The cost-effectiveness of sibutramine in non-diabetic obese patients: evidence from four Western countries

Modelling the cost-effectiveness of human milk and breastfeeding in preterm infants in the United Kingdom

OBJECTIVES

To estimate the cost savings and health benefits in the UK NHS that could be achieved if human milk usage in the NICU was increased.

METHODS

A systematic review established the disease areas with the strong sources of evidence of the short, medium and long-term benefits of human milk for preterm infants as opposed to the use of formula milk. The analysis assessed the economic impact of reducing rates of necrotising enterocolitis, sepsis, sudden infant death syndrome, leukaemia, otitis media, obesity and neurodevelopmental impairment.

RESULTS

Based on the number of preterm babies born in 2013, if 100% of premature infants being fed mother's milk could be achieved in the NICU, the total lifetime cost savings to the NHS due to improved health outcomes is estimated to be £46.7 million (£30.1 million in the first year) with a total lifetime QALY gain of 10,594, There would be 238 fewer deaths due to neonatal infections and SIDS, resulting in a reduction of approximately £153.4 million in lifetime productivity. Sensitivity analyses indicated that results were robust to a wide range of inputs.

CONCLUSIONS

This analysis established that increasing the use of human milk in NICUs in the UK would lead to cost savings to the NHS. More research is needed on the medium and long term health and economic outcomes associated with breastfeeding preterm infants, and the differences between mother's own and donor breast milk.

The cost-effectiveness of the LighterLife weight management programme as an intervention for obesity in England

LighterLife Total is a very low calorie diet total dietary replacement weight reduction programme that provides Foodpacks, behavioural change therapy and group support appropriate for people with a body mass index of 30 kg m(-2) or above. A model was built to assess the cost-effectiveness of LighterLife Total, compared with (i) no treatment, Counterweight, Weight Watchers and Slimming World, as a treatment for obesity in those with a body mass index of 30 kg m(-2) or above, and (ii) no treatment, gastric banding and gastric bypass in those with a body mass index of 40 kg m(-2) or above. Change in body mass index over time was modelled, and prevalence of comorbidities (diabetes, coronary heart disease and colorectal cancer) was calculated. Costs (of intervention and treatment for comorbidities) and quality-adjusted life years were calculated. LighterLife Total was cost-effective against no treatment, Counterweight, Weight Watchers and Slimming World in the 30+ kg m(-2) group (incremental cost-effectiveness ratios: £11 895, £12 453, £12 585 and £12 233, respectively). In the 40+ kg m(-2) group, LighterLife Total was cost-effective against no treatment (incremental cost-effectiveness ratio: £4356), but less effective than gastric banding and bypass.

Modelling the economics of type 2 diabetes mellitus prevention: a literature review of methods

Our objective was to review modelling methods for type 2 diabetes mellitus prevention cost-effectiveness studies. The review was conducted to inform the design of a policy analysis model capable of assisting resource allocation decisions across a spectrum of prevention strategies. We identified recent systematic reviews of economic evaluations in diabetes prevention and management of obesity. We extracted studies from two existing systematic reviews of economic evaluations for the prevention of diabetes. We extracted studies evaluating interventions in a non-diabetic population with type 2 diabetes as a modelled outcome, from two systematic reviews of obesity intervention economic evaluations. Databases were searched for studies published between 2008 and 2013. For each study, we reviewed details of the model type, structure, and methods for predicting diabetes and cardiovascular disease. Our review identified 46 articles and found variation in modelling approaches for cost-effectiveness evaluations for the prevention of type 2 diabetes. Investigation of the variables used to estimate the risk of type 2 diabetes suggested that impaired glucose regulation, and body mass index were used as the primary risk factors for type 2 diabetes. A minority of cost-effectiveness models for diabetes prevention accounted for the multivariate impacts of interventions on risk factors for type 2 diabetes. Twenty-eight cost-effectiveness models included cardiovascular events in addition to type 2 diabetes. Few cost-effectiveness models have flexibility to evaluate different intervention types. We conclude that to compare a range of prevention interventions it is necessary to incorporate multiple risk factors for diabetes, diabetes-related complications and obesity-related co-morbidity outcomes.

The impact of weight loss on health-related quality-of-life: implications for cost-effectiveness analyses

PURPOSE

To assess the impact of weight loss on health-related quality-of-life (HRQL), to describe the factors associated with improvements in HRQL after weight loss, and to assess the relationship between obesity as assessed by body mass index (BMI) and HRQL before and after weight loss.

METHODS

We studied 188 obese patients with BMI ≥ 32 kg/m(2) with one or more comorbidities or ≥35 kg/m(2). All patients had baseline and follow-up assessments of BMI and HRQL using the EuroQol (EQ-5D) and its visual analog scale (VAS) before and after 6 months of medical weight loss that employed very low-calorie diets, physical activity, and intensive behavioral counseling.

RESULTS

At baseline, age was 50 ± 8 years (mean ± SD), BMI was 40. 0 ± 5.0 kg/m(2), EQ-5D-derived health utility score was 0.85 ± 0.13, and VAS-reported quality-of-life was 0.67 ± 0.18. At 6-month follow-up, BMI decreased by 7.0 ± 3.2 kg/m(2), EQ-5D increased by 0.06 [interquartile range (IQR) 0.06-0.17], and VAS increased by 0.14 (IQR 0.04-0.23). In multivariate analyses, improvement in EQ-5D and VAS were associated with lower baseline BMI, greater reduction in BMI at follow-up, fewer baseline comorbidities, and lower baseline HRQL. For any given BMI category, EQ-5D and VAS tended to be higher at follow-up than at baseline.

CONCLUSION

Measured improvements in HRQL between baseline and follow-up were greater than predicted by the reduction in BMI at follow-up. If investigators use cross-sectional data to estimate changes in HRQL as a function of BMI, they will underestimate the improvement in HRQL associated with weight loss and underestimate the cost-utility of interventions for obesity treatment.

A systematic review and critical assessment of health state utilities: weight change and type 2 diabetes mellitus

OBJECTIVE

The study aimed to conduct a systematic literature search to identify health state utilities for weight change in type 2 diabetes mellitus (T2DM) and to review those values for appropriateness for inclusion in a submission to the National Institute for Health and Clinical Excellence (NICE).

METHODS

The search was conducted using keywords and Medical Subject Heading (MeSH) terms designed to exhaustively capture health state utility values across a variety of known economic, health technology assessment and peer-reviewed publication databases. The values were then critically reviewed from the perspective of the NICE reference case (2008 methods guide).

RESULTS

The search resulted in a large number of repeat references across databases suggesting good sensitivity. Thirty-three articles were selected for inclusion and subjected to a critical review including their methodological quality, symmetry with the NICE reference case, sample size and country source. This critical review led to a shortlist of nine utility studies, all of which had potential for inclusion in cost-utility models or a meta-analysis.

CONCLUSIONS

A relatively large number of utilities have been collected in weight change and T2DM. Many of these utility values are not suitable for inclusion in a NICE submission. A better way of reviewing the methodological quality of utilities is needed.

An economic evaluation of adaptive e-learning devices to promote weight loss via dietary change for people with obesity

Background

The prevalence of obesity is over 25 % in many developed countries. Obesity is strongly associated with an increased risk of fatal and chronic conditions such as cardiovascular disease and type 2 diabetes. Therefore it has become a major public health concern for many economies. E-learning devices are a relatively novel approach to promoting dietary change. The new generation of devices are ‘adaptive’ and use interactive electronic media to facilitate teaching and learning. E-Learning has grown out of recent developments in information and communication technology, such as the Internet, interactive computer programmes, interactive television and mobile phones. The aim of this study is to assess the cost-effectiveness of e-learning devices as a method of promoting weight loss via dietary change.

Methods

An economic evaluation was performed using decision modelling techniques. Outcomes were expressed in terms of Quality-Adjusted Life-Years (QALYs) and costs were estimated from a health services perspective. All parameter estimates were derived from the literature. A systematic review was undertaken to derive the estimate of relative treatment effect.

Results

The base case results from the e-Learning Economic Evaluation Model (e-LEEM) suggested that the incremental cost-effectiveness ratio was approximately £102,000 per Quality-Adjusted Life-Year (QALY) compared to conventional care. This finding was robust to most alternative assumptions, except a much lower fixed cost of providing e-learning devices. Expected value of perfect information (EVPI) analysis showed that while the individual level EVPI was arguably negligible, the population level value was between £37 M and £170 M at a willingness to pay between £20,000 to £30,000 per additional QALY.

Conclusion

The current economic evidence base suggests that e-learning devices for managing the weight of obese individuals are unlikely to be cost-effective unless their fixed costs are much lower than estimated or future devices prove to be much more effective.

Changes in body weight and food choice in those attempting smoking cessation: a cluster randomised controlled trial

BACKGROUND

Fear of weight gain is a barrier to smoking cessation and significant cause of relapse for many people. The provision of nutritional advice as part of a smoking cessation programme may assist some in smoking cessation and perhaps limit weight gain. The aim of this study was to determine the effect of a structured programme of dietary advice on weight change and food choice, in adults attempting smoking cessation.

METHODS

Cluster randomised controlled design. Classes randomised to intervention commenced a 24-week intervention, focussed on improving food choice and minimising weight gain. Classes randomised to control received "usual care".

RESULTS

Twenty-seven classes in Greater Glasgow were randomised between January and August 2008. Analysis, including those who continued to smoke, showed that actual weight gain and percentage weight gain was similar in both groups. Examination of data for those successful at giving up smoking showed greater mean weight gain in intervention subjects (3.9 (SD 3.1) vs. 2.7 (SD 3.7) kg). Between group differences were not significant (p = 0.23, 95% CI -0.9 to 3.5). In comparison to baseline improved consumption of fruit and vegetables and breakfast cereal were reported in the intervention group. A higher percentage of control participants continued smoking (74% vs. 66%).

CONCLUSIONS

The intervention was not successful at minimising weight gain in comparison to control but was successful in facilitating some sustained improvements in the dietary habits of intervention participants. Improved quit rates in the intervention group suggest that continued contact with advisors may have reduced anxieties regarding weight gain and encouraged cessation despite weight gain. Research should continue in this area as evidence suggests that the negative effects of obesity could outweigh the health benefits achieved through reductions in smoking prevalence.

Economic evaluation of lifestyle interventions for preventing diabetes and cardiovascular diseases

Lifestyle interventions (i.e., diet and/or physical activity) are effective in delaying or preventing the onset of diabetes and cardiovascular disease. However, policymakers must know the cost-effectiveness of such interventions before implementing them at the large-scale population level. This review discusses various issues (e.g., characteristics, modeling, and long-term effectiveness) in the economic evaluation of lifestyle interventions for the primary and secondary prevention of diabetes and cardiovascular disease. The diverse nature of lifestyle interventions, i.e., type of intervention, means of provision, target groups, setting, and methodology, are the main obstacles to comparing evaluation results. However, most lifestyle interventions are among the intervention options usually regarded as cost-effective. Diabetes prevention programs, such as interventions starting with targeted or universal screening, childhood obesity prevention, and community-based interventions, have reported favorable cost-effectiveness ratios.

An evaluation of the genotoxic and cytotoxic effects of the anti-obesity drugs sibutramine and fenproporex

Anti-obesity medications deserve special considerations at the present time due to an increasing number of overweight and obese people who require these therapeutic alternatives. Obesity is positively associated with several chronic illnesses, including cancer. In this work, we evaluated the possible genotoxic and/or cytotoxic actions of two drugs, sibutramine and fenproporex, in the doses of 10, 20 and 40 mg/kg body weight (bw), administered intraperitoneally in male Swiss mice. The genotoxic effect was analyzed by comet assay and micronucleus test. We found that both drugs increased the frequency of genotoxic damage in Swiss mice, but did not present cytotoxic activities towards the polychromatic erythrocytes of the bone marrow of these animals.

Cost-effectiveness of pharmacological anti-obesity treatments: a systematic review

AIM

To review economic evaluations of weight loss drugs and compare reported incremental cost-effectiveness ratios (ICERs).

METHODS

A literature search was conducted for cost-effectiveness (CEAs) and cost-utility analyses (CUAs) of sibutramine, orlistat and rimonabant.

RESULTS

Fourteen unique articles were identified (11 CUAs and 3 CEAs; 9 orlistat, 4 sibutramine and 1 rimonabant). All used diet and exercise as comparator, whereas none included indirect costs. Time horizons varied from treatment period only (1-4 years) to 80 years (median 7.5 years). Longer studies modeled effects on diabetes, micro- and macrovascular complications, coronary heart disease and death. Of the CUAs, the median ICER was 16,000 euro(2007)/QALY (quality-adjusted life-year; range 10,000-88,000), with the worst cost-effectiveness when recommended stop rules for non-responding patients were not applied. All studies but three were funded by the manufacturing company, and the median ICER was considerably higher for independent than for sponsored analyses (62,000 euro vs 15,000 euro/QALY). However, two of the three independent CUAs did not use recommended stop rules, as compared with one of eight manufacturer-sponsored analyses. The results were most sensitive to assumptions regarding weight loss sustainability and utility per kilogram lost. Side effects and dropout because of reasons other than lack of efficacy were generally not incorporated.

CONCLUSION

Published economic evaluations indicate that orlistat, sibutramine and rimonabant are within the range of what is generally regarded as cost-effective. Uncertainty remains about weight loss sustainability, utility gain associated with weight loss and extrapolations from transient weight loss to long-term health benefits. Modeling of head-to-head comparisons and attrition is needed, as are analyses conducted independently of manufacturing companies.