Primary and secondary care service use and costs associated with frailty in an ageing population: longitudinal analysis of an English primary care cohort of adults aged 50 and over, 2006-2017

BACKGROUND

Frailty becomes more prevalent and healthcare needs increase with age. Information on the impact of frailty on population level use of health services and associated costs is needed to plan for ageing populations.

AIM

To describe primary and secondary care service use and associated costs by electronic Frailty Index (eFI) category.

DESIGN AND SETTING

Retrospective cohort using electronic health records. Participants aged ≥50 registered in primary care practices contributing to the Oxford Royal College of General Practitioners Research and Surveillance Centre, 2006-2017.

METHODS

Primary and secondary care use (totals and means) were stratified by eFI category and age group. Standardised 2017 costs were used to calculate primary, secondary and overall costs. Generalised linear models explored associations between frailty, sociodemographic characteristics. Adjusted mean costs and cost ratios were produced.

RESULTS

Individual mean annual use of primary and secondary care services increased with increasing frailty severity. Overall cohort care costs for were highest in mild frailty in all 12 years, followed by moderate and severe, although the proportion of the population with severe frailty can be expected to increase over time. After adjusting for sociodemographic factors, compared to the fit category, individual annual costs doubled in mild frailty, tripled in moderate and quadrupled in severe.

CONCLUSIONS

Increasing levels of frailty are associated with an additional burden of individual service use. However, individuals with mild and moderate frailty contribute to higher overall costs. Earlier intervention may have the most potential to reduce service use and costs at population level.

The effectiveness and safety of heat/cold therapy in adults with lymphoedema: systematic review

PURPOSE

The aim of this review is to assess the efficacy and safety of using heat and cold therapy for adults with lymphoedema.

METHODS

A multi-database search was undertaken. Only studies which included adults with lymphoedema who were treated with heat or cold therapy reporting any outcome were included. Screening, data extraction, and assessment of bias were undertaken by a single reviewer and verified by a second. Due to the substantial heterogeneity, a descriptive synthesis was undertaken.

RESULTS

Eighteen studies were included. All nine studies which assessed the effects of heat-therapy on changes in limb circumference reported a point estimate indicating some reduction from baseline to end of study. Similarly, the five studies evaluating the use of heat-therapy on limb volume demonstrated a reduction in limb volume from baseline to end-of-study. Only four studies reported adverse events of which all were deemed to be minor. Only two studies explored the effects of cold therapy on lymphoedema.

CONCLUSIONS

Tentative evidence suggests heat-therapy may have some benefit in treating lymphoedema with minimal side effects. However, further high-quality randomised controlled trials are required, with a particular focus on moderating factors and assessment of adverse events.

1071 INCIDENCE OF RECORDED OSTEOPOROSIS, OSTEOPENIA AND FRAGILITY FRACTURE IN OLDER PEOPLE: ANALYSIS OF UK PRIMARY CARE DATA

Introduction

Osteoporosis is common in later life, leading to fragility fractures associated with increased mortality, disability, and costs. There is a surprising lack of data regarding the incidence of osteoporosis. We aimed to estimate the incidence of recorded diagnosis of osteoporosis, osteopenia, and fragility fracture in older people, explore time trends in diagnosis, and differences by age, sex, and social deprivation.

Method

We used de-identified patient data provided as part of routine primary care (IQVIA Medical Research Database (IMRD). All patients aged 50-99y registered with THIN (The Health Improvement Network) participating practices between 1/1/2000–31/12/2018 were included. Crude incidence rates (IR) were estimated per 10,000 person-years (PY). We used Poisson regression to calculate adjusted Incidence Rate Ratios (IRR) accounting for sex, age, calendar year and deprivation.

Results

The IR of osteoporosis was significantly higher in women, 84.32 (95%CI 83.81–84.83) vs. 16.66 (95%CI 16.43–16.90) in men per 10,000PY. In women, recorded IR of osteoporosis reached a peak in 2009. In the adjusted model, older men in most deprived areas had a higher IRR of osteoporosis [1.67 (95% 1.59–1.74)] compared to those in least deprived areas. Women were more likely to be diagnosed with osteopenia compared to men, at any age. Incidence of osteopenia diagnosis increased over time. In the adjusted model, men in most deprived areas had a higher IRR of osteopenia [1.44 (95%CI 1.35–1.53)] compared to least deprived areas. The IR of fragility fracture was higher in women, 84.97 (95%CI 84.45–85.48) vs. 31.15 (95%CI 30.83–31.48) in men per 10,000PY. In the adjusted model, men in most deprived areas had an increased IRR of fragility fracture [1.53 (95%CI 1.48–1.59)] compared to least deprived areas.

Conclusion

Community bone health interventions might be targeted at populations at higher risk of fragility fractures, including older men living in socially deprived areas.

768 PREDICTORS OF INDEPENDENCE IN COMMUNITY-DWELLING OLDER PEOPLE

Introduction

Many people wish to retain their independence as they age. Therefore, identifying factors that can predict sustainability of independence for older people over time are essential for preventing functional decline and maintaining quality of life.

Method

Longitudinal, health, social and economic data, from community-dwelling older people aged ≥75 years (collected at baseline (BL), 6, 12, 24 and 48 months), were obtained from the ongoing Community Ageing Research (CARE 75+) cohort study. Linear regression models were used to identify predictors of independence. The Nottingham Extended Activities of Daily Living (NEADL) score (range 0–66) at 12 months from BL was the dependent variable (DV) to indicate independence. Independent variables (IV)s were selected based on interviews with CARE75+ participants and known predictors such as, ethnicity and frailty. Each IV was regressed against the DV in univariable analyses. All IVs with p value <0.1 from univariable analyses, including baseline NEADL score, were included in the multivariable model.

Results

Data from 1,277 participants (mean (SD) age 84.61 (4.95); 49% male) were analysed. The multivariable model (adjusted R2: 0.71) showed that, in addition to higher BL NEADL (estimated effect 0.49, 95% confidence interval (CI) 0.41 to 0.58), white ethnicity, good sight, lower level of frailty, ability to perform basic activities of daily living, lower depression score, lower cognitive impairment, younger age, living circumstances, fewer hours of informal support, greater physical functioning and lower pain scores were predictors of a higher NEADL at 12 months (p < 0.05 for all).

Conclusion

As well as physical health, social and psychological variables are important in predicting independence, based on NEADL score, over time. Further research into the mechanisms behind these relationships will be conducted.

825 DEVELOPMENT OF THE ANTICHOLINERGIC MEDICATION INDEX (ACMI)

Introduction

Medications with Anticholinergic (AC) properties, are prescribed to treat a range of conditions. Older people are increasingly likely to be prescribed multiple AC medications, but are also more likely to experience unwanted adverse effects, such as falls and delirium. The risks of adverse outcomes increase with the number and potency of AC medications prescribed. The aim of this study was to use a prognostic modelling approach to develop an AC Medication Index (ACMI) that identifies patients at high risk of AC medication side effects.

Methods

The prognostic model was developed using data on patients aged 65–95 years, registered with a general practice contributing data to ‘Connected Bradford’ in 2019. A Time-dependent Cox model was fitted, with hospital admission for delirium or falls as the composite outcome and AC medications, age, sex and important clinical factors (e.g. dementia, arthritis, urinary incontinence) as predictors. Concordance and Negalkerke’s R2 derived from five-fold cross-validation were used to assess model performance.

Results

There were 151,604 patients included in the study, of whom 47,035 (31.0%) were prescribed ≥1 AC medication during 2019. Codeine, Prednisolone, Furosemide and Amitriptyline were most commonly prescribed with 7.4%, 4.0%, 3.8% and 3.1% of patients prescribed these medications at least once in 2019, respectively. During 2019, 6,078 (4.0%) patients experienced a hospital admission with delirium or a fall, with the rate being increased in those prescribed ≥1 AC medication during 2019 (4.8% vs 3.7%; p < 0.001). The prognostic model yielded a discrimination statistic of 0.86 with an R2 of 0.1.

Conclusion

The model used to develop the ACMI shows good discrimination. External validation will soon be performed using data from the SAIL databank and the ACMI will be further developed as a tool for use in primary care.

696 UNDERSTANDING INDEPENDENCE—OLDER PEOPLE’S PERSPECTIVES

Introduction

Independence is an important personal goal for many older people. Achieving this goal in practice requires a shared-understanding of independence between older people and those supporting them, but a consensus of understanding remains elusive. This study aims to provide a basis for a person-centred understanding of independence by identifying which factors are important to the meaning, and experience, of independence for older people.

Method

In-depth interviews were conducted to explore the understandings of community-dwelling older people. Participants were purposively sampled from the Community Ageing Research 75+ cohort study. Analysis was guided by the Framework approach. Themes were identified through deductive and inductive exploration of the transcripts.

Results

Fourteen older people were interviewed ranging from 76–98 years old, six were male. Five themes were identified. The first three themes: participation, autonomy and control, underpinned participants’ understandings of independence. Engaging in meaningful activities, making decisions, and having control over help received were fundamental to participants’ understandings of independence. These three themes provided the common building blocks for unique configurations of independence. The importance of psychological qualities to the facilitation of independence, as they enabled participants to navigate environmental and social set-backs, presented a fourth theme, ‘Mind over Matter’. The final theme, ‘Participation reinforces psychological qualities’ represented the virtuous circle through which participation in meaningful activities reinforced the psychological attributes necessary to maintain independence.

Conclusion

Meanings of independence are as diverse as the people who develop them, whatever the age group. For the older participants of this study, despite differences, the meaning and facilitation of independence comprised several common themes. Achieving independence was a case of ‘Mind over Matter’ requiring personal effort, irrespective of environmental supports. Participation in meaningful activities was both a goal of independence and a means to reinforce the psychological qualities and energy needed to maintain it.

Do home adaptation interventions help to reduce emergency fall admissions? A national longitudinal data-linkage study of 657,536 older adults living in Wales (UK) between 2010 and 2017

Background

falls are common in older people, but evidence for the effectiveness of preventative home adaptations is limited.

Aim

determine whether a national home adaptation service, Care&Repair Cymru (C&RC), identified individuals at risk of falls occurring at home and reduced the likelihood of falls.

Study Design

retrospective longitudinal controlled non-randomised intervention cohort study.

Setting

our cohort consisted of 657,536 individuals aged 60+ living in Wales (UK) between 1 January 2010 and 31 December 2017. About 123,729 individuals received a home adaptation service.

Methods

we created a dataset with up to 41 quarterly observations per person. For each quarter, we observed if a fall occurred at home that resulted in either an emergency department or an emergency hospital admission. We analysed the data using multilevel logistic regression.

Results

compared to the control group, C&RC clients had higher odds of falling, with an odds ratio (OR [95% confidence interval]) of 1.93 [1.87, 2.00]. Falls odds was higher for females (1.44 [1.42, 1.46]), older age (1.07 [1.07, 1.07]), increased frailty (mild 1.57 [1.55, 1.60], moderate 2.31 [2.26, 2.35], severe 3.05 [2.96, 3.13]), and deprivation (most deprived compared to least: 1.16 [1.13, 1.19]). Client fall odds decreased post-intervention; OR 0.97 [0.96, 0.97] per quarter. Regional variation existed for falls (5.8%), with most variation at the individual level (31.3%).

Conclusions

C&RC identified people more likely to have an emergency fall admission occurring at home, and their service reduced the odds of falling post-intervention. Service provisioning should meet the needs of an individual and need varies by personal and regional circumstance.

454 ASSOCIATION BETWEEN STATINS AND MAJOR ADVERSE CARDIAC EVENTS AMONG OLDER ADULTS WITH FRAILTY: A SYSTEMATIC REVIEW

Background

Statins reduce the risk of major adverse cardiovascular events (MACE), however, their clinical benefit for primary and secondary prevention among older adults with frailty is uncertain. This review investigates whether statins prescribed for primary and secondary prevention are associated with reduced MACE among adults aged ≥65 years with frailty.

Methods

Systematic review of studies published between 01.01.1952 and 01.01.2019 in MEDLINE, Embase, Scopus, Web of Science, Cochrane Library and the International Pharmaceutical Abstracts. Studies that investigated the effect of statins on MACE among adults ≥65 years with a validated frailty assessment were included. Data were extracted from the papers as per a pre-published protocol, PROSPERO: CRD42019127486. Risk of bias was assessed using the Cochrane Risk of Bias in non-randomised studies of interventions.

Finding

18794 abstracts were identified for screening. From these, six cohort studies fulfilled the inclusion criteria. There were no randomised clinical trials. Of studies involving statins for primary and secondary prevention (n = 6), one found statins were associated with reduced mortality (hazard ratio (HR) 0.58, 95% confidence interval (CI) 0.37–0.93) and another found they were not (p = 0.73). One study of statins used for secondary prevention found they were associated with reduced mortality (HR 0.28, 95%CI 0.21–0.39). No studies investigated the effect of statins for primary prevention or the effect of statins on the frequency of MACE.

Discussion

This review summarizes the existing available evidence for decision making for statin prescribing for older adults with frailty. This study identified only observational evidence that, among older people with frailty, statins are associated with reduced mortality when prescribed for secondary prevention, and an absence of evidence evaluating statin therapy for primary prevention. The findings of this study highlight that randomised trial data are urgently needed to better inform the use of statins among older adults living with frailty.

48 Do Exercise Programmes for Older People with Sarcopenia or Frailty Deliver An Evidence-Based Service? Findings From A UK Survey

Background

Awareness of sarcopenia and frailty is growing and both are known to be potentially reversible with effective resistance training. We aimed to establish whether existing exercise programmes offered to people with sarcopenia or frailty adhere to the known evidence base.

Methods

We conducted a national on-line survey of practitioners delivering exercise programmes to older people with sarcopenia or frailty. The link to the online survey was distributed through the British Geriatrics Society, Chartered Society of Physiotherapy Special Interest Group for Older People (AGILE), the NHS England Future Collaboration Platform “Supporting People Living with Frailty” forum and social media. Questions covered target population and aims of the exercise programme, type, duration and frequency of exercise, progress assessment and outcome measures. Descriptive analyses were conducted using SPSS v24.

Results

136 responses were received from respondents who worked for NHS Trusts, clinical commissioning groups, private practices, and third sector providers. 94% of respondents reported prescribing or delivering exercise programmes to people with sarcopenia or frailty. Most programmes (81/135 [60%]) were primarily designed to prevent or reduce falls. Resistance training was reported as the main focus of the programme in only 11/123 (9%); balance training was the main focus in 61/123 (50%) and functional exercise in 28/123 (23%). Exercise was offered once a week or less by 81/124 (65%) of respondents; the median number of sessions offered was 8.5 (IQR 6 to 12). Outcome measures suitable for assessing the effect of resistance training programmes were reported by fewer than half of respondents (hand grip: 13/119 [11%]; chair stands: 55/119 [46%], short physical performance battery: 4/119 [3%]).

Conclusions

Current exercise programmes offered to older people with sarcopenia or frailty lack the frequency, duration or specificity of exercise likely to improve outcomes for this group of patients.

Prescription of oral anticoagulation for stroke prophylaxis in atrial fibrillation according to frailty status: a national study of 536,995 primary care records

Background

At least 10 million people in Europe have a diagnosis of atrial fibrillation (AF). People with AF commonly have concomitant frailty, rendering them vulnerable to various adverse outcomes. Whilst appropriate prescription of oral anticoagulation (OAC) is associated with reduced risk of stroke and mortality, there are fears of iatrogenic harm in older people with frailty.

Purpose

Previous studies give conflicting evidence of the association between frailty and OAC prescription and are based on small samples from select cohorts. Therefore, we provide data of the association between OAC prescription and frailty for a large representative cohort of patients with AF.

Methods

This cross-sectional study used EHR for 536,955 patients in England aged ≥65 years on 31/12/2015. Clinical Terms Version 3 (CTV-3) codes were used to identify AF and relevant past medical history (PMH, including: cancer, varices, intracranial or gastrointestinal haemorrhage). Frailty was determined according to the validated electronic frailty index (eFI, a cumulative deficit score of 36 possible deficits), and categorised into robust (0–0.12), mild (>0.12–0.24), moderate (>0.24–0.36) or severe (>0.36) frailty.

Patients with a CHA2DS2-VASc score of ≥2 were considered eligible for OAC prescription. Prescription of OAC among those eligible (warfarin or direct oral anticoagulant [DOAC]) or not was established using prescribing data within the EHR.

Poisson regression modelling was used to determine the odds of OAC prescription for each frailty category compared with non-frail (robust) individuals. Odds ratios (ORs) and 95% confidence intervals (CIs) were reported with and without adjustment for sex, deprivation, PMH, concomitant prescription of medications that increase bleeding risk (including antiplatelets, steroids, non-steroidal anti-inflammatories).

Results

Of the cohort, 61,177 (11.4%) had AF. Of these, 58,204 (95.1%) were eligible for OAC, which was prescribed in 30,916 (53.1%) people. Individuals prescribed OAC were on average 5 months younger than those not prescribed OAC (80.1 vs 80.5 years, p<0.001), and had a slightly higher CHA2DS2-VASc score (4.0 vs 3.8, p<0.001). Frailty was identified in 54,734 (89.5%) patients with AF.

OAC was prescribed in 2,028 of 4,863 (41.7%) patients in the robust category; 10,221 of 19,198 (53.2%) with mild; 11,167 of 20,099 (55.6%) with moderate; and 7,500 of 14,044 (53.4%) with severe frailty. In comparison to the robust category, frailty was associated with higher odds of OAC prescription: mild frailty OR 1.6 (95% CI 1.5 to 1.7); moderate 1.7 (1.6 to 1.9); severe 1.6 (1.5 to 1.7). Adjustment for confounding variables increased the magnitude of the association (Figure 1).

Conclusion

People with AF and advancing frailty were more likely to be prescribed an anticoagulant than those with AF who are robust. Specific safety and efficacy data for OAC are needed in people with AF and frailty to better inform clinical decision-making.

Figure 1

Funding Acknowledgement

Type of funding source: Public hospital(s). Main funding source(s): CW was funded by the Hull-York Medical School. He is now an NIHR clinical lecturer.

Moving Towards Common Data Elements and Core Outcome Measures in Frailty Research

With aging populations around the world, frailty is becoming more prevalent increasing the need for health systems and social systems to deliver optimal evidence based care. However, in spite of the growing number of frailty publications, high-quality evidence for decision making is often lacking. Inadequate descriptions of the populations enrolled including frailty severity and frailty conceptualization, lack of use of validated frailty assessment tools, utilization of different frailty instruments between studies, and variation in reported outcomes impairs the ability to interpret, generalize and implement the research findings. The utilization of common data elements (CDEs) and core outcome measures (COMs) in clinical trials is increasingly being adopted to address such concerns. To catalyze the development and use of CDEs and COMs for future frailty studies, the Canadian Frailty Network (www.cfn-nce.ca; CFN), a not-for-profit pan-Canadian nationally-funded research network, convened an international group of experts to examine the issue and plan the path forward. The meeting was structured to allow for an examination of current frailty evidence, ability to learn from other COMs and CDEs initiatives, discussions about specific considerations for frailty COMs and CDEs and finally the identification of the necessary steps for a COMs and CDEs consensus initiative going forward. It was agreed at the onset of the meeting that a statement based on the meeting would be published and herein we report the statement.

85 A Cross-Sectional Study Assessing Agreement Between Self-Reported and General Practice Recorded Health Conditions Among Community Dwelling Older Adults

Introduction

Self-reported data regarding health conditions are utilised in both clinical practice and research, however, their agreement with general practice records is variable. The extent of this variability is poorly studied among older adults, particularly among those with multiple health conditions, cognitive impairment or frailty. This study investigates the agreement between self-reported and general practice recorded data among such patients and the impact of participant factors on this agreement.

Methods

Data on health conditions was collected from participants in the Community Ageing Research 75+ (CARE75+) study (n=964) by self-reporting during face to face assessment and interrogation of the participants’ practice health records. Agreement between self-report and practice records was assessed using Kappa statistics and the effect of participant demographics using logistic regression.

Results

Agreement ranged from K=0.25-1.00. The presence of ≥2 health conditions modified agreement for cancer (odds ratio, OR:0.62, 95% confidence interval, CI:0.42-0.94), diabetes (OR:0.55, 95%CI:0.38-0.80), dementia (OR:2.82, 95%CI:1.31-6.13) and visual impairment (OR:3.85, 95%CI:1.71-8.62). Frailty reduced agreement for cerebrovascular disease (OR:0.45, 95%CI:0.23-0.89), heart failure (OR:0.40, 95%CI:0.19-0.84) and rheumatoid arthritis (OR:0.41, 95%CI:0.23-0.75). Cognitive impairment reduced agreement for dementia (OR:0.36, 95%CI:0.21-0.62), diabetes (OR:0.47, 95%CI:0.33-0.67), heart failure (OR:0.53, 95%CI:0.35-0.80), visual impairment (OR:0.42, 95%CI:0.25-0.69) and rheumatoid arthritis (OR:0.53, 95%CI:0.37-0.76).

Conclusions

Significant variability exists for agreement between self-reported and general practice recorded comorbidities. This is further affected by individuals’ baseline demographics. This study is the first to assess frailty as a factor modifying agreement and highlights the importance of utilising the general practice records as the gold standard for data collection from older adults.

External validation of the electronic Frailty Index using the population of Wales within the Secure Anonymised Information Linkage Databank

Background

frailty has major implications for health and social care services internationally. The development, validation and national implementation of the electronic Frailty Index (eFI) using routine primary care data has enabled change in the care of older people living with frailty in England.

Aims

to externally validate the eFI in Wales and assess new frailty-related outcomes.

Study design and setting

retrospective cohort study using the Secure Anonymised Information Linkage (SAIL) Databank, comprising 469,000 people aged 65–95, registered with a SAIL contributing general practice on 1 January 2010.

Methods

four categories (fit; mild; moderate and severe) of frailty were constructed using recognised cut points from the eFI. We calculated adjusted hazard ratios (HRs) from Cox regression models for validation of existing outcomes: 1-, 3- and 5-year mortality, hospitalisation, and care home admission for validation. We also analysed, as novel outcomes, 1-year mortality following hospitalisation and frailty transition times.

Results

HR trends for the validation outcomes in SAIL followed the original results from ResearchOne and THIN databases. Relative to the fit category, adjusted HRs in SAIL (95% CI) for 1-year mortality following hospitalisation were 1.05 (95% CI 1.03-1.08) for mild frailty, 1.24 (95% CI 1.21-1.28) for moderate frailty and 1.51 (95% CI 1.45-1.57) for severe frailty. The median time (lower and upper quartile) between frailty categories was 2,165 days (lower and upper quartiles: 1,510 and 2,831) from fit to mild, 1,155 days (lower and upper quartiles: 756 and 1,610) from mild to moderate and 898 days (lower and upper quartiles: 584 and 1,275) from moderate to severe.

Conclusions

further validation of the eFI showed robust predictive validity and utility for new outcomes.

P2524Extent and outcomes of frailty in older people with atrial fibrillation: a nationwide study using primary care data

Background

The prevalence of atrial fibrillation (AF) in older people is increasing, as is frailty. Frailty describes an increased vulnerability to adverse outcomes, whereby the balance of risk and benefit associated with an intervention may be more nuanced. However, there are limited data from a community setting on the prevalence of AF and frailty in older people.

It is important to understand the burden of AF and frailty, and the associated impact on mortality and stroke disease in order to inform shared decision making with patients, and also inform guidelines for this increasing group of older people.

Purpose

To estimate the prevalence of AF and the burden of frailty in patients with AF, in a large primary care dataset. To report stroke and mortality by frailty group.

Methods

We used electronic health records of 537,051 patients in England aged 65 years or older on 31/12/2015, with follow-up for all-cause mortality and ischaemic or unclassified stroke to 11/04/2017. Patients with a history of AF were identified using Clinical Terms Version 3 (CTV-3) codes. Frailty was identified up to the point of study entry using the electronic frailty index (eFI, the proportion of deficits out of 36 possible deficits), and categorised into robust (0–0.12), mild (>0.12–0.24), moderate (>0.24–0.36) or severe (>0.36) frailty.

Median CHA2DS2-VASc and ATRIA scores for patients with frailty were compared with the robust group using Mann-Whitney.

The association between frailty status, all-cause mortality and stroke was calculated using Cox proportional hazards models, adjusted for age and sex.

Results

Of the cohort, 61,177 patients (11.4%) had AF. Of those with AF, 27,987 (45.8%) were female, and 54,734 (89.5%) had frailty. 6,443 (10.5%) were classified as robust; 20,352 (33.3%) mildly frail; 20,315 (33.2%) moderately frail; and 14,067 (23.0%) severely frail.

The median number of eFI-defined deficits among patients with AF was 9 (interquartile range [IQR] 6–12). Median stroke and bleeding scores were higher in those with frailty compared with the robust group (CHA2DS2-VASc 4 [IQR 3–5] v 2 [2–3], p≤0.001; ATRIA 4 [2–6] v 1 [0–2], p≤0.001).

During 73,338 patient-years of follow-up, there were 6,805 (11.1%) deaths and 945 (1.54%) strokes. Compared with the robust group, all-cause mortality and stroke were higher with increasing frailty. Mortality: mild frailty hazard ratio 1.53 (95% confidence interval 1.29–1.80); moderate frailty 2.50 (2.13–2.94); severe frailty 4.26 (3.63–5.01). Stroke: mild frailty 1.36 (0.99–1.85); moderate frailty 1.67 (1.23–2.28); severe 1.99 (1.45–2.73).

Kaplan-Meier survival curves by frailty

Conclusion

The prevalence of AF among those aged over 65 years in primary care in England is high, the majority of whom are frail. Increasing severity of frailty was associated with higher mortality and stroke rates.

The extent to which the judicious use of oral anticoagulation may improve clinical outcomes for patients with AF and frailty is currently unknown.

Acknowledgement/Funding

CPG: Bayer, BMS, AstraZeneca, Novartis Vifor Pharma, Menerini

Study protocol for investigating the impact of community home modification services on hospital utilisation for fall injuries: a controlled longitudinal study using data linkage

INTRODUCTION

This study will evaluate the effectiveness of home adaptations, both in preventing hospital admissions due to falls for older people, and improving timely discharge. Results will provide evidence for services at the interface between health and social care, informing policies seeking to promote healthy ageing through prudent healthcare and fall prevention.

METHODS AND ANALYSIS

All individuals living in Wales, UK, aged 60 years and over, will be included in the study using anonymised linked data from the Secure Anonymised Information Linkage Databank. We will use a national database of home modifications implemented by the charity organisation Care & Repair Cymru (C&R) from 2009 to 2017 to define an intervention cohort. We will use the electronic Frailty Index to assign individual levels of frailty (fit, mild, moderate or severe) and use these to create a comparator group (non-C&R) of people who have not received a C&R intervention. Coprimary outcomes will be quarterly numbers of emergency hospital admissions attributed to falls at home, and the associated length of stay. Secondary outcomes include the time in moving to a care home following a fall, and the indicative financial costs of care for individuals who had a fall. We will use appropriate multilevel generalised linear models to analyse the number of hospital admissions related to falls. We will use Cox proportional hazard models to compare the length of stay for fall-related hospital admissions and the time in moving to a care home between the C&R and non-C&R cohorts. We will assess the impact per frailty group, correct for population migration and adjust for confounding variables. Indicative costs will be calculated using financial codes for individual-level hospital stays. Results will provide evidence for services at the interface between health and social care, informing policies seeking to promote healthy ageing through prudent healthcare and prevention.

ETHICS AND DISSEMINATION

Information governance requirements for the use of record-linked data have been approved and only anonymised data will be used in our analysis. Our results will be submitted for publication in peer-reviewed journals. We will also work with lay members and the knowledge transfer team at Swansea University to create communication and dissemination materials on key findings.

The clinical effectiveness and cost-effectiveness of treatments for idiopathic pulmonary fibrosis: a systematic review and economic evaluation

BACKGROUND

Idiopathic pulmonary fibrosis (IPF) is a life-limiting lung disease that generally affects people over 60 years old. The main symptoms are shortness of breath and cough, and as the disease progresses there is a considerable impact on day-to-day life. Few treatments are currently available.

OBJECTIVES

To conduct a systematic review of clinical effectiveness and an analysis of cost-effectiveness of treatments for IPF based on an economic model informed by systematic reviews of cost-effectiveness and quality of life.

DATA SOURCES

Eleven electronic bibliographic databases, including MEDLINE, EMBASE, Web of Science, and The Cochrane Library and the Centre for Reviews and Dissemination databases, were searched from database inception to July 2013. Reference lists of relevant publications were also checked and experts consulted.

METHODS

Two reviewers independently screened references for the systematic reviews, extracted and checked data from the included studies and appraised their risk of bias. An advisory group was consulted about the choice of interventions until consensus was reached about eligibility. A narrative review with meta-analysis was undertaken, and a network meta-analysis (NMA) was performed. A decision-analytic Markov model was developed to estimate cost-effectiveness of pharmacological treatments for IPF. Parameter values were obtained from NMA and systematic reviews. Univariate and probabilistic sensitivity analyses were undertaken. The model perspective is NHS and Personal Social Services, and discount rate is 3.5% for costs and health benefits.

RESULTS

Fourteen studies were included in the review of clinical effectiveness, of which one evaluated azathioprine, three N-acetylcysteine (NAC) (alone or in combination), four pirfenidone, one BIBF 1120, one sildenafil, one thalidomide, two pulmonary rehabilitation, and one a disease management programme. Study quality was generally good, with a low risk of bias. The current evidence suggests that some treatments appear to be clinically effective. The model base-case results show increased survival for five pharmacological treatments, compared with best supportive care, at increased cost. General recommendations cannot be made of their cost-effectiveness owing to limitations in the evidence base.

LIMITATIONS

Few direct comparisons of treatments were identified. An indirect comparison through a NMA was performed; however, caution is recommended in the interpretation of these results. In relation to the economic model, there is an assumption that pharmacological treatments have a constant effect on the relative rate of per cent predicted forced vital capacity decline.

CONCLUSIONS

Few interventions have any statistically significant effect on IPF and a lack of studies on palliative care approaches was identified. Research is required into the effects of symptom control interventions, in particular pulmonary rehabilitation and thalidomide. Other research priorities include a well-conducted randomised controlled trial on inhaled NAC therapy and an updated evidence synthesis once the results of ongoing studies are reported.

STUDY REGISTRATION

This study is registered as PROSPERO CRD42012002116.

FUNDING

The National Institute for Health Research Health Technology Assessment programme.

Systematic review of cognitive behavioural therapy for the management of headaches and migraines in adults

AIM

This systematic review aimed to establish if cognitive behavioural therapy (CBT) can reduce the physical symptoms of chronic headache and migraines in adults.

METHODS

Evidence from searches of eight databases was systematically sought, appraised and synthesised. Screening of title and abstracts was conducted independently by two reviewers. Full papers were screened, data extracted and quality assessed by one reviewer and checked by a second. Data were synthesised narratively by intervention due to the heterogeneity of the studies. The inclusion criteria specified randomised controlled trials with CBT as an intervention in adults suffering from chronic headaches/migraines not associated with an underlying pathology/medication overuse. CBT was judged on the basis of authors describing the intervention as CBT. The diagnosis of the condition had to be clinician verified. Studies had to include a comparator and employ headache/migraine-specific outcomes such as patient-reported headache days.

RESULTS

Out of 1126 screened titles and abstracts and 20 assessed full papers, 10 studies met the inclusion criteria of the review. Some studies combined CBT with another intervention, as well as employing varying numbers of comparators. CBT was statistically significantly more effective in improving some headaches-related outcomes in CBT comparisons with waiting lists (three studies), in combination with relaxation compared with relaxation only (three studies) or antidepressant medication (one study), with no statistically significant differences in three studies.

CONCLUSIONS

The findings of this review were mixed, with some studies providing evidence in support of the suggestion that people experiencing headaches or migraines can benefit from CBT, and that CBT can reduce the physical symptoms of headache and migraines. However, methodology inadequacies in the evidence base make it difficult to draw any meaningful conclusions or to make any recommendations.

The prevalence and outcomes of frailty in older cancer patients: a systematic review

BACKGROUND

Frailty is a state of vulnerability to poor resolution of homeostasis following a stressor event, such as chemotherapy or cancer surgery. Better knowledge of the epidemiology of frailty could help drive a global cancer care strategy for older people. The aim of this review was to establish the prevalence and outcomes of frailty and pre-frailty in older cancer patients.

METHODS

Observational studies that reported data on the prevalence and/or outcomes of frailty in older cancer patients with any stage of solid or haematological malignancy were considered. We searched Medline, CINAHL, Cochrane Library, EMBASE, Web of Science, Allied and Complementary medicine, Psychinfo and ProQuest (1 January 1996 to 30 June 2013). The primary outcomes were prevalence of frailty, treatment-related side-effects, unplanned hospitalization and mortality. Risk of bias was assessed using the Newcastle-Ottawa checklist.

RESULTS

Data from 20 studies evaluating 2916 participants are included. The median reported prevalence of frailty and pre-frailty was 42% (range 6%-86%) and 43% (range 13%-79%), respectively. A median of 32% (range 11%-78%) of patients were classified as fit. Frailty was independently associated with increased all-cause mortality [adjusted 5-year hazard ratio (HR) 1.87, 95% confidence interval (CI) 1.36-2.57]. There was evidence of increased risk of postoperative mortality for both frailty (adjusted 30-day HR 2.67, 95% CI 1.08-6.62) and pre-frailty (adjusted HR 2.33, 95% CI 1.20-4.52). Treatment complications were more frequent in those with frailty, including intolerance to cancer treatment (adjusted odds ratio 4.86, 95% CI 2.19-10.78) and postoperative complications (adjusted 30-day HR 3.19, 95% CI 1.68-6.04).

CONCLUSIONS

More than half of older cancer patients have pre-frailty or frailty and these patients are at increased risk of chemotherapy intolerance, postoperative complications and mortality. The findings of this review support routine assessment of frailty in older cancer patients to guide treatment decisions, and the development of multidisciplinary geriatric oncology services.

Corrigendum

Summary

A previous version of this report was published in July 2013. The report was corrected on page v in November 2013. For further information, or for copies of the original material, please contact Nihredit@soton.ac.uk.

Using process data to understand outcomes in sexual health promotion: an example from a review of school-based programmes to prevent sexually transmitted infections

This article discusses how process indicators can complement outcomes as part of a comprehensive explanatory evaluation framework, using the example of skills-based behavioural interventions to prevent sexually transmitted infections and promote sexual health among young people in schools. A systematic review was conducted, yielding 12 eligible outcome evaluations, 9 of which included a process evaluation. There were few statistically significant effects in terms of changes in sexual behaviour outcomes, but statistically significant effects were more common for knowledge and self-efficacy. Synthesis of the findings of the process evaluations identified a range of factors that might explain outcomes, and these were organized into two overarching categories: the implementation of interventions, and student engagement and intervention acceptability. Factors which supported implementation and engagement and acceptability included good quality teacher training, involvement and motivation of key school stakeholders and relevance and appeal to young people. Factors which had a negative impact included teachers' failure to comprehend the theoretical basis for behaviour change, school logistical problems and omission of topics that young people considered important. It is recommended that process indicators such as these be assessed in future evaluations of school-based sexual health behavioural interventions, as part of a logic model.

Are educational interventions to prevent catheter-related bloodstream infections in intensive care unit cost-effective?

BACKGROUND

There is increasing interest in evidence-based educational interventions in central venous catheter care. It is unclear how effective these are at reducing the risk of bloodstream infections from the use of intravascular catheters (catheter-BSIs) and the associated costs and health benefits.

AIM

To estimate the additional costs and health benefits from introducing such interventions and the costs associated with catheter-BSIs.

METHODS

A comprehensive epidemiological and economic review was performed to develop the parameters for an economic model to assess the cost-effectiveness of introducing an educational intervention compared with clinical practice without the intervention. The model follows the clinical pathway of cohorts of patients from their admission to an intensive care unit (ICU), where some may acquire catheter-BSI, and estimates the associated costs, mortality and life expectancy.

FINDINGS

The additional cost per catheter-BSI episode was £3940. The results of this model demonstrate that introducing an additional educational intervention to prevent catheter-BSI improved patient life expectancy and reduced overall costs.

CONCLUSION

Introducing evidence-based education is likely to reduce the incidence of catheter-BSI and the model results suggest that the cost of introducing the interventions will be outweighed by savings related to reduced ICU bed occupancy costs.

Dasatinib, high-dose imatinib and nilotinib for the treatment of imatinib-resistant chronic myeloid leukaemia: a systematic review and economic evaluation

BACKGROUND

The present report was commissioned as a supplement to an existing technology assessment report produced by the Peninsula Technology Assessment Group (PenTAG), which evaluated the clinical effectiveness and cost-effectiveness of dasatinib and nilotinib in patients who are either resistant or intolerant to standard-dose imatinib.

OBJECTIVES

This report evaluates the clinical effectiveness and cost-effectiveness of dasatinib, nilotinib and high-dose imatinib within their licensed indications for the treatment of people with chronic myeloid leukaemia (CML) who are resistant to standard-dose imatinib.

DATA SOURCES

Bibliographic databases were searched from inception to January 2011, including The Cochrane Library, MEDLINE (Ovid), EMBASE (Ovid), and MEDLINE In-Process & Other Non-Indexed Citations. Bibliographies of related papers were screened, key conferences were searched, and experts were contacted to identify additional published and unpublished references.

REVIEW METHODS

This report includes systematic reviews of clinical effectiveness and cost-effectiveness studies, an independent appraisal of information submitted by drug manufacturers to the National Institute for Health and Clinical Excellence (NICE), an independent appraisal of the PenTAG economic evaluation, and new economic analyses adapting the PenTAG economic model. Standard systematic procedures involving two reviewers to maintain impartiality and transparency, and to minimise bias, were conducted.

RESULTS

Eleven studies met the inclusion criteria. Four of these studies included new data published since the PenTAG report; all of these were in chronic-phase CML. No relevant studies on the clinical effectiveness of nilotinib were found. The clinical effectiveness studies on dasatinib [one arm of a randomised controlled trial (RCT)] and high-dose imatinib (one arm of a RCT and three single-arm cohort studies) had major methodological limitations. These limitations precluded a comparison of the different arms within the RCT. Data from the studies are summarised in this report, but caution in interpretation is required. One economic evaluation was identified that compared dasatinib with high-dose imatinib in patients with chronic-phase CML who were CML resistant to standard-dose imatinib. Two industry submissions and the PenTAG economic evaluation were critiqued and differences in the assumptions and results were identified. The PenTAG economic model was adapted and new analyses conducted for the interventions dasatinib, nilotinib and high-dose imatinib and the comparators interferon alfa, standard-dose imatinib, stem cell transplantation and hydroxycarbamide. The results suggest that the three interventions, dasatinib, nilotinib and high-dose imatinib, have similar costs and cost-effectiveness compared with hydroxycarbamide, with a cost-effectiveness of around £30,000 per quality-adjusted life-year gained. However, it is not possible to derive firm conclusions about the relative cost-effectiveness of the three interventions owing to great uncertainty around data inputs. Uncertainty was explored using deterministic sensitivity analyses, threshold analyses and probabilistic sensitivity analyses.

LIMITATIONS

The paucity of good-quality evidence should be considered when interpreting this report.

CONCLUSIONS

This review has identified very limited new information on clinical effectiveness of the interventions over that already shown in the PenTAG report. Limitations in the data exist; however, the results of single-arm studies suggest that the interventions can lead to improvements in haematological and cytogenetic responses in people with imatinib-resistant CML. The economic analyses do not highlight any one of the interventions as being the most cost-effective; however, the analysis results are highly uncertain owing to lack of agreement on appropriate assumptions. Recommendations for future research made by PenTAG, for a good-quality RCT comparing the three treatments remain.

The clinical effectiveness and cost-effectiveness of long-term weight management schemes for adults: a systematic review

OBJECTIVE

To assess the long-term clinical effectiveness and cost-effectiveness of multicomponent weight management schemes for adults in terms of weight loss and maintenance of weight loss.

DATA SOURCES

Bibliographic databases were searched from inception to December 2009, including the Cochrane Library, MEDLINE (Ovid), EMBASE (Ovid), and MEDLINE In-Process & Other Non-Indexed Citations. Bibliographies of related papers were screened, key conferences and symposia were searched and experts were contacted to identify additional published and unpublished references.

REVIEW METHODS

For the clinical effectiveness review, two reviewers independently screened titles and abstracts for eligibility. Inclusion criteria were applied to the full text of retrieved papers by one reviewer and checked by a second reviewer using a pre-piloted inclusion flow chart. The studies were long-term randomised controlled trials (RCTs) of adult participants who were classified by body mass index as overweight or obese. Interventions were multicomponent weight management programmes (including diet, physical activity and behaviour change strategies) that assessed weight measures. Programmes that involved the use of over-the-counter medicines licensed in the UK were also eligible. For the cost-effectiveness review two reviewers independently screened studies for inclusion. Cost-effectiveness, cost-utility, cost-benefit or cost-consequence analyses were eligible. Data were extracted using a standardised and pre-piloted data extraction form. The quality of included studies was assessed using standard criteria. Studies were synthesised through a narrative review with full tabulation of results.

RESULTS

A total of 3358 references were identified, of which 12 were included in the clinical effectiveness review. Five RCTs compared multicomponent interventions with non-active comparator groups. In general, weight loss appeared to be greater in the intervention groups than in the comparator groups. Two RCTs compared multicomponent interventions that focused on the diet component. In these studies there were no statistically significant differences in weight loss between interventions. Four RCTs compared multicomponent interventions that focused on the physical activity component. There was little consistency in the pattern of results seen, in part owing to the differences in the interventions. In one RCT the intervention focused on the goal-setting interval and it appeared that weight loss was greatest in those given daily goals compared with weekly goals. Overall, where measured, it appeared that most groups began to regain weight at further follow-up. Of the 419 studies identified in the cost-effectiveness searches, none met the full inclusion criteria. Two economic evaluations are described in our review; however, caution is required in their interpretation, as they did not meet all inclusion criteria. Lifetime chronic disease models were used in these studies and the models included the costs and benefits of avoiding chronic illness. Both studies found the interventions to be cost-effective, with estimates varying between -£473 and £7200 (US$12,640) per quality-adjusted life-year gained; methodological omissions from these studies were apparent and caution is therefore required in the interpretation of these results.

CONCLUSIONS

Long-term multicomponent weight management interventions were generally shown to promote weight loss in overweight or obese adults. Weight changes were small however and weight regain was common. There were few similarities between the included studies; consequently an overall interpretation of the results was difficult to make. There is some evidence that weight management interventions are likely to be cost-effective, although caution is required as there were some limitations in the two cost-evaluation studies described.

FUNDING

The National Institute for Health Research Health Technology Assessment programme.

The effectiveness and cost-effectiveness of behavioural interventions for the prevention of sexually transmitted infections in young people aged 13-19: a systematic review and economic evaluation

OBJECTIVES

To assess the effectiveness and cost-effectiveness of schools-based skills-building behavioural interventions to encourage young people to adopt and maintain safer sexual behaviour and to prevent them from acquiring sexually transmitted infections (STIs).

DATA SOURCES

Electronic bibliographic databases (e.g. MEDLINE, MEDLINE In-Process & Other Non-Indexed Citations, EMBASE, CINAHL, PsycINFO, CCRCT, NHS EED and DARE) were searched for the period 1985 to March 2008. Bibliographies of systematic reviews and related papers were screened and experts contacted to identify additional published and unpublished references.

REVIEW METHODS

A systematic review of effectiveness and economic evaluation of cost-effectiveness were carried out. A descriptive map of studies that met inclusion criteria was produced, and keywords were developed and systematically applied to these studies to identify a policy-relevant subset of studies for the systematic review. Outcome data for variables including sexual behaviour were extracted. An economic model was developed to compare the costs and consequences of the behavioural interventions. A Bernoulli statistical model was constructed to describe the probability of STI infection.

RESULTS

There were few significant differences between the interventions and comparators in terms of changes in sexual behaviour outcomes, although there were some significant differences for knowledge and some measures of self-efficacy. The studies included in this review conducted relatively short follow-up assessments at a time when many young people were becoming sexually active. It is therefore possible that favourable behaviour change may have occurred, and become more cost-effective, with time, as sexual activity becomes more routine in young people's lives. The quality of the intervention provider influenced whether or not young people found the interventions to be acceptable and engaging; enthusiasm and considerable expertise were important for effective class management and delivery of skills-building activities, and a supportive school culture was also helpful. Recognition of young people's individual needs in relation to sexual health was another important factor. No conclusions could be drawn on the impact of the interventions on sexual health inequalities due to a lack of relevant data on socioeconomic status, gender and ethnicity. The results of the economic evaluation were considered to be illustrative, mainly due to the uncertainty of the effect of intervention on behavioural outcomes. The results were most sensitive to changes in parameter values for the intervention effect, the transmission probability of STIs and the number of sexual partners. The costs of teacher-led and peer-led behavioural interventions, based on the resources estimated from the relevant randomised controlled trials in our systematic review, were 4.30 pounds and 15 pounds per pupil, respectively. Teacher-led interventions were more cost-effective than peer-led interventions due to the less frequent need for training. The incremental cost-effectiveness of the teacher-led and peer-led interventions was 20,223 pounds and 80,782 pounds per quality-adjusted life-year gained, respectively. An analysis of individual parameters revealed that future research funding should focus on assessing the intervention effect for condom use from a school-based intervention.

CONCLUSIONS

School-based behavioural interventions for the prevention of STIs in young people can bring about improvements in knowledge and increased self-efficacy, but the interventions did not significantly influence sexual risk-taking behaviour or infection rates. Future investigation should include long-term follow-up to assess the extent to which safer sexual behaviour is adopted and maintained into adulthood, and prospective cohort studies are needed to look at the parameters that describe the transmission of STIs between partners. Funding should focus on the effectiveness of the interventions on influencing behaviour.

Gemcitabine for the treatment of metastatic breast cancer

This paper presents a summary of the evidence review group (ERG) report into the evidence for the clinical effectiveness and cost-effectiveness of gemcitabine with paclitaxel for the first-line treatment of metastatic breast cancer (MBC) in patients who have already received chemotherapy treatment with an anthracycline, compared with current standard of care, based upon the manufacturer's submission to the National Institute for Health and Clinical Excellence (NICE) as part of the single technology appraisal (STA) process. The clinical evidence for gemcitabine as a treatment for MBC comes from the unpublished JHQG trial (some data commercial-in-confidence): overall survival was 3 months longer for the gemcitabine/paclitaxel arm (18.5 months) than for the paclitaxel arm (15.8 months) (p = 0.0489); gemcitabine/paclitaxel also improved tumour response and time to documented progression of disease compared with paclitaxel monotherapy, but haematological serious adverse events were more common. In the absence of any formal methods of indirect comparison there is insufficient robust evidence to compare the relative effectiveness of gemcitabine/paclitaxel with docetaxel monotherapy or docetaxel/capecitabine combination therapy. The manufacturers used a Markov state transition model to estimate the effect of treatment with five different chemotherapy regimes, adopting a 3-year time horizon with docetaxel monotherapy as the comparator. Health state utilities for different stages of disease progression and for patients experiencing treatment-related toxicity are used to derive quality-adjusted life expectancy with each treatment. The base-case cost-effectiveness estimate for gemcitabine/paclitaxel versus docetaxel is 17,168 pounds per quality-adjusted life-year (QALY). When longer survival with docetaxel is assumed in a sensitivity analysis, the incremental cost-effectiveness ratio (ICER) is 30,000 pounds per QALY. Probabilistic sensitivity analysis estimates a 70% probability of gemcitabine/paclitaxel being cost-effective relative to docetaxel at a willingness-to-pay threshold of 35,000 pounds. There is considerable uncertainty over the results because of the lack of formal quality assessment or assessment of the comparability of the 15 trials included in the input data, and the questionable validity of the indirect comparison method adopted. An illustrative analysis using a different method for indirect comparison carried out by the ERG produces an ICER of 45,811 pounds per QALY for gemcitabine/paclitaxel versus docetaxel. The guidance issued by NICE in November 2006 as a result of the STA states that gemcitabine in combination with paclitaxel, within its licensed indication, is recommended as an option for the treatment of MBC only when docetaxel monotherapy or docetaxel plus capecitabine is also considered appropriate.

Lapatinib for the treatment of HER2-overexpressing breast cancer

This paper presents a summary of the evidence review group (ERG) report into the clinical effectiveness and cost-effectiveness of lapatinib for the treatment of advanced or metastatic HER2-overexpressing breast cancer based upon a review of the manufacturer's submission to the National Institute for Health and Clinical Excellence (NICE) as part of the single technology appraisal (STA) process. The scope included women with advanced, metastatic or recurrent HER2-overexpressing breast cancer who have had previous therapy that includes trastuzumab. Outcomes were time to progression, progression-free survival, response rates, overall survival, health-related quality of life and adverse effects. The submission's evidence came from one randomised controlled trial (RCT) of reasonable methodological quality, although it was not powered to detect a statistically significant difference in mean overall survival. Median time to progression was longer in the lapatinib plus capecitabine arm than in the capecitabine monotherapy arm {27.1 [95% confidence interval (CI) 17.4 to 49.4] versus 18.6 [95% CI 9.1 to 36.9] weeks; hazard ratio 0.57 [95% CI 0.43 to 0.77; p = 0.00013]}. Median overall survival was very similar between the groups [67.7 (95% CI 58.9 to 91.6) versus 66.6 (95% CI 49.1 to 75.0) weeks; hazard ratio 0.78 (95% CI 0.55 to 1.12; p = 0.177)]. Median progression-free survival was statistically significantly longer in the lapatinib plus capecitabine group than in the capecitabine monotherapy group [27.1 (95% CI 24.1 to 36.9) versus 17.6 (95% CI 13.3 to 20.1) weeks; hazard ratio 0.55 (95% CI 0.41 to 0.74); p = 0.000033]. The manufacturer's economic model to estimate progression-free and overall survival for patients with HER2-positive advanced/metastatic breast cancer who had relapsed following treatment with an anthracycline, a taxane and trastuzumab was appropriate for the disease area. The base-case incremental cost-effectiveness ratios (ICERs) for lapatinib plus capecitabine compared with capecitabine monotherapy or vinorelbine monotherapy were higher than would conventionally be considered cost-effective. When compared with trastuzumab-containing regimes, lapatinib plus capecitabine dominated. In sensitivity analyses the ICER for lapatinib plus capecitabine compared with capecitabine monotherapy or vinorelbine monotherapy was robust to variation in assumptions. In all sensitivity analyses the ICERs remained higher than would conventionally be considered cost-effective. ICERs for trastuzumab-containing regimes were particularly sensitive to assumptions over the frequency of treatment, which had a large effect on the cost-effectiveness of lapatinib plus capecitabine. In conclusion, there was a general lack of evidence on the effectiveness of comparators included in the model and on key parameters such as dose adjustments and the model outputs need to be interpreted in the light of this uncertainty. At the time of writing, NICE were still considering the available evidence for this appraisal.

Lapatinib for the treatment of HER2-overexpressing breast cancer

This paper presents a summary of the evidence review group (ERG) report into the clinical effectiveness and cost-effectiveness of lapatinib for the treatment of advanced or metastatic HER2overexpressing breast cancer based upon a review of the manufacturer’s submission to the National Institute for Health and Clinical Excellence (NICE) as part of the single technology appraisal (STA) process. The scope included women with advanced, metastatic or recurrent HER2-overexpressing breast cancer who have had previous therapy that includes trastuzumab. Outcomes were time to progression, progression-free survival, response rates, overall survival, health-related quality of life and adverse effects. The submission’s evidence came from one randomised controlled trial (RCT) of reasonable methodological quality, although it was not powered to detect a statistically significant difference in mean overall survival. Median time to progression was longer in the lapatinib plus capecitabine arm than in the capecitabine monotherapy arm {27.1 [95% confidence interval (CI) 17.4 to 49.4] versus 18.6 [95% CI 9.1 to 36.9] weeks; hazard ratio 0.57 [95% CI 0.43 to 0.77; p = 0.00013]}. Median overall survival was very similar between the groups [67.7 (95% CI 58.9 to 91.6) versus 66.6 (95% CI 49.1 to 75.0) weeks; hazard ratio 0.78 (95% CI 0.55 to 1.12; p = 0.177)]. Median progression-free survival was statistically significantly longer in the lapatinib plus capecitabine group than in the capecitabine monotherapy group [27.1 (95% CI 24.1 to 36.9) versus 17.6 (95% CI 13.3 to 20.1) weeks; hazard ratio 0.55 (95% CI 0.41 to 0.74); p = 0.000033]. The manufacturer’s economic model to estimate progression-free and overall survival for patients with HER2-positive advanced/metastatic breast cancer who had relapsed following treatment with an anthracycline, a taxane and trastuzumab was appropriate for the disease area. The base-case incremental cost-effectiveness ratios (ICERs) for lapatinib plus capecitabine compared with capecitabine monotherapy or vinorelbine monotherapy were higher than would conventionally be considered cost-effective. When compared with trastuzumab-containing regimes, lapatinib plus capecitabine dominated. In sensitivity analyses the ICER for lapatinib plus capecitabine compared with capecitabine monotherapy or vinorelbine monotherapy was robust to variation in assumptions. In all sensitivity analyses the ICERs remained higher than would conventionally be considered cost-effective. ICERs for trastuzumab-containing regimes were particularly sensitive to assumptions over the frequency of treatment, which had a large effect on the cost-effectiveness of lapatinib plus capecitabine. In conclusion, there was a general lack of evidence on the effectiveness of comparators included in the model and on key parameters such as dose adjustments and the model outputs need to be interpreted in the light of this uncertainty. At the time of writing, NICE were still considering the available evidence for this appraisal.

Infliximab for the treatment of adults with psoriasis

This paper presents a summary of the evidence review group (ERG) report into the clinical and cost-effectiveness of infliximab for the treatment of moderate to severe plaque psoriasis, in accordance with the licensed indication, based on the evidence submission from Schering-Plough to the National Institute for Health and Clinical Excellence (NICE) as part of the single technology appraisal (STA) process. The outcomes stated in the manufacturer's definition of the decision problem were severity [Psoriasis Area and Severity Index (PASI) score], remission rates, relapse rates and health-related quality of life. The main evidence in the submission comes from four randomised controlled trials (RCT) comparing infliximab with placebo and eight RCTs comparing either etanercept or efalizumab with placebo. At week 10, patients on infliximab had a significantly higher likelihood of attaining a reduction in PASI score than placebo patients. There were also statistically significant differences between infliximab and placebo in the secondary outcomes. In the comparator trials both the efalizumab and etanercept arms included a significantly higher proportion of patients who achieved a reduction in PASI score at week 12 than the placebo arms. No head-to-head studies were identified directly comparing infliximab with etanercept or efalizumab. The manufacturer carried out an indirect comparison, but the ERG had reservations about the comparison because of the lack of information presented and areas of uncertainty in relation to the included data. The economic model presented by the manufacturer was appropriate for the disease area and given the available data. The cost-effectiveness analysis estimates the mean length of time that an individual would respond to infliximab compared with continuous etanercept and the utility gains associated with this response. The base-case incremental cost-effectiveness ratio (ICER) for infliximab compared with continuous etanercept for patients with severe psoriasis was 26,095 pounds per quality-adjusted life-year. A one-way sensitivity analysis, a scenario analysis and a probabilistic sensitivity analysis were undertaken by the ERG. The ICER is highly sensitive to assumptions about the costs and frequency of inpatient stays for non-responders of infliximab. The guidance issued by NICE in August 2007 as a result of the STA states that infliximab within its licensed indication is recommended for the treatment of adults with very severe plaque psoriasis, or with psoriasis that has failed to respond to standard systematic therapies. Infliximab treatment should be continued beyond 10 weeks in people whose psoriasis has shown an adequate response to treatment within 10 weeks. In addition, when using the Dermatology Life Quality Index (DLQI), care should be taken to take into account the patient's disabilities, to ensure DLQI continues to be an accurate measure.

Gemcitabine for the treatment of metastatic breast cancer

This paper presents a summary of the evidence review group (ERG) report into the evidence for the clinical effectiveness and cost-effectiveness of gemcitabine with paclitaxel for the first-line treatment of metastatic breast cancer (MBC) in patients who have already received chemotherapy treatment with an anthracycline, compared with current standard of care, based upon the manufacturer’s submission to the National Institute for Health and Clinical Excellence (NICE) as part of the single technology appraisal (STA) process. The clinical evidence for gemcitabine as a treatment for MBC comes from the unpublished JHQG trial (some data commercial-in-confidence): overall survival was 3 months longer for the gemcitabine/paclitaxel arm (18.5 months) than for the paclitaxel arm (15.8 months) (p = 0.0489); gemcitabine/paclitaxel also improved tumour response and time to documented progression of disease compared with paclitaxel monotherapy, but haematological serious adverse events were more common. In the absence of any formal methods of indirect comparison there is insufficient robust evidence to compare the relative effectiveness of gemcitabine/paclitaxel with docetaxel monotherapy or docetaxel/capecitabine combination therapy. The manufacturers used a Markov state transition model to estimate the effect of treatment with five different chemotherapy regimes, adopting a 3-year time horizon with docetaxel monotherapy as the comparator. Health state utilities for different stages of disease progression and for patients experiencing treatment-related toxicity are used to derive quality-adjusted life expectancy with each treatment. The base-case cost-effectiveness estimate for gemcitabine/paclitaxel versus docetaxel is £17,168 per quality-adjusted life-year (QALY). When longer survival with docetaxel is assumed in a sensitivity analysis, the incremental cost-effectiveness ratio (ICER) is £30,000 per QALY. Probabilistic sensitivity analysis estimates a 70% probability of gemcitabine/paclitaxel being cost-effective relative to docetaxel at a willingness-to-pay threshold of £35,000. There is considerable uncertainty over the results because of the lack of formal quality assessment or assessment of the comparability of the 15 trials included in the input data, and the questionable validity of the indirect comparison method adopted. An illustrative analysis using a different method for indirect comparison carried out by the ERG produces an ICER of £45,811 per QALY for gemcitabine/paclitaxel versus docetaxel. The guidance issued by NICE in November 2006 as a result of the STA states that gemcitabine in combination with paclitaxel, within its licensed indication, is recommended as an option for the treatment of MBC only when docetaxel monotherapy or docetaxel plus capecitabine is also considered appropriate.

Diagnostic strategies using DNA testing for hereditary haemochromatosis in at-risk populations: a systematic review and economic evaluation

OBJECTIVE

To evaluate DNA testing for detecting hereditary haemochromatosis (HHC) in subgroups of patients suspected of having the disorder and in family members of those diagnosed with HHC.

DATA SOURCES

Major electronic databases, searched from inception to April 2007.

REVIEW METHODS

A systematic review was undertaken using a priori methods and a de novo model developed to assess costs and consequences of DNA testing.

RESULTS

Eleven studies were identified for estimating the clinical validity of genotyping for the C282Y mutation for the diagnosis of HHC. No clinical effectiveness studies meeting the inclusion criteria were identified. Two North American cost-effectiveness studies of reasonable quality were identified but their generalisability to the UK is not clear. Three cohort studies met the inclusion criteria for the review of psychosocial aspects. All had methodological limitations and their generalisability is difficult to determine. The clinical sensitivity of C282Y homozygosity for HHC ranged from 28.4% to 100%, or from 91.3% to 92.4% when considering only the most relevant studies. Clinical specificity ranged from 98.8% to 100%. One study found that gene testing was a cost-effective method of screening relatives of patients with haemochromatosis, whereas the other found that genotyping the spouse of a homozygote was the most cost-efficient strategy. Genetic testing for haemochromatosis appears to be well accepted, is accompanied by few negative psychosocial outcomes and may lead to reduced anxiety. The de novo economic model showed that, in people suspected of having haemochromatosis, the DNA strategy is cost saving compared with the baseline strategy using liver biopsy (cost saved per case detected 123 pounds), largely because of the reduction in liver biopsies. For family testing of siblings the DNA strategy is not cost saving because of the costs of the DNA test (additional cost per case detected 200 pounds). If the cost of the test were to reduce from 100 pounds to 60 pounds, the DNA strategy would be the cheaper one. For family testing of offspring the DNA test strategy is cheaper than the baseline biochemical testing strategy (cost saved per case detected 7982 pounds). Sensitivity analyses showed that the conclusions in each case are robust across all reasonable parameter values.

CONCLUSIONS

The preferred strategy in practice is DNA testing in conjunction with testing iron parameters when there is clear clinical indication of risk for haemochromatosis because of biochemical criteria or when there is familial risk for HHC. Access to genetic testing and centralisation of test provision in expert laboratories would lower the cost of testing, improve the cost-effectiveness of the strategy and improve the quality of information provided to clinicians and patients.

Bortezomib for the treatment of multiple myeloma patients

This paper presents a summary of the evidence review group (ERG) report into the clinical effectiveness and cost-effectiveness of bortezomib for the treatment of multiple myeloma patients at first relapse and beyond, in accordance with the licensed indication, based upon the evidence submission from Ortho Biotech to the National Institute for Health and Clinical Excellence (NICE) as part of the single technology appraisal (STA) process. The outcomes stated in the manufacturer's definition of the decision problem were time to disease progression, response rate, survival and quality of life. The literature searches for clinical and cost-effectiveness studies were adequate and the one randomised controlled trial (RCT) included was of reasonable quality. Results from the RCT suggest that bortezomib increases survival and time to disease progression compared with high-dose dexamethasone (HDD) in multiple myeloma patients who have had a relapse after one to three treatments. Cost-effectiveness analysis based on the same trial and an observational study was reasonable and gave an estimated cost per life-year gained of 30,750 pounds, which ranged from 27,957 pounds to 36,747 pounds on sensitivity analysis. An attempt was made to replicate the results of the manufacturer's model and to compare the results to the Kaplan-Meier survival curve presented in the manufacturer's submission. In addition, a one-way sensitivity analysis and a probabilistic sensitivity analysis were undertaken, as well as additional scenario analyses. Based on these analyses the ERG suggests that the cost-effectiveness results presented in the manufacturer's submission may underestimate the cost per life-year gained for bortezomib therapy (versus high-dose dexamethasone) when potential UK practice and scenarios are considered. The guidance issued by NICE in June 2006 as a result of the STA states that bortezomib monotherapy for the treatment of relapsed multiple myeloma is clinically effective compared with HDD but has not been shown to be cost-effective and is not recommended for the treatment of progressive multiple myeloma in patients who have received at least one previous therapy and who have undergone, or are unsuitable for, bone marrow transplantation.

Psychosocial aspects of DNA testing for hereditary hemochromatosis in at-risk individuals: a systematic review

AIM

To review the psychosocial benefits and harms of DNA testing for HFE-related hereditary hemochromatosis (HH) in at-risk individuals.

BACKGROUND

HH is a common genetic disease in people of European descent. DNA-based predisposition testing is used for diagnosis or in the context of family testing, but there are concerns about potential psychosocial consequences.

METHODS

Fifteen electronic databases (including Medline and Cochrane) were searched from inception to April 2007 to identify any quantitative or qualitative primary research that considered DNA testing of individuals considered at-risk of HH and reported psychosocial outcomes. Inclusion criteria, data extraction, and quality assessment were undertaken by standard methodology.

RESULTS

Three observational studies met the inclusion criteria of the review; each had methodological limitations. On receipt of test results, anxiety levels fell or were unchanged; general health-related quality-of-life outcomes improved in some aspects, or were unchanged with respect to pretest result values. Outcomes were not reported separately for those referred for diagnosis and those with family history of HH. Results suggest that genetic testing for HH in at-risk individuals is accompanied by few negative psychosocial outcomes.

CONCLUSION

The evidence on the psychosocial aspects of DNA testing for HH in at-risk individuals is limited. Further research might be required if other factors influencing the natural history of the disease phenotype are identified.

Infliximab for the treatment of adults with psoriasis

This paper presents a summary of the evidence review group (ERG) report into the clinical and cost-effectiveness of infliximab for the treatment of moderate to severe plaque psoriasis, in accordance with the licensed indication, based on the evidence submission from Schering-Plough to the National Institute for Health and Clinical Excellence (NICE) as part of the single technology appraisal (STA) process. The outcomes stated in the manufacturer’s definition of the decision problem were severity [Psoriasis Area and Severity Index (PASI) score], remission rates, relapse rates and health-related quality of life. The main evidence in the submission comes from four randomised controlled trials (RCT) comparing infliximab with placebo and eight RCTs comparing either etanercept or efalizumab with placebo. At week 10, patients on infliximab had a significantly higher likelihood of attaining a reduction in PASI score than placebo patients. There were also statistically significant differences between infliximab and placebo in the secondary outcomes. In the comparator trials both the efalizumab and etanercept arms included a significantly higher proportion of patients who achieved a reduction in PASI score at week 12 than the placebo arms. No head-to-head studies were identified directly comparing infliximab with etanercept or efalizumab. The manufacturer carried out an indirect comparison, but the ERG had reservations about the comparison because of the lack of information presented and areas of uncertainty in relation to the included data. The economic model presented by the manufacturer was appropriate for the disease area and given the available data. The cost-effectiveness analysis estimates the mean length of time that an individual would respond to infliximab compared with continuous etanercept and the utility gains associated with this response. The base-case incremental cost-effectiveness ratio (ICER) for infliximab compared with continuous etanercept for patients with severe psoriasis was £26,095 per quality-adjusted life-year. A one-way sensitivity analysis, a scenario analysis and a probabilistic sensitivity analysis were undertaken by the ERG. The ICER is highly sensitive to assumptions about the costs and frequency of inpatient stays for non-responders of infliximab. The guidance issued by NICE in August 2007 as a result of the STA states that infliximab within its licensed indication is recommended for the treatment of adults with very severe plaque psoriasis, or with psoriasis that has failed to respond to standard systematic therapies. Infliximab treatment should be continued beyond 10 weeks in people whose psoriasis has shown an adequate response to treatment within 10 weeks. In addition, when using the Dermatology Life Quality Index (DLQI), care should be taken to take into account the patient’s disabilities, to ensure DLQI continues to be an accurate measure.

Bortezomib for the treatment of multiple myeloma patients

This paper presents a summary of the evidence review group (ERG) report into the clinical effectiveness and cost-effectiveness of bortezomib for the treatment of multiple myeloma patients at first relapse and beyond, in accordance with the licensed indication, based upon the evidence submission from Ortho Biotech to the National Institute for Health and Clinical Excellence (NICE) as part of the single technology appraisal (STA) process. The outcomes stated in the manufacturer’s definition of the decision problem were time to disease progression, response rate, survival and quality of life. The literature searches for clinical and cost-effectiveness studies were adequate and the one randomised controlled trial (RCT) included was of reasonable quality. Results from the RCT suggest that bortezomib increases survival and time to disease progression compared with high-dose dexamethasone (HDD) in multiple myeloma patients who have had a relapse after one to three treatments. Cost-effectiveness analysis based on the same trial and an observational study was reasonable and gave an estimated cost per life-year gained of £30,750, which ranged from £27,957 to £36,747 on sensitivity analysis. An attempt was made to replicate the results of the manufacturer’s model and to compare the results to the Kaplan–Meier survival curve presented in the manufacturer’s submission. In addition, a one-way sensitivity analysis and a probabilistic sensitivity analysis were undertaken, as well as additional scenario analyses. Based on these analyses the ERG suggests that the cost-effectiveness results presented in the manufacturer’s submission may underestimate the cost per life-year gained for bortezomib therapy (versus high-dose dexamethasone) when potential UK practice and scenarios are considered. The guidance issued by NICE in June 2006 as a result of the STA states that bortezomib monotherapy for the treatment of relapsed multiple myeloma is clinically effective compared with HDD but has not been shown to be cost-effective and is not recommended for the treatment of progressive multiple myeloma in patients who have received at least one previous therapy and who have undergone, or are unsuitable for, bone marrow transplantation.

A decision analysis model for diagnostic strategies using DNA testing for hereditary haemochromatosis in at risk populations

BACKGROUND

New techniques for diagnosing hereditary haemochromatosis (HHC) have become available alongside traditional tests such as liver biopsy and serum iron studies.

AIM

To evaluate DNA tests in people suspected of having haemochromatosis at clinical presentation compared to liver biopsy, and in family members of those diagnosed with haemochromatosis compared to phenotypic iron studies in UK.

METHODS

Decision analytic models were constructed to compare the costs and consequences of the diagnostic strategies for a hypothetical cohort of people with suspected haemochromatosis. For each strategy, the number of cases of haemochromatosis identified and treated and the resources used were estimated.

RESULTS

For diagnostic strategies in people suspected clinically of having haemochromatosis, the DNA strategy is cost saving compared to liver biopsy (cost saved per case detected, 123 pounds) and continues to be so across all ranges of parameters. For family testing, the DNA strategy is cost saving for the offspring of the proband but not for siblings. If the DNA test cost were to reduce by 40% to 60 pounds or, if in the phenotypic model, those with initially normal iron indices were retested twice instead of once, the DNA strategy would be the cheaper one.

CONCLUSION

Diagnostic strategies involving DNA testing are likely to be cost saving in clinical cases with iron overload and in the offspring of index cases. This study supports the UK guideline recommendations for the use of DNA testing in UK.

Cardioprotection against the toxic effects of anthracyclines given to children with cancer: a systematic review

OBJECTIVES

To evaluate the technologies used to reduce anthracycline-induced cardiotoxicity in children. Also to evaluate cardiac markers to quantify cardiotoxicity, and identify cost-effectiveness studies and future research priorities.

DATA SOURCES

Eight electronic databases were searched from inception to January 2006. Bibliographies of related papers were assessed for relevant studies and experts contacted to identify additional published references.

REVIEW METHODS

A systematic review of the evidence was undertaken using a priori methods.

RESULTS

Four randomised controlled trials (RCTs) met the inclusion criteria of the review, each considering a different cardioprotective intervention; all trials included children with acute lymphoblastic leukaemia, and one also included children with non-Hodgkin's lymphoma. However, all had methodological limitations. No cost-effectiveness studies were identified. One RCT and six cohort studies on the use of cardiac markers met the inclusion criteria of the review, but also had methodological limitations. Of the two RCTs that considered continuous infusion versus bolus (rapid) infusion, one found that continuous infusion of doxorubicin did not offer any cardioprotection over bolus; the other suggested that continuous infusion of daunorubicin had less cardiotoxicity than bolus. Two studies considered cardioprotective agents, one concluded that dexrazoxane prevents or reduces cardiac injury without compromising the antileukaemic efficacy of doxorubicin and the other reported a protective effect of coenzyme Q10 on cardiac function during anthracycline therapy. One RCT suggested that cardiac troponin T can be used to assess the effectiveness of the cardioprotective agent dexrazoxane. Two cohort studies considering atrial natriuretic peptide and two considering brain (B-type) natriuretic peptide suggested that these chemicals are elevated in some subgroups of children treated with anthracyclines for cancer. N-terminal B-type natriuretic peptide levels were significantly elevated in children treated with anthracyclines who had cardiac dysfunction. One cohort study found that serum lipid peroxide was higher in younger children treated with doxorubicin than correspondingly aged children not receiving doxorubicin. No differences in carnitine levels were found in children treated with doxorubicin and a group of healthy children in one cohort study.

CONCLUSIONS

It is difficult to draw conclusions about the effectiveness of technologies for reducing or preventing cardiotoxicity and about the use of cardiac markers in children as the evidence is limited in quantity and quality. The lack of standardisation for monitoring and reporting cardiac performance is problematic. Not all studies report effectiveness in terms of cardiac outcomes and event-free survival with supporting statistical analyses. Studies are mostly small and of short duration, making generalisation difficult. Increasing numbers of survivors of childhood cancer treated with anthracyclines will experience cardiac damage and require long-term surveillance and management. This will have an impact on cardiac services and costs. Diverse medical problems and other late sequelae that affect cardiac outcome will have an impact on other specialist services. Mechanisms to reduce or prevent cardiotoxicity from anthracycline therapy and cardiac markers to improve monitoring could alter the extent of this impact on service provision. RCTs of the different methods for reducing or preventing cardiotoxicity in children treated with anthracyclines for cancer with long-term follow-up are needed to determine whether the technologies influence the development of cardiac damage. Cost-effectiveness research is also required.