The cost of prevalent and incident cardiovascular disease in people with type 2 diabetes in Scotland: data from the Scottish Care Information-Diabetes Collaboration

AIM

To compare costs for three groups of people with type 2 diabetes, those at high risk of future cardiovascular disease, those without cardiovascular disease and those with established cardiovascular disease, and to also compare costs incurred by people with type 2 diabetes with an incident cardiovascular disease event with those who remain incident event-free over a 3-year period.

METHODS

Data about people with type 2 diabetes in Scotland were obtained from the Scottish Care Information Diabetes registry. Data linkage was used to retrieve information on healthcare utilization, care home use and deaths. Productivity effects were estimated for those of non-pensionable age. We estimated costs over 12 months (prevalent cardiovascular disease) and 3 years from incident cardiovascular disease event.

RESULTS

Mean annual cost per person with established cardiovascular disease was £6900, £3300 for a person at high risk of future cardiovascular disease, and £2500 for a person without cardiovascular disease and not at high risk. In year 1, the cost of an incident cardiovascular disease event was £16 700 compared with £2100 for people without an incident event. Over 2 years, the cumulative costs were £21 500 and £4200, and by year 3, £25 000 and £5900, respectively.

CONCLUSIONS

Cardiovascular disease in people with type 2 diabetes places a significant financial burden on healthcare and the wider economy. Our results emphasize the financial consequences of cardiovascular disease prevention strategies.

87 Effects of Community Falls Prevention Service Closure on ICD-10 Coded Fracture Rates in Older People: An Interrupted Time Series Approach

Introduction

Guidelines on falls prevention recommend case ascertainment based on opportunistic case ascertainment and referral in those who have fallen. In October 2009 we implemented a novel multidisciplinary, multifactorial falls, syncope and dizziness service with enhanced case-ascertainment through proactive, primary care-based screening for associated risk factors. In addition to comprehensive geriatric assessment, 25% of 4032 service participants underwent strength and balance training. The baseline outcomes have been previously reported.1 Funding was withdrawn, and the service closed on 31/01/2014. We examined the effect of service-closure on fractures presenting to secondary care with and without the service running.

Methods

An interrupted time series method was used. ICD-10 coded fracture numbers attending secondary care were determined (Hospital Episode Statistics from 01/02/2012-31/05/2017) for all North Tyneside residents ≥60 years at the time of service closure, including 25-months with, and 40-months without, service provision.

Results

There was a 0.9% (p=0.018) monthly reduction in falls over 25-months of service provision which increased during the winter months of a 9.8% (p=0.015) increase. In the month following the service closure there was an initial increase in fractures of 8.5% (p=0.231), followed by an increase in the monthly time trend of 1% (p=0.018). This resulted in a post-service monthly increase in fractures of 0.1%, an estimated extra 625 fractures over the 40-month post-service cessation period. At an average £8600 per fracture, the estimated cost may have been £5,375,000.

Conclusions

In this naturalistic experiment, following an initial drop in fractures, disinvestment in this service resulted in a rise in elders’ fractures presenting to secondary care. The closure of the service may have had a large unintended cost, averaging £1.5 million annually, versus annual running costs of £220,000. Further research is needed to control for patient-level characteristics and to establish the cost-effectiveness of the service.

74 Effects of Community Falls Prevention Service Closure on Ischaemic Heart Disease Attendances in Secondary Care: An Interrupted Time Series Approach

Background

In 2009 we implemented a novel multidisciplinary, multifactorial falls, syncope and dizziness service model utilising proactive, primary care-based screening (≥60 years). Participants underwent comprehensive geriatric assessment, while 25% of the 4032 service participants had exercise training. All had additional lifestyle advice on exercise, alcohol intake, weight loss and smoking cessation. The preliminary outcomes of this approach have been previously reported, with occult atrial fibrillation, murmurs, ECG-evident ischaemic heart disease (IHD) etc reported to GPs for further action.1 Funding was withdrawn and the service closed on 31/01/2014. We examined IHD secondary care attendances with and without service provision.

Methods

Patients: North Tyneside residents ≥60 years at time of closure of the service in January 2014, who were presented acutely to secondary care with IHD using an interrupted time series method. ICD-10 coded IHD numbers were determined (Hospital Episode Statistics from 01/02/2012[date of a change in coding compared to service commencement in 2009] until 31/05/2017) including 25-months with, and 40-months without, service provision.

Results

The Table summarises the change in IHD +/- service provision; there was a significant reduction in IHD non-elective admissions during both time series’, but the reduction was significantly lower without service provision.

In addition, immediately following the service closure there was an initial increase in IHD complications of 18.4% (p=0.059) followed by an increase in the time trend of 2.7% (p=0.029), resulting in a 0.6% post-service monthly reduction in IHD complications.

Conclusions

Disinvestment in this service resulted in a slowdown in the underlying reduction of IHD diagnoses in secondary care. However, further research is needed to control for patient-level characteristics, the economic impact and to look at the effect of the service on other cardiovascular diseases.

Reference

1. Parry SW. JAGS 2016; 64 (11):2368–2373.

Clinical effectiveness and cost-effectiveness of foot orthoses for people with established rheumatoid arthritis: an exploratory clinical trial

OBJECTIVES

Foot orthoses are commonly prescribed as an intervention for people with rheumatoid arthritis (RA). Data relating to the cost-effectiveness of foot orthoses in people with RA are limited. The aim was to evaluate the clinical and cost-effectiveness of two types of foot orthoses in people with established RA.

METHOD

A single-blind randomized controlled trial was undertaken to compare custom-made foot orthoses (CMFOs) and simple insoles (SIs) in 41 people with established RA. The Foot Function Index (FFI) was used to measure foot pain, disability, and functional limitation. Costs were estimated from the perspective of the UK National Health Service (NHS), societal (patient and family) perspective, and secondary care resource use in terms of the intervention and staff time. Effects were assessed in terms of health gain expressed as quality-adjusted life years (QALYs).

RESULTS

At baseline, 20 participants received a CMFO and 21 participants received an SI. After 16 weeks foot pain improved in both the CMFOs (p = 0.000) and the SIs (p < 0.01). However, disability scores improved for CMFOs (p < 0.001) but not for SIs (p = 0.40). The cost-effectiveness results demonstrated no difference in cost between the arms (CMFOs: £159.10; SIs: £79.10; p = 0.35), with the CMFOs being less effective in terms of cost per QALY gain (p < 0.001).

CONCLUSIONS

In people with established RA, semi-rigid customized foot orthoses can improve pain and disability scores in comparison to simple insoles. From a cost-effectiveness perspective, the customized foot orthoses were far more expensive to manufacture, with no significant cost per QALY gain.

Synthesis and structure-activity relationships of a series of penicillin-derived HIV proteinase inhibitors: heterocyclic ring systems containing P1' and P2' substituents

As an extension of our earlier work based upon a single penicillin-derived thiazolidine moiety we have found that the decahydroisoquinoline grouping, also present in Ro 31-8959, is an effective replacement for one of the thiazolidine units in C2 symmetric penicillin-derived dimers. Reaction of racemic epoxide 6 with [3S-[3 alpha, 4a alpha, 8a alpha]]-decahydro-N-(1,1-dimethylethyl)-3- isoquinolinecarboxamide gave diasteroisomers 34a and 34b. The stereochemistry of the hydroxyl grouping of 34a was determined to be (S). Reaction of the amines derived from 34a and 34b with thiazolidine 8a gave 50 and 51, respectively. Compound 50 was a potent inhibitor of HIV proteinase (IC50 = 23 nM) with antiviral activity against HIV-1 in vitro (EC50 C8166 cells = 50 nM). However, a poor pharmacokinetic profile in the dog for compound 50 and its analogues, in keeping with earlier studies on penicillin-derived dimers in three species, precluded their development as potential antivirals.

Synthesis and structure-activity relationships of a series of penicillin-derived HIV proteinase inhibitors containing a stereochemically unique peptide isostere

A series of HIV-1 proteinase inhibitors was synthesized based upon a single penicillin derived thiazolidine moiety. Reaction of the C-4 carboxyl group with (R)-phenylalaninol gave amide 10 which was a moderately potent inhibitor of HIV-1 proteinase (IC50 = 0.15 microM). Further modifications based on molecular modeling studies led to compound 48 which contained a stereochemically unique statine-based isostere. This was a potent competitive inhibitor (Ki = 0.25 nM) with antiviral activity against HIV-1 in vitro (5 microM). Neither modification to the benzyl group in an attempt to improve interaction with the S2' pocket, nor introduction of a hydrogen bond donating group to interact with residue Gly48' resulted in improved inhibitory or antiviral activity.

A series of penicillin-derived C2-symmetric inhibitors of HIV-1 proteinase: structural and modeling studies

The binding modes of a series of penicillin-derived C2 symmetric dimer inhibitors of HIV-1 proteinase were investigated by NMR, protein crystallography, and molecular modeling. The compounds were found to bind in a symmetrical fashion, tracing and S-shaped course through the active site, with good hydrophobic interactions in the S1/S1' and S2/S2' pockets and hydrogen bonding of inhibitor amide groups. Interactions with the catalytic aspartates appeared poor and the protein conformation was very similar to that seen in complexes with peptidomimetics, in spite of the major differences in ligand structure.