UK Pounds Research Articles

Cost-effectiveness of Rosiglitazone Combination Therapy for the Treatment of Type 2 Diabetes Mellitus in the UK

Recent clinical trial results have demonstrated that, in patients with type 2 diabetes, second-line treatment of rosiglitazone in combination with metformin can lead to significant improvements in the control of fasting plasma glucose/ glycosylated haemoglobin A1c (HbA1c) after the failure of metformin monotherapy. Our objective was to assess the cost-effectiveness of the use of rosiglitazone in combination with metformin in overweight and obese patients with type 2 diabetes in the UK, failing to maintain glycaemic control with metformin monotherapy compared with conventional care using metformin in combination with sulfonylurea. The Diabetes Decision Analysis of Cost--type 2 (DiDACT) model, an established long-term economic model of type 2 diabetes, which projects the relationship between treatment and HbA1c over extended periods, was used to determine the health outcomes and economic impact for matched age and sex cohorts of 1000 patients with type 2 diabetes. The perspective was that of the UK National Health Service and all costs were in UK pounds sterling. Treatment with rosiglitazone in combination with metformin provides better glycaemic control over the remaining lifetime of patients than metformin and sulfonylurea combination therapy. Patients treated with rosiglitazone combination therapy were predicted to have a longer life expectancy, gaining 123 and 140 additional life years per 1000 patients in the obese and overweight cohorts, respectively. Improvements in morbidity and a delay in the start of insulin therapy resulted in a projected improvement in quality of life. These effects combine with projected improved survival to yield 131 and 209 additional quality-adjusted life-years (QALYs) per 1000 patients in the obese and overweight cohorts, respectively. Discounted incremental cost-effectiveness ratios were estimated at pounds 16,700 per QALY gained for the obese cohort and pounds 11,600 per QALY gained for the overweight cohort. The model predicts that rosiglitazone in combination with metformin is a cost-effective treatment in the UK for both obese and overweight patients failing on metformin monotherapy, compared with conventional therapy using metformin in combination with sulfonylurea.

Hungry for help

While obesity is the hot topic in dietetics, malnutrition costs the NHS far more. Recent guidelines from the National Institute for Health and Clinical Excellence (NICE) have addressed the problem but with the NHS strapped for cash, it is unlikely to be a high priority. Older people, especially those with long-term conditions, are vulnerable to malnutrition. Malnutrition is estimated to cost the UK pounds 73 billion a year. Malnourished people take longer to recover from illness and are more prone to complications.

Evaluation of molecular techniques in prediction and diagnosis of cytomegalovirus disease in immunocompromised patients

OBJECTIVES: To evaluate selected molecular tests in diagnosis and screening of cytomegalovirus (CMV) infection in immunosuppressed patients. DESIGN: Clinical and cost-effectiveness were assessed through a prospective two-stage trial of CMV screening regimes in a routine service setting. Different molecular test results were fed back to clinicians in each stage, plus antigenaemia results. The technical performance of the molecular methods was assessed through an independent masked comparison of each molecular test against the established (antigenaemia) test. Scientists performing a particular test were blind to the other test results for that sample. Diagnostic and therapeutic impact were recorded prospectively for all tests, to include any effect on diagnostic certainty, changes to CMV therapy and any other reported impact on patient management. The cost of each test was estimated under different laboratory conditions. Prospective patients undergoing CMV screening were compared with consecutive historical controls in the same unit. Towards the end of the study, a survey of all UK virology laboratories was undertaken to identify current CMV screening practice and test preferences. In addition, all UK renal transplant surgeons and haematology transplant centres were surveyed in order to identify current clinical practice and perceptions of the benefits of CMV screening. SETTING: Study patients were recruited from University Hospital Wales (UHW), Cardiff. Staff in the Cardiff Public Health Laboratory Service virology laboratory performed the tests. PARTICIPANTS: A consecutive series of transplant patients was recruited to the prospective study over a 42-month period, totalling 98 renal and 140 haematology patients. A consecutive series of historical controls was identified, with 199 renal and 136 haematology patients who underwent transplants in the UHW during the 29 months prior to the prospective CMV screening trial.

A cost-utility analysis of pimecrolimus vs. topical corticosteroids and emollients for the treatment of mild and moderate atopic eczema

Conventional treatments for atopic eczema include topical corticosteroids (TCS) and emollients. Pimecrolimus, an immunosuppressant, was licensed in the U.K. in 2003 as an alternative treatment of mild to moderate atopic eczema. To assess the cost-utility of pimecrolimus as a treatment for mild and moderate atopic eczema when compared with conventional treatments which use TCS and emollients. A Markov state-transition model was developed to represent the cyclical nature of atopic eczema and provide an economic analysis of cost-utility for treatment alternatives from the perspective of a third party payer (U.K. National Health Service). A range of methods was used to obtain data for transition probabilities, costs and quality of life. These included a systematic review of published effectiveness data, expert opinion, and a utility study conducted by the authors. Separate cohort analyses were modelled to distinguish between children and adult populations and between differing treatment patterns for facial and body eczema. One-way sensitivity analyses and probabilistic sensitivity analysis (using Monte-Carlo simulation) were performed. Baseline cost-utility outputs from the model show that, in all tested scenarios, TCS dominate pimecrolimus (i.e. TCS are both cheaper and more effective). However, the differences in benefits between treatments output by the model are very small. Sensitivity analyses highlight the importance of cost variations in pimecrolimus. Where pimecrolimus is compared with emollient only it is probably cost effective at a willingness-to-pay threshold of 30 000 UK pounds per quality-adjusted life year. There are likely to be few situations in which the use of pimecrolimus for the treatment of atopic eczema can be justified on economic grounds. Exceptions are likely to be in cases where TCS have been shown to be ineffective, unacceptable due to adverse events, or where a patient is unwilling to accept TCS treatment despite appropriate education and support and emollient alone is the alternative clinical option.

A personalized snack‐based intervention for hip fracture patients: development, feasibility and acceptability

Undernutrition is common in older people admitted to hospital with hip fracture. Oral supplementation with sip feeds may be provided but compliance is a major problem. To develop a personalized snack-based intervention for practical implementation in hip fracture patients and to assess feasibility, adherence, acceptability and cost. Twenty-three older hip fracture patients with a mean age (SD) 84.1 (6.3) were provided with three between-meal snacks daily for 4 weeks following surgery. Dietary counselling, assessment of acceptability and feasibility were undertaken and costs of intervention calculated. Sixteen of the 23 participants recruited completed the study. Mean estimated energy derived from the snacks provided 26% of daily energy requirements. Monitoring adherence proved problematic and stocktakes highlighted discrepancies. Although several participants reported that they did not usually eat between meals, overall the intervention was acceptable to participants. The cost of implementation was 21.29 UK pounds per participant per week. Although it proved feasible, practical difficulties were encountered with implementation and adherence due to timing. A more appropriate time to deliver such an intervention may be after the acute phase is over and patients are back home. The costs compared favourably with the alternative of providing sip feeds.

Cost-effectiveness analysis of surgeryversus conservative treatment for uncomplicated varicose veins in a randomized clinical trial

Despite being a common procedure, the cost effectiveness of surgery for varicose veins has not been established. Cost-effectiveness analysis was carried out alongside a randomized clinical trial at two vascular units within National Health Service (NHS) hospitals. Some 246 patients with uncomplicated varicose veins and evidence of saphenofemoral or saphenopopliteal reflux were allocated randomly to receive either conservative management or surgical treatment. Incremental cost per quality-adjusted life year (QALY) gained at 24 months following randomization was calculated. Total NHS costs during the 2-year study period were higher for the surgically treated group (733 UK pounds) than for those who had conservative treatment (345 UK pounds). The difference in costs was statistically significant. The mean incremental health gain from surgical treatment at 24 months was 0.083 QALYs, leading to a base-case estimate of 4682 UK pounds per QALY gained. Assuming an implicit threshold maximum willingness-to-pay value of 20 000 UK pounds for a QALY, the probability of surgical treatment for varicose veins falling below this threshold value was 70 per cent. This result was found to be robust to sensitivity analysis. For patients with uncomplicated varicose veins and evidence of saphenofemoral or saphenopopliteal reflux, surgical treatment for varicose veins offers a modest health benefit for relatively little additional NHS cost relative to conservative treatment.

Evaluation of the cost-effectiveness of Sirolimus versus cyclosporin for immunosuppression after renal transplantation in the United Kingdom

The purpose of this study was to evaluate the cost-effectiveness of sirolimus compared with cyclosporin for the postsurgical management of renal transplant recipients, from the perspective of the UK National Health Service and the Personal Social Service. A discrete event stochastic simulation model was developed to evaluate both cost-effectiveness and cost utility over 10 and 20 years after transplant using historical data on 937 renal transplant recipients from the University Hospital of Wales in Cardiff, United Kingdom. The simulation was designed to forecast the incidence of acute rejection events, graft failure, retransplant, frequency of hemodialysis (HD) and peritoneal dialysis (PD), and death. Cox proportional hazard models were derived from historical transplant data, in which 1-, 2-, and 3-year post-transplant serum creatinine levels were used as the key drivers for predicting graft success and survival. Costs were reported as year-2003 UK pounds sterling (1 UK pound = US $1.76). Probabilistic sensitivity analysis was conducted and results reported with particular attention to 2 threshold values, 30,000/QALY and 20,000/QALY RESULTS: Over a 10-year time horizon, treatment with sirolimus was projected to produce a gain of 0.60 discounted year of functioning graft with a cost savings of 276 UK pounds per patient. Over a 20-year time horizon these benefits increased to 1.59 discounted years of functioning graft and a cost savings of 7405 UK pounds per patient. Using sensitivity analysis of the 10-year model, the only factors found to cause the probability of exceeding a 30,000 ceiling to be >5% were the proportion of subjects maintaining continuous graft function and the use of low-dose cyclosporin. With the 20-year model, sirolimus maintained cost-effectiveness across most scenarios in sensitivity analysis. In this model analysis, sirolimus was cost-effective compared with cyclosporin for 10 to 20 years after renal transplantation in the United Kingdom, from the perspective of the UK National Health Service and Personal Social Service.

Service costs for severe personality disorder at a special hospital

Much attention has been given to the reform of services for people with personality disorder in the UK, yet little is known of the cost of existing services, particularly in secure forensic settings. Existing cost estimates almost always rely on aggregate estimates of the cost of care rather than individual-level costing, but the latter is necessary for the economic evaluation of new services. This paper uses a new instrument for recording service use in secure forensic settings to report the service use and care package costs of 16 patients being considered for the dangerous and severe personality disorder programme in the Personality Disorder Directorate at Rampton, a high secure hospital in Nottinghamshire, UK. The mean cost over a six-month period was 65,545 UK pounds (approximately 131,000 pounds per annum) but there was considerable variation within this figure, with a range of 59,119 to 82,709 UK pounds. Aggregate costs for individuals in secure hospital settings hide substantial variation between individuals. This paper demonstrates the feasibility of estimating the cost of individual care packages in a secure forensic setting.

Point-of-care controls for nosocomial legionellosis combined with chlorine dioxide potable water decontamination: a two-year survey at a Welsh teaching hospital

This study reports a two-year programme of attempted eradication of Legionella colonization in the potable water supply of a 1000-bed tertiary care teaching hospital in Wales. There was a simultaneous, point-of-care, sterile-water-only policy for all intensive care units (ICU) and bone marrow and renal transplant units in order to prevent acquisition of nosocomial Legionnaires' disease. The programme was initiated following a case of nosocomial pneumonia caused by Legionella pneumophila serogroup 1-Bellingham-like genotype A on the cardiac ICU. The case occurred 14 days after mitral and aortic valve replacement surgery. Clinical and epidemiological investigations implicated aspiration of hospital potable water as the mechanism of infection. Despite interventions with chlorine dioxide costing over 25000 UK pounds per annum, Legionella has remained persistently present in significant numbers (up to 20000 colony forming units/L) and with little reduction in the number of positive sites. Two further cases of nosocomial disease occurred over the following two-year period; in one case, aspiration of tap water was implicated again, and in the other case, instillation of contaminated water into the right main bronchus via a misplaced nasogastric tube was implicated. These cases arose because of inadvertent non-compliance with the sterile-water-only policy in high-risk locations. Enhanced clinical surveillance over the same two-year period detected no other cases of nosocomial disease. This study suggests that attempts at eradication of Legionella spp. from complex water systems may not be a cost-effective measure for prevention of nosocomial infections, and to the best of our knowledge is the first study from the UK to suggest that the introduction of a sterile-water-only policy for ICUs and other high-risk units may be a more cost-effective approach.

Imatinib for the treatment of patients with unresectable and/or metastatic gastrointestinal stromal tumours: systematic review and economic evaluation

To assess the clinical and cost-effectiveness of imatinib in the treatment of unresectable and/or metastatic, KIT-positive, gastrointestinal stromal tumours (GISTs), relative to current standard treatments. Electronic databases. As there were no randomised trials that have directly compared imatinib with the current standard treatment in patients with advanced GIST, this review included non-randomised controlled studies, cohort studies, and case series that reported effectiveness results of treatment with imatinib and/or other interventions in patients with advanced GIST. The effectiveness assessment was based on the comparison of results from imatinib trials and results from studies of historical control patients. Economic evaluation was mainly based on an assessment and modification (when judged necessary) of a model submitted by Novartis. Evidence from published uncontrolled trials involving 187 patients, and from abstracts reporting similar uncontrolled trials involving 1700 patients, indicates that approximately 50% of imatinib-treated individuals with advanced GIST experience a dramatic clinical response in terms of at least a 50% reduction in tumour mass. At present, although useful data are accumulating, it is not possible to predict which patients may respond in this way. Fifteen studies where possible GIST patients had been treated with therapies other than imatinib or best supportive care were also identified. All imatinib-treated patients experienced adverse effects, although they were relatively mild. Overall, imatinib was reported to be well tolerated. The most common serious events included unspecified haemorrhage and neutropenia. Skin rash, oedema and periorbital oedema were the common adverse events observed. Patients on the highest dose regimen (1000 mg per day in one trial) may experience dose-limiting drug toxicity. A structured assessment was carried out of the Novartis economic evaluation of imatinib for unresectable and/or metastatic GIST. The model was clearly presented and well written, its structure and input data were transparent, and the level of simplification was reasonable in terms of the objectives and data availability. However, the original Novartis model overestimated the cost-effectiveness of imatinib because of disproportion of survival and time-to-treatment failure in the imatinib arm, and the use of a possibly biased survival curve for patients in the control arm. The original Novartis model was modified to correct these two important shortcomings, which made it less sensitive to the choice of the survival curve for the control patients. According to the modified Novartis model, the estimated cost per quality-adjusted life-year (QALY) was 85,224 UK pounds (range 51,515--98,889 UK pounds) after 2 years, 41,219 UK pounds (27,331--44,236 UK pounds) after 5 years and 29,789 UK pounds (21,404--33,976 UK pounds) after 10 years. The results from a new Birmingham model were also within the range of estimates from the modified Novartis model. Evidence from uncontrolled studies indicates that the treatment with imatinib brings about clinically significant shrinkage of tumour mass in about half of patients with unresectable and/or metastatic, KIT-positive GIST. Results of modelling based on data from uncontrolled studies suggest that imatinib treatment improves survival in patients with unresectable and/or metastatic GIST. The economic evaluation modelling suggests that the cost per QALY gained ranges from 51,515 to 98,889 UK pounds after 2 years, from 27,331 to 44,236 UK pounds after 5 years, and from 21,404 to 33,976 UK pounds after 10 years. Further research is needed into quality of life within trials involving patients with advanced malignancy, and long-term follow-up of adverse events is needed. Subgroup analysis of which, if any, patient types have a better or worse response to imatinib is also required. Analysis of individual patient data may be a good way of exploring these issues. There are many uncertainties surrounding imatinib prescription, such as the length of time patients should be on imatinib, the dose, drug resistance and the optimum time-point in the disease course at which to give the drug. Secondary research such as an update of this systematic review and a reassessment of the model is highly recommended when ongoing trials reach completion.

Cost‐effective faster wound healing with a sustained silver‐releasing foam dressing in delayed healing leg ulcers – a health‐economic analysis

The aim of this analysis was to examine the cost-effectiveness of Contreet Foam (A) in comparison with three other commonly used venous leg ulcer treatment protocols: Aquacel Ag (B), Actisorb Silver (C) and Iodoflex (D). A health-economic analysis reflecting the UK treatment practice and cost structure was performed. The analysis was set up to assess the cost of relative wound area reduction over a 4-week treatment period. The model was validated by a UK expert panel consisting of four wound care specialists. To assure that the 4-week model had a realistic link to cost-effectiveness of complete wound healing, a Markov analysis was also performed. Sensitivity analyses were carried out to ensure validity. Protocol A and C proved to be the most effective treatments. The mean relative reduction in wound area after 4 weeks of treatment was 50.2% (protocol A), 23.9% (protocol B), 44.6% (protocol C) and 36.0% (protocol D). Cost-effectiveness ratios showed that protocol A proved to be the most cost-effective treatment, and protocol B the least. The cost per percentage reduction in wound area was 9.50 UK pounds for protocol A, compared to 16.50-17.60 UK pounds for the other treatment options. The cost-effectiveness of complete healing (Markov analysis) and sensitivity analyses confirmed these results. Using Contreet Foam instead of the other dressing alternatives may imply savings of 2.2-4.4 million UK pounds per year to the National Health Service.

A survey of dental school applicants' career intentions and the balance with family life

To investigate the career plans of prospective dental students and how they foresee their work life balance. Applicants to Dundee and Manchester dental schools completed anonymous questionnaires when they attended for interview. The useable response rate was 94% (n=436). The majority of the respondents (91.3%) intended working full time when they enter the workforce, with no significant variation detected between males and females. The cohort anticipated their mean salary to be just over 28,000 UK pounds, five years into their career, although the males felt they would be earning 5,000 UK pounds more than the females. Individuals of Pakistani and Indian origin thought they would earn most, and Asians least. Sixty-five per cent would enter general dental practice and, of these, only 2.8% expected to work exclusively within the NHS. Fifteen per cent intended to go into the hospital dental service, with orthodontics the most popular choice of subspecialty (43.7%), followed by oral surgery (31.1%). Significant variation was seen between ethnic groups, with the hospital and community dental services being more popular with those who identified themselves as of non-white ethnic origin, although the majority would still plan on entering general dental practice. Almost half (44.5%) would take time out of their career to concentrate on childcare when children were of pre-school age, with a further 11% taking longer. Ninety per cent of females and 70% of males anticipated taking time out, of a varying duration. Half of the respondents indicated that they felt a child would affect their career to a moderate extent. The dental profession will be severely affected if both males and females take time out of their careers in the future. As well as a work force shortage, the problems of accessibility to NHS dental services will be exacerbated if fewer dentists choose to provide NHS care.

Cost-utility analyses of intensive blood glucose and tight blood pressure control in type 2 diabetes (UKPDS 72)

This study estimated the economic efficiency (1) of intensive blood glucose control and tight blood pressure control in patients with type 2 diabetes who also had hypertension, and (2) of metformin therapy in type 2 diabetic patients who were overweight. We conducted cost-utility analysis based on patient-level data from a randomised clinical controlled trial involving 4,209 patients with newly diagnosed type 2 diabetes conducted in 23 hospital-based clinics in England, Scotland and Northern Ireland as part of the UK Prospective Diabetes Study (UKPDS). Three different policies were evaluated: intensive blood glucose control with sulphonylurea/insulin; intensive blood glucose control with metformin for overweight patients; and tight blood pressure control of hypertensive patients. Incremental cost : effectiveness ratios were calculated based on the net cost of healthcare resources associated with these policies and on effectiveness in terms of quality-adjusted life years gained, estimated over a lifetime from within-trial effects using the UKPDS Outcomes Model. The incremental cost per quality-adjusted life years gained (in year 2004 UK prices) for intensive blood glucose control was 6,028 UK pounds, and for blood pressure control was 369 UK pounds. Metformin therapy was cost-saving and increased quality-adjusted life expectancy. Each of the three policies evaluated has a lower cost per quality-adjusted life year gained than that of many other accepted uses of healthcare resources. The results provide an economic rationale for ensuring that care of patients with type 2 diabetes corresponds at least to the levels of these interventions.

Cost effectiveness analysis of using quantitative ultrasound as a selective pre-screen for bone densitometry

It has been suggested that quantitative ultrasound (QUS) could be used as a selective population pre-screen, to maximise the cost effectiveness of referral for dual energy X-ray absorptiometry (DXA) assessment of bone mineral density (BMD). We set out to examine how such an approach might perform in the assessment of women who were referred by general practitioners for DXA via the open access service in Cardiff. In 115 women aged 40-80 (mean 69) years we used DXA to measure BMD at lumbar spine and hip, and QUS to measure broadband ultrasound attenuation (BUA) in the heel. A bottom-up approach was used to estimate the costs of DXA and QUS. We examined the cost effectiveness of using QUS as a pre-screen, only referring subjects for the more expensive DXA assessment if BUA were less than a pre-determined threshold. The unit costs of pencil-beam DXA and QUS were approximately 44 UK pounds and 16 UK pounds respectively. We identified a BUA threshold of 60 dB/MHz as the most cost effective, and calculated a sensitivity of 81% and specificity of 89% in identifying those subjects whom DXA assessment subsequently identified as having osteoporosis. At the BUA threshold of 60 dB/MHz, pre-screening saved 969 UK pounds at the expense of missing ten women with osteoporosis as diagnosed by DXA. Therefore the cost per additional woman with osteoporosis identified using DXA alone was only 97 UK pounds. QUS assessment does not appear to have a significant cost effective benefit as a pre-screen for DXA in the studied population. A QUS pre-screen would be cost effective only if this investigation could be performed at a substantially lower cost.

A randomised controlled trial comparing low dose vaginal misoprostol and dinoprostone vaginal gel for inducing labour at term

To compare the efficacy of low dose vaginal misoprostol and dinoprostone vaginal gel for induction of labour at term. A single-blind randomised controlled trial. Antenatal and labour ward of a UK district general hospital. Two hundred and sixty-eight women requiring induction of labour at term (>37 weeks of gestation) with no significant fetal or medical condition, no previous uterine surgery and no contraindication to prostaglandin. Misoprostol 25 microg (one-quarter of a 100 microg tablet) was inserted into the posterior vaginal fornix every 4 hours (to a maximum of six doses) or dinoprostone vaginal gel 1-2 mg 6 hourly (maximum of 3 mg in 24 hours). Induction-to-vaginal delivery interval. Requirements for oxytocin, mode of delivery, number of women delivering < 24 hours, incidence of uterine contraction abnormalities, incidence of abnormal cardiotocograph (CTG) recordings, 5-minute Apgar scores, umbilical cord pH recordings, analgesia requirements, admission to NICU and blood loss at delivery. There were no significant differences between the two groups in induction-to-vaginal delivery interval, mode of delivery, number of women delivering within 24 hours and neonatal outcomes. The incidence of uterine contraction abnormalities (tachysystole and hyperstimulation) and the incidence of abnormal CTG recordings were also similar for both groups. Low dose vaginal misoprostol is as effective as dinoprostone gel for inducing labour at term. There would be substantial cost savings, estimated at around 3.9 million UK pounds per annum, for maternity services if low dose misoprostol became the agent of choice for inducing labour in the UK.

The economic consequences of preterm birth duringthe first 10 years of life

To examine the association between gestational age at the time of birth and long-term use and cost of hospital inpatient services. Multi-level modelling of the hospital service utilisation and cost profile of each child born in hospital during 1978-1988 in two areas covered by the Oxford Record Linkage Study. Oxfordshire and West Berkshire. 117,212 children divided into four subgroups by gestational age at birth: <28 weeks, 28-31 weeks, 32-36 weeks, 37 weeks or greater. Number and duration of hospital admissions during the first 10 years of life. Costs, expressed in pound sterling and valued at 1998-1999 prices, of hospital inpatient services. The cumulative cost of hospital inpatient admissions incurred during the first 10 years of life, including the initial birth admission, averaged 17,819.94 [22,322.87 UK pounds] for children born at <28 weeks gestation, 17,751.00 [19,055.53 UK pounds] for children born at 28-31 weeks gestation, 5,376.39 [7,393.78 UK pounds] for children born at 32-36 weeks gestation, and 1,658.63 [3,409.14 UK pounds] for children born at 37 weeks gestation or greater. The adjusted number of hospital inpatient admissions, inpatient days and costs, respectively, over the first 10 years of life was 130%, 77% and 443% higher for children born at <28 weeks gestation than for children born at term. The adverse sequelae of preterm birth are likely to have considerable long-term economic consequences for the health services and for society as a whole.

Cost effectiveness of drotrecogin alfa (activated) for the treatment of severe sepsis in the United Kingdom*

Drotrecogin alfa (activated) is licensed in Europe for the treatment of severe sepsis in patients with multiple organ failure. We constructed a model to assess the cost effectiveness of drotrecogin alfa (activated) from the perspective of the UK National Health Service when used in adult intensive care units. Patient outcomes from a 28-day international clinical trial (PROWESS) and a subsequent follow-up study (EVBI) were supplemented with UK data. Cost effectiveness was assessed as incremental cost per life year and per quality adjusted life year saved compared to placebo alongside best usual care. Applying the 28-day mortality outcomes of the PROWESS study, the model produced a cost per life year saved of 4608 UK pounds and cost per quality adjusted life year saved of 6679 UK pounds. Equivalent results using actual hospital outcomes were 7625 UK pounds per life year and 11,051 UK pounds per quality adjusted life year. Drotrecogin alfa (activated) appears cost effective in treating severe sepsis in UK intensive care units.

Carpal tunnel syndrome, the search for a cost-effective surgical intervention: a randomised controlled trial

There is insufficient evidence regarding the clinical and cost-effectiveness of surgical interventions for carpal tunnel syndrome. This study evaluates the cost, effectiveness and cost-effectiveness of minimally invasive surgery compared with conventional open surgery. 194 sufferers (208 hands) of carpal tunnel syndrome were randomly assigned to each treatment option. A self-administered questionnaire assessed the severity of patients' symptoms and functional status pre- and postoperatively. Treatment costs were estimated from resource use and hospital financial data. Minimally invasive carpal tunnel decompression is marginally more effective than open surgery in terms of functional status, but not significantly so. Little improvement in symptom severity was recorded for either intervention. Minimally invasive surgery was found to be significantly more costly than open surgery. The incremental cost effectiveness ratio for functional status was estimated to be 197 UK pounds, such that a one percentage point improvement in functioning costs 197 UK pounds when using the minimally invasive technique. Minimally invasive carpal tunnel decompression appears to be more effective but more costly. Initial analysis suggests that the additional expense for such a small improvement in function and no improvement in symptoms would not be regarded as value-for-money, such that minimally invasive carpal tunnel release is unlikely to be considered a cost-effective alternative to the traditional open surgery procedure.

Cost‐effective method for laparoscopic choledochotomy

Recent reports have noted that postoperative complications following open or laparoscopic choledochotomy for common bile duct (CBD) exploration are mainly related to the T-tube presence, and that there has been no trend of decrease in the laparoscopic era. Laparoscopic endobiliary stent placement with primary closure of the CBD has been proposed as a safe and effective alternative to T-tube placement. Between January 1999 and January 2003, 53 consecutive patients suffering from proven choledocholithiasis underwent laparoscopic common bile exploration (LCBDE) via choledochotomy. In the early period, a T-tube was placed at the end of the procedure (group A, n = 32) while, from June 2001 onwards, laparoscopic biliary stent placement and primary CBD closure were chosen as the drainage method (group B, n = 21). Six patients developed T-tube-related complications postoperatively. Univariate analysis revealed statistically significant lower morbidity rate and shorter postoperative hospital stay for the stent group. Although not statistically significant, a median saving of 780 UK pounds per patient was observed in the stent group. Biliary endoprosthesis placement following laparoscopic choledochotomy avoids the well-known complications of a T-tube, leading to a shorter postoperative hospital stay. The method is safe and effective and it should also be considered as cost-effective compared to T-tube placement. Further studies are required in order to document cost-effectiveness of the method.

Requirements for DXA for the management of osteoporosis in Europe

The availability of dual energy X-ray absorptiometry (DXA) varies markedly in different countries. There is, however, little information to indicate the optimal requirements for this technology. The principal aim of this study was to estimate the requirements for DXA in Europe for the assessment and treatment of osteoporosis. Three assessment scenarios were chosen. The first envisaged screening of all women with DXA at the age of 65 years. A second scenario comprised a screening programme based on the identification of clinical risk factors with the selective addition of BMD tests in those close to an intervention threshold. The third scenario envisaged a case finding strategy where women aged 65 years were identified on the basis of risk factors and referred for DXA. Requirements for women aged more than 65 years were amortised over a 10-year period. A secondary aim was to estimate the number and cost of osteoporotic fractures in Europe. The requirements for DXA in assessment ranged from 4.21 to 11.21 units/million of the population. The most efficient assessment scenario was the use of clinical risk factors with the selective use of BMD. With this scenario, an additional 6.39 units/million would be required to monitor treatment giving a total requirement of 10.6 units/million. In 2000, the number of osteoporotic fractures was estimated at 3.79 million, of which 0.89 million were hip fractures (179,000 hip fractures in men and 711,000 in women). The total direct costs were estimated at 31.7 billion Euros (21.165 billion UK pounds), which were expected to increase to 76.7 billion Euros (51.1 billion UK pounds) in 2050 based on the expected changes in the demography of Europe.