Hazel Pilgrim

Workplace involvement improves return to work rates among employees with back pain on long-term sick leave: a systematic review of the effectiveness and cost-effectiveness of interventions

Purpose. Long-term sickness absence among workers is a major problem in industrialised countries. The aim of the review is to determine whether interventions involving the workplace are more effective and cost-effective at helping employees on sick leave return to work than those that do not involve the workplace at all. Methods. A systematic review of controlled intervention studies and economic evaluations. Sixteen electronic databases and grey literature sources were searched, and reference and citation tracking was performed on included publications. A narrative synthesis was performed. Results. Ten articles were found reporting nine trials from Europe and Canada, and four articles were found evaluating the cost-effectiveness of interventions. The population in eight trials suffered from back pain and related musculoskeletal conditions. Interventions involving employees, health practitioners and employers working together, to implement work modifications for the absentee, were more consistently effective than other interventions. Early intervention was also found to be effective. The majority of trials were of good or moderate quality. Economic evaluations indicated that interventions with a workplace component are likely to be more cost effective than those without. Conclusion. Stakeholder participation and work modification are more effective and cost effective at returning to work adults with musculoskeletal conditions than other workplace-linked interventions, including exercise.

Supplemental calcium in the chemoprevention of colorectal cancer: a systematic review and meta-analysis

OBJECTIVE The aim of the review was to assess the evidence for the effectiveness of calcium in reducing the recurrence of adenomas and the occurrence of colorectal cancer among populations at high, intermediate, and low risk of the disease. METHODS A systematic review of randomized controlled trials (RCTs) was performed to compare calcium alone, and with other agents, versus placebo. Nine databases (Cochrane Library, MEDLINE, PreMEDLINE, CINAHL, EMBASE, Web of Science, Biological Abstracts, the National Research Register, and Current Controlled Trials) were searched for published and unpublished trials. Searches were not restricted by either language or date of publication. All searches were completed in January 2010. Database thesaurus and free text terms for calcium and adenomas or colorectal cancer were used to search for trial reports; additional terms were used to search for other agents of interest, such as NSAIDs and folic acid. Search terms consisted of a combination of terms for colorectal cancer (eg, colon or colorectal and neoplasm or cancer or adenoma) and terms for calcium and RCTs. The initial searches were conducted in June 2008, with update searches in January 2010 to identify more recent studies. The reference lists of relevant studies were also searched for additional papers not identified by the search of electronic databases. Studies had to satisfy the following criteria to be included: RCTs about calcium, with or without other chemopreventive agents, in adults with familial adenomatous polyposis (FAP), hereditary nonpolyposis colorectal cancer, or a history of colorectal adenomas, or with no increased baseline risk of colorectal cancer. Meta-analysis was performed. For discrete and numerical outcomes, relative risks (RRs) and risk differences were reported with 95% CIs. The random-effects model was used to account for clinical and methodologic variations between trials. RESULTS The original and update searches of electronic databases produced 3835 citations, of which 6 studies (8 papers) met the inclusion criteria. Supplemental calcium had no effect on the number of adenomas in 1 small trial of patients with FAP. Meta-analysis of 3 trials in individuals with a history of adenomas showed a statistically significant reduction in the RR for adenoma recurrence (RR = 0.80 [95% CI, 0.69-0.94], P = 0.006) for those receiving calcium 1200 to 2000 mg/d, but no effect was seen in advanced adenoma (RR = 0.77 [95% CI, 0.501.17], P = NS). Meta-analysis of 2 trials in populations with no increased baseline risk for colorectal cancer suggested that calcium, with or without vitamin D, had no effect on the RR for colorectal cancer (RR = 0.62 [95% CI, 0.11-3.40], P = NS). CONCLUSION Published reports indicated that supplemental calcium was effective for the prevention of adenoma recurrence in populations with a history of adenomas, but no similar effect was apparent in populations at higher or lower risk.

Trastuzumab for the treatment of primary breast cancer in HER2-positive women: a single technology appraisal.

This paper presents a summary of the evidence review group (ERG) report into the the clinical and cost-effectiveness of trastuzumab for the treatment of primary breast cancer in human epidermal growth factor 2 (HER2)-positive women based upon a review of the manufacturers submission to the National Institute for Health and Clinical Excellence (NICE) as part of the single technology appraisal (STA) process. The manufacturers scope restricts the intervention to intravenous trastuzumab given for 1 year after surgery and after the completion of standard adjuvant chemotherapy, and the comparator to standard therapy without trastuzumab. The clinical rationale for the duration of treatment in the scope is open to question and leads to the exclsuion of one potentially relevant trial. The submitted evidence reports that the 3-weekly regimen of trastuzumab produced a relative reduction in all-cause mortality of 24-33%. Meta-analysis of all available studies based on 12 months of trastuzumab showed that there was a statistically significant 30% relative improvement in overall survival using the 3-weekly regimen. A study looking at weekly cycles of trastuzumab, excluded in the manufacturers submission, produced a relative reduction in all-cause mortality of 59%, which was not statistically significant. All included studies showed a statistically significant difference in the risk of recurrence or death from any cause (disease-free survival), favouring trastuzumab. There was a statistically significant increase in the relative risk of a serious adverse event in women treated with 3-weekly cycles of trastuzumab, with no excess toxicity in the study evaluating weekly cycles. Estimates of cost-effectiveness provided by the manufacturer were based on data from the HERA trial using the 3-weekly regimen of trastuzumab. The economic model was a state-transition model that compared the lifetime impact of adding 1 year of trastuzumab therapy to standard care with standard care alone. The initial cost-effectiveness estimate was 5687 pounds per additional quality-adjusted life-year (QALY) gained, rising to a maximum of 8689 pounds upon one-way sensitivity analysis. The base-case estimate of cost-effectiveness was subsequently revised by the manufacturer, resulting in an estimated incremental cost per additional QALY gained of 2387 pounds. A number of assumptions behind the manufacturers model may be optimistic and could mean that the incremental costs per QALY gained were underestimated. Additional analysis carried out by the evidence review group concluded that the incremental cost-effectiveness ratio (ICER) is expected to be around 20,000 pounds to 30,000 pounds. The addition of potential long-term cardiac events could push the ICER above 30,000 pounds, although there is no long-term evidence to date surrounding this issue. In addition, the small study excluded from the manufacturers submission raises the possibility of an equally effective but shorter regimen, incurring lower cost and toxicity and with greater patient convenience. The guidance issued by NICE in June 2006 as a result of the STA states that trastuzumab, given at 3-week intervals for 1 year or until disease recurrence, is recommended as a treatment option for women with early-stage HER2-positive breast cancer following surgery, chemotherapy and radiotherapy.

Systematic review and narrative synthesis of the effectiveness of contraceptive service interventions for young people, delivered in educational settings.

STUDY OBJECTIVE This review was undertaken to determine the effectiveness of contraception service interventions for young people that were delivered in educational settings. DESIGN We conducted a systematic review and narrative synthesis. SETTING Interventions were included where they were delivered in educational institutions, including schools, colleges, and pupil referral units. PARTICIPANTS Young people aged 19 and under. Studies of wider age groups were included if the majority of participants were aged under 19 years. INTERVENTIONS We included interventions which consisted of contraceptive service provision, and also interventions to encourage young people to use existing contraceptive services. MAIN OUTCOME MEASURES The main outcome measures used in the studies were: rate of teenage pregnancy, rate of contraceptive use, and sexual behavior. Many outcome measures were self reported. RESULTS Twenty-nine papers were included which reported on interventions to prevent adolescent pregnancy (and repeat pregnancy), school-based health centers, contraceptive use in college students, and multicomponent interventions. Intensive case management intervention conducted by a culturally matched school-based social worker (along with other components including peer education) were shown to be effective in preventing repeat adolescent pregnancy, at least for the duration of the intervention. Also, school-based health centers appear to be most effective when contraception provision is made available on site. CONCLUSIONS The evidence from these papers is limited, in terms of both quality and quantity, along with consistency of findings, but some recommendations in relation to effective interventions can be made.

The costs and benefits of bowel cancer service developments using discrete event simulation

Colorectal cancer includes cancerous growths in the colon, rectum and appendix and affects around 30 000 people in England each year. Maximizing health benefits for patients with colorectal cancer requires consideration of costs and outcomes across the whole service. In an era of scarce healthcare resources, there is a need to consider not only whether technologies and services may be considered clinically effective, but also whether they are cost-effective, that is, whether they represent value for money for the health service. Through the development of a whole disease model, it is possible to evaluate the cost-effectiveness of a range of options for service development consistently within a common framework. Discrete event simulation has been used to model the complete colorectal cancer patient pathway from patient presentation through to referral and diagnosis, treatment, follow-up, potential recurrence, treatment of metastases and end-of-life care. This simulation model has been used to examine the potential cost-effectiveness of different options for change across the entire colorectal cancer pathway. This paper provides an empirical demonstration of the potential application of modelling entire disease areas to inform clinical policy and resource allocation decision-making.

Systematic review of economic evidence for the detection, diagnosis, treatment, and follow-up of colorectal cancer in the United Kingdom

OBJECTIVES The aim of this study was to examine the availability and consistency of economic evidence for the detection, diagnosis, treatment, and follow-up of colorectal cancer. METHODS A systematic review of UK economic evaluations of colorectal cancer interventions was undertaken. Searches were undertaken across ten electronic databases. Studies were critically appraised through reference to a conceptual model of UK colorectal cancer services. RESULTS Forty-seven studies met the inclusion criteria. There is a substantial economic evidence base surrounding population-level colorectal screening, surgical procedures, and cytotoxic therapies for the adjuvant and palliative treatment of colorectal cancer. There is limited evidence concerning the diagnosis of suspected colorectal cancer, curative treatments for metastatic disease and follow-up regimens for nonmetastatic disease. No studies were identified relating to the economics of radiotherapy, surveillance of increased-risk groups, end-of-life care, or the management of hereditary colorectal cancer. Where evidence is available, studies are subject to important differences concerning treatment options, decision criteria, and incongruent assumptions concerning the disease and its management. CONCLUSIONS Across many aspects of the colorectal cancer service, current practice appears to have emerged without the consideration or support of economic evidence. There is a need to develop a common understanding how colorectal cancer models should be structured and implemented.

Estimating the direct costs of bowel cancer services provided by the National Health Service in England

OBJECTIVES Bowel cancer is the second most common cancer in England and Wales, accounting for approximately 13,000 deaths per year. Economic evaluations and national guidance have been produced for individual treatments for bowel cancer. However, it has been suggested that Primary Care Trusts develop program budgeting or equivalent methodology demonstrating a whole system approach to investment and disinvestment. The objective of this study was to provide a baseline framework for considering a whole system approach to estimate the direct costs of bowel cancer services provided by the National Health Service (NHS) in England. METHODS A treatment pathway, developed in 2005, was used to construct a service pathway model to estimate the direct cost of bowel cancer services in England. RESULTS The service pathway model estimated the direct cost of bowel cancer services to the NHS to be in excess of £1 billion in 2005. Thirty-five percent of the cost is attributable to the screening and testing of patients with suspected bowel cancer, subsequently diagnosed as cancer-free. CONCLUSIONS This study is believed to be the most comprehensive attempt to identify the direct cost of managing bowel cancer services in England. The approach adopted could be useful to assist local decision makers in identifying those aspects of the pathway that are most uncertain in terms of their cost-effectiveness and as a basis to explore the implications of re-allocated resources. Research recommendations include the need for detailed costs on surgical procedures, high-risk patients and the utilization of the methods used in this study across other cancers.

Assessment of a 7-day turn-around for the reporting of cervical smear results using discrete event simulation

A discrete event simulation (DES) model has been used to analyse options with the potential to facilitate a 7-day turn-around of cervical screening results in England, with the aim of reducing the anxiety experienced by the participants. Detailed information regarding the cervical screening process collected from the NHS Cancer Screening Programme, research papers, current national guidelines and five cytology laboratories in England was used to inform a DES model representing a typical laboratory. A number of options for change were evaluated. The simulation model suggested that it would be feasible to improve the result turn-around times from 95% within 11 weeks to 95% within 2 weeks; and from an average current result turn-around time of around 6 weeks, to over 50% within 7 days. Moreover, the options for change should be cost saving in the long term.

Modelling the cost‐effectiveness and capacity impact of changes to colposcopy referral guidelines for women with mild dyskaryosis in the UK Cervical Screening Programme

Objective  To evaluate the capacity implications and health economic impact of new guidelines recommending referral to colposcopy after one mild result during cervical screening rather than after two consecutive mild results.

Meta-analysis: folic acid in the chemoprevention of colorectal adenomas and colorectal cancer: META-ANALYSIS: FOLIC ACID IN THE CHEMOPREVENTION OF COLORECTAL CANCER

Aliment Pharmacol Ther 31, 708–718