Personal Social Services Research Articles

TP2 TREATMENT PATTERNS IN SPINAL MUSCULAR ATROPHY: INTERVIEWS WITH HEALTHCARE PROFESSIONALS IN THE UNITED KINGDOM

Spinal muscular atrophy (SMA) is a rare genetic disorder characterized by weakness and atrophy in skeletal muscles. Excluding the prenatal onset form (type 0), SMA is classified into 4 phenotypes based on severity, with type 1 being the most severe. Emerging treatments are shifting the treatment paradigm, but little is known about current treatment patterns. The objective is to collect data on treatment patterns in SMA types 1, 2 and 3 in the UK through health care professional (HCP) interviews. HCPs, who had seen at least 2 patients with SMA in the past 12 months, were recruited through contacts in clinical centers in the UK. Informed consent was obtained from all respondents with subsequent telephone interviews. Interviews were conducted with 16 HCPs from 8 UK regions: nine neurologists, three pulmonologists, two physiotherapists, one nurse, and one health visitor. HCPs reported that paths to diagnosis depend on symptom timing, and HCPs involved. Time to diagnosis was estimated at up to 3 months for SMA 1, and up to 12 months for SMA 2 and 3. HCPs agreed on key approaches to management and care coordination. Patients’ geographic proximity to hospital often determines who coordinates care. The existence and characteristics of phases in SMA was divisive, although focus was on ventilation, nutrition, and mobility. Many HCPs are involved in patient care, with community support being essential, however, HCPs were not able to report on palliative care and personal social services. The challenges faced by HCPs in SMA are numerous and include lack of resources and lack of effective treatment. HCP reports underline the complexity of treatment coordination for SMA, between hospitals and communities. Management is focused on ventilation, feeding and mobility, with involvement of a large number of HCPs. A comprehensive SMA care model is needed.

Cost-effectiveness of negative-pressure wound therapy in adults with severe open fractures of the lower limb: evidence from the WOLLF randomized controlled trial.

The aim of this study was to estimate the cost-effectiveness of negative-pressure wound therapy (NPWT) in comparison with standard wound management after initial surgical wound debridement in adults with severe open fractures of the lower limb. An economic evaluation was conducted from the perspective of the United Kingdom NHS and Personal Social Services, based on evidence from the 460 participants in the Wound Management of Open Lower Limb Fractures (WOLLF) trial. Economic outcomes were collected prospectively over the 12-month follow-up period using trial case report forms and participant-completed questionnaires. Bivariate regression of costs (given in £, 2014 to 2015 prices) and quality-adjusted life-years (QALYs), with multiple imputation of missing data, was conducted to estimate the incremental cost per QALY gained associated with NPWT dressings. Sensitivity and subgroup analyses were undertaken to assess the impacts of uncertainty and heterogeneity, respectively, surrounding aspects of the economic evaluation. The base case analysis produced an incremental cost-effectiveness ratio of £267 910 per QALY gained, reflecting higher costs on average (£678; 95% confidence interval (CI) -£1082 to £2438) and only marginally higher QALYS (0.002; 95% CI -0.054 to 0.059) in the NPWT group. The probability that NPWT is cost-effective in this patient population did not exceed 27% regardless of the value of the cost-effectiveness threshold. This result remained robust to several sensitivity and subgroup analyses. This trial-based economic evaluation suggests that NPWT is unlikely to be a cost-effective strategy for improving outcomes in adult patients with severe open fractures of the lower limb. Cite this article: Bone Joint J 2019;101-B:1392-1401.

PCN179 TREOSULFAN-BASED CONDITIONING VS BUSULFAN-BASED CONDITIONING FOR ALLOGENEIC HAEMATOPOIETIC STEM CELL TRANSPLANTATION IN PATIENTS WITH AML OR MDS — A UK COST-UTILITY ANALYSIS

Cost-utility analyses comparing alternative conditioning regimens for patients undergoing allogeneic haematopoietic stem cell transplantation (alloHSCT) have not previously been conducted. A cost-utility analysis was developed to compare a treosulfan and fludarabine conditioning regimen (Tr-Fl) versus busulfan with fludarabine based conditioning (Bu-Fl) prior to alloHSCT, for patients with acute myeloid leukaemia (AML) or myelodysplastic syndrome (MDS) considered ineligible to receive standard conditioning regimens. A partitioned survival model was developed to compare Tr-Fl with Bu-Fl from a UK National Health Service and Personal Social Services perspective. Patients started in the induction/alloHSCT health state, before transitioning to alloHSCT recovery (remission), relapse/progression and death after the first model cycle. Data on patient characteristics, overall survival (OS), event-free survival (EFS) and adverse events were collected from a head to head phase III clinical trial. OS and EFS were extrapolated beyond the trial duration using parametric survival models. A functional cure assumption was applied at 5 years based on clinical expert opinion, with subsequent mortality defined using a hazard ratio for long-term post-HSCT patients applied to UK life table data. Utilities and mapping algorithms were identified through systematic and targeted literature review and were adjusted for age and sex using a published model for general population utility. Costs of treatment, adverse events, inpatient/outpatient care, and mortality were included in the analysis. Tr-Fl dominated Bu-Fl, with incremental quality-adjusted life-years (QALYs) and costs of 0.78 and -£17,689, respectively. Probabilistic sensitivity analysis indicated that Tr-FL had an 94.1% probability of cost-effectiveness at a £30,000 per QALY threshold. Tr-Fl also dominated Bu-Fl for each indication subgroup, with incremental QALYs of 0.71 and 1.03 and incremental costs of -£24,138 and -£2,570 for AML and MDS, respectively. Tr-Fl is a highly cost-effective conditioning treatment for alloHSCT patients with AML or MDS ineligible for standard conditioning regimens, compared with Bu-Fl.

Cost-effectiveness of psychological interventions for children and young people with post-traumatic stress disorder.

PTSD in youth may lead to long-lasting psychological implications, educational difficulties and increased healthcare costs. Psychological interventions have been shown to be effective in its management. The objective of this study was to assess the cost-effectiveness of a range of psychological interventions for children and young people with PTSD. A decision-analytic model was constructed to compare costs and quality-adjusted life years (QALYs) of 10 psychological interventions and no treatment for children and young people with PTSD, from the perspective of the National Health Service and personal social services in England. Effectiveness data were derived from a systematic review and network meta-analysis. Other model input parameters were based on published sources, supplemented by expert opinion. Cognitive therapy for PTSD, a form of individual trauma-focused cognitive behavioural therapy (TF-CBT), appeared to be the most cost-effective intervention for children and young people with PTSD (with a probability of .78 amongst the 11 evaluated options at a cost-effectiveness threshold of £20,000/QALY), followed by narrative exposure (another form of individual TF-CBT), play therapy, and other forms of individual TF-CBT. After excluding cognitive therapy from the analysis, narrative exposure appeared to be the most cost-effective option with a .40 probability of being cost-effective amongst the remaining 10 options. EMDR, parent training and group TF-CBT occupied middle cost-effectiveness rankings. Family therapy and supportive counselling were less cost-effective than other active interventions. There was limited evidence for some interventions, in particular cognitive therapy for PTSD and parent training. Individual forms of TF-CBT and, to a lesser degree, play therapy appear to be cost-effective in the treatment of children and young people with PTSD. Family therapy and supportive counselling are unlikely to be cost-effective relative to other interventions. There is a need for well-conducted studies that examine the long-term clinical and cost-effectiveness of a range of psychological treatments for children and young people with PTSD.

Ticagrelor Removal by CytoSorb® in Patients Requiring Emergent or Urgent Cardiac Surgery: A UK-Based Cost-Utility Analysis.

BackgroundAcute coronary syndrome patients receiving dual antiplatelet therapy who need emergent or urgent cardiac surgery are at high risk of major bleeding, which can impair postoperative outcomes. CytoSorb®, a blood purification technology based on adsorbent polymer, has been demonstrated to remove ticagrelor from blood during on-pump cardiac surgery.ObjectiveThe aim of this study was to evaluate the cost utility of intraoperative removal of ticagrelor using CytoSorb versus usual care among patients requiring emergent or urgent cardiac surgery in the UK.MethodsA de novo decision analytic model, based on current treatment pathways, was developed to estimate the short- and long-term costs and outcomes. Results from randomised clinical trials and national standard sources such as National Health Service (NHS) reference costs were used to inform the model. Costs were estimated from the NHS and Personal Social Services perspective. Deterministic and probabilistic sensitivity analyses (PSAs) explored the uncertainty surrounding the input parameters.ResultsIn emergent cardiac surgery, intraoperative removal of ticagrelor using CytoSorb was less costly (£12,933 vs. £16,874) and more effective (0.06201vs. 0.06091 quality-adjusted life-years) than cardiac surgery without physiologic clearance of ticagrelor over a 30-day time horizon. For urgent cardiac surgery, the use of CytoSorb was less costly than any of the three comparators—delaying surgery for natural washout without adjunctive therapy, adjunctive therapy with short-acting antiplatelet agents, or adjunctive therapy with low-molecular-weight heparin. Results from the PSAs showed that CytoSorb has a high probability of being cost saving (99% in emergent cardiac surgery and 53–77% in urgent cardiac surgery, depending on the comparators). Cost savings derive from fewer transfusions of blood products and re-thoracotomies, and shorter stay in the hospital/intensive care unit.ConclusionsThe implementation of CytoSorb as an intraoperative intervention for patients receiving ticagrelor undergoing emergent or urgent cardiac surgery is a cost-saving strategy, yielding improvement in perioperative and postoperative outcomes and decreased health resource use.Electronic supplementary materialThe online version of this article (10.1007/s41669-019-00183-w) contains supplementary material, which is available to authorized users.

Early invasive strategy in senior patients with non-ST-segment elevation myocardial infarction: is it cost-effective? - a decision-analytic model and value of information analysis

BackgroundNon-ST-elevation myocardial infarction (NSTEMI) is the most common type of heart attack in the UK and it is becoming increasingly prevalent among older people. An early invasive treatment strategy may...

The Contribution of Religious to Irish Healthcare

The Contribution of Religious to Irish Healthcare Tim O’Sullivan A recent Studies special issue, ‘The Nuns’ Story: Writing the Record’, included a comment by Deirdre Raftery that ‘Irish women religious have left a vast, and largely undocumented, legacy to healthcare and education’.1 This comment could be extended to male religious as well in healthcare, in areas such as intellectual disability and mental health services. Growing appreciation of the neglect of the contribution of religious has led to significant work on religious congregations in recent years, such as that reported on in Studies by Raftery and others. In the field of social policy, there has been considerable analysis of the historical importance of Catholic health care providers in Irish social services, but relatively little coverage ‘from within’ of Catholic non-profit providers in Ireland – partly perhaps because of their own reticence or their pragmatic focus on progressing the job at hand rather than in theorising about it.2 Many analyses set out statecentred narratives that view the involvement in social provision of non-profit providers, and particularly those with a religious motivation, as anomalous and distracting from the responsibility of the State to provide basic social services.3 . Interest in the perspectives of religious has also clearly suffered because of their declining numbers and relative importance in Irish social services and because of grave concerns about the historical abuses in residential child care services run by religious orders.4 As a result, although Catholic providers have been a very significant stakeholder in Irish social services, their perspectives on these services have arguably received limited coverage in the social policy literature. Nevertheless, as the Studies authors suggested, there is a strong case today for a more balanced reflection on the contribution of the religious. This contribution is not just an historical one, even if the religious orders delivering healthcare are in significant decline in Ireland. An important recent report chaired by Catherine Day on the role of voluntary organisations in publicly funded health and personal social services made it clear that the Tim O’Sullivan Studies • volume 108 • number 431 288 Studies_layout_AUTUMN-2019.indd 56 21/08/2019 09:14 faith-based contribution to Irish healthcare remains substantial.5 This article seeks to reflect on the contribution of the religious in healthcare, while taking account of their own perspectives. It offers some thoughts on the Day report and draws on a 2013 study of my own, which incorporated interviews with representatives of significant Catholic healthcare providers.6 Substantial presence of religious in Irish healthcare The Day report listed seven Catholic hospitals that are still under religious ownership: the Mater Misericordiae University Hospital, St Vincent’s University Hospital and Temple Street Children’s University Hospital in Dublin; Mercy University Hospital, Cork; Cappagh National Orthopaedic Hospital, Dublin; St Michael’s Hospital, Dun Laoghaire and St John’s Hospital, Limerick. It also noted that there was a faith-based element in the governance arrangements of several additional hospitals. It referred to the planned withdrawal of the Sisters of Charity from St Vincent’s and added that the number of voluntary acute hospitals owned by religious orders may be reduced to four in the coming years: Cappagh, the Mater, the Mercy and St John’s (par. 3.3). In the same paragraph, the report stated that two thirds of all disability services are still provided directly by the voluntary sector, including eighty per cent of residential places. A number of large disability service providers are faith-based, for example: Brothers of Charity Services Ireland, Carriglea Cairde Services, Daughters of Charity Disability Support Services, Saint John of God Community Services. These organisations, the review group stated, account for approximately fifty-eight per cent of the funding allocated to disability service providers under the ‘Section 38’ funding system. A somewhat State-centred distinction is drawn at times in the Irish policy literature between large non-profit bodies that provide services ‘on behalf of’ a statutory body and community and voluntary organizations that provide other services and undertake developmental activities to meet social need without being delivery agencies on behalf of a statutory agency.7 . In legal terms, this distinction is reflected in the 2004 Health Act...

The Dynamics of British Welfare Pluralism from Post World War II until the New Labour Government: Personal Social Service Policy for the Elderly

The Dynamics of British Welfare Pluralism from Post World War II until the New Labour Government: Personal Social Service Policy for the Elderly

Refractory depression - cost-effectiveness of radically open dialectical behaviour therapy: findings of economic evaluation of RefraMED trial.

Refractory depression is a major contributor to the economic burden of depression. Radically open dialectical behaviour therapy (RO DBT) is an unevaluated new treatment targeting overcontrolled personality, common in refractory depression, but it is not yet known whether the additional expense of RO DBT is good value for money.AimsTo estimate the cost-effectiveness of RO DBT plus treatment as usual (TAU) compared with TAU alone in people with refractory depression (trial registration: ISRCTN85784627). We undertook a cost-effectiveness analysis alongside a randomised trial evaluating RO DBT plus TAU versus TAU alone for refractory depression in three UK secondary care centres. Our economic evaluation, 12 months after randomisation, adopted the perspective of the UK National Health Service (NHS) and personal social services. It evaluated cost-effectiveness by comparing the net cost of RO DBT with the net gain in quality-adjusted life-years (QALYs), estimated using the EQ-5D-3L measure of health-related quality of life. The additional cost of RO DBT plus TAU compared with TAU alone was £7048 and was associated with a difference of 0.032 QALYs, yielding an incremental cost-effectiveness ratio (ICER) of £220 250 per QALY. This ICER was well above the National Institute for Health and Care Excellence (NICE) upper threshold of £30 000 per QALY. A cost-effectiveness acceptability curve indicated that RO DBT had a zero probability of being cost-effective compared with TAU at the NICE £30 000 threshold. In its current resource-intensive form, RO DBT is not a cost-effective use of resources in the UK NHS.Declaration of interestR.H. is co-owner and director of Radically Open Ltd, the RO DBT training and dissemination company. D.K. reports grants outside the submitted work from the National Institute for Health Research (NIHR). T.L. receives royalties from New Harbinger Publishing for sales of RO DBT treatment manuals, speaking fees from Radically Open Ltd, and a grant outside the submitted work from the Medical Research Council. He was co-director of Radically Open Ltd between November 2014 and May 2015 and is married to Erica Smith-Lynch, the principal shareholder and one of two directors of Radically Open Ltd. H.O'M. reports personal fees outside the submitted work from the Charlie Waller Institute and Improving Access to Psychological Therapy. S.R. provides RO DBT supervision through her company S C Rushbrook Ltd. I.R. reports grants outside the submitted work from NIHR and Health & Care Research Wales. M. Stanton reports personal fees outside the submitted work from British Isles DBT Training, Stanton Psychological Services Ltd and Taylor & Francis. M. Swales reports personal fees outside the submitted work from British Isles DBT Training, Guilford Press, Oxford University Press and Taylor & Francis. B.W. was co-director of Radically Open Ltd between November 2014 and February 2015.

Cardiovascular magnetic resonance in emergency patients with multivessel disease or unobstructed coronary arteries: a cost-effectiveness analysis in the UK

ObjectiveTo identify the key drivers of cost-effectiveness for cardiovascular magnetic resonance (CMR) when patients activate the primary percutaneous coronary intervention (PPCI) pathway.DesignEconomic decision models for two patient subgroups populated from...

Genomic Surveillance of Methicillin-resistant Staphylococcus aureus: A Mathematical Early Modeling Study of Cost-effectiveness.

BackgroundGenomic surveillance of methicillin-resistant Staphylococcus aureus (MRSA) identifies unsuspected transmission events and outbreaks. Used proactively, this could direct early and highly targeted infection control interventions to prevent ongoing spread. Here, we evaluated the cost-effectiveness of this intervention in a model that compared whole-genome sequencing plus current practice versus current practice alone.MethodsA UK cost-effectiveness study was conducted using an early model built from the perspective of the National Health Service and personal social services. The effectiveness of sequencing was based on the relative reduction in total MRSA acquisitions in a cohort of hospitalized patients in the year following their index admissions. A sensitivity analysis was used to illustrate and assess the level of confidence associated with the conclusions of our economic evaluation.ResultsA cohort of 65 000 patients were run through the model. Assuming that sequencing would result in a 90% reduction in MRSA acquisition, 290 new MRSA cases were avoided. This gave an absolute reduction of 28.8% and avoidance of 2 MRSA-related deaths. Base case results indicated that the use of routine, proactive MRSA sequencing would be associated with estimated cost savings of over £728 290 per annual hospitalized cohort. The impact in total quality-adjusted life years (QALYs) was relatively modest, with sequencing leading to an additional 14.28 QALYs gained. Results were most sensitive to changes in the probability of a MRSA-negative patient acquiring MRSA during their hospital admission.ConclusionsWe showed that proactive genomic surveillance of MRSA is likely to be cost-effective. Further evaluation is required in the context of a prospective study.

The Vest™ High-Frequency Chest Wall Oscillation System Compared with Manual Chest Wall Physiotherapy for Managing Airway Clearance in Patients with Complex Neurological Disorders: A UK-based Cost-Effectiveness Analysis

Background: Weakness in the muscles used to breathe and swallow can lead to difficulties with airway clearance for people with neurological disorders including neuromuscular disease and cerebral palsy. This can lead to aspiration and other respiratory problems which are the leading causes of death in patients with complex neurological disorders. The Vest™ system supports airway clearance through the use of High-Frequency Chest Wall Oscillation (HFCWO) to loosen secretions in the chest by reducing their viscosity. Objective: To assess the cost-effectiveness of the Vest™ system versus Manual Chest Wall Physiotherapy (MCWP) for airway clearance in patients with neurological disorders including neuromuscular disease and cerebral palsy. Methods: A decision-analytic Markov model was developed to estimate the cost-effectiveness of HFCWO and MCWP over 5- and 10-year time horizons. Costs were estimated from the perspective of the UK National Health Service and personal social services. The main input parameters in the model were: rates of respiratory infection, respiratory-related hospitalisation, antibiotic use for respiratory infection and cost of the Vest™ system. The input parameters were informed by existing clinical guidelines and literature. Sensitivity analyses were conducted to explore uncertainties around the input parameters. Results: Over 5- and 10-year time horizons, the Vest™ system results in more quality-adjusted life-years and lower costs per patient. The Vest™ system has a high probability of being cost-effective (>98%) at willingness-to-pay thresholds of £20,000 and £30,000. The estimated average cost saving per patient over a 5-year time horizon is £5,660 (SD = £2362). Our results show that the Vest™ system may result in approximately £6 million cost savings per 1,000 patients with complex neurological disorders in 5 years. Per 1,000 patients, 2,442 hospital admissions and 49,868 bed days could be averted with the use of the Vest™ system. Our results were generally robust to the sensitivity analyses performed. Conclusion: The Vest™ system results in fewer respiratory infection episodes and hospitalisations, and thus less National Health Service (NHS) resource use, than current practice. Therefore, it is highly likely to be a cost-saving strategy.

A matter of choice—professionals’ views on the incorporation of practical work with intimate partner violence into Swedish personal social services

During the last decades, efforts have been made to increase local support provided to victims of intimate partner violence (IPV) in Sweden. As with other social problems, responsibility to address IPV falls on the municipal personal social services. The present article draws upon data obtained via structured telephone interviews with designated personal social services staff members from a sample of 99 municipalities, focusing on aspects of potential progress in social work with IPV. The results show that successful incorporation of IPV into personal social services largely seems to depend upon the commitment and dedication of individual actors within the organisations. Furthermore, the data indicate that competence in this field depends on personal inclination, with attention to IPV appearing as ‘a matter of choice’. The results are analysed using neo-institutional theory as well as concepts related to social movement studies, with focus on individual agency in organisational change and the potential relevance of IPV as an issue related to gender inequality to gender inequality. The analysis suggests that while IPV social work may challenge institutionalised practises within social services, change may go both ways with IPV being reframed to fit within the established framework of social services.

Cost-Effectiveness Analysis of Fulvestrant 500mg in Endocrine Therapy-Naïve Postmenopausal Women with Hormone Receptor-Positive Advanced Breast Cancer in the UK.

IntroductionThe selective estrogen receptor degrader fulvestrant is approved for the first-line treatment of postmenopausal patients with hormone receptor-positive (HR+), locally advanced or metastatic breast cancer who have not received prior endocrine therapy. We evaluated the cost-effectiveness of fulvestrant versus comparator treatments in endocrine therapy-naïve patients with locally advanced or metastatic breast cancer.MethodsA three-health-state (progression free, progressed disease, and death) partitioned survival model from the UK National Health Service and Personal Social Services perspective was developed to extrapolate study data for the cumulative probability of progression-free survival and overall survival to a lifetime (30-year) horizon. Relative comparator data were derived from a systematic literature review-informed network meta-analysis. Sensitivity analyses were applied to assess the impact of uncertainty in the parameter input values on the results.ResultsOver a lifetime horizon (30 years), the incremental cost (British pounds sterling) per patient associated with fulvestrant treatment was £18,867 versus anastrozole, £23,097 versus letrozole, and £17,131 versus tamoxifen, with incremental quality-adjusted life-years of 0.55, 0.77, and 0.76, respectively, and incremental cost-effectiveness ratios of £34,109, £29,827, and £22,532, respectively. The largest difference in costs between fulvestrant and the comparators was related to treatment costs.ConclusionsResults suggest that fulvestrant could potentially be a cost-effective option compared with other endocrine monotherapies (anastrozole, letrozole, and tamoxifen) for treating endocrine therapy-naïve, postmenopausal women with HR+, locally advanced or metastatic breast cancer.Electronic supplementary materialThe online version of this article (10.1007/s41669-019-0134-3) contains supplementary material, which is available to authorized users.

Cost-minimisation analysis of home care reablement for older people in England: A modelling study.

Many governments have introduced or encouraged home-care reablement schemes for older people at home with the aim of improving outcomes and reducing costs. We examined if such schemes have the potential to reduce costs from the perspective of the National Health Service (NHS) and Personal Social Services (PSS) in England. Our study was carried out to inform recommendations of a national guideline. Cost-minimisation analysis was carried out using decision-analytic Markov modelling. Home-care reablement was compared with standard home care. Costs included those of the intervention, home care and hospital admission. Uncertainty was explored using univariate and probabilistic sensitivity analysis. Mean costs per person were £56,499 (95% confidence interval 55,690 to 57,307) in the reablement group, and £58,560 (95% confidence interval 57,800 to 59,319) in the standard care group. The mean difference was -£2,061 (95% confidence interval 1,933 to 2,129). The probability that home-care reablement costs less than standard home care was 94.5% (95% confidence interval 93.1 to 95.9). In sensitivity analyses, this probability remained above 85% in all scenarios. Home-care reablement can be a successful cost-minimisation strategy for supporting some older people. More research is needed about the impact of home-care reablement on health outcomes for different groups of older people; and the effects of different durations of reablement on outcomes and costs for different subpopulations.

Cost-effectiveness analysis of ribociclib plus letrozole versus palbociclib plus letrozole in the United Kingdom.

ObjectiveTo evaluate the cost-effectiveness of ribociclib plus letrozole versus palbociclib plus letrozole in post-menopausal women with hormone receptor positive (HR+) and human epidermal growth receptor 2 negative (HER2−) advanced breast cancer from a UK payer perspective.MethodsA cohort-based partitioned survival model was developed to evaluate the cost-effectiveness of ribociclib plus letrozole versus palbociclib plus letrozole in post-menopausal women with HR+/HER2− advanced breast cancer over a lifetime horizon. The analysis was carried out from a National Health Services and Personal Social Services perspective, and results are presented in incremental costs per quality adjusted life years. Clinical data from three randomized controlled trials (MONALEESA-2, PALOMA-1 and PALOMA-2 studies) were used, and supplemented with available real world evidence. Costs categories comprised of drug acquisition, medical management, and treatment of adverse events. Healthcare resource utilization data were identified from literature and unit costs sourced from secondary sources. Utility values were derived from MONALEESA-2 study and were supported with values identified from literature. Both deterministic and probabilistic analyses were carried out to assess uncertainty.ResultsIn the base case, treatment with ribociclib plus letrozole increased mean progression free survival (PFS) by 4.1 months and overall survival by 5.0 months compared to palbociclib plus letrozole. Further, treatment with ribociclib plus letrozole resulted in cost-savings of £8464 and incremental QALYs of 0.261, demonstrating that treatment with ribociclib plus letrozole is dominant to treatment with palbociclib plus letrozole. The probabilistic analysis also yielded mean cost-savings of £7914 and mean QALY gain of 0.273. At willingness-to-pay threshold of £30 000 per QALY, treatment with ribociclib plus letrozole had a 92% probability of being cost-effective compared to palbociclib and letrozole.ConclusionsThe results of the analysis demonstrate that ribociclib plus letrozole treatment is both cost-saving and a cost-effective option amongst the available cyclin dependent kinase 4/6 inhibitors for the treatment of post-menopausal women with advanced breast cancer. The biggest driver of the cost savings were the lower acquisition costs of ribociclib.

Cost-effectiveness Analysis of Ribociclib plus Letrozole versus Palbociclib plus Letrozole in the United Kingdom

Objective: To evaluate the cost-effectiveness of ribociclib plus letrozole versus palbociclib plus letrozole in post-menopausal women with hormone receptor positive (HR+) and human epidermal growth receptor 2 negative (HER2-) advanced breast cancer from a UK payer perspective. Methods: A cohort-based partitioned survival model was developed to evaluate the cost-effectiveness of ribociclib plus letrozole versus palbociclib plus letrozole in post-menopausal women with HR+/HER2- advanced breast cancer over a lifetime horizon. The analysis was carried out from a National Health Services and Personal Social Services perspective, and results are presented in incremental costs per quality adjusted life years. Clinical data from three randomized controlled trials (MONALEESA-2, PALOMA-1 and PALOMA-2 studies) were used, and supplemented with available real world evidence. Costs categories comprised of drug acquisition, medical management, and treatment of adverse events. Healthcare resource utilization data were identified from literature and unit costs sourced from secondary sources. Utility values were derived from MONALEESA-2 study and were supported with values identified from literature. Both deterministic and probabilistic analyses were carried out to assess uncertainty. Results: In the base case, treatment with ribociclib plus letrozole increased mean progression free survival (PFS) by 4.1 months and overall survival by 5.0 months compared to palbociclib plus letrozole. Further, treatment with ribociclib plus letrozole resulted in cost-savings of £8464 and incremental QALYs of 0.261, demonstrating that treatment with ribociclib plus letrozole is dominant to treatment with palbociclib plus letrozole. The probabilistic analysis also yielded mean cost-savings of £7914 and mean QALY gain of 0.273. At willingness-to-pay threshold of £30 000 per QALY, treatment with ribociclib plus letrozole had a 92% probability of being cost-effective compared to palbociclib and letrozole. Conclusions: The results of the analysis demonstrate that ribociclib plus letrozole treatment is both cost-saving and a cost-effective option amongst the available cyclin dependent kinase 4/6 inhibitors for the treatment of post-menopausal women with advanced breast cancer. The biggest driver of the cost savings were the lower acquisition costs of ribociclib.

Conditions for helping relations in specialized personal social services – a client perspective on the influence of organizational struc-ture

ABSTRACT This article highlights organizational structure as a factor influencing conditions for helping relations. It is based on a survey study and an interview study, both directed at parents in families that have parallel contacts in different parts of Swedish personal social services (PSS). The aim is to describe and analyse conditions for helping relations when clients with complex needs encounter specialized PSS. Low system trust, people processing dimensions of work, and an organizational and a professional emphasis on formal organizational structures and boundaries were found to constitute unfavourable conditions. Conversely, an occurrence of individual trust, people sustaining and people changing dimensions of work, as well as informal organization and individual social workers’ boundary spanning efforts, constituted favourable conditions. The article concludes that greater understanding of how clients are affected by contextual service conditions can give some pointers towards how to generally improve services for vulnerable and disadvantaged populations.

The cost effectiveness of REACH-HF and home-based cardiac rehabilitation compared with the usual medical care for heart failure with reduced ejection fraction: A decision model-based analysis.

BackgroundThe REACH-HF (Rehabilitation EnAblement in CHronic Heart Failure) trial found that the REACH-HF home-based cardiac rehabilitation intervention resulted in a clinically meaningful improvement in disease-specific health-related quality of life in patients with reduced ejection fraction heart failure (HFrEF). The aims of this study were to assess the long-term cost-effectiveness of the addition of REACH-HF intervention or home-based cardiac rehabilitation to usual care compared with usual care alone in patients with HFrEF.Design and methodsA Markov model was developed using a patient lifetime horizon and integrating evidence from the REACH-HF trial, a systematic review/meta-analysis of randomised trials, estimates of mortality and hospital admission and UK costs at 2015/2016 prices. Taking a UK National Health and Personal Social Services perspective we report the incremental cost per quality-adjusted life-year (QALY) gained, assessing uncertainty using probabilistic and deterministic sensitivity analyses.ResultsIn base case analysis, the REACH-HF intervention was associated with per patient mean QALY gain of 0.23 and an increased mean cost of £400 compared with usual care, resulting in a cost per QALY gained of £1720. Probabilistic sensitivity analysis indicated a 78% probability that REACH-HF is cost effective versus usual care at a threshold of £20,000 per QALY gained. Results were similar for home-based cardiac rehabilitation versus usual care. Sensitivity analyses indicate the findings to be robust to changes in model assumptions and parameters.ConclusionsOur cost-utility analyses indicate that the addition of the REACH-HF intervention and home-based cardiac rehabilitation programmes are likely to be cost-effective treatment options versus usual care alone in patients with HFrEF.

Economic evaluation plan of a randomised controlled trial of intra-nodular injection of anti-TNF and placebo among patients with early Dupuytren's disease: Repurposing Anti-TNF for Treating Dupuytren's Disease (RIDD).

Dupuytren's disease (DD) is a common fibroproliferative condition of the palmar and digital fascia of the hand; however, there is currently no approved treatment for early stage DD. The objective of this paper is to describe the methods applied to assess the cost-effectiveness of adalimumab injections compared to usual care for controlling the progression of early stage DD in the Repurposing Anti-TNF for Treating Dupuytren's Disease (RIDD) trial. Measure of effectiveness and resource use will be obtained from a randomised clinical trial, carried out in three healthcare centres, and recruiting a minimum of 138 patients aged 18 years and above with a diagnosis of early stage DD. Resource use and utility measures (quality-adjusted life years) will be collected at 3, 6, 9, 12 (primary outcome endpoint) and 18 months post-randomisation. A within-trial cost-utility analysis (CUA) will be conducted at 12 months and if the intervention is effective, a decision analytic model will be applied to estimate the lifetime effectiveness and costs. The analysis will be performed from a health system (National Health Service and personal social services) perspective. Sensitivity analysis will be conducted to assess the robustness of the results. RIDD is the first randomised controlled trial with an economic evaluation conducted among patients with early stage DD. The protocol described here records our intent to conduct both a within-trial CUA alongside the RIDD study and a lifetime CUA using decision-analytic modelling.