Therapy In England Research Articles

Improving access to psychological therapies in England

Improving access to psychological therapies in England

A Further Decrease in the Rates of Administration of Electroconvulsive Therapy in England.

Electroconvulsive therapy (ECT) is an effective treatment of major depression, and there have been consistent improvements in the administration of ECT in the past decade. However, studies have reported a steady decline in the rates of use of ECT in the United Kingdom and Ireland. Despite this, there has been no consistent record of how much ECT is being given or to whom it is given, for more than 20 years. The purpose of this study is to estimate the change in frequency of ECT use, the length of courses, patient demographics, and clinical outcomes between 2006 and 2 periods of 2012/2013 and 2014/2015. In 2012/2013, clinics were asked to complete an online survey giving details of every patient who started a course of ECT between April 1, 2012, and March 31, 2013. This was repeated for the same period in 2014/2015. There continues to be a striking decline in the number of courses of ECT prescribed. Course length has increased. Women are twice as likely to be prescribed ECT as men. Modal age is 60 to 80 years, and the most common diagnosis is depression. Most courses were rated as clinically effective, especially for people with severe illnesses. Maintenance ECT is used at half the clinics surveyed. The use of ECT in England continues to decline. The reasons for this are unclear and need investigation.

Unsafe opioid replacement therapy in England and Wales: a mixed-methods study

BackgroundThe UK has the highest prevalence of illicit drug use in developed countries. Opioid replacement therapy (ORT) aims to reduce illicit opioid use, but inadequate monitoring of treatment can lead to serious preventable adverse drug reactions. We undertook a mixed-methods observational study of unsafe care received by adult patients receiving ORT in primary care. MethodsThe National Reporting and Learning System collates all patient safety incident reports written by health-care professionals in England and Wales. We searched all primary care reports from April 1, 2005, to Sept 30, 2013, for the truncated terms “meth*” and “bupre*”. Free-text reports were read by clinical reviewers (RG, MA) and characterised with codes to describe what happened, underlying causes, harm outcome, and severity. Exploratory descriptive and thematic analyses were done to identify factors underpinning unsafe care. FindingsWe identified 282 incidents of unsafe care, with 223 involving methadone and the rest buprenorphine (59). Over half (153) of reports described harm. Incidents occurred at every stage of providing ORT: prescribing (47), dispensing (148), and monitoring and communication of compliance (76). Dispensing errors occurred because of human error (46) and staff not following protocols (30)—for example, dispensing methadone as take out instead of supervised consumption. Monitoring failures led to patients being dispensed methadone despite three consecutive missed doses (which should trigger re-titration) and patients having duplicate prescriptions. Failures in communication between services underpinned many errors. InterpretationThis study is the largest characterisation, to our knowledge, of unsafe care for patients undergoing ORT in primary care. Although incident reporting systems are prone to under-reporting, our results pinpoint clear ways to improve systems and processes throughout the National Health Service. The unsafe care identified in our study would have been largely prevented by centralised medication record systems, automated alerts for missed doses, electronic prescriptions, and pharmacy team safety meetings. FundingNational Institute for Health Research (NIHR) Health Services and Delivery Research (HS&DR) programme (project number 12/64/118).

Invited commentary … On poverty, politics and psychology.

Associations between deprivation and mental health have long been known. This commentary discusses recent work examining this in relation to the uptake, delivery and outcomes of psychological therapies in England. These associations are complex but it is clear that implementation of evidence-based interventions should consider area-level characteristics.

O035 Is cefixime back? Trends in gonococcal resistance to current and previous front line therapies in England and Wales since the 2011 guideline change

Background/introduction Antimicrobial resistance (AMR) in Neisseria gonorrhoeae threatens effective treatment and infection control. Treatment guidelines for gonorrhoea are revised when the prevalence of resistance to first-line therapy exceeds 5%; in the UK this last occurred in 2011, prompting a treatment guideline change from cefixime to dual therapy with ceftriaxone and azithromycin. Aim(s)/objectives Describe emerging trends in gonococcal resistance to current and previous first-line therapies using data from the Gonococcal Resistance to Antimicrobials Surveillance Programme (GRASP). Methods GRASP collects N. gonorrhoeae isolates from July–September annually from 27 genitourinary medicine clinics in England and Wales. The minimum inhibitory concentration (MIC) of each isolate to seven antimicrobials is determined, then linked to demographic, clinical and behavioural data. Data from 2011–2014 were considered in this analysis. For each antimicrobial, the test for trend in resistance was determined and MIC distributions were compared using the Kolmogorov–Smirnov test. Results In 2014, there was no ceftriaxone resistance (MIC ≥ 0.125 mg/L), but the modal MIC drifted to 0.004 mg/L from 0.002 mg/L in 2011 (p Discussion/conclusion Despite the decline in resistance in cefixime, the drifting MIC distribution suggests isolates are less susceptible than previous years. Ongoing monitoring of AMR with strong compliance with national treatment guidelines is essential to retain gonorrhoea as a treatable infection.

Predicting hospital costs for patients receiving renal replacement therapy to inform an economic evaluation.

To develop a model to predict annual hospital costs for patients with established renal failure, taking into account the effect of patient and treatment characteristics of potential relevance for conducting an economic evaluation, such as age, comorbidities and time on treatment. The analysis focuses on factors leading to variations in inpatient and outpatient costs and excludes fixed costs associated with dialysis, transplant surgery and high cost drugs. Annual costs of inpatient and outpatient hospital episodes for patients starting renal replacement therapy in England were obtained from a large retrospective dataset. Multiple imputation was performed to estimate missing costs due to administrative censoring. Two-part models were developed using logistic regression to first predict the probability of incurring any hospital costs before fitting generalised linear models to estimate the level of cost in patients with positive costs. Separate models were developed to predict inpatient and outpatient costs for each treatment modality. Data on hospital costs were available for 15,869 incident dialysis patients and 4511 incident transplant patients. The two-part models showed a decreasing trend in costs with increasing number of years on treatment, with the exception of dialysis outpatient costs. Age did not have a consistent effect on hospital costs; however, comorbidities such as diabetes and peripheral vascular disease were strong predictors of higher hospital costs in all four models. Analysis of patient-level data can result in a deeper understanding of factors associated with variations in hospital costs and can improve the accuracy with which costs are estimated in the context of economic evaluations.

Evaluating variation in use of definitive therapy and risk-adjusted prostate cancer mortality in England and the USA

ObjectivesProstate cancer mortality (PCM) in the USA is among the lowest in the world, whereas PCM in England is among the highest in Europe. This paper aims to assess the...

Predictors of patient non-attendance at Improving Access to Psychological Therapy services demonstration sites

BackgroundImproving Access to Psychological Therapy (IAPT) services have increased the number of people with common mental health disorders receiving psychological therapy in England, but concerns remain about how equitably these services are accessed. MethodUsing cohort patient data (N=363) collected as part of the independent evaluation of the two demonstration sites, logistic regression was utilised to identify socio-demographic, clinical and service factors predictive of IAPT non-attendance. ResultsSignificant predictors of IAPT first session non-attendance by patients were: lower non-risk score on the Clinical Outcomes in Routine Evaluation-Outcome Measure (CORE-OM); more frequent thoughts of “being better off dead” (derived from the CORE-OM); either a very recent onset of common mental health disorder (1 month or less) or a long term condition (more than 2 years); and site. LimitationsThe small sample and low response rate are limitations, as the sample may not be representative of all those referred to IAPT services. The predictive power of the logistic regression model is limited and suggests other variables not available in the dataset may also be important predictors. ConclusionsThe clinical characteristics of risk to self, severity of emotional distress, and illness duration, along with site, were more predictive of IAPT non-attendance than socio-demographic characteristics. Further testing of the relationship between these variables and IAPT non-attendance is recommended. Clinicians should monitor IAPT uptake in those they refer and implement strategies to increase their engagement with services, particularly when referring people presenting with suicidal ideation or more chronic illness.

PD34-03 RADICAL PROSTATECTOMY WITH ADJUVANT RADIOTHERAPY VERSUS ANDROGEN DEPRIVATION THERAPY PLUS RADIOTHERAPY FOR ADVANCED, NON-DISTANT METASTATIC PROSTATE CANCER

INTRODUCTION AND OBJECTIVES: Prostate-cancer mortality in the USA is reported to be amongst the lowest in the world. Given known differences in management of prostate cancer patients, this paper compares risk-adjusted prostate-cancer mortality in England and the USA. METHODS: Patients diagnosed with non-metastatic prostate cancer between 2004 and 2008 were identified using English hospital admission records linked to national cancer registry data, and the American Surveillance, Epidemiology and End Results programme. Complete data were available for 222,163 patients. Patients were stratified into low, intermediate and high-risk groups according to disease characteristics. Competing-risks survival analyses were used to estimate hazard ratios (HR) adjusted for age, ethnicity, year of diagnosis, Gleason score and tumour stage. RESULTS: In comparison to patients in the USA, English patients were more likely to present at an older age (70-79 years: England 44.2%, US 29.3%, p<0.001), with higher clinical tumour stage (cT3-4: England 25.1%, US 8.6%, p<0.001) and higher Gleason score (GS 8-10: England 20.7%, USA 11.2%, p<0.001). They were also less likely to receive radical therapy, with greatest difference amongst patients with high-risk disease (England 30%, USA 83%, p<0.001). English patients were more likely to die of prostate-cancer (HR 1.9, 95% CI 1.7-2.0, p<0.001). However, this difference was no longer statistically significant when it was also adjusted for radical therapy (HR 1.0, 95% CI 1.0-1.1, p1⁄40.3). CONCLUSIONS: After risk-adjustment, prostate-cancer mortality is significantly higher in England compared to the USA for men with intermediate and high-risk disease. This difference appears to be explained by less frequent use of radical therapy in England.

Comparison of radical treatment and mortality in patients with nonmetastatic prostate cancer in England and the United States.

46 Background: Prostate-cancer mortality in the U.S. is amongst the lowest globally. Given historical differences in management between England and the U.S., this paper aims to determine if risk-adjusted prostate-cancer mortality is inferior amongst men in England compared to the U.S. Methods: Patients diagnosed with non-metastatic prostate-cancer between 2004 and 2008 were identified using English hospital admission records linked to national cancer registry data, and the American Surveillance, Epidemiology and End Results program. Complete data were available for 222,163 patients. Patients were stratified into low-, intermediate-, and high-risk groups according to disease characteristics. Patient demographics from the two countries were compared using the Chi-square test. Competing-risks survival analyses were used to estimate relative six-year prostate-cancer mortality. Results: In comparison to patients in the U.S., English patients were more likely to present at an older age (70 to 79: England 44.2%, USA 29.3%, p&lt;0.001), with higher clinical tumour stage (cT3-4: England 25.1%, USA 8.6%, p&lt;0.001) and higher Gleason score (GS 8-10: England 20.7%, USA 11.2%, p&lt;0.001). They were also less likely to receive radical therapy, with greatest disparity amongst patients with high-risk disease (England 30%, U.S. 83%, p&lt;0.001). After adjusting for age, ethnicity, year of diagnosis, Gleason score, and tumour stage, English patients were more likely to die of prostate cancer (all risk groups: HR 1.9, 95% CI 1.7-2.0, p&lt;0.001). However, this difference was no longer statistically significant on adjustment for radical therapy (all risk groups: HR 1.0, 95% CI 1.0-1.1, p=0.336). Conclusions: After risk adjustment, prostate-cancer mortality is significantly higher in England compared to the U.S. for men with intermediate- and high-risk disease. This difference appears to be explained by decreased use of radical therapy in England.

Global resistance of Neisseria gonorrhoeae

Neisseria gonorrhoeae has demonstrated a remarkable genetic capacity to acquire antimicrobial resistance (AMR) determinants. This review focuses on the recent developments in respect of third generation extended spectrum cephalosporin (ESC)-resistant gonorrhoea and the search for future treatment options. The estimated incidence of new gonorrhoea cases is increasing, and the antimicrobial resistance profile of N. gonorrhoeae is worsening. The most significant recent finding has been the emergence of extensively drug-resistant (XDR) N. gonorrhoeae characterized by very high ceftriaxone minimum inhibitory concentrations. A national switch from cefixime to high-dose ceftriaxone as first-line antigonococcal therapy in England and Wales, as well as parts of Japan, has been accompanied by a reduction in the prevalence of oral ESC-resistant gonococci. Azithromycin given in combination with either gentamicin or gemifloxacin has been shown to be an effective alternative antigonococcal therapy. Both ertapenem and solithromycin have good in-vitro activity against ESC-resistant N. gonorrhoeae strains. Current strategies to control gonococcal AMR should focus on the use of higher doses of ceftriaxone given as part of dual therapy and further evaluation of alternative drug combinations. The emergence of XDR gonorrhoea argues for enhanced efforts to develop novel antimicrobial agents and a gonococcal vaccine.

Variation in centre-specific survival in patients starting renal replacement therapy in England is explained by enhanced comorbidity information from hospitalization data

Unadjusted survival on renal replacement therapy (RRT) varies widely from centre to centre in England. Until now, missing data on case mix have made it impossible to determine whether this variation reflects genuine differences in the quality of care. Data linkage has the capacity to reduce missing data. Modelling of survival using Cox proportional hazards of data returned to the UK Renal Registry on patients starting RRT for established renal failure in England. Data on ethnicity, socioeconomic status and comorbidity were obtained by linkage to the Hospital Episode Statistics database, using data from hospitalizations prior to starting RRT. Patients with missing data were reduced from 61 to 4%. The prevalence of comorbid conditions was remarkably similar across centres. When centre-specific survival was compared after adjustment solely for age, survival was below the 95% limit for 6 of 46 centres. The addition of variables into the multivariable model altered the number of centres that appeared to be 'outliers' with worse than expected survival as follows: ethnic origin four outliers, socioeconomic status eight outliers and year of the start of RRT four outliers. The addition of a combination of 16 comorbid conditions present at the start of RRT reduced the number of centres with worse than expected survival to one. Linked data between a national registry and hospital admission dramatically reduced missing data, and allowed us to show that nearly all the variation between English renal centres in 3-year survival on RRT was explained by demographic factors and by comorbidity.

Geographic Inequity in the Availability of Cognitive Behavioural Therapy in England and Wales: A 10-Year Update

Improving access to psychological therapies, and in particular cognitive behavioural therapy (CBT), has been a health service priority in England and Wales over the past decade. The delivery of CBT has been limited by a scarcity of resources and further limited by the inequitable geographic distribution of CBT therapists. The current study replicates and extends our previous analysis of the geography of British Association of Behavioural and Cognitive Psychotherapies (BABCP) membership (Shapiro, Cavanagh and Lomas, 2003) 10 years later in order to evaluate the progress made in improving equitable access to CBT. This paper presents the absolute and comparative geographic distribution of current BABCP members, accredited CBT practitioners, and BABCP members who are nurses or clinical psychologists in England and Wales. Efforts to improve the availability of CBT in England and Wales are reflected in the doubling of total membership, and a 4.5 fold increase in accredited membership over the last 10 years. There is evidence that the magnitude of inequity in the geographic availability of CBT therapists has decreased, but that inequity is still evident. Limitations of using BABCP membership data as a proxy measure of CBT availability are acknowledged. A five-fold discrepancy in accredited CBT practitioners between the best and least well-served population decile indicates ongoing "postcode availability" of the best qualified CBT practitioners. Possible strategies to improve the availability of CBT and remedy this inequity are discussed.

Treatment patterns and therapy effectiveness in psoriasis patients initiating biologic therapy in England

Objective: To describe biologic treatment patterns and effectiveness among patients with psoriasis who initiated biologic therapy. Methods: A chart review was conducted for 169 patients with psoriasis initiating biologic treatment between 1 July 2005 and 30 June 2009 from six dermatology clinics. Severity was measured by the Psoriasis Area and Severity Index (PASI) at baseline and time of treatment change. Biologic treatment patterns in the 12 months following initiation (discontinuation, switching, dose increase, and persistence) were collected. Results: Mean (SD) PASI score at initiation was 18.4 (7.8). Eighteen percent of patients discontinued biologic use, 12% switched, and 7% increased biologic dose within the first 12 months. Patients persistent on initial biologic therapy (64%) achieved a mean PASI score of 3.8 at 12 months; 69% achieved PASI ≥75. For patients who discontinued due to lack of effectiveness, mean PASI score was 22.6; no patient reached PASI ≥75. Among patients who switched, mean PASI was 15.7 (0% PASI ≥75) at the time of switch. In those who increased their dose, mean PASI score was 9.1 (43% reached PASI ≥75) at the time of dose increase. Conclusions: A large proportion (36%) of patients changed or discontinued biologic therapy within the first year. These patients experienced limited PASI response, if any, suggesting an unmet need for this population.

Experience with Long-Term Lenalidomide (LEN) Treatment in the Clinical Setting: Results From the UK Revlimid® Treatment Continuation Scheme™ (TCS)

AbstractAbstract 4067 Background:Existing evidence has shown that continuing treatment with LEN plus dexamethasone (LEN-DEX) until disease progression in responding patients (pts) with relapsed/refractory multiple myeloma (RRMM) is associated with improved survival. In accordance with National Institute of Clinical Excellence (NICE) guidelines, LEN-DEX is reimbursed for treatment of RRMM pts after ≥2 therapies in England and Wales (current license after ≥1 prior therapy). The TCS database was designed as part of the NICE agreed pt access scheme, to track the duration of treatment for RRMM pts prescribed LEN-DEX. This scheme was not designed to record reasons for dose adjustments or treatment discontinuation. We studied LEN starting dose, dose modifications, and duration of treatment (in an anonymized dataset generated for statistical analysis). Methods:This prospective cohort analysis focused on pts enrolled in the TCS program between 1 July 2009 and 1 May 2010, to allow pts to be followed up for at least 2 years, unless they discontinued treatment earlier. The cut-off date was 30 June 2012. Associations between ordered categorical variables were measured by Spearman's rank correlation or Pearson's correlation for continuous variables. Baseline covariates (age and starting dose) were modeled using multivariable logistic regression with possible interactions considered. Statistical significance was considered at the 5% significance level. Results:A total of 1,286 pts with RRMM from 185 UK treatment centers were evaluable. The median age was 69 yrs (range, 34–91); 427 pts were aged <65 yrs (33%), 529 pts were aged 65–74 yrs (41%), and 330 pts were aged >75 yrs (26%).Majority of pts (n = 835; 65%) initiated LEN treatment according to the recommended starting dose of 25 mg/d; 180 (14%) pts started at 15 mg, 212 (16%) at 10 mg, and 59 (5%) at 5 mg. Dose modifications were reported in 50% of pts, and the median number of changes in dose per subject was 1 (range, 0–15). The greatest percentage of dose modifications per cycle occurred in pts with the lowest starting dose (5 mg). A total of 340 (45%) pts who started on 25 mg/d and received >1 cycle required no dose adjustments. There was a relationship between dose adjustment and duration of treatment; pts without an adjustment received an average of 9.1 cycles while those with at least one form of adjustment received 14.3 cycles (P < 0.001).The median number of cycles administered was 7 (range, 1–38), similar to that seen in LEN clinical trials (median 9.2 mos in pts with ≥2 prior therapies); 456 (35%) pts remained on therapy for ≥12 cycles and 201 (16%) pts remained on therapy for ≥24 cycles. Six percent of all pts receiving ≥24 cycles had dose modifications directly after cycle 1, with the percentage of dose modifications steadily decreasing from cycle 6 onwards. There was a positive association between a higher starting dose and longer treatment duration (P < 0.001). Of the pts who started on 25 mg/d and ≤10 mg/d, 18% and 9% received ≥24 cycles, respectively.There was a significant negative correlation between age and the number of cycles administered (P = 0.018): of the pts aged <75 yrs, 17% received ≥24 cycles; pts ≥75 yrs, 11% received ≥24 cycles.Multivariate analyses were carried out to evaluate predictors for treatment duration. Age and starting dose were both found to be statistically significant predictors for a treatment duration lasting ≥24 mos: pts aged <65 yrs and 65–74 yrs were 1.61 times (P = 0.030) and 1.65 times (P = 0.019) more likely to have a duration >24 mos compared with pts ≥75 years, respectively. Pts were 2 times (P = 0.010) more likely to achieve ≥24 cycles if receiving 25 mg as their starting compared with those starting on 10 mg/d. Conclusions:Results of this “real-world” clinical analysis support 25 mg LEN as an optimal starting dose for the majority of RRMM pts. A positive correlation between the recommended starting dose and longer treatment duration was observed. In addition, individual dose adjustments of LEN during therapy appeared to be associated with extended treatment duration in this setting. Disclosures:Williams:Celgene, Janssen-Cilag: Honoraria. Simcock:Celgene: Employment. Lodhi:Celgene: Employment. Robinson:Celgene: Employment. Davies:Celgene, Johnson & Johnson, Onyx, Novartis: Honoraria, Speakers Bureau; Merck: Speakers Bureau.

Lenalidomide for multiple myeloma: cost-effectiveness in patients with one prior therapy in England and Wales

To determine the cost effectiveness of lenalidomide plus dexamethasone (LEN/DEX) versus DEX alone in managing multiple myeloma (MM) patients who have failed one prior therapy. An individual simulation model was designed to capture the costs and outcomes of LEN/DEX versus DEX therapy in relapsed refractory MM patients. MM009/010 efficacy data were adjusted for treatment cross-over and extrapolated to patient lifetime. Resource use for MM disease progression and adverse events were obtained from expert physicians and costed from the perspective of the National Health Service (England and UK) and included a patient access scheme for LEN. Utility values were obtained from published literature. The simulation model estimated an incremental improvement in time to progression of 9.5 months, an additional 3.2 life-years, and 2.2 quality adjusted life years (QALY) for LEN/DEX compared to DEX alone. Including the costs of therapy with the patient access scheme, adverse events, and disease follow-up, the incremental cost effectiveness ratio was £30,153/QALY for LEN/DEX compared to DEX alone in MM patients who have failed one prior therapy. LEN/DEX is a cost effective oncology therapy from the perspective of the NHS for MM patients with one prior treatment.

A postcode lottery for cardiac rhythm management?

British Journal of Cardiac NursingVol. 7, No. 3 CommentA postcode lottery for cardiac rhythm management?Andrew J Turley, Nicholas J LinkerAndrew J TurleySearch for more papers by this author, Nicholas J LinkerSearch for more papers by this authorAndrew J Turley; Nicholas J LinkerPublished Online:27 Sep 2013https://doi.org/10.12968/bjca.2012.7.3.132AboutSectionsView articleView Full TextPDF/EPUB ToolsAdd to favoritesDownload CitationsTrack CitationsPermissions ShareShare onFacebookTwitterLinked InEmail View article References Boriani G, Berti E, Biffi M et al. (2010) Implantable electrical devices for prevention of sudden cardiac death: data on implant rates from a ‘real world’ regional registry. Europace 12: 1224–1224 Crossref, Google ScholarCunningham D, Charles R, Cunningham M, de Lange A for HRUK Audit Group (2011) Cardiac Rhythm Management: UK National Clinical Audit 2010. http://www.devicesurvey.com (accessed 23February 2012) Google ScholarCunnington MS, Plummer CJ, McDiarmid AK, McComb JM (2008) The patient journey from symptom onset to pacemaker implantation. QJM 101: 955–955 Crossref, Google ScholarCunnington MS, Plummer CJ, McComb JM (2009) Delays and adverse clinical outcomes associated with unrecognized pacing indications. QJM 102: 485–485 Crossref, Google ScholarCunnington MS, Plummer CJ, McComb JM (2010) A survey of investigations performed prior to permanent pacemaker implantation. Age Ageing 39: 135–135 Crossref, Google ScholarDickstein K, Vardas PE, Auricchio A et al. (2010) 2010 Focused Update of ESC Guidelines on device therapy in heart failure: an update of the 2008 ESC Guidelines for the diagnosis and treatment of acute and chronic heart failure and the 2007 ESC guidelines for cardiac and resynchronization therapy. Developed with the special contribution of the Heart Failure Association and the European Heart Rhythm Association. Eur Heart J 31: 2677–87 Crossref, Google ScholarEpstein AE, DiMarco JP, Ellenbogen KA et al. (2008) ACC/AHA/HRS 2008 Guidelines for Device-Based Therapy of Cardiac Rhythm Abnormalities: A Report of the American College of Cardiology/ American Heart Association Task Force on Practice Guidelines (Writing Committee to Revise the ACC/AHA/NASPE 2002 Guideline Update for Implantation of Cardiac Pacemakers and Antiarrhythmia Devices) Developed in Collaboration With the American Association for Thoracic Surgery and Society of Thoracic Surgeons. J Am Coll Cardiol 51: e1–e62 Crossref, Google ScholarFerreira AM, Adragão P, Cavaco DM et al. (2008) Benefit of cardiac resynchronization therapy in atrial fibrillation patients vs. patients in sinus rhythm: the role of atrioventricular junction ablation. Europace 10: 809–809 Crossref, Google ScholarMcComb JM, Plummer CJ, Cunningham MW, Cunningham D (2009) Inequity of access to implantable cardioverter defibrillator therapy in England: possible causes of geographical variation in implantation rates. Europace 11: 1308–1308 Crossref, Google ScholarNational Institute for Health and Clinical Excellence (2006) Implantable Cardioverter Defibrillators for Arrhythmias [Technology appraisal 95] http://publications.nice.org.uk/implantable-cardioverter-defibrillators-for-arrhythmias-ta95. Google ScholarNational Institute for Health and Clinical Excellence (2007) Cardiac Resynchronization Therapy for the Treatment of Heart Failure [Technology appraisal 120] from http://publications.nice.org.uk/cardiac-resynchronization-therapy-for-the-treatment-of-heart-failure-ta120 Google ScholarScott PA, Turner NG, Chungh A, Morgan JM, Roberts PR (2009) Varying implantable cardio-verter defibrillator referral patterns from implanting and non-implanting hospitals. Europace 11: 1048–1048 Crossref, Google Scholar FiguresReferencesRelatedDetails 1 March 2012Volume 7Issue 3ISSN (online): 2052-2207 Metrics History Published online 27 September 2013 Published in print 1 March 2012 Information© MA Healthcare LimitedPDF download

Cost-Effectiveness of Lenalidomide in Multiple Myeloma Patients with 1 Prior Therapy in England and Wales,

Abstract 4181 Introduction:Lenalidomide plus dexamethasone (Len+Dex) is approved by EMA for patients with multiple myeloma (MM) who have received at least 1 prior therapy. In the wake of NICE's guidance on Thalidomide and Bortezomib TA 228 for 1st-line treatment of MM, Len+Dex may be the only available novel therapy option with potential to extend survival beyond traditional therapies for patients failing the NICE recommended initial treatments; thalidomide or bortezomib both in combination with melphalan and prednisone. Therefore, economic modelling was undertaken to evaluate the cost-effectiveness of Len+Dex from the perspective of the National Health Service (NHS), England and Wales. Methods:An Excel-based individual simulation model was developed to account for disease history which affects time-to-progression (TTP) and overall survival (OS) in relapse refractory MM patients. The OS for each individual within the model was calculated as the combination of that patient's TTP and post progression survival (PPS). The TTP efficacy was derived from a subgroup analysis of patients from the MM-009/010 pivotal trials who had received only 1 prior therapy. The derived equation for TTP included parameters for treatment response, Len+Dex treatment effect and certain baseline characteristics of patients with only 1 prior therapy. The PPS for patients within the model was also derived from the MM-009/010 trials; however, since 47% of patients on Dex switched to Len+Dex at progression, there was a significant Len+Dex effect in the Dex PPS. To account for this, the Dex PPS was calibrated using the longer follow up from the UK Medical Research Council (MRC) trials. Resource use for monitoring and adverse events was obtained via a survey of expert hematologists in the UK. Costs were taken from NHS sources and included a Patient Access Scheme where patients received Len free of charge beyond 26 cycles of use. Utility values were taken from published literature and applied to patients prior to progression (based on their best response rate achieved) and after progression. The robustness of the model results were assessed by sensitivity analyses whereby individual model parameters were varied across their confidence intervals (CI). Results reported include life-years (LY), quality-adjusted life-years (QALY), costs, cost per LY gained and cost per QALY gained. NICE technology appraisal methodology guidelines were followed when modelling over a lifetime horizon and applying a 3.5% discount rate for future benefits and costs. All costs presented are in British pounds. Results:Len+Dex had a substantial increase in health-related outcomes compared to Dex alone, with LYs of 5.37 vs. 2.15 and QALYs of 3.69 vs. 1.49, respectively. The associated drug costs for Len+Dex over the patients' lifetime were higher: however, survival benefits accrued over the same time period offset the cost differences between the two regimens, resulting in a cost per LY gained of 20,639 and per QALY gained of 30,153. The model results remained robust to sensitivity analysis conducted on most parameters and utility estimates. The only parameter that affected the results was the adjustment factor for Dex survival when varied across its 95% CI (see table). Discussion:These results indicated that Len+Dex at 2nd line is cost-effective for a novel drug in an orphan disease compared to Dex alone. Despite Len+Dex only being recommended by NICE for use in MM patients with 2 or more prior therapies (with the recent NICE decision to allow thalidomide and Velcade in de novo patients), treatment alternatives for 2nd line therapy with novel agents is more limited. It is important for clinicians to consider the costs and benefits of 2nd line therapy. This analysis demonstrated that Len+Dex is cost-effective for 2nd line patients and meets the commonly quoted cost per QALY threshold of 30,000. Modelled Results:Len/DexDexDifferenceClinical OutcomesMedian TTP (in months)14.094.639.46Life-years5.372.153.22QALYs3.691.492.20Cost Outcomes (British pound)Medication61,98814161,847Monitoring6,9142,8804,034AE Management777175602Incremental cost-effectiveness (British pound)ICER-LYICER-QALY% difference from base case QALYBase case20,63930,153–Upper 95% CI DEX OS27,22538,97529.3%Lower 95% CI DEX OS17,50425,82014.4% Disclosures:Schey:Celgene: Consultancy. Stern:United BioSource Corporation: Employment; Celgene: Consultancy. Dhanasiri:Celgene: Employment. Brown:United BioSource Corporation: Employment; Celgene: Consultancy.

Improving lipid profiles and increasing use of lipid-lowering therapy in England: results from a national cross-sectional survey - 2006

To evaluate blood lipid levels in the adult English population in 2006 and to report change in the use and efficacy of lipid-lowering treatment since 2003 after which time the general practitioner contract introduced a 'pay-per-performance' approach. Cross-sectional surveys. Nationally representative sample of 14,142 noninstitutionalized adults (>16 years) living in England, partaking in the Health Survey for England 2006. Mean levels of total, HDL, non-HDL and total/HDL cholesterol ratio, prevalence of hypercholesterolaemia, use of lipid lowering agents and lipid levels and control rates among those on treatment. Age-standardized mean cholesterol levels fell from 5·49 mM in men and 5·56 mM in women in 2003 to 5·26 and 5·37 mM, respectively, in 2006. In 2006, 59% of adults had a total cholesterol ≥ 5·0 mM and 11% reported lipid-lowering treatment, of whom 66% had a total cholesterol < 5·0 mM and 22% were < 4·0 mM. The majority of those with established coronary heart disease, stroke or diabetes but fewer than one quarter of those with hypertension or ≥ 20% estimated 10-year cardiovascular risk and no established CVD took lipid-lowering drugs. Lipid lowering treatment rates increased fivefold and control rates among the treated (to < 5·0 mM) more than doubled between 1998 and 2006. About one-third of those with established CVD or diabetes had cholesterol levels of < 4·0 mM. Previously reported improvements in treatment and control rates between 1998 and 2003 continued between 2003 and 2006, with the biggest increases among those with established CVD and diabetes.

POD-03.03 Increased Cardiac Admission Rates in Prostate Cancer Patients Treated with Androgen Deprivation Therapy in England

Androgen deprivation therapy (ADT) has been shown to improve the overall quality of life in prostate cancer patients but does carry significant side effects including deleterious effects on cardiovascular health. US publications have shown a link between cardiovascular morbidity and ADT. This is an important area and there is no current UK data published on this subject.