UK National Health Service Perspective Research Articles

PMH34 - A CONCEPTUAL ECONOMIC MODEL FOR DIGITAL INTERVENTIONS IN SERIOUS MENTAL ILLNESS

Inadequate treatment response in serious mental illness (SMI) patients is widespread, with contributing factors including poor adherence, lifestyle (e.g. activity, sleep and mood) and treatment regimen. Digital interventions that increase the quality and quantity of information available to clinicians have the potential to improve clinical decision making and hence patient outcomes in SMI, as well as leading to cost savings from a reduced need for unplanned care. This study aimed to develop a conceptual framework to assess the savings arising from using digital interventions to support decision making, and to identify value drivers and evidence gaps. A conceptual economic model was developed to predict the impact of a digital intervention on SMI patients’ treatment and outcomes from a UK National Health Service perspective over a 5-year time horizon. The intervention was assumed to provide clinicians with information on the adherence of patients to their current treatment regimen for 3 months, enabling more personalised patient support and better-informed decisions when adjusting or switching treatments. Model inputs were informed by targeted literature searches and expert opinion. Scenario analyses investigated a range of intervention efficacies in the absence of relevant clinical data. Base case model results showed that cost savings per patient of £1,929 in year 1 and at least £7,500 over 5 years could be achieved when using the digital intervention. Using a conservatively estimated eligible population of 22,000, the intervention could generate savings of £42.4 million in year 1 and £165 million over 5 years. This conceptual model demonstrates that using digital interventions can lead to cost savings and improved patient outcomes; it can also be readily adapted to specific interventions. However, robust, quantitative data on the impact of digital interventions on clinician decision making are needed to ensure the analysis is useful for resource allocation decisions.

PMU67 - COST-EFFECTIVENESS ANALYSIS OF IXEKIZUMAB VERSUS SECUKINUMAB IN PATIENTS WITH PSORIATIC ARTHRITIS AND CONCOMITANT MODERATE-TO-SEVERE PSORIASIS IN THE UNITED KINGDOM

Biologic disease-modifying antirheumatic drugs (bDMARDs) are a major driver of total costs in psoriatic arthritis (PsA), a chronic inflammatory rheumatic condition associated with psoriasis. To date, there are no cost-effectiveness analyses (CEAs) comparing the interleukin-17A antagonists ixekizumab and secukinumab in PsA in the UK. We conducted a CEA from the UK National Health Service perspective to compare the cost-effectiveness of ixekizumab versus secukinumab in bDMARD-naïve patients with PsA and concomitant moderate-to-severe psoriasis. A Markov model derived from the widely accepted York model was developed. The model used a lifetime horizon with monthly cycles. Treatment sequences evaluated were ixekizumab→ustekinumab→best supportive care (BSC) versus secukinumab→ustekinumab→BSC. The model included the health states trial bDMARD period, continuous bDMARD treatment, BSC and death. At the end of the bDMARD trial period, Psoriatic Arthritis Response Criteria (PsARC) responders transitioned to continuous treatment with trial bDMARD. PsARC non-responders and patients who discontinued continuous treatment transitioned to trial period of next bDMARD or BSC, as appropriate. Clinical efficacy was measured in terms of proportion of patients achieving a PsARC response and change from baseline Health Assessment Questionnaire – Disability Index (HAQ-DI) and Psoriasis Area Severity Index (PASI) scores, which were derived from network meta-analyses. Health utilities were estimated by applying regression analysis to HAQ-DI and PASI scores collected in the SPIRIT trials with ixekizumab in PsA. Only direct medical costs were included. Ixekizumab was associated with lower total costs (£155,455 vs £155,530 [year of costing 2017]) and higher total QALYs (8.127 vs 7.989) than secukinumab, although differences were modest. Robustness of results was assessed through deterministic and probabilistic sensitivity analyses. In bDMARD-naïve patients with PsA and concomitant moderate-to-severe psoriasis in the UK, first-line ixekizumab in this biologic treatment sequence provided slight advantages in cost savings and QALYs gained over first-line secukinumab in a similar sequence.

Does Structured Exercise Improve Cognitive Impairment in People with Mild to Moderate Dementia? A Cost-Effectiveness Analysis from a Confirmatory Randomised Controlled Trial: The Dementia and Physical Activity (DAPA) Trial.

BackgroundPrevious studies suggest that physical exercise could slow dementia progression. However, evidence for the cost effectiveness of structured exercise is conflicting and based on small trials.ObjectivesThe objective of this study was to compare the cost effectiveness of a tailored, structured, moderate- to high-intensity exercise programme versus usual care in people with mild to moderate dementia.MethodsAn economic evaluation was conducted from the UK National Health Service and personal social services perspective, based on data from a large randomised controlled trial. The primary clinical outcome was the participant reported ADAS-Cog (Alzheimer’s Disease Assessment Scale–Cognitive Subscale) at 12 months. Costs (£; 2014–2015 prices) were collected prospectively over a 12-month follow-up period. A bivariate regression of costs and quality-adjusted life-years (QALYs), with multiple imputation of missing data, was conducted with the view to estimating the incremental cost per QALY gained and the incremental net monetary benefit (INMB) associated with the exercise programme plus usual care versus usual care. Sensitivity analyses were undertaken to assess the impact of uncertainty surrounding aspects of the economic evaluation, and pre-specified subgroup analyses explored heterogeneity in the cost-effectiveness results.ResultsParticipants (n = 494) were randomised to exercise plus usual care or usual care only. By 12 months the mean ADAS-Cog score had worsened slightly to 25.2 (standard deviation [SD] 12.3) in the exercise arm and 23.8 (SD 10.4) in the usual care: difference − 1.4, 95% confidence interval (CI) − 2.6 to − 0.2 (p = 0.03). The mean (standard error [SE]) costs over 12 months for experimental versus control was £5945 (US$7856) versus £4597 (US$6574), respectively; (difference: £1347 [$1926]; p = 0.0426). Mean (SE) QALY estimates were 0.787 (0.012) versus 0.826 (0.019), respectively (p = 0.090). The probability that the exercise programme is cost effective was < 1% across cost-effectiveness thresholds. INMBs ranged between –£2601 (US$3719) and £2158 (US$3086) at cost-effectiveness thresholds between £15,000 (US$21,450) and £30,000 (US$42,900) per QALY. The cost-effectiveness results remained robust to several sensitivity and subgroup analyses.ConclusionsBuilding on the clinical results of the trial, which showed that the structured exercise programme evaluated does not slow cognitive impairment in people with mild to moderate dementia, this economic evaluation shows that the programme is not cost effective.Electronic supplementary materialThe online version of this article (10.1007/s41669-018-0097-9) contains supplementary material, which is available to authorized users.

Cost-effectiveness of roflumilast as an add-on to triple inhaled therapy vs triple inhaled therapy in patients with severe and very severe COPD associated with chronic bronchitis in the UK.

PurposePatients with severe COPD are at high risk of experiencing disease exacerbations, which require additional treatment and are associated with elevated mortality and increased risk of future exacerbations. Some patients continue to experience exacerbations despite receiving triple inhaled therapy (ICS plus LAMA plus LABA). Roflumilast is recommended by the Global Initiative for Chronic Obstructive Lung Disease as add-on treatment to triple inhaled therapy for these patients. This cost-effectiveness analysis compared costs and quality-adjusted life-years for roflumilast plus triple inhaled therapy vs triple inhaled therapy alone, using data from the REACT and RE2SPOND trials.Patients and methodsPatients included in the analysis had severe to very severe COPD, FEV1 <50% predicted, symptoms of chronic bronchitis and ≥2 exacerbations per year. Our model was adapted from a previously published and validated model, and the analyses conducted from a UK National Health Service perspective. A scenario analysis considered a subset of patients who had experienced at least one COPD-related hospitalization within the previous year.ResultsRoflumilast as add-on to triple inhaled therapy was associated with non-significant reductions in rates of both moderate and severe exacerbations compared with triple inhaled therapy alone. The incremental cost-effectiveness ratio (ICER) for roflumilast as add-on to triple inhaled therapy was £24,976. In patients who had experienced previous hospitalization, roflumilast was associated with a non-significant reduction in the rate of moderate exacerbations, and a statistically significant reduction in the rate of severe exacerbations. The ICER for roflumilast in this population was £7,087.ConclusionsRoflumilast is a cost-effective treatment option for patients with severe or very severe COPD, chronic bronchitis, and a history of exacerbations. The availability of roflumilast as add-on treatment addresses an important unmet need in this patient population.

PMD56 - Cost-Effectiveness Analysis of the use of Coblation Technology Versus Mechanical Debridement in Knee Chondroplasty - A UK National Health Service Perspective

PMD56 - Cost-Effectiveness Analysis of the use of Coblation Technology Versus Mechanical Debridement in Knee Chondroplasty - A UK National Health Service Perspective

AV2 - Cost-Effectiveness Analysis of Baseline Testing for Resistance-Associated Polymorphisms to Optimise Treatment Duration in Genotype 1 Non-Cirrhotic Treatment-Naïve Patients with Chronic Hepatitis C Virus

Sustained virologic response (SVR) to direct-acting antiviral regimens containing non-structural protein 5A (NS5A) inhibitor over eight weeks is 95% in genotype 1 (GT1) non-cirrhotic treatment-naïve (TN) patients with hepatitis C virus (HCV). Patients with resistance to the NS5A inhibitor have lower SVR (<85%), and there is evidence that higher SVR (>95%) can be achieved with 12 weeks treatment. We compared the lifetime cost-effectiveness of testing for NS5A resistance at baseline and optimising treatment duration based on the presence of NS5A polymorphisms, using a UK National Health Service perspective. A decision tree and Markov model was used to simulate treatment outcomes and natural disease progression for GT1 non-cirrhotic TN patients in the UK. We compared baseline testing with ‘no testing’. Under ‘no testing’, patients received eight weeks treatment with ledipasvir/sofosbuvir (LDV/SOF). Under ‘testing’, patients with (15%) and without (85%) NS5A polymorphisms were given LDV/SOF for 12 and eight weeks, respectively. We modelled retreatment with the same regimen for 12 weeks in patients that failed initial treatment and considered different SVR thresholds. Evidence on model parameters were taken from published studies. Baseline testing for NS5A polymorphisms generated marginally higher lifetime costs (£32,593.78) and quality-adjusted life years (QALYs) (15.29) per 1,000 patients over ‘no testing’ (£31,207.36; 15.27), assuming 80% SVR to retreatment in each arm, and produced an incremental cost-effectiveness ratio (ICER) of £75,618.55. If the SVR rate for retreatment was 100% in those without NS5A polymorphisms, against 80% in other patients, the ICER was £30,797.79; if SVR was 70% in NS5A-resistant patients, the ICER was £33,289.90. Optimising treatment duration with LDV/SOF for HCV GT1 non-cirrhotic TN patients based on NS5A resistance is not cost-effective, unless high levels of SVR to retreatment are observed in patients with and without NS5A polymorphisms. Results are sensitive to the prevalence of NS5A polymorphisms and baseline test-costs.

PCN105 - Cost-Effectiveness of Ceritinib In Previously Untreated ALK-Positive Non-Small Cell Lung Cancer in the United Kingdom

To assess the cost-effectiveness of ceritinib versus crizotinib in the treatment of anaplastic lymphoma kinase-positive (ALK+) advanced non-small cell lung cancer (NSCLC) from the UK National Health Service (NHS) and Personal Social Service (PSS) perspective. A partitioned survival model with three health states (stable/progressive/death) was built to evaluate costs and effectiveness associated with first-line treatment with ceritinib compared to crizotinib over a 20-year time horizon. Efficacy inputs (progression-free and overall survival) of ceritinib were estimated using data from a phase III randomized trial (ASCEND-4) and were extrapolated beyond the trial period using parametric survival models. Relative efficacy of ceritinib vs. crizotinib was estimated using matching-adjusted indirect comparison based on ASCEND-4 trial data and published PROFILE 1014 results. Drug acquisition, administration, adverse event, and medical costs associated with each health state were obtained from publicly available databases or literature. Treatment-specific utilities for the pre-progression state were based on EQ-5D results from each trial. Utility for the progressive state was obtained from literature. Incremental costs per quality-adjusted life year (QALY) and life years (LY) gained were estimated comparing ceritinib vs. crizotinib. Deterministic and probabilistic sensitivity analyses were performed. Over a 20-year time horizon, total QALYs was estimated to be 3.22 for first-line treatment with ceritinib and 2.68 for first-line treatment with crizotinib. Total LYs were estimated to be 4.51 and 3.85, respectively. Total costs over the 20-year time horizon were £106,954 for ceritinib and £91,970 for crizotinib. Thus, the incremental cost per QALY gained over a 20-year time horizon was estimated to be £27,936 for ceritinib vs. crizotinib, and the corresponding incremental cost per LY gained was estimated to be £22,599. Results were robust to sensitivity analyses. Compared with crizotinib, ceritinib offers a cost-effective option in the treatment of previously untreated ALK+ advanced NCSLC.

PRS32 - Cost-Minimization Analysis of Adding a New Single Inhaler Triple Therapy (SITT) for the Treatment of Patients with Chronic Obstructive Pulmonary Disease (Copd) in the UK

Single inhaler, once-daily fluticasone furoate/umeclidinium/vilanterol (FF/UMEC/VI) 100/62.5/25μg recently licensed in the EU, was demonstrated non-inferior to its component multiple inhaler triple therapy (MITT) FF/VI + UMEC (Study 200812, 2017) and achieved at least similar health benefits versus alternative MITTs in a network meta-analysis. A cost-minimization analysis (CMA) was developed to compare per patient pharmacy costs of FF/UMEC/VI to licensed MITTs over 1, 5 and 10 years from a UK National Health Service (NHS) perspective. The target population was adults with moderate/ severe COPD, currently treated with triple therapy, as determined by local prescribing data. Not all prescribed MITTs are currently licensed for treatment of COPD in the UK, however, all were included in the weighted price analysis. Only drug acquisition costs were included in this analysis, with cost per day calculated using pack prices from MIMS 2017 together with dose and pack size. The cost of all MITTs was assumed to be the sum of individual ICS/LABA and LAMA component costs. A 3.5% discount rate applied beyond year one. In year one, FF/UMEC/VI was cost-saving compared to all licensed comparators except FF/VI (25μg/100μg) + generic tiotropium (TIO, 16μg), where FF/UMEC/VI was costlier by £20.70 per patient. Cost savings per patient with FF/UMEC/VI ranged from £31 (vs salmeterol/ fluticasone propionate [SAL/FP, 25/125μg] + generic TIO [16μg]) to £376 (vs formoterol fumarate/FP [10/250μg] + TIO [18μg]). When compared to a weighted average cost of prescribed ICS/LABA + LAMA MITTs, FF/UMEC/VI was cost-saving (cost savings of £147 per patient over one year). A similar trend was observed at later timepoints. Inclusion of FF/UMEC/VI on UK NHS formularies would result in at least as good clinical outcomes but with the potential to reduce the drug cost burden of COPD. Funding: GSK (HO1613835)

Cost-effectiveness of a model consultation to support self-management in patients with osteoarthritis.

ObjectivesThe aim of this study was to estimate the cost-effectiveness of a model OA consultation for OA to support self-management compared with usual care. MethodsAn incremental cost–utility analysis using patient responses to the three-level EuroQoL-5D (EQ-5D) questionnaire was undertaken from a UK National Health Service perspective alongside a two-arm cluster-randomized controlled trial. Uncertainty was explored through the use of cost-effectiveness acceptability curves.ResultsDifferences in health outcomes between the model OA consultation and usual care arms were not statistically significant. On average, visits to the orthopaedic surgeon were lower in the model OA consultation arm by −0.28 (95% CI: −0.55, −0.06). The cost–utility analysis indicated that the model OA consultation was associated with a non-significant incremental cost of £−13.11 (95% CI: −81.09 to 54.85) and an incremental quality adjusted life year (QALY) of −0.003 (95% CI: −0.03 to 0.02), with a 44% chance of being cost-effective at a threshold of £20 000 per QALY gained. The percentage of participants who took time off and the associated productivity cost were lower in the model OA consultation arm.ConclusionImplementing National Institute for Health and Care Excellence guidelines using a model OA consultation in primary care does not appear to lead to increased costs, but health outcomes remain very similar to usual care. Even though the intervention seems to reduce the demand for orthopaedic surgery, overall it is unlikely to be cost-effective.

Economic Analysis of First-Line Treatment with Cetuximab or Panitumumab for RAS Wild-Type Metastatic Colorectal Cancer in England.

Combination therapies with cetuximab (Erbitux®; Merck Serono UK Ltd) and panitumumab (Vectibix®; Amgen UK Ltd) are shown to be less effective in adults with metastatic colorectal cancer who have mutations in exons 2, 3 and 4 of KRAS and NRAS oncogenes from the rat sarcoma (RAS) family. The objective of the study was to estimate the cost effectiveness of these drugs in patients with previously untreated RAS wild-type (i.e. non-mutated) metastatic colorectal cancer, not eligible for liver resection at baseline, from the UK National Health Service and Personal Social Services perspective. We constructed a partitioned survival model to evaluate the long-term costs and benefits of cetuximab and panitumumab combined with either FOLFOX (folinic acid, fluorouracil and oxaliplatin) or FOLFIRI (folinic acid, fluorouracil and irinotecan) vs. FOLFOX or FOLFIRI alone. The economic analysis was based on three randomised controlled trials. Costs and quality-adjusted life-years were discounted at 3.5% per annum. Based on the evidence available, both drugs fulfil the National Institute for Health and Care Excellence's end-of-life criteria. In the analysis, assuming discount prices for the drugs from patient access schemes agreed by the drug manufacturers with the Department of Health, predicted mean incremental cost-effectiveness ratios for cetuximab + FOLFOX, panitumumab + FOLFOX and cetuximab + FOLFIRI compared with chemotherapy alone appeared cost-effective at the National Institute for Health and Care Excellence's threshold of £50,000 per quality-adjusted life-year gained, applicable to end-of-life treatments. Cetuximab and panitumumab were recommended by the National Institute for Health and Care Excellence for patients with previously untreated RAS wild-type metastatic colorectal cancer, not eligible for liver resection at baseline, for use within the National Health Service in England. Both treatments are available via the UK Cancer Drugs Fund.

Cost calculation for a flash glucose monitoring system for UK adults with type 1 diabetes mellitus receiving intensive insulin treatment

AimsTo estimate the costs associated with a flash glucose monitoring system as a replacement for routine self-monitoring of blood glucose (SMBG) in patients with type 1 diabetes mellitus (T1DM) using intensive insulin, from a UK National Health Service (NHS) perspective. MethodsThe base-case cost calculation was created using the maximum frequency of glucose monitoring recommended by the 2015 National Institute for Health and Care Excellence guidelines (4–10 tests per day). Scenario analyses considered SMBG at the frequency observed in the IMPACT clinical trial (5.6 tests per day) and at the frequency of flash monitoring observed in a real-world analysis (16 tests per day). A further scenario included potential costs associated with severe hypoglycaemia. ResultsIn the base case, the annual cost per patient using flash monitoring was £234 (19%) lower compared with routine SMBG (10 tests per day). In scenario analyses, the annual cost per patient of flash monitoring compared with 5.6 and 16 SMBG tests per day was £296 higher and £957 lower, respectively. The annual cost of severe hypoglycaemia for flash monitoring users was estimated to be £221 per patient, compared with £428 for routine SMBG users (based on 5.6 tests/day), corresponding to a reduction in costs of £207. ConclusionsThe flash monitoring system has a modest impact on glucose monitoring costs for the UK NHS for patients with T1DM using intensive insulin. For people requiring frequent tests, flash monitoring may be cost saving, especially when taking into account potential reductions in the rate of severe hypoglycaemia.

Cost-effectiveness of TYRX absorbable antibacterial envelope for prevention of cardiovascular implantable electronic device infection

Aims: Infection is a major complication of cardiovascular implantable electronic device (CIED) therapy that usually requires device extraction and is associated with increased morbidity and mortality. The TYRX Antibacterial Envelope is a polypropylene mesh that stabilizes the CIED and elutes minocycline and rifampin to reduce the risk of post-operative infection.Methods: A decision tree was developed to assess the cost-effectiveness of TYRX vs standard of care (SOC) following implantation of four CIED device types. The model was parameterized for a UK National Health Service perspective. Probabilities were derived from the literature. Resource use included drug acquisition and administration, hospitalization, adverse events, device extraction, and replacement. Incremental cost-effectiveness ratios (ICERs) were calculated from costs and quality-adjusted life-years (QALYs).Results: Over a 12-month time horizon, TYRX was less costly and more effective than SOC when utilized in patients with an ICD or CRT-D. TYRX was associated with ICERs of £46,548 and £21,768 per QALY gained in patients with an IPG or CRT-P, respectively. TYRX was cost-effective at a £30,000 threshold at baseline probabilities of infection exceeding 1.65% (CRT-D), 1.95% (CRT-P), 1.87% (IPG), and 1.38% (ICD).Limitations and conclusions: Device-specific infection rates for high-risk patients were not available in the literature and not used in this analysis, potentially under-estimating the impact of TYRX in certain devices. Nevertheless, TYRX is associated with a reduction in post-operative infection risk relative to SOC, resulting in reduced healthcare resource utilization at an initial cost. The ICERs are below the accepted willingness-to-pay thresholds used by UK decision-makers. TYRX, therefore, represents a cost-effective prevention option for CIED patients at high-risk of post-operative infection.

Cost Calculation for a Flash Glucose Monitoring System for Adults With Type 2 Diabetes Mellitus Using Intensive Insulin – a UK Perspective

Aims: Estimate the costs associated with flash glucose monitoring as a replacement for routine self-monitoring of blood glucose (SMBG) in patients with type 2 diabetes mellitus (T2DM) using intensive insulin, from a UK National Health Service (NHS) perspective. Methods: The base-case cost calculation used the frequency of SMBG and healthcare resource use observed in the REPLACE trial. Scenario analyses considered SMBG at the flash monitoring frequencies observed in the REPLACE trial (8.3 tests per day) and a real-world analysis (16 tests per day). Results: Compared with 3 SMBG tests per day, flash monitoring would cost an additional £585 per patient per year, offset by a £776 reduction in healthcare resource use, based on reductions in emergency room visits (41%), ambulance call-outs (66%) and hospital admissions (77%) observed in the REPLACE trial. Per patient, the estimated total annual cost for flash monitoring was £191 (13.4%) lower than for SMBG. In the scenarios based on acquisition cost alone, flash monitoring was cost-neutral versus 8.3 SMBG tests per day (5% decrease) and cost-saving at higher testing frequencies. Conclusion: From a UK NHS perspective, for patients with T2DM using intensive insulin, flash monitoring is potentially cost-saving compared with routine SMBG irrespective of testing frequency.

Cost-effectiveness of solifenacin compared with oral antimuscarinic agents for the treatment of patients with overactive bladder in the UK

ABSTRACTObjective: To evaluate the cost-effectiveness of solifenacin 5 mg/day versus other oral antimuscarinic agents used for overactive bladder (OAB) from a UK National Health Service (NHS) perspective. Study design: In a Markov model, hypothetical patients received solifenacin 5 mg/day or a comparator antimuscarinic, after which they could switch to an alternative antimuscarinic. The model estimated incremental cost-effectiveness ratios (ICER), expressed as cost per quality-adjusted life year (QALY) over a 5-year period. Results: Solifenacin 5 mg/day was the dominant treatment strategy (i.e., less costly and more effective) versus tolterodine extended-release (ER) 4 mg/day, fesoterodine 4 and 8 mg/day, oxybutynin ER 10 mg/day and solifenacin 10 mg/day, and was cost-effective (i.e., ICERs below the £30,000 per QALY threshold generally applied in the NHS) versus oxybutynin immediate release (IR) 10 mg/day, tolterodine IR 4 mg/day and trospium chloride 60 mg/day. The probability of solifenacin 5 mg/day being dominant/cost-effective at a willingness-to-pay threshold of £30,000 per QALY was 57–98%. Conclusions: Solifenacin 5 mg/day appears to be a cost-effective strategy for the treatment of OAB over a 5-year timeframe compared with other oral antimuscarinic agents in the UK. These findings are important for decision-makers considering the economic implications of selecting treatments for OAB.

Cost-Effectiveness of Ribociclib Plus Letrozole Versus Palbociclib Plus Letrozole for Postmenopausal Women with Hormone Receptor-Positive (HR+), Human Epidermal Growth Factor Receptor 2-Negative (HER2–) Advanced/Metastatic Breast Cancer from A UK National Health Service Perspective

Cost-Effectiveness of Ribociclib Plus Letrozole Versus Palbociclib Plus Letrozole for Postmenopausal Women with Hormone Receptor-Positive (HR+), Human Epidermal Growth Factor Receptor 2-Negative (HER2–) Advanced/Metastatic Breast Cancer from A UK National Health Service Perspective

Aerobic exercise for vasomotor menopausal symptoms: A cost-utility analysis based on the Active Women trial.

ObjectiveTo compare the cost-utility of two exercise interventions relative to a control group for vasomotor menopausal symptoms.DesignEconomic evaluation taking a UK National Health Service and Personal Social Services perspective and a societal perspective.SettingPrimary care.PopulationPeri- and postmenopausal women who have not used hormone therapy in the past 3 months and experience ≥ 5 episodes of vasomotor symptoms daily.MethodsAn individual and a social support-based exercise intervention were evaluated. The former (Exercise-DVD), aimed to prompt exercise with purpose-designed DVD and written materials, whereas the latter (Exercise-Social support) with community exercise social support groups. Costs and outcomes associated with these interventions were compared to those of a control group, who could only have an exercise consultation. An incremental cost-utility analysis was undertaken using bootstrapping to account for the uncertainty around cost-effectiveness point-estimates.Main outcome measureCost per quality-adjusted life-year (QALY).ResultsData for 261 women were available for analysis. Exercise-DVD was the most expensive and least effective intervention. Exercise-Social support was £52 (CIs: £18 to £86) and £18 (CIs: -£68 to £105) more expensive per woman than the control group at 6 and 12 months post-randomisation and led to 0.006 (CIs: -0.002 to 0.014) and 0.013 (CIs: -0.01 to 0.036) more QALYs, resulting in an incremental cost-effectiveness ratio of £8,940 and £1,413 per QALY gained respectively. Exercise-Social support had 80%-90% probability of being cost-effective in the UK context. A societal perspective of analysis and a complete-case analysis led to similar findings.ConclusionsExercise-Social support resulted in a small gain in health-related quality of life at a marginal additional cost in a context where broader wellbeing and long-term gains associated with exercise and social participation were not captured. Community exercise social support groups are very likely to be cost-effective in the management of vasomotor menopausal symptoms.

Cost-effectiveness analysis of single-use negative pressure wound therapy dressings (sNPWT) to reduce surgical site complications (SSC) in routine primary hip and knee replacements.

We sought to evaluate the cost-effectiveness of single-use negative pressure wound therapy in patients undergoing primary hip and knee replacements using effectiveness data from a recently completed non-blinded randomized controlled trial. A decision analytic model was developed from UK National Health Service perspective using data from a single-centre trial. 220 patients were randomized to treatment with either single-use negative pressure wound therapy or standard care i.e., film dressings of clinician choice and followed for 6 weeks. Outcomes included dressing changes, length of stay, surgical site complications, cost and quality adjusted life years. The randomized controlled trial reported a reduction in dressing changes (p = 0.002), SSC (p = 0.06) and LOS (p = 0.07) in favor of single-use negative pressure wound therapy compared with standard care. The model estimated 0.116 and 0.115 QALY gained, 0.98 and 0.92 complications avoided for single-use negative pressure wound therapy and standard care, respectively. The cost/patient was £5,602 ($7,954) and £6,713 ($9,559) for single-use negative pressure wound therapy and standard care respectively resulting in cost-saving of £1,132 ($1,607) in favor of single-use negative pressure wound therapy. Greater savings were observed in subgroups of higher risk patients with BMI ≥ 35 and ASA ≥ 3 i.e., £7,955 ($11,296) and £7,248 ($10,293), respectively. The findings were robust to a range of sensitivity analyses. In conclusion, single-use negative pressure wound therapy can be considered a cost saving intervention to reduce surgical site complications following primary hip and knee replacements compared with standard care. Providers should consider targeting therapy to those patients at elevated risk of surgical site complications to maximize efficiency.

Cost-Effectiveness of Haemorrhoidal Artery Ligation versus Rubber Band Ligation for the Treatment of Grade II-III Haemorrhoids: Analysis Using Evidence from the HubBLe Trial.

AimHaemorrhoids are a common condition, with nearly 30,000 procedures carried out in England in 2014/15, and result in a significant quality-of-life burden to patients and a financial burden to the healthcare system. This study examined the cost effectiveness of haemorrhoidal artery ligation (HAL) compared with rubber band ligation (RBL) in the treatment of grade II–III haemorrhoids.MethodThis analyses used data from the HubBLe study, a multicentre, open-label, parallel group, randomised controlled trial conducted in 17 acute UK hospitals between September 2012 and August 2015. A full economic evaluation, including long-term cost effectiveness, was conducted from the UK National Health Service (NHS) perspective. Main outcomes included healthcare costs, quality-adjusted life-years (QALYs) and recurrence. Cost-effectiveness results were presented in terms of incremental cost per QALY gained and cost per recurrence avoided. Extrapolation analysis for 3 years beyond the trial follow-up, two subgroup analyses (by grade of haemorrhoids and recurrence following RBL at baseline), and various sensitivity analyses were undertaken.ResultsIn the primary base-case within-trial analysis, the incremental total mean cost per patient for HAL compared with RBL was £1027 (95% confidence interval [CI] £782–£1272, p < 0.001). The incremental QALYs were 0.01 QALYs (95% CI −0.02 to 0.04, p = 0.49). This generated an incremental cost-effectiveness ratio (ICER) of £104,427 per QALY. In the extrapolation analysis, the estimated probabilistic ICER was £21,798 per QALY. Results from all subgroup and sensitivity analyses did not materially change the base-case result.ConclusionsUnder all assessed scenarios, the HAL procedure was not cost effective compared with RBL for the treatment of grade II-III haemorrhoids at a cost-effectiveness threshold of £20,000 per QALY; therefore, economically, its use in the NHS should be questioned.Electronic supplementary materialThe online version of this article (doi:10.1007/s41669-017-0023-6) contains supplementary material, which is available to authorized users.

MICE or NICE? An economic evaluation of clinical decision rules in the diagnosis of heart failure in primary care

BackgroundDetection and treatment of heart failure (HF) can improve quality of life and reduce premature mortality. However, symptoms such as breathlessness are common in primary care, have a variety of causes and not all patients require cardiac imaging. In systems where healthcare resources are limited, ensuring those patients who are likely to have HF undergo appropriate and timely investigation is vital. DesignA decision tree was developed to assess the cost-effectiveness of using the MICE (Male, Infarction, Crepitations, Edema) decision rule compared to other diagnostic strategies to identify HF patients presenting to primary care. MethodsData from REFER (REFer for EchocaRdiogram), a HF diagnostic accuracy study, was used to determine which patients received the correct diagnosis decision. The model adopted a UK National Health Service (NHS) perspective. ResultsThe current recommended National Institute for Health and Care Excellence (NICE) guidelines for identifying patients with HF was the most cost-effective option with a cost of £4400 per quality adjusted life year (QALY) gained compared to a “do nothing” strategy. That is, patients presenting with symptoms suggestive of HF should be referred straight for echocardiography if they had a history of myocardial infarction or if their NT-proBNP level was ≥400pg/ml. The MICE rule was more expensive and less effective than the other comparators. Base-case results were robust to sensitivity analyses. ConclusionsThis represents the first cost-utility analysis comparing HF diagnostic strategies for symptomatic patients. Current guidelines in England were the most cost-effective option for identifying patients for confirmatory HF diagnosis. The low number of HF with Reduced Ejection Fraction patients (12%) in the REFER patient population limited the benefits of early detection.

Latent tuberculous screening of recent migrants attending language classes: a cohort study and cost analysis.

England's national tuberculosis (TB) strategy recommends testing for and treatment of latent tuberculous infection (LTBI) among new migrants. Programmatic testing occurs in primary care, which may be inaccessible for some individuals. Current strategies could therefore be complemented by screening in other settings. To investigate the feasibility and effectiveness of LTBI screening in a community college. A cohort study using observational data collected during the pilot study. Eligible students from high-incidence countries provided consent and were tested with a single-step interferon-gamma release assay (IGRA) and enrolled. We used single and multivariable analyses to estimate screening effectiveness and to explore different subgroups. We included costs from a UK National Health Service perspective. Screening uptake was 75% and treatment completion was 85%. Of 440 students, 71 (16%) were LTBI-positive; two had active TB. There was an association of positivity with age and incidence in the country of origin. Three incidence thresholds met our criteria for screening: countries with >40, >100 and >200 cases per 100 000 population, plus students from sub-Saharan Africa. We found that LTBI screening can be offered effectively in a community college, and could be a complement to primary care-based programmes in low-incidence countries.