Malcolm Whitfield

CHOICE OF NSAID AND MANAGEMENT STRATEGY IN RHEUMATOID ARTHRITIS AND OSTEOARTHRITIS : THE IMPACT ON COSTS AND OUTCOMES IN THE UK

Objective:Although nonsteroidal anti-inflammatory drugs (NSAIDs) are an effective therapy for rheumatoid arthritis, they are associated with significant adverse effects, the management of which imposes additional costs on the healthcare system. Prescribing NSAIDs which have a lower risk of major adverse effects as the first-line NSAID for patients with rheumatoid arthritis and osteoarthritis may be expected to lead to an improvement in clinical outcomes and reduce overall treatment costs. This analysis examines data from a published randomised controlled trial of 5 NSAIDs to explore these hypotheses.Design and Setting:Data from a clinical trial comparing 5 NSAIDs were combined with published cost data to construct 2 clinical decision models, reflecting alternative approaches to the management of major and minor adverse effects in the UK.Interventions:The 5 NSAIDs evaluated in the analysis were nabumetone, diclofenac, ibuprofen, piroxicam and naproxen, although only the results for ibuprofen and nabumetone are reported.Main outcome measures and results:The total cost of care per patient receiving nabumetone was estimated to be between 25 pounds sterling (£) and £41 more expensive than ibuprofen. In a hypothetical cohort of 100 000 patients, there were between 690 and 821 more major adverse effects using ibuprofen than nabumetone. The cost per life-year gained (LYG) from using nabumetone rather than ibuprofen ranged between £1880 and £2517 (1995 values), depending upon the management of adverse effects.Conclusions:These results indicate that: (i) prescribing the newer, currently more expensive, NSAIDs will not necessarily lead to cost savings; (ii) the management of adverse effects can have a significant impact on costs; and (iii) the additional cost may be justifiable in terms of the mortality and morbidity gains associated with the new lower-risk NSAIDs.

Economic implications of the use of basiliximab in addition to triple immunosuppressive therapy in renal allograft recipients: a UK perspective.

AbstractObjective: To compare resource use and costs in renal transplant recipients treated with basiliximab or placebo plus triple immunosuppressive therapy. Design: International randomised, double-blind, placebo-controlled trial; economic evaluation undertaken alongside the efficacy trial. The economic evaluation was performed from a UK National Health Service hospital perspective. Setting: 31 centres in 12 countries. Participants: 345 renal transplant recipients were enrolled; 340 were randomised (basiliximab 168; placebo 172) and included in the intention-to-treat analysis. Intervention: Treatment with placebo or basiliximab (20mg intravenous bolus) on day 0 and day 4 after transplantation Main outcome measures: Resource utilisation in multiple categories and treatment costs for basiliximab and placebo-treated patients during the 6-month post-transplantation period. Results: No statistically significant differences were found in any of the economically important categories of resource use or in the mean cost of treatment per person across the whole trial. The mean cost of treatment, including the cost of basiliximab, was £16 095 for basiliximab recipients and £15 864 (1997/1998 costs) for placebo recipients, a mean difference of £231 (95%CI: −£1983 to £2446), which was not significant. Basiliximab treatment led to a significant reduction in acute rejection episodes (basiliximab 20.8%; placebo 34.9%; p = 0.005). Conclusions: Basiliximab therapy confers a significant clinical benefit to renal transplant recipients without increasing overall treatment costs.

Pharmacoeconomic evaluation of simulect prophylaxis in renal transplant recipients

Advances in immunosuppressive therapy have substantially improved one-year clinical outcomes for renal transplantation.1 However, acute rejection still occurs in up to 50% of kidney transplantation recipients during the first year,2 and it remains the major contributor to chronic rejection and long-term graft failure. [3], [4] and [5] Although episodes of acute rejection are reversible with heightened doses of steroids and antibody therapy, the implications for increased healthcare costs and poor long-term outcome underscore the importance of developing therapies to reduce acute rejection. Basiliximab (Simulect, Novartis, Basel, Switzerland) is a high-affinity chimeric antiinterleukin-2 receptor monoclonal antibody that is indicated for the prophylaxis of acute rejection after renal transplantation. [6] and [7] Randomised clinical trials have demonstrated that basiliximab is highly effective in suppressing acute rejection when used in combination with dual therapy of cyclosporin and steroids. [8] and [9] Recently, a phase III international multi-centre trial was performed to evaluate the effectiveness of basiliximab in renal transplantation patients receiving a standard triple therapy regimen of cyclosporin, steroids, and azathioprine.10 An economic evaluation of the trial was undertaken alongside the clinical studies. We determined the economic impact of adding basiliximab to triple therapy. Our objectives were to compare within-trial resource use between basiliximab-treated and placebo-treated patients within six months of renal transplantation and to evaluate the cost implications of basiliximab use, relative to clinical outcomes.

Developing a Model to Estimate the Potential Impact of Municipal Investment on City Health

This article summarizes a process which exemplifies the potential impact of municipal investment on the burden of cardiovascular disease (CVD) in city populations. We report on Developing an evidence-based approach to city public health planning and investment in Europe (DECiPHEr), a project part funded by the European Union. It had twin objectives: first, to develop and validate a vocational educational training package for policy makers and political decision takers; second, to use this opportunity to iterate a robust and user-friendly investment tool for maximizing the public health impact of ‘mainstream’ municipal policies, programs and investments. There were seven stages in the development process shared by an academic team from Sheffield Hallam University and partners from four cities drawn from the WHO European Healthy Cities Network. There were five iterations of the model resulting from this process. The initial focus was CVD as the biggest cause of death and disability in Europe. Our original prototype ‘cost offset’ model was confined to proximal determinants of CVD, utilizing modified ‘Framingham’ equations to estimate the impact of population level cardiovascular risk factor reduction on future demand for acute hospital admissions. The DECiPHEr iterations first extended the scope of the model to distal determinants and then focused progressively on practical interventions. Six key domains of local influence on population health were introduced into the model by the development process: education, housing, environment, public health, economy and security. Deploying a realist synthesis methodology, the model then connected distal with proximal determinants of CVD. Existing scientific evidence and cities’ experiential knowledge were ‘plugged-in’ or ‘triangulated’ to elaborate the causal pathways from domain interventions to public health impacts. A key product is an enhanced version of the cost offset model, named Sheffield Health Effectiveness Framework Tool, incorporating both proximal and distal determinants in estimating the cost benefits of domain interventions. A key message is that the insights of the policy community are essential in developing and then utilising such a predictive tool.

Good-quality social care for people with Parkinson’s disease : a qualitative study

Objectives The study examines the meaning of good-quality social care for people with Parkinsons disease and their carers. It identifies, from their perspective, the impact of good-quality social care on health and well-being. Design Qualitative case study methodology, interview and framework analysis techniques were used. Setting: community locations in the north and midlands of England. Participants Data were collected from 43 participants including individual interviews with people with Parkinsons disease (n=4), formal and informal social care providers (n=13), 2 focus groups, 1 with people with Parkinsons disease and their carers (n=17), and 1 with professionals (n=8), plus a telephone interview with a former commissioner. Findings Good-quality social care, delivered in a timely fashion, was reported to have a positive impact on health. Furthermore, there is an indication that good-quality social care can prevent untoward events, such as infections, symptom deterioration and deterioration in mental health. The concept of the ‘Impact Gap’ developed from the findings, illustrates how the costs of care may be reduced by delivering good-quality social care. Control, choice and maintaining independence emerged as indicators of good-quality social care, irrespective of clinical condition. Participants identified characteristics indicative of good-quality social care specific to Parkinsons disease, including understanding Parkinsons disease, appropriate administration of medication, timing of care and reassessment. ‘Parkinsons aware’ social care was seen to generate psychological, physical and social benefits that were inter-related. Conclusions The findings indicate how maximising quality in social care delivery for people with Parkinsons disease can impact on health and well-being. Long-term or short-term benefits may result in prevented events and reductions in health and social care resource. Health professionals can be instrumental in early detection of and signposting to social care.

Nabumetone compared with Ibuprofen and a weighted NSAID combination: an economic evaluation

SummaryAn economic evaluation has been performed to assess the cost effectiveness of using nabumetone to treat Osteoarthritis (OA) or Rheumatoid Arthritis (RA) compared to alternative NSAIDs (plain NSAIDs only, ie. excludes combinations). Clinical decision analysis has been used to model the costs and outcomes of treatment building on the results of a large, open label, randomised, controlled, multicentre US clinical study, from an NHS perspective. In the treatment of OA/RA, nabumetone carries a lower risk of major side effects and potential associated mortality, than either ibuprofen or a weighted NSAID comparator. The cost per life year gained, by prescribing nabumetone, in place of other NSAIDs, ranges from £1,656 to £3,087.If reducing the risk of major side effects is a priority then the additional potential costs of prescribing Nabumetone to achieve this end compares favourably to many expenditures already made within the NHS. On this basis, prescribing nabumetone for OA/RA may be considered a cost e...

Are there just barriers? Institutional perspective on the development of e-health in Poland

Abstract Development of e-health in Poland has suffered from multiple setbacks and delays. This paper presents views on and experiences with implementation of e-health solutions of three groups of respondents: buyers, suppliers and external experts with the aim of establishing to what extent and in what way e-health development was taking place in Polish public health care and if there were any national policy targets or European targets influencing this development. It is based on desktop studies and interviews conducted in Poland in the spring and summer of 2015. The interviews largely confirmed findings from the desktop study: legal obstacles were the decisive factor hindering the development of e-health, especially telemedicine, with extensive insufficiency of basic IT infrastructure closely following. Stakeholders were deterred from engaging with telemedicine, and from procuring e-health using non-standard procedures, from fear of legal liability. Some doctor’s resistance to e-health was also noted. There are reasons for optimism. Amendment to the Act on the System of Information in Health Care removed most legal obstacles to e-health. The Polish national payer (NFZ) has started introducing reimbursement for remote services, though it is still too early see results of these changes. Some doctors′ reluctance to telemedicine may change due to demographic changes in this professional group, younger generations may regard ICT-based solutions as a norm. In the same time, poor development of basic IT infrastructure in Polish hospitals is likely to persist, unless a national programme of e-health development is implemented (with funds secured) and contracting e-health services by NFZ is introduced on a larger scale.

Developing a framework for estimating the potential impact of obesity interventions in a European city

Obesity is a global challenge for healthy populations. It has given rise to a wide range of public health interventions, focusing on supportive environments and lifestyle change, including diet, physical activity and behavioural change initiatives. Impact is variable. However, more evidence is slowly becoming available and is being used to develop new interventions. In a period of austerity, momentum is building to review these initiatives and understand what they do, how they do it and how they fit together. Our project seeks to develop a relatively straight forward systematic framework using readily accessible data to map the complex web of initiatives at a policy, population, group and individual level aiming to promote healthy lifestyles, diet and physical activity levels or to reduce obesity through medical treatments in a city or municipality population. It produces a system for classifying different types of interventions into groupings which will enable commissioners to assess the scope and distribution of interventions and make a judgement about gaps in provision and the likely impact on mean body mass index (BMI) as a proxy measure for health. Estimated impact in each level or type of intervention is based upon a summary of the scientific evidence of clinical and/or cost effectiveness. Finally it seeks, where possible, to quantify the potential effects of different types of interventions on BMI and produce a cost per unit of BMI reduced. This approach is less sophisticated but identifies the areas where more sophisticated evaluation would add value.

Introduction of a non-ported peripheral intravenous catheter with multi-use blood control septum offers improvements in the overall efficiency of the procedure and is clinically well accepted

Financial challenges that the National Health Service (NHS), England, faces may jeopardise its future. This study evaluated the direct cost of using two different safety peripheral intravenous cannulae (SPIVC) with and without a blood control septum, including the cost of device and clinician time. Observation of 103 cannulations demonstrated a 54 second (29%) time reduction per cannulation with the non-ported SPIVC with multi-use blood control septum (Introcan Safety® 3 B Braun), compared to the standard ported SPIVC (Vasofix® Safety B Braun) (P < 0.05). The direct cost analysis, including clinician time, demonstrated that the introduction of SPIVC with multi-use blood control septum could offer time efficiency savings equivalent to a reduction in average cannulation costs by 25%. 82% of users perceived the insertion of SPIVC with multi-use blood control septum to be easy to use; 82% would choose to use it in clinical practice.