Do-not-attempt resuscitation policy reduced in-hospital cardiac arrest rate and the cost of care in a developing country

We aim to study the characteristics and outcomes of patients with a Do-Not-Attempt Resuscitation and to determine its impact on the Cost of In-Hospital Cardiac Arrest. A retrospective study of all adult patients admitted to the hospital from June 2021 to May 2022 who had a Do-Not-Resuscitate order. We abstracted patients' socio-demographics, physiologic parameters, primary diagnosis, and comorbidities from the electronic medical records. We calculated the potential economic cost using the median ICU length of stay for the admitted IHCA patients during the study period. There were 28,866 acute admissions over the study period, and 788 patients had DNR orders. The median (IQR) age was 71 (55-82) years, and 50.3% were males. The most prevalent primary diagnosis was sepsis, 426 (54.3%), and cancer was the most common comorbidity. More than one comorbidities were present in 642 (80%) of the cohort. Of the DNR patients, 492 (62.4%) died, while 296 (37.6%) survived to discharge. Cancer was the primary diagnosis in 65 (22.2%) of those who survived, compared with 154 (31.3%) of those who died (P = 0.002). Over the study period, 153 patients had IHCA and underwent CPR, with an IHCA rate of 5.3 per 1,000 hospital admissions. Without a DNR policy, an additional 492 patients with cardiac arrest would have had CPR, resulting in an IHCA rate of 22.3 per 1000 hospital admissions. Most DNR patients in our setting had sepsis complicated by multiple comorbidities. The DNR policy reduced our IHCA incidence by 76% and prevented unnecessary post-resuscitation ICU care.

Trial-based economic evaluation of the system-integrated activation of community health volunteers in rural Ghana

BACKGROUND

Globally, steps to revitalise programmes deploying community health workers (CHWs) on a national scale have been growing, but few economic evaluations have been done on system-integrated CHW programmes. Ghana has dual cadres of CHWs: community health officers (CHOs) and community health volunteers (CHVs). CHO plays a major role in primary health services but has suffered from chronic staff shortages. We activated CHVs in communities to mitigate the negative impact due to CHO shortages. The CHVs conducted home visits and provided health education to prevent childhood diseases.

OBJECTIVE

We evaluated the cost-effectiveness and cost-benefit of activating CHVs.

METHODS

In a cluster-randomised trial with 40 communities in rural Ghana, the changes in disease incidence were inferred from a statistical model using a Bayesian generalised linear multilevel model. We evaluated the total incremental cost, benefit, and effectiveness for the intervention from an economic model. In cost-effectiveness analysis, disability-adjusted life years (DALYs) were estimated using a decision tree model. In the cost-benefit analysis, the cost-benefit ratio and net present value of benefit were estimated using a decision tree model, and a standardised sensitivity analysis was conducted. The decision tree model was a one-year cycle and run over 10-years. Costs, benefits, and effectiveness were discounted at a rate of 3% per year.

RESULTS

According to the cost-effectiveness analysis, the programme was highly likely to exceed the WHO-CHOICE threshold (1-3 times GDP per capita), but it was unlikely to exceed the conservative threshold (10-50% of GDP per capita). In the cost-benefit analysis, the mean and median cost-benefit ratios were 6.4 and 4.8, respectively.

CONCLUSION

We found the potential economic strengths in the cost-benefit analysis. To integrate CHW programmes with national health systems, we need more research to find the most effective scope of work for CHWs.

The Pharmacoeconomic Impact of Pharmaceutical Care in the Hospital: Protocol for an Overview of Systematic Reviews

BACKGROUND

The clinical activities developed by pharmacists in a hospital environment can improve health outcomes and generate savings for hospitals. However, to determine whether pharmaceutical interventions are cost effective, it is essential to define a method according to which cost-effectiveness is intended to be measured. In addition, the quality of economic assessments and the amount of information present in systematic reviews in the literature make it difficult to analyze the effects of this intervention.

OBJECTIVE

This paper aims to provide an overview of systematic reviews on the pharmacoeconomic impact of the performance of pharmaceutical care in hospitals.

METHODS

A systematic search of the Cochrane Library databases, PubMed or MEDLINE, LILACS, Scopus, Web of Science, Google Scholar, and Open Thesis will be performed using the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) statement. The search will involve the use of keywords determined using the Medical Subject Headings database to define the search terms and include the following terms: "pharmacoeconomics," "pharmaceutical care," and "hospital." The study designs to be included will be systematic reviews of good quality. Studies will be included that address pharmacoeconomics; studies that evaluated pharmaceutical care in hospitals; and studies published in Portuguese, English, or Spanish. The primary outcome sought in the systematic reviews will be the cost ratio in monetary units and the outcomes in monetary or natural units. The secondary economic outcomes considered will be determined based on factors associated with the drugs and translated into benefit, efficacy, or utility.

RESULTS

It is intended to start this overview in January 2023. Thus far, only previous searches have been carried out to contextualize the theme and build the protocol.

CONCLUSIONS

This overview will determine the pharmacoeconomic impact of pharmaceutical care interventions in the hospital environment. In addition, this study will point out which clinical outcomes in natural units are impacted by the performance of pharmaceutical care and the strengths and limitations of each approach. It will also identify gaps in the literature and areas for future work.

TRIAL REGISTRATION

PROSPERO CRD42019140665; https://tinyurl.com/bddwnz43.

Economics of Medical and Surgical Management of Chronic Rhinosinusitis with Nasal Polyps: A Contemporary Review

BACKGROUND

Chronic rhinosinusitis (CRS) with nasal polyposis (CRSwNP) is a chronic inflammatory condition with significant patient morbidity and associated healthcare costs. While the economic burden of CRS overall has been previously described, the economic impact of CRSwNP has received less attention. Patients with CRSwNP have higher disease burden and healthcare resource utilization than those with CRS without nasal polyposis. Rapid evolution of medical management in recent years with the use of targeted biologics warrants further investigation into the economic burden of CRSwNP.

OBJECTIVE

Provide an updated review of the literature on the economic impact of CRSwNP.

METHODS

A literature review.

RESULTS

Research shows that patients with CRSwNP have higher direct costs and usage of ambulatory services compared to matched non-CRS controls. Patients undergoing functional endoscopic sinus surgery (FESS) incur roughly $13,000 in costs which is particularly relevant given the rate of disease recidivism and need for revision surgery associated with CRSwNP. Disease burden additionally leads to indirect costs through loss of wages and productivity due to work absenteeism and presenteeism, with estimates of up to roughly $10,000 lost in mean annual productivity cost in refractory CRSwNP. Several studies have shown FESS to be more cost-effective in intermediate and long-term management than medical therapy with biologics, despite similar long-term outcomes with respect to quality-of-life metrics.

CONCLUSION

CRSwNP is a chronic condition with high recurrence rates making it a challenge to manage over time. Current research suggests that FESS is more cost-effective than medical management, including use of newer biologics. Further investigation into both direct and indirect costs associated with medical management is warranted to perform accurate cost-effectiveness analyses and allow for the best allocation of limited healthcare resources.

Cost-effectiveness of 10-kHz spinal cord stimulation therapy compared with conventional medical management over the first 12 months of therapy for patients with nonsurgical back pain: randomized controlled trial

OBJECTIVE

This analysis evaluated if spinal cord stimulation (SCS) at 10 kHz plus conventional medical management (CMM) is cost-effective compared with CMM alone for the treatment of nonsurgical refractory back pain (NSRBP).

METHODS

NSRBP subjects were randomized 1:1 into the 10-kHz SCS (n = 83) or CMM (n = 76) group. Outcomes assessed at 6 months included EQ-5D 5-level (EQ-5D-5L), medication usage, and healthcare utilization (HCU). There was an optional crossover at 6 months and follow-up to 12 months. The incremental cost-effectiveness ratio (ICER) was calculated with cost including all HCU and medications except for the initial device and implant procedure, and cost-effectiveness was analyzed based on a willingness-to-pay threshold of < $50,000 per quality-adjusted life-year.

RESULTS

Treatment with 10-kHz SCS resulted in a significant improvement in quality of life (QOL) over CMM (EQ-5D-5L index score change of 0.201 vs -0.042, p < 0.001) at a lower cost, based on reduced frequency of HCU resulting in an ICER of -$4964 at 12 months. The ICER was -$8620 comparing the 6 months on CMM with postcrossover on 10-kHz SCS.

CONCLUSIONS

Treatment with 10-kHz SCS provides higher QOL at a lower average cost per patient compared with CMM. Assuming an average reimbursement for device and procedure, 10-kHz SCS therapy is predicted to be cost-effective for the treatment of NSRBP compared with CMM within 2.1 years.

Sodium-Glucose Cotransporter 2 Inhibitor Use Among Individuals Age <65 with Type 2 Diabetes and Heart Failure with Reduced Ejection Fraction: A Cost-Benefit Analysis

Background

Type 2 diabetes (T2D) patients face increased risk of heart failure (HF) as they age. Sodium-glucose cotransporter 2 inhibitors (SGLT-2i) have demonstrated effectiveness in reducing HF hospitalizations in patients with T2D and HF with reduced ejection fraction (HFrEF). Diabetes guidelines recommend SGLT-2i therapy for patients with HFrEF; however, SGLT-2i cost is high.

Objective

Study objectives were to assess SGLT-2i utilization and HF hospitalization rates in commercially insured adults (age <65) with T2D and heart failure with reduced ejection fraction (HFrEF) taking metformin with/without SGLT-2i use and conduct a cost-benefit analysis of SGLT-2i use from payer and societal perspectives.

Methods

Economic models included HF hospitalization rates from real-world data (RWD) and hospitalization rate reductions from RWD and SGLT-2i clinical trials. Real-world HF hospitalization rates were obtained from claims data (MarketScan Commercial Database, years 2013-2018). Societal perspective analyses included indirect costs. Sensitivity analyses were conducted on key parameters.

Results

Among adults with T2D and HFrEF age 30-64, SGLT-2i use increased (1.1% to 17.4%) between 2013 and 2018. The HF hospitalization rate without SGLT-2i use vs with was 15.5% vs 11.0% (absolute risk reduction of 4.5%). Base case scenario net-benefit was negative across all payer perspective models, while positive for societal-perspective. Payer perspective overall net-benefit in 30-64 population: -$1,725,758 (-$4106 per person). Societal perspective net-benefit in 30-64 population: $5,996,851 ($14,269 per person). In sensitivity analyses, estimated per person base case societal net-benefit of $14,269 was most sensitive to changes in baseline HF hospitalization rates, post-discharge mortality rates, and readmission rates. Lowering SGLT-2i prescription costs 50% and 80% resulted in per person net-benefit increases of $1737 and $4004, respectively.

Conclusion

SGLT-2i utilization has steadily increased, with lower HF hospitalization rates observed among SGLT-2i users. Societal benefits of SGLT-2i use in this population are substantive; payer benefits are negative unless SGLT-2i cost is drastically reduced.

Fracture liaison service utilising an emergency department information system to identify patients effectively reduce re-fracture rate is cost-effective and cost saving in Western Australia

OBJECTIVES

To assess the benefits of the Emergency Department Information System (EDIS)-linked fracture liaison service (FLS).

METHODS

Patients identified through EDIS were invited to attend an FLS at the intervention hospital, the Sir Charles Gairdner Hospital (SCGS-FLS). The intervention group was compared to usual care. Retrospective control (RC) at this hospital determined historical fracture risk (SCGH-RC). Prospective control (PC) was from a comparator, Fremantle Hospital (FH-PC). The main outcome measures were cost-effectiveness from a health system perspective and quality of life by EuroQOL (EQ-5D). Bottom-up cost of medical care, against the cost of managing recurrent fracture (weighted basket), was determined from the literature and 2013/14 Australian Refined Diagnosis Related Groups (AR-DRG) prices. Mean incremental cost-effectiveness ratios were simulated from 5000 bootstrap iterations. Cost-effectiveness acceptability curves were generated.

RESULTS

The SCGH-FLS program reduced absolute re-fracture rates versus control cohorts (9.2-10.2%), producing an estimated cost saving of AUD$750,168-AUD$810,400 per 1000 patient-years in the first year. Between-groups QALYs differed with worse outcomes in both control groups (p < 0.001). The SCGH-FLS compared with SCGH-RC and FH-PC had a mean incremental cost of $8721 (95% CI -$1218, $35,044) and $8974 (95% CI -$26,701, $69,929), respectively, per 1% reduction in 12-month recurrent fracture risk. The SCGH-FLS compared with SCGH-RC and FH-PC had a mean incremental cost of $292 (95% CI -$3588, $3380) and -$261 (95% CI -$1521, $471) per EQ-5D QALY gained at 12 months respectively. With societal willingness to pay of $16,000, recurrent fracture is reduced by 1% in >80% of patients.

CONCLUSIONS

This simple and easy model of identification and intervention demonstrated efficacy in reducing rates of recurrent fracture and was cost-effective and potentially cost saving.

Evidence-based circumcision policy for Australia

The aim was (1) to perform an up-to-date systematic review of the male circumcision (MC) literature and (2) to determine the number of adverse medical conditions prevented by early MC in Australia. Searches of PubMed using "circumcision" with 39 keywords and bibliography searches yielded 278 publications meeting our inclusion criteria. Early MC provides immediate and lifetime benefits, including protection against: urinary tract infections, phimosis, inflammatory skin conditions, inferior penile hygiene, candidiasis, various STIs, and penile and prostate cancer. In female partners MC reduces risk of STIs and cervical cancer. A risk-benefit analysis found benefits exceeded procedural risks, which are predominantly minor, by approximately 200 to 1. It was estimated that more than 1 in 2 uncircumcised males will experience an adverse foreskin-related medical condition over their lifetime. An increase in early MC in Australia to mid-1950s prevalence of 85% from the current level of 18.75% would avoid 77,000 cases of infections and other adverse medical conditions over the lifetime for each annual birth cohort. Survey data, physiological measurements, and the anatomical location of penile sensory receptors responsible for sexual sensation indicate that MC has no detrimental effect on sexual function, sensitivity or pleasure. US studies found that early infant MC is cost saving. Evidence-based reviews by the AAP and CDC support early MC as a desirable public health measure. Although MC can be performed at any age, early MC maximizes benefits and minimises procedural risks. Parents should routinely be provided with accurate, up-to-date evidence-based information in an unbiased manner early in a pregnancy so that they have time to weigh benefits and risks of early MC and make an informed decision should they have a son. Parental choice should be respected. A well-trained competent practitioner is essential and local anaesthesia should be routinely used. Third party coverage of costs is advocated.

Where Do We Go From Here? A Framework for Using Susceptible-Infectious-Recovered Models for Policy Making in Emerging Infectious Diseases

OBJECTIVES

Throughout the coronavirus disease 2019 pandemic, susceptible-infectious-recovered (SIR) modeling has been the preeminent modeling method to inform policy making worldwide. Nevertheless, the usefulness of such models has been subject to controversy. An evolution in the epidemiological modeling field is urgently needed, beginning with an agreed-upon set of modeling standards for policy recommendations. The objective of this article is to propose a set of modeling standards to support policy decision making.

METHODS

We identify and describe 5 broad standards: transparency, heterogeneity, calibration and validation, cost-benefit analysis, and model obsolescence and recalibration. We give methodological recommendations and provide examples in the literature that employ these standards well. We also develop and demonstrate a modeling practices checklist using existing coronavirus disease 2019 literature that can be employed by readers, authors, and reviewers to evaluate and compare policy modeling literature along our formulated standards.

RESULTS

We graded 16 articles using our checklist. On average, the articles met 6.81 of our 19 categories (36.7%). No articles contained any cost-benefit analyses and few were adequately transparent.

CONCLUSIONS

There is significant room for improvement in modeling pandemic policy. Issues often arise from a lack of transparency, poor modeling assumptions, lack of a system-wide perspective in modeling, and lack of flexibility in the academic system to rapidly iterate modeling as new information becomes available. In anticipation of future challenges, we encourage the modeling community at large to contribute toward the refinement and consensus of a shared set of standards for infectious disease policy modeling.

A Systematic Review of the Cost-Utility of Spinal Cord Stimulation for Persistent Low Back Pain in Patients With Failed Back Surgery Syndrome

STUDY DESIGN

Systematic Review.

OBJECTIVES

To review the literature surrounding the cost-effectiveness of implanting spinal cord stimulators for failed back surgery syndrome.

METHODS

A systematic review was conducted inclusive of all publications in the Medline database and Cochrane CENTRAL trials register within the last 10 years (English language only) assessing the cost-effectiveness of Spinal Cord Stimulator device implantation (SCSdi) in patients with previous lumbar fusion surgery.

RESULTS

The majority of reviewed publications that analyzed cost-effectiveness of SCSdi compared to conventional medical management (CMM) or re-operation in patients with failed back surgery syndrome (FBSS) showed an overall increase in direct medical costs; these increased costs were found in nearly all cases to be offset by significant improvements in patient quality of life. The cost required to achieve these increases in quality adjusted life years (QALY) falls well below $25 000/QALY, a conservative estimate of willingness to pay.

CONCLUSIONS

The data suggest that SCSdi provides both superior outcomes and a lower incremental cost: effectiveness ratio (ICER) compared to CMM and/or re-operation in patients with FBSS. These findings are in spite of the fact that the majority of studies reviewed were agnostic to the type of device or innervation utilized in SCSdi. Newer devices utilizing burst or higher frequency stimulation have demonstrated their superiority over traditional SCSdi via randomized clinical trials and may provide lower ICERs.

Identifying the Value of an eHealth Intervention Aimed at Cognitive Impairments: Observational Study in Different Contexts and Service Models

BACKGROUND

Value is one of the central concepts in health care, but it is vague within the field of summative eHealth evaluations. Moreover, the role of context in explaining the value is underexplored, and there is no explicit framework guiding the evaluation of the value of eHealth interventions. Hence, different studies conceptualize and operationalize value in different ways, ranging from measuring outcomes such as clinical efficacy or behavior change of patients or professionals to measuring the perceptions of various stakeholders or in economic terms.

OBJECTIVE

The objective of our study is to identify contextual factors that determine similarities and differences in the value of an eHealth intervention between two contexts. We also aim to reflect on and contribute to the discussion about the specification, assessment, and relativity of the "value" concept in the evaluation of eHealth interventions.

METHODS

The study concerned a 6-month eHealth intervention targeted at elderly patients (n=107) diagnosed with cognitive impairment in Italy and Sweden. The intervention introduced a case manager role and an eHealth platform to provide remote monitoring and coaching services to the patients. A model for evaluating the value of eHealth interventions was designed as monetary and nonmonetary benefits and sacrifices, based on the value conceptualizations in eHealth and marketing literature. The data was collected using the Mini-Mental State Examination (MMSE), the clock drawing test, and the 5-level EQ-5D (EQ-5D-5L). Semistructured interviews were conducted with patients and health care professionals. Monetary data was collected from the health care and technology providers.

RESULTS

The value of an eHealth intervention applied to similar types of populations but differed in different contexts. In Sweden, patients improved cognitive performance (MMSE mean 0.85, SD 1.62, P<.001), reduced anxiety (EQ-5D-5L mean 0.16, SD 0.54, P=.046), perceived their health better (EQ-5D-5L VAS scale mean 2.6, SD 9.7, P=.035), and both patients and health care professionals were satisfied with the care. However, the Swedish service model demonstrated an increased cost, higher workload for health care professionals, and the intervention was not cost-efficient. In Italy, the patients were satisfied with the care received, and the health care professionals felt empowered and had an acceptable workload. Moreover, the intervention was cost-effective. However, clinical efficacy and quality of life improvements have not been observed. We identified 6 factors that influence the value of eHealth intervention in a particular context: (1) service delivery design of the intervention (process of delivery), (2) organizational setup of the intervention (ie, organizational structure and professionals involved), (3) cost of different treatments, (4) hourly rates of staff for delivering the intervention, (5) lifestyle habits of the population (eg, how physically active they were in their daily life and if they were living alone or with family), and (6) local preferences on the quality of patient care.

CONCLUSIONS

Value in the assessments of eHealth interventions need to be considered beyond economic terms, perceptions, or behavior changes. To obtain a holistic view of the value created, it needs to be operationalized into monetary and nonmonetary outcomes, categorizing these into benefits and sacrifices.

Monitoring Cardiorespiratory Fitness in Professional Soccer Players: Is It Worth the Prick?

PURPOSE

To compare between-tests changes in submaximal exercise heart rate (HRex, 3 min, 12 km/h) and the speed associated with 4 mmol/L of blood lactate (V4mmol) in soccer players to get insight into their level of agreement and respective sensitivity to changes in players' fitness.

METHODS

A total of 19 elite professional players (23 [3] y) performed 2 to 3 graded incremental treadmill tests (3-min stages interspersed with 1 min of passive recovery, starting speed 8 km/h, increment 2 km/h until exhaustion or 18 km/h if exhaustion was not reached before) over 1.5 seasons. The correlation between the changes in HRex and V4mmol was examined. Individual changes in the 2 variables were compared (>2 × typical error considered "clear").

RESULTS

The changes in HRex and V4mmol were largely correlated (r = .82; 90% confidence interval, .65-.91). In more than 90% of the cases, when a clear individual change in HRex was observed, it was associated with a similar clear change in V4mmol (the same direction, improvement, or impairment of fitness) and conversely.

CONCLUSIONS

When it comes to testing players submaximally, the present results suggest that practitioners can use HRex or V4mmol interchangeably with confidence. However, in comparison with a field-based standardized warm-up run (3-4 min, all players together), the value of a multistage incremental test with repeated blood lactate samplings is questionable for a monitoring purpose given its time, labor, cost, and poorer player buy-in.

Hydrogen Peroxide 40% for the Treatment of Seborrheic Keratoses

OBJECTIVE

Hydrogen peroxide 40% (HP40) was approved by the US Food and Drug Administration for topical treatment of seborrheic keratosis (SK) in December 2017. This article will review phase II and III clinical trials to assess the drug's efficacy, safety, and clinical application.

DATA SOURCES

A systematic literature review was performed using the terms "Eskata AND seborrheic keratosis," and "hydrogen peroxide AND seborrheic keratosis" in the OVID MEDLINE, PubMed, Cochrane Library, EMBASE, and Web of Science databases. ClinicalTrials.gov was searched to identify ongoing or nonpublished studies.

STUDY SELECTION AND DATA ABSTRACTION

Articles written in English between January 2000 and mid-June 2020 discussing phase II and phase III clinical trials were evaluated.

DATA SYNTHESIS

In 2 phase III clinical trials, 4% and 8% of patients treated with HP40 had a Physician Lesion Assessment score of zero for all 4 SKs, respectively, compared with 0% in both vehicle groups at the primary end point of day 106 (P < 0.01; P < 0.0001).

RELEVANCE TO PATIENT CARE AND CLINICAL PRACTICE

HP40, although less effective, has a better safety profile than other treatment options. It should be especially considered for treatment of facial SKs, where it is most efficacious and where other treatment modalities, such as cryotherapy, are more challenging.

CONCLUSIONS

HP40 is a new, safe alternative treatment for SKs, although it is expensive and only modestly effective, both of which somewhat limit its overall utility. HP40 is a promising topical alternative, particularly for cosmetically sensitive locations, such as the face.

COVID-19 and myeloma: what are the implications for now and in the future?

The pandemic has affected every aspect of myeloma care. Immediate focus is minimising risk of contracting coronavirus disease 2019 (COVID-19) and the sequelae of infection. However, what does the future hold for our patients? What lessons will be taken forward to tackle myeloma in the fiscally constrained future? If we embrace the challenges that will emerge in the post-pandemic environment, the treatment delivered to patients could be more cost-effective and better tailored than before. Healthcare delivery post-COVID-19 will not return to how it was, and now is the time to invest in novel strategies to deliver the best possible outcomes for patients.

Real-World Evaluation of Dosing in Patients Converted From Insulin Glargine (Lantus) to Insulin Glargine (Basaglar)

Background: Basaglar, insulin glargine (BGlar; Eli Lilly, Indianapolis, IN), a follow-on biologic, was developed after the patent for Lantus, insulin glargine (LGlar; Sanofi-Aventis, Paris, France) expired. Objective: To compare the dosing and hemoglobin A_1C (A1C)-lowering effects of BGlar compared with LGlar in a real-world setting. Methods: Adult patients, at 5 clinics, with type 1 (T1DM) or type 2 diabetes mellitus (T2DM) who were converted from LGlar to BGlar were included in this retrospective observational study. The primary outcome compared mean basal insulin dose (U/d) from the date of conversion to 6 months. Basal insulin and total daily insulin doses were also compared from baseline to 3- and 12-months postconversion, as also change in A1C, body weight, and estimated monthly acquisition costs of basal insulin. Results: Of the 225 patients included, 56% were male, and 81% had T2DM. The mean conversion dose (U/d) of LGlar was 46.3 ± 32.7. There was no significant difference in the mean BGlar dose (U/d) at 6 months (45.9 ± 33.5; P = 0.52), nor was there a statistical difference at 3 or 12 months. There were no significant differences in change in A1C at any time point. The estimated monthly acquisition cost of BGlar was significantly less than that for LGlar at conversion ($286 vs $341, P < 0.001) and 6 months ($290 vs $351, P < 0.001) respectively. Conclusion/Relevance: The results of this retrospective study suggest that BGlar resulted in similar glycemic outcomes compared with LGlar in a real-world setting and may be a preferable option in a value-based health care environment.

Impact of imaging modality on clinical outcome in Hodgkin lymphoma in a resource constraint setting

Treatment of Hodgkin lymphoma (HL) has evolved with risk-stratified therapy based on PET-CT scan at multiple timepoints. In a resource constraint setting even a single PET-CT scan ($400) is inaccessible to many patients, who are re-assessed with only clinical examination, abdominal ultrasonogram and/or x-ray (C/U/X) ($10). To compare clinical outcomes in patients with HL who have had suboptimal imaging after completion of chemotherapy for HL, with those who had a CT or PET-CT, 283 patients were treated for HL from 2011 to 2015, and 268 patients completed six cycles of ABVD therapy with response assessment modality by CT/PET in 185 patients and by C/U/X in 83. There was no difference in the number of patients with advanced (64·1% vs. 61·1%; P = 0·650) or bulk disease (8·1% vs. 7·2%). A significantly higher number of patients in the CT/PET group received IFRT (25·4% vs. 7·7%; P = 0·0005). The three-year overall survival and progression-free survival of all treated patients (n = 283) was 83·5 ± 2·3% and 76·7 ± 2·6% respectively [median follow-up 36 months (range 2-93)]. At three years, the overall relapse-free survival (RFS) was 80·1 ± 2·5%, with RFS of 77 ± 3·2% vs. 85 ± 4·0% in the CT/PET group and C/U/X groups respectively (P = 0·349). There was no difference in RFS between the two groups either in early-stage disease (88·1 ± 4·6% vs. 91·8 ± 5·6%; P = 0·671) or late-stage disease (73·9 ± 4·8% vs. 81·3 ± 6·0%; P = 0·747). The only significant factor adversely affecting RFS was advanced disease (P = 0·004). Factors not affecting RFS were age (P = 0·763), sex (P = 0·925), bulk disease (P = 0·889) and imaging modality (P = 0·352). There was no difference in relapse rates between patients who had suboptimal imaging compared to those who had a PET/CT. It is possible to use these basic imaging modalities when resources are a constraint, with acceptable outcomes.

Impact of molecular point-of-care testing on clinical management and in-hospital costs of patients suspected of influenza or RSV infection: a modeling study

Background

At hospital admission, patients suspected of infection with influenza or respiratory syncytial virus (RSV) are placed in isolation, pending the outcome of diagnostics. In a significant number, isolated care proves unnecessary. We investigated the potential impact of molecular point‐of‐care (POC) diagnostics on patient management and in‐hospital costs.

Method

Prospective collection of data on resource utilization within the hospital from consecutive patients 18 years or older presenting at our university medical center with symptoms of respiratory tract infection from December 2016 to April 2017. A cost analysis was conducted using Markov modeling comparing the actual course of events (on the basis of routine diagnostic tests) with two hypothetical scenarios: when POC would impact time to diagnosis only (scenario 1) or on discharge from the hospital, too (scenario 2).

Results

A total of 283 patients were included, of whom 217 (76.7%) were admitted. Influenza and RSV were detected in 31% and 7% of the patients, respectively. Fifty‐four percent of patients tested negative, of which 79% were kept in isolated care waiting for test results, with a median duration of 24 hours. Median length of stay was 6.0 days. Mean total in‐hospital costs per patient were € 5243. Introducing POC would lower mean costs per patient to € 4904 (scenario 1) and € 4206 (scenario 2). At the hospital level, this would result in a total cost reduction of € 95 937 to € 293 471 in a single influenza season.

Conclusions

Introducing POC testing for patients presenting with symptoms of viral respiratory tract infection can reduce time‐to‐diagnosis, hospital stay and, thereby, in‐hospital costs.

Comparison of carbon fibre and aluminium materials in the construction of ultralight wheelchairs

Carbon fibre-reinforced polymers have been used in the sporting goods industry for decades, and wheelchairs have incorporated the material since the late 1980s. There is no independently collected data available on carbon fibre-reinforced polymer wheelchairs' performance on the ANSI/RESNA testing standards, however. This study evaluated three full carbon fibre wheelchair specimens to determine their performance versus similar wheelchairs. Testing determined that while the frames survived more testing cycles than any other wheelchair, the casters and rear tires failed similarly to other devices. Overall, due to the purchase cost, the cost benefit of the tested wheelchair model was similar to aluminium wheelchairs.Implications for rehabilitationCarbon fibre wheelchair construction is a viable alternative to aluminium, titanium, or steel construction, and decreasing costs will continue to improve the benefits of carbon fibre over these modelsCarbon fibre wheelchair found to be more durable than aluminium models, but are also much more expensive. The additional cost may be justified for some users that need the increased durability, howeverIncreased durability will reduce the number of repairs and warranty claims, potentially reducing the burden on a wheelchair user, and also improving their ability to travel and participate in their communityThe low weight of carbon fibre wheelchairs may increase the mobility of some users by allowing them to transfer more easily into and out of vehicles and manoeuvre throughout the environment.

Retrospective evaluation of a local protocol used to enhance laboratory savings through minimizing the performance of alkaline phosphatase isoenzyme analysis

BACKGROUND

Alkaline phosphatase isoenzyme analysis is an expensive and time-consuming laboratory test. We evaluated the effect of a locally derived screening algorithm for alkaline phosphatase isoenzyme requests on the number of alkaline phosphatase isoenzyme analyses performed, laboratory cost and patient care.

METHOD

A total of 110 alkaline phosphatase isoenzyme analysis requests from the year 2015 were reviewed and subsequent alkaline phosphatase concentrations were monitored over a two-year period, to determine if the decision of performing/not performing alkaline phosphatase isoenzyme analysis, based on the algorithm, had an impact on patient care and laboratory cost. All alkaline phosphatase isoenzyme analysis requests with two consecutive elevated alkaline phosphatase concentrations (>upper limit of reference interval) were screened and, subject to the gamma glutamyl transferase being within the reference interval, either Bone alkaline phosphatase or 25 hydroxyvitamin D was measured depending on the age of the patient.

RESULTS

Compliance with this algorithm led to the normalization of subsequent serum alkaline phosphatase in 97% of patients without requiring alkaline phosphatase isoenzyme analysis. The cost of performing Bone alkaline phosphatase and 25 hydroxyvitamin D in-house was £778.50, while the cost of performing alkaline phosphatase isoenzyme analysis would have been £3040. This resulted in a laboratory saving of £2261.50.

CONCLUSIONS

Implementation of this algorithm led to a significant reduction in alkaline phosphatase isoenzyme analysis, without compromising patient care. Total savings could be increased if 25 hydroxyvitamin D was used as a first-line test, for all patients with an elevated alkaline phosphatase and a normal gamma glutamyl transferase regardless of age. This algorithm is cost-effective and can be implemented in laboratories with 25 hydroxyvitamin D assay.

Comparison of High-Strength Aluminum Ultralight Wheelchairs Using ANSI/RESNA Testing Standards

Background: The use of ultralight manual wheelchairs has been shown to benefit wheelchair users when compared to other types. New aluminum alloy frame materials coming to the market have not been independently evaluated for durability and cost benefit. Methods: Three 70XX aluminum ultralight wheelchair models were tested and compared based on dimensions, stability, and durability using the ANSI/RESNA standards. The results were also compared to previous manual wheelchair studies. Results: This study found that there were no significant cost benefit or durability differences between the wheelchairs tested and previous aluminum or titanium ultralight rigid models. Additionally, 5 of the 9 wheelchairs tested failed to meet the minimum ANSI/RESNA requirements for durability. Conclusion: These results are similar to results from previous rigid ultralight wheelchair studies and indicate that the quality of wheelchairs of this type has not improved and better requirements are necessary for wheelchairs marketed in the United States.

The cost-effectiveness of immediate treatment or watch and wait with deferred chemotherapy for advanced asymptomatic follicular lymphoma

Recent evidence has shown that immediate treatment with rituximab induction, with and without maintenance, substantially reduces the need for further treatment in patients with advanced asymptomatic follicular lymphoma. This analysis estimates the cost-effectiveness of immediate treatment approaches in comparison to a watch and wait approach from the perspective of the UK National Health Service. A Markov decision model was developed to estimate the cost-effectiveness of treatment strategies in patients with asymptomatic follicular lymphoma. The model was populated using effectiveness data from a systematic literature review with the key clinical data sourced from a randomised trial, in which the treatment strategies were compared. Costs were estimated using UK national sources. In comparison to watchful waiting, both rituximab strategies were found to be more effective and cost saving. In comparison to rituximab induction, the addition of rituximab maintenance marginally increased effectiveness but substantially increased costs, resulting in an incremental cost-effectiveness ratio (ICER) of £69 406 per quality-adjusted life year (QALY). In probabilistic sensitivity analysis, rituximab induction was found to have a 68% probability of being cost-effective at a threshold of £20 000 per QALY. In conclusion, active treatment with rituximab induction is a cost-effective strategy to adopt in patients with asymptomatic follicular lymphoma.

Comparison of hospital length of stay in patients treated with non-vitamin K oral anticoagulants or parenteral agents plus warfarin for venous thromboembolism

Objectives:

Existing research comparing hospital length of stay for patients treated with non–vitamin K oral anticoagulants or parenteral bridging to warfarin has been conducted primarily with the agent rivaroxaban. The objective of this study was to compare hospital length of stay between patients initiated on the non–vitamin K oral anticoagulants, apixaban or rivaroxaban, and patients initiated on parenteral anticoagulation agents plus warfarin for the treatment of venous thromboembolism.

Methods:

A retrospective cohort study was conducted at an 859-bed, not-for-profit, teaching hospital. Adult patients admitted for a primary diagnosis of venous thromboembolism between 1 November 2012 and 31 August 2015 and treated with apixaban or rivaroxaban or a parenteral anticoagulant plus warfarin were included in the study. Eligible patients were identified using International Classification of Diseases, Ninth Revision codes for a primary diagnosis of acute thromboses and emboli and medication administration record data. Individuals using anticoagulation therapy prior to admission, released from the emergency department, or treated with thrombectomy or fibrinolytic therapy were excluded.

Results:

A total of 152 patients were included in this study. Patient characteristics, including renal function, were similar between study arms. Venous thromboembolism treatment with apixaban or rivaroxaban compared to a parenteral anticoagulant plus warfarin was associated with a reduced hospital length of stay (2.63 vs 5.33 days; p < 0.05) and decreased total hospital cost adjusted to 2015 dollars (US$21,694 vs US$38,851; p = 0.013).

Conclusion:

These results suggest that treatment with a non–vitamin K anticoagulant may significantly reduce hospital length of stay and total hospital cost compared to a parenteral anticoagulant plus warfarin for patients admitted for venous thromboembolism.

Protecting and promoting mental health of nurses in the hospital setting: Is it cost-effective from an employer's perspective?

OBJECTIVES

Nurses are at elevated risk of burnout, anxiety and depressive disorders, and may then become less productive. This begs the question if a preventive intervention in the work setting might be cost-saving from a business perspective.

MATERIAL AND METHODS

A cost-benefit analysis was conducted to evaluate the balance between the costs of a preventive intervention among nurses at elevated risk of mental health complaints and the cost offsets stemming from improved productivity. This evaluation was conducted alongside a cluster-randomized trial in a Dutch academic hospital. The control condition consisted of screening without feedback and unrestricted access to usual care (N = 206). In the experimental condition screen-positive nurses received personalized feedback and referral to the occupational physician (N = 207).

RESULTS

Subtracting intervention costs from the cost offsets due to reduced absenteeism and presenteeism resulted in net-savings of 244 euros per nurse when only absenteeism is regarded, and 651 euros when presenteeism is also taken into account. This corresponds to a return-on-investment of 5 euros up to 11 euros for every euro invested.

CONCLUSIONS

Within half a year, the cost of offering the preventive intervention was more than recouped. Offering the preventive intervention represents a favorable business case as seen from the employer's perspective.

Economic evaluation of HBV vaccination: A systematic review of recent publications (2000-2013)

AIM

To conduct a systematic review of the economic evaluations (EE) of HBV vaccination, taking also into account the studies published in the new millennium.

METHODS

An extensive scientific literature review was conducted using two electronic medical journal databases: Scopus and PubMed engines for published studies on EE of HBV vaccination.

RESULTS

22 articles were reviewed, 9, 5 and 8 cost-effectiveness, cost-benefit and cost-utility analysis, respectively. Studies were mainly concerning EE of universal vaccination (UV), mostly with regards to low or low-medium income countries. For high income countries, EE were focused on the possible implementation of HBV vaccination in particular settings, such as diabetic, renal and other chronic conditions care, as well as infectious diseasesUV has usually a very good cost-effectiveness ratio (80%), ranging from cost-saving (China) or few Euro per LY/QALY gained (in Thailand, and Vietnam) to 630.00$/QALY in USA (Asian and Pacific Islands) Moreover, EE of HBV vaccination are favorable in the infectious diseases field as well as for chronic conditions. In relation to diabetes the studies gave controversial results.

CONCLUSION

This systematic review highlighted the importance of introducing HBV vaccination not only for infant UV program but also for other settings in which patients are people affected by communicable and non-communicable diseases.

Comparison between neurostimulation techniques repetitive transcranial magnetic stimulation vs electroconvulsive therapy for the treatment of resistant depression: patient preference and cost-effectiveness

OBJECTIVES

Major depressive disorder (MDD) is a common disorder, widely distributed in the population, and is often associated with severe symptoms and functional impairment. It has been estimated that 30% of MDD patients do not benefit adequately from therapeutic interventions, including pharmacotherapy and psychotherapy. Treatment-resistant depression (TRD) is generally defined as a failure to achieve remission, despite therapeutic interventions.

AIM

The most effective treatment alternatives for TRD are hospitalization, electroconvulsive therapy (ECT), and transcranial magnetic stimulation (TMS). Here we compared the clinical effectiveness of ECT and TMS, including success rates, patient responses, side-effect profiles, and financial worthiness.

RESULTS

We found that ECT (P<0.0001) was more effective than TMS (P<0.012) (not statistically significant in group effect) in TRD patients. However, ECT patients reported a higher percentage of side effects (P<0.01) and the TMS treatment scored better in terms of patient preference. The cost benefit of ECT was higher than that of TMS (US$2075 vs US$814). Patient's preferences for treatment could be more intense in the TMS, if the TMS is included in the Health Maintenance Organization's service list.

CONCLUSION

We propose that both of these treatment options should be available in psychiatric wards, thus expanding the therapeutic toolkit for TRD.

Cost minimization in treatment of adult degenerative scoliosis

OBJECT

Back pain is an increasing concern for the aging population. This study aims to evaluate if minimally invasive surgery presents cost-minimization benefits compared with open surgery in treating adult degenerative scoliosis.

METHODS

Seventy-one patients with adult degenerative scoliosis received 2-stage, multilevel surgical correction through either a minimally invasive spine surgery (MIS) approach with posterior instrumentation (n = 38) or an open midline (Open) approach (n = 33). Costs were derived from hospital and rehabilitation charges. Length of stay, blood loss, and radiographic outcomes were obtained from electronic medical records. Functional outcomes were measured with Oswestry Disability Index (ODI) and visual analog scale (VAS) surveys.

RESULTS

Patients in both cohorts were similar in age (Age(MIS) = 65.68 yrs, Age(Open) = 63.58 yrs, p = 0.28). The mean follow-up was 18.16 months and 21.82 months for the MIS and Open cohorts, respectively (p = 0.34). MIS and Open cohorts had an average of 4.37 and 7.61 levels of fusion, respectively (p < 0.01). Total inpatient charges were lower for the MIS cohort ($269,807 vs $391,889, p < 0.01), and outpatient rehabilitation charges were similar ($41,072 vs $49,272, p = 0.48). MIS patients experienced reduced length of hospital stay (7.03 days vs 14.88 days, p < 0.01) and estimated blood loss (EBL) (EBL(MIS) = 470.26 ml, EBL(Open)= 2872.73 ml, p < 0.01). Baseline ODI scores were lower in the MIS cohort (40.03 vs 48.04, p = 0.03), and the cohorts experienced similar 1-year improvement (ΔODI(MIS) = -15.98, ΔODI(Open) = -21.96, p = 0.25). Baseline VAS scores were similar (VAS(MIS) = 6.56, VAS(Open)= 7.10, p = 0.32), but MIS patients experienced less reduction after 1 year (ΔVAS(MIS) = -3.36, ΔVAS(Open) = -4.73, p = 0.04). Preoperative sagittal vertical axis (SVA) were comparable (preoperative SVA(MIS) = 63.47 mm, preoperative SVA(Open) = 71.3 mm, p = 0.60), but MIS patients had larger postoperative SVA (postoperative SVA(MIS) = 51.17 mm, postoperative SVA(Open) = 28.17 mm, p = 0.03).

CONCLUSIONS

Minimally invasive surgery demonstrated reduced costs, blood loss, and hospital stays, whereas open surgery exhibited greater improvement in VAS scores, deformity correction, and sagittal balance. Additional studies with more patients and longer follow-up will determine if MIS provides cost-minimization opportunities for treatment of adult degenerative scoliosis.

Cost-benefit analysis: newborn screening for inborn errors of metabolism in Lebanon

OBJECTIVES

Few countries in the Middle East-North Africa region have adopted national newborn screening for inborn errors of metabolism by tandem mass spectrometry (MS/MS). We aimed to evaluate the cost-benefit of newborn screening for such disorders in Lebanon, as a model for other developing countries in the region.

METHODS

Average costs of expected care for inborn errors of metabolism cases as a group, between ages 0 and 18, early and late diagnosed, were calculated from 2007 to 2013. The monetary value of early detection using MS/MS was compared with that of clinical "late detection", including cost of diagnosis and hospitalizations.

RESULTS

During this period, 126000 newborns were screened. Incidence of detected cases was 1/1482, which can be explained by high consanguinity rates in Lebanon. A reduction by half of direct cost of care, reaching on average 31,631 USD per detected case was shown. This difference more than covers the expense of starting a newborn screening programme.

CONCLUSION

Although this model does not take into consideration the indirect benefits of the better quality of life of those screened early, it can be argued that direct and indirect costs saved through early detection of these disorders are important enough to justify universal publicly-funded screening, especially in developing countries with high consanguinity rates, as shown through this data from Lebanon.

Economic Comparison of an Empirical Versus Diagnostic-Driven Strategy for Treating Invasive Fungal Disease in Immunocompromised Patients

PURPOSE

Patients with persistent or recurrent neutropenic fevers at risk of invasive fungal disease (IFD) are treated empirically with antifungal therapy (AFT). Early treatment using a diagnostic-driven (DD) strategy may reduce clinical and economic burdens. We compared costs and outcomes of both strategies from a UK perspective.

METHODS

An empirical strategy with conventional amphotericin B deoxycholate (C-AmB), liposomal amphotericin B (L-AmB), or caspofungin was compared with a DD strategy (initiated based on positive ELISA results for galactomannan antigen) and/or positive results for Aspergillus species on polymerase chain reaction assay) using C-AmB, voriconazole, or L-AmB in a decision-analytic model. Rates of IFD incidence, overall mortality, and IFD-related mortality in adults expected to be neutropenic for ≥10 days were obtained. The empirical strategy was assumed to identify 30% of IFD and targeted AFT to improve survival by a hazard ratio of 0.589. AFT-specific adverse events were obtained from a summary of product characteristics. Resource use was obtained, and costs were estimated by using standard UK costing sources. All costs are presented in 2012 British pounds sterling.

FINDINGS

Total costs were 32% lower for the DD strategy (£1561.29) versus the empirical strategy (£2301.93) due to a reduced incidence of adverse events and decreased use of AFT. Administration of AFT was reduced by 41% (DD strategy, 74 of 1000; empirical strategy, 125 of 1000), with similar survival rates.

IMPLICATIONS

This study suggests that a DD strategy is likely to be cost-saving versus empirical treatment for immunocompromised patients with persistent or recurrent neutropenic fevers.

Neglected tools for neglected diseases: mathematical models in economic evaluations

Despite many current interventions against neglected tropical diseases (NTDs) being highly cost-effective, new strategies are needed to reach the WHO's control and elimination goals. Here we argue for the importance of incorporating economic evaluations of new strategies in decisions regarding resource allocation. Such evaluation should ideally be conducted using dynamic transmission models that capture inherent nonlinearities in transmission and the indirect benefits ('herd effects') of interventions. A systematic review of mathematical models that have been used for economic analysis of interventions against the ten NTDs covered by the London Declaration reveals that only 16 out of 49 studies used dynamic transmission models, highlighting a fundamental--but addressable--gap in the evaluation of interventions against NTDs.

Pharmacoeconomics and the medicinal chemist

Pharmacoeconomics is a rational, scientific approach to compare the value (in terms of both cost and patient outcome) of one medication or drug therapy regimen to another. The impact of this new approach on both the practicing medicinal chemist and broader drug discovery efforts is considered.

The Economics of Strategies to Reduce Respiratory Syncytial Virus Hospitalizations in Alaska

BACKGROUND

Alaska Native infants experience high rates of respiratory syncytial virus (RSV) hospitalizations. Through 2008, Alaska administered a 7-dose (maximum) palivizumab regime to high-risk infants from October to May. In 2009, the maximum was reduced to 3 doses for 32- to 34-week preterm babies and 6 doses for other groups.

METHODS

We used 11 years of data and regional Medicaid reimbursement rates to model the cost effectiveness of 4 palivizumab intervention strategies to reduce RSV hospitalizations among Alaskan infants including: current strategy, old strategy (1998-2008), and 2 hypothetical strategies using the current strategy plus 1 or 3 doses to all newborn infants during the RSV season.

RESULTS

The current strategy represents 5 hospitalizations averted per year for the palivizumab cohort (∼50-56 children) at ∼$52 846 per hospitalization averted, compared with no intervention. Compared with the old strategy, the mean cost per hospitalization prevented for the current strategy was 63% lower, net program costs were 85% lower, and the mean hospitalizations prevented were 27% lower. Compared with current strategy only, the addition of 1 dose to all newborns during the RSV season could decrease the mean cost per hospitalization prevented by 23%, increase the number of hospitalizations prevented by 2.5-fold, and increase the net programmatic costs by 3.3-fold; administering up to 3 doses to infants further reduced hospitalizations and increased costs.

CONCLUSIONS

The current palivizumab strategy improved the cost-effectiveness ratio compared with the old strategy. Further improvement could be obtained by adding doses for Alaskan Native newborns during the RSV season; however, programmatic costs would increase.

Clinical usefulness and cost effectiveness of fractional flow reserve among Indian patients (FIND study)

OBJECTIVES

To study the clinical usefulness, cost benefit, and medium term outcome of fractional flow reserve (FFR) based management of coronary artery disease of intermediate severity.

BACKGROUND

In spite of the advantages of FFR there is paucity of data in Indian population who have frequent diffuse, small and multivessel disease where it would probably be more beneficial in terms of cost and outcome.

METHODS

The treating cardiologist's management decision with both FFR and angiographic data was compared with that of a reviewing cardiologist decision based on a retrospective analysis of angiogram alone.

RESULTS

Eighty-one vessels with intermediate lesions in 59 patients required 26 stents lesser when FFR data was added to the angiogram. The concordance of management decision was about 58% which means that >40% of intermediate lesions would be misclassified as significant based on angiography alone. There were no major events at a mean follow up of 11 ± 5 months. The net cost benefit in favor of FFR based management was INR 8,57,600 (USD 15,600) in our centre.

CONCLUSION

Indians with more severe form of CAD benefit from a FFR based management plan for intermediate lesions, both clinically and economically. © 2014 Wiley Periodicals, Inc.

Economic evaluation of Varicella vaccination: results of a systematic review

INTRODUCTION

The aim of the present study is to review the economic burden of varicella disease and the benefit of universal varicella vaccination in different settings pending its implementation in all Italian regions.

MATERIALS AND METHODS

Research was conducted using PubMed, Scopus and ISI databases. Score quality and data extraction were performed for all included studies.

RESULTS

Twenty-three articles met the criteria: 15 cost-effectiveness, 8 cost-benefit and one cost-utility analysis. Varicella vaccination could save the society from €637,762 (infant strategy) to 53 million annually (combined infant and adolescent strategy). The median and the mean quality scores resulted in 91.8% and 85.4% respectively; 11 studies were considered of high quality and 12 of low quality.

DISCUSSION

The studies are favorable to the introduction of universal varicella vaccination in Italy, being cost saving and having a positive impact on morbidity. The quality score of the studies varied greatly: recent analyses were of comparable quality to older studies.

A Novel Estimation of the Impact of Treatment with Entecavir on Long-Term Mortality, Morbidity, and Health Care Costs of Chronic Hepatitis B in China

OBJECTIVES

Health care decision makers are increasingly concerned about the value of chronic hepatitis B (CHB) treatments in China. This analysis aims at estimating the relative value of entecavir as a first-line option at treatment initiation and for different treatment durations from a holistic perspective.

METHODS

CHB was simulated by using a Markov disease transition model with disease states based on available natural history data. The model assumed 5-year treatment duration with entecavir, lamivudine, telbivudine, and adefovir based on published clinical data. The speed of disease progression varies by viral load and hepatitis B "e" antigen status. Direct medical costs included medication and management of liver complications. The primary output was the estimated cost savings of entecavir per patient per day versus the comparator.

RESULTS

For treatment duration of 5 years and a follow-up period of 30 years, entecavir treatment was translated into specific patient benefit of an estimated cost saving of $2.69 per day compared with no treatment. In addition, long-term usage of entecavir resulted in daily $2.33 and $1.73 cost saving compared with short-term usage (1-year and 2-year, respectively). Among available treatment options in China, entecavir treatment exhibited about $0.90 to $1.81 daily cost saving versus the comparators. The detailed daily cost saving of entecavir is summarized as follows-entecavir versus lamivudine: $1.81, entecavir versus telbivudine: $0.90, entecavir versus adefovir: $2.02, and entecavir versus generic adefovir: $1.37.

CONCLUSIONS

Long-term usage of entecavir exhibits the characteristics of a favorable CHB treatment, which translates into economic value as opposed to either no treatment or alternative strategies.

Health and Wellbeing Boards for a new public health

We remind readers of the evidence that community empowerment is a cost-effective way to improve health, and also that the conditions now exist to develop this approach in the UK, by facilitating collaboration between clusters of general practices and multiple other organisations. We argue that it is the role of Health and Wellbeing Boards to make sure that this huge potential is realised.

Substance misuse prevention and economic analysis: challenges and opportunities regarding international utility

Economic analyses of substance misuse prevention assess the intervention cost necessary to achieve a particular outcome, and thereby provide an additional dimension for evaluating prevention programming. This article reviews several types of economic analysis, considers how they can be applied to substance misuse prevention, and discusses challenges to enhancing their international relevance, particularly their usefulness for informing policy decisions. Important first steps taken to address these challenges are presented, including the disease burden concept and the development of generalized cost-effectiveness, advances that facilitate international policy discussions by providing a common framework for evaluating health care needs and program effects.

Health and Wellbeing Boards for a new public health

We remind readers of the evidence that community empowerment is a cost-effective way to improve health, and also that the conditions now exist to develop this approach in the UK, by facilitating collaboration between clusters of general practices and multiple other organisations. We argue that it is the role of Health and Wellbeing Boards to make sure that this huge potential is realised.