SPACE FOR COPD delivered as a maintenance programme on pulmonary rehabilitation discharge: protocol of a randomised controlled trial evaluating the long-term effects on exercise tolerance and mental well-being

INTRODUCTION

The benefits achieved during pulmonary rehabilitation (PR) are known to be sustained for 6-12 months after the initial programme. Several maintenance trials have been conducted but were heterogeneous in terms of duration, frequency and labour cost. There is no consensus on one best strategy. SPACE FOR COPD (Self-management Programme of Activity, Coping and Education for Chronic Obstructive Pulmonary Disease) is a home-based self-management programme, which has been shown previously to be effective in primary and secondary care settings and is to be tested here as a maintenance programme. The aim is to evaluate the efficacy of the SPACE FOR COPD programme (manual and group sessions), on exercise tolerance and mental well-being, compared with usual care following PR in patients with COPD.

METHODS AND ANALYSIS

A prospective, multicentre, single-blinded randomised controlled trial requiring 116 participants with a clinical diagnosis of COPD who have finished PR within 4 weeks will be randomised 1:1 to either a usual care group or a SPACE FOR COPD programme group. The intervention comprises a home-based manual and 4, 2-hour group sessions adopting motivational interviewing techniques over 12 months. The primary outcome is endurance capacity measured by the Endurance Shuttle Walking Test at 12 months. Secondary outcomes are: maximal exercise capacity, health-related quality of life, mood, patient activation, physical activity, lung function and healthcare costs. The measures will be taken at baseline, 6 and 12 months. Patient interviews and staff focus groups will be conducted to explore barriers, facilitators and views about the intervention at the end of the study. A framework analysis will be used for the interpretation of qualitative data.

ETHICS AND DISSEMINATION

The trial was granted ethical approval from Health Research Authority and Health and Care Research Wales (HCRW19/EM/0267 on 10 October 2019). Results will be made available to all stakeholders through a dissemination event, conferences and peer-reviewed publications.

TRIAL REGISTRATION NUMBER

ISRCTN30110012.

Guidelines for composing and assessing a paper on the treatment of pain: A practical application of evidence-based medicine principles to a cost-effectiveness analysis of the MINT randomized clinical trials

Objective

Apply established principles of evidence-based medicine to the interpretation of the cost-effectiveness analysis related to the MINT Randomized Clinical Trials (RCTs).

Design

Editorial.

Methods

Spine Intervention Society's guidelines for assessing studies on the treatment of pain were applied to a published cost-effectiveness analysis of radiofrequency denervation data from the MINT RCTs.

Results

Application of evidence-based medicine principles reveals the MINT RCTs' major deficiencies in patient selection, diagnostic paradigm, radiofrequency neurotomy technique, co-interventions, outcome measurement, power analysis study sample characteristics, data analysis, and loss to follow-up; which marginalizes the generalizability and conclusions of the cost-effectiveness analysis.

Conclusions

The cost analysis performed in "Cost-Effectiveness of Radiofrequency Denervation for Patients With Chronic Low Back Pain: The MINT Randomized Clinical Trials" is based on the MINT RCTs results. The MINT RCTs significant metholodological design flaws, lead to issues in validty for the subsequent cost-effectiveness analysis. Application of the cost-effective analysis to patient care paradigms should be limited given the concerns with validity.

"Time Traveling Is Just Too Dangerous" but Some Methods Are Worth Revisiting: The Advantages of Expected Loss Curves Over Cost-Effectiveness Acceptability Curves and Frontier

BACKGROUND

Cost-effectiveness acceptability curves (CEACs) and the cost-effectiveness acceptability frontier (CEAF) are the recommended graphical representations of uncertainty in a cost-effectiveness analysis (CEA). Nevertheless, many limitations of CEACs and the CEAF have been recognized by others. Expected loss curves (ELCs) overcome these limitations by displaying the expected foregone benefits of choosing one strategy over others, the optimal strategy in expectation, and the value of potential future research all in a single figure.

OBJECTIVES

To revisit ELCs, illustrate their benefits using a case study, and promote their adoption by providing open-source code.

METHODS

We used a probabilistic sensitivity analysis of a CEA comparing 6 cerebrospinal fluid biomarker test-and-treat strategies in patients with mild cognitive impairment. We showed how to calculate ELCs for a set of decision alternatives. We used the probabilistic sensitivity analysis of the case study to illustrate the limitations of currently recommended methods for communicating uncertainty and then demonstrated how ELCs can address these issues.

RESULTS

ELCs combine the probability that each strategy is not cost-effective on the basis of current information and the expected foregone benefits resulting from choosing that strategy (ie, how much is lost if we recommended a strategy with a higher expected loss). ELCs display how the optimal strategy switches across willingness-to-pay thresholds and enables comparison between different strategies in terms of the expected loss.

CONCLUSIONS

ELCs provide a more comprehensive representation of uncertainty and overcome current limitations of CEACs and the CEAF. Communication of uncertainty in CEA would benefit from greater adoption of ELCs as a complementary method to CEACs, the CEAF, and the expected value of perfect information.

[Cost-effectiveness analysis of sofosbuvir, peginterferon and ribavirin in patients with chronic hepatitis C: Early treatment in the initial stage of fibrosis vs. delayed treatment in advanced fibrosis]

AIMS

Cost-effectiveness analysis of sofosbuvir combined with peginterferon alpha-2a and ribavirin (SOF/Peg-IFN/RBV) in early versus advanced fibrosis in previously untreated patients with chronic hepatitis C genotype 1 (CHC-GT1), from the perspective of the Spanish National Health System (NHS).

METHODS

A Markov model was developed to compare lifetime costs and outcomes (life years gained [LYGs] and quality-adjusted life years [QALYs]) of 2 treatment strategies: SOF/Peg-IFN/RBV administered during early fibrosis (mild-moderate fibrosis; F2-F3) or advanced fibrosis (cirrhosis; F4). Efficacy (sustained virologic response), annual transition probabilities, disease management costs and utilities were obtained from the literature. Costs and outcomes were discounted annually at 3%. Direct costs were considered, expressed in Euros (€, 2014). Probabilistic sensitivity analysis (PSA) was also performed.

RESULTS

SOF/Peg-IFN/RBV therapy at F2-F3 was more effective (19.12 LYGs and 14.14 QALYs) compared to F4. In a cohort of 1,000 patients, SOF/Peg-IFN/RBV prevented 66 cases of decompensated cirrhosis, 60 hepatocellular carcinomas and 4 liver transplantations compared with therapy in advanced fibrosis. The total lifetime cost of early therapy (€43,263) was less than the cost of treatment in the advanced stage (€49,018). Early therapy was a dominant strategy, more effective and less costly in all simulations. In the PSA analysis, administration of SOF/PEG-IFN/RBV at F2-F3 was dominant in all simulations.

CONCLUSIONS

Starting SOF/Peg-IFN/RBV therapy at F2-F3, compared with therapy at F4, reduced the incidence of liver disease complications and was associated with cost savings for the Spanish NHS in CHC-GT1 patients.

Cost-effectiveness acceptability curves revisited

Since the introduction of the cost-effectiveness acceptability curve (CEAC) in 1994, its use as a method to describe uncertainty around incremental cost-effectiveness ratios (ICERs) has steadily increased. In this paper, first the construction and interpretation of the CEAC is explained, both in the context of modelling studies and in the context of cost-effectiveness (CE) studies alongside clinical trials. Additionally, this paper reviews the advantages and limitations of the CEAC. Many of the perceived limitations can be attributed to the practice of interpreting the CEAC as a decision rule while it was not developed as such. It is argued that the CEAC is still a useful tool in describing and quantifying uncertainty around the ICER, especially in combination with other tools such as plots on the CE plane and value-of-information analysis.

Cost-utility analyses of diagnostic laboratory tests: a systematic review

OBJECTIVE

To review and evaluate the literature of cost-utility analyses (CUAs) regarding diagnostic laboratory testing.

METHODS

We reviewed all articles related to diagnostic laboratory testing in the Tufts Medical Center Cost-Effectiveness Analysis Registry (www.cearegistry.org), which contains detailed information on over 2000 published CUAs through 2008. We analyzed the extent to which the studies adhered to recommended practices for conducting and reporting cost-effectiveness analyses. We also recorded whether the studies contained information on diagnostic test accuracy and costs, and whether any account was taken of potential benefits or harms of testing that are unrelated to subsequent treatment, such as the reassurance value of testing.

RESULTS

We identified 141 published CUAs pertaining to diagnostic laboratory testing published through 2008 which contained 433 separate incremental cost-effectiveness ratios. Prior to 2000, there were only 20 CUAs published, but the number averaged 13.4 annually thereafter. Most studies focused on hematology/oncology (n = 42, 30%) and obstetrics/gynecology (n = 36, 26%) applications. Approximately 63% (n = 89) of studies clearly reported information about the accuracy of the test, but only 10% (n = 14) mentioned test safety or possible risks. A small number (n = 10, 7%) mentioned or considered the potential value or harm of testing unrelated to treatment consequences. Over 55% of the reported incremental cost-effectiveness ratios (ICERs) were either dominant (more quality-adjusted life years for less cost), or below $50,000 per quality-adjusted life years gained (in 2008 US dollars).

CONCLUSION

The number of CUAs investigating laboratory diagnostic testing has increased substantially with applications to diverse clinical areas. The literature reveals many areas in which testing represents good value for money. The vast majority of studies have not considered preferences for test information unrelated to treatment consequences.

Assessing costs and potential returns of evidence-based programs for seniors

The authors describe the customary tools used by health services researchers to conduct economic evaluations of health interventions. Recognizing the inherent challenges of these tools for utilization in contemporary public health practice, we recommend a practical cost-benefit analysis (PCBA) to allow public health practitioners to assess the economic merits of their existing public health programs. The PCBA estimates what health effects and corresponding medical cost avoidance would be required to support the costs associated with implementing a community-based prevention program. We apply the PCBA to evaluate a statewide evidence-based falls prevention program for seniors in Texas. We estimate a positive return on realized costs due to avoided direct and indirect medical expenses if the program averts 7 falls among 140 participants within the first year. While acknowledging the demonstrated health-related benefits of public health interventions, we provide a practical ex-post economic evaluation methodology to assess return on investment as a more simplistic yet effective alternative for public health practitioners versus contemporary analyses of health services researchers.