Dyfrig A. Hughes

Cost-effectiveness analysis of Hla b*5701 genotyping in preventing abacavir hypersensitivity

OBJECTIVE Abacavir, a human immunodeficiency virus-1 (HIV-1) nucleoside-analogue reverse transcriptase inhibitor, causes severe hypersensitivity in 4-8% of patients. HLA B*5701 is a known genetic risk factor for abacavir hypersensitivity in Caucasians. Our aim was to confirm the presence of this genetic factor in our patients, and to determine whether genotyping for HLA B*5701 would be a cost-effective use of healthcare resources. METHODS Patients with and without abacavir hypersensitivity were identified from a UK HIV clinic. Patients were genotyped for HLA B*5701, and pooled data used for calculation of test characteristics. The cost-effectiveness analysis incorporated the cost of testing, cost of treating abacavir hypersensitivity, and the cost and selection of alternative antiretroviral regimens. A probabilistic decision analytic model (comparing testing versus no testing) was formulated and Monte Carlo simulations performed. RESULTS Of the abacavir hypersensitive patients, six (46%) were HLA B*5701 positive, compared to five (10%) of the non-hypersensitive patients (odds ratio 7.9 [95% confidence intervals 1.5-41.4], P = 0.006). Pooling of our data on HLA B*5701 with published data resulted in a pooled odds ratio of 29 (95% CI 6.4-132.3; P < 0.0001). The cost-effectiveness model demonstrated that depending on the choice of comparator, routine testing for HLA B*5701 ranged from being a dominant strategy (less expensive and more beneficial than not testing) to an incremental cost-effectiveness ratio (versus no testing) of Euro 22,811 per hypersensitivity reaction avoided. CONCLUSIONS Abacavir hypersensitivity is associated with HLA B*5701, and pre-prescription pharmacogenetic testing for this appears to be a cost-effective use of healthcare resources.

Is exercise effective in promoting mental well-being in older age? A systematic review.

Background: Promoting the mental well-being of older people has been neglected. Aim: To examine the clinical and cost-effectiveness of exercise and physical activity interventions on mental well-being in people aged 65+. Design: Systematic review, meta-analysis, economic model. Methods: Reports published in English, identified by searching 25 databases, 11 websites and references lists of systematic reviews. Eligible studies were those with a comparison or control group or offering qualitative evidence; exercise and physical activity interventions for people aged 65 and above living at home, in the community, in supported housing or in residential care homes; including outcome measures of mental well-being, not simply measures of depression or anxiety. Low-quality studies were excluded from the data synthesis. Results: An overall effect of exercise on mental well-being was found (standardised effect size = 0.27; CI = 0.14–0.40). The included interventions were designed for older people, targeted those who are sedentary and delivered in a community setting, primarily through a group-based approach led by trained leaders. As a minimum, the evidence would suggest two exercise sessions per week, each of 45 min duration. There is some indication that exercise can also improve the mental well-being of frail elders. Economic evidence indicated incremental cost-effectiveness ratios (compared with minimal intervention) of £7300 and £12,100 per quality adjusted life year gained for community-based walking and exercise programmes, respectively. Conclusions: Mental well-being in later life is modifiable through exercise and physical activity. To generalise the findings, there is a need for more evidence of effectiveness from older people in the UK.

Parenting programme for parents of children at risk of developing conduct disorder: cost effectiveness analysis

Objective To investigate the cost effectiveness of a parenting programme. Design An incremental cost effectiveness analysis alongside a pragmatic randomised controlled trial of the effectiveness of a group parenting programme delivered through Sure Start in the community. Setting Sure Start areas in north and mid Wales. Participants Parents of 116 children aged 36-59 months (87% of the clinical sample) at risk of developing conduct disorders defined by scoring over the clinical cut off on the Eyberg child behaviour inventory). Children were identified by health visitors and recruited by the research team. Intervention The Webster-Stratton Incredible Years basic parenting programme or a six month waiting list control. Main outcome measure Incremental cost per unit of improvement on the intensity score of the Eyberg child behaviour inventory. Results The bootstrapped incremental cost effectiveness ratio point estimate was �73 (€109,

Dabigatran etexilate versus warfarin in management of non-valvular atrial fibrillation in UK context: quantitative benefit-harm and economic analyses

142) per one point improvement on the intensity score (95% confidence interval �42 to �140). It would cost �5486 (€8190,

SOCIETAL VIEWS ON NICE, CANCER DRUGS FUND AND VALUE‐BASED PRICING CRITERIA FOR PRIORITISING MEDICINES: A CROSS‐SECTIONAL SURVEY OF 4118 ADULTS IN GREAT BRITAIN

10 666) to bring the child with the highest intensity score to below the clinical cut-off point and �1344 (€2006,

Nurse-led vs. conventional physician-led follow-up for patients with cancer: systematic review

2618) to bring the average child in the intervention group within the non-clinical limits on the intensity score (below 127). For a ceiling ratio of �100 (€149,

Generic and therapeutic substitutions in the UK: are they a good thing?

194) per point increase in intensity score, there is an 83.9% chance of the intervention being cost effective. The mean cost per child attending the parenting group was �1934 (€2887,

Costs of Medication Nonadherence in Patients with Diabetes Mellitus: A Systematic Review and Critical Analysis of the Literature

3760) for eight children and �1289 (€1924,

Follow-up of cancer in primary care versus secondary care: systematic review

2506) for 12 children, including initial costs and materials for training group leaders. When we categorised the sample into relatively mild, moderate, and severe behaviour groups based on intensity scores at baseline the intervention seemed more cost effective in those with the highest risk of developing conduct disorder. Conclusion This parenting programme improves child behaviour as measured by the intensity score of the Eyberg child behaviour inventory at a relatively low cost and was cost effective compared with the waiting list control. This parenting programme involves modest costs and demonstrates strong clinical effect, suggesting it would represent good value for money for public spending.

Cost-effectiveness of biological therapy for Crohn's disease: Markov cohort analyses incorporating United Kingdom patient-level cost data.

Objectives To determine the incremental net health benefits of dabigatran etexilate 110 mg and 150 mg twice daily and warfarin in patients with non-valvular atrial fibrillation and to estimate the cost effectiveness of dabigatran in the United Kingdom. Design Quantitative benefit-harm and economic analyses using a discrete event simulation model to extrapolate the findings of the RE-LY (Randomized Evaluation of Long-Term Anticoagulation Therapy) study to a lifetime horizon. Setting UK National Health Service. Population Cohorts of 50 000 simulated patients at moderate to high risk of stroke with a mean baseline CHADS2 (Congestive heart failure, Hypertension, Age≥75 years, Diabetes mellitus, previous Stroke/transient ischaemic attack) score of 2.1. Main outcome measures Quality adjusted life years (QALYs) gained and incremental cost per QALY of dabigatran compared with warfarin. Results Compared with warfarin, low dose and high dose dabigatran were associated with positive incremental net benefits of 0.094 (95% central range −0.083 to 0.267) and 0.146 (−0.029 to 0.322) QALYs. Positive incremental net benefits resulted for high dose dabigatran in 94% of simulations versus warfarin and in 76% of those versus low dose dabigatran. In the economic analysis, high dose dabigatran dominated the low dose, had an incremental cost effectiveness ratio of £23 082 (€26 700;