Construct validity of SF-6D health state utility values in an employed population

BACKGROUND

Health utility values permit cost utility analysis in workplace health promotion; however, utility measures of working populations have not been validated.

AIM

To investigate construct validity of SF-6D health utility in a public service workforce.

METHODS

SF-12v2 Health Survey was administered to 3,408 randomly selected public service employees in Australia in 2010. SF-12 scores were converted to SF-6D health utility values. Associations and correlates of SF-6D with health, socio-demographic and work characteristics [comorbidities, body mass index (BMI), Kessler-10 psychological distress (K10), education, salary, effort-reward imbalance (ERI), absenteeism] were explored. Ceiling effects were analysed. Nationally representative employee SF-6D values from the Household, Income and Labour Dynamics in Australia (HILDA) survey (n = 11,234) were compared. All analyses were stratified by sex.

RESULTS

Mean (SE) age was 45.7 (0.35) males; 44.5 (0.22) females. Females represented 72 % of the sample. Mean (SE) health utility 0.792 (0.004); 0.771 (0.003) was higher in males. SF-6D demonstrated both a significant inverse association (p < 0.01) and negative correlations (female; male) with K10 (r = -0.63; r = -0.66), comorbidity count (r = -0.40; r = -0.33), ERI (r = -0.37; r = -0.34) and absenteeism (p < 0.005, r = -0.25; r = -0.21). Mean (SE) SF-6D in HILDA was 0.792 (0.002); 0.775 (0.003) males; females. Correlates and associations in all samples were similar. The general employed demonstrated a significant inverse association with age and positive association with salary. SF-6D was independent of BMI.

CONCLUSIONS

Psychological distress, comorbidity, effort-reward imbalance and absenteeism are negatively associated with employee health. SF-6D is a valid measure of perceived health states in working populations.

A decision tree model for the implementation of a safety strategy in the horse-racing industry

OBJECTIVES

The profession of a horse-racing jockey is a dangerous one. We developed a decision tree model quantifying the effects of implementing different safety strategies on jockey fall and injury rates and their associated costs.

METHODS

Data on race-day falls were obtained from stewards' reports from August 2002 to July 2009. Insurance claim data were provided by Principal Racing Authorities and workers' compensation authorities in each jurisdiction. Fall and claim incidence data were used as baseline rates. The model considered (1) the status quo, in which policy was unchanged; and (2) compared it with four hypothetical changes in policy that restricted apprentice jockeys from riding less-accomplished horses, with the aim of improving safety by reducing incidence of injurious jockey falls. Second-order Monte Carlo simulations were conducted to account for uncertainties.

RESULTS

The point estimate for mean costs of falls under the status quo was $30.73/ride, with falls by apprentice jockeys with <250 career race rides riding horses with less than five race starts contributing the highest costs ($98.49/ride). The hypothetical safety strategies resulted in a 1.04%-5.07% decrease in fall rates versus status quo. For three of the four strategies, significant reductions of 8.74%-13.13% in workers' compensation costs over one single race season were predicted. Costs were highly sensitive to large claims.

CONCLUSIONS

This model is a useful instrument for comparing potential changes in cost and risks associated with implementing new safety strategies in the horseracing industry.

Depression in working adults: comparing the costs and health outcomes of working when ill

Objective

Working through a depressive illness can improve mental health but also carries risks and costs from reduced concentration, fatigue, and poor on-the-job performance. However, evidence-based recommendations for managing work attendance decisions, which benefit individuals and employers, are lacking. Therefore, this study has compared the costs and health outcomes of short-term absenteeism versus working while ill (“presenteeism”) amongst employed Australians reporting lifetime major depression.

Methods

Cohort simulation using state-transition Markov models simulated movement of a hypothetical cohort of workers, reporting lifetime major depression, between health states over one- and five-years according to probabilities derived from a quality epidemiological data source and existing clinical literature. Model outcomes were health service and employment-related costs, and quality-adjusted-life-years (QALYs), captured for absenteeism relative to presenteeism, and stratified by occupation (blue versus white-collar).

Results

Per employee with depression, absenteeism produced higher mean costs than presenteeism over one- and five-years ($42,573/5-years for absenteeism, $37,791/5-years for presenteeism). However, overlapping confidence intervals rendered differences non-significant. Employment-related costs (lost productive time, job turnover), and antidepressant medication and service use costs of absenteeism and presenteeism were significantly higher for white-collar workers. Health outcomes differed for absenteeism versus presenteeism amongst white-collar workers only.

Conclusions

Costs and health outcomes for absenteeism and presenteeism were not significantly different; service use costs excepted. Significant variation by occupation type was identified. These findings provide the first occupation-specific cost evidence which can be used by clinicians, employees, and employers to review their management of depression-related work attendance, and may suggest encouraging employees to continue working is warranted.

Health economics analysis of insulin aspart vs. regular human insulin in type 2 diabetes patients, based on observational real life evidence from general practices in Germany

BACKGROUND

A retrospective analysis of German general practice data demonstrated that insulin aspart (IA) was associated with a significantly reduced incidence of macrovascular events (MVE: stroke, myocardial infarction, peripheral vascular disease or coronary heart disease) vs. regular human insulin (RHI) in type 2 diabetes patients. Economic implications, balanced against potential improvements in quality-adjusted life years (QALYs) resulting from lower risks of complications with IA in this setting have not yet been explored.

METHODS

A decision analysis model was developed utilizing 3-year initial MVE rates for each comparator, combined with published German-specific insulin and MVE costs and health utilities to calculate number needed to treat (NNT) to avoid any MVE, incremental costs and QALYs gained/ person for IA vs. RHI. A 3-year time horizon and German 3(rd)-party payer perspective were used. Probabilistic sensitivity analysis was performed, sampling from distributions of key parameters. Additional sensitivity analyses were performed.

RESULTS

NNT over a 3 year period to avoid any MVE was 8 patients for IA vs. RHI. Due to lower MVE rates, IA dominated RHI with 0.020 QALYs gained (95% confidence interval: 0.014-0.025) and cost savings of EUR 1 556 (1 062-2 076)/person for IA vs. RHI over the 3-year time horizon. Sensitivity analysis revealed that IA would still be overall cost saving even if the cost of IA was double the cost/unit of RHI.

CONCLUSIONS

From a health economics perspective, IA was the superior alternative for the insulin treatment of type 2 diabetes, with lower incidence of MVE events translating to improved QALYs and lower costs vs. RHI within a 3-year time horizon.

A systematic review and meta-analysis of utility-based quality of life for osteoporosis-related conditions

This study aimed to statistically combine multiple health state utility values (HSUVs) reported in the literature for patients with osteoporosis and osteoporotic fractures. Fracture events were associated with decrements in HSUVs which differed between fracture sites. We have provided summary values for use in future health economics analyses in osteoporosis. Osteoporotic fractures have high financial and health burden. Economic evaluations on osteoporotic fracture prevention have been frequently performed in past decades. One of the challenges in the economic evaluations was to identify consistent health state utility values (HSUVs) to use for osteoporotic fracture-related conditions. The objective of this study was to determine summary measures of multiple HSUVs reported in the literature for patients with osteoporosis and osteoporotic fractures. We performed a systematic review, meta-analysis and meta-regression of published literature that reported HSUVs for osteoporotic fracture-related conditions. There were 62 studies representing 142,477 patients included. In total, 362 HSUVs were identified: 106 for pre-fracture; 89 for post-hip fracture; 130 for post-vertebral fracture and 37 for post-wrist fracture. The pooled HSUVs, using a random-effects model were 0.76 (95% CI 0.75, 0.77, I (2) = 0.99) for pre-fracture; 0.57 (95% CI 0.52, 0.63, I (2) =1) for post-hip fracture; 0.59 (95% CI 0.55, 0.62, I (2) = 0.99) for post-vertebral facture and 0.72 (95% CI 0.67, 0.78, I (2) = 1) for post-wrist fracture. Heterogeneities were addressed through meta-regression. HSUVs immediately following hip, vertebral and wrist fractures were 0.31, 0.44 and 0.61, respectively. Patients' HSUVs improved over time following fracture events: HSUVs for the first year after hip, vertebral and wrist fractures were 0.59, 0.55 and 0.78, respectively; and 0.66, 0.66 and 0.81 for subsequent years. Fractures were associated with significant decrements in HSUVs. This study provides a standard set of HSUVs that can be used in health economic assessments in osteoporosis.

Residents with mild cognitive decline and family members report health students 'enhance capacity of care' and bring 'a new breath of life' in two aged care facilities in Tasmania

BACKGROUND

Care provided by student doctors and nurses is well received by patients in hospital and primary care settings. Whether the same is true for aged care residents of nursing homes with mild cognitive decline and their family members is unknown.

OBJECTIVE

To investigate the perspectives of aged care residents with mild cognitive decline and their family members on interdisciplinary student placements in two residential aged care facilities (RACF) in Tasmania.

DESIGN, SETTING AND PARTICIPANTS

A mixed methods design was employed with both qualitative and quantitative data collected. All participants were interviewed and completed a questionnaire on residents' quality of life, during or after a period of student placements in each facility (October-November, 2012). Qualitative data were coded for themes following a grounded theory approach, and quantitative data were analysed using SPSS.

RESULTS

Twenty-one participants (13 residents and 8 family members) were recruited. Four themes were identified from the qualitative data and included (i) increased social interaction and facility vibrancy; (ii) community service and personal development, (iii) vulnerability and sensitivity (learning to care) and (iv) increased capacity and the confidence of enhanced care. Residents' quality of life was reported to be mostly good in the presence of the students, despite their high care needs.

CONCLUSION

Residents with mild cognitive decline and their family members perceive a wide array of benefits of student provided care in RACFs including increased social interaction. Future quantitative research should focus on whether changes in care occur for residents as a result of student involvement.

A systematic review of models used in cost-effectiveness analyses of preventing osteoporotic fractures

This review was aimed at the evolution of health economic models used in evaluations of clinical approaches aimed at preventing osteoporotic fractures. Models have improved, with medical continuance becoming increasingly recognized as a contributor to health and economic outcomes, as well as advancements in epidemiological data. Model-based health economic evaluation studies are increasingly used to investigate the cost-effectiveness of osteoporotic fracture preventions and treatments. The objective of this study was to carry out a systematic review of the evolution of health economic models used in the evaluation of osteoporotic fracture preventions. Electronic searches within MEDLINE and EMBASE were carried out using a predefined search strategy. Inclusion and exclusion criteria were used to select relevant studies. References listed of included studies were searched to identify any potential study that was not captured in our electronic search. Data on country, interventions, type of fracture prevention, evaluation perspective, type of model, time horizon, fracture sites, expressed costs, types of costs included, and effectiveness measurement were extracted. Seventy-four models were described in 104 publications, of which 69% were European. Earlier models focused mainly on hip, vertebral, and wrist fracture, but later models included multiple fracture sites (humerus, pelvis, tibia, and other fractures). Modeling techniques have evolved from simple decision trees, through deterministic Markov processes to individual patient simulation models accounting for uncertainty in multiple parameters. Treatment continuance has been increasingly taken into account in the models in the last decade. Models have evolved in their complexity and emphasis, with medical continuance becoming increasingly recognized as a contributor to health and economic outcomes. This evolution may be driven in part by the desire to capture all the important differentiating characteristics of medications under scrutiny, as well as the advancement in epidemiological data relevant to osteoporosis fractures.

Computer modeling of diabetes and its complications: a report on the Fifth Mount Hood challenge meeting

OBJECTIVES

The Mount Hood Challenge meetings provide a forum for computer modelers of diabetes to discuss and compare models, to assess predictions against data from clinical trials and other studies, and to identify key future developments in the field. This article reports the proceedings of the Fifth Mount Hood Challenge in 2010.

METHODS

Eight modeling groups participated. Each group was given four modeling challenges to perform (in type 2 diabetes): to simulate a trial of a lipid-lowering intervention (The Atorvastatin Study for Prevention of Coronary Heart Disease Endpoints in Non-Insulin-Dependent Diabetes Mellitus [ASPEN]), to simulate a trial of a blood glucose-lowering intervention (Action in Diabetes and Vascular Disease: Preterax and Diamicron Modified Release Controlled Evaluation [ADVANCE]), to simulate a trial of a blood pressure-lowering intervention (Cardiovascular Risk in Diabetes [ACCORD]), and (optional) to simulate a second trial of blood glucose-lowering therapy (ACCORD). Model outcomes for each challenge were compared with the published findings of the respective trials.

RESULTS

The results of the models varied from each other and, in some cases, from the published trial data in important ways. In general, the models performed well in terms of predicting the relative benefit of interventions, but performed less well in terms of quantifying the absolute risk of complications in patients with type 2 diabetes. Methodological challenges were highlighted including matching trial end-point definitions, the importance of assumptions concerning the progression of risk factors over time, and accurately matching the patient characteristics from each trial.

CONCLUSIONS

The Fifth Mount Hood Challenge allowed modelers, through systematic comparison and validation exercises, to identify important differences between models, address key methodological challenges, and discuss avenues of research to improve future diabetes models.

The economic impact of multiple sclerosis in Australia in 2010

Background:

Multiple sclerosis (MS) has a major impact on health and is a substantial burden on patients and society. We estimated the annual costs of MS in Australia from individual and societal perspectives using data from the Australian MS Longitudinal Study (AMSLS) and prevalence figures from 2010.

Methods:

Direct and indirect costs were estimated from a subsample of 712 AMSLS subjects who completed baseline and follow-up economic impact surveys. All costs are in 2010 Australian dollars (AUD).

Results:

Annual costs per person with MS were AUD48,945 (95% CI: 45,138 to 52,752). Total costs were AUD1.042 (0.9707 to 1.1227) billion based on a prevalence of 21,283. The largest component was indirect costs due to loss of productivity (48%). Costs increased with increasing disability: AUD36,369, AUD58,890 and AUD65,305 per patient per year for mild, moderate and severe disability, respectively. Total costs of MS to Australian society have increased 58% between 2005 and 2010.

Conclusions:

This study confirms that MS imposes a substantial burden on Australian society, particularly impacting on productivity. The burden increases with worsening disability associated with the disease. Investment in interventions that slow progression, as well as resources, services and environments that assist people with MS to retain employment, is supported.

A novel method for calculating prevalence of multiple sclerosis in Australia

Objectives:

The purpose of this study was to determine the prevalence of multiple sclerosis (MS) in Australia in 2010 using a novel method based on Australia-wide prescription data for MS-specific disease modifying agents. The results obtained were validated against two other prevalence estimates.

Methods:

We obtained the total number of scripts for medications that were used exclusively for the treatment of MS written in Australia for the period January–December 2010. The percentage of MS patients using medications (42–55%) was taken from state-specific surveys of MS Society clients. To estimate prevalence we divided the annual number of scripts dispensed by 12 and adjusted for penetration of medications by state.

Results:

The prevalence of MS in Australia in 2010 calculated using the prescription method was 21,283 people (95.5/100,000). This compared to 21,200 people (95.2/100,000) obtained from the Australian Bureau of Statistics (ABS) Survey of Disability, Ageing and Carers (SDAC) survey of 2009 and 20,471 people (91.9/100,000) using MS Society client numbers. Prevalence increased with increasing latitude, with the prevalence for Tasmania over seven times that of the Northern Territory. Results were sensitive to the percentage of people with MS being treated.

Conclusions:

Calculation of prevalence of MS using nation-wide prescription data is a novel method that generates results similar to other potentially more resource-intensive methods.

Psychosocial factors in adults with chronic kidney disease: characteristics of pilot participants in the Tasmanian Chronic Kidney Disease study

BACKGROUND

Psychosocial factors including depression, anxiety and lower social support are common in patients with chronic kidney disease (CKD). However the influence of these potentially modifiable risk factors on morbidity and mortality in this renal population is unknown. The Tasmanian Chronic Kidney Disease study is a prospective cohort study which aims to examine the influence of both biomedical and psychosocial factors on disease progression, decision making and length and quality of life in adults with severe CKD, prior to kidney replacement therapy (KRT). This paper describes the recruitment, baseline characteristics and initial follow-up of pilot participants.

METHODS

Adults aged > 18 years with stage 4 CKD (eGFR 15-29 mls/min/1.73 m2) and not receiving dialysis were recruited via treating physicians. Measures included depression (9-item Patient Health Questionnaire), anxiety (Beck Anxiety Inventory) and social support (Multidimensional Scale of Perceived Social Support). Primary outcomes were kidney disease progression, use of KRT and health-related quality of life (Kidney Disease and Quality of Life Short Form and the EQ-5D).

RESULTS

Of those invited (n = 105), 49 provided consent and completed baseline assessment. There were no significant differences between responders and non-responders in age, gender and socio-economic status (all p > 0.05). Participants were predominantly male (63.3%) with a mean age of 72.6 ± 10.2 years. Mean serum creatinine was 241 ± 62 μmol/L with mean eGFR 22 ± 5 mls/min/1.73 m2. Prevalence of major depression and moderate to severe anxiety was 10% and 9% respectively. Less severe depression and fewer anxiety symptoms were associated with higher health-related quality of life. Follow-up at 10-months showed CKD progression in 34% of participants (use of KRT in 16%, stage 5 CKD without KRT in 18%), one death, with the remainder stable at CKD stage 3 or 4.

CONCLUSIONS

Results indicate that a larger prospective study is feasible and has the capacity to examine the influence of biomedical and psychosocial factors on kidney disease progression, use of dialysis and transplantation, and salient personal and economic outcomes. Findings have the potential to provide an evidence base for revising healthcare provision in order to optimize the care of patients with CKD.

Genetic variation in C20orf54, PLCE1 and MUC1 and the risk of upper gastrointestinal cancers in Caucasian populations

Recently, two large genome-wide association studies, conducted in Chinese populations, have reported associations between upper gastrointestinal cancer and the rs2274223, rs13042395 and rs4072037 polymorphisms in PLCE1, C20orf54 and MUC1, respectively. We aimed to determine whether similar associations existed for Caucasian populations. We genotyped two population-based, case-control studies of upper gastrointestinal cancer; the first study included 290 gastric cancer (GC) cases and 376 controls and the second study included 306 GC cases, 107 oesophageal adenocarcinoma cancer cases, 52 oesphageal squamous cell cancer cases and 211 controls. Odds ratios (OR) and 95% confidence intervals (CIs) were computed from logistic models and adjusted for confounding variables. The rs4072037 polymorphism in MUC1 was associated with a reduced risk of GC of intestinal histological type (OR 0.4; 95% CI 0.2-0.9) and a reduced risk of oesophageal squamous cell cancer (OR 0.5; 95% CI 0.2-1.0), but not oesphageal adenocarcinoma. Similarly, rs2274223 in PLCE1 was associated with a reduced risk of oesophageal squamous cell cancer (OR 0.5; 95% CI 0.3-1.0), but not oesphageal adenocarcinoma. We observed no association between rs13042395 in Corf54 and the risk of gastric or oesphageal cancer in either of the two studies. Our findings for rs4072037 and the risk of GC are in agreement with one previous report for a Caucasian population. To the best of our knowledge, this is the first study to report an association between rs2274223 and rs4072037 and the risk of oesophageal squamous cell carcinoma in a Caucasian population.

Extreme ultraviolet interferometer using high-order harmonic generation from successive sources

We present a new interferometer technique whereby multiple extreme ultraviolet light pulses are generated at different positions within a single laser focus (i.e., from successive sources) with a highly controllable time delay. The interferometer technique is tested with two generating media to create two extreme ultraviolet light pulses with a time delay between them. The delay is found to be a consequence of the Gouy phase shift. Ultimately the apparatus is capable of accessing unprecedented time scales by allowing stable and repeatable delays as small as 100 zs.

Characteristics of, and insurance payments for, injuries to cyclists in Tasmania, 1990-2010

OBJECTIVE

To describe the characteristics and costs of injuries to cyclists resulting in a 3rd party insurance claim in Tasmania.

METHODS

Data on injuries to cyclists were obtained from the Motor Accident Insurance Board (MAIB) for the period 1990-2010. Frequency and insurance costs of injuries to cyclists were compared to injuries incurred by other road users. Descriptive analyses of cycling injuries and insurance costs by year, age and sex of claimant, and type and location of injury are presented.

RESULTS

Annual costs of insurance claims by cyclists averaged AUD 3.9 million. There was a significant decrease in the frequency of claims made by all road users combined over the study period, but not for cyclists. Cycling injuries made up 2.0% of claims but accounted for 3.4% of the total costs and were among the road user groups with the highest mean costs per claim. Fractures (20.7%) were the most common cycling injury. Brain injuries led to the highest mean claim costs (AUD 1,559,032), and accounted for 66.8% of claim costs made by cyclists.

CONCLUSIONS

Mean costs per claim for cycling injuries are high compared to those made by most other road users. The costs of these injuries impose a substantial burden on insurance payers. The high costs and severity of claims by cyclists compared to other road users demonstrates the high vulnerability of cyclists, and lends support to increasing separation of cyclists from motor vehicles.

Ten years of experience with biphasic insulin aspart 30: from drug development to the latest clinical findings

Biphasic insulin aspart 30 (BIAsp 30) includes 30% soluble rapid-acting insulin aspart (IAsp) along with an intermediate-acting 70% protaminated IAsp that provides coverage of prandial and basal insulin in a single injection. As BIAsp 30 has been available internationally for 10 years, this review provides a comprehensive overview of the discovery of BIAsp 30, its pharmacokinetic and pharmacodynamic profile, safety and efficacy outcomes from the clinical trial programme, 'real-life' clinical insights provided by observational study data, and cost effectiveness and quality-of-life information. These studies have demonstrated that BIAsp 30 once or twice daily is an appropriate option for insulin initiation. BIAsp 30 also provides a switch option in patients on biphasic human insulin (BHI). Switching from BHI to BIAsp 30 is associated with improved postprandial glucose (PPG) and reduced nocturnal and major hypoglycaemia, although daytime hypoglycaemia is higher with BIAsp 30. Intensification of BIAsp 30 can be achieved by increasing the number of daily doses up to three times daily with meals. Therefore, BIAsp 30 provides an intensification option for individuals who are not achieving control with basal insulin and would prefer the simplicity of a single biphasic insulin instead of progressing to a basal-bolus approach. BIAsp 30 has a simple dose-titration algorithm, which enables patients to effectively self-titrate their insulin dose. Cost-effectiveness analyses have demonstrated that BIAsp 30 is cost effective or dominant compared with BHI 30 or insulin glargine in a number of healthcare settings. In conclusion, BIAsp 30 offers a simple and flexible option for insulin initiation and intensification that provides coverage of both fasting and prandial glucose.

Cost and clinical implications of diabetes prevention in an Australian setting: a long-term modeling analysis

AIMS/HYPOTHESIS

Metformin and intensive lifestyle changes (ILC) reduced the incidence of type 2 diabetes (T2D) versus standard care (control) in overweight or obese subjects with impaired glucose tolerance (IGT) in the Diabetes Prevention Program (DPP) trial and Diabetes Prevention Program Outcomes Study (DPPOS). We projected lifetime clinical and economic outcomes based on the results from the DPP+DPPOS, from a 3rd-party payer perspective in Australia.

METHODS

A semi-Markov, 2nd-order Monte Carlo model was developed with four health states: "normal glucose regulation" (NGR); IGT; T2D and 'dead'. Outcomes were discounted at 5% annually. Univariate and probabilistic sensitivity analyses were performed. Incremental cost-effectiveness ratios (ICERs) were calculated.

RESULTS

Cumulative incidence (standard deviation) of T2D was 89.7% (0.2), 83.8% (0.2) and 73.4% (0.3%) for control, metformin and ILC respectively. Lifetime incremental direct costs were $1217 (4411) per subject for metformin versus control, with cost savings of $289 (4296) for ILC versus control. ILC therefore dominated control, with improvements in clinical outcomes and overall cost savings. Incremental costs per QALY-gained for metformin versus control were $10,142. Probability of cost-effectiveness at willingness-to-pay threshold of $50,000 was 78% and 100% for metformin or ILC respectively. Results were most sensitive to probabilities of developing T2D and costs of implementing the interventions.

CONCLUSIONS/INTERPRETATION

Substantial improvements in lifetime clinical outcomes could be expected in high risk subjects treated with metformin or ILC. Prevention of T2D in this group of subjects is good value for money, and may even lead to long term cost savings.

Cost-effectiveness of the Concord Minimal Trauma Fracture Liaison service, a prospective, controlled fracture prevention study

We evaluated the cost-effectiveness of a fracture liaison service prospectively designed to have a parallel control group treated by standard care. The clinical effectiveness of this service was associated with an incremental cost-effectiveness ratio versus standard care of Australian dollars (AUD) 17,291 per quality-adjusted life year (QALY) gained.

INTRODUCTION

Osteoporotic fractures are a major burden for national health services. The risk of re-fracture following an osteoporotic fracture is particularly high. In a study unique in prospectively having a control group treated by standard care, we recently demonstrated that a Minimal Trauma Fracture Liaison (MTFL) service significantly reduces the risk of re-fracture by 80%. Since the service involves greater use of resources, we have now evaluated whether it is cost-effective.

METHODS

A Markov model was developed that incorporated fracture probabilities and resource utilization data (expressed in AUD) obtained directly from the 4-year MTFL service clinical study. Resource utilization, local cost and mortality data and fracture-related health utility data were used to calculate QALYs with the MTFL service and standard care. Main outcome measures were: additional costs of the MTFL service over standard care, the financial savings achieved through reduced fractures and changes in QALYs associated with reduced fractures calculated over a 10-year simulation period. Costs and QALYs were discounted at 5% annually. Sensitivity analyses quantified the effects of different assumptions of effectiveness and resource utilization associated with the MTFL service.

RESULTS

The MTFL service improved QALYs by 0.089 years and led to increased costs of AUD 1,486 per patient versus standard care over the 10-year simulation period. The incremental cost-effectiveness ratio versus standard care was AUD 17,291 per QALY gained. Results were robust under all plausible assumptions.

CONCLUSIONS

The MTFL service is a cost-effective intervention to reduce recurrent osteoporotic fractures.

Evaluating the long-term cost-effectiveness of liraglutide versus exenatide BID in patients with type 2 diabetes who fail to improve with oral antidiabetic agents

BACKGROUND

The global clinical and economic burden of type 2 diabetes is substantial. Recently, clinical trials with glucagon-like peptide-1 (GLP-1) receptor agonists (liraglutide and exenatide) have shown a multifactorial clinical profile with the potential to address many of the clinical needs of patients and reduce the burden of disease.

OBJECTIVE

The goal of this study was to evaluate the long-term cost-effectiveness of once-daily liraglutide versus exenatide BID in patients with type 2 diabetes who failed to improve with metformin and/or sulfonylurea, based on the results of a previous clinical trial in 6 European countries (Switzerland, Denmark, Norway, Finland, the Netherlands, and Austria).

METHODS

A validated computer simulation model of diabetes was used to predict life expectancy, quality-adjusted life years (QALYs), and incidence of diabetes-related complications in patients receiving liraglutide (1.8 mg once daily) or exenatide (10 μg BID). Baseline cohort characteristics and treatment effects were derived from the Liraglutide Effect and Action in Diabetes 6 trial. Country-specific complication costs were taken from published sources. Simulations were run over 40 years from third-party payer perspectives. Future costs and clinical benefits were discounted at country-specific discount rates. Sensitivity analyses were performed.

RESULTS

Liraglutide was associated with improvements of 0.12 to 0.17 QALY and a reduced incidence of most diabetes-related complications versus exenatide in all settings. Evaluation of total direct medical costs (treatment plus complication costs) suggest that liraglutide was likely to cost between Euro (€) 1023 and €1866 more than exenatide over patients' lifetimes, leading to incremental cost-effectiveness ratios per QALY gained versus exenatide of: Switzerland, CHF (Swiss francs) 10,950 (€6902); Denmark, Danish krone [kr] 88,160 (€11,805); Norway, Norwegian krone [kr], 111,916 (€13,546); Finland, €8459; the Netherlands, €8119; and Austria, €8516.

CONCLUSIONS

Long-term projections indicated that liraglutide was associated with benefits in life expectancy, QALYs, and reduced complication rates versus exenatide. Liraglutide was cost-effective from a health care payer perspective in Switzerland, Denmark, Norway, Finland, the Netherlands, and Austria.

Experimental ionization of atomic hydrogen with few-cycle pulses

We present experimental data on strong-field ionization of atomic hydrogen by few-cycle laser pulses. We obtain quantitative agreement at the 10% level between the data and an ab initio simulation over a wide range of laser intensities and electron energies.

The cost-effectiveness of interventions in diabetes: a review of published economic evaluations in the UK setting, with an eye on the future

AIM

To synthesise key outcomes data from cost-effectiveness studies in diabetes, in the UK setting, and describe a narrative for the evidence-base, in order to understand the direction that future health economics research in this field could be heading.

METHODS

The peer-reviewed literature was searched at http://www.pubmed.com for health economics analyses in diabetes in the UK setting published between 1995 and 2008, using the keywords: "costs", "cost-effectiveness", "diabetes", "UK". Studies on screening for diabetes or prevention of diabetes were excluded, along with studies that looked purely at cost of diabetes treatment or monitoring.

RESULTS

There were over 350 hits on MEDLINE. A total of 23 articles were identified and reviewed. 18 studies were in type 2, two in type 1 and three studies in both types 1 and type 2 diabetes. All studies evaluated treatment from the perspective of the NHS, with the time horizons varying from 12 months to patient lifetimes. 13 studies estimated quality-adjusted life expectancy (QALE). The majority of studies used health economics modelling techniques to project clinical benefit and cost outcomes beyond the context of clinical trials, with Markov-type models predominating. The United Kingdom Prospective Study of Diabetes was the most frequently cited source of clinical effectiveness and cost data. Most studies were funded by the pharmaceutical industry and evaluated more expensive products, rather than cheaper generic therapies such as human insulin and metformin monotherapy.

CONCLUSION

Treatment-to-target in patients with diabetes in the UK is generally cost-effective and sometimes cost-saving vs. standard care. Ongoing health economics analysis in diabetes is essential as new clinical data are published. Future analysis of clinical and cost outcomes in diabetes could be expected to look beyond the impact of interventions on HbA1c in isolation, as manufacturers seek to differentiate innovative products in the market. Furthermore, it is anticipated that the competitiveness in the market for interventions in diabetes will lead to future cost-effectiveness analysis taking more interest in comparisons of off-patent medication and generic, fixed-dose combination therapies.

Growth hormone improves body composition, fasting blood glucose, glucose tolerance and liver triacylglycerol in a mouse model of diet-induced obesity and type 2 diabetes

AIMS/HYPOTHESIS

Growth hormone has been used experimentally in two studies to treat individuals with type 2 diabetes, with both reporting beneficial effects on glucose metabolism. However, concerns over potential diabetogenic actions of growth hormone complicate its anticipated use to treat type 2 diabetes. Thus, an animal model of type 2 diabetes could help evaluate the effects of growth hormone for treating this condition.

METHODS

Male C57BL/6J mice were placed on a high-fat diet to induce obesity and type 2 diabetes. Starting at 16 weeks of age, mice were treated once daily for 6 weeks with one of four different doses of growth hormone. Body weight, body composition, fasting blood glucose, insulin, glucose tolerance, liver triacylglycerol, tissue weights and blood chemistries were determined.

RESULTS

Body composition measurements revealed a dose-dependent decrease in fat and an increase in lean mass. Analysis of fat loss by depot revealed that subcutaneous and mesenteric fat was the most sensitive to growth hormone treatment. In addition, growth hormone treatment resulted in improvement in glucose metabolism, with the highest dose normalising glucose, glucose tolerance and liver triacylglycerol. In contrast, insulin levels were not altered by the treatment, nor did organ weights change. However, fasting plasma leptin and resistin were significantly decreased after growth hormone treatment.

CONCLUSIONS/INTERPRETATION

Growth hormone therapy improves glucose metabolism in this mouse model of obesity and type 2 diabetes, providing a means to explore the molecular mechanism(s) of this treatment.

A hexapole magnetic guide for neutral atomic beams

In this paper we present a multiple element magnetic device to guide atoms using a spatially inhomogeneous magnetic field formed by a series of permanent hexapole magnets. The operation of the device is demonstrated using an enhanced beam of neon atoms in the 3P2 metastable state. These atoms are guided around a bend of 30 degrees from their original path. A flux of 4.35 x 10(9) +/- 2 x 10(7) atoms s(-1) was measured after the device yielding a transmission efficiency of approximately 9% of the input flux. Simulations of the center of mass motion of the atoms through the magnetic guide have been performed giving reasonable agreement with the experimental results.

Long-term cost-effectiveness of pioglitazone versus placebo in addition to existing diabetes treatment: a US analysis based on PROactive

OBJECTIVE

To estimate the long-term cost-effectiveness of adding pioglitazone versus placebo to standard treatment in high-risk patients with type 2 diabetes.

METHODS

The validated CORE Diabetes Model was modified to project long-term clinical and cost outcomes associated with pioglitazone versus placebo, based on results from PROactive. The model retained basic structure and functionality, with interdependent Markov submodels, Monte Carlo simulation and user interface. Adjustments to submodels were made to accommodate the PROactive primary end points. The analysis was from the perspective of a third party US health-care payer perspective, projected over a lifetime horizon using a 3% annual discount.

RESULTS

Over a lifetime horizon, addition of pioglitazone was associated with increased life expectancy (0.237 life-years) and quality-adjusted life expectancy (QALE) [0.166 quality-adjusted life-years (QALYs)] versus placebo. Estimated long-term complication rates showed that pioglitazone reduced the number of events versus placebo for most outcomes. Lifetime total direct costs were marginally higher with pioglitazone versus placebo ($272,694 vs. $265,390, difference $7,305). The incremental cost-effectiveness ratio for pioglitazone versus placebo was $44,105 per QALY gained. Probabilistic sensitivity analysis indicated a 55% likelihood that pioglitazone would be considered cost-effective in the United States, with a willingness to pay of $50,000 per QALY gained.

CONCLUSIONS

The addition of pioglitazone to existing therapy in high-risk patients with type 2 diabetes was projected to improve life expectancy, QALE and complication rates compared with placebo. Addition of pioglitazone was in the range generally considered acceptable.

Cost-effectiveness of early versus late cinacalcet treatment in addition to standard care for secondary renal hyperparathyroidism in the USA

OBJECTIVES

The objective of this research was to estimate lifetime cost-effectiveness of treating patients with cinacalcet early (when parathyroid hormone [PTH] levels are in the range of 300-500 pg/ml) versus delaying treatment with cinacalcet (cinacalcet initiated when PTH levels are > 800 pg/ml) in patients with secondary hyperparathyroidism (SHPT) in the US setting.

METHODS

A Markov model was developed to simulate the effects of early versus delayed use of cinacalcet (plus standard of care). Four different PTH ranges (< or = 300 pg/ml; 301-500 pg/ml; 501-800 pg/ml; > 800 pg/ml) were used to represent four different health states within the Markov model. Associated with each Markov state (PTH range) were varying risks of major SHPT complications, including cardiovascular disease (CVD), fracture (Fx), and parathyroidectomy (PTx). Baseline cohort characteristics and risks of CVD, Fx, and PTx by PTH category were derived from a large US renal database and published sources. Costs were estimated from the US Renal Data System database and reported in 2006 US Dollars ($). Clinical and economic outcomes were discounted at 3.0% per annum.

RESULTS

Early treatment was projected to improve quality-adjusted life years (QALYs) by 0.337 years compared to delaying treatment. The incremental cost-effectiveness ratio was $17,275 per QALY gained.

CONCLUSIONS

Early treatment with cinacalcet was associated with improvements in QALYs and would represent good value for money compared to delaying treatment with cinacalcet.

Cost-effectiveness of intensified versus conventional multifactorial intervention in type 2 diabetes: results and projections from the Steno-2 study

OBJECTIVE

To assess the cost-effectiveness of intensive versus conventional therapy for 8 years as applied in the Steno-2 study in patients with type 2 diabetes and microalbuminuria.

RESEARCH DESIGN AND METHODS

A Markov model was developed to incorporate event and risk data from Steno-2 and account Danish-specific costs to project life expectancy, quality-adjusted life expectancy (QALE), and lifetime direct medical costs expressed in year 2005 Euros. Clinical and cost outcomes were projected over patient lifetimes and discounted at 3% annually. Sensitivity analyses were performed.

RESULTS

Intensive treatment was associated with increased life expectancy, QALE, and lifetime costs compared with conventional treatment. Mean +/- SD undiscounted life expectancy was 18.1 +/- 7.9 years with intensive treatment and 16.2 +/- 7.3 years with conventional treatment (difference 1.9 years). Discounted life expectancy was 13.4 +/- 4.8 years with intensive treatment and 12.4 +/- 4.5 years with conventional treatment. Lifetime costs (discounted) for intensive and conventional treatment were euro45,521 +/- 19,697 and euro41,319 +/- 27,500, respectively (difference euro4,202). Increased costs with intensive treatment were due to increased pharmacy and consultation costs. Discounted QALE was 1.66 quality-adjusted life-years (QALYs) higher for intensive (10.2 +/- 3.6 QALYs) versus conventional (8.6 +/- 2.7 QALYs) treatment, resulting in an incremental cost-effectiveness ratio of euro2,538 per QALY gained. This is considered a conservative estimate because accounting prescription of generic drugs and capturing indirect costs would further favor intensified therapy.

CONCLUSIONS

From a health care payer perspective in Denmark, intensive therapy was more cost-effective than conventional treatment. Assuming that patients in both arms were treated in a primary care setting, intensive therapy became dominant (cost- and lifesaving).

Evaluating the cost-effectiveness of therapy conversion to insulin detemir in patients with type 2 diabetes in Germany: a modelling study of long-term clinical and cost outcomes

OBJECTIVES

To evaluate the long-term cost-effectiveness of transferring type 2 diabetes patients to an insulin detemir regimen after failure to achieve adequate control with oral antidiabetic agents (OADs) alone, or in combination with neutral protamine hagedorn (NPH) insulin, or with insulin glargine in Germany.

METHODS

A computer simulation model of diabetes was used to make long-term projections of future clinical outcomes and direct medical costs based on findings from a German subanalysis of the PREDICTIVE trial. The study analysed the impact of converting patients failing their current treatments to an insulin detemir regimen. Therapy conversion to insulin detemir +/- OADs was associated with a significant reduction in glycosylated haemoglobin (HbA(1)c) compared with OADs alone, NPH insulin +/- OADs, and insulin glargine +/- OADs. Across all three groups, hypoglycaemia rates decreased by 80% and patients lost an average of 0.9 kg of body weight during treatment with insulin detemir +/- OADs.

RESULTS

Therapy conversion to insulin detemir +/- OADs was projected to improve life expectancy by 0.28 years compared with OADs alone, and by 0.13 years compared with the NPH and glargine regimens. Transfer to insulin detemir was associated with improvements in quality-adjusted life expectancy of 0.21 quality-adjusted life years (QALYs) over OADs alone, 0.28 QALYs over NPH +/- OADs, and 0.29 QALYs over glargine +/- OADs. Insulin detemir was associated with savings over patient lifetimes due to reduced diabetes-related complications in all three comparisons.

CONCLUSIONS

Therapy conversion to insulin detemir +/- OADs in type 2 diabetes patients failing OADs alone, NPH or insulin glargine regimens was associated with improvements in life expectancy, quality-adjusted life expectancy and cost savings in all three scenarios evaluated.

Biphasic insulin aspart 70/30 vs. insulin glargine in insulin naïve type 2 diabetes patients: modelling the long-term health economic implications in a Swedish setting

OBJECTIVES

To evaluate the long-term clinical and economic outcomes of biphasic insulin aspart 70/30 (BIAsp 70/30) treatment vs. insulin glargine in insulin naïve, type 2 diabetes patients failing oral antidiabetic drugs in a Swedish setting.

METHODS

A published and validated computer simulation model (the CORE Diabetes Model) was used to project life expectancy, quality-adjusted life expectancy (QALE) and costs over patient lifetimes. Cohort characteristics [54.5% male, mean age 52.4 years, 9 years mean diabetes duration, mean glycosylated haemoglobin (HbA1c) 9.77%] and treatment effects were based on results from the Initiate Insulin by Aggressive Titration and Education (INITIATE) clinical trial. Direct medical costs were accounted in 2006 Swedish Kronor (SEK) and economic and clinical benefits were discounted at 3% per annum.

RESULTS

Biphasic insulin aspart 70/30 treatment when compared with insulin glargine treatment was associated with improvements in discounted life expectancy of 0.21 years (13.10 vs. 12.89 years) and QALE of 0.21 quality-adjusted life years (QALYs) (9.16 vs. 8.96 QALYs). Reductions in the incidence of diabetes-related complications in the BIAsp 70/30 treatment arm led to reduced total costs of SEK 10,367 when compared with insulin glargine (SEK 396,475 vs. SEK 406,842) over patient lifetimes. BIAsp 70/30 treatment was projected to be dominant (cost and lifesaving) when compared with insulin glargine in the base case analysis.

CONCLUSIONS

Biphasic insulin aspart 70/30 treatment was associated with improved clinical outcomes and reduced costs compared with insulin glargine treatment over patient lifetimes. These results were driven by improved HbA1c levels associated with BIAsp 70/30 compared with insulin glargine and the accompanying reduction in diabetes-related complications despite increases in body mass index.

An Asian regional analysis of cost-effectiveness of early irbesartan treatment versus conventional antihypertensive, late amlodipine, and late irbesartan treatments in patients with type 2 diabetes, hypertension, and nephropathy

OBJECTIVE

The prevalence of type 2 diabetes, often leading to diabetic nephropathy, has increased globally, especially in Asia. Irbesartan treatment delays the progression of kidney disease at the early (microalbuminuria) and late (proteinuria) stages of nephropathy in hypertensive type 2 diabetics. This treatment has proven to be cost-effective in Western countries. This study assessed the cost-effectiveness of early irbesartan treatment in Asian settings.

METHODS

An existing lifetime model was reprogrammed in Microsoft Excel to compare irbesartan started at an early stage to irbesartan or amlodipine started at a late stage, and standard treatments from a health-care perspective in China, Malaysia, Thailand, South Korea, and Taiwan. The main effectiveness parameters were incidences of end-stage renal disease, time in dialysis, and life expectancy. All costs were converted to 2004 US$ using official purchasing power parity. Local data were obtained for costs, transplantation,dialysis, and mortality rates. Probabilities regarding disease progression after treatment with the investigated drugs were extracted from two published clinical trials. A probabilistic sensitivity analysis was performed.

RESULTS

Early use of irbesartan yielded the largest clinical and economic benefits reducing need for dialysis by 61% to 63% versus the standard treatment, total costs by 9% (Thailand) to 42% (Taiwan), and increasing life expectancy by 0.31 to 0.48 years. Early irbesartan had a 66% (Thailand) to 95% (Taiwan) probability of being dominant over late irbesartan.

CONCLUSION

Although the absolute results varied in different settings, reflecting differences in epidemiology, management, and costs, early irbesartan treatment was a cost-effective alternative in the Asian settings.

Cost-effectiveness of insulin aspart versus human soluble insulin in type 2 diabetes in four European countries: subgroup analyses from the PREDICTIVE study

OBJECTIVES

To evaluate the long-term health economic outcomes associated with insulin aspart (IAsp) compared to human soluble insulin (HI) in type 2 diabetes patients on basal-bolus therapy in Sweden, Spain, Italy and Poland.

METHODS

A published computer simulation model of diabetes was used to predict life expectancy, quality-adjusted life expectancy and incidence of diabetes-related complications. Baseline cohort characteristics (age 61.6 years, duration of diabetes 13.2 years, 45.1% male, HbA(1c) 8.2%, BMI 29.8 kg/m(2)) and treatment effects were derived from the PREDICTIVE observational study. Country-specific complication costs were derived from published sources. The analyses were run over 35-year time horizons from third-party payer perspectives in Spain, Italy and Poland and from a societal perspective in Sweden. Future costs and clinical benefits were discounted at country-specific discount rates. Sensitivity analyses were performed.

RESULTS

IAsp was associated with improvements in discounted life expectancy and quality-adjusted life expectancy, and a reduced incidence of most diabetes-related complications versus HI in all four settings. IAsp was associated with societal cost-savings in Sweden (SEK 2470), direct medical cost-savings in Sweden and Spain (SEK 8248 and euro 1382, respectively), but increased direct costs in Italy (euro 2235) and Poland (euro 743). IAsp was associated with improved quality-adjusted life expectancy in Sweden (0.077 QALYs), Spain (0.080 QALYs), Italy (0.120 QALYs) and Poland (0.003 QALYs).

CONCLUSIONS

IAsp was dominant versus HI in both Sweden and Spain, would be considered cost-effective in Italy with an incremental cost-effectiveness ratio of euro 18,597 per QALY gained, but would not be considered cost-effective in Poland.

A health economic analysis of screening and optimal treatment of nephropathy in patients with type 2 diabetes and hypertension in the USA

BACKGROUND

Nephropathy is an indicator of end-organ damage and is a strong predictor of an increased risk of cardiovascular disease and death in patients with diabetes. Screening can lead to early identification and treatment, both of which incur costs. However, identification and treatment may slow or prevent progression to a more expensive stage of the disease and thus may save money. We assessed the health economic impact of screening for nephropathy (microalbuminuria and overt nephropathy) followed by optimal renoprotective-based antihypertensive therapy in a US setting.

METHODS

A Markov model simulated the lifetime impact of screening with semi-quantitative urine dipsticks in a primary care setting of hypertensive patients with type 2 diabetes and subsequent treatment with irbesartan 300 mg in patients identified as having nephropathy. Progression from no nephropathy to end-stage renal disease (ESRD) was simulated. Probabilities, utilities, medication and ESRD treatment costs came from published sources. Clinical outcomes and direct medical costs were projected. Second order Monte Carlo simulation was used to account for uncertainty in multiple parameters. Annual discount rates of 3% were used where appropriate.

RESULTS

Screening, followed by optimized treatment, led to a 44% reduction in the cumulative incidence of ESRD and improvements in non-discounted life expectancy of 0.25 +/- 0.22 years/patient (mean +/- SD). Quality-adjusted life expectancy was improved by 0.18 +/- 0.15 quality-adjusted life years (QALYs)/patient and direct costs increased by $244 +/- 3499/patient. The incremental cost-effectiveness ratio was $20 011 per QALY gained for screening and optimized treatment versus no screening. There was a 77% probability that screening and optimized therapy would be considered cost effective with a willingness to pay a threshold of $50 000.

CONCLUSION

In patients with type 2 diabetes and hypertension, screening for nephropathy and treatment with a renoprotective-based antihypertensive agent was projected to improve patient outcomes and represent excellent value in a US setting.

[Health economic consequences of insulin analogues in the treatment of type 1 diabetes in Denmark]

INTRODUCTION

Diabetes is a major challenge to the Danish health care system, and complications account for the majority of total treatment costs.

MATERIALS AND METHODS

The majority of type 1 diabetes patients in Denmark are treated with the flexible basal-bolus insulin regimen. Use of insulin analogues provides superior metabolic control, lower blood glucose viability, flexible life style, reduced frequency of hypoglycaemia and no undesired weight gain. The long term health economic consequences were projected in a published and validated Markov model. Treatment effects of insulin analogues and a similar human insulin regimen were based on results from a clinical RCT study and Danish health care costs were applied in the model.

RESULTS

In the model, the improved glycaemic control and the reduction in hypoglycaemia episodes obtained with insulin analogues resulted in a reduction in late stage diabetes complications, improved quality of life and increased life expectancy compared to human insulin. The incremental costs-effectiveness ratio was estimated to DKK 55,867 per quality-adjusted life year gained, which is considered beneficial to society.

CONCLUSION

Modelling predicts insulin analogues to be a cost-effective alternative to human insulin in Denmark.

Cost-effectiveness analysis of thiazolidinediones in uncontrolled type 2 diabetic patients receiving sulfonylureas and metformin in Thailand

OBJECTIVE

The national essential drug committee in Thailand suggested that only one of thiazolidinediones be included in hospital formulary but little was know about their cost-effectiveness values. This study aims to determine an incremental cost-effectiveness ratio of pioglitazone 45 mg compared with rosiglitazone 8 mg in uncontrolled type 2 diabetic patients receiving sulfonylureas and metformin in Thailand.

METHODS

A Markov diabetes model (Center for Outcome Research model) was used in this study. Baseline characteristics of patients were based on Thai diabetes registry project. Costs of diabetes were calculated mainly from Buddhachinaraj hospital. Nonspecific mortality rate and transition probabilities of death from renal replacement therapy were obtained from Thai sources. Clinical effectiveness of thiazolidinediones was retrieved from a meta-analysis. All analyses were based on the government hospital policymaker perspective. Both cost and outcomes were discounted with the rate of 3%. Base-case analyses were analyzed as incremental cost per quality-adjusted life year (QALY) gained. A series of sensitive analyses were performed.

RESULTS

In base-case analysis, the pioglitazone group had a better clinical outcomes and higher lifetime costs. The incremental cost per QALY gained was 186,246 baht (US$ 5389). The acceptability curves showed that the probability of pioglitazone being cost-effective was 29% at the willingness to pay of one time of Thai gross domestic product per capita (GDP per capita). The effect of pioglitazone on %HbA1c decrease was the most sensitive to the final outcomes.

CONCLUSIONS

Our findings showed that in type 2 diabetic patients who cannot control their blood glucose under the combination of sulfonylurea and metformin, the use of pioglitazone 45 mg fell in the cost-effective range recommended by World Health Organization (one to three times of GDP per capita) on average, compared to rosiglitazone 8 mg. Nevertheless, based on sensitivity analysis, its probability of being cost-effective was quite low. Hospital policymakers may consider our findings as part of information for the decision-making process.

Estimating the long-term cost-effectiveness of exenatide in the United States: an adjunctive treatment for type 2 diabetes mellitus

OBJECTIVES

This analysis provides an early estimate of the cost-effectiveness of adjunctive exenatide in treating type 2 diabetes mellitus in the United States. Data from pivotal phase III 30-week clinical trials and 52 weeks of their subsequent open-label extension studies (i.e., 82 weeks total) were used to project the effects of 30 years of adjunctive exenatide treatment.

METHODS

This analysis utilized a published and validated Markov model incorporating Monte Carlo simulation with tracker variables to estimate the clinical and cost outcomes of adding exenatide to a background of metformin and/or sulfonylurea treatment, with the effects of 30 years of adjunctive exenatide treatment (projected from data from 82 weeks of exenatide treatment) compared with no additional treatment beyond metformin and/or a sulfonylurea. Sensitivity analyses were performed on key clinical assumptions, discount rates, and shorter time horizons.

RESULTS

The base-case scenario (30 years of exenatide) yielded an incremental cost-effectiveness ratio (ICER) of $35,571. We found that shortening the time horizons and removing the lipid effects of exenatide had the greatest negative impact on ICERs when performing sensitivity analysis.

CONCLUSIONS

Our analysis demonstrated that exenatide used for 20 or 30 years compared with no additional treatment beyond metformin and/or a sulfonylurea is cost-effective in the adjunctive treatment of type 2 diabetes with an ICER less than $50,000 per life-year gained. Sensitivity analyses suggest that, in addition to sustained reduction in HbA(1c), the added clinical effects of improved lipid values, systolic blood pressure, and reduced body mass index all positively contributed to the cost-effectiveness of exenatide.

Irbesartan treatment of patients with type 2 diabetes, hypertension and renal disease: a UK health economics analysis

The objective of the study was to determine the impact of irbesartan treatment on life expectancy (LE), costs and progression to end-stage renal disease (ESRD) in hypertensive type 2 diabetes patients. A peer-reviewed and published Markov model was used to simulate progression from microalbuminuria to overt nephropathy, doubling of serum creatinine, ESRD and all-cause mortality in hypertensive patients with type 2 diabetes. Three treatment strategies were evaluated: (i) 'control' regimen of conventional antihypertensive therapy (excluding angiotensin-converting enzyme inhibitors, angiotensin-2-receptor antagonists and dihydropyridine calcium-channel blockers), (ii) 'early irbesartan' 300 mg daily and (iii) 'late irbesartan' 300 mg daily (started when overt nephropathy developed). Transition probabilities determining nephropathy progression were taken from the Irbesartan in Reduction of Microalbuminuria-2 study, Irbesartan in Diabetic Nephropathy Trial and other published sources. Outcomes were projected over 25 years. The mean +/- SD cumulative incidence of ESRD was reduced by 8.8% +/- 0.6 and 12.4% +/- 0.7 in patients treated with early irbesartan compared with late irbesartan and control respectively. Early irbesartan treatment improved undiscounted LE by 1.38 +/- 0.08 years (discounted: 0.81 +/- 0.04 years) compared with late irbesartan and 1.41 +/- 0.08 years (discounted: 0.83 +/- 0.04 years) compared with control. Early irbesartan treatment was projected to save (mean +/- SD) pounds 2310 +/- 327 and pounds 3801 +/- 327 over patient lifetimes compared with late irbesartan and control respectively. Irbesartan treatment is predicted to improve survival and reduce costs in hypertensive patients with type 2 diabetes and microalbuminuria compared with 'control'. Early irbesartan treatment is more effective than late irbesartan. Irbesartan is a valuable treatment option in this patient group in a UK setting.

Cost-effectiveness of diabetes case management for low-income populations

OBJECTIVE

To evaluate the cost-effectiveness of Project Dulce, a culturally specific diabetes case management and self-management training program, in four cohorts defined by insurance status.

DATA SOURCES/STUDY SETTING

Clinical and cost data on 3,893 persons with diabetes participating in Project Dulce were used as inputs into a diabetes simulation model.

STUDY DESIGN

The Center for Outcomes Research Diabetes Model, a published, peer-reviewed and validated simulation model of diabetes, was used to evaluate life expectancy, quality-adjusted life expectancy (QALY), cumulative incidence of complications and direct medical costs over patient lifetimes (40-year time horizon) from a third-party payer perspective. Cohort characteristics, treatment effects, and case management costs were derived using a difference in difference design comparing data from the Project Dulce program to a cohort of historical controls. Long-term costs were derived from published U.S. sources. Costs and clinical benefits were discounted at 3.0 percent per annum. Sensitivity analyses were performed.

PRINCIPAL FINDINGS

Incremental cost-effectiveness ratios of $10,141, $24,584, $44,941, and $69,587 per QALY gained were estimated for Project Dulce participants versus control in the uninsured, County Medical Services, Medi-Cal, and commercial insurance cohorts, respectively.

CONCLUSIONS

The Project Dulce diabetes case management program was associated with cost-effective improvements in quality-adjusted life expectancy and decreased incidence of diabetes-related complications over patient lifetimes. Diabetes case management may be particularly cost effective for low-income populations.

PROactive 06: cost-effectiveness of pioglitazone in Type 2 diabetes in the UK

AIMS

To determine the cost-effectiveness of adding pioglitazone to existing treatment regimens in patients with Type 2 diabetes with a history of macrovascular disease who are at high risk of further cardiovascular events.

METHODS

We conducted two analyses. A within-trial cost-effectiveness analysis (CEA) based on data from the PROspective pioglitAzone Clinical Trial In macroVascular Events (PROactive) Study was performed to estimate the impact of additional pioglitazone treatment on life expectancy, quality-adjusted life expectancy (QALE) and macrovascular events. PROactive data was then used as a basis for a lifetime modelling analysis using a modified version of the validated CORE diabetes model that simulated the same outcomes over a 35-year time horizon. We accounted for direct medical costs from a health-care payer perspective and related these to the clinical outcomes from the study. Costs and benefits were discounted at 3.5% per annum and extensive sensitivity analyses were performed to account for uncertainty in input parameters.

RESULTS

(i) Within-trial CEA: compared with placebo, pioglitazone was associated with improved life expectancy (undiscounted 0.0109 years), increased QALE [0.0190 quality-adjusted life years (QALYs)] and slightly higher costs ( pounds 102 per patient). After a mean treatment period of 3 years, the incremental cost-effectiveness ratio (ICER) of pioglitazone vs. placebo was pounds 5396 per QALY gained. The ICERs were relatively insensitive to cost and utility values and were most sensitive to event rates in the pioglitazone arm. (ii) Long-term CEA: pioglitazone was associated with improvements in clinical outcomes based on model projections beyond the PROactive Study. Patients treated with pioglitazone could expect improved life expectancy (undiscounted 0.406 years), increased QALE (0.152 QALYs) and higher costs of care ( pounds 619 per patient) compared with those on existing treatment alone. The base case analysis indicated that the ICER of pioglitazone vs. placebo was pounds 4060 per QALY gained. The cost-effectiveness acceptability curve showed there was an 84.3% likelihood that pioglitazone would be considered cost-effective in the UK using a willingness-to-pay threshold of pounds 30 000 per QALY gained. These long-term results were most sensitive to variation in the time horizon, the duration of cardiovascular benefit of pioglitazone, and changes in mortality rates.

CONCLUSIONS

The addition of pioglitazone to existing therapy in patients with Type 2 diabetes at high risk of further cardiovascular events is cost-effective and represents good value for money by currently accepted standards in the UK.

Health economic implications of irbesartan treatment versus standard blood pressure control in patients with type 2 diabetes, hypertension and renal disease: a Hungarian analysis

To perform a health economic analysis on treatment with irbesartan in patients with type 2 diabetes and hypertension. A Markov model was adapted to the Hungarian setting to simulate renal deterioration from the development of microalbuminuria to nephropathy, doubling of serum creatinine, end-stage renal disease (ESRD) and all-cause mortality. Outcomes for two treatments were evaluated: (1) a placebo regimen of standard antihypertensive medications, and (2) the addition of irbesartan 300 mg administered daily, with both treatment initiated after developing microalbuminuria. Outcomes were discounted at 5% annually to correspond with national guidelines. Treatment with irbesartan was estimated to improve undiscounted life expectancy by 0.98 +/- 0.05 years, reduce the cumulative incidence of ESRD by 7.5 +/- 0.4%, and reduce lifetime costs by Hungarian Forints (HUF) 519,993 +/- 70,814, compared to placebo. Irbesartan was projected to improved life expectancy and reduce costs compared to placebo in the Hungarian setting in hypertensive patients with type 2 diabetes and microalbuminuria.

Therapy conversion to insulin detemir among patients with type 2 diabetes treated with oral agents: a modeling study of cost-effectiveness in the United States

The aim of this study was to gain a preliminary indication of the long-term clinical and economic implications of converting treatment for patients with type 2 diabetes to insulin detemir+/-oral hypoglycemic agents (OHAs) in a routine clinical practice setting in the United States. With the use of outcome data and patient characteristics reported from an ongoing prospective observational trial, a validated computer simulation model of diabetes was used to project the clinical and cost outcomes associated with therapy conversion to insulin detemir over a 35-y period from (1) OHA only, (2) neutral protamine Hagedorn insulin (NPH)+/-OHA, and (3) insulin glargine+/-OHA. Cost-effectiveness was assessed from a third-party healthcare payer perspective for the year 2005. Costs and clinical outcomes were discounted at a rate of 3%. Treatment with insulin detemir+/-OHA was associated with increases in quality-adjusted life expectancy of 0.309, 0.350, and 0.333 quality-adjusted life-years (QALYs) versus treatment with OHA alone, NPH+/-OHA, and insulin glargine+/-OHA, respectively. Increases in pharmacy costs were partially offset by reduced complications, rticularly renal complications and neuropathy. Projected incremental cost-effectiveness ratios were well within the range considered to represent good value in the United States, at $7412, $6269, and $3951 per QALY gained for treatment with Idet+/-OHA versus OHA alone, NPH+/-OHA, and Iglarg+/-OHA, respectively. On the basis of preliminary evidence of short-term improvements in glycemic control and reduced hypoglycemia, therapy conversion to insulin detemir+/-OHA from OHA alone, NPH+/-OHA, or insulin glargine+/-OHA was projected to increase quality-adjusted life expectancy and to represent a cost-effective treatment option in the United States.

Exenatide versus insulin glargine in patients with type 2 diabetes in the UK: a model of long-term clinical and cost outcomes

OBJECTIVES

The aim of this study was to evaluate the long-term clinical and economic outcomes associated with exenatide or insulin glargine, added to oral therapy in individuals with type 2 diabetes inadequately controlled with combination oral agents in the UK setting.

METHODS

A published and validated computer simulation model of diabetes was used to project long-term complications, life expectancy, quality-adjusted life expectancy and direct medical costs. Probabilities of diabetes-related complications were derived from published sources. Treatment effects and patient characteristics were extracted from a recent randomised controlled trial comparing exenatide with insulin glargine. Simulations incorporated published quality of life utilities and UK-specific costs from 2004. Pharmacy costs for exenatide were based on 20, 40, 60, 80 and 100% of the US value (as no price for the UK was available at the time of analysis). Future costs and clinical benefits were discounted at 3.5% annually. Sensitivity analyses were performed.

RESULTS

In the base-case analysis exenatide was associated with improvements in life expectancy of 0.057 years and in quality-adjusted life expectancy of 0.442 quality-adjusted life years (QALYs) versus insulin glargine. Long-term projections demonstrated that exenatide was associated with a lower cumulative incidence of most cardiovascular disease (CVD) complications and CVD-related death than insulin glargine. Using the range of cost values, evaluation results showed that exenatide is likely to fall in a range between dominant (cost and life saving) at 20% of the US price and cost-effective (with an ICER of 22,420 pounds per QALY gained) at 100% of the US price, versus insulin glargine.

CONCLUSIONS

Based on the findings of a recent clinical trial, long-term projections indicated that exenatide is likely to be associated with improvement in life expectancy and quality-adjusted life expectancy compared to insulin glargine. The results from this modelling analysis suggest that that exenatide is likely to represent good value for money by generally accepted standards in the UK setting in individuals with type 2 diabetes inadequately controlled on oral therapy.

Insulin therapy in type 2 diabetes patients failing oral agents: cost-effectiveness of biphasic insulin aspart 70/30 vs. insulin glargine in the US

OBJECTIVES

To project the long-term clinical and economic outcomes of treatment with biphasic insulin aspart 30 (BIAsp 70/30, 30% soluble and 70% protaminated insulin aspart) vs. insulin glargine in insulin-naïve type 2 diabetes patients failing to achieve glycemic control with oral antidiabetic agents alone (OADs).

METHODS

Baseline patient characteristics and treatment effect data from the recent 'INITIATE' clinical trial served as input to a peer-reviewed, validated Markov/Monte-Carlo simulation model. INITIATE demonstrated improvements in HbA1c favouring BIAsp 70/30 vs. glargine (-0.43%; p < 0.005) and greater efficacy in reaching glycaemic targets among patients poorly controlled on OAD therapy. Effects on life expectancy (LE), quality-adjusted life expectancy (QALE), cumulative incidence of diabetes-related complications and direct medical costs (2004 USD) were projected over 35 years. Clinical outcomes and costs were discounted at a rate of 3.0% per annum. Sensitivity analyses were performed.

RESULTS

Improvements in glycaemic control were projected to lead to gains in LE (0.19 +/- 0.24 years) and QALE (0.19 +/- 0.17 years) favouring BIAsp 70/30 vs. glargine. Treatment with BIAsp 70/30 was also associated with reductions in the cumulative incidences of diabetes-related complications, notably in renal and retinal conditions. The incremental cost-effectiveness ratio was $46 533 per quality-adjusted life year gained with BIAsp 70/30 vs. glargine (for patients with baseline HbA1c >/= 8.5%, it was $34 916). Total lifetime costs were compared to efficacy rates in both arms as a ratio, which revealed that the lifetime cost per patient treated successfully to target HbA1c levels of <7.0% and </= 6.5% were $80 523 and $93 242 lower with BIAsp 70/30 than with glargine, respectively.

CONCLUSIONS

Long-term treatment with BIAsp 70/30 was projected to be cost-effective for patients with type 2 diabetes insufficiently controlled on OADs alone compared to glargine. Treatment with BIAsp 70/30 was estimated to represent an appropriate investment of healthcare dollars in the management of type 2 diabetes.

Continuous subcutaneous insulin infusion versus multiple daily injections of insulin: economic comparison in adult and adolescent type 1 diabetes mellitus in Australia

BACKGROUND

Recent meta-analyses in the published medical literature have found improved glycaemic control with continuous subcutaneous insulin infusion (CSII) compared with multiple daily injections (MDI) of insulin for patients with diabetes mellitus. In Australia, CSII is predominantly used in type 1 diabetes mellitus (T1DM) patient populations. OBJECTIVE/INTERVENTION: To project long-term costs and outcomes of CSII (Novorapid or Humalog) compared with MDI (NPH insulin plus Novorapid or Humalog) in adult and adolescent T1DM patients in Australia.

METHODS

The study was a modelling analysis utilising a lifetime horizon in adult and adolescent specialty care T1DM patient populations from Australia. Published Australian diabetes complication costs (adjusted to Australian dollars [$A], year 2006 values), treatment costs and discount rates of 5.0% per annum were applied to costs and clinical outcomes. A lifetime horizon was taken, considering only direct medical costs and excluding indirect and non-medical costs. The validated CORE diabetes model employs standard Markov/Monte Carlo simulation techniques. It was used to simulate diabetes progression in Australian adult (mean age 43 years, duration of diabetes 17 years, mean glycosylated haemoglobin [HbA(1c)] 8.2%) and adolescent (mean age 17 years, duration of diabetes 6 years, mean HbA(1c) 8.9%) patients with baseline characteristics taken predominantly from Australian National Diabetes Information Audit and Benchmarking (ANDIAB) in Australia. The main outcome measures were incremental costs and effectiveness of CSII compared with MDI in Australian adult and adolescent patients with T1DM.

RESULTS

Mean direct lifetime costs were $A34,642 higher with CSII treatment than with MDI for adult patients and $A41,779 higher for adolescent patients. Treatment with CSII was associated with an improvement in life expectancy of 0.393 years for adults compared with MDI and 0.537 years for adolescents. The corresponding gains in QALYs were 0.467 QALYs and 0.560 QALYs for adults and adolescents, respectively. This produced incremental cost effectiveness ratios (ICERs) of $A88,220 and $A77,851 per life-year gained for CSII compared with MDI for adult and adolescent T1DM patients, respectively, in Australia. These data also produced corresponding ICERs of $A74,147 per QALY and $A74,661/QALY for adult and adolescent T1DM patients, respectively. Sensitivity analyses suggested that our base-case assumptions were mostly robust with improvements in ICERs for reduction in hypoglycaemic events with CSII treatment and worse ICERs for lower HbA(1c) changes associated with CSII treatment compared with MDI.

CONCLUSIONS

Our analysis suggests that CSII is associated with ICERs in the range of $A53,022-259,646 per QALY gained, with most ICERs representing good value for money in Australia under the majority of scenarios explored.

A French cost-consequence analysis of the renoprotective benefits of irbesartan in patients with type 2 diabetes and hypertension

OBJECTIVES

We performed a cost-consequence analysis in a French setting of the renoprotective benefit of irbesartan in hypertensive type 2 diabetes patients over a 25-year period.

RESEARCH DESIGN AND METHODS

A previously published Markov model simulated progression from microalbuminuria to overt nephropathy, doubling of serum creatinine, end-stage renal disease and death. Three treatment strategies with analogous blood pressure control were compared: (A) control--conventionally medicated antihypertensive therapy (excluding angiotensin converting enzyme inhibitors, other angiotensin-2-receptor antagonists and dihydropyridine calcium channel blockers) initiated at microalbuminuria; (B) early irbesartan--(300 mg daily added to control, initiated with microalbuminuria) and (C) late irbesartan--(300 mg daily, initiated with overt nephropathy). Probabilities came from the Irbesartan in Reduction of Microalbuminuria-2 study, Irbesartan in Diabetic Nephropathy Trial and other sources. Clinical and economic outcomes were projected over 25 years. Annual discount rates were 3%.

RESULTS

Compared to control, early use of irbesartan added (mean +/- standard deviation) 1.51 +/- 0.08 undiscounted life years (discounted: 0.94 +/- 0.05 years), while late irbesartan added 0.07 +/- 0.01 (0.04 +/- 0.01) years/patient. Early irbesartan added 1.03 +/- 0.06 discounted quality-adjusted life years (QALYs), while late irbesartan added 0.06 +/- 0.01 QALYs. Early and late irbesartan treatments were projected to save 22,314 +/- 1273 euro and 6619 +/- 820 euro/patient, respectively versus control. Sensitivity analysis showed that even over short time horizons both irbesartan treatments were superior to the control group.

CONCLUSIONS

In France, early irbesartan treatment improved quality and length of life and reduced costs in hypertensive patients with type 2 diabetes and microalbuminuria. Late irbesartan therapy is beneficial, but earlier irbesartan leads to better outcomes.

Health economic implications of irbesartan plus conventional antihypertensive medications versus conventional blood pressure control alone in patients with type 2 diabetes, hypertension, and renal disease in Switzerland

OBJECTIVES

The aim of this health economic modelling study was to investigate the effect of irbesartan combined with conventional antihypertensive medications compared to conventional antihypertensive therapy alone on the progression of nephropathy in patients with hypertension, type 2 diabetes and microalbuminuria in a Swiss setting.

METHODS

In simulated patients with hypertension and type 2 diabetes, treatment of microalbuminuria with irbesartan 300 mg daily plus conventional antihypertensive medications was compared to a control regimen (conventional medications excluding angiotensin converting enzyme inhibitors, other angiotensin-2-receptor antagonist and dihydropyridine calcium channel blockers). Progression from microalbuminuria to nephropathy, doubling of serum creatinine, ESRD, and all-cause mortality was simulated over a 25-year time horizon using a published Markov model adapted to a Swiss setting. Transition probabilities were based on the Irbesartan in Reduction of Microalbuminuria-2 Study, Irbesartan in Diabetic Nephropathy Trial and other sources. Costs and clinical outcomes were discounted at 5% annually according to Swiss guidelines, and a third party payer perspective was taken.

RESULTS

Treatment with irbesartan was projected to improve mean life expectancy by 0.57 years compared to conventional antihypertension treatment (undiscounted 1.22 years). Irbesartan treatment was associated with cost savings of CHF 21,488 per patient over the 25-year time horizon. Sensitivity analysis showed that irbesartan therapy remained dominant to conventional antihypertension treatment over a range of plausible assumptions.

CONCLUSIONS

Addition of irbesartan to conventional antihypertension therapy was projected to improve life expectancy and reduce costs in hypertensive patients with type 2 diabetes and microalbuminuria in a Swiss setting.

Improving life expectancy and decreasing the incidence of complications associated with type 2 diabetes: a modelling study of HbA1c targets

To project the long-term clinical and cost outcomes that accompany predefined improvements in glycaemic control in patients with type 2 diabetes. A peer-reviewed, validated, non-product-specific Markov model of type 2 diabetes was used to project the long-term clinical and cost outcomes associated with three HbA1c reduction scenarios (vs. no reduction): (i) decreasing mean HbA1c from 9.5% to 8.0%; (ii) from 8.0% to 7.0%; and (iii) from 7.0% to 6.5%. A typical baseline US type 2 diabetes cohort derived from National Health and Nutrition Examination Survey data was simulated over a lifetime horizon (35 years). Incidence of diabetes-related complications and costs (2005 USD) were accounted based on published data. Discount rates (3% per annum) were applied to clinical benefits and costs. Sensitivity analyses were performed. Stepwise reductions in HbA1c as an independent variable correlated with delayed time to diabetes-related complications and a reduced cumulative incidence of complications, including cardiovascular, renal and neurologic comorbidities. Related costs also decreased. Reductions in both poorly- (9.5-8.0%) and better-controlled (7.0-6.5%) patients produced incremental gains in undiscounted life expectancy (LE) [1.06 (0.31) and 0.32 (0.34) years [mean (SD)], respectively]. Similar improvement patterns were observed in quality-adjusted life expectancy (QALE). Benefits from sequential reduction scenarios, when aggregated, exhibited the most dramatic effect. Improved glycaemic control was associated with reductions in complication rates and costs, as well as increased LE and QALE among type 2 patients. These data illustrate the long-term importance of reaching normoglycaemia and support intensified HbA1c control as a cornerstone of effective long-term type 2 diabetes management.

Klinische und gesundheitsökonomische Auswirkungen einer frühen Irbesartan-Therapie bei Typ-2-Diabetes, Hypertonie und Nierenerkrankung

BACKGROUND AND OBJECTIVE

It was the aim of this study to project the long-term clinical and cost outcomes of irbesartan treatment, based on data from the irbesartan in Reduction of Microalbuminuria-2 (IRMA-2) study and the irbesartan in Diabetic Nephropathy Trial (IDNT), in hypertensive patients with type 2 diabetes and renal disease in Germany.

PATIENTS AND METHODS

A Markov model adapted to the German setting simulated progression of renal disease and associated changes in mortality in patients with hypertension, type 2 diabetes and microalbuminuria. Early irbesartan 300 mg daily (initiated at microalbuminuria) and late irbesartan (initiated at overt nephropathy) were compared to a control scheme of antihypertensive standard medications with comparable blood pressure control, initiated at microalbuminuria. Cumulative incidence of ESRD, time to onset of ESRD, life expectancy (LE), quality-adjusted life years (QALY) and costs were projected over 25 years for 1,000 simulated patients, from a third party payer perspective. Clinical and cost outcomes were discounted at 5% per annum.

RESULTS

When compared to standard blood pressure control, both early and late treatment with irbesartan were projected to reduce the cumulative incidence of ESRD fromm23.80.3% to 9.10.6% and 19.83%, increase discounted LE by 0.670.04 and 0.030.00 years, and improve QALY by 0.750.04 and 0.070.01 years per treated patient, respectively. Early irbesartan treatment was associated with a cost savings of i 12,658825 per patient while late irbesartan treatment was associated with a cost savings of i 4,116575 per patient compared to control over the 25-year time horizon.

CONCLUSIONS

Early irbesartan treatment was projected to improve LE and QALY, and reduce the onset of ESRD, with cost savings, in hypertensive patients with type 2 diabetes and microalbuminuria in Germany. Later use of irbesartan in overt nephropathy is also superior to standard care. These findings suggest that irbesartan should be started earlier and continued long-term.