Clinical outcomes and cost-effectiveness of three different compression systems in newly-diagnosed venous leg ulcers in the UK

OBJECTIVE

To assess clinical outcomes and cost-effectiveness of using a two-layer cohesive compression bandage (TLCCB; Coban 2) compared with a two-layer compression system (TLCS; KTwo) and a four-layer compression system (FLCS; Profore) in treating newly-diagnosed venous leg ulcers (VLUs) in clinical practice in the UK, from the perspective of the NHS.

METHOD

This was a retrospective cohort analysis of the case records of patients with newly-diagnosed VLUs randomly extracted from The Health Improvement Network (THIN) database (a nationally representative database of clinical practice among patients registered with general practitioners in the UK) who were treated with either TLCCB (n=200), TLCS (n=200) or FLCS (n=200). The clinical outcomes and cost-effectiveness of the alternative compression systems were estimated over six months after starting treatment.

RESULTS

Patients' mean age was 72 years and 58% were female. Time from wound onset to the start of compression was a mean of two months, and when starting compression the wound size was a mean of 45 cm². The distribution of healing was significantly different between the three groups; 76% of wounds in the TLCCB group healed by six months compared with 70% and 64% in the TLCS and FLCS groups, respectively (p=0.006). Time to healing was significantly less in the TLCCB group compared with the two other groups (p=0.003). Patients in the TLCCB group experienced better health-related quality of life over six months (0.413 quality-adjusted life years (QALYs) per patient), compared with the TLCS and FLCS groups (0.404 and 0.396 QALYs per patient, respectively). The mean six-month NHS management cost was £3045, £3842 and £4480 per patient in the TLCCB, TLCS and FLCS groups, respectively.

CONCLUSION

Real-world evidence demonstrates that treating newly-diagnosed VLUs with TLCCB, compared with the other two compression systems, affords a more cost-effective use of NHS-funded resources in clinical practice since it resulted in an increased healing rate, better health-related quality of life and a reduction in NHS management cost.

Is it time to re-appraise the role of compression in non-healing venous leg ulcers?

OBJECTIVE

To evaluate the role of compression in non-healing venous leg ulcers (VLUs) of > 3 months' duration.

METHOD

Patients' records from three independent data sets of non-healing VLUs of > 3 months'duration were re-analysed.Two data sets were separate audits of clinical practice and the third comprised patients' records from a randomised controlled trial. Some patients in each data set were never treated with compression. The effect of compression on healing at 6 months was tested with logistic regression.

RESULTS

In each data set, patients in the compression and no-compression groups were matched according to ulcer size and duration; there were no differences in comorbidities. Comparing the no-compression with the compression groups, the healing rate at 6 months was 68% vs 48% in study 1, 12% vs 6% in study 2, and 26% vs 11% in study 3. Use of compression was found to be an independent predictor of not healing with an odds ratio of 0.422, 0.456 and 0.408 in studies 1, 2 and 3 respectively.

CONCLUSION

The healing rate of non-healing VLUs of > 3 months' duration in the no-compression groups was double that of VLUs in the compression groups. These findings have the potential for treatment modification if confirmed in a prospective trial.

DECLARATION OF INTEREST

There were no external sources of funding for this study. The authors have no conflicts of interest that are directly relevant to the content of this manuscript, which remains their sole responsibility.

Costs and outcomes over 36 years of patients with phenylketonuria who do and do not remain on a phenylalanine-restricted diet

BACKGROUND

To quantify the costs and consequences of managing phenylketonuria (PKU) in the UK and to estimate the potential implications to the UK's National Health Service (NHS) of keeping patients on a phenylalanine-restricted diet for life.

METHOD

A computer-based model was constructed depicting the management of PKU patients over the first 36 years of their life, derived from patients suffering from this metabolic disorder in The Health Improvement Network database (a nationally representative database of patients registered with general practitioners in the UK). The model was used to estimate the incidence of co-morbidities and the levels of healthcare resource use and corresponding costs over the 36 years.

RESULTS

Patients who remained on a phenylalanine-restricted diet accounted for 38% of the cohort. Forty-seven per cent of patients discontinued their phenylalanine-restricted diet between 15 and 25 years of age. Of these, 73% remained off diet and 27% restarted a restricted diet at a mean 30 years of age. Fifteen per cent of the cohort had untreated PKU. Eleven per cent of patients who remained on a phenylalanine-restricted diet for 36 years received the optimum amount of prescribed amino acid supplements. Patients had a mean 12 general practitioner visits per year and one hospital outpatient visit annually, but phenylalanine levels were only measured once every 18 to 24 months. The mean NHS cost (at 2007/08 prices) of managing a PKU sufferer over the first 36 years of their life was estimated to range between £21 000 and £149 000, depending on the amount of prescribed nutrition they received.

CONCLUSION

The findings suggest that the majority of patients with PKU were under-treated. The NHS cost of patient management should not be an obstacle to encouraging patients to remain on a restricted diet until further information becomes available about the long-term clinical impact of stopping such a diet. Nevertheless, patients require counselling and managed follow up regardless of the choices they make about their diet.

Modelling the cost-effectiveness of electric stimulation therapy in non-healing venous leg ulcers

OBJECTIVE

To estimate the cost-effectiveness of using electric stimulation (ES) therapy (Accel-Heal) plus dressings and compression bandaging compared with dressings and compression bandaging alone in treating chronic, non-healing venous leg ulcers (VLUs) of >6 months' duration from the perspective of the National Health Service (NHS) in the UK.

METHOD

A 5-month Markov model was constructed, depicting the management of a chronic, non-healing VLU of >6 months' duration. The model considers the decision by a clinician to continue with a patient's previous care plan (comprising dressings and compression bandaging) or treating with ES therapy plus dressings and compression bandaging. The model was used to estimate the relative cost-effectiveness of ES therapy at 2008-2009 prices.

RESULTS

According to the model, 38% of VLUs are expected to heal within 5 months after starting ES therapy, with a further 57% expected to improve. This improvement in clinical outcome is expected to lead to a 6% health gain of 0.017 QALYs (from 0.299 to 0.316 QALYs) over 5 months. The model also showed that using ES therapy instead of continuing with a patient's previous care plan is expected to reduce the NHS cost of managing them by 15%, from £880 to £749, due in part to a 27% reduction in the requirement for nurse visits (from mean 49.0 to 35.9 visits per patient) over the first 5 months after the start of treatment. Hence, use of ES therapy was found to be a dominant treatment (improved outcome for less cost).

CONCLUSION

Within the model's limitations, use of ES therapy potentially affords the NHS a cost-effective treatment, compared with patients remaining on their previous care plan in managing chronic, non-healing VLUs of >6 months' duration. However, this is dependant on the number of ES therapy units per treatment, the unit cost of the device, and the number of nurse visits required to manage patients in clinical practice.

DECLARATION OF INTEREST

This study was sponsored by Synapse Microcurrent Ltd., manufacturers of Accel-Heal. The authors have no other conflicts of interest that are directly relevant to the content of this manuscript. In particular, Synapse Microcurrent Ltd. had no role in the study design, in the collection, analysis and interpretation of data, or in writing the manuscript.

Resource implications and budget impact of managing cow milk allergy in the UK

AIM

To determine current treatment patterns for infants with cow milk allergy (CMA) and the associated resource implications and budget impact, from the perspective of the UK's National Health Service (NHS).

METHODS

A computer-based model was constructed depicting current management of newly-diagnosed infants with CMA derived from patients suffering from this allergy in The Health Improvement Network (THIN) Database. The model spanned a period of 12 months following initial presentation to a general practitioner (GP) and was used to estimate the 12-monthly healthcare cost (at 2006/07 prices) of treating an annual cohort of 18,350 infants from when they initially present to their GP.

RESULTS

Patients presenting with a combination of gastrointestinal and atopic symptoms accounted for 59% of all patients. From the initial GP visit for CMA it took a mean 2.2 months to be put on diet, although treatment varied according to presenting symptoms. A total of 60% of all infants were initially treated with soy, 18% with an extensively hydrolysed formula and 3% with an amino acid formula. A mean 9% of patients remained symptomatic on soy and 29% on an extensively hydrolysed formula. The total cost of managing CMA over the first 12 months following initial presentation to a GP was estimated to be £1,381 per patient and £25.6 million for an annual cohort of 18,350 infants.

LIMITATIONS

Patients were not randomised to treatment and resource use was not collected prospectively. Nevertheless, 1,000 eligible patients have been included in the analysis, which should be a sufficiently large sample to accurately assess treatment patterns and healthcare resource use in actual clinical practice. The diagnosis of CMA may not be secure in all cases. Nevertheless, patients were diagnosed as having CMA by a clinician and have been managed by their GP as if they had CMA.

CONCLUSION

CMA imposes a substantial burden on the NHS. Any strategy that improves healthcare delivery and thereby shortens time to treatment, time to diagnosis and time to symptom resolution should potentially decrease the burden this allergy imposes on the health service and release resources for alternative use.

The cost-effectiveness of macrogol 3350 compared to lactulose in the treatment of adults suffering from chronic constipation in the UK

BACKGROUND

It is unknown whether macrogol 3350 (Movicol) affords the UK's National Health Service (NHS) a cost-effective addition to the current range of laxatives.

AIM

To estimate the cost-effectiveness of macrogol 3350 compared with lactulose in the treatment of chronic constipation, from the perspective of the UK's NHS.

METHODS

A decision model depicting the management of chronic constipation was constructed using clinical outcomes and resource use values derived from patients suffering from chronic constipation in The Health Independent Network (THIN) database. The model was used to estimate the cost-effectiveness of a GP prescribing macrogol 3350 instead of lactulose to treat adults > or =18 years of age suffering from chronic constipation.

RESULTS

Sixty-eight percent of patients given macrogol 3350 were successfully treated within 6 months after starting treatment compared to 60% of patients given lactulose.Patients' health status at 6 months was estimated to be 0.458 and 0.454 quality-adjusted life years (QALYs) in the macrogol 3350 and lactulose groups respectively. The total 6-monthly NHS cost of initially treating patients with macrogol 3350 or lactulose was estimated to be pound420 (US $688) and pound419 (US $686) respectively. Hence, the cost per QALY gained with macrogol 3350 was estimated to be pound250 (US $410).

CONCLUSION

Macrogol 3350 affords the NHS a cost-effective addition to the range of laxatives available for this potentially resource-intensive condition.

Modelling the resource implications and budget impact of managing cow milk allergy in Australia

OBJECTIVE

To estimate the resource implications and budget impact of current clinical practice for managing cow milk allergy (CMA) in Australia, from the perspective of the publicly funded healthcare system.

METHODS

A decision model was constructed using published clinical outcomes and clinician-derived resource utilisation estimates. The model was used to estimate the expected 6-monthly levels of healthcare resource use and corresponding costs attributable to managing 6150 new CMA sufferers following referral to a specialist.

RESULTS

The expected 6-monthly costs of managing 6150 newly-diagnosed infants with CMA following referral to a specialist was an estimated (Australian dollars, AU$) AU$6.5 million at 2006/07 prices. Clinical nutrition preparations were found to be the primary cost driver accounting for 62% of the total 6-monthly cost and clinician visits were the secondary cost driver accounting for up to a further 28% of the total 6-monthly cost. Sensitivity analysis showed there would be fewer visits to hospital-based paediatric gastroenterologists and paediatric immunologists/allergists if all newly-diagnosed patients were prescribed an amino acid formula (AAF) following referral to a specialist, instead of being managed according to current practice.

CONCLUSION

CMA imposes a substantial burden on the publicly funded healthcare system in Australia. However, using an AAF as the initial treatment for CMA can potentially release limited hospital resources for alternative use within the paediatric healthcare system.

Palliative care treatment patterns and associated costs of healthcare resource use for specific advanced cancer patients in the UK

The purpose of this paper is to identify the treatment patterns and corresponding costs of healthcare resource use associated with palliative care for different types of advanced cancer patients, from the time they started strong opioid treatment until death. This was a modelling study performed from the perspective of the UK's National Health Service (NHS). A data set was created comprising 547 patients in the DIN-Link database who had a Read code for malignant neoplasms with a specific tumour-type diagnosis and who received their first strong opioid between 1 January 1998 and 30 September 2000 and died during that period. Palliative care-related resource utilization data were obtained from the DIN-Link database. Unit costs at 2000/2001 prices were applied to the resource use estimates to determine the mean cost of palliative care from the start of treatment until death. There were significant differences in age between patients with different cancer types and in patients' survival from diagnosis, time to the start of palliative care and duration of palliative care. The mean duration from cancer diagnosis to the start of strong opioid treatment ranged from 0.7 to 5.4 years in patients with lung and breast cancer respectively. Moreover, the length of palliative care ranged from 180 to 372 days in patients with these cancer types respectively. There were also statistically significant differences in resource use between patients with different cancer types, but this reflected, in part, the varying durations of palliative care. Nevertheless, there were also differences in the monthly number of primary care visits reflecting the different number of monthly prescriptions. There was no apparent relationship between the length and corresponding cost of palliative care which ranged from 1816 pounds sterling for colon cancer to 4789 pounds sterling for ovarian cancer. Additionally, on average, only a third of all patients also received 4-hourly morphine as part of their initial strong opioid treatment. The total cost of palliative care varied between cancer type and reflects, at least in part, the distinct clinical features associated with different tumours and the varying lengths of survival following the start of strong opioid treatment. Nevertheless, no apparent relationship was found between length of palliative care and corresponding costs. This analysis provides data on palliative care resource use for a variety of cancers and could provide useful input when planning local healthcare strategies and building service commissioning models.

Cost-effectiveness of venlafaxine XL compared with diazepam in the treatment of generalised anxiety disorder in the United Kingdom

This study used decision modelling to compare the cost-effectiveness of venlafaxine XL (Efexor XL) to that of diazepam to treat non-depressed patients suffering from generalised anxiety disorder (GAD), from the perspective of the United Kingdom's National Health Service (NHS). Starting treatment with venlafaxine XL instead of diazepam significantly increased the expected probability of being in remission by 83% at 6 months (from 16.8% to 30.7%), and the expected probability of relapsing at 6 months was decreased by 79% (from 16.9% to 3.5%). The expected 6-month NHS cost of using venlafaxine XL to treat GAD was estimated to be pounds sterling 353 compared to pounds sterling 311 with diazepam. Hence starting GAD treatment with venlafaxine XL (75 mg per day) instead of diazepam (5 mg three times per day) is clinically more effective and the cost-effective strategy for managing non-depressed patients suffering from GAD in the UK.

Impacted cerumen: composition, production, epidemiology and management

In the UK, some 2.3 million people suffer cerumen ('ear wax') problems serious enough to warrant management, with approximately 4 million ears syringed annually. Impacted cerumen is a major cause of primary care consultation, and a common comorbidity in ENT patients, the elderly, infirm and people with mental retardation. Despite this, the physiology, clinical significance and management implications of excessive and impacted cerumen remain poorly characterized. There are no well-designed, large, placebo-controlled, double-blind studies comparing treatments, and accordingly, the evidence surrounding the management of impacted cerumen is inconsistent, allowing few conclusions. The causes and management of impacted cerumen require further investigation. Physicians are supposed to follow the edicts and principles of evidence-based medicine and clinical governance. Currently, in patients with impacted cerumen, the lack of evidence makes this impossible.

The annual cost of blood transfusions in the UK

This study estimated the annual UK cost of blood transfusions in 2000/2001, updating a study we performed in 1994/1995. The analysis was based on published data, information from interviews with National Health Service (NHS) personnel and a structured questionnaire for blood donors. The annual cost of provision and transfusion of blood products increased by 256% in real terms, to pounds 898 million in 2000/2001, whereas the number of whole-blood donations increased by 2% to 2.8 million. The number of apheresis donations decreased by 52% to 70 000. Total blood product units issued to hospitals in 2000/2001 increased by 17% and were used in an estimated 1.7 million transfusions. The estimated NHS cost for an adult transfusion was pounds 635 for red blood cells, pounds 378 for fresh frozen plasma, pounds 347 for platelets and pounds 834 for cryoprecipitate. Blood donors incurred an annual direct cost of pounds 8.1 million and 3.1 million hours of used leisure time. There was also an indirect cost of pounds 7.2 million arising from lost productivity. The large increases since 1994/1995 reflect a real increase in expenditure by the blood transfusion services, partly due to the introduction of leucodepletion, greater hospital resource use due to more transfusions being undertaken and under-recording of hospital activity in 1994/1995.

The clinical and cost considerations of bisphosphonates in preventing bone complications in patients with metastatic breast cancer or multiple myeloma

The bisphosphonates are potent inhibitors of osteoclast-mediated bone resorption and are now the treatment of choice for the management of hypercalcaemia of malignancy. The incidences of hypercalcaemia and other skeletal complications (bone pain, pathological fracture) remain high despite apparent responses to systemic therapy, with particularly high event rates in women with advanced skeletal metastases of breast cancer. This review focuses on studies addressing the long-term efficacy of bisphosphonates to reduce skeletal complications in breast cancer (5 studies) and multiple myeloma (4 studies), with particular reference to controlled studies of sufficient magnitude and duration to allow confidence in the estimation of efficacy. Bearing in mind the limitations of differences in trial design and the lack of direct studies comparing drugs, adequate exposure to a bisphosphonate reduces the incidence of skeletal complication by 30 to 40% in both breast cancer and multiple myeloma. Oral clondronate and intravenous pamidronate have similar efficacy in both diseases, but the duration of efficacy may differ between drugs. Both agents have shown intriguing survival benefits in subgroups of patients. The numbers needed to treat (NNT) to prevent a skeletal complication during one year are lowest in metastatic skeletal disease in breast cancer (NNT < 8) but also compare very favourably with other disease for patients with recurrent nonskeletal breast cancer or multiple myeloma (NNTs 7 to 31 depending on the complication to be prevented). Treatment costs of both breast cancer and multiple myloma are driven by inpatient and outpatient hospital visits so that bisphosphonate regimens should be developed that reduce both. Further research is required to determine if subgroups of patients can be better identified that will derive particular benefit, or perhaps no benefit at all, from bisphosphonate therapy. It is not known whether more potent bisphosphonates will deliver greater clinical efficacy in the future.

Economic impact of tibolone compared with continuous-combined hormone replacement therapy. In the management of postmenopausal women with climacteric symptoms in the UK

OBJECTIVE

To estimate the economic impact of using tibolone 2.5 mg compared with 17 beta-estradiol 2 mg/norethisterone acetate 1 mg (E2/NETA) in postmenopausal women with climacteric symptoms.

DESIGN AND SETTING

This was a modelling study performed from the perspective of the UK's National Health Service (NHS).

METHODS

The clinical outcomes from a previously reported trial were used as the clinical basis for the analysis, which showed that 48 weeks' treatment with tibolone and E2/NETA significantly alleviated the climacteric symptoms experienced by postmenopausal women. These data were combined with resource utilisation estimates derived from a panel of 10 GPs and 3 gynaecologists, enabling us to construct a Markov model depicting changes in the health status of postmenopausal women. The model was used to estimate the expected NHS costs and consequences after 48 weeks' treatment with tibolone and E2/NETA.

MAIN OUTCOME MEASURES AND RESULTS

The mean expected direct healthcare cost of using tibolone and E2/NETA to manage postmenopausal women for 48 weeks was estimated to be 260 Pounds and 239 Pounds (1997/1998 prices) per patient, respectively. Starting hormone replacement therapy (HRT) with tibolone instead of E2/NETA was equally effective in alleviating climacteric symptoms (65.9 and 62.2%, respectively; p = 0.516) over 48 weeks and significantly reduced the incidence of vaginal bleeding by 36% (p < 0.0001) and breast tenderness by 57% (p < 0.0001) for a mean additional cost of 21 Pounds (ranging between -3 Pounds and 42 Pounds) per patient. The acquisition cost of HRT was the primary cost driver for tibolone-treated patients, whereas the cost of managing adverse events was the primary cost driver for E2/NETA-treated patients.

CONCLUSIONS

The true cost of prescribing tibolone and E2/NETA is impacted on by a broad range of resources, not only drug acquisition costs. Although the acquisition cost of tibolone is higher than that of E2/NETA, the difference in the expected NHS cost of the first year of treatment between the 2 HRTs is negligible. This is because of the higher incidence of adverse events among E2/NETA-treated patients, which also results in a higher continuation rate among tibolone-treated patients. Factors such as patient preferences should also be taken into consideration so that treatment choices are not decided solely on the basis of acquisition costs.

Economic impact of using mirtazapine compared to amitriptyline and fluoxetine in the treatment of moderate and severe depression in the UK

This study modelled the economic impact of mirtazapine, compared to amitriptyline and fluoxetine, in the management of moderate and severe depression in the UK, as well as the costs related to discontinuation of antidepressant treatment. Decision models of the management of moderate and severe depression were developed from clinical trial data, resource use obtained from interviews with general practitioners and psychiatrists, and published literature, and were used to estimate the expected direct National Health Service (NHS) costs of managing a patient with moderate or severe depression. The expected cost of healthcare resource use attributable to managing a patient suffering from moderate or severe depression who discontinues antidepressant treatment, irrespective of the initial treatment, was estimated to be pounds sterling 206 (range pounds sterling 50 to pounds sterling 504) over five months. Using mirtazapine instead of amitriptyline for seven months increases the proportion of successfully treated patients by 21% (from 19.2 to 23.2%) and reduces the expected direct NHS cost by pounds sterling 35 per patient (from pounds sterling 448 to pounds sterling 413). Using mirtazapine instead of fluoxetine for six months increases the proportion of successfully treated patients by 22% (from 15.6 to 19.1%), albeit for an additional cost to the NHS of pounds sterling 27 per patient (from pounds sterling 394 to pounds sterling 420). In conclusion, this study suggests that mirtazapine is a cost-effective antidepressant compared to amitriptyline and fluoxetine in the management of moderate and severe depression in the UK.

Annual cost of erectile dysfunction to UK Society

OBJECTIVE

The objective of this study was to estimate the annual socioeconomic burden imposed by erectile dysfunction (ED) on UK society.

DESIGN AND SETTING

Health service resource use attributable to ED during 1997/1998 was obtained from appropriate databases and a panel of 22 hospital specialists comprising urologists, genito-urinary physicians, diabetologists and sexual health physicians. National unit resource costs at 1996/1997 prices were applied to the resource use data to estimate the annual National Health Service (NHS) cost of managing ED. A structured questionnaire pertaining to direct costs and absenteeism from work attributable to ED was mailed to a randomly selected sample of 5000 individuals who experience ED.

MAIN OUTCOME MEASURES AND RESULTS

During 1997/1998, the annual NHS cost was estimated to be 43.9 Pounds million for managing 113,600 men with ED. Outpatient visits were the major cost driver, accounting for 65% of the annual cost. Drugs prescribed by general practitioners (GPs) accounted for a further 25%. GP consultations and penile prosthetic surgery each accounted for 4%. Tests initiated by GPs accounted for 2%, while other resources accounted for less than 1%. The annual cost was sensitive to the number of outpatient visits and, to a lesser extent, to the number of prescriptions for ED treatments, but insensitive to changes in use of the other resources. Completed questionnaires were received from 23% (n = 1141) of the sample of individuals who experience ED. From the survey, it was estimated that the NHS managed 35% of individuals with ED in the last year. Assuming this to be representative, the total potential population of individuals with ED in the UK was estimated to be approximately 324,600 men. The total population of individuals with ED (n = 324,600 men) was estimated to incur 7.0 Pounds million annually in direct costs attributable to ED and to lose 19,630 days a year from work as a result of their ED, costing society 2.2 Pounds million in lost gross domestic product.

CONCLUSIONS

ED imposes a relatively small burden on UK society--53 Pounds million. Of this, 83% is borne by the NHS and 13% by patients. Indirect costs to society due to lost productivity account for the remaining 4%. The total NHS cost is strongly influenced by the number of hospital outpatient visits. Therefore, the future burden will depend largely on patients' eligibility to receive ED treatments on the NHS.

Cost effectiveness of amphotericin B plus G-CSF compared with amphotericin B monotherapy. Treatment of presumed deep-seated fungal infection in neutropenic patients in the UK

OBJECTIVE

To assess the economic impact of adding granulocyte colony-stimulating factor (G-CSF) to amphotericin B to treat a presumed deep-seated fungal infection in neutropenic patients. This study was conducted from the perspective of the National Health Service (NHS) hospital sector.

DESIGN

We used our previously reported trial as the clinical basis for the analysis (see Participants and interventions). These data were combined with resource utilisation data, enabling us to construct a decision tree model of the treatment paths attributable to managing patients in each arm of the trial. The model was used to calculate the cost effectiveness of using amphotericin B plus G-CSF compared to amphotericin B monotherapy in neutropenic patients with a presumed deep-seated fungal infection.

SETTING

An adult leukaemia/bone marrow transplant (BMT) unit in a large UK teaching hospital.

PARTICIPANTS

Patients with a neutrophil count of < 0.5 x 10(9)/L and having a presumed deep-seated fungal infection after either chemotherapy or stem cell/bone marrow transplantation for haematological malignancy.

INTERVENTIONS

29 patients received intravenous amphotericin B (1 mg/kg daily) plus subcutaneous G-CSF (3 to 5 micrograms/kg daily) and 30 patients received intravenous amphotericin B (1 mg/kg daily) monotherapy. The clinical trial showed that 62% of patients responded to antifungal treatment with amphotericin B plus G-CSF compared to 33% of patients who responded to amphotericin B monotherapy (p = 0.027). Nonresponders went on to receive a lipid formulation of amphotericin B.

MAIN OUTCOME MEASURE AND RESULTS

The mean cost per patient treated with amphotericin B plus G-CSF was 11,247 Pounds and the corresponding cost for amphotericin B monotherapy was 14,317 Pounds (1996/1997 values)--a cost reduction of 3070 Pounds per patient. Sensitivity analyses demonstrated that the addition of G-CSF to conventional amphotericin B in the treatment of a presumed deep-seated fungal infection offers not only clinical benefits, but cost benefits which are robust to changes in clinical and economic parameters.

CONCLUSION

From a UK hospital perspective, amphotericin B plus G-CSF is cost effective compared with amphotericin B monotherapy in managing a presumed deep-seated fungal infection in neutropenic patients. This result should provide strong arguments to clinicians and policy-makers for the adoption of this treatment strategy in such patients.

Cost-effectiveness of mirtazapine compared to amitriptyline and fluoxetine in the treatment of moderate and severe depression in austria

This study estimated the cost-effectiveness of mirtazapine, compared to amitriptyline and fluoxetine, in the management of moderate and severe depression in Austria, as well as the costs related to the discontinuation of antidepressant treatment from the perspective of the Austrian Sick Funds (Gebietskrankenkassen). The economic analyses were based on a meta-analysis of four randomised clinical trials comparing mirtazapine with amitriptyline, and on a six week comparative trial of mirtazapine and fluoxetine which was extrapolated to six months using assumptions derived from the literature. Decision models of the treatment paths and associated resource use attributable to managing moderate and severe depression in Austria were developed from clinical trial data, information on Austrian clinical practice obtained from interviews with an Austrian Delphi panel (comprising psychiatrists and GPs), and from published literature. The models were used to estimate the expected costs to the Gebietskrankenkassen of managing a patient with moderate or severe depression, and the indirect cost per patient to Austrian society due to lost productivity. The expected cost to the Gebietskrankenkassen of healthcare resource use attributable to managing a patient suffering from moderate or severe depression who discontinues antidepressant treatment was estimated to be ATS 4,088 over five months, of which hospitalisations accounted for nearly 69% of the cost. Using mirtazapine instead of amitriptyline for 28 weeks increases the proportion of successfully treated patients by 21% (from 19.2 to 23.2%), and reduces the expected cost to the Gebietskrankenkassen by ATS 1,112 per patient (from ATS 31,411 to ATS 30,299). Patients treated with mirtazapine and amitriptyline for 28 weeks are expected to miss 4.76 and 5.01 weeks of work respectively, due to their depression. Hence, the expected indirect cost to Austrian society over this period was estimated to be ATS 58, 787 and ATS 61,851 per patient respectively. Using mirtazapine instead of fluoxetine for six months increases the proportion of successfully treated patients by 22% (from 15.6 to 19.1%), albeit for a negligible additional cost to the Gebietskrankenkassen of ATS 408 per patient (from ATS 29,205 to ATS 29,613). Patients treated with mirtazapine and fluoxetine for six months are expected to miss 4.53 weeks of work, due to their depression. Hence, the expected indirect cost to Austrian society due to lost productivity was estimated to be ATS 55,900 per patient with either antidepressant. In conclusion, this study suggests that despite the differences in acquisition costs, mirtazapine is a cost-effective antidepressant compared to amitriptyline and fluoxetine, supporting the adoption of this treatment in the management of moderate and severe depression in Austria.

Cost of schizophrenia to UK Society. An incidence-based cost-of-illness model for the first 5 years following diagnosis

OBJECTIVE

This study estimated the cost to UK society of an annual cohort of newly diagnosed patients with schizophrenia over the first 5 years following diagnosis, using an incidence-based cost-of-illness framework.

DESIGN AND SETTING

A discrete event model of the course of schizophrenia was constructed, based on a literature review and interviews among a panel of healthcare professionals (n = 7). Seven discrete disease states were defined within the model. Patients' movements between these disease states enabled 10 disease courses to be identified. In each disease state, the model estimated resource use and corresponding costs borne by the National Health Service (NHS), Local Authorities, the Home Office and society as a result of lost productivity.

PATIENTS AND PARTICIPANTS

The model simulated patients' movements between disease states over the first 5 years following diagnosis. Since there are 7500 new cases of schizophrenia per year in the UK, the model was run for 7500 patient simulations.

MAIN OUTCOME MEASURES AND RESULTS

The total discounted cost to society attributable to an annual cohort of newly-diagnosed patients with schizophrenia over the first 5 years following diagnosis was estimated at 862 million Pounds (range: 788 million Pounds to 926 million Pounds in sensitivity analysis). The discounted mean 5-year cost was estimated to be approximately 115,000 Pounds (range: 105,000 Pounds to 124,000 Pounds) per patient or approximately 23,000 Pounds (range: 21,000 Pounds to 25,000 Pounds) per patient per year. The NHS accounted for 38% of the total cost, Local Authorities for 12% and the Home Office for 1%. Indirect costs due to lost productivity accounted for 49%. Of the NHS costs, hospital admissions accounted for 69% and hospital visits (outpatient, day ward and day centre attendances) for a further 26%. Drugs (antipsychotics and adjunctive medications) accounted for 2%.

CONCLUSIONS

NHS expenditure and lost productivity costs predominated, irrespective of disease course. This indicates that treatments that reduce hospitalisation and potentially enable patients to return to active employment could significantly reduce the societal burden of schizophrenia.

Economic impact of feeding a phenylalanine-restricted diet to adults with previously untreated phenylketonuria

The aim of the present study was to estimate the direct healthcare cost of managing adults with previously untreated phenylketonuria (PKU) for one year before any dietary restrictions and for the first year after a phenylalanine- (PHE-) restricted diet was introduced. The resource use and corresponding costs were estimated from medical records and interviews with health care professionals experienced in caring for adults with previously untreated PKU. The mean annual cost of caring for a client being fed an unrestricted diet was estimated to be 83 996 pound silver. In the first year after introducing a PHE-restricted diet, the mean annual cost was reduced by 20 647 pound silver to 63 348 pound silver as a result of a reduction in nursing time, hospitalizations, outpatient clinic visits and medications. However, the economic benefit of the diet depended on whether the clients were previously high or low users of nursing care. Nursing time was the key cost-driver, accounting for 79% of the cost of managing high users and 31% of the management cost for low users. In contrast, the acquisition cost of a PHE-restricted diet accounted for up to 6% of the cost for managing high users and 15% of the management cost for low users. Sensitivity analyses showed that introducing a PHE-restricted diet reduces the annual cost of care, provided that annual nursing time was reduced by more than 8% or more than 5% of clients respond to the diet. The clients showed fewer negative behaviours when being fed a PHE-restricted diet, which may account for the observed reduction in nursing time needed to care for these clients. In conclusion, feeding a PHE-restricted diet to adults with previously untreated PKU leads to economic benefits to the UK's National Health Service and society in general.

Economic impact of using clodronate in the management of patients with multiple myeloma

The economic impact of using prophylactic clodronate as an adjunct to chemotherapy in the management of multiple myeloma for the first 4 years following diagnosis was established from the perspective of the National Health Service (NHS). A state-transition model of the course of multiple myeloma was constructed using the MRC VI myelomatosis trial results and information on patient management obtained retrospectively from clinical trialists. Data were collected on resource use and corresponding costs for standard management and managing severe hypercalcaemia, vertebral and non-vertebral fractures. Managing patients with prophylactic clodronate cost the NHS a mean 22 934 pound silver per patient; comprising 16 697 pounds silver for standard management, 4862 pound silver for clodronate therapy and 1376 pound silver for adverse events. Managing patients without prophylactic clodronate cost a mean 19 557 pound silver (16 697 pound silver and 2860 pound silver for standard management and adverse events respectively). Therefore prophylactic clodronate therapy increased the cost by 3377 pound silver, or 17% per patient. Hospitalization accounted for 32% of the total cost, whereas chemotherapy accounted for 5%. The results were robust to sensitivity analyses (range 2605 pound silver-4150 pound silver). Further studies are required to assess the impact of prophylactic clodronate on quality of life to enable the clinical benefits and additional cost of this treatment to be compared with other healthcare interventions.

Cost analysis of palliative care for terminally ill cancer patients in the UK after switching from weak to strong opioids. Palliative Care Advisory Committee

OBJECTIVE

We constructed a UK-based decision model of palliative care for terminally ill cancer patients who were switched from a weak to a strong opioid so that the expected direct healthcare costs in the UK could be estimated from the time a patient commenced a strong opioid until death.

DESIGN

Decision analysis techniques were used to estimate the expected total direct healthcare cost per patient, stratified according to the first choice of strong opioid. The model was based on prescription data on 1975 terminally ill cancer patients who were on the Intercontinental Medical Statistics database, Mediplus (IMS Ltd, Middlesex, England). Resource-use data were obtained from published literature, a Delphi Panel and an advisory panel with expertise in palliative care.

MAIN OUTCOME MEASURES AND RESULTS

The expected cost of managing terminally ill cancer patients after they switched from a weak to a strong opioid ranged from 2391 pounds sterling (Pounds) to 3701 Pounds at 1995/1996 prices, depending primarily on the patient's duration of survival. Sensitivity analyses showed that the cost could be as low as 1500 Pounds or as high as 6000 Pounds, depending on resource use (at 1995/1996 prices). The key cost drivers were: hospice care, hospitalisation, general practitioner (GP) consultations and specialist nurse visits. In contrast, neither the choice of opioid nor managing constipation impacted substantially on the expected cost. Approximately two-thirds of the expected total cost was incurred by the UK National Health Service (NHS), with the remainder incurred by voluntary and charitable sectors. Hospice care and hospitalisation collectively accounted for between 50 and 80% of the expected costs. Management of patients in the community by the primary healthcare team accounted for between 10 and 40% of the costs. The acquisition cost of opioids accounted for between 2 and 8% of the expected cost and discounting the cost of these drugs sold to hospitals did not impact substantially on the total expected costs. The use of other resources such as antiemetics, NSAIDS, antidepressants and gastrointestinal drugs accounted for up to 3% of the expected cost.

CONCLUSION

The expected cost of palliative care in the UK healthcare setting ranged from approximately 2500 Pounds to 4000 Pounds (1500 Pounds to 6000 Pounds in the sensitivity analysis) depending on the length of survival after patients switch from weak to strong opioids. Since opioids account for only 2 to 8% of expected costs, factors other than economic issues, such as tolerability profile, patient preference and convenience of use, should form the basis of clinical decision-making between opioids with similar analgesic efficacy.

The annual cost of blood transfusions in the United Kingdom

This study estimated the annual cost of blood transfusions in the UK during 1994/1995. The analysis was based on published data, information derived from interviews with relevant NHS personnel and a purpose-designed structured questionnaire of blood donors. The cost to the UKs blood transfusion services of providing blood and blood products for transfusion was 165.5 Pounds million in 1994/1995. During this period, 2.75 million conventional donations of whole blood and 144,000 apheresis donations of platelets and plasma were collected: 2.58 million units of red blood cells were issued, resulting in approximately 866,000 red blood cell transfusions; 334,000 units of fresh frozen plasma and 1.16 million units of platelets were issued, resulting in approximately 17,000 and 188,000 isolated plasma and platelet transfusions, respectively. Hospital resource use attributable to providing blood transfusions during 1994/1995 cost the NHS 52.6 Pounds million. In total, blood transfusions cost the NHS 218.2 Pounds million during 1994/1995. Of this, red blood cell transfusions accounted for 76% of the annual cost, isolated platelet transfusions 16%, isolated plasma transfusions 1% and other products 7%. Donors incurred direct costs of 3.1 Pounds million and indirect costs of 11.2 Pounds million were accrued due to lost productivity. Additionally, blood donors gave up 2.5 million hours of their leisure time donating blood.

Community-acquired pneumonia: the annual cost to the National Health Service in the UK

The aim of this study was to estimate the direct annual healthcare costs to the UK National Health Service (NHS) of managing community-acquired pneumonia. Using a prevalence-based burden of illness approach, health service resource use and corresponding costs attributable to the management of community-acquired pneumonia during 1992/1993 in the UK were obtained from published sources and commercial databases, and supplemented by a telephone survey of general practitioners, finance directors, community nurses, receptionists and nurses in out-patient respiratory clinics, ambulance services, and consultant respiratory physicians. The study was appraised by a Peer Review Panel, representing a cross-section of experts from different locations. This study was a predefined subgroup analysis of a previous, larger study that estimated the annual cost to the NHS of treating all community-acquired lower respiratory tract infections. The analysis shows that there are 261,000 episodes of community-acquired pneumonia annually in the UK, costing 440.7 million pounds at 1992/1993 prices (32% of the annual cost for all community-acquired lower respiratory tract infections). Approximately 83,153 annual cases of community-acquired pneumonia are treated in hospital (32% of all episodes) and account for 96% of the annual cost. The average cost for managing pneumonia in the community is 100 pounds per episode, compared to 1,700-5,100 pounds when the patient is hospitalized, depending on the length of hospitalization. Hospitalization accounts for 87% of the total annual cost. In conclusion, community-acquired pneumonia in the UK incurs a direct healthcare cost of 440.7 million pounds annually at 1992/1993 prices. Developing and implementing strategies to prevent and minimize hospitalization will significantly reduce this annual cost and should be assessed in future studies.

A cost analysis of a treatment policy of a deliberate perioperative increase in oxygen delivery in high risk surgical patients

OBJECTIVE

To investigate the cost implications of a treatment policy of a deliberate perioperative increase of oxygen delivery in high risk surgical patients.

DESIGN

A cost-effectiveness analysis comparing 'protocol' high risk surgical patients in whom oxygen delivery was specifically targeted towards 600 ml/min/m2 with 'control' patients.

INTERVENTIONS

In a randomised, controlled clinical trial we previously demonstrated a significant reduction in mortality (5.7% vs 22.2%, p = 0.015) and morbidity (0.68 +/- 0.16 complications vs 1.35 +/- 0.20, p = 0.008) in 'protocol' high risk surgical patients in whom oxygen delivery was specifically targeted towards 600 ml/min per m2 compared with 'control' patients. This current study retrospectively analysed the medical care and National Health Service resource use of each patient in the trial. Departmental purchasing records and business managers were consulted to identify the unit cost of these resources, and thereby the cost of treating each patient was calculated.

RESULTS

The median cost of treating a protocol patient was lower than for a control patient (6,525 pounds vs 7,784 pounds) and this reduction was due mainly to a decrease in the cost of treating postoperative complications (median 213 pounds vs 668 pounds). The cost of obtaining a survivor was 31% lower in the protocol group.

CONCLUSION

Perioperative increase of oxygen delivery in high risk surgical patients not only improves survival, but also provides an actual and relative cost saving. This may have important implications for the management of these patients and the funding of intensive care.

Enzyme activities in the androgenized rat uterus refractory to oestrogenic stimulation

Uterine enzymes involved in the intermediary metabolism of glucose have been measured in the androgenized rat in which there is evidence of diminution of the oestrogenic responses despite raised glycogen and glucose typical of maximal oestrogenic stimulation. Phosphofructokinase and isocitrate dehydrogenase (NADP, cytosolic) activities were significantly decreased in the androgenized rat and were elevated following treatment with natural progesterone and synthetic progestins which partially reverse the uterine abnormalities of the androgenized rat. Mitochondrial protein was decreased in the uterus of the androgenized rat but there was an apparent sparing effect on isocitrate (NAD) and malate (NAD) dehydrogenase. The data suggest that selective effects on specific enzymes involved in intermediary metabolism are a feature of the refractory state associated with constant oestrogenic stimulation. The possible cellular mechanisms underlying these effects are discussed.

The effects of chronic manganese chloride treatment expressed as age-dependent, transient changes in rat brain synaptosomal uptake of amines

As a result of chronic manganese treatment of rats from conception onwards, a decrease was observed in the uptake of dopamine, but not of noradrenaline or serotonin, by synaptosomes isolated from hypothalamus, striatum, and midbrain and in choline uptake by hypothalamic synaptosomes obtained from 70-90-day-old animals. In 100-120-day-old manganese-treated rats the only difference observed was increased choline uptake by striatal synaptosomes. All comparisons were with age-matched controls. These results, which are consistent with views of a dopaminergic and cholinergic involvement in manganese encephalopathy, point out that changes in these systems are observable only at specific times during manganese intoxication.