The effectiveness of an individually tailored oral health educational programme on oral hygiene behaviour in patients with periodontal disease: a blinded randomized-controlled clinical trial (one-year follow-up)

AIM

To evaluate the effectiveness of an individually tailored oral health educational programme for oral hygiene self-care in patients with chronic periodontitis compared with the standard treatment.

MATERIAL AND METHOD

A randomized, evaluator-blinded, controlled trial with two different active treatments were used with 113 subjects (60 females and 53 males) randomly allocated to an experimental or a control group. The individually tailored oral health educational programme was based on cognitive behavioural principles and the individual tailoring for each participant was based on participants' thoughts, intermediate, and long-term goals, and oral health status. The effect of the programmes on gingivitis [gingival index (GI)], oral hygiene [plaque indices (PlI) and self-report], and participants' global rating of treatment was evaluated 3 and 12 months after oral health education and non-surgical treatment.

RESULTS

Between baseline and the 12-month follow-up, the experimental group improved both GI and PlI more than the control group. The mean gain-score difference was 0.27 for global GI [99.2% confidence interval (CI): 0.16-0.39, p<0.001] and 0.40 for proximal GI (99.2% CI: 0.27-0.53, p<0.001). The mean gain-score difference was 0.16 for global PlI (99.2% CI: 0.03-0.30, p=0.001), and 0.26 for proximal PlI (99.2% CI: 0.10-0.43, p<0.001). The subjects in the experimental group reported a higher frequency of daily inter-dental cleaning and were more certain that they could maintain the attained level of behaviour change.

CONCLUSION

The individually tailored oral health educational programme was efficacious in improving long-term adherence to oral hygiene in periodontal treatment. The largest difference was for interproximal surfaces.

Economic evaluation of high-dose (80 mg/day) atorvastatin treatment compared with standard-dose (20 mg/day to 40 mg/day) simvastatin treatment in Canada based on the Incremental Decrease in End-Points Through Aggressive Lipid-Lowering (IDEAL) trial

BACKGROUND

The Incremental Decrease in End-Points Through Aggressive Lipid-Lowering (IDEAL) trial demonstrated incremental cardiovascular benefit of treatment with high-dose atorvastatin (80 mg/ day) versus standard-dose simvastatin (20 mg/day to 40 mg/day) in 8888 patients with a previous myocardial infarction (MI) over a median follow-up period of 4.8 years.

OBJECTIVES

To assess the cost-effectiveness of high-dose atorvastatin versus standard-dose simvastatin treatment in patients with a history of MI from a Canadian societal perspective.

METHODS

In a within-trial analysis, end point-related events, resources used and productivity losses occurring during the IDEAL trial were aggregated by treatment arm on an intention-to-treat basis to calculate the incremental cost per event avoided. Additionally, quality-adjusted survival was projected using a lifetime Markov model. Transition probabilities, workdays lost, use of study medication and cardiovascular hospitalization rates were based on IDEAL trial data. Hospitalization, study medication and productivity costs were included. Probabilistic and deterministic sensitivity analyses were performed.

RESULTS

Compared with standard-dose simvastatin, atorvastatin 80 mg led to 0.099 fewer events per patient and cost savings over 4.8 years of treatment. Over a lifetime horizon, atorvastatin 80 mg led to 0.023 qualityadjusted life years (QALYs) gained per patient at an incremental cost of $26,795/QALY gained. The incremental cost-effectiveness ratio remained below $50,000/QALY in 78% of 1000 simulations. Exclusion of indirect costs resulted in an incremental cost-effectiveness ratio of $38,834/QALY. Results were relatively sensitive to baseline age, but robust with respect to sex, baseline low-density lipoprotein cholesterol levels, diabetes status and hospitalization costs.

CONCLUSION

From a Canadian societal perspective, high-dose atorvastatin is cost-effective compared with standard-dose simvastatin in patients with a previous MI.

An individually tailored treatment programme for improved oral hygiene: introduction of a new course of action in health education for patients with periodontitis

OBJECTIVES

To describe and evaluate an individually tailored treatment programme based on a behavioural medicine approach to oral hygiene self-care for patients with chronic periodontitis.

METHODS

Two experimental single-case studies with multiple-baseline design across different self-administered oral hygiene behaviours were conducted. Cognitive Behavioural techniques were used to organize the strategies for the intervention and the approach to counselling was inspired by and structured in accordance with Motivational Interviewing. The central features in the programme were the individual analysis of knowledge and oral hygiene habits, individually set goals for oral hygiene behaviour, practice of manual dexterity for oral hygiene aids, continuous self-monitoring of the behaviour and prevention of relapse.

RESULTS

Both participants reached the predecided criteria for clinical significance in reducing plaque and bleeding on probing. Reductions of periodontal probing depth were achieved as well. The positive results remained stable throughout the 2-year study period.

CONCLUSION

The successful application of this educational model suggests that it could be used as a method for tailoring interventions targeted to oral hygiene for patients with periodontal conditions. The programme will now be tested in a larger randomized controlled trial.

Resource use associated with type 2 diabetes in Asia, Latin America, the Middle East and Africa: results from the International Diabetes Management Practices Study (IDMPS)

AIMS

To estimate diabetes-related resource use and investigate its predictors among individuals with type 2 diabetes in 24 countries in Asia, Latin America, the Middle East and Africa.

METHODS

Cross-sectional observational data on diabetes-related resource use were collected from 15,016 individuals with type 2 diabetes within the second wave of International Diabetes Management Practices Study. Mean (SD) annual quantities were determined and predictors of diabetes-related hospitalisations, inpatient days, emergency room visits and absenteeism were investigated using negative binomial regression.

RESULTS

Patients in Asia (n = 4678), Latin America (n = 6090) and the Middle East and Africa (n = 4248) made a mean (SD) of 3.4 (6.9), 5.4 (6.7) and 2.5 (4.4) General Practitioner visits per year. The mean (SD) number of inpatient days amounted to 3.8 (18.1), 2.2 (13.9) and 2.6 (13.5) per year. Results of the regression analysis showed the major influence of diabetes-related complications and inadequate glycaemic control on resource use. The expected annual rate of hospitalisation of patients with macrovascular complications compared with those without was 4.7 times greater in Asia [incidence rate ratio (IRR) = 4.7, 95% CI: 2.8-7.8, n = 2551], 5.4 times greater in Latin America (IRR = 5.4, 95% CI: 3.0-9.8, n = 3228) and 4.4 times greater in the Middle East and Africa (IRR = 4.4, 95% CI: 2.8-6.9, n = 2630).

CONCLUSIONS

Micro- and macrovascular complications and inadequate glycaemic control are significant predictors of resource use in people with type 2 diabetes of developing countries. This knowledge confirms the health economic importance of early diagnosis of diabetes, education of patients and glycaemic control.

The access to oncology drugs in France, Germany, Italy, Spain, and the United Kingdom: A comparison based on data from 1998 to 2007

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Background: Drugs constitute a key element in the treatment of solid tumors and in haematology. We have analysed the access and uptake of oncology drugs in 27 countries over a 10 year period (1998–2007) based on sales data provided by IMS Health ( www.comparatorreports.se ). Methods: In this special analysis we study a set of “mature” cancer drugs ( irinotecan, aromatase inhibitors (AIs), oxaliplatin, docetaxel, rituximab, gemcitabine, trastuzumab and imatinib) available in 2002 or before and a set of “new” cancer drugs (bortezomib, cetuximab, bevacizumab, pemetrexed, erlotinib, sorafinib, sunitinib and dasatinib) available in 2003 or later. The “mature” drugs have been selected based on the fact that they have been available for a long period of time (at least 5 years) and that there is accumulated evidence based on clinical trials, epidemiological studies and clinical experience that they have had a major and clinically relevant impact on the outcome in different areas of oncology. Results: We see very different patterns of use in countries studied. The total use of cancer drugs (€/capita) in 2007 is highest in France and lowest in the UK, with the other countries at a relatively similar level in between. The pattern of use of “new drugs” follows that of “mature drugs”, but the very low use of new drugs in UK is noticeable. The differences seen between groups are also reflected in the use of individual drugs, although for example AIs and trastuzumab in the “mature” group have a more uniform use across the countries. The expected survival for cancer patients have been, in general, lower in the UK compared to other western European countries, but further studies are needed to establish the impact of treatment patterns on population outcome. Conclusions: The similarity in use of both “mature” and “new” oncology drugs indicate that differences in access, found for example between France and UK, is related to health care system factors rather that evidence on outcome of use of the drugs.

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Diabetes--the cost of illness and the cost of control. An estimate for Sweden 1978

This study estimates the economic cost of diabetes mellitus in Sweden 1978. It also addresses the question of potential savings from improved metabolic control. Economic costs of illness include direct costs for medical care and indirect costs from lost production due to morbidity and premature death. The total costs of diabetes are estimated at 1300 million SEK in Sweden 1978. The direct costs for medical care accounted for 43% of these costs. Lost production due to permanent disability is the dominating indirect costs, and accounts for 60% of indirect costs and one third of the total costs. Institutional care accounts for two thirds of the direct costs. The costs for drugs and medical devices amount to 128 million SEK or 1000 SEK per insulin- or oraldependent diabetic. Costs for control of diabetes are estimated to 20% of the total cost and 50% of direct costs. The conclusion is that there are great potential benefits to be expected from improved self control of diabetes.

Health-related quality of life (EQ-5D) before and one year after surgery for lumbar spinal stenosis

We investigated the pre-operative and one-year post-operative health-related quality of life (HRQoL) outcome by using a Euroqol (EQ-5D) questionnaire in 230 patients who underwent surgery for lumbar spinal stenosis. Data were obtained from the National Swedish Registry for operations on the lumbar spine between 2001 and 2002. We analysed the pre- and postoperative quality of life data, age, gender, smoking habits, pain and walking ability. The relative differences were compared to a Swedish EQ-5D population survey. The mean age of the patients was 66 years, and there were 123 females (53%). Before the operation 62 (27%) of the patients could walk more than 500 m. One year after the operation 150 (65%) were able to walk 500 m or more. The mean EQ-5D score improved from 0.36 to 0.64, and the HRQoL improved in 184 (80%) of the patients. However, they did not reach the level reported by a matched population sample (mean difference 0.18). Women had lower pre- and post-operative EQ-5D scores than men. Severe low back pain was a predictor for a poor outcome.

Incorporating adherence into health economic modelling of osteoporosis

Osteoporosis medications are seldom taken according to the recommendations of health-care providers. A theoretical model was constructed to investigate the variables of drug adherence that affect the cost-effectiveness of drugs, using osteoporosis treatment as a model. Important variables were the magnitude of drug effect, drug price, and fracture-related costs.

INTRODUCTION

Adherence to anti-fracture medication is far from optimal and poses a challenge in osteoporosis management. The objectives of this study were to develop a model that could address adherence and identify the important drivers of cost-effectiveness.

METHODS

An individual state transition model was constructed to compare two theoretical medications, one of which conferred optimal adherence and was 50% more costly. Adherence was divided into persistence and compliance. Partial compliance was assumed to be associated with a 20% loss of anti-fracture effect. Non-persistent patients had an offset time as long as their time on medication, to a maximum of 5 years.

RESULTS

The potentially important drivers of cost-effectiveness include reduced drug effectiveness due to poor compliance, offset time, fracture risk, anti-fracture drug effect, and drug price. Optimal adherence was associated with fewer osteoporotic fractures, and the impact was more evident among those with prior fractures. However, the health benefits of adherence were often partially offset by increased intervention costs associated with the improved drug-taking behaviour.

CONCLUSIONS

High adherence is likely to be associated with added value for health-care systems, but should be used with care as a central health economic argument.

Market and patient access to new oncology products in Europe: a current, multidisciplinary perspective

To air challenging issues related to patient and market access to new anticancer agents, the Biotherapy Development Association--an international group focused on developing targeted cancer therapies using biological agents--convened a meeting on 29 November 2007 in Brussels, Belgium. The meeting provided a forum for representatives of pharmaceutical companies and academia to interact with European regulatory and postregulatory agencies. The goal was to increase all parties' understanding of their counterparts' roles in the development, licensure, and appraisal of new agents for cancer treatment, events guided by an understanding that cancer patients should have rapid and equitable access to life-prolonging treatments. Among the outcomes of the meeting were a greater understanding of the barriers facing drug developers in an evolving postregulatory world, clarity about what regulatory and postregulatory bodies expect to see in dossiers of new anticancer agents as they contemplate licensure and reimbursement, and several sets of recommendations to optimize patients' access to innovative, safe, effective, and fairly priced cancer treatments.

Late-onset posttraumatic skin and soft-tissue infections caused by rapid-growing mycobacteria in tsunami survivors

BACKGROUND

In the tsunami catastrophe in Thailand in 2004, several thousand Swedish tourists were injured, with contaminated crush trauma of the legs being the main cause of injury among the survivors.

METHODS

Patient and laboratory data for those who received hospital care in Stockholm and Gothenburg and contracted late-onset infections due to rapid-growing mycobacteria were reviewed retrospectively. Also, concomitant infections were recorded.

RESULTS

Fifteen patients with late-onset skin and soft-tissue infections due to rapid-growing mycobacteria are described here. Mycobacterium abscessus was isolated in 7 cases, Mycobacterium fortuitum was isolated in 6 cases, and Mycobacterium peregrinum and Mycobacterium mageritense were isolated in 1 case each. The infections appeared after a delay of 20-105 days (median, 60 days) after the trauma, targeting undamaged skin located near primary sutured wounds or skin grafts. Antimycobacterial drugs were given to 9 (60%) of the patients. The course of infection was protracted, but all infections due to rapid-growing mycobacteria healed within 12 months. Concomitant subcutaneous infections due to other microorganisms, such as Burkholderia pseudomallei or Cladophialophora bantiana, appeared early or late after the trauma.

CONCLUSIONS

Repeated cultures of abscess and wound specimens for Mycobacterium species may be needed to find the etiologic agents causing contaminated skin and soft-tissue infections, such as those that developed after traumas that occurred during the tsunami. These cultures are especially necessary when symptoms appear late and when conventional bacterial culture results are negative. A biopsy is recommended for the best yield and for complementary histopathological examination.

Children developing type 1 diabetes before 6 years of age have increased linear growth independent of HLA genotypes

AIMS/HYPOTHESIS

High birthweight and increased childhood growth are risk factors for type 1 diabetes. Relative birthweight is associated with HLA genotypes that confer a high risk of diabetes. Our aims were to test whether young children prior to clinical onset of type 1 diabetes have increased: (1) birthweight or birth length standard deviation scores (SDS); (2) height development SDS; or (3) BMI SDS during first 18 months of life and whether these parameters are related to HLA genotypes or mid-parental height (MPH).

METHODS

Birthweight, birth length, weight and height were obtained from 58 type 1 diabetes children and 155 controls matched for HLA or not in the Diabetes Prediction in Skåne study.

RESULTS

Birth length SDS corrected for MPH was increased in children developing diabetes compared with all (p < 0.048) and with non-HLA- (p < 0.050) but not with HLA-matched controls. Children developing diabetes had increased height gain at 0 to 18 months of age (p < 0.005). Diabetic children were significantly taller from 6 to 18 months of age when correcting for MPH compared with non-HLA-matched as well as HLA-matched controls, but BMI was not increased.

CONCLUSIONS/INTERPRETATION

Birth length SDS was associated with diabetes risk HLA. When corrected for MPH, children developing diabetes were taller at birth than non-HLA- but not taller than HLA-matched controls. Diabetic children had increased MPH-corrected height up to 18 months of age compared with both HLA- and non-HLA-matched controls. High-risk HLA affects prenatal growth, but other factors may explain the increased postnatal linear growth in children developing diabetes.

The cost-effectiveness of the treatment of high risk women with osteoporosis, hypertension and hyperlipidaemia in Sweden

This paper assessed the cost-effectiveness of the treatment of high risk women with osteoporosis, hypertension and hyperlipidaemia in Sweden, using one model and a societal perspective. Cost-effective scenarios were found in all these chronic disorders. These findings are of relevance for decisions on the efficient allocation of health care resources.

INTRODUCTION

There is a need to assess the cost-effectiveness (CE) of treatment of osteoporosis from a societal perspective and to relate this to the CE of interventions in other disease areas. This is of relevance for decisions on the efficient allocation of health care resources within and between disease areas. The purpose of the paper was to estimate the CE of the treatment and prevention of osteoporosis and to put that into the perspective of treating hypertension and hyperlipidaemia. The CE was assessed for different high risk female populations aged 50-80 years.

METHODS

The estimation of CE was based on a model populated with data for Sweden.

RESULTS

Compared to no intervention, a 5-year treatment of osteoporosis, hypertension, and hyperlipidaemia, is cost effective for most of the assessed high risk female populations. The cost per gained quality adjusted life year (QALY) for the treatment of a 70-year-old woman never exceeded SEK 330,000 (US$ 44,000), which is generally judged as an acceptable cost for a gained QALY.

CONCLUSIONS

The study demonstrates that it is possible to produce reliable estimates of the CE of treatments in different disease areas within the context of a single model.

A large Escherichia coli O157 outbreak in Sweden associated with locally produced lettuce

In 2005 a large outbreak of verotoxin-producing Escherichia coli (VTEC) occurred in Sweden. Cases were interviewed and cohort and case-control studies were conducted. Microbiological investigations were performed using polymerase chain reaction (PCR) to detect the Shiga-like toxin (Stx) genes followed by cultivation and pulsed-field gel electrophoresis. A total of 135 cases were recorded, including 11 cases of hemolytic uremic syndrome. The epidemiological investigations implicated lettuce as the most likely source of the outbreak, with an OR of 13.0 (CI 2.94-57.5) in the case-control study. The lettuce was irrigated by water from a small stream, and water samples were positive for Stx 2 by PCR. The identical VTEC O157 Stx 2 positive strain was isolated from the cases and in cattle at a farm upstream from the irrigation point. An active surveillance and reporting system was crucial and cooperation between all involved parties was essential for quickly identifying the cause of this outbreak. Handling of fresh greens from farm to table must be improved to minimize the risk of contamination.

Electrostatic contributions to the binding of Ca2+ in calbindin mutants. A Monte Carlo study

Monte Carlo simulation is used to calculate the free energy of binding of calcium ions to the native and several mutant forms of bovine calbindin D(9K) in salt solution. The simulations are performed in the canonical ensemble wherein free energies are calculated with a modified Widom method. The protein is modelled as a set of fixed hard spheres of fractional or unit charge with the surrounding solution as a dielectric continuum containing counterions and added salt particles. The interior of the protein is assumed to have the same dielectric permittivity as the solvent, which turns out to be an excellent approximation. Indeed, this simple model is able to predict accurately experimentally measured shifts in the calcium binding constants of up to five orders of magnitude, due to mutations and added salt.

The cost-utility of maintenance treatment with venlafaxine in patients with recurrent major depressive disorder

AIMS

The Prevention of Recurrent Episodes of Depression with venlafaxine XR for Two Years trial has reported advantages with maintenance treatment for patients with recurrent depressive disorder. The aim of this study was to assess the cost-utility of maintenance treatment with venlafaxine in patients with recurrent major depressive disorder, based on a recent clinical trial.

METHODS

A Markov simulation model was constructed to assess the cost-utility of maintenance treatment for 2 years in recurrently depressed patients in Sweden. Risk of relapse and recurrence was based on a recent randomised clinical trial assessing the efficacy and tolerability of maintenance treatment with venlafaxine over 2 years. Costs and quality of life estimations were retrieved from a naturalistic longitudinal observational study conducted in Sweden. Health effects were quantified as quality-adjusted life-years (QALYs). Sensitivity analyses were conducted on key parameters employed in the model.

RESULTS

In the base-case analysis, the cost per QALY gained of venlafaxine compared with no treatment was estimated at $18,500 over 2 years. In a probabilistic sensitivity analysis, we found that maintenance treatment with venlafaxine is cost-effective with 90% probability at a willingness to pay per QALY of $67,000 or less. Our long-term analyses also indicate that even under conservative assumptions about future risks of recurrences, maintenance treatment is cost-effective.

CONCLUSION

The present study indicates that maintenance treatment for 2 years with venlafaxine is cost-effective in patients with recurrent major depressive disorder.

The burden of rheumatoid arthritis and access to treatment: outcome and cost-utility of treatments

Within the series of articles investigating the burden of rheumatoid arthritis (RA), this paper reviews the methods used for economic assessment of the RA treatments by HTA agencies and other bodies involved in cost-effectiveness analysis and the current status of the field. The overall methods, as well as the challenges, of cost-effectiveness analysis in RA are common to all chronic progressive diseases where much of the treatment benefit is delayed, while costs occur immediately. Also, as in all disabling diseases, much of the costs occur outside the health-care system, due to the rapid loss of work capacity and the need for informal care in the later stages of the disease. Thus, it is essential to adopt a long-term view and consider costs from the perspective of society, rather than the health-care service, to increase the relevance of the results for policy making.

The burden of rheumatoid arthritis and access to treatment: uptake of new therapies

This paper presents data on international differences in use of TNF inhibitors. It is part of a study on burden and cost of RA, access to new therapies and the role of HTA in determining access and cost-effectiveness. United States has the fastest most extensive use of the new drugs, about three times the average in the western European countries and Canada. Eastern and central European countries as well as Australia, South Africa and Turkey lag far behind. However, some smaller European countries, most notably Norway and Sweden have use of the new drugs not far behind the United States. While the income level of the country, and thus the health care expenditures per capita is a major factor for determining use in low and middle income countries, there are still considerable differences among countries with similar high total health care expenditures. Differences in prices are considerable between the US and Europe due to the changes in exchange rates between the US dollar and the Euro, but high and low use is not systematically related to differences in price.

The burden of rheumatoid arthritis and access to treatment: determinants of access

As part of the study "The Burden of Rheumatoid Arthritis (RA) and Patient Access to Treatment", this paper reviews the impact on access to RA drugs of the approval processes, pricing and funding decisions and times to market (access) in different countries. In addition, an overview of health technology assessments (HTA) and the economic literature related to RA treatments is provided. The time from approval to market access ranged from immediate to over 500 days in the countries included in the study. A total of 55 HTA reports were identified, 40 of them in the period between 2002 and 2006; 29 were performed by European HTA agencies, 14 in Canada and 7 in the United States. A total of 239 economic evaluations related to RA were identified in a specialized health economic database (HEED).

Funding of headache research in Europe

Migraine costs European Society 27 billion Euro per year. Other headaches may account for a similar amount. Given this enormous impact, the question arises as to whether the funding of research efforts in this field are sufficient. A recent European study called the Resource Allocation to Brain Research in Europe (RABRE) examined funding of brain research. Identified charities and Government agencies in Europe filled out a questionnaire regarding their funding of brain diseases. Industry spending was evaluated by three different previously validated methods. In the present report, detailed results are presented for migraine and other headaches. In 2004, migraine research was funded by nearly 315 million Euro . Of this, 308 million Euro was invested by the pharmaceutical industry, whereas public funding was estimated at 7 million Euro . No funding was identified for non-migraine headache disorders. Of the public spending, 714,000 Euro came from private foundations. There was a very large difference between different European countries in the funding of headache research. When public funding was compared with the cost of different brain disorders, migraine funding was in the middle range. This was due to relatively large industry funding. Compared with societal costs, migraine received the least public funds amongst all brain disorders, i.e. 0.025%. We conclude that migraine attracts reasonable interest from the pharmaceutical industry, but Governmental and charity funding is extremely low and no funding was identified for non-migraine headache disorders. Considering the huge economic impact of these disorders, public funding of research into migraine and other headaches should be greatly increased in the future.

Economic evaluation of ASCOT-BPLA: antihypertensive treatment with an amlodipine-based regimen is cost effective compared with an atenolol-based regimen

OBJECTIVE

To compare the cost effectiveness of an amlodipine-based strategy and an atenolol-based strategy in the treatment of hypertension in the UK and Sweden.

DESIGN

A prospective, randomised trial complemented with a Markov model to assess long-term costs and health effects.

SETTING

Primary care.

PATIENTS

Patients with moderate hypertension and three or more additional risk factors.

INTERVENTIONS

Amlodipine 5-10 mg with perindopril 4-8 mg added as needed or atenolol 50-100 mg with bendroflumethiazide 1.25-2.5 mg and potassium added as needed

MAIN OUTCOME MEASURES

Cost per cardiovascular event and procedure avoided, and cost per quality-adjusted life-year gained.

RESULTS

In the UK, the cost to avoid one cardiovascular event or procedure would be euro18 965, and the cost to gain one quality-adjusted life-year would be euro21 875. The corresponding figures for Sweden were euro13 210 and euro16 856.

CONCLUSIONS

Compared with the thresholds applied by NICE and in the Swedish National Board of Health and Welfare's Guidelines for Cardiac Care, an amlodipine-based regimen is cost effective for the treatment of hypertension compared with an atenolol-based regimen in the population studied.