Plumb JM, Edwards SJ
Cost-effectiveness analysis of proton pump inhibitors compared to omeprazole
in the healing of reflux oesophagitis
J Med Econ 2002; 5: 11-23
In 1998, the National Health Service (NHS) in England and Wales spent over £314
million on proton pump inhibitors (PPIs). The National Institute for Clinical
Excellence (NICE) guidance on the use of PPIs in dyspepsia advises that the least
expensive appropriate PPI be used. Consequently, the objective of this study was
to assess the cost-effectiveness of all PPIs for the healing of reflux oesophagitis
over 8 weeks from the perspective of the UK's NHS.
A decision analysis model was developed using healing rates derived from a systematic
review of all PPIs using omeprazole as a common comparator. The economic analysis
indicates that esomeprazole is cost-effective compared with all other PPIs currently
available for healing reflux oesophagitis.
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Lafuma A, Fagnani F, Berdeaux G
Cost and effectiveness of ciprofloxacin + hydrocortisone versus neomycin + polymyxin
B + hydrocortisone in France for the treatment of acute otitis externa
J Med Econ 2002; 5: 25-38
The cost-effectiveness of two topical otic combinations, ciprofloxacin + hydrocortisone
and polymyxin B-neomycin-hydrocortisone (PNH), was assessed in the treatment of
acute otitis externa (AOE). Two randomised controlled double-masked trials compared
their clinical and bacteriological efficacy and safety after 7 to 10 days of qid
treatment. The treatment failure cost was established from a panel of ENT specialists
and GPs. A decision-tree analysis was constructed to reproduce the results of
empirical treatment. The most often encountered species were Pseudomonas aeruginosa
(82.4%) and Staphylococcus aureus (9.7%). Patients documented with P aeruginosa
had a better ciprofloxacin + hydrocortisone bacterial and clinical efficacy. The
cost of AOE first-line failure was EUR 94.44 (Societal) and EUR 57.24 (Sécurité
Sociale). The savings associated with ciprofloxacin + hydrocortisone (Cipro HC®)
were respectively EUR 3.87 and EUR 2.85. This model shows that topical ciprofloxacin
+ hydrocortisone could be a cost saving alternative in the treatment of AOE, provided
its public price does not exceed EUR 10.60.
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Belsey JD
Primary care workload in the management of chronic pain. A retrospective cohort
study using a GP database to identify resource implications for UK primary care
J Med Econ 2002; 5: 39-50
The management of chronically painful conditions is relatively labour intensive,
as there is no single treatment regime that can be reliably forecast to control
symptoms across a broad range of patients and underlying conditions. The achievement
of effective and well tolerated analgesia therefore carries considerable workload
implications. This study set out to quantify the impact of managing therapy with
nonsteroidal antiinflammatories and nonopiate analgesics within UK general practice.
Two separate cohorts of patients were defined from the MediPlus GP database,
in order to characterise the workload impact of both established and new patients
being treated with antiinflammatory/analgesic agents. Where treatment changes
occurred, the underlying reasons for these changes were identified, if possible.
The relative importance of these reasons was appraised and expressed both in terms
of the number of appointments used and the direct costs attributable.
Similar results were obtained for both cohorts. Changes of therapy reflected
side effects, intolerance and allergy in 23-25% of cases, lack of efficacy in
20-22%, and resolution of the underlying condition in 7-10% of cases. No reason
was attributable in 44-47% of changes. Extrapolating these results to a national
level suggests that management of therapy in these patients accounts for 4.6 million
appointments per year, equivalent to 793 whole time GPs, at a total cost of around
£69 million.
The use of nonsteroidal antiinflammatories and nonopiate analgesics is associated
with a significant impact on primary care workload, with poor efficacy being the
trigger for almost as many consultations as poor tolerability. Addressing this
issue may offer an important contribution towards reducing maximum waiting time
for appointments in general practice towards the target of 48 hours.
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Odeyemi IAO, Guest JF
Modelling the economic impact of recombinant activated Factor VII and activated
prothrombin-complex concentrate in the treatment of a mild to moderate bleed in
adults with inhibitors to clotting Factors VIII and IX at a comprehensive care
centre in the UK
J Med Econ 2002; 5: 51-64
To estimate the costs and consequences of using recombinant activated Factor
VII (rFVIIa; NovoNordisk)), compared with activated prothrombin-complex concentrate
(aPCC; FEIBA (Baxter Healthcare)) to manage a minor (i.e. mild to moderate) bleeding
episode at a haemophilia treatment centre (Comprehensive Care Centre (CCC)) in
the UK among adults with high titre, high responding inhibitors (>10 BU).
This was a modelling study performed from the perspective of the UK's National
Health Service (NHS).
Clinical outcomes and resource utilisation attributable to managing a minor bleed
were obtained from published literature, supplemented with information about treatment
patterns and associated resource utilisation derived from interviews with 22 consultant
haematologists experienced in managing inhibitor patients. Using these data sources,
a decision tree modelling the management of a minor bleed at a CCC was constructed.
Unit resource costs at 1999/2000 prices were applied to the resource utilisation
estimates in the model to calculate the expected NHS cost of managing a minor
bleeding episode. Consensus on the probabilities and resource utilisation estimates
in the model were reached at a meeting comprising seven of the 22 consultant haematologists.
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Haycox A, Mitchell G, Niziol C, Featherstone F
Cost effectiveness of asthma treatment with a breath-actuated pressurised metered
dose inhaler (BAI) - a prescribing claims study of 1,856 patients using a traditional
pressurised metered dose inhaler (MDI) or a breath-actuated device
J Med Econ 2002; 5: 65-77
High levels of asthma resource use in the UK indicate that optimal control is
not being achieved. This may be at least partly due to improper inhaler technique
with metered dose inhalers (MDIs). One solution may be to prescribe inhalers that
are easier to use, i.e. breath-actuated inhalers (BAIs). This analysis used a
primary care database to assess the extent to which BAI (Easi-Breathe®) patients
differ from MDI patients in terms of their asthma related-resource costs. A child
using the BAI had annual asthma medication costs that were £16.83 higher than
a child using an MDI and an adult using the BAI had medication costs that were
£3.02 higher. This was expected due to the higher unit cost of the salbutamol
BAI compared to the salbutamol MDI. However, a breakdown of medication costs showed
that antibiotic and oral steroid costs were lower in the BAI group. The higher
medication costs for BAI users were offset by the lower non-medication costs (£46.57
and £69.09 less for children and adults using the BAI, respectively). The result
was a lower cost overall for BAI users compared to MDI users. Asthma is a therapeutic
area which imposes a significant burden on both patients and health services.
Given its increasing prevalence and morbidity levels, it is important to ensure
that all possible steps are taken by clinicians to reduce this burden wherever
possible. Such steps may include the prescription of BAIs.
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Belsey JD
The clinical and financial impact of oral triptans - an updated meta-analysis
J Med Econ 2002; 5: 79-89
In a previous meta-analysis we demonstrated that rizatriptan 10 mg is a clinically
and cost-effective treatment option in acute migraine, when compared with other
available oral triptans. The current paper updates this analysis, to include data
for almotriptan and eletriptan.
A literature search identified all placebo-controlled randomised clinical trials
involving oral triptans published up to February 2002. The proportion of patients
rendered pain-free over 2 hours was identified for each agent, and the results
pooled using a random-effects model. Numbers needed to treat (NNT) were calculated
for each agent. Using current UK drug costs, an estimate of the expenditure required
per patient rendered pain free at 2 hours was also made.
Twenty-nine studies, involving 45 active treatment arms were identified. Based
on the NNT analysis, significantly more patients achieved pain-free status at
2 hours with rizatriptan 10 mg than with sumatriptan 100 mg (p<0.02), sumatriptan
50 mg (p<0.01), eletriptan 40 mg (p<0.01), zolmitriptan 2.5 mg (p<0.05),
almotriptan 12.5 mg (p<0.01) and naratriptan 2.5 mg (p<0.001). There was
no significant difference between rizatriptan 10 mg, eletriptan 80 mg and zolmitriptan
5 mg for this endpoint. Based on acquisition costs alone, there was a statistically
significant difference between the cost-effectiveness ratios of rizatriptan 10
mg (£14.15) and sumatriptan 100 mg (£37.61; p<0.001), zolmitriptan 5 mg (£33.26;
p<0.001), naratriptan 2.5 mg (£33.66; p<0.01), sumatriptan 50 mg (£28.71;
p<0.001) and eletriptan 80 mg (£28.17; p<0.001). There was no significant
difference between the cost-effectiveness ratios calculated for rizatriptan 10
mg and almotriptan 12.5 mg (£15.06), eletriptan 40 mg (£17.37) and zolmitriptan
2.5 mg (£20.22).
Rizatriptan 10 mg is the only agent studied that demonstrated high levels of
both clinical and cost-effectiveness. It can therefore be considered and ideal
first-line treatment choice in the management of the acute migraine attack.
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François C, Sintonen H, Toumi M
Introduction of escitalopram, a new SSRI in Finland: comparison of cost-effectiveness
between the other SSRIs and SNRI for the treatment of depression and estimation
of the budgetary impact
J Med Econ 2002; 5: 91-107
A cost-effectiveness study of major depressive disorder was undertaken to compare
escitalopram, a new SSRI, with citalopram, fluoxetine and venlafaxine in Finland.
A decision-tree model with a 6-month horizon was constructed using probabilities
issued from comparative trial data, a standardised literature review and an expert
panel. The therapeutic success (remission) and the treatment costs were the main
outcomes. The expected success rate was 51.4% for escitalopram, 45.6% for citalopram,
45.6 for fluoxetine and 49.6% for venlafaxine. Average expected total costs per
patient are similar for escitalopram (EUR 857) and venlafaxine (EUR 876), and
higher for citalopram (EUR 990) and fluoxetine (EUR 959). The budgetary impact
shows a decrease in the total healthcare budget estimated at EUR 11.7 million.
Escitalopram is a more cost-effective treatmetn than citalopram, fluoxetine and
venlafaxine in the treatment of depression and its increased utilisation would
reduce healthcare costs for the treatment of depression in Finland.
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Greenberg RN, Cagnoni PJ, Wingard JR, Prendergast MM, Tong KB
Factors associated with increased hospital costs in patients treated with lipid-based
amphotericin B for empirical therapy
J Med Econ 2002; 5: 109-118
Lipid-based amphotericin B agents have been studied in a number of clinical settings
and patient populations, most notably as empirical therapy for patients at-risk
for systemic fungal infection and for patients with documented invasive disease.
In clinical practice, lipid-based therapies have been considered second- or even
third-line therapy due to concerns about costs. However, few analyses have been
conducted to determine those factors associated with empirical antifungal therapy
and lipid-based agents that are most likely to influence hospital costs and length
of stay.
The purpose of this analysis is to determine which demographic, treatment, and
clinical outcome factors contribute to increased hospital costs and length of
stay in patients treated empirically with a lipid-based amphotericin B agent.
A retrospective analysis of 89 patients enrolled in the clinical study was performed
to assess hospital costs and length of stay following the start of empirical antifungal
therapy. Bivariate and multivariate regressions were performed to identify variables
most likely to affect hospital costs and length of stay.
Allogeneic bone marrow transplant (BMT) status, days of treatment, doubling of
baseline creatinine, and dialysis were found to be predictive both of increased
hospital costs and length of stay. Length of stay and number of concomitant nephrotoxic
agents also were found to affect hospital costs.
Overall, risk factors and clinical outcomes associated with nephrotoxicity increased
hospital costs and length of stay in patients treated empirically with lipid-based
antifungal agents. Renal dialysis also increased hospital cost significantly.
For empirical antifungal therapy, providers should consider both patient-specific
risk factors and product-specific outcomes in selecting an appropriate agent.
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Odeyemi IAO, Guest JF
Modelling the economic impact of recombinant activated factor VII compared to
activated prothrombin-complex concentrate in the home treatment of a mild to moderate
bleed in adults with inhibitors to clotting Factors VIII and IX in the UK
J Med Econ 2002; 5: 119-133
This study estimated the costs and consequences of using recombinant activated
Factor VII (rFVIIa; NovoSeven®) at home, compared to activated prothrombin-complex
concentrate (aPCC; FEIBA®) at home, to manage a minor (i.e. mild to moderate)
bleeding episode in adults with high titre, high responding inhibitors (>10 BU).
The analysis was performed from the perspective of the UK’s National Health Service
(NHS).
Clinical outcomes and resource utilisation attributable to managing a minor bleed
were obtained from published literature, supplemented with information about treatment
patterns and associated resource utilisation derived from interviews with a panel
of 22 consultant haematologists experienced in managing inhibitor patients. Using
these data sources a decision tree modelling the management of a minor bleed,
initially at home, was constructed. Unit resource costs at 1999/2000 prices were
applied to the resource utilisation estimates in the model to estimate the expected
mean NHS cost of managing a minor bleeding episode. Consensus on the probabilities
and resource utilisation estimates in the model were reached at a meeting comprising
seven panel members.
The expected mean NHS cost of managing a minor bleeding episode initially treated
with rFVIIa or aPCC at home was estimated to be £12,944 and £14,645, respectively.
Additionally, the expected mean time to resolving a minor bleeding episode when
initially treated with rFVIIa or aPCC at home was estimated to be 32 hours and
60 hours, respectively. Hence, rFVIIa improves clinical outcome compared to aPCC,
but at no additional cost to the NHS, resulting in rFVIIa being the cost-effective
treatment. This finding warrants further study in a prospective, comparative,
randomised, controlled study.
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Smyth ETM, Barr JG, Hogg GM, Oppenheim BA
A pharmacoeconomic evaluation of piperacillin/tazobactam versus meropenem in
the treatment of adult febrile neutropenia
J Med Econ 2002; 5: 135-145
A study involving 80 patients has established the safety and efficacy of piperacillin/tazobactam
(PT) versus meropenem (ME) in the treatment of febrile neutropenia. The study
reported here assessed 78 of 80 patients and has shown that the total antimicrobial
costs of the two study arms were very similar, except for the acquisition costs
of the two study drugs and the antimicrobial prescription costs in the post-study
period. The total antimicrobial costs for the PT and ME arms for the prestudy,
study and post-study periods, respectively, were: PT £2,052.22/ME £1,140.49, PT
£28,726.57/ME £49,954.80 and PT £10,863.45/ME £3,542.27. A detailed review of
these post-study antimicrobial prescriptions demonstrated that cost differences
lay in the prescription of antibacterial antimicrobials. This post-study difference
lay in the additional prescription of 145.15 defined daily doses of antibacterial
antimicrobials in the PT arm and were ascribed, in the main, to teicoplanin, vancomycin,
imipenem, metronidazole and ciprofloxacin. Forty-three percent of the total post-study
antibacterial cost was due to the use of imipenem in eight patients in the PT
arm.
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