Julian F. Guest

Health economic impact of managing patients following a community-based diagnosis of malnutrition in the UK.

BACKGROUND & AIMSnTo examine the effect of malnutrition on clinical outcomes and healthcare resource use from initial diagnosis by a general practitioner (GP) in the UK.nnnMETHODSn1000 records of malnourished patients were randomly selected from The Health Improvement Network database and matched with a sample of 996 patients records with no previous history of malnutrition. Patients outcomes and resource use were quantified for six months following diagnosis.nnnRESULTSnMalnourished patients utilised significantly more healthcare resources (e.g. 18.90 versus 9.12 GP consultations; pxa0<xa00.001, and 13% versus 5% were hospitalised; pxa0<xa00.05). The six-monthly cost of managing the malnourished and non-malnourished group was £1753 and £750 per patient respectively, generating an incremental cost of care following a diagnosis of malnutrition of £1003 per patient. Thirteen percent and 2% of patients died in the malnourished and non-malnourished group respectively (pxa0<xa00.001). Independent predictors of mortality were: malnutrition (OR: 7.70); age (per 10 years) (OR: 10.46); and the Charlson Comorbidity Index Score (per unit score) (OR: 1.24).nnnCONCLUSIONnThe healthcare cost of managing malnourished patients was more than twice that of managing non-malnourished patients, due to increased use of healthcare resources. After adjusting for age and comorbidity, malnutrition remained an independent predictor of mortality.

Cost-effectiveness of using continuous positive airway pressure in the treatment of severe obstructive sleep apnoea/hypopnoea syndrome in the UK

Objective: A study was undertaken to estimate the cost-effectiveness of using continuous positive airway pressure (CPAP) in the management of patients with severe obstructive sleep apnoea/hypopnoea syndrome (OSAHS) compared with no treatment from the perspective of the UK’s National Health Service (NHS). Methods: A Markov model was constructed to assess the cost-effectiveness of CPAP compared with no treatment. The model depicted the management of a 55-year-old patient with severe OSAHS as defined by an apnoea-hypopnoea index (AHI) >30 and daytime sleepiness (Epworth Sleepiness Scale score ⩾12). The model spans a period of 14 years. Results: According to the model, 57% of untreated patients are expected to be alive at the end of 14 years compared with 72% of patients treated with CPAP. Untreated patients are expected to cost the NHS £10u2009645 (95% CI £7988 to £14u2009098) per patient over 14 years compared with £9672 (95% CI £8057 to £12u2009860) per CPAP-treated patient. Treatment with CPAP for a period of 1 year was found not to be a cost-effective option since the cost per quality-adjusted life year (QALY) gained is expected to be >£20u2009000, but after 2 years of treatment the cost per QALY gained is expected to be £10u2009000 or less and, after 13 years of treatment, CPAP becomes a dominant treatment (ie, more effective than no treatment for less cost). Conclusion: Within the limitations of the model, CPAP was found to be clinically more effective than no treatment and, from the perspective of the UK’s NHS, a cost-effective strategy after a minimum of 2 years of treatment.

Health economic burden that different wound types impose on the UK's National Health Service

The aim of this study was to estimate the patterns of care and annual levels of health care resource use attributable to the management of different wound types by the UKs National Health Service (NHS) in 2012/2013 and the annual costs incurred by the NHS in managing them. This was a retrospective cohort analysis of the records of 2000 patients in The Health Improvement Network (THIN) Database. Patients characteristics, wound‐related health outcomes and all health care resource use were quantified, and the total NHS cost of patient management was estimated at 2013/2014 prices. The NHS managed an estimated 2·2 million patients with a wound during 2012/2013. Patients were predominantly managed in the community by general practitioners (GPs) and nurses. The annual NHS cost varied between £1·94 billion for managing 731 000 leg ulcers and £89·6 million for managing 87 000 burns, and associated comorbidities. Sixty‐one percent of all wounds were shown to heal in an average year. Resource use associated with managing the unhealed wounds was substantially greater than that of managing the healed wounds (e.g. 20% more practice nurse visits, 104% more community nurse visits). Consequently, the annual cost of managing wounds that healed in the study period was estimated to be £2·1 billion compared with £3·2 billion for the 39% of wounds that did not heal within the study year. Within the study period, the cost per healed wound ranged from £698 to £3998 per patient and that of an unhealed wound ranged from £1719 to £5976 per patient. Hence, the patient care cost of an unhealed wound was a mean 135% more than that of a healed wound. Real‐world evidence highlights the substantial burden that wounds impose on the NHS in an average year. Clinical and economic benefits to both patients and the NHS could accrue from strategies that focus on (a) wound prevention, (b) accurate diagnosis and (c) improving wound‐healing rates.

Clinical Outcomes and Cost-effectiveness of Continuous Positive Airway Pressure to Manage Obstructive Sleep Apnea in Patients With Type 2 Diabetes in the U.K.

OBJECTIVE To assess clinical outcomes and cost-effectiveness of using continuous positive airway pressure (CPAP) to manage obstructive sleep apnea (OSA) in patients with type 2 diabetes (T2D) from the perspective of the U.K.’s National Health Service (NHS). RESEARCH DESIGN AND METHODS Using a case-control design, 150 CPAP-treated patients with OSA and T2D were randomly selected from The Health Improvement Network (THIN) database (a nationally representative database of patients registered with general practitioners in the U.K.) and matched with 150 OSA and T2D patients from the same database who were not treated with CPAP. The total NHS cost and outcomes of patient management in both groups over 5 years and the cost-effectiveness of CPAP compared with no CPAP treatment were estimated. RESULTS Using CPAP was associated with significantly lower blood pressure at 5 years and increasingly lower HbA1c levels over 5 consecutive years compared with untreated OSA patients. At 5 years, the HbA1c level in the CPAP-treated group was 8.2% (66.0 mmol/mol) vs. 12.1% (108.4 mmol/mol) in the control group (P < 0.03). Use of CPAP significantly increased patients’ health status by 0.27 quality-adjusted life years (QALYs) per patient over 5 years (P < 0.001) and NHS management costs by £4,141 per patient over 5 years; the cost per QALY gained with CPAP was £15,337. CONCLUSIONS Initiating treatment with CPAP in OSA patients with T2D leads to significantly lower blood pressure and better controlled diabetes and affords a cost-effective use of NHS resources. These observations have the potential for treatment modification if confirmed in a prospective study.

Utility values for chronic myelogenous leukemia chronic phase health states from the general public in the United Kingdom

Abstract This study estimated time trade-off preference values associated with the four chronic myelogenous leukemia (CML) chronic phase-related health states (i.e. untreated, hematologic response, cytogenetic response and molecular response) among members of the general public in the UK (n = 241). All four health states were associated with decreases in preference values from full health. The molecular response to treatment was the most preferred health state (mean utility of 0.94). The second-most preferred health state was cytogenetic response followed by hematologic response (mean utilities were 0.89 and 0.80, respectively). The least preferred health state was untreated chronic phase CML (mean utility of 0.72). The utility values for each state were significantly different from one another (p < 0.001). This study demonstrated and quantified the impact that more robust treatment responses have on the health-related quality of life of patients with chronic phase CML.

Modelling the resource implications of managing adults with Fabry disease in Italy

Eur J Clin Invest 2011; 41 (7): 710–718

Venous leg ulcer management in clinical practice in the UK: costs and outcomes

The aim of this study was to estimate the patterns of care and annual levels of health care resource use attributable to managing venous leg ulcers (VLUs) in clinical practice by the UKs National Health Service (NHS) and the associated costs of patient management. This was a retrospective cohort analysis of the records of 505 patients in The Health Improvement Network (THIN) Database. Patients characteristics, wound‐related health outcomes and health care resource use were quantified, and the total NHS cost of patient management was estimated at 2015/2016 prices. Overall, 53% of all VLUs healed within 12 months, and the mean time to healing was 3·0 months. 13% of patients were never prescribed any recognised compression system, and 78% of their wounds healed. Of the 87% who were prescribed a recognised compression system, 52% of wounds healed. Patients were predominantly managed in the community by nurses with minimal clinical involvement of specialist clinicians. Up to 30% of all the VLUs may have been clinically infected at the time of presentation, and only 22% of patients had an ankle brachial pressure index documented in their records. The mean NHS cost of wound care over 12 months was an estimated £7600 per VLU. However, the cost of managing an unhealed VLU was 4·5 times more than that of managing a healed VLU (£3000 per healed VLU and £13 500 per unhealed VLU). This study provides important insights into a number of aspects of VLU management in clinical practice that have been difficult to ascertain from other studies and provides the best estimate available of NHS resource use and costs with which to inform policy and budgetary decisions.

Cost-effectiveness of using adjunctive porcine small intestine submucosa tri-layer matrix compared with standard care in managing diabetic foot ulcers in the US

OBJECTIVEnTo estimate the cost-effectiveness of using tri-layer porcine small intestine submucosa (SIS; Oasis Ultra) as an adjunct to standard care compared with standard care alone in managing diabetic foot ulcers (DFUs) in the US, from the perspective of Medicare.nnnMETHODnA Markov model was constructed to simulate the management of diabetic neuropathic lower extremity ulcers over a period of one year in the US. The model was used to estimate the cost-effectiveness of initially using adjunctive SIS compared with standard care alone to treat a DFU in the US at 2016 prices.nnnRESULTSnAt 12 months after the start of treatment, the use of adjunctive SIS instead of standard care alone is expected to lead to a 42 % increase in the number of ulcer-free months, 32 % increase in the probability of healing, a 3 % decrease in the probability of developing complicated ulcers and a 1 % decrease in the probability of undergoing an amputation. Health-care resource use is expected to be reduced by 11-14 % among patients who are initially managed with adjunctive SIS compared with those initially managed with standard care alone, with the exception of debridement, which is expected to be reduced by 35 %. Hence, the total health-care cost of starting treatment with adjunctive SIS instead of standard care alone was estimated to reduce payer costs by 1% (i.e.

Utility values for specific chronic myeloid leukemia chronic phase health states from the general public in the United Kingdom.

105 per patient) over 12 months following the start of treatment.nnnCONCLUSIONnWithin the studys limitations, the use of adjunctive SIS instead of standard care alone improves outcome for less cost and thereby affords a cost-effective use of Medicare-funded resources in the management of neuropathic foot ulcers among adult patients with type 1 or 2 diabetes mellitus in the US.

Diabetic foot ulcer management in clinical practice in the UK: costs and outcomes

Abstract This study elicited time trade-off (TTO) and standard gamble (SG) preference values associated with four health states corresponding to response levels in chronic phase chronic myeloid leukemia (CML) from members of the general public in the UK (n = 235). Health states studied were treatment-free remission (TFR), complete molecular response (CMR, i.e. undetectable disease on treatment), molecular response and reappearance of detectable disease (i.e. relapse from TFR to molecular response requiring treatment). TFR was the most preferred health state (mean utility of 0.97 [TTO] and 0.87 [SG]) followed by CMR (mean utility of 0.96 [TTO] and 0.85 [SG]) followed by molecular response (mean utility of 0.94 [TTO] and 0.80 [SG]) followed by reappearance of detectable disease (mean utility of 0.90 [TTO] and 0.72 [SG]). SG values were significantly lower than TTO values (p < 0.001). The study demonstrated that different treatment responses may impact on the health-related quality of life of patients with chronic phase CML.