Simulation-based estimates of effectiveness and cost-effectiveness of smoking cessation in patients with chronic obstructive pulmonary disease

A cost-effectiveness analysis of national smoking cessation services among chronic obstructive pulmonary disease patients in Thailand

AIMS

Thailand's national smoking cessation services (FAH-SAI clinics) were founded in 2010. A cost-effectiveness analysis (CEA) is needed to inform policymakers of the allocation and prioritization of the limited budget to maximize the value for money of reimbursing these services. Chronic obstructive pulmonary disease (COPD) patients would benefit from smoking cessation services. Therefore, this study aimed to assess the cost-effectiveness of these multidisciplinary services compared to the usual care among COPD patients in Thailand from a societal perspective.

METHODS

We conducted a CEA from a societal perspective using a Markov model to simulate lifetime costs and quality-adjusted life years (QALYs) gained by each smoking cessation intervention over the patient's lifetime. We derived the effectiveness of the smoking cessation services from a multicenter, longitudinal study of smoking cessation services in Thailand and estimated the natural quit rate, transition probabilities, health utility, and cost data from the published literature. Costs and outcomes were discounted at 3%. Sensitivity analyses were performed.

RESULTS

Compared to the usual care, FAH-SAI clinics were associated with higher costs (4,207 THB (US$133)) and improved QALYs (0.11), with an incremental cost-effectiveness ratio of 37,675 THB/QALY (US$1,187/QALY). The effectiveness of FAH-SAI clinics was a key driver of the cost-effectiveness results. At the willingness-to-pay (WTP) threshold of 160,000 THB (US$5,042) per QALY gained, the probability of being cost-effective was 96.5%.

CONCLUSIONS

FAH-SAI clinics were cost-effective under Thailand's WTP threshold. Our results could inform policymakers in allocating resources to support smoking cessation services for COPD patients in Thailand.

Cost-effectiveness of integrated disease management for high risk, exacerbation prone, patients with chronic obstructive pulmonary disease in a primary care setting

Background

We evaluate the cost-effectiveness of the ‘Best Care’ integrated disease management (IDM) program for high risk, exacerbation prone, patients with chronic obstructive pulmonary disease (COPD) compared to usual care (UC) within a primary care setting from the perspective of a publicly funded health system (i.e., Ontario, Canada).

Methods

We conducted a model-based, cost-utility analysis using a Markov model with expected values of costs and outcomes derived from a Monte-Carlo Simulation with 5000 replications. The target population included patients started in GOLD II with a starting age of 68 years in the trial-based analysis. Key input parameters were based on a randomized control trial of 143 patients (i.e., UC (n = 73) versus IDM program (n = 70)). Results were shown as incremental cost per quality-adjusted life year (QALY) gained.

Results

The IDM program for high risk, exacerbation prone, patients is dominant in comparison with the UC group. After one year, the IDM program demonstrated cost savings and improved QALYs (i.e., UC was dominated by IDM) with a positive net-benefit of $5360 (95% CI: ($5175, $5546) based on a willingness to pay of $50,000 (CAN) per QALY.

Conclusions

This study demonstrates that the IDM intervention for patients with COPD in a primary care setting is cost-effective in comparison to the standard of care. By demonstrating the cost-effectiveness of IDM, we confirm that investment in the delivery of evidence based best practices in primary care delivers better patient outcomes at a lower cost than UC.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12962-022-00377-w.

I.

Interventions that can reduce the frequency and severity of exacerbations in patients who suffer from COPD have the potential to reduce the financial burden of COPD on the health system;

II.

This is the first study that demonstrates the cost-effectiveness of integrated disease management for patients who suffer from COPD within a primary care environment;

III.

This study makes the case for embedding Certified Respiratory Educators (CREs) within the primary care environment to improve the quality of life of patients who suffer from COPD, as well as alleviating unnecessary health services utilization and decreasing the overall financial burden of the disease on the health system.

Cost-effectiveness of domiciliary non-invasive ventilation in patients with chronic obstructive pulmonary disease

BACKGROUND

Chronic obstructive pulmonary disease (COPD) is a chronic disease associated with recurring exacerbations, which influence morbidity and mortality for the patient, while placing significant resource burdens on healthcare systems. Non-invasive ventilation (NIV) in a domiciliary setting can help prevent admissions, but the economic evidence to support NIV use is limited.

METHODS

A Markov model-based cost-utility analysis from the UK National Health Service perspective compared the cost-effectiveness of domiciliary NIV with usual care for two end-stage COPD populations; a stable COPD population commencing treatment with no recent hospital admission; and a posthospital population starting treatment following admission to hospital for an exacerbation. Hospitalisation rates in patients receiving domiciliary NIV compared with usual care were derived from randomised controlled studies in a recent systematic review. Other model parameters were updated with recent evidence.

RESULTS

At the threshold of £20 000 per quality-adjusted life-year (QALY) domiciliary NIV is 99.9% likely cost-effective in a posthospital population, but unlikely (4%) to be cost-effective in stable populations. The incremental cost-effective ratio (ICER) was £11 318/QALY gained in the posthospital population and £27 380/QALY gained in the stable population. Cost-effectiveness estimates were sensitive to longer-term readmission and mortality risks, and duration of benefit from NIV. Indeed, for stable Global Initiative for Chronic Obstructive Lung Disease (GOLD) for stage 4 patients, or with higher mortality and exacerbation risks, ICERs were close to the £20 000/QALY threshold.

CONCLUSION

Domiciliary NIV is likely cost-effective for posthospitalised patients, with uncertainty around the cost-effectiveness of domiciliary NIV in stable patients with COPD on which further research should focus.

Operational Modeling with Health Economics to Support Decision Making for COPD Patients

OBJECTIVE

To assess the impact of interventions for improving the management of chronic obstructive pulmonary disease (COPD), specifically increased use of pulmonary rehabilitation (PR) on patient outcomes and cost-benefit analysis.

DATA SOURCES

We used the national Hospital Episode Statistics (HES) datasets in England, local data and experts from the hospital setting, National Prices and National Tariffs, reports and the literature around the effectiveness of PR programs.

STUDY DESIGN

The COPD pathway was modeled using discrete event simulation (DES) to capture the patient pathway to an adequate level of detail as well as randomness in the real world. DES was further enhanced by the integration of a health economic model to calculate the net benefit and cost of treating COPD patients based on key sets of interventions.

DATA COLLECTION/EXTRACTION METHODS

A total of 150 input parameters and 75 distributions were established to power the model using the HES dataset, outpatient activity data from the hospital and community services, and the literature.

PRINCIPAL FINDINGS

The simulation model showed that increasing referral to PR (by 10%, 20%, or 30%) would be cost-effective (with a benefit-cost ratio of 5.81, 5.95, and 5.91, respectively) by having a positive impact on patient outcomes and operational metrics. Number of deaths, admissions, and bed days decreased (ie, by 3.56 patients, 4.90 admissions, and 137.31 bed days for a 30% increase in PR referrals) as well as quality of life increased (ie, by 5.53 QALY among 1540 patients for the 30% increase).

CONCLUSIONS

No operational model, either statistical or simulation, has previously been developed to capture the COPD patient pathway within a hospital setting. To date, no model has investigated the impact of PR on COPD services, such as operations, key performance, patient outcomes, and cost-benefit analysis. The study will support policies around extending availability of PR as a major intervention.

The long-term outcomes of tobacco control strategies based on the cognitive intervention for smoking cessation in COPD patients

OBJECTIVE

To evaluate the long-term efficacy of tobacco control strategies based on cognitive intervention for smoking cessation in chronic obstructive pulmonary disease (COPD) patients, and to provide basis for clinical practice.

MATERIALS AND METHODS

102 COPD patients with a long-term history of smoking from the outpatient clinic were recruited in the study. These smokers were randomly divided into intervention group and control group. The intervention group received a cognitive intervention containing individual consultation, telephone follow-ups and self-help materials, etc. The prevalence of quitting smoking, acute exacerbation (AE), lung function and survival were compared in the groups in 10 years.

RESULTS

There were significant differences between the intervention group and the control group in the rate of persistent quitting smoking in half a year (17.6% vs 3.9%) (P < 0.05), the rate of quitting smoking at the 6th month (58.8% vs 33.3%) (P < 0.05). After 3 months (P < 0.01) and 6 months (P < 0.01), the difference in body weight between the intervention group and the control group was statistically significant. Intervention-group patients had fewer AE per year (P < 0.01) and higher FEV1/FVC ratio (P < 0.01) after 5-year and 10-year follow-up. Besides, the FEV1% predicted in the intervention patients was higher than that in control group after 10-year follow-up. The ages of patients in the death group were greater than those in the survival group. Death-group patients had longer smoking times, higher smoking index, and later onset of COPD symptoms. Death-group patients had lower FEV1% predicted (P < 0.05) and FEV1/FVC ratio (P < 0.01). During 10-year follow-up, 30 patient deaths were recorded (the control group: n = 48; 19 deaths, and intervention group: n = 46; 11 deaths), and patients in the control group had lower survival than those in the intervention group. (P < 0.05).

CONCLUSION

The method of quitting smoking based on cognitive intervention is an effective way for COPD patients to quit smoking successfully. Quitting smoking can slower deterioration in lung function and improve the survival of COPD patients.

CLINICAL TRIAL REGISTRATION NUMBER

ChiCTR2000031239 (Chinese clinical trial registry).

Predictive Value of Combining Inflammatory Biomarkers and Rapid Decline of FEV1 for COPD in Chinese Population: A Prospective Cohort Study

Background

In China, the high prevalence and mortality rate of Chronic Obstructive Pulmonary Disease (COPD) and the poor intervention effect makes it into a heavy social burden. The main reason is that the current diagnosis of COPD mainly based on the static lung function, which is difficult for early intervention. Through matching a predictive model for high-risk groups of COPD that rewards FEV₁ rapid decline as the core, we will establish the early warning model and prove its validity and socio-economic value.

Methods

This is a multi-center, prospective, cohort study. A total of 10,000 people aged 40∼75 without lung disease will be recruited and followed for 3 years. Some questionnaires such as St George’s Respiratory Questionnaire (SGRQ), income class, educational level, comorbidity, smoking habit, and biomass smoke exposure history will be collected. The baseline level of Interleukin 6 (IL-6), high-sensitivity C-reactive Protein (hs-CRP), microRNAs-23a (miR-23a) in peripheral blood and pH value in exhaled breath condensate (EBC) will be measured, lung spirometry will be tested in the first, second, and fourth years. Primary outcome is the incidence of COPD, multivariate regression analysis will be used to establish the predictive model for COPD in China.

Discussion

With the rapid decline of lung function as the core and the baseline inflammatory biomarkers in peripheral blood and pH of the exhaled breath condensate as affecting factors, a predictive model to achieve early detection of high-risk COPD groups will be established and promoted.

Trial registration

This study has been registered at www.ClinicalTrials.gov (registration identifier: NCT03532893) on 21 May 2018, https://register.clinicaltrials.gov.

Is stratification testing for treatment of chronic obstructive pulmonary disease exacerbations cost-effective in primary care? an early cost-utility analysis

Objectives

Patients with chronic obstructive pulmonary disease (COPD) who experience acute exacerbations usually require treatment with oral steroids or antibiotics, depending on the etiology of the exacerbation. Current management is based on clinician's assessment and judgement, which lacks diagnostic accuracy and results in overtreatment. A test to guide these decisions in primary care is in development. We developed an early decision model to evaluate the cost-effectiveness of this treatment stratification test in the primary care setting in the United Kingdom.

Methods

A combined decision tree and Markov model was developed of COPD progression and the exacerbation care pathway. Sensitivity analysis was carried out to guide technology development and inform evidence generation requirements.

Results

The base case test strategy cost GBP 423 (USD 542) less and resulted in a health gain of 0.15 quality-adjusted life-years per patient compared with not testing. Testing reduced antibiotic prescriptions by 30 percent, potentially lowering the risk of antimicrobial resistance developing. In sensitivity analysis, the result depended on the clinical effects of treating patients according to the test result, as opposed to treating according to clinical judgement alone, for which there is limited evidence. The results were less sensitive to the accuracy of the test.

Conclusions

Testing may be cost-saving in primary care, but this requires robust evidence on whether test-guided treatment is effective. High quality evidence on the clinical utility of testing is required for early modeling of diagnostic tests generally.

Modelling a budgetary impact analysis for funding drug-based smoking cessation therapies for patients with major depressive disorder in Spain

BACKGROUND

Smoking is associated with high healthcare resource utilisation and cost to society. Patients with major depressive disorder (MDD) exhibit high susceptibility to nicotine dependence. Varenicline, bupropion and nicotine replacement therapy are all indicated for smoking cessation; however funding by the Spanish national health system (SNHS) is limited. We modelled a budgetary impact analysis (BIA) to estimate the impact of the SNHS funding drug-based therapies for smoking cessation in smokers with MDD.

METHODS

The BIA compared the current unfunded scenario versus a funded scenario (varenicline, bupropion, nicotine replacement therapy combined with medical follow-up and counselling) using the Spanish SNHS and societal perspectives. The BIA design was a hybrid model using a decision tree algorithm (population size: smokers with MDD) and Markov chains (smoking cessation attempts) over a 5-year horizon. Smoking cessation drug efficacy was derived from clinical trials, and smoking cessation costs avoided were taken from an analysis of the Spanish National Health Survey. Results were shown as incremental cost savings. Scenarios and threshold univariate sensitivity analyses tested model robustness.

RESULTS

The funded scenario resulted in an increase of 43,478 cessation attempts and 8930 fewer smokers after 5 years compared to the unfunded scenario. The cost of funding was €25.3 million and costs avoided were €26.5 million. There was a cumulative 5-year incremental cost saving of €1.2 million to Spanish society. Results were robust using alternative scenarios.

CONCLUSIONS

Funding smoking cessation drugs in patients with MDD is of economic benefit to Spain and could produce net savings from the third year of implementation.

A Systematic Review of Health Economics Simulation Models of Chronic Obstructive Pulmonary Disease

BACKGROUND

Many decision-analytic models with varying structures have been developed to inform resource allocation in chronic obstructive pulmonary disease (COPD).

OBJECTIVES

To review COPD models for their adherence to the best practice modeling recommendations and their assumptions regarding important aspects of the natural history of COPD.

METHODS

A systematic search of English articles reporting on the development or application of a decision-analytic model in COPD was performed in MEDLINE, Embase, and citations within reviewed articles. Studies were summarized and evaluated on the basis of their adherence to the Consolidated Health Economic Evaluation Reporting Standards. They were also evaluated for the underlying assumptions about disease progression, heterogeneity, comorbidity, and treatment effects.

RESULTS

Forty-nine models of COPD were included. Decision trees and Markov models were the most popular techniques (43 studies). Quality of reporting and adherence to the guidelines were generally high, especially in more recent publications. Disease progression was modeled through clinical staging in most studies. Although most studies (n = 43) had incorporated some aspects of COPD heterogeneity, only 8 reported the results across subgroups. Only 2 evaluations explicitly considered the impact of comorbidities. Treatment effect had been mostly modeled (20) as both reduction in exacerbation rate and improvement in lung function.

CONCLUSIONS

Many COPD models have been developed, generally with similar structural elements. COPD is highly heterogeneous, and comorbid conditions play an important role in its burden. These important aspects, however, have not been adequately addressed in most of the published models.

[French data from the Continuing to Confront COPD (C2C) survey]

INTRODUCTION

This article describes the French data which contributed to the international "Continuing to Confront COPD" (C2C) survey conducted in 2013 across 12 countries. Its objective was to describe the characteristics, symptoms and impact of COPD on health status, daily activities and working life in adults identified with the study definition as COPD; i.e., reporting a diagnosis of COPD, emphysema, chronic bronchitis (CB) or symptoms of CB either currently present or for which they had been treated in the past.

METHODS

Subjects 40 years or older were screened using random-digit-dialing and those fulfilling the study COPD definition were invited to complete the full survey.

RESULTS

The proportion of respondents with COPD (according to study definition) in France was estimated at 7.5%. Among 300 respondents with COPD and complete questionnaire data, 48% were male, 44% aged over 70years, 45% were overweight and 72% had a smoking history. COPD had a severe or very severe impact (COPD assessment test score>20) on health for 43%. Dyspnea (mMRC ≥ 1) was reported by 70% and a limitation of at least 20% of daily activities by 65%. The mean number of exacerbations was 2/year and 16% had been admitted to hospital for respiratory problems during the past year. However, using direct questions, 80% subjects considered that they had mild to moderately severe disease and 78% reported an acceptable health status.

CONCLUSION

The impact of COPD is markedly underestimated by respondents with COPD despite a high level of symptoms, poor health status and frequent exacerbations as assessed with validated measures.

Simulation-Based Estimates of the Effectiveness and Cost-Effectiveness of Pulmonary Rehabilitation in Patients with Chronic Obstructive Pulmonary Disease in France

BACKGROUND

The medico-economic impact of pulmonary rehabilitation in patients with chronic obstructive pulmonary disease (COPD) is poorly documented.

OBJECTIVE

To estimate the effectiveness and cost-effectiveness of pulmonary rehabilitation in a hypothetical cohort of COPD patients.

METHODS

We used a multi-state Markov model, adopting society's perspective. Simulated cohorts of French GOLD stage 2 to 4 COPD patients with and without pulmonary rehabilitation were compared in terms of life expectancy, quality-adjusted life years (QALY), disease-related costs, and the incremental cost-effectiveness ratio (ICER). Sensitivity analyses included variations of key model parameters.

PRINCIPAL FINDINGS

At the horizon of a COPD patient's remaining lifetime, pulmonary rehabilitation would result in mean gain of 0.8 QALY, with an over disease-related costs of 14 102 € per patient. The ICER was 17 583 €/QALY. Sensitivity analysis showed that pulmonary rehabilitation was cost-effective in every scenario (ICER <50 000 €/QALY).

CONCLUSIONS

These results should provide a useful basis for COPD pulmonary rehabilitation programs.

The cost-effectiveness of domiciliary non-invasive ventilation in patients with end-stage chronic obstructive pulmonary disease: a systematic review and economic evaluation

BACKGROUND

Chronic obstructive pulmonary disease (COPD) is a chronic progressive lung disease characterised by non-reversible airflow obstruction. Exacerbations are a key cause of morbidity and mortality and place a considerable burden on health-care systems. While there is evidence that patients benefit from non-invasive ventilation (NIV) in hospital during an acute exacerbation, evidence supporting home use for more stable COPD patients is limited. In the U.K., domiciliary NIV is considered on health economic grounds in patients after three hospital admissions for acute hypercapnic respiratory failure.

OBJECTIVE

To assess the clinical effectiveness and cost-effectiveness of domiciliary NIV by systematic review and economic evaluation.

DATA SOURCES

Bibliographic databases, conference proceedings and ongoing trial registries up to September 2014.

METHODS

Standard systematic review methods were used for identifying relevant clinical effectiveness and cost-effectiveness studies assessing NIV compared with usual care or comparing different types of NIV. Risk of bias was assessed using Cochrane guidelines and relevant economic checklists. Results for primary effectiveness outcomes (mortality, hospitalisations, exacerbations and quality of life) were presented, where possible, in forest plots. A speculative Markov decision model was developed to compare the cost-effectiveness of domiciliary NIV with usual care from a UK perspective for post-hospital and more stable populations separately.

RESULTS

Thirty-one controlled effectiveness studies were identified, which report a variety of outcomes. For stable patients, a modest volume of evidence found no benefit from domiciliary NIV for survival and some non-significant beneficial trends for hospitalisations and quality of life. For post-hospital patients, no benefit from NIV could be shown in terms of survival (from randomised controlled trials) and findings for hospital admissions were inconsistent and based on limited evidence. No conclusions could be drawn regarding potential benefit from different types of NIV. No cost-effectiveness studies of domiciliary NIV were identified. Economic modelling suggested that NIV may be cost-effective in a stable population at a threshold of £30,000 per quality-adjusted life-year (QALY) gained (incremental cost-effectiveness ratio £28,162), but this is associated with uncertainty. In the case of the post-hospital population, results for three separate base cases ranged from usual care dominating to NIV being cost-effective, with an incremental cost-effectiveness ratio of less than £10,000 per QALY gained. All estimates were sensitive to effectiveness estimates, length of benefit from NIV (currently unknown) and some costs. Modelling suggested that reductions in the rate of hospital admissions per patient per year of 24% and 15% in the stable and post-hospital populations, respectively, are required for NIV to be cost-effective.

LIMITATIONS

Evidence on key clinical outcomes remains limited, particularly quality-of-life and long-term (> 2 years) effects. Economic modelling should be viewed as speculative because of uncertainty around effect estimates, baseline risks, length of benefit of NIV and limited quality-of-life/utility data.

CONCLUSIONS

The cost-effectiveness of domiciliary NIV remains uncertain and the findings in this report are sensitive to emergent data. Further evidence is required to identify patients most likely to benefit from domiciliary NIV and to establish optimum time points for starting NIV and equipment settings.

FUTURE WORK RECOMMENDATIONS

The results from this report will need to be re-examined in the light of any new trial results, particularly in terms of reducing the uncertainty in the economic model. Any new randomised controlled trials should consider including a sham non-invasive ventilation arm and/or a higher- and lower-pressure arm. Individual participant data analyses may help to determine whether or not there are any patient characteristics or equipment settings that are predictive of a benefit of NIV and to establish optimum time points for starting (and potentially discounting) NIV.

STUDY REGISTRATION

This study is registered as PROSPERO CRD42012003286.

FUNDING

The National Institute for Health Research Health Technology Assessment programme.

Do Model-Based Studies in Chronic Obstructive Pulmonary Disease Measure Correct Values of Utility? A Meta-Analysis

BACKGROUND

Chronic obstructive pulmonary disease (COPD) is a progressive chronic disease that has considerable impact on utility-based health-related quality of life. Utility is a key input of many decision analytic models used for economic evaluations.

OBJECTIVE

To systematically review COPD-related utilities and to compare these with alternative values used in decision models.

METHODS

The literature review comprised studies that generated utilities for COPD-related stages based on EuroQol five-dimensional questionnaire surveys of patients and of decision models of COPD progression that have been used for economic evaluations. The utility values used in modeling studies and those from the meta-analysis of actual patient-level studies were compared and differences quantified.

RESULTS

Twenty decision modeling studies that used utility value as an input parameter were found. Within the same span of publication period, 13 studies involving patient-level utility data were identified and included in the meta-analysis. The estimated mean utility values ranged from 0.806 (95% confidence interval [CI] 0.747-0.866) for stage I to 0.616 (95% CI 0.556-0.676) for stage IV. The utility scores for comparable stages in modeling studies were different (significant difference 0.045 [95% CI 0.041-0.052] for stage III). Modeling studies consistently used higher utility values than the average reported patient-level data.

CONCLUSIONS

COPD decision analytic models are based on a limited range of utility values that are systematically different from average values estimated using a meta-analysis. A more systematic approach in the application of utility measures in economic evaluation is required to appropriately reflect current literature.

Mathematical Modeling in Tobacco Control Research: Initial Results From a Systematic Review

OBJECTIVES

The US Food and Drug Administration has expressed interest in using mathematical models to evaluate potential tobacco policies. The goal of this systematic review was to synthesize data from tobacco control studies that employ mathematical models.

METHODS

We searched five electronic databases on July 1, 2013 to identify published studies that used a mathematical model to project a tobacco-related outcome and developed a data extraction form based on the ISPOR-SMDM Modeling Good Research Practices. We developed an organizational framework to categorize these studies and identify models employed across multiple papers. We synthesized results qualitatively, providing a descriptive synthesis of included studies.

RESULTS

The 263 studies in this review were heterogeneous with regard to their methodologies and aims. We used the organizational framework to categorize each study according to its objective and map the objective to a model outcome. We identified two types of study objectives (trend and policy/intervention) and three types of model outcomes (change in tobacco use behavior, change in tobacco-related morbidity or mortality, and economic impact). Eighteen models were used across 118 studies.

CONCLUSIONS

This paper extends conventional systematic review methods to characterize a body of literature on mathematical modeling in tobacco control. The findings of this synthesis can inform the development of new models and the improvement of existing models, strengthening the ability of researchers to accurately project future tobacco-related trends and evaluate potential tobacco control policies and interventions. These findings can also help decision-makers to identify and become oriented with models relevant to their work.

Cost Effectiveness of Free Access to Smoking Cessation Treatment in France Considering the Economic Burden of Smoking-Related Diseases

CONTEXT

In France more than 70,000 deaths from diseases related to smoking are recorded each year, and since 2005 prevalence of tobacco has increased. Providing free access to smoking cessation treatment would reduce this burden. The aim of our study was to estimate the incremental cost-effectiveness ratios (ICER) of providing free access to cessation treatment taking into account the cost offsets associated with the reduction of the three main diseases related to smoking: lung cancer, chronic obstructive pulmonary disease (COPD) and cardiovascular disease (CVD). To measure the financial impact of such a measure we also conducted a probabilistic budget impact analysis.

METHODS AND FINDINGS

We performed a cost-effectiveness analysis using a Markov state-transition model that compared free access to cessation treatment to the existing coverage of €50 provided by the French statutory health insurance, taking into account the cost offsets among current French smokers aged 15-75 years. Our results were expressed by the incremental cost-effectiveness ratio in 2009 Euros per life year gained (LYG) at the lifetime horizon. We estimated a base case scenario and carried out a Monte Carlo sensitivity analysis to account for uncertainty. Assuming a participation rate of 7.3%, the ICER value for free access to cessation treatment was €3,868 per LYG in the base case. The variation of parameters provided a range of ICER values from -€736 to €15,715 per LYG. In 99% of cases, the ICER for full coverage was lower than €11,187 per LYG. The probabilistic budget impact analysis showed that the potential cost saving for lung cancer, COPD and CVD ranges from €15 million to €215 million at the five-year horizon for an initial cessation treatment cost of €125 million to €421 million.

CONCLUSION

The results suggest that providing medical support to smokers in their attempts to quit is very cost-effective and may even result in cost savings.

Supported self-management for patients with moderate to severe chronic obstructive pulmonary disease (COPD): an evidence synthesis and economic analysis

BACKGROUND

Self-management (SM) support for patients with chronic obstructive pulmonary disease (COPD) is variable in its coverage, content, method and timing of delivery. There is insufficient evidence for which SM interventions are the most effective and cost-effective.

OBJECTIVES

To undertake (1) a systematic review of the evidence for the effectiveness of SM interventions commencing within 6 weeks of hospital discharge for an exacerbation for COPD (review 1); (2) a systematic review of the qualitative evidence about patient satisfaction, acceptance and barriers to SM interventions (review 2); (3) a systematic review of the cost-effectiveness of SM support interventions within 6 weeks of hospital discharge for an exacerbation of COPD (review 3); (4) a cost-effectiveness analysis and economic model of post-exacerbation SM support compared with usual care (UC) (economic model); and (5) a wider systematic review of the evidence of the effectiveness of SM support, including interventions (such as pulmonary rehabilitation) in which there are significant components of SM, to identify which components are the most important in reducing exacerbations, hospital admissions/readmissions and improving quality of life (review 4).

METHODS

The following electronic databases were searched from inception to May 2012: MEDLINE, MEDLINE In-Process and Other Non-Indexed Citations, EMBASE, Cochrane Central Register of Controlled Trials (CENTRAL), and Science Citation Index [Institute of Scientific Information (ISI)]. Subject-specific databases were also searched: PEDro physiotherapy evidence database, PsycINFO and the Cochrane Airways Group Register of Trials. Ongoing studies were sourced through the metaRegister of Current Controlled Trials, International Standard Randomised Controlled Trial Number database, World Health Organization International Clinical Trials Registry Platform Portal and ClinicalTrials.gov. Specialist abstract and conference proceedings were sourced through ISI's Conference Proceedings Citation Index and British Library's Electronic Table of Contents (Zetoc). Hand-searching through European Respiratory Society, the American Thoracic Society and British Thoracic Society conference proceedings from 2010 to 2012 was also undertaken, and selected websites were also examined. Title, abstracts and full texts of potentially relevant studies were scanned by two independent reviewers. Primary studies were included if ≈90% of the population had COPD, the majority were of at least moderate severity and reported on any intervention that included a SM component or package. Accepted study designs and outcomes differed between the reviews. Risk of bias for randomised controlled trials (RCTs) was assessed using the Cochrane tool. Random-effects meta-analysis was used to combine studies where appropriate. A Markov model, taking a 30-year time horizon, compared a SM intervention immediately following a hospital admission for an acute exacerbation with UC. Incremental costs and quality-adjusted life-years were calculated, with sensitivity analyses.

RESULTS

From 13,355 abstracts, 10 RCTs were included for review 1, one study each for reviews 2 and 3, and 174 RCTs for review 4. Available studies were heterogeneous and many were of poor quality. Meta-analysis identified no evidence of benefit of post-discharge SM support on admissions [hazard ratio (HR) 0.78, 95% confidence interval (CI) 0.52 to 1.17], mortality (HR 1.07, 95% CI 0.74 to 1.54) and most other health outcomes. A modest improvement in health-related quality of life (HRQoL) was identified but this was possibly biased due to high loss to follow-up. The economic model was speculative due to uncertainty in impact on readmissions. Compared with UC, post-discharge SM support (delivered within 6 weeks of discharge) was more costly and resulted in better outcomes (£683 cost difference and 0.0831 QALY gain). Studies assessing the effect of individual components were few but only exercise significantly improved HRQoL (3-month St George's Respiratory Questionnaire 4.87, 95% CI 3.96 to 5.79). Multicomponent interventions produced an improved HRQoL compared with UC (mean difference 6.50, 95% CI 3.62 to 9.39, at 3 months). Results were consistent with a potential reduction in admissions. Interventions with more enhanced care from health-care professionals improved HRQoL and reduced admissions at 1-year follow-up. Interventions that included supervised or unsupervised structured exercise resulted in significant and clinically important improvements in HRQoL up to 6 months.

LIMITATIONS

This review was based on a comprehensive search strategy that should have identified most of the relevant studies. The main limitations result from the heterogeneity of studies available and widespread problems with their design and reporting.

CONCLUSIONS

There was little evidence of benefit of providing SM support to patients shortly after discharge from hospital, although effects observed were consistent with possible improvement in HRQoL and reduction in hospital admissions. It was not easy to tease out the most effective components of SM support packages, although interventions containing exercise seemed the most effective. Future work should include qualitative studies to explore barriers and facilitators to SM post exacerbation and novel approaches to affect behaviour change, tailored to the individual and their circumstances. Any new trials should be properly designed and conducted, with special attention to reducing loss to follow-up. Individual participant data meta-analysis may help to identify the most effective components of SM interventions.

STUDY REGISTRATION

This study is registered as PROSPERO CRD42011001588.

FUNDING

The National Institute for Health Research Health Technology Assessment programme.

Models for estimating projections for disease prevalence and burden: a systematic review focusing on chronic obstructive pulmonary disease

OBJECTIVE

Epidemiological models for estimating the prevalence and burden of disease inform health policy and service planning decisions. Our aim was to describe the challenges in evaluating such models using the example of epidemiological models for chronic obstructive pulmonary disease (COPD).

METHODS

Two reviewers searched Medline, Embase, CAB Abstracts and World Health Organization (WHO) Databases from 1980 to November 2013 for epidemiological models of COPD prevalence and burden. Two reviewers extracted data and assessed the quality of the studies. We then undertook a descriptive and narrative synthesis of data.

RESULTS

We identified 22 models employing a variety of techniques to calculate the prevalence and/or burden of COPD. Models calculated prevalence and/or mortality or other facet of disease burden using demographics and risk factors or trends, Markov-type modelling and microsimulation modelling. The six models which scored highly on the quality framework were: the Peabody model, which generated estimates of COPD prevalence; the WHO DISMOD II model which produced burden estimates in terms of disability adjusted life years with COPD and life years lost to COPD; the Atsou model which gave the life expectancy gains of individual smokers who quit smoking and associated costs; two Dutch COPD models which produced estimates of mortality and health care costs related to COPD; and the Pichon-Riviere model which gave the costs and cost effectiveness of smoking quit programmes.

CONCLUSIONS

The field of chronic disease modelling is burgeoning. As a result, policy makers need to understand how to interpret epidemiological models and their data sources.

Utilities for asthma and COPD according to category of severity: a comprehensive literature review

BACKGROUND

Asthma and chronic obstructive pulmonary disease (COPD) are incurable diseases that impact quality-of-life.

OBJECTIVE

To summarize original research articles that measured or utilized preference-based utilities or disutilities according to disease severity.

METHODS

Medline and Embase were searched from inception until the end of November 2014. Two reviewers independently searched the literature with differences settled through discussion. Data extracted included utility scores as determined in original research categorized according to disease severity as well as disutilities associated with exacerbations or comorbidities. Data were tabulated and analyzed descriptively.

RESULTS

In total, 862 articles were identified, 790 were rejected, and 69 analyzed. There were 44 dealing with COPD and 25 with asthma. Average utilities determined by research were 0.828 ± 0.062, 0.765 ± 0.090, 0.711 ± 0.120, and 0.607 ± 0.120 for mild, moderate, severe, and very severe COPD, respectively. Utilities used in economic analyses were 0.866 ± 0.038, 0.770 ± 0.024, 0.739 ± 0.045, and 0.596 ± 0.075, respectively. Disutilities (annual) ranged from 0.002-0.378; major and minor exacerbations had respective disutilities of 0.287 and 0.108. For asthma patients, utilities were for 0.86 ± 0.32, 0.83 ± 0.065, and 0.74 ± 0.029, for mild, moderate, and severe disease, respectively.

CONCLUSIONS

Utilities have been summarized according to severity category of asthma and COPD. These values should be useful for researchers undertaking economic analyses of these diseases.

Chronic obstructive pulmonary disease case finding by community pharmacists: a potential cost-effective public health intervention

Objectives

This study aims to pilot a community pharmacy chronic obstructive pulmonary disease (COPD) case finding service in England, estimating costs and effects.

Methods

Patients potentially at risk of COPD were screened with validated tools. Smoking cessation was offered to all smokers identified as potentially having undiagnosed COPD. Cost and effects of the service were estimated.

Key findings

Twenty-one community pharmacies screened 238 patients over 9 months. One hundred thirty-five patients were identified with potentially undiagnosed COPD; 88 were smokers. Smoking cessation initiation provided a project gain of 38.62 life years, 19.92 quality-adjusted life years and a cost saving of £392.67 per patient screened.

Conclusions

COPD case finding by community pharmacists potentially provides cost-savings and improves quality of life.

Cost-effectiveness models for chronic obstructive pulmonary disease: cross-model comparison of hypothetical treatment scenarios

OBJECTIVES

To compare different chronic obstructive pulmonary disease (COPD) cost-effectiveness models with respect to structure and input parameters and to cross-validate the models by running the same hypothetical treatment scenarios.

METHODS

COPD modeling groups simulated four hypothetical interventions with their model and compared the results with a reference scenario of no intervention. The four interventions modeled assumed 1) 20% reduction in decline in lung function, 2) 25% reduction in exacerbation frequency, 3) 10% reduction in all-cause mortality, and 4) all these effects combined. The interventions were simulated for a 5-year and lifetime horizon with standardization, if possible, for sex, age, COPD severity, smoking status, exacerbation frequencies, mortality due to other causes, utilities, costs, and discount rates. Furthermore, uncertainty around the outcomes of intervention four was compared.

RESULTS

Seven out of nine contacted COPD modeling groups agreed to participate. The 5-year incremental cost-effectiveness ratios (ICERs) for the most comprehensive intervention, intervention four, was €17,000/quality-adjusted life-year (QALY) for two models, €25,000 to €28,000/QALY for three models, and €47,000/QALY for the remaining two models. Differences in the ICERs could mainly be explained by differences in input values for disease progression, exacerbation-related mortality, and all-cause mortality, with high input values resulting in low ICERs and vice versa. Lifetime results were mainly affected by the input values for mortality. The probability of intervention four to be cost-effective at a willingness-to-pay value of €50,000/QALY was 90% to 100% for five models and about 70% and 50% for the other two models, respectively.

CONCLUSIONS

Mortality was the most important factor determining the differences in cost-effectiveness outcomes between models.

Effective behaviour change techniques in smoking cessation interventions for people with chronic obstructive pulmonary disease: a meta-analysis

PURPOSE

The purpose of this study was to identify the behaviour change techniques (BCTs) that are associated with greater effectiveness in smoking cessation interventions for people with chronic obstructive pulmonary disease (COPD).

METHODS

A systematic review and meta-analysis was conducted. Web of Knowledge, CINAHL, EMBASE, PsycINFO, and MEDLINE were searched from the earliest date available to December 2012. Data were extracted and weighted average effect sizes calculated; BCTs used were coded according to an existing smoking cessation-specific BCT taxonomy.

RESULTS

Seventeen randomized controlled trials (RCTs) were identified that involved a total sample of 7446 people with COPD. The sample-weighted mean quit rate for all RCTs was 13.19%, and the overall sample-weighted effect size was d+ = 0.33. Thirty-seven BCTs were each used in at least three interventions. Four techniques were associated with significantly larger effect sizes: Facilitate action planning/develop treatment plan, Prompt self-recording, Advise on methods of weight control, and Advise on/facilitate use of social support. Three new COPD-specific BCTs were identified, and Linking COPD and smoking was found to result in significantly larger effect sizes.

CONCLUSIONS

Smoking cessation interventions aimed at people with COPD appear to benefit from using techniques focussed on forming detailed plans and self-monitoring. Additional RCTs that use standardized reporting of intervention components and BCTs would be valuable to corroborate findings from the present meta-analysis.

Case finding for chronic obstructive pulmonary disease in primary care: a pilot randomised controlled trial

BACKGROUND

Chronic obstructive pulmonary disease (COPD) is a major cause of morbidity and mortality. However, much of the disease burden remains undiagnosed.

AIM

To compare the yield and cost effectiveness of two COPD case-finding approaches in primary care.

DESIGN AND SETTING

Pilot randomised controlled trial in two general practices in the West Midlands, UK.

METHOD

A total of 1634 ever-smokers aged 35-79 years with no history of COPD or asthma were randomised into either a 'targeted' or 'opportunistic' case-finding arm. Respiratory questionnaires were posted to patients in the 'targeted' arm and provided to patients in the 'opportunistic' arm at routine GP appointments. Those reporting at least one chronic respiratory symptom were invited for spirometry. COPD was defined as pre-bronchodilator forced expiratory volume in 1 second/forced vital capacity (FEV1/FVC)<0.7 and FEV1<80% of predicted. Primary outcomes were the difference in the proportion of patients diagnosed with COPD and the cost per case detected.

RESULTS

Twenty-six per cent (212/815) in the 'targeted' and 13.6% (111/819) in the 'opportunistic' arm responded to the questionnaire and 78.3% (166/212) and 73.0% (81/111), respectively, reported symptoms; 1.2% (10/815) and 0.7% (6/819) of patients in the 'targeted' and 'opportunistic' arms were diagnosed with COPD (difference in proportions = 0.5% [95% confidence interval {CI} = -0.5% to 3.08%]). Over a 12-month period, the 'opportunistic' case-finding yield could be improved to 1.95% (95% CI = 1.0% to 2.9%). The cost-per case detected was £424.56 in the 'targeted' and £242.20 in the 'opportunistic' arm.

CONCLUSION

Opportunistic case finding may be more effective and cost effective than targeting patients with a postal questionnaire alone. A larger randomised controlled trial with adequate sample size is required to test this.

Effectiveness of individual counseling for smoking cessation in smokers with chronic obstructive pulmonary disease and asymptomatic smokers

Few studies have examined the effect of individual counseling for smoking cessation in China. The present study evaluated the efficacy of individual counseling in patients with chronic obstructive pulmonary disease (COPD) and asymptomatic smokers. This prospective randomized study evaluated 85 smokers with COPD and 105 asymptomatic smokers with normal lung function. The individuals were randomly allocated to intervention and control groups. Subjects in the intervention group were provided with individual cognitive counseling based on face-to-face individual consultation, self-help materials and nine telephone follow-ups. Subjects in the control group were provided with simple smoking cessation advice. The smoking status for all subjects and the St. George’s Respiratory Questionnaire (SGRQ) for COPD patients were assessed at baseline, week 4 and month 6. The COPD patient exacerbations during the 6 months were recorded. In the total study population, individual counseling resulted in higher abstinence rates compared with those in the control: Intervention vs. control, 23.4 vs. 10.4% (P=0.007), respectively. Similar results were observed in the smokers with COPD: Intervention vs. control, 40.5 vs. 18.6% (P=0.027), respectively. However, for asymptomatic smokers, the effect of individual counseling was identified to be statistically insignificant: Intervention vs. control, 9.6 vs. 3.8% (P=0.230), respectively. SGRQ scores and COPD exacerbations were significantly improved in patients who abstained from smoking compared with those in the patients who failed to stop smoking. Airway obstruction, quitting motivation and individual counseling were predictors associated with smoking cessation. Airway obstruction was the most significant predictor of smoking cessation (odds ratio, 4.215; 95% confidence interval, 2.215–7.865). The results of the present study show that individual counseling is an effective method for smoking cessation, particularly in COPD patients. However, its efficacy in asymptomatic smokers requires confirmation in further studies.