such as amoxicillin, tetracycline, or trimethoprim-sulfamethoxazole as originally expected. Despite the similar antimicrobial activities and broad-spectrum coverage of both ciprofloxacin and usual care, the trends in clinical outcomes and all quality of life measurements favor ciprofloxacin. In patients suffering from an AECB with a history of moderate to severe chronic bronchitis and at least four AECBs in the previous year, ciprofloxacin treatment offered substantial clinical and economic benefits. In these patients, ciprofloxacin may be the preferred first antimicrobial choice.

Treatment cost of acute exacerbations of chronic bronchitis.

In 1994, the National Center for Health Statistics estimated that more than 14 million people (54 per thousand) had chronic bronchitis and sought treatment for 90.9% of their acute episodes. However, few studies have been done on the treatment cost of chronic bronchitis using national data. We conducted a retrospective analysis of claims for patients treated for acute exacerbations of chronic bronchitis (AECB) to assess the frequency of services rendered and the costs to the health care system. Records were selected for the study based on a primary diagnosis of AECB according to the International Classification of Diseases, Ninth Revision, code. Medicare was the primary source of data on patients aged > or =65 years; data from the National Healthcare and Cost Utilization Project, the National Ambulatory Medical Care Survey, and the National Hospital Ambulatory Medical Care Survey were used for patients aged <65 years. We calculated a total treatment cost of $1.2 billion for patients aged > or =65 years and $419 million for patients aged <65 years. These calculations were based on the following: 280,839 hospital discharges resulting in hospital costs of $1.1 billion for the 207,540 patients aged > or =65 years, and $408 million for the 73,299 patients aged <65 years. The mean hospital length of stay was 6.3 days with a mean cost of $5497 for patients aged > or =65 years and 5.8 days with a mean cost of $5561 for younger patients. Room and board represented the largest percentage of the mean hospital costs of AECB. Inpatient physician services cost $32 million and $11 million for the 2 age groups, respectively. Diagnosis-specific data for outpatient services were found to be less reliable than inpatient data, possibly due to diagnostic coding omissions; 331,000 outpatient office visits for AECB were found for those aged > or =65 years and 237,000 visits for those aged <65 years, resulting in respective total outpatient costs of $24.9 million and $15.1 million. If the number of outpatient visits remain consistent with 1994 levels, there would be 5.8 million visits annually for those aged > or =65 years and 4.2 million visits for those aged <65 years; total outpatient costs would be $452 million and $317 million, respectively. Because the treatment costs of AECB are largely the costs of hospitalization, any new therapy that allows more patients to be treated in the outpatient setting is likely to generate significant savings.

Economics of a reduction in smoking: case study from Heartbeat Wales.

STUDY OBJECTIVE: This study aims to apply economic principles and techniques in evaluating a health promotion programme. DESIGN: This study is an economic appraisal of the Heartbeat Wales no smoking intervention programme. The costs incurred over the four year period 1985-89 have been identified and estimates have been made of the likely future impact of the reduced smoking prevalence within Wales in terms of reduced morbidity and displaced mortality in three disease groups--coronary heart disease, lung cancer, and chronic bronchitis. SETTING: Wales, UK. RESULTS: The net present value of benefits is considerably greater than costs in terms of both the NHS and the economy as a whole in Wales. In addition, the net costs per life year saved shows that the programme generates additional working life years at relatively low cost. Because not all the benefits can be fully attributed to the programme 'impact rates' ranging from 100 to 10% have been applied to the level of benefits. The evidence suggests that even if only 10% of the benefits could be attributed to the programme there is still a positive net present value of benefits. The relative efficiency of this programme has not been considered here. CONCLUSION: Large scale benefits to the NHS and the economy as a whole can be derived from reductions in smoking.

Economic evaluation of ciprofloxacin compared with usual antibacterial care for the treatment of acute exacerbations of chronic bronchitis in patients followed for 1 year.

OBJECTIVE: To undertake a 1-year prospective economic evaluation of ciprofloxacin compared with usual antibacterial care (any antibacterial other than a quinolone) for the treatment of acute exacerbations of chronic bronchitis (AECB) in adults presenting with a type I or type II AECB. DESIGN: Patients entered the study with an initial AECB and were randomised to the ciprofloxacin group or the usual care group. The following measurements were taken at the end of each AECB and every 3 months: resource utilisation, St. George's Respiratory Questionnaire, Nottingham Health Profile and Health Utilities Index (HUI). The following additional measurements were taken after each AECB: AECB-symptom days and willingness to pay to avoid the AECB. Economic evaluations were performed from the societal viewpoint and the viewpoint of a major third-party payer. Cost-effectiveness analysis was based on cost per AECB-symptom day averted; cost-utility analysis (CUA) was based on cost per quality-adjusted life-year (QALY) gained using the HUI as the basis for calculating QALYs. Cost-benefit analysis was based on the willingness-to-pay (WTP) data. SETTING: This was a study of outpatients enrolled from 46 family physicians and 2 respirologists in Ontario (29 sites) and Québec (19 sites), Canada, between November 1993 and June 1994. PATIENTS AND PARTICIPANTS: 240 adult male and female patients aged > or = 18 years with chronic bronchitis. MAIN OUTCOME MEASURES AND RESULTS: WTP data did not pass scope tests for reasonableness. Ciprofloxacin was more costly and provided better outcomes compared with usual antibacterial care. The base-case results are as follows (1994/1995 values): the incremental annual cost was 578 Canadian dollars ($Can) from the societal viewpoint and $Can840 for the third-party payer; the cost-effectiveness ratio per AECB-symptom day averted was $Can209 from the societal viewpoint and $Can304 for the third-party payer; the cost-utility ratio per QALY gained was $Can18,600 from the societal viewpoint and $Can27,000 for the third-party payer. According to Laupacis criteria, these CUA results are strong evidence in favour of adoption from the societal viewpoint and moderate evidence in favour from the viewpoint of the third-party payer. A subgroup analysis suggests that ciprofloxacin may be particularly cost effective, even 'win-win', in patients with more severe disease. CONCLUSIONS: The sensitivity analyses indicate that the results are relatively robust. Nevertheless, the statistical uncertainty in the results is sufficient that the findings cannot be accepted unequivocally. A further study with a larger sample size would be useful to confirm (or deny) the findings of this study.

Acute exacerbations of chronic bronchitis: a pharmacoeconomic review of antibacterial use.

Chronic bronchitis is a common problem affecting a large proportion of the adult population. People with chronic bronchitis are subject to recurrent attacks of bronchial inflammation called acute exacerbations of chronic bronchitis (AECBs). In patients with AECBs, symptoms may worsen due to a bacterial infection; the exacerbation is then known as an acute bacterial exacerbation of chronic bronchitis (ABECB). ABECBs are thought to be controllable through the use of antibacterial agents. In this paper we review current evidence on the cost of chronic bronchitis and AECBs, the cost effectiveness of antibacterials in the management of ABECB, and the factors that may affect the cost-effectiveness of antibacterials in the management of ABECB. We find that the number of economic evaluations conducted in this area is small. Of the few economic evaluations that have been conducted there has been only one prospective economic evaluation based on a clinical trial. The remainder are simple decision analysis-based modelling studies or retrospective database studies. Our principle findings are as follows: a key factor affecting the cost-effective use of antibacterials in the management of ABECB is the definitive diagnosis of the condition. Unfortunately, diagnosing a bacterial cause of an AECB is difficult, which presents problems in ensuring that antibacterials are not prescribed unnecessarily;current evidence suggests but does not prove that use of more effective but more costly first-line antibacterials may be relatively cost effective and may minimise overall expenditure by reducing the high costs associated with treatment failure;chronic bronchitis and AECB have a significant and negative physical and psychological effect on health-related quality of life. In conclusion, the small number of economic evaluations conducted in this area, coupled with the nature of the design of these studies, precludes a definitive statement recommending which specific antibacterial should be preferred on cost-effectiveness grounds for the management of ABECB. On the basis of our findings we suggest some topics for further research.

Azithromycin compared with clarithromycin in the treatment of adult patients with acute purulent tracheobronchitis: a cost of illness study.

Adult, professionally active patients with acute purulent tracheobronchitis were treated with azithromycin (3 or 5 days; n = 62) or clarithromycin (7 to 10 days; n = 69) in an open, randomized study. Bronchitis-related costs and treatment efficacy were assessed at day 5-6 and day 14-21. Both antibiotics were of equal clinical efficacy, although the median time to improvement of symptoms was significantly shorter for azithromycin patients than for clarithromycin patients. Some 77% of azithromycin patients and 78% of clarithromycin patients were unable to work for at least 1 day. The total time when patients were unable to work was shorter for azithromycin patients than for clarithromycin patients, but this difference did not remain significant when weekends and holidays were taken into account. Further studies are needed to assess the impact of azithromycin on time to clinical improvement, on lost working days, and on the associated costs.

[Pharmacoeconomic study of antibiotic therapy for exacerbations of chronic bronchitis and chronic obstructive pulmonary disease in Latin America]. / Estudio farmacoeconómico del tratamiento antibiótico de las agudizaciones de la bronquites crónica y la EPOC en Latinoamérica.

Chronic obstructive pulmonary disease (COPD) and chronic bronchitis are highly prevalent diseases. Studies designed to analyze the economic impact of these diseases in Latin American countries have not previously been published. In the present study we analyzed the direct health care costs of treating patients with exacerbations of chronic bronchitis and COPD in Argentina, Brazil, Colombia, Ecuador, Mexico, Peru, and Venezuela, applying the real cost of drugs and medical acts in those 7 countries to the pattern of treatment and outcomes obtained from a study carried out in primary care settings in Spain. The mean direct health care cost ranged from US $98 in Colombia to $329 in Argentina. Most of the cost was related to failure of therapy, which accounted for 52% of the total cost of exacerbation, with the lowest rate in Colombia at 28.6% and the highest in Ecuador at 59.3% The cost of antibiotic therapy represented 19% of the total cost; the rest was owing to other drugs or medical visits. Exacerbations generate significant costs for health care systems. There are considerable variations related mainly to differences between systems. Antibiotic therapy represents a small part of the overall cost. The use of more effective antibiotics, if they can reduce failure rates, may be a cost-effective strategy.