Maria Raikou

Cost effectiveness of an intensive blood glucose control policy in patients with type 2 diabetes: economic analysis alongside randomised controlled trial (UKPDS 41)

Abstract Objective: To estimate the cost effectiveness of conventional versus intensive blood glucose control in patients with type 2 diabetes. Design: Incremental cost effectiveness analysis alongside randomised controlled trial. Setting: 23 UK hospital clinic based study centres. Participants: 3867 patients with newly diagnosed type 2 diabetes (mean age 53 years). Interventions: Conventional (primarily diet) glucose control policy versus intensive control policy with a sulphonylurea or insulin. Main outcome measures: Incremental cost per event-free year gained within the trial period. Results: Intensive glucose control increased trial treatment costs by £695 (95% confidence interval £555 to £836) per patient but reduced the cost of complications by £957 (£233 to £1681) compared with conventional management. If standard practice visit patterns were assumed rather than trial conditions, the incremental cost of intensive management was £478 (-£275 to £1232) per patient. The within trial event-free time gained in the intensive group was 0.60 (0.12 to 1.10) years and the lifetime gain 1.14 (0.69 to 1.61) years. The incremental cost per event-free year gained was £1166 (costs and effects discounted at 6% a year) and £563 (costs discounted at 6% a year and effects not discounted). Conclusions: Intensive blood glucose control in patients with type 2 diabetes significantly increased treatment costs but substantially reduced the cost of complications and increased the time free of complications.

Cost-effectiveness analysis of intensive blood-glucose control with metformin in overweight patients with Type II diabetes (UKPDS No. 51)

Aims/hypothesis. To estimate the economic efficiency of intensive blood-glucose control with metformin compared with conventional therapy primarily with diet in overweight patients with Type II (non-insulin-dependent) diabetes mellitus. Methods. Cost-effectiveness analysis based on patient level data from a randomised clinical controlled trial involving 753 overweight ( > 120 % ideal body weight) patients with newly diagnosed Type II diabetes conducted in 15 hospital-based clinics in England, Scotland and Northern Ireland as part of the UK Prospective Diabetes Study. Subjects were allocated at random to an intensive blood-glucose control policy with metformin (n = 342) or a conventional policy primarily with diet (n = 411). The analysis was based on the cost of health care resources associated with metformin and conventional therapy and the estimated effectiveness in terms of life expectancy gained from within-trial effects. Results. Intensive blood-glucose control with metformin produced a net saving of £ 258 per patient (1997 United Kingdom prices) over the trial period (median duration of 10.7 years) due to lower complication costs, and increased life expectancy by 0.4 years (costs and benefits discounted at 6 %). Conclusions/interpretation. As metformin is both cost-saving in the United Kingdom and extends life expectancy when used as first line pharmacological therapy in overweight Type II diabetic patients, its use should be attractive to clinicians and health care managers alike. [Diabetologia (2001) 44: 298–304]

Cost-effectiveness of Population Screening for BRCA Mutations in Ashkenazi Jewish Women Compared With Family History–Based Testing

Background: Population-based testing for BRCA1/2 mutations detects the high proportion of carriers not identified by cancer family history (FH)–based testing. We compared the cost-effectiveness of population-based BRCA testing with the standard FH-based approach in Ashkenazi Jewish (AJ) women. Methods: A decision-analytic model was developed to compare lifetime costs and effects amongst AJ women in the UK of BRCA founder-mutation testing amongst: 1) all women in the population age 30 years or older and 2) just those with a strong FH (≥10% mutation risk). The model assumes that BRCA carriers are offered risk-reducing salpingo-oophorectomy and annual MRI/mammography screening or risk-reducing mastectomy. Model probabilities utilize the Genetic Cancer Prediction through Population Screening trial/published literature to estimate total costs, effects in terms of quality-adjusted life-years (QALYs), cancer incidence, incremental cost-effectiveness ratio (ICER), and population impact. Costs are reported at 2010 prices. Costs/outcomes were discounted at 3.5%. We used deterministic/probabilistic sensitivity analysis (PSA) to evaluate model uncertainty. Results: Compared with FH-based testing, population-screening saved 0.090 more life-years and 0.101 more QALYs resulting in 33 days’ gain in life expectancy. Population screening was found to be cost saving with a baseline-discounted ICER of -£2079/QALY. Population-based screening lowered ovarian and breast cancer incidence by 0.34% and 0.62%. Assuming 71% testing uptake, this leads to 276 fewer ovarian and 508 fewer breast cancer cases. Overall, reduction in treatment costs led to a discounted cost savings of £3.7 million. Deterministic sensitivity analysis and 94% of simulations on PSA (threshold £20000) indicated that population screening is cost-effective, compared with current NHS policy. Conclusion: Population-based screening for BRCA mutations is highly cost-effective compared with an FH-based approach in AJ women age 30 years and older.

Cost-effectiveness analysis of oxaliplatin compared with 5-fluorouracil/leucovorin in adjuvant treatment of stage III colon cancer in the US†

The MOSAIC trial demonstrated that oxaliplatin/5‐fluorouracil/leucovorin (FU/LV) (FOLFOX4) as adjuvant treatment of TNM stage II and III colon cancer significantly improves disease‐free survival compared with 5‐FU/LV alone. For stage III patients the 4‐year disease‐free survival (DFS) was 69% in the FOLFOX4 arm vs 61% in the LV5FU2 arm, P = .002). The cost‐effectiveness of FOLFOX4 in stage III patients was evaluated from a US Medicare perspective.

Centre-specific or average unit costs in multi-centre studies? Some theory and simulation

Costing issues are increasingly being addressed in multi-centre studies. In this paper, two methods for collecting costing information are compared within a simulated clinical trial setting. One method estimates average treatment costs by applying unit costs averaged across treatment centres to centre-specific volumes of resource use. The second uses centre-specific information for both the unit costs and the resource volumes, and then averages across centres. Using a pre-specified production relation between the different volumes of resource use, and simulating changes in unit costs, it is shown that these two methods result in statistically different estimates of average treatment costs. This finding holds, regardless of the degree of substitutability between the resource volumes, except when considerable uncertainty surrounds treatment centre responses to relative changes in unit costs. The findings suggest that a more cautious approach should be adopted in the collection, calculation and interpretation of treatment costs in multi-centre studies.

Long-Term Mortality, Morbidity and Hospital Care following Intracerebral Hemorrhage: An 11-Year Cohort Study

Background and Purpose: Intracerebral hemorrhage (ICH) represents the severest form of stroke, yet examinations of long-term prognosis and associated health care use are rare. This study assessed survival, morbidity and cost of hospital care over 11 years following a first-ever ICH in the UK. Methods: We used a population-based retrospective inception cohort design using data from the Hospital Record Linkage System in Scotland. Long-term survival, morbidity and treatment provided in hospitals were evaluated in all patients with a first diagnosis of ICH in 1995. A cohort of ischemic stroke (IS) patients was also examined for comparison. Results: A total of 705 patients with ICH and 8,893 with IS were identified. The mean age was 65 years (SD = 17.2) for ICH and 73 years (SD = 11.8) for IS at stroke onset. The acute in-hospital mortality was 45.7 and 30.1% for ICH and IS, 51.2 and 39.9% at 1 year, while 76.0 and 80.4% were dead 11 years later. The cumulative risk of nonfatal or fatal ICH was 8.0, 12.7 and 13.7% at 1, 5 and 10 years, and 7.0, 11.1 and 12.9% for IS in the ICH cohort. The mean cost of initial hospital care was GBP 10,332 (SD = 19,919) for ICH and GBP 9,937 (SD = 15,777) for IS. The mean total costs over 11 years were GBP 18,629 (SD = 29,943) for ICH and GBP 21,505 (SD = 27,190) for IS. Conclusion: Following a first ICH, individuals have a poorer short-term prognosis than individuals with IS, yet both ICH and IS imply significant follow-up care.

The economics of screening and treatment in type 2 diabetes mellitus

AbstractA systematic review of the literature was conducted to identify articles on the economics of type 2 diabetes mellitus. Articles were classified into two main categories: cost/burden-of-illness studies of type 2 diabetes and economic evaluations of type 2 diabetes interventions. This systematic review was supplemented by an overview of the findings relating to economic evaluations of associated diabetic complications. A number of conclusions emerge from this review, the most important of which is that intensive treatment of patients with type 2 diabetes appears to be relatively cost effective compared with more conservative strategies. This finding reflects the cost offsets that arise from the range and degree of complications attributable to diabetes. Primary prevention of type 2 diabetes also appears to be cost effective, particularly in high-risk groups. The evidence on screening for type 2 diabetes is less conclusive and further economic analysis is required.

An economic evaluation of atenolol vs. captopril in patients with Type 2 diabetes (UKPDS 54)

Aims   To compare the net cost of a tight blood pressure control policy with an angiotensin converting enzyme inhibitor (captopril) or β blocker (atenolol) in patients with Type 2 diabetes.

An assessment of the cost of percutaneous pulmonary valve implantation (PPVI) versus surgical pulmonary valve replacement (PVR) in patients with right ventricular outflow tract dysfunction

Abstract Background: Percutaneous pulmonary valve implantation (PPVI) using the Melody* transcatheter pulmonary valve is a new procedure introduced in 2000 as a less invasive treatment for right ventricular outflow tract (RVOT) dysfunction. The aim of this new procedure is to restore pulmonary valve competence without the need of open-chest operation. By prolonging the conduit lifespan, it delays surgical pulmonary valve replacement (PVR) and it can therefore potentially reduce the number of open-chest interventions over a patient’s lifetime. PPVI has been shown to be feasible and safe and can be performed with a low complication rate. Objectives and Methods: The aim of this study is to assess the cost of PPVI and the cost of surgical pulmonary valve replacement (PVR) in patients with right ventricular outflow tract dysfunction using a cohort simulation model applied to the UK population. Results: The model resulted in an estimate of mean cost per patient of £5,791 when PPVI is unavailable as a treatment option and in an estimate of mean cost per patient of £8,734 when PPVI is available over the 25-year period of analysis. After sensitivity analysis was undertaken the results showed that the mean per patient cost difference in implementing PPVI over 25 years as compared to surgical PVR lies somewhere between £2,041 and £3,913. Limitations: Given the lack of long-term data on treatment progression, the cost estimates derived here are subject to considerable uncertainty, and extensive sensitivity analysis has been used to counter this. Consequently this study is merely indicative of the levels of cost which can be expected in a cohort of 1,000 patients faced with a choice of treatment with PPVI or surgery. It is not a cost-effectiveness study but it helps place current knowledge on short-term benefits into context. Conclusions: As this analysis shows PPVI is associated with a relatively small increase in treatment management costs over a long time period. It is left entirely to the reader to value whether this inferred increase in long-term cost is worthwhile given the known short-term benefits and any personal judgement formed over long-term benefit.

An Assessment of Health Related Quality of Life in a Male Prison Population in Greece Associations with Health Related Characteristics and Characteristics of Detention

Background. Prisoners constitute a group with increased health and social care needs. Although implementing policies that aim at improving outcomes within this population should be a priority area, studies that attempt to assess health outcomes and health related quality of life (HRQoL) in this population are limited. Aim. To assess HRQoL in a prison population in Greece and to explore the relationship between HRQoL and a set of individual sociodemographic and health related characteristics and characteristics of detention. Methods. A cross-sectional study involving 100 male prisoners was conducted in the prison of Corinth in Greece. HRQoL was assessed through the use of the SF-36 and the EQ-5D. Results. The mean physical and mental summary scores of the SF-36 were 55.33 and 46.82, respectively. The EQ-VAS mean score was 76.41%, while the EQ-5D index was 0.72. Multivariate analysis identified a statistical relationship between HRQoL and the conditions of detention, controlling for the effect of sociodemographic characteristics, morbidity, and mental problems. The use of narcotics in particular is significantly associated with lower HRQoL. Conclusions. Implementation of policies that aim at preventing the use of narcotics within the prison environment is expected to contribute to improved HRQoL in this population.