The cost of inflammatory bowel disease in high-income settings: a Lancet Gastroenterology & Hepatology Commission

The cost of caring for patients with inflammatory bowel disease (IBD) continues to increase worldwide. The cause is not only a steady increase in the prevalence of Crohn's disease and ulcerative colitis in both developed and newly industrialised countries, but also the chronic nature of the diseases, the need for long-term, often expensive treatments, the use of more intensive disease monitoring strategies, and the effect of the diseases on economic productivity. This Commission draws together a wide range of expertise to discuss the current costs of IBD care, the drivers of increasing costs, and how to deliver affordable care for IBD in the future. The key conclusions are that (1) increases in health-care costs must be evaluated against improved disease management and reductions in indirect costs, and (2) that overarching systems for data interoperability, registries, and big data approaches must be established for continuous assessment of effectiveness, costs, and the cost-effectiveness of care. International collaborations should be sought out to evaluate novel models of care (eg, value-based health care, including integrated health care, and participatory health-care models), as well as to improve the education and training of clinicians, patients, and policy makers.

Compliance to guideline-recommended pharmacotherapy in patients with heart failure, 2014 to 2020

Background

Poor drug adherence in heart failure (HF) is associated with increased morbidity and mortality.

Aims

We aimed to investigate compliance to European guidelines for treatment of HF in Norway by measuring initiation and persistence of inhibitors of the renin-angiotensin system (RASi), β-blockers (BB) and mineralocorticoid receptor antagonists (MRA).

Methods

We included all patients ≥18 years with a first hospital contact for HF registered in the Norwegian Patient Registry (NPR) between 2014–2020. Patients >80 years of age and patients that deceased within the first 30 days were excluded. The study population was linked to the Norwegian Prescription Database for longitudinal data on drug prescriptions. Dual HF therapy was defined as taking at least two recommended HF drug classes, triple HF therapy was defined as taking all three drug classes. To estimate initiation, we counted the days from index HF to the first HF prescription, dual HF therapy and triple HF therapy within the first 365 days. We repeated the analysis for drug-naive patients, as some patients receive HF drugs for other indications or based on a tentative HF diagnosis. Patients were considered persistent if they did not experience any treatment break of more than 30 days. We allowed for stockpiling up to a maximum of 60 days, except for when the dose changed or if patients switched medication within the same drug class. Initiation and persistence were calculated by the Kaplan-Meier method, followed to death or December 2020.

Results

Out of 54,899 patients, 75%, 69% and 21% initiated BB, RASi and MRA, respectively (Figure 1). 13% of the population did not receive any of the three drug groups. Dual HF therapy was prescribed to 61% of the patients and triple HF therapy to 16%. In drug-naive patients, a lower proportion received any HF-drug within the first year (BB, 61%; RASi, 55%; and MRA, 19%), however, a higher proportion was collected within the first 30 days (BB, 48%; RASi, 46%; and MRA, 11%). Among the patients initiating therapy, 72% were persistent on BB, 71% on RASi and 48% on MRA throughout the first year with prominent declines in persistence around 3 and 6 months after initiation (Figure 2). Two years after initiation, the proportions of patients on BB, RASi and MRA decreased to 58%, 57% and 31%, respectively. The 5-year persistence was 38%, 37% and 15%, respectively.

Conclusion

This study found poor treatment compliance to HF medications in a real-world population of HF patients with only 61% of patients initiating dual pharmacotherapy and only 16% received all three dug classes. Nearly half of the patients discontinued RASi and BB within 2 years. The results suggest that systematic efforts should be done to increase the proportion of patients on guideline recommended therapies. These efforts should be focused on early initiation of multiple drug therapies as well as to maintain patients on treatment over time.

Funding Acknowledgement

Type of funding sources: Other. Main funding source(s): Novartis Norway AS and The Norwegian Research Council

The spread of drug use: epidemic models or social interaction?

This chapter argues that models trying to explain the spread of drug use should not be based on standard epidemiological models developed to describe the spread of infectious diseases. The main weaknesses of the standard model are the lack of attention to micro-foundations and the inappropriateness of several of its assumptions in the context of drug use. An approach based on mechanisms and social interaction is argued to provide a promising alternative to the standard approach. To illustrate this, a model of the spread of drugs based on two mechanisms has been developed (observational learning and social stigma). Lastly, some of the difficulties in testing and deriving policy implications in these models are discussed.