OP0198-HPR A STRUCTURED MODEL FOR OA CARE IN PRIMARY HEALTHCARE IS A COST-EFFECTIVE ALTERNATIVE COMPARED TO USUAL CARE FOR PEOPLE WITH HIP AND KNEE OA

Background:

To improve quality of care for patients with hip and knee osteoarthritis (OA), a structured model for integrated OA care was developed based on international treatment recommendations. A previous analysis of a cluster RCT (cRCT) showed that compared to usual care, the intervention group reported higher quality of care and greater satisfaction with care. Also, more patients were treated according to international guidelines and fulfilled recommendations for physical activity at the 6-month follow-up.

Objectives:

To assess the cost-utility of a structured model for hip or knee OA care.

Methods:

A cRCT with stepped-wedge cohort design was conducted in 6 Norwegian municipalities (clusters) in 2015-17. The OA care model was implemented in one cluster at the time by switching from “usual care” to the structured model. The implementation of the model was facilitated by interactive workshops for general practitioners (GPs) and physiotherapists (PTs) with an update on OA treatment recommendations. The GPs explained the OA diagnosis and treatment alternatives, provided pharmacological treatment when appropriate, and suggested referral to physiotherapy. The PT-led patient OA education programme was group-based and lasted 3 hours followed by an 8–12-week individually tailored resistance exercise programme with twice weekly 1-hour supervised group sessions (5–10 patients per PT). An optional 10-hours Healthy Eating Program was available. Participants were ≥45 years with symptomatic hip or knee OA.

Costs were measured from the healthcare perspective and collected from several sources. Patients self-reported visits in primary healthcare at 3, 6, 9 and 12 months. Secondary healthcare visits and joint surgery data were extracted from the Norwegian Patient Register. The health outcome, quality-adjusted life-year (QALY), was estimated based on the EQ-5D-5L scores at baseline, 3, 6, 9 and 12 months. The result of the cost-utility analysis was reported using the incremental cost-effectiveness ratio (ICER), defined as the incremental costs relative to incremental QALYs (QALYs gained). Based on Norwegian guidelines, the threshold is €27500. Sensitivity analyses were performed using bootstrapping to assess the robustness of reported results and presented in a cost-effectiveness plane (Figure 1).

Results:

The 393 patients’ mean age was 63 years (SD 9.6) and 74% were women. 109 patients were recruited during control periods (control group), and 284 patients were recruited during interventions periods (intervention group). Only the intervention group had a significant increase in EQ-5D-5L utility scores from baseline to 12 months follow-up (mean change 0.03; 95% CI 0.01, 0.05) with QALYs gained: 0.02 (95% CI -0.08, 0.12). The structured OA model cost approx. €301 p.p. with an additional €50 for the Healthy Eating Program. Total 12 months healthcare cost p.p. was €1281 in the intervention and €3147 in the control group, resulting in an incremental cost of -€1866 (95% CI -3147, -584) p.p. Costs related to surgical procedures had the largest impact on total healthcare costs in both groups. During the 12-months follow-up period, 5% (n=14) in the intervention compared to 12% (n=13) in the control group underwent joint surgery; resulting in a mean surgical procedure cost of €553 p.p. in the intervention as compared to €1624 p.p. in the control group. The ICER was -€93300, indicating that the OA care model resulted in QALYs gained and cost-savings. At a threshold of €27500, it is 99% likely that the OA care model is a cost-effective alternative.

Conclusion:

The results of the cost-utility analysis show that implementing a structured model for OA care in primary healthcare based on international guidelines is highly likely a cost-effective alternative compared to usual care for people with hip and knee OA. More studies are needed to confirm this finding, but this study results indicate that implementing structured OA care models in primary healthcare may be beneficial for the individual as well as for the society.

Disclosure of Interests:

None declared

Cost-effectiveness of liver transplantation in patients with colorectal metastases confined to the liver

BACKGROUND

Patients with non-resectable colorectal metastases are currently treated with chemotherapy. However, liver transplantation can increase the 5-year survival rate from 9 to 56 per cent if the cancer is confined to the liver. The aim of this study was to estimate the cost-effectiveness of liver transplantation for colorectal liver metastases.

METHODS

A Markov model with a lifetime perspective was developed to estimate the life-years, quality-adjusted life-years (QALYs), direct healthcare costs and cost-effectiveness for patients with non-resectable colorectal liver metastases who received liver transplantation or chemotherapy alone.

RESULTS

In non-selected cohorts, liver transplantation increased patients' life expectancy by 3·12 life-years (2·47 QALYs), at an additional cost of €209 143, giving an incremental cost-effectiveness ratio (ICER) of €67 140 per life-year (€84 667 per QALY) gained. In selected cohorts (selection based on tumour diameter, time since primary cancer, carcinoembryonic antigen levels and response to chemotherapy), the effect of liver transplantation increased to 4·23 life-years (3·41 QALYs), at a higher additional cost (€230 282), and the ICER decreased to €54 467 per life-year (€67 509 per QALY) gained. Given a willingness to pay of €70 500, the likelihood of transplantation being cost-effective was 0·66 and 0·94 (0·23 and 0·67 QALYs) for non-selected and selected cohorts respectively.

CONCLUSION

Liver transplantation was cost-effective but only for highly selected patients. This might be possible in countries with good access to grafts and low waiting list mortality.

Hemiarthroplasty compared to internal fixation with percutaneous cannulated screws as treatment of displaced femoral neck fractures in the elderly: cost-utility analysis performed alongside a randomized, controlled trial

We estimated the cost-effectiveness of hemiarthroplasty compared to internal fixation for elderly patients with displaced femoral neck fractures. Over 2 years, patients treated with hemiarthroplasty gained more quality-adjusted life years than patients treated with internal fixation. In addition, costs for hemiarthroplasty were lower. Hemiarthroplasty was thus cost effective.

INTRODUCTION

Estimating the cost utility of hemiarthroplasty compared to internal fixation in the treatment of displaced femoral neck fractures in the elderly.

METHODS

A cost-utility analysis (CUA) was conducted alongside a clinical randomized controlled trial at a university hospital in Norway; 166 patients, 124 (75%) women with a mean age of 82 years were randomized to either internal fixation (n = 86) or hemiarthroplasty (n = 80). Patients were followed up at 4, 12, and 24 months. Health-related quality of life was assessed with the EQ-5D, and in combination with time used to calculate patients' quality-adjusted life years (QALYs). Resource use was identified, quantified, and valued for direct and indirect hospital costs and for societal costs. Results were expressed in incremental cost-effectiveness ratios.

RESULTS

Over the 2-year period, patients treated with hemiarthroplasty gained 0.15-0.20 more QALYs than patients treated with internal fixation. For the hemiarthroplasty group, the direct hospital costs, total hospital costs, and total costs were non-significantly less costly compared with the internal fixation group, with an incremental cost of €2,731 (p = 0.81), €2,474 (p = 0.80), and €14,160 (p = 0.07), respectively. Thus, hemiarthroplasty was the dominant treatment. Sensitivity analyses by bootstrapping supported these findings.

CONCLUSION

Hemiarthroplasty was a cost-effective treatment. Trial registration, NCT00464230.

Evidence of uptake, biotransformation and DNA binding of polyaromatic hydrocarbons in Atlantic cod and corkwing wrasse caught in the vicinity of an aluminium works

Feral Atlantic cod (Gadus morhua) and corkwing wrasse (Symphodus melops) were investigated for polyaromatic hydrocarbon (PAH) contamination in the Karmsund strait, western Norway. This strait is highly contaminated with PAHs, and a main source is the chronic release of gas-scrubbing effluents from a local aluminium works. In both species, the level of biliary PAH metabolites and hepatic DNA adducts were higher in fish collected near the aluminium works. Interestingly, a significantly higher level of both biliary PAH metabolites and hepatic DNA adducts was found in corkwing wrasse as compared to cod, indicating a higher potential for genotoxic effects in this species. Hepatic cytochrome P4501A (CYP1A) in cod estimated by ethoxyresorufin-O-deethylase and an immunoassay technique (ELISA), seemed to be weakly induced at the contaminated sites. At the most contaminated site, skin ulcers and fin erosion were detected in about 70 and 45% of the cods, respectively. The data demonstrated that both cod and corkwing wrasse may be suitable target species for PAH pollution monitoring.

PAH metabolites in bile, cytochrome P4501A and DNA adducts as environmental risk parameters for chronic oil exposure: a laboratory experiment with Atlantic cod

In order to perform environmental risk assessments with regard to oil contamination in the sea, it is important to obtain knowledge about threshold levels for possible adverse effects in marine organisms. With this objective in mind, selected biomarkers were studied in Atlantic cod (Gadus morhua) chronically exposed to mechanically dispersed crude oil. The fish were exposed for 30 days in a continuous flow system to nominal concentrations of 0.06, 0.25 and 1 ppm North Sea crude oil. Fish were sampled five times during the exposure period. In addition, the 1 ppm group and the control group were sampled 1 week after the end of exposure. Polyaromatic hydrocarbon (PAH) concentrations in the seawater were analysed regularly by direct fluorescence and, at one occasion, by gas chromatography with mass spectrographic detection (GC/MS) measurements. Liver samples were analysed for parent PAH levels by means of GC/MS measurements, and PAH metabolites in bile were analysed by means of fixed wavelength fluorescence. Cytochrome P450 induction in liver was estimated by ethoxyresorufin-O-deethylase (EROD) activity, and hepatic DNA adducts were analysed by the 32P-postlabelling assay. The parent PAH concentrations in liver showed peak levels 3 days after the start of exposure, followed by a reduction towards the end of the experiment. In contrast, the PAH metabolites in bile and EROD activity showed generally increasing levels throughout the whole exposure period, indicating an increased biotransformation efficiency. The level of DNA adducts in the 1 ppm group showed a stable increase during the entire exposure period. Only a slight, non-significant decrease in DNA adduct levels was observed after 7 days of recovery in clean water. Exposure-dependent responses were observed for all three biomarkers. The lowest nominal concentration of dispersed oil in water, 0.06 ppm, corresponded to a measured total PAH concentration in the water of 0.3 ppb. Atlantic cod exposed to this concentration showed increased levels of PAH metabolites in bile and a slight induction of CYP1A, as well as formation of DNA adducts when compared with control fish. Particularly noteworthy is the detection of DNA adducts at such a low exposure concentration of oil in water, which, to our knowledge, is a novel finding. These dose-response data may serve as useful contributions when assessing environmental risk with regard to marine oil pollution.

Field observations of the relation between satellite and sea radiances in coastal waters

Estimates of the different contributions to the satellite radiance above the outer Oslofjord are presented. The contribution from the sea is of the order of 10% of the total signal, and the part due to reflection from the sea surface constitutes 10-20%. The presence of land may increase the satellite radiance up to 4-9%, but such effects, which are probably reduced to 1/e at a distance of 1 km from the coast, cannot be detected in the present measurements. In situ observations of the marine radiance are corrected for shadings by ship and instrument and for varying solar altitude. The average correction for the self-shading effect of the marine instrument becomes 30-50% in these waters. The linear relations between satellite and sea radiances are determined with correlation coefficients of better than 0.95. The observed minimum value of the satellite radiance (or darkest pixel) is not a satisfactory approximation for the atmospheric correction. It is concluded that, in coastal waters and at the present stage, satellite observations have to be combined with field measurements to obtain reliable results.

Two-stream irradiance model for deep waters

The two-stream model expresses the vertical attenuation coefficient K and the irradiance ratio R as functions of the absorption coefficient a, the backward scattering coefficient b(b), the downward and upward average cosines micro (d) and micro (u), and the normalized reflectance coefficients of downward and upward scalar irradiance, r(d) and r(u). While K/a and R are almost linear functions of b(b)/a when b(b)/a is small, they will approach asymptotic values, which only depend on r(d), r(u), micro (d), and micro (u) when b(b)/a becomes large. The results agree well with oceanic observations of K and R. They also agree with theoretical results derived by other methods. Still proper testing of the model in turbid waters remains.

Local immunoreactivity and human papillomavirus (HPV) in oral precancer and cancer lesions

A retrospective longitudinal study was performed on 20 patients with oral leukoplakia, 10 of which developed an oral squamous cell carcinoma, to assess whether any alterations in the local immunologic reactivity could be found of value in predicting the subsequent behavior of the lesions. During the major period of follow-up, the relative frequency of in situ IgA-producing plasma cells was significantly higher in biopsies from patients subsequently developing cancer than in patients showing no cancer development. Preceding the malignant transformation by 12 to 15 months, however, a remarkable shift from IgA to IgG plasma cell predominance was noticed in the biopsies of the cancer series, not detectable in the non-cancer group. HPV group specific capsid antigens were found in seven cases of the cancer series and in six of the non-cancer group. The possible diagnostic implications of these results are discussed.

Amalgam-related oral lichenoid reaction

In 52 patients with oral lichen planus topographically related to amalgam restorations, the fillings were replaced by other materials in 18, 16 of whom experienced complete remission of the lesions within 1-12 months. These results are discussed in relation to the results of epicutaneous patch tests for possible allergy to a number of mercury compounds. The term "oral lichenoid reaction", is suggested to describe these lesions.

Malignant transformation in oral lichen planus

A carcinoma arose in the buccal mucosa of a 71-year-old woman suffering from several systemic diseases, and on extensive medication. The buccal mucosa had been affected by oral lichen planus for more than 9 years. The possibility of malignant transformation of oral lichen planus is discussed.

Viral hepatitis in dentists in Norway

Exceptions have occurred to the generally reported high prevalence of viral hepatitis in dentists. Thus a recent questionnaire survey (1) indicated a low risk of hepatitis in dental professionals in Norway. The present supplementary study was based on frequencies of serological markers of viral hepatitis and disclosed an exposure rate to hepatitis B insignificantly higher than that of the general population. The frequency of antibody to hepatitis A virus was equal to that of the general population.

Oral antrostomy

Removal of localized polypous maxillary sinus membrane is, in our opinion, occasionally indicated in conjunction with surgical closure of oroantral communication. An alternative to nasal antrostomy is presented in this paper. Packing the maxillary sinus with gauze to prevent the collection of blood and to secure drainage is achieved by carrying the end of the gauze strip subperiosteally and through the vertical incision in the anterior part of the vestibule. This technique was applied in the treatment of the 12 patients included in this study. All of these were treated as outpatients. At follow-up visits after 2 months to 1 years, all patients were found to be without symptoms or complaints.