Keith Bodger

Cost of illness of inflammatory bowel disease in the UK: a single centre retrospective study

Background and aims: The potentially high costs of care associated with inflammatory bowel disease (IBD) are recognised but we have little knowledge of the scale, profile, or determinants of these costs in the UK. This study aimed to describe costs of illness for a group of IBD patients and determine factors associated with increased healthcare costs. Setting: A university hospital serving a target population of approximately 330 000. Patients and methods: A six month cohort of IBD patients receiving any form of secondary care was identified, comprising 307 cases of ulcerative (or indeterminate) colitis and 172 cases of Crohn’s disease. Demographic and clinical data were abstracted from clinical records and individual resource use was itemised for all attributable costs (including extraintestinal manifestations). Item costs were derived from national and local sources. Cost data were expressed as mean six month costs per patient (with 95% confidence interval (CI)) obtained using non-parametric bootstrapping. Determinants of cost were analysed using generalised linear regression modelling. A postal survey of patients was undertaken to examine indirect costs, out of pocket expenses, and primary care visits. Results: Inpatient services (medical and/or surgical) were required by 67 patients (14%) but accounted for 49% of total secondary care costs. Drug costs accounted for less than a quarter of total costs. Individual patient costs ranged from £73 to £33 254 per six months. Mean (95% CI) six month costs per patient were £1256 (£988, £1721) for colitis and £1652 (£1221, £2239) for Crohn’s disease. Hospitalisation, disease severity grade, and disease extent correlated positively with cost of illness but costs were independent of age or sex. Compared with quiescent cases of IBD, disease relapse was associated with a 2–3-fold increase in costs for non-hospitalised cases and a 20-fold increase in costs for hospitalised cases. Survey data suggested average six month costs were <£30 per patient for primary care visits (both diseases) and median loss of earnings were £239 for colitis and £299 for Crohn’s disease. Conclusions: This study represents the first detailed characterisation of the scale and determinants of costs of illness for IBD in a British hospital. Hospitalisation affected a minority of sufferers but accounted for half of the total direct costs falling on the healthcare system.

Clinical economics review: medical management of inflammatory bowel disease

Inflammatory bowel diseases, although they are uncommon and rarely fatal, typically present during the period of economically productive adult life. Patients may require extensive therapeutic intervention as a result of the chronic, relapsing nature of the diseases. Their medical management includes oral and topical 5‐amino salicylic acid derivatives and corticosteroids, as well as antibiotics and immunosuppressive therapies. Assessing the cost‐effectiveness of rival treatments requires valid, reliable global assessments of outcome which consider quality of life, as well as the usual clinical end‐points. Macro‐economic studies of the overall impact of inflammatory bowel disease on health care systems have so far been largely confined to North America, where the total annual US costs, both direct and indirect, incurred by the estimated 380 000–480 000 sufferers has been put at around US2bn. Drugs were estimated to account for only 10% of total costs, whereas surgery and hospitalization account for approximately half. Studies from Europe suggest that the proportion of patients with Crohn’s disease and ulcerative colitis who are capable of full time work is 75% and 90%, respectively. However, whilst only a minority of inflammatory bowel disease patients suffer chronic ill health and their life expectancy is normal, obtaining life assurance may be problematic, suggesting a misconception that inflammatory bowel disease frequently results in a major impact on an individual’s economic productivity.

Gastric mucosal secretion of interleukin-10: relations to histopathology, Helicobacter pylori status, and tumour necrosis factor-alpha secretion.

BACKGROUND: Interleukin-10 (IL-10) is an 18 kDa peptide with a range of anti-inflammatory and immunosuppressive properties. AIM: To determine whether this cytokine is involved in gastric mucosal inflammation in Helicobacter pylori infection. METHODS: The production of IL-10 by antral mucosal biopsy specimens during short term in vitro culture was determined by measuring IL-10 content of supernatants by enzyme linked immunosorbent assay (ELISA). H pylori status was determined by serology and histology, with gastritis scored using the Sydney system. Tumour necrosis factor-alpha (TNF-alpha) content of supernatants was also determined in a subgroup of patients. RESULTS: IL-10 secretion was significantly greater in patients with H pylori associated chronic gastritis than in patients who were H pylori negative with normal mucosa/reactive changes, and those with H pylori negative chronic gastritis (p < 0.01 and < 0.05 respectively). There was a significant correlation overall between IL-10 secretion and chronic inflammation score (r = 0.40). Secretion of TNF-alpha, which was significantly higher in H pylori infected patients than uninfected patients with a normal mucosa (p < 0.04), correlated with scores for chronic inflammation and activity (r = 0.39 and 0.38 respectively), but was only weakly correlated with IL-10 secretion (r = 0.22, NS). CONCLUSIONS: Gastric mucosal production of IL-10 and TNF-alpha are increased in chronic gastritis associated with H pylori infection, and mucosal cytokine secretion varies with important histopathological aspects of gastric inflammation. Whereas the secretion of IL-10 in H pylori infection may be protective, limiting tissue damage caused by inflammation, it may also contribute towards failure of the immune response to eliminate the organism.

Cost of Illness of Crohn’s Disease

Crohn’s disease is a chronic inflammatory bowel disease of unknown aetiology which affects around 35 000 people in the UK (population 56.8 million). The potential for onset in early adult life, disease chronicity and a need for hospitalisation and surgery mean that the disease can be associated with substantial healthcare costs.Cost-of-illness studies focusing on direct medical costs have identified that over half the average costs associated with the disease relate to hospital costs. Estimates of the contribution of drug costs to the total direct economic burden have varied between 4.6 and 25%. Figures for average annual direct costs per patient in the US have been put at between

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

US6561 (1990 values) and

Predictive value of alarm features in a rapid access upper gastrointestinal cancer service

US12 417 (1994 values), whereas European studies have given much lower cost estimates (

Variation in Serum Pepsinogens With Severity and Topography of Helicobacter pylori‐Associated Chronic Gastritis in Dyspeptic Patients Referred for Endoscopy

US655, 1994 values). However, all studies have highlighted that much of the total cost of illness relates to extensive interventions required by a small proportion of severely affected individuals. Indirect costs associated with reduced productivity in Crohn’s disease can be high, with long periods of absenteeism and early disability. However, most patients (90%) remain in the workforce and life expectancy is relatively normal.A variety of drugs are employed for the treatment of Crohn’s disease, both in an attempt to induce clinical remission in active disease and to maintain remission once this has been achieved. Comparative data on cost effectiveness is lacking, though crude estimates based on randomised trials suggest that the frequently prescribed aminosalicylates, which have only modest efficacy, are a relatively costly drug option. The costs associated with adverse drug effects, particularly for corticosteroids, have not been formally quantified.Despite high costs, new drug therapies for more severe disease, such as anti-tumour necrosis factor (TNF-α) antibodies, may prove a cost-effective option if the need for hospitalisation is reduced. In a modelling exercise, a US group estimated that if a theoretical new drug was introduced which was capable of reducing non-drug costs (including hospitalisation) by a fifth despite doubling the overall drugs bill, there would still be a reduction in the overall costs of Crohn’s disease by 13%. Although surgical therapy is costly, there may be prolonged post-surgical remission following resection of localised disease and early surgery may represent a cost-effective option for selected patients.Without formal cost-effectiveness analyses, or (better still) clinical trials incorporating cost data, decisions about the relative efficiency of treatment alternatives for Crohn’s disease remain subjective and more research is clearly required in this area.

Prescribing patterns for dyspepsia in primary care: a prospective study of selected general practitioners

Background  Anti‐TNF‐alpha agents for Crohns disease (CD) have good clinical efficacy but high acquisition cost compared to rival drugs.

Altered colonic glycoprotein expression in unaffected monozygotic twins of inflammatory bowel disease patients

Aims: (i) To determine the value of individual alarm features for predicting cancer in subjects referred to a rapid access upper gastrointestinal cancer service; and (ii) to develop a clinical prediction model for cancer and to prospectively validate this model in a further patient cohort. Methods: Patient demographics, referral indications, and subsequent diagnosis were recorded prospectively. Logistic regression analyses were employed to determine the predictive value of individual alarm features in an evaluation cohort of 1852 consecutive cases. The potential impact of applying a modified set of referral criteria was then examined in a validation cohort of 1785 patients. Results: Evaluation cohort: mean age was 59 years; cancer prevalence 3.8%; and serious benign pathology 12.8%. Dysphagia (odds ratio (OR) 3.1), weight loss (OR 2.6), and age >55 years (OR 9.5) were found to be significant predictive factors for cancer but the value of other accepted alarm features was more limited. In particular, uncomplicated dyspepsia in those over 55 years was a negative predictive factor for cancer within this high risk cohort (OR 0.1). Validation cohort: the clinical prediction model would have selected 92% of cancer patients for fast track investigation while reducing the “two week rule” workload by 572 cases (31%). Conclusions: Fast track endoscopy in subjects fulfilling current criteria for suspected upper gastrointestinal malignancy results in a significant yield of cancer (∼4%) and serious benign diseases such as peptic ulceration, strictures, and severe oesophagitis (13%). However, the predictive value of individual features for cancer varies widely. Uncomplicated dyspepsia in older subjects was a poor predictor of cancer. Application of narrower referral criteria for accessing fast track services may reduce pressures while retaining high sensitivity for cancer.

Variation in gastroscopy rate in English general practice and outcome for oesophagogastric cancer: retrospective analysis of Hospital Episode Statistics

It has long been recognised that specific patterns of gastritis are linked with different gastroduodenal diseases and that serum pepsinogens vary with the histological state of the gastric mucosa. With the discovery of the role of Helicobacter pylori in chronic gastritis and the availability of noninvasive tests for H. pylori infection, individuals with H. pylori gastritis can now be identified without endoscopic biopsy. However, without a knowledge of the pattern and severity of gastritis it is impossible to predict the likelihood of significant associated gastroduodenal pathology.