What do international pharmacoeconomic guidelines say about economic data transferability?

OBJECTIVES

The objectives of this article were to assess the positions of the various national pharmacoeconomic guidelines on the transferability (or lack of transferability) of clinical and economic data and to review the methods suggested in the guidelines for addressing issues of transferability.

METHODS

A review of existing national pharmacoeconomic guidelines was conducted to assess recommendations on the transferability of clinical and economic data, whether there are important differences between countries, and whether common methodologies have been suggested to address key transferability issues. Pharmacoeconomic guidelines were initially identified through the ISPOR Web site. In addition, those national guidelines not included in the ISPOR Web site, but known to us, were also considered.

RESULTS

Across 27 sets of guidelines, baseline risk and unit costs were uniformly considered to be of low transferability, while treatment effect was classified as highly transferable. Results were more variable for resource use and utilities, which were considered to have low transferability in 63% and 45% of cases, respectively. There were some differences between older and more recent guidelines in the treatment of transferability issues.

CONCLUSIONS

A growing number of jurisdictions are using guidelines for the economic evaluation of pharmaceuticals. The recommendations in existing guidelines regarding the transferability of clinical and economic data are quite diverse. There is a case for standardization in dealing with transferability issues. One important step would be to update guidelines more frequently.

The relationship between visual field loss in glaucoma and health-related quality-of-life

PURPOSE

to investigate the relationship between visual field loss and health-related quality-of-life (HRQOL) in patients with ocular hypertension (OHT) or primary open-angle glaucoma (POAG).

METHODS

we conducted a cross-sectional study among 537 OHT and POAG patients from seven hospitals in The Netherlands. Clinical information was obtained from medical files. Patients completed a questionnaire, containing generic HRQOL instruments (EQ-5D and Health Utilities Index mark 3), vision-specific National Eye Institute Visual Functioning Questionnaire (VFQ-25), and glaucoma-specific Glaucoma Quality-of-Life questionnaire (GQL-15). The impact of visual field loss on HRQOL scores was analysed with multiple linear regression analyses.

RESULTS

a relationship between mean deviation (MD) and HRQOL was found after adjusting for age, gender, visual acuity, medication side effects, laser trabeculoplasty, and glaucoma surgery. We found interaction between MD in both eyes for GQL and VFQ-25 scores. The relationship between MD and utility was non-linear, with utility only affected at MD-values below -25 dB in the better eye. Visual acuity, side effects, and glaucoma surgery independently affected HRQOL. Binocular MD and MD in the better eye had similar impacts on HRQOL, whereas MD in the worse eye had an independent effect. HRQOL was affected more by binocular defects in the inferior than in the superior hemifield.

CONCLUSION

visual field loss in progressing glaucoma is independently associated with a loss in both disease-specific and generic quality-of-life. It is important to prevent progression, both in early and in advanced glaucoma, especially in patients with inferior hemifield defects and severe defects in either eye.

Long term costs and effects of reducing the number of twin pregnancies in IVF by single embryo transfer: the TwinSing study

Background

Pregnancies induced by in vitro fertilisation (IVF) often result in twin gestations, which are associated with both maternal and perinatal complications. An effective way to reduce the number of IVF twin pregnancies is to decrease the number of embryos transferred from two to one. The interpretation of current studies is limited because they used live birth as outcome measure and because they applied limited time horizons. So far, research on long-term outcomes of IVF twins and singletons is scarce and inconclusive. The objective of this study is to investigate the short (1-year) and long-term (5 and 18-year) costs and health outcomes of IVF singleton and twin children and to consider these in estimating the cost-effectiveness of single embryo transfer compared with double embryo transfer, from a societal and a healthcare perspective.

Methods/Design

A multi-centre cohort study will be performed, in which IVF singletons and IVF twin children born between 2003 and 2005 of whom parents received IVF treatment in one of the five participating Dutch IVF centres, will be compared. Data collection will focus on children at risk of health problems and children in whom health problems actually occurred. First year of life data will be collected in approximately 1,278 children (619 singletons and 659 twin children). Data up to the fifth year of life will be collected in approximately 488 children (200 singletons and 288 twin children). Outcome measures are health status, health-related quality of life and costs. Data will be obtained from hospital information systems, a parent questionnaire and existing registries. Furthermore, a prognostic model will be developed that reflects the short and long-term costs and health outcomes of IVF singleton and twin children. This model will be linked to a Markov model of the short-term cost-effectiveness of single embryo transfer strategies versus double embryo transfer strategies to enable the calculation of the long-term cost-effectiveness.

Discussion

This is, to our knowledge, the first study that investigates the long-term costs and health outcomes of IVF singleton and twin children and the long-term cost-effectiveness of single embryo transfer strategies versus double embryo transfer strategies.

Cost-effectiveness of tailored print communication, telephone motivational interviewing, and a combination of the two: results of an economic evaluation alongside the Vitalum randomized controlled trial

BACKGROUND

The aim of the present study was to evaluate the cost-effectiveness of tailored print communication (TPC), telephone motivational interviewing (TMI), a combination of the two, and no intervention on two outcomes in adults aged 45 to 70, half of them having hypertension: increasing the number of public health guidelines met for three behaviors (physical activity and fruit and vegetable consumption), and impact on quality adjusted life years (QALYs).

METHODS

Participants (n = 1,629) from 23 Dutch general practices were randomized into one of four groups, which received 4 TPCs, 4 TMIs, 2 of each (combined), or no intervention (control), respectively. The self-reported outcomes, measured at baseline and 73 weeks follow-up (7 months after the last intervention component), were difference in total number of guidelines met at follow-up compared to baseline, and number of QALYs experienced over 73 weeks. The costs of implementing the intervention were estimated using a bottom-up approach.

RESULTS

At 73 weeks follow-up participants showed increased adherence with 0.62 (TPC), 0.40 (TMI), 0.50 (combined), and 0.26 (control) guidelines compared to baseline, and experienced 1.09, 1.08, 1.08, and 1.07 QALYs, respectively. The costs for the control group were considered to be zero. TMI was more expensive (€107 per person) than both the combined intervention (€80) and TPC (€57). The control condition was most cost-effective for lower ceiling ratios, while TPC had the highest probability of being most cost-effective for higher ceiling ratios (more than €160 per additional guideline met, and €2,851 for each individual QALY).

CONCLUSIONS

For low society's willingness to pay, the control group was most cost-effective for the number of QALYs experienced over 73 weeks. This also applied to the increase in the number of guidelines met at lower ceiling ratios, whereas at higher ceiling ratios, TPC had a higher probability of being more cost-effective than the TMI, combined or control conditions. This also seemed to apply for QALYs experienced over 73 weeks. More research is needed on the long-term efficacy of both TPC and TMI, as well as on how to increase their cost-effectiveness.

TRIAL REGISTRATION

Dutch Trial Register NTR1068.

The transferability of valuing lost productivity across jurisdictions. differences between national pharmacoeconomic guidelines

For at least two decades, there has been an intense debate on whether and how to include the value of lost productivity in economic evaluations. This debate is often reflected in pharmacoeconomic guidelines, which have been developed to indicate the methods and requirements for the design, execution, and reporting of economic evaluations in a particular country.

OBJECTIVE

To examine what various national pharmacoeconomic guidelines recommend regarding the identification, measurement, and valuation of lost productivity.

METHODS

First, the theoretical framework on how lost productivity can be identified, measured, and valued is described. Second, a summary sheet has been used to identify various pharmacoeconomic guidelines recommendations regarding the value of lost productivity.

RESULTS

Twenty-two of the 30 guidelines identified recommend performing economic evaluations using the societal perspective. Nevertheless, even if the societal perspective is recommended, it is not always clear how the value of lost productivity should be taken into account. Most guidelines recommend including the costs of absenteeism from paid and/or unpaid work. In addition, although no agreement exists on how lost productivity should be valued, none of the guidelines recommended using the US panel approach for the valuation of lost productivity.

DISCUSSION

The different recommendations hinder international transferability of the value of lost productivity. This difficulty is mainly caused by different recommendations regarding identification and valuation. These differences result from the debate and lack of consensus on including the value of lost productivity losses in economic evaluations. It will become easier to transfer data across jurisdictions if all data are reported transparently.

Association between guideline adherence and clinical outcome for patients referred for diagnostic breast imaging

OBJECTIVE

To assess the adherence to a guideline for additional breast ultrasonography in a cross-sectional survey among hospitals in The Netherlands. Furthermore, consequences of current practice non-adherence for the patient outcome of diagnostic breast imaging were studied.

METHODS

Current practice was compared with a guideline made up of three recommendations for the use of ultrasonography after mammography and three recommendations for not using ultrasonography. All patients referred for mammography to the radiology departments of the participating hospitals during 2 months in 2004 were eligible for the study. No data on the gold standard for breast cancer were analysed, but clinical consequences were estimated by using a probability model based on the data of a former prospective clinical study.

RESULTS

In total, 17 of the 66 hospitals approached were participating in the study. Of the 13,694 patients assessed for eligibility, 6457 were included. High adherence rates (81-97%, mean 94%) were observed for the recommendations, which indicate additional ultrasonography, whereas lower adherence rates (68-94%, mean 83%) were seen for the recommendations which do not advise additional ultrasonography. Overall, in all included hospitals, non-adherence would result in 27.2 false-positive and 1.1 false-negative imaging results.

CONCLUSION

Current daily practice of diagnostic breast imaging in the hospitals in this survey corresponds to a great extent to the guideline proposed. Non-adherence in current practice results in a relatively small number of false-positive and false-negative imaging results.

Modeling complex treatment strategies: construction and validation of a discrete event simulation model for glaucoma

OBJECTIVE

Discrete event simulation (DES) modeling has several advantages over simpler modeling techniques in health economics, such as increased flexibility and the ability to model complex systems. Nevertheless, these benefits may come at the cost of reduced transparency, which may compromise the model's face validity and credibility. We aimed to produce a transparent report on the construction and validation of a DES model using a recently developed model of ocular hypertension and glaucoma.

METHODS

Current evidence of associations between prognostic factors and disease progression in ocular hypertension and glaucoma was translated into DES model elements. The model was extended to simulate treatment decisions and effects. Utility and costs were linked to disease status and treatment, and clinical and health economic outcomes were defined. The model was validated at several levels. The soundness of design and the plausibility of input estimates were evaluated in interdisciplinary meetings (face validity). Individual patients were traced throughout the simulation under a multitude of model settings to debug the model, and the model was run with a variety of extreme scenarios to compare the outcomes with prior expectations (internal validity). Finally, several intermediate (clinical) outcomes of the model were compared with those observed in experimental or observational studies (external validity) and the feasibility of evaluating hypothetical treatment strategies was tested.

RESULTS

The model performed well in all validity tests. Analyses of hypothetical treatment strategies took about 30 minutes per cohort and lead to plausible health-economic outcomes.

CONCLUSION

There is added value of DES models in complex treatment strategies such as glaucoma. Achieving transparency in model structure and outcomes may require some effort in reporting and validating the model, but it is feasible.

Transferability of model-based economic evaluations: the case of trastuzumab for the adjuvant treatment of HER2-positive early breast cancer in the Netherlands

INTRODUCTION

Geographic transferability of model-based cost-effectiveness results may facilitate and shorten the reimbursement process of new pharmaceuticals. This study provides a real world example of transferring a cost-effectiveness study of trastuzumab for the adjuvant treatment of HER2-positive early breast cancer from the United Kingdom to The Netherlands.

METHODS

Three successive steps were taken. Step 1: Collect available information with regard to the original model, and assess transferability using existing checklists. Step 2: Adapt transferability-limiting factors. Step 3: Obtain a country-specific estimate of cost-effectiveness.

RESULTS

The structure of the UK model was transferable, although some of the model inputs needed adaptation. From a health-care perspective, the Dutch estimate amounted to euro5828/quality-adjusted life-year gained. From a societal perspective, the incremental cost-effectiveness ratio was dominant.

CONCLUSION

Transferability of a model-based UK-study in three steps proved to be an efficient method to provide an early indication of the cost-effectiveness of trastuzumab and has led to the provisional reimbursement of the treatment.

Impact of ankylosing spondylitis on sick leave, presenteeism and unpaid productivity, and estimation of the societal cost

Aim

To describe the influence of ankylosing apondylitis (AS) on sick leave, presenteeism and unpaid work restrictions and to estimate related productivity costs.

Methods

142 consecutive and unselected patients with AS under the care of rheumatologists participated in a longitudinal observational study and completed the Health and Labour Questionnaire (HLQ) assessing disease-related sick leave, presenteeism and restrictions in unpaid work over the previous 2 weeks. Logistic regressions explored which explanatory variables were associated with work outcome. Productivity loss was valued in monetary terms.

Results

Among 72 patients in paid employment, 12% had sick leave over a period of 2 weeks and 53% experienced an adverse influence of AS on work productivity while at work. Over this period they reported on average of 5.8 h sick leave and 2.4 inefficient working hours, for which they estimated an extra 1.9 h were needed to complete unfinished work. Among all patients (n=137), 71% had experienced restrictions in unpaid work during the previous 2 weeks with 42% needing help for these tasks for an average of 8 h. The annual production costs for the total group were €1451 (95% CI 425 to 2742) per patient for sick leave, €967 (95% CI 503 to 1496) to compensate for hours worked inefficiently while at work and €1930 (95% CI 1404 to 2471) to substitute loss of unpaid work production.

Conclusion

Patients with AS not only have substantial sick leave but also experience restrictions while being at work and when performing unpaid tasks. Limitations in physical functioning are strongly associated with work restrictions. Societal costs of formal and informal care are comparable with the costs of sick leave and presenteeism combined.

Glucosamine sulphate in the treatment of knee osteoarthritis: cost-effectiveness comparison with paracetamol

INTRODUCTION

The aim of this study was to explore the cost-effectiveness of glucosamine sulphate (GS) compared with paracetamol and placebo (PBO) in the treatment of knee osteoarthritis. For this purpose, a 6-month time horizon and a health care perspective was used.

MATERIAL AND METHODS

The cost and effectiveness data were derived from Western Ontario and McMaster Universities Osteoarthritis Index data of the Glucosamine Unum In Die (once-a-day) Efficacy trial study by Herrero-Beaumont et al. Clinical effectiveness was converted into utility scores to allow for the computation of cost per quality-adjusted life year (QALY) For the three treatment arms Incremental Cost-Effectiveness Ratio were calculated and statistical uncertainty was explored using a bootstrap simulation.

RESULTS

In terms of mean utility score at baseline, 3 and 6 months, no statistically significant difference was observed between the three groups. When considering the mean utility score changes from baseline to 3 and 6 months, no difference was observed in the first case but there was a statistically significant difference from baseline to 6 months with a p-value of 0.047. When comparing GS with paracetamol, the mean baseline incremental cost-effectiveness ratio (ICER) was dominant and the mean ICER after bootstrapping was -1376 euro/QALY indicating dominance (with 79% probability). When comparing GS with PBO, the mean baseline and after bootstrapping ICER were 3617.47 and 4285 euro/QALY, respectively.

CONCLUSION

The results of the present cost-effectiveness analysis suggested that GS is a highly cost-effective therapy alternative compared with paracetamol and PBO to treat patients diagnosed with primary knee OA.

Efficacy and cost-effectiveness of nutritional intervention in elderly after hip fracture: design of a randomized controlled trial

Background

Hip fracture patients often have an impaired nutritional status at the time of fracture, which can result in a higher complication rate, prolonged rehabilitation time and increased mortality. A study was designed to evaluate the effect of nutritional intervention on nutritional status, functional status, total length of stay, postoperative complications and cost-effectiveness.

Methods

Open-labelled, multi-centre, randomized controlled trial in hip fracture patients aged 55 years and above. The intervention group receives dietetic counselling (by regular home visits and telephone calls) and oral nutritional supplementation for three months after surgery. The control group receives usual dietetic care as provided by the hospital. Outcome assessment is performed at three and six months after hip fracture.

Discussion

Patient recruitment has started in July 2007 and has ended in December 2009. First results are expected in 2011.

Trial registration

ClinicalTrials.gov NCT00523575

Economic evaluation of online computerised cognitive-behavioural therapy without support for depression in primary care: randomised trial

BACKGROUND

Evidence about the cost-effectiveness and cost utility of computerised cognitive-behavioural therapy (CCBT) is still limited. Recently, we compared the clinical effectiveness of unsupported, online CCBT with treatment as usual (TAU) and a combination of CCBT and TAU (CCBT plus TAU) for depression. The study is registered at the Netherlands Trial Register, part of the Dutch Cochrane Centre (ISRCTN47481236).

AIMS

To assess the cost-effectiveness of CCBT compared with TAU and CCBT plus TAU.

METHOD

Costs, depression severity and quality of life were measured for 12 months. Cost-effectiveness and cost-utility analyses were performed from a societal perspective. Uncertainty was dealt with by bootstrap replications and sensitivity analyses.

RESULTS

Costs were lowest for the CCBT group. There are no significant group differences in effectiveness or quality of life. Cost-utility and cost-effectiveness analyses tend to be in favour of CCBT.

CONCLUSIONS

On balance, CCBT constitutes the most efficient treatment strategy, although all treatments showed low adherence rates and modest improvements in depression and quality of life.

[Cost-effectiveness of new drugs impacts reimbursement decision making but room for improvement]

OBJECTIVE

For new drugs to be included in appendix 1B of the drug reimbursement system, they must have proven added therapeutic value, an acceptable budget impact, and be cost-effective. To validate the latter, pharmacoeconomic evaluations have become mandatory. These evaluations should adhere to guidelines for pharmacoeconomic research. Our study evaluates: 1) the extent to which the pharmacoeconomic evaluations adherence pharmacoeconomic guidelines; 2) which guidelines are decisive in evaluating the validation of cost-effectiveness of new drugs; and 3) the impact of pharmacoeconomics in the recommendations and final decision making on drug reimbursement.

DESIGN

Retrospective, descriptive study.

METHOD

We examined all 1B requests for reimbursement submitted to the Dutch Health Care Insurance Board and the Medicinal Products Reimbursement Committee between 1 January 2005 and 30 September 2008, and on which recommendations on drug reimbursement have been published (n = 21). Data on adherence to guidelines, validation of cost-effectiveness, and recommendations and decision making on drug reimbursement were extracted from publicly available sources by two independent evaluators. Quantitatively and qualitatively descriptive analyses were carried out.

RESULTS

Since pharmacoeconomic evaluations have become mandatory, these evaluations increasingly adhere to guidelines for pharmacoeconomic research. This was particularly true of the perspective chosen, the relevant treatment comparator and the incremental and total analyses of costs and effects of the drugs under comparison. However, cost-effectiveness of new drugs was often inadequately validated by incorrect indications for drug use, and incorrect forms of evaluation or periods of analysis. In addition, costs and effects were not always correctly analysed, nor and not enough insight was provided into the analysis model used. Partially on the basis of pharmacoeconomics, 12 new drugs are reimbursed and 9 not.

CONCLUSION

Cost-effectiveness of new drugs and more valid pharmacoeconomic evaluations appear to play an ever more important role in reimbursement decision making and the pursuit of better and affordable health care.

Involving patients in cardiovascular risk management with nurse-led clinics: a cluster randomized controlled trial

BACKGROUND

Preventive guidelines on cardiovascular risk management recommend lifestyle changes. Support for lifestyle changes may be a useful task for practice nurses, but the effect of such interventions in primary prevention is not clear. We examined the effect of involving patients in nurse-led cardiovascular risk management on lifestyle adherence and cardiovascular risk.

METHODS

We performed a cluster randomized controlled trial in 25 practices that included 615 patients. The intervention consisted of nurse-led cardiovascular risk management, including risk assessment, risk communication, a decision aid and adapted motivational interviewing. The control group received a minimal nurse-led intervention. The self-reported outcome measures at one year were smoking, alcohol use, diet and physical activity. Nurses assessed 10-year cardiovascular mortality risk after one year.

RESULTS

There were no significant differences between the intervention groups. The effect of the intervention on the consumption of vegetables and physical activity was small, and some differences were only significant for subgroups. The effects of the intervention on the intake of fat, fruit and alcohol and smoking were not significant. We found no effect between the groups for cardiovascular 10-year risk.

INTERPRETATION

Nurse-led risk communication, use of a decision aid and adapted motivational interviewing did not lead to relevant differences between the groups in terms of lifestyle changes or cardiovascular risk, despite significant within-group differences.

Cost analysis of the Dutch obstetric system: low-risk nulliparous women preferring home or short-stay hospital birth--a prospective non-randomised controlled study

Background

In the Netherlands, pregnant women without medical complications can decide where they want to give birth, at home or in a short-stay hospital setting with a midwife. However, a decrease in the home birth rate during the last decennium may have raised the societal costs of giving birth. The objective of this study is to compare the societal costs of home births with those of births in a short-stay hospital setting.

Methods

This study is a cost analysis based on the findings of a multicenter prospective non-randomised study comparing two groups of nulliparous women with different preferences for where to give birth, at home or in a short-stay hospital setting. Data were collected using cost diaries, questionnaires and birth registration forms. Analysis of the data is divided into a base case analysis and a sensitivity analysis.

Results

In the group of home births, the total societal costs associated with giving birth at home were €3,695 (per birth), compared with €3,950 per birth in the group for short-stay hospital births. Statistically significant differences between both groups were found regarding the following cost categories 'Cost of contacts with health care professionals during delivery' (€138.38 vs. €87.94, -50 (2.5-97.5 percentile range (PR)-76;-25), p < 0.05), 'cost of maternity care at home' (€1,551.69 vs. €1,240.69, -311 (PR -485; -150), p < 0.05) and 'cost of hospitalisation mother' (€707.77 vs. 959.06, 251 (PR 69;433), p < 0.05). The highest costs are for hospitalisation (41% of all costs). Because there is a relatively high amount of (partly) missing data, a sensitivity analysis was performed, in which all missing data were included in the analysis by means of general mean substitution. In the sensitivity analysis, the total costs associated with home birth are €4,364 per birth, and €4,541 per birth for short-stay hospital births.

Conclusion

The total costs associated with pregnancy, delivery, and postpartum care are comparable for home birth and short-stay hospital birth. The most important differences in costs between the home birth group and the short-stay hospital birth group are associated with maternity care assistance, hospitalisation, and travelling costs.

A prospective randomized multicenter comparison on health-related quality of life: the value of add-on arrhythmia surgery in patients with paroxysmal, permanent or persistent atrial fibrillation undergoing valvular and/or coronary bypass surgery

INTRODUCTION

This is a multicenter, prospective, randomized controlled trial to determine the effect of add-on arrhythmia surgery on health-related quality of life during 1-year follow-up of cardiac surgery patients with atrial fibrillation.

METHODS

150 patients with documented atrial fibrillation were randomly assigned to undergo cardiac surgery with or without add-on surgery. Patients completed quality of life questionnaires, comprising the RAND 36-item Health Survey 1.0 (SF-36), Multidimensional Fatigue Inventory-20 (MFI-20) and EuroQoL (EQ-5D and VAS) at baseline and 3, 6, and 12 months following operation.

RESULTS

132 patients completed the questionnaires at a minimum of one time-point during follow-up. At baseline patient characteristics, operative data and health-related quality of life were comparable. At 12-month follow-up 62 patients were free of atrial fibrillation without significant differences between groups (P = 0.28). Conversion to SR occurred in 69.8% (37/53) of patients with paroxysmal AF, in 28.2% (11/39) of patients with permanent AF and in 44.4% (12/27) of patients in persistent AF. Cardiac surgery in general resulted in an overall improvement of the RAND SF-36 and the MFI-20. However, the EQ-5D showed a significant deterioration in the subscale Pain/Discomfort for both groups (P < 0.001), with a significant worse outcome for the control group (P = 0.006).

CONCLUSIONS

Health-related quality of life in patients with paroxysmal, permanent and persistent atrial fibrillation improves after cardiac surgery regardless of giving add-on surgery or not, but this improvement is presumably more affected by treating the underlying heart disease than by restoring sinus rhythm.

Cost-effectiveness of postural exercise therapy versus physiotherapy in computer screen-workers with early non-specific work-related upper limb disorders (WRULD); a randomized controlled trial

Background

Exercise therapies generate substantial costs in computer workers with non-specific work-related upper limb disorders (WRULD).

Aims

To study if postural exercise therapy is cost-effective compared to regular physiotherapy in screen-workers with early complaints, both from health care and societal perspective.

Methods

Prospective randomized trial including cost-effectiveness analysis; one year follow-up. Participants: Eighty-eight screen-workers with early non-specific WRULD; six drop-outs. Interventions: A ten week postural exercise program versus regular physiotherapy. Outcome measures: Effectiveness measures: Pain: visual analogous scale (VAS), self-perceived WRULD (yes/no). Functional outcome: Disabilities of Arm, Shoulder and Hand- Dutch Language Version (DASH-DLV). Quality of life outcome: EQ-5D.

Economic measures: health care costs including patient and family costs and productivity costs resulting in societal costs. Cost-effectiveness measures: health care costs and societal costs related to the effectiveness measures. Outcome measures were assessed at baseline; three, six and twelve months after baseline.

Results

At baseline both groups were comparable for baseline characteristics except scores on the Pain Catastrophizing Scale and comparable for costs. No significant differences between the groups concerning effectiveness at one year follow-up were found. Effectiveness scores slightly improved over time. After one year 55% of participants were free of complaints. After one year the postural exercise group had higher mean total health care costs, but lower productivity costs compared to the physiotherapy group. Mean societal costs after one year (therefore) were in favor of postural exercise therapy [- €622; 95% CI -2087; +590)]. After one year, only self- perceived WRULD seemed to result in acceptable cost-effectiveness of the postural exercise strategy over physiotherapy; however the probability of acceptable cost-effectiveness did not exceed 60%.

Considering societal costs related to QALYs, postural exercise therapy had a probability of over 80% to be cost-effective over a wide range of cost-effectiveness ceiling ratios; however based on a marginal QALY-difference of 0.1 over a 12 month time frame.

Conclusion

Although our trial failed to find significant differences in VAS, QALYs and ICERs based on VAS and QALYs at one-year follow-up, CEACs suggest that postural exercise therapy according to Mensendieck/Cesar has a higher probability of being cost-effective compared to regular physiotherapy; however further research is required.

Trial registration

ISRCTN 15872455

Clinical effectiveness of online computerised cognitive-behavioural therapy without support for depression in primary care: randomised trial

BACKGROUND

Computerised cognitive-behavioural therapy (CCBT) might offer a solution to the current undertreatment of depression.

AIMS

To determine the clinical effectiveness of online, unsupported CCBT for depression in primary care.

METHOD

Three hundred and three people with depression were randomly allocated to one of three groups: Colour Your Life; treatment as usual (TAU) by a general practitioner; or Colour Your Life and TAU combined. Colour Your Life is an online, multimedia, interactive CCBT programme. No assistance was offered. We had a 6-month follow-up period.

RESULTS

No significant differences in outcome between the three interventions were found in the intention-to-treat and per protocol analyses.

CONCLUSIONS

Online, unsupported CCBT did not outperform usual care, and the combination of both did not have additional effects. Decrease in depressive symptoms in people with moderate to severe depression was moderate in all three interventions. Online CCBT without support is not beneficial for all individuals with depression.

The transferability of economic evaluations:testing the model of Welte

OBJECTIVE

One of the existing methods to assess the transferability of economic evaluations is the model of Welte, which is a decision-chart method that includes general and specific knockout criteria and a transferability checklist. This study aims to test Welte's model with the help of a case study.

METHODS

In this study, foreign studies were transferred to The Netherlands and then compared with a Dutch reference study. In the case study, the cost-effectiveness of physiotherapy was compared with a multidisciplinary treatment. With the help of a systematic search, several foreign studies could be identified. Based on these foreign studies, two different predictions were produced for The Netherlands. In the “all studies prediction,” all foreign studies were used. In the “Welte's model prediction,” only the foreign studies were used, which passed the general and specific knockout criteria. Both predictions were compared with the Dutch reference case.

RESULTS

A total of 14 non-Dutch studies were identified. Seven studies did not pass the general knockout criteria and one study did not pass the specific knockout criteria. As a result, 14 studies were included in the “all studies prediction” and 6 studies in the “Welte's model prediction.” The predictions yielded different results and the “Welte's model prediction” proved better on costs than the “all studies prediction.”

DISCUSSION

The application of Welte's model does influence cost and effects estimates when transferring economic data between countries. However, more cases should be subjected to the Welte transferability model before a final conclusion can be drawn.

Cost-of-illness of rheumatoid arthritis and ankylosing spondylitis

OBJECTIVE

To assess, quantify and summarise the cost of illness of rheumatoid arthritis (RA) and ankylosing spondylitis (AS) from the societal perspective.

METHODS

Original studies reporting costs of RA or AS were searched systematically. Both cost-of-illness studies and economic evaluations of therapies were included. Studies were appraised for patient and study characteristics, type of costs and actual costs. Reported costs were aggregated by cost categories and overall mean costs were summarised by cost domain (healthcare, patient and family, and productivity costs).

RESULTS

Overall mean costs of RA (euro14,906 per year) were above that of AS (euro9,374 per year), while the relative distribution of costs over cost domains was approximately similar. For both diseases, productivity costs based on the human cost approach were 3 to 10 times higher than the friction costs and accounted for more than half the total costs of both diseases.

CONCLUSION

Productivity costs constitute the largest part of the total cost-off-illness of RA and AS reflecting the high burden of the disease on work participation. Although total and direct costs of illness in RA were higher than in AS, the average age of AS patients was 10 years lower and therefore, lifetime costs associated with AS may actually be equal or higher.

Healthcare financing systems for increasing the use of tobacco dependence treatment

BACKGROUND

We hypothesized that provision of financial assistance for smokers trying to quit, or reimbursement of their care providers, could lead to an increased rate of successful quit attempts.

OBJECTIVES

The primary objective of this review was to assess the impact of reducing the costs of providing or using smoking cessation treatment by health care financing interventions on abstinence from smoking and utilization of smoking cessation treatment.

SEARCH STRATEGY

We searched the Cochrane Tobacco Addiction group specialized register; the Cochrane Central Register of Controlled Trials (CENTRAL) Issue 3, 2008; MEDLINE (from January 1966 to August 2008) and EMBASE (from January 1980 to August 2008) to identify trials.

SELECTION CRITERIA

We included randomized controlled trials (RCTs) and controlled trials involving financial benefit interventions to smokers or their health care providers or both.

DATA COLLECTION AND ANALYSIS

Three reviewers independently extracted data and assessed the quality of the included studies. Rate ratios (RR) were calculated for individual studies on an intention-to-treat basis and meta-analysis was performed using a random effects model. We included economic evaluations when a study presented the costs and effects of two or more alternatives.

MAIN RESULTS

We found nine trials involving financial interventions directed at smokers and two studies directed at health care providers.There was a statistically significant favourable effect of full financial interventions directed at smokers on continuous abstinence compared to no interventions with a risk ratio (RR) of 4.38 (95% CI 1.94 to 9.87). There was also a significant effect of full financial interventions when compared to no interventions on the number of participants making a quit attempt (RR 1.19; 95% CI 1.07 to 1.32; N = 3). There was a significant effect of financial interventions directed at health care providers in increasing the utilization of behavioural interventions for smoking cessation (RR 1.33; 95% CI 1.01 to 1.77). Comparison of full benefit with partial or no benefit resulted in costs per additional quitter ranging from $260 to $1453.

AUTHORS' CONCLUSIONS

Full financial interventions directed at smokers when compared to no financial interventions could increase the proportion quitting, quit attempts and utilization of pharmacotherapy by smokers. Although the absolute differences were small the costs per additional quitter were low. The methodological qualities of the included studies need to be taken into consideration in interpreting the conclusions.

Economic evaluation of an integrated diagnostic approach for psychogeriatric patients: results of a randomized controlled trial

CONTEXT

Because of the increasing number of elderly people with dementia, the costs of dementia and dementia care are expected to grow rapidly in the coming decades. Cost-effectiveness results are relevant for decision making about new strategies in dementia care.

OBJECTIVE

To evaluate the cost-effectiveness of an integrated multidisciplinary diagnostic facility for diagnosing dementia in ambulatory psychogeriatric patients.

DESIGN

Randomized controlled trial with an economic evaluation component.

SETTING

The Maastricht Evaluation of a Diagnostic Intervention for Cognitively Impaired Elderly, Maastricht University Hospital, Maastricht, the Netherlands.

PATIENTS

A total of 137 patients who received care in the multidisciplinary diagnostic facility and 93 who received usual care.

MAIN OUTCOME MEASURES

Quality-adjusted life-years (QALYs) as the main outcome measure and cognition and behavioral problems as secondary outcome measures.

RESULTS

Compared with patients receiving usual care, patients who visited the diagnostic facility gained a mean 0.05 QALY at the extra cost of euro65. The incremental cost per QALY amounted to euro1267. This point estimate lies beneath commonly accepted thresholds and is within an acceptable range of uncertainty. With regard to the secondary analyses, cost-effectiveness results showed a substantial amount of uncertainty and were therefore indecisive.

CONCLUSION

On the basis of the main cost-per-QALY analysis, the use of the integrated multidisciplinary diagnostic facility is cost-effective for the diagnosis and management of dementia in ambulatory patients.

Value for money in changing clinical practice: should decisions about guidelines and implementation strategies be made sequentially or simultaneously?

Decisions about clinical practice change, that is, which guidelines to adopt and how to implement them, can be made sequentially or simultaneously. Decision makers adopting a sequential approach first compare the costs and effects of alternative guidelines to select the best set of guideline recommendations for patient management and subsequently examine the implementation costs and effects to choose the best strategy to implement the selected guideline. In an integral approach, decision makers simultaneously decide about the guideline and the implementation strategy on the basis of the overall value for money in changing clinical practice. This article demonstrates that the decision to use a sequential v. an integral approach affects the need for detailed information and the complexity of the decision analytic process. More importantly, it may lead to different choices of guidelines and implementation strategies for clinical practice change. The differences in decision making and decision analysis between the alternative approaches are comprehensively illustrated using 2 hypothetical examples. We argue that, in most cases, an integral approach to deciding about change in clinical practice is preferred, as this provides more efficient use of scarce health-care resources.