Stephen Chaplin

Incidence and costs of unintentional falls in older people in the United Kingdom

Study objective: To estimate the number of accident and emergency (A&E) attendances, admissions to hospital, and the associated costs as a result of unintentional falls in older people. Design: Analysis of national databases for cost of illness. Setting: United Kingdom, 1999, cost to the National Health Service (NHS) and Personal Social Services (PSS). Participants: Four age groups of people 60 years and over (60–64, 65–69, 70–74, and ⩾75) attending an A&E department or admitted to hospital after an unintentional fall. Databases analysed were the Home Accident Surveillance System (HASS) and Leisure Accident Surveillance System (LASS), and Hospital Episode Statistics (HES). Main results: There were 647 721 A&E attendances and 204 424 admissions to hospital for fall related injuries in people aged 60 years and over. For the four age groups A&E attendance rates per 10 000 population were 273.5, 287.3, 367.9, and 945.3, and hospital admission rates per 10 000 population were 34.5, 52.0, 91.9, and 368.6. The cost per 10 000 population was £300 000 in the 60–64 age group, increasing to £1 500 000 in the ⩾75 age group. These falls cost the UK government £981 million, of which the NHS incurred 59.2%. Most of the costs (66%) were attributable to falls in those aged ⩾75 years. The major cost driver was inpatient admissions, accounting for 49.4% of total cost of falls. Long term care costs were the second highest, accounting for 41%, primarily in those aged ⩾75 years. Conclusions: Unintentional falls impose a substantial burden on health and social services.

An economic evaluation of Fluvastatin used for the prevention of cardiac events following successful first percutaneous coronary intervention in the UK

AbstractAims: To estimate the costs, benefits and cost effectiveness, from the UK NHS perspective, of fluvastatin (relative to no HMG-CoA reductase inhibitor [statin]) for the secondary prevention of major adverse cardiac events following a successful first percutaneous coronary intervention (PCI). Methods: A cost-effectiveness analysis was undertaken using efficacy data from the Lescol® Intervention Prevention Study (LIPS). LIPS was a randomised, double-blind, placebo-controlled trial undertaken in 77 centres (predominantly in Europe). Patients included in the trial had moderate hypercholesterolaemia and had successfully undergone their first PCI. Fluvastatin (Lescol®) 40mg twice daily plus dietary counselling was given to the intervention group for up to 4 years; the control group received dietary counselling only. A Markov model was used to estimate the incremental costs per QALY gained over a 10-year period, with cost data drawn from the UK NHS (2002 values). Monte Carlo simulations and multivariate analysis were used to assess uncertainty. Costs were discounted at 6% per annum, and health outcomes at 1.5% per annum. Results: On average, treatment with fluvastatin cost an additional £300 (SD £303) [€423; SD €428] per patient and resulted in an additional 0.092 (SD 0.06) QALYs per patient over 10 years compared with controls. The incremental cost per QALY gained with fluvastatin versus the control group was £3207 (SD £5497) [€4527; SD €7759]. Fluvastatin was dominant (better outcomes and lower costs) in 15.9% of the simulations and was dominated in 2.9%. The key determinants of cost effectiveness were: the effectiveness of fluvastatin in reducing acute myocardial infarction, subsequent PCI, coronary artery bypass graft and cardiac deaths; the utility weight associated with a subsequent post-PCI state; the cost of fluvastatin; and the time horizon evaluated. Conclusions: Fluvastatin is the only statin which has proven effective in preventing major coronary adverse events in new PCI patients; other statins lack this evidence. This Markov model, with its underlying assumptions and data, suggests that fluvastatin is a viable and economically efficient pharmaceutical (relative to no statin) to reduce heart disease in the UK when given routinely to all patients following PCI.

An economic evaluation of sevelamer in patients new to dialysis

ABSTRACT Objective: The overall objective of this study was to estimate the costs and outcomes associated with treatment with sevelamer for hyperphosphataemia compared with calcium-based binders. Methods: Using published data on mortality and hospitalisation rates, a Markov model was developed to predict health outcomes and associated costs for the treatment of hyperphosphataemia using either sevelamer or calcium binders in chronic kidney disease patients who had recently started haemodialysis. Patient outcomes were modelled for 5 years, and incremental cost-effective ratios (ICERs) were calculated for sevelamer relative to calcium carbonate and calcium acetate binders. The perspective adopted was that of the UK National Health Service. Results: The total 5-year discounted treatment cost for patients treated with sevelamer is £24 216, while for the calcium carbonate group total cost was £17 695. This is an incremental cost of £6521 per sevelamer-treated patient over 5 years. Patients receiving sevelamer can be expected to experience 2.70 quality-adjusted life years (QALYs) compared to 2.46 for those treated with calcium carbonate (i.e. an incremental gain of 0.24 QALYs). This results in an incremental cost per QALY of £27 120 and an incremental cost per life year gained of £15 508. Results were similar with calcium acetate. Conclusion: Together with the unique morbidity and mortality benefits, this study suggests that treatment with sevelamer confers clinical benefits with a modest investment of additional economic resources.

An Economic Evaluation of Valsartan for Post-MI Patients in the UK Who Are Not Suitable for Treatment with ACE Inhibitors

OBJECTIVES The overall objective of this study was to estimate the costs and outcomes associated with treatment with valsartan for post-myocardial infarction (post-MI) patients with left ventricular systolic dysfunction, heart failure, or both, who are not suitable for treatment with angiotensin-converting enzyme (ACE) inhibitors, compared to placebo. METHODS A Markov model, using data drawn from the Valsartan in Acute Myocardial Infarction (VALIANT) trial and other trials, was developed to predict the future health pathways, resource use, and costs for patients who have recently experienced an MI. Patients received either valsartan (mean dose 247 mg) or placebo. Cost data were drawn from national databases and published literature, although health outcome utility weights were derived from existing studies. Patient outcomes were modeled for 10 years, and incremental cost-effective ratios were calculated for valsartan compared with placebo. RESULTS Over a period of 10 years, a cohort of 1000 patients treated with valsartan experienced 147 fewer cardiovascular deaths, 37 fewer nonfatal MIs, and 95 fewer cases of heart failure than a cohort who received placebo. The incremental cost of valsartan, compared with placebo, was 2680 pound per patient, although the incremental effectiveness of valsartan was 0.5021 quality-adjusted life-years (QALYs) gained per patient. Therefore, the incremental cost per QALY for treatment with valsartan was 5338 pound. When analysis was undertaken using life-years rather than QALYs, the cost per life-year gained was 4672 pound. CONCLUSIONS For patients who are not suitable for treatment with ACE inhibitors, valsartan is a viable and cost-effective treatment for their management after an MI.

Warfarin monitoring economic evaluation of point of care self-monitoring compared to clinic settings.

Abstract Objective: To determine the cost-effectiveness of home-based point-of-care self-monitoring compared to clinic-based care for patients managed on long-term warfarin medication. Current evidence is inconsistent; results should reduce uncertainty and inform service delivery. Methods: A Markov model compared self-testing and self-management, using point-of-care devices to usual care in patients with atrial fibrillation and mechanical heart valves. The primary clinical end-points were stroke and mortality avoided; costs and utilities were associated with these events. The costs of warfarin monitoring were included in the model. Results: Over 10 years, self-monitoring saved £1187 per person compared to usual care. Patients who self-monitored had notably fewer strokes and deaths. The results were sensitive to life-years gained and cost of the device. If the NHS purchased the device, financial break-even was achieved at the end of the second year; if the patient bought the device the NHS saved money every year. If 10% of the current 950,000 patients switched to point-of-care devices for 10 years, the NHS could save over £112million. Limitations: Clinical studies had a relatively short duration and only data on composite end-points were reported. Conclusions: With training, self-testing and self-management are safe, reliable, and cost-effective for a sizable proportion of patients receiving long-term warfarin. Compared to clinic-based services, self-monitoring offers the NHS the potential to make cost savings and release bed-days by reducing the number of strokes experienced by these high-risk patients.

P368: The economic assessment of an environmental intervention: discrete deployment of copper for infection control in ICUs

Health Economics evaluations are typically applied to medications or surgery costs, but this unique study has investigated the economic benefits of discrete deployment of antimicrobial copper alloy touch surfaces in ICUs. Copper/copper alloy surfaces have been shown to act as an adjunct to standard infection control practices in diverse clinical settings, continuously reducing contamination by over 90%. Moreover, work reported by Dr Michael Schmidt at the first ICPIC revealed the link between reduced bioburden and significant reductions in the risk of acquiring an HCAI. This study investigates the cost-effectiveness of this intervention, comparing expenditure with the improvements in patient outcomes and other tangible benefits.