A cost-effectiveness analysis of antimicrobial treatment of community-acquired pneumonia taking into account resistance in Belgium

ABSTRACT

Objective: This article assesses the cost-effectiveness of outpatient antimicrobial treatment of community-acquired pneumonia (CAP) taking into account resistance in Belgium.

Research design and methods: Our decision analytic model focused on mild to moderate CAP, but did not consider severe CAP. Treatment pathways reflected empirical treatment initiated in the absence of data on CAP aetiology. First-line treatment consisted of moxifloxacin, co-amoxiclav, cefuroxime or clarithromycin. If first-line treatment was unsuccessful, patients were either hospitalised or second-line treatment with a different antimicrobial was initiated. Clinical failure rates were obtained from the published literature or expert opinion. Costs were calculated using published sources from the third-party payer perspective.

Main outcome measures: Effectiveness measures included first-line clinical failure avoided, second-line treatment avoided, hospitalisation avoided and death avoided. Healthcare costs were included, but costs of productivity loss were not considered.

Results: Costs of treating a CAP episode amounted to 144€ with moxifloxacin/co-amoxiclav; 222€ with co-amoxiclav/clarithromycin; 211€ with cefuroxime/moxifloxacin; and 193€ with clarithromycin/moxifloxacin. The rate of first-line failure was 5%, 16%, 19% and 18% for these four treatment strategies, respectively. The rate of second-line treatment amounted to 4%, 13%, 16% and 15%, respectively. The hospitalisation rate was 1%, 4%, 4% and 4%, respectively. The death rate was 0.01%, 0.04%, 0.03% and 0.03%, respectively. Sensitivity analyses supported the dominance of moxifloxacin/co-amoxiclav in nearly all scenarios.

Conclusions: First-line treatment of CAP patients with moxifloxacin followed by co-amoxiclav or hospitalisation if required was more effective and less costly as compared with first-line treatment with co-amoxiclav, cefuroxime or clarithromycin.     

Estimating the economic impact of a half-day reduction in length of hospital stay among patients with community-acquired pneumonia in the US

ABSTRACT

Background: A recent study suggested that levofloxacin significantly reduces the hospital length of stay (LOS), by 0.5 days (p?=?0.02), relative to moxifloxacin in patients with community-acquired pneumonia (CAP). The current analysis evaluated the potential economic impact of this half-day reduction in LOS.

Methods: A cost model was developed to estimate the impact of a half-day reduction in LOS for CAP hospitalizations in the US. CAP incidence, hospitalization rate, and costs were obtained from published studies in PubMed and from publicly available government sources. The average daily cost of hospitalization was estimated for fixed costs, which comprise 59% of total inpatient costs. Costs from prior years were inflated to 2007 US dollars using the consumer price index. A range of cost savings, calculated using inpatient CAP costs from several studies, was extrapolated to the US CAP population.

Results: Using the Centers for Disease Control National Hospital Discharge estimate of 5.3 days LOS for CAP, and an average cost (2007 $US) of $13,009 per CAP hospitalization, a daily fixed cost of $1448 was estimated. The resultant half-day reduction in costs associated with LOS was $724/hospitalization (range $457 to $846/hospitalization). When fixed and variable costs were considered, the estimated savings were $1227.27/episode. The incidence of CAP was estimated to be 1.9% (5.7 million cases/year based on current population census), and the estimated rate of CAP hospitalization was 19.6% (1.1 million annual hospitalizations). At $13,009/CAP-related hospitalization, total fixed inpatient costs of $8.6 billion annually were projected. The half-day reduction in LOS would therefore generate potential annual savings of approximately $813 million (range $513 million to $950 million). When total costs (fixed plus variable) were estimated, the mean savings for a half-day reduction would be approximately $1227/episode (range of $775 to $1434) or $1.37 billion annually in the US CAP population (range of $871 million to $1.6 billion). Limitations include the use of a single study for the estimation of fixed costs but a diversity of sources used for estimates of other variables, and lack of data with respect to the effects on costs of diagnostic-related groups, discounted contracts, and capitated payments.

Conclusions: A relatively small decrease in LOS in CAP can have a substantial cost impact, with estimated savings of $457 to $846 per episode or $500-$900 million annually. Additional evaluation is warranted for interpreting these cost-savings in the context of current antibiotic prescribing patterns.     

Economic evaluation of tiotropium and salmeterol in the treatment of chronic obstructive pulmonary disease (COPD) in Greece

ABSTRACT

Objective: The objective of the study was to assess the cost-effectiveness of two therapeutic alternatives for chronic obstructive pulmonary disease in the Greek National Health Service (NHS) setting.

Methods: A Markov probabilistic model was used to compare tiotropium with salmeterol. A Monte Carlo simulation with 5000 cases was run in the probabilistic analysis. The model was designed to compute the expected time spent in each state, the expected number of exacerbations occurring and the expected treatment cost per patient. Probabilities were extracted from clinical trials, resource utilisation and cost data from a Greek university hospital.

Results: Quality adjusted life years were 0.70 (95% Uncertainty Interval [UI]: 0.63 to 0.77) in the tiotropium arm and 0.68 (95% UI: 0.60 to 0.75) in the salmeterol arm; a difference of 0.02 (95% UI: –0.08 to 0.13). Exacerbations reached 0.85 (95% UI: 0.80 to 0.91) in the tiotropium arm and 1.02 (95% UI: 0.84 to 1.21) in the salmeterol arm, a difference of –0.17 (95% UI: –0.37 to 0.02). Estimates of the mean annual cost per patient were €2504 (€2122 to €2965) in the tiotropium arm and €2655 (€2111 to €3324) in the salmeterol arm, a difference of –€151 (–€926 to €580). Stochastic analysis showed that tiotropium may have an advantage in reducing exacerbations. The probability that tiotropium is cost-effective was 65% at a ceiling value of €0 and reached 77% at a ceiling ratio of €1000. Results stay fairly constant in various sensitivity analyses.

Conclusion: Even though tiotropium is more expensive to buy than salmeterol in the Greek NHS (using Greek costs there was no statistically significant difference in total costs between tiotropium and salmeterol), overall, during the course of a year, it is actually associated with a lower prevalence of exacerbations and lower treatment costs and thus may represent a viable and cost-effective alternative in the Greek NHS setting.     

Hospital visits and costs following outpatient treatment of CAP with levofloxacin or moxifloxacin

Abstract

Background:

Hospital admissions (inpatient and emergency room) are a major source of medical costs for community-acquired pneumonia (CAP) initially treated in the outpatient setting. Current CAP treatment guidelines do not differentiate between outpatient treatment with levofloxacin and moxifloxacin.     

Clinical implications of 750 mg, 5-day levofloxacin for the treatment of community-acquired pneumonia

SUMMARY

Objective: To evaluate the time to symptom resolution and IV-to-PO transition in community-acquired pneumonia (CAP) patients treated with 750?mg or 500?mg levofloxacin.

Research Design: A retrospective, subset analysis of a multicenter, randomized, double-blind, controlled trial comparing 750?mg levofloxacin for 5 days to 500?mg levofloxacin for 10 days for the treatment of CAP.

Patients and Methods: A total of 528 CAP patients were included. Baseline symptoms were re-evaluated on Day 3 of therapy, and time to IV-to-PO transition was recorded for inpatients.

Results: For the overall population, 67.4% of patients receiving 750?mg levofloxacin had resolution of fever by Day 3 of therapy, compared to 54.6% of 500?mg treated patients (?P = 0.006). Patients who started on 750?mg levofloxacin IV (?N = 108) transitioned to PO in an average of 2.68 days while those starting on 500?mg IV (?N = 124) transitioned in 2.95 days (?P = 0.144). The median time for IV-to-PO switch was 2.35 days and 2.75 days for patients receiving 750?mg and 500?mg levofloxacin, respectively (?P = 0.098, log rank test). By Day 3 of therapy, 68% of patients receiving the 750?mg dose had transitioned from IV to PO levofloxacin, compared with 61% of the 500?mg group (?P = 0.280). The safety profiles were comparable for the two regimens.

Conclusions: The 750?mg levofloxacin dose resulted in a greater proportion of patients with resolution of CAP symptoms by Day 3 when compared with 500?mg therapy. Consequently, the 750?mg regimen trended toward more rapid transition to PO, potentially resulting in lower overall drug costs. Time to switch from IV to PO was determined by the investigators’ discretion rather than a set protocol. Additionally, length of stay data was not collected in this study, which can significantly impact overall healthcare costs. Further research is required to fully understand the economic impact of the 750?mg, 5-day levofloxacin regimen.     

Comparison of costs of sublingual immunotherapy and drug treatment in grass-pollen induced allergy: results from the SIMAP database study

ABSTRACT

Objectives: This analysis is focused on the comparison of costs of allergic rhinitis (R) alone or with allergic asthma (R?+?A) in grass pollen allergy, for subjects treated with sublingual immunotherapy (SLIT) and symptomatic drugs, versus standard care controls.

Methods: The SIMAP (Sublingual IMmunotherapy in Allergic Patients) study is a longitudinal observational database operated by a network of Allergy centers. Patients suffering from grass pollen allergy were included in this analysis and assigned to SLIT (plus drugs as needed) or to treatment with drugs alone. Outcome measures included use of medications, SLIT, visits and tests. Costs were assessed from the perspective of the Italian National Health Service; unit costs were obtained from published sources to produce an average cost/patient for the first year after enrolment.

Results: One hundred and two patients were analyzed. Demographics were comparable in the two groups. Overall per patient yearly cost of treatment was higher in SLIT patients, both in the whole sample (€311 vs. €180/patient), in the R (€288 vs. €116) and R?+?A (€362 vs. €230) subpopulations, with R?+?A patients generating more costs than R patients in both groups. Nevertheless considerable savings were obtained in the cost of symptomatic drugs (?22% for R; ?34% for R?+?A) in SLIT patients.

Conclusions: Other studies have shown that SLIT can reduce the use of drugs for asthma and rhinitis, but this is the first time this outcome has been demonstrated in a routine care population (in the medical practice environment of an observational study) within the first year of treatment.     

Acute coronary syndromes in Europe: 1-year costs and outcomes

ABSTRACT

Objective: This study aims to estimate costs (including medications prescribed, intervention rates and hospital utilization) and health outcomes of acute coronary syndromes (ACS) during the first year following diagnosis.

Research design and methods: Treatment pathways for ACS patients were developed and country-specific resource use was multiplied by unit costs. Countries examined were the United Kingdom (UK), France, Germany, Italy and Spain. Patients with unstable angina and acute myocardial infarction (ST-segment elevation and non-ST-segment elevation with/without Q-wave) were considered. The study models the incidence of ACS, 1-year mortality, investigations, revascularisation, pharmaceutical use and medical management. Economic outcomes were direct healthcare costs (in 2004 Euros), including total cost, cost per patient with ACS and cost per capita.

Results: The estimated number of deaths in the first year following ACS diagnosis ranged from around 22?500 in Spain to over 90?000 in Germany. The largest contributors to total costs are hospital stay and revascularisation procedures. Pharmaceuticals were estimated at 14–25% of ACS total cost. The total cost of ACS in the UK is estimated around €1.9 billion, compared with €1.3 billion in France, €3.3 billion in Germany, €3.1 billion in Italy and €1.0 billion in Spain. The cost per ACS patient ranges from €7009 (in the UK) to €12?086 (Italy).

Conclusions: Countries with higher expenditure on ACS patients tended to have lower case-fatality rates, and countries with the lowest incidence of ACS also had the lowest cost per capita. The costs of ACS constitute a large proportion of total healthcare expenditure of Western European economies.     

Cost-effectiveness in Italy of preventive treatment with ramipril in patients at high risk of cardiovascular events

ABSTRACT

Objectives: A cost-effectiveness analysis was conducted in Italy of preventive treatment with ramipril (an angiotensin converting enzyme [ACE] inhibitor) compared to no treatment in patients at high risk of cardiovascular death. The analysis was based on data extracted from the HOPE trial.

Methods: The current life table method was used in order to model a lifetime time horizon for outcomes and costs. The cohorts used were 1000 subjects on ramipril, and 1000 subjects on placebo enrolled in the HOPE trial. Kaplan–Meier curves at 5 years of the clinical study were fitted using an exponential model over a lifetime horizon, the outcome variables being myocardial infarction, stroke, revascularization and death. Total direct medical costs have been considered from a third-party payer's perspective – the Italian National Health Service. Resources involved in each event/activity were estimated using the modified Delphi technique with a panel of six clinicians. Types of resources reported included drug therapies, laboratory and imaging tests, physician visits, outpatient and inpatient rehabilitation, as well as medical and surgical hospital admissions. The incremental cost per life year gained was the main measure of the analysis.

Results: ICER (incremental cost-effectiveness ratio) decreases with the length of the treatment period. After the first year the ICER is €55?062 and subsequently decreases to about €12?770 at 5 years, €5945 at 10 years and €3726 at 20 years. The two ways sensitivity analysis showed that at 5 years ICERs range from a saving of €4059 to a cost of €22?929 (at 20 years they are €1814 and €4434), mainly depending on the cost of drug and cost of events. Previous analyses in other countries based on the HOPE study obtained ICER values which are comparable with our results, when taking into account the different cost structure of the health care systems.

Conclusions: On the basis of these results, the use of ramipril is likely to represent an efficient use of public health expenditure in the Italian healthcare system.     

Hospitalization rates among patients with community-acquired pneumonia treated with telithromycin vs clarithromycin: results from two randomized,double-blind,clinical trials

SUMMARY

Aims: To compare hospitalization rates among patients with community-acquired pneumonia (CAP) treated with oral telithromycin and clarithromycin, based on pooled data from two randomized, double-blind, multinational clinical trials.

Patients and methods: Adult patients with CAP eligible for oral therapy (Study 1, n = 448; Study 2, n = 575) received telithromycin 800?mg once daily for 10 (Study 1, 2-arms), 5 or 7 (Study 2, 3-arms) days, or clarithromycin 500?mg twice daily for 10?days. Frequency of CAP-related hospitalizations, physician visits/tests/procedures, and additional respiratory tract infection-related antibacterial use, as well as CAP-related length of hospital stay and hospitalization costs, were compared by treatment group (intent to treat populations) up until the late post-therapy visit (Days 31–36). Study investigators blinded to treatment regimen assessed whether hospital admissions were CAP related.

Results: Despite equivalent clinical efficacy for telithromycin vs clarithromycin in the clinically evaluable per-protocol populations (n = 784) (88.8% [428/482] vs 90.1% [272/302] – difference: –1.3%; 95% CI: –6.0, 3.4), telithromycin treatment for 5, 7, or 10?days was associated with significantly fewer CAP-related hospitalizations (?p = 0.023) and CAP-related hospital days (?p = 0.025) vs clarithromycin (reduction of 2.3 hospitalizations and 23.4 hospital days per 100 patients). Accordingly, estimated CAP-related hospitalization costs were significantly lower (?p = 0.025) for telithromycin recipients (US$30?231 less per 100 patients). CAP-related hospitalizations, duration of hospital stay, and hospitalization costs for 7- to 10-day telithromycin – the approved dosing regimen for CAP – were significantly lower (?p = 0.023, 0.025, and 0.025, respectively) than for clarithromycin.

Conclusions: Data from this study indicate that telithromycin 800?mg once daily for 5, 7, or 10?days provides an effective therapy for patients with CAP, and may be associated with fewer CAP-related hospitalizations and hospital days than clarithromycin 500?mg twice daily for 10?days. Treatment with telithromycin could, therefore, potentially translate into cost savings in the management of CAP.     

XELOX versus FOLFOX6 as an adjuvant treatment in colorectal cancer: an economic analysis

ABSTRACT

Objectives: An economic analysis (based on interim data from a long-term, randomised, multi-centre, controlled, clinical trial) to evaluate chemotherapy with XELOX (capecitabine/oxaliplatin) versus FOLFOX6 (5Fluorouracil/leucovorin/oxaliplatin) as an adjuvant treatment for high risk colorectal cancer patients in Greece.

Methods: As survival rate was the same in the two arms, a cost-minimisation analysis was carried out, from the perspectives of the National Health Service (NHS), Social Insurance Funds (SIF) and patients in Greece. Patient data were combined with 2008 unit prices to estimate the total cost of patient care, the patients’ travelling expenditure and their productivity losses. Raw data were bootstrapped 5000 times in order to allow statistical testing.

Results: From an NHS perspective, the mean chemotherapy cost was €8762 with FOLFOX6 and €9713 with XELOX; costs of administration and hospitalisations were €5154 and €1050, respectively. Total treatment cost with FOLFOX6 reached €17?480 and with XELOX €12?525, a difference of €4955 (p?<?0.001) in favour of the latter therapy. From an SIF perspective, the total cost of treatment was €16?240 with FOLFOX6 and €12?617 with XELOX, a reduction of €3623 (p?<?0.001) with the latter therapy. Mean patient travelling cost was €184 with FOLFOX6 and €80 with XELOX, a difference of €104 (p?<?0.001). Mean productivity loss was €100 with FOLFOX6 and €31 with XELOX, a difference of €69 (p?<?0.001).

Conclusions: Chemotherapy combining oral capecitabine and oxaliplatin reduces total treatment cost for the Greek National Health Service and Social Insurance Funds, mainly through a reduction in the cost of administration. From patients’ perspective, it reduces travelling expenditure and productivity losses. Therefore, this combination may be a cost-effective approach for the management of colorectal cancer patients who have had surgery in Greece. This is an analysis alongside a clinical trial, and should be interpreted in this specific context in which it was undertaken.     

Clopidogrel versus aspirin in patients with atherothrombosis: CAPRIE-based calculation of cost-effectiveness for Germany

ABSTRACT

Objectives: To model the 2-year cost-effectiveness of secondary prevention with clopidogrel versus aspirin (acetylsalicylic acid) (ASS) in German patients with myocardial infarction (MI), ischaemic stroke (IS) or diagnosed with peripheral arterial disease (PAD), based on CAPRIE trial data and from the perspective of German third party payers (TPP).

Methods: An existing Markov model was adapted to Germany by using German cost data. The model was extended by using different datasets for cardiovascular event survival times (Framingham vs. Saskatchewan health databases) and in two separate scenarios.

Results: The treatment with clopidogrel leads to a reduction of 13.19 vascular events per 1000 patients, of which 2.21 are vascular deaths. The overall incremental costs for the 2-year management of atherothrombotic patients with clopidogrel instead of ASS are calculated to be about €1 241 440 per 1000 patients. The number of life-years saved (LYS) has been calculated as the difference in the number of life-years lost due to vascular death or events with ASS versus clopidogrel: it is 86.35 LYS when analysis is based on Framingham data and 66.07 LYS with Saskatchewan-based survival data. The incremental costs per LYS are €14 380 and €18 790, respectively. Cost-effectiveness is sensitive to changes in survival data, discounting and daily costs of clopidogrel, but stable against substantial (± 25%) changes in all other cost data.

Conclusion: The findings for Germany are in line with published results for Belgium (€13 390 per LYS) and also with results for Italy (€17 500 per LYS), both based on Saskatchewan data, and with a French analysis based on Framingham data (€15 907 per LYS). Even if no officially accepted cost-effectiveness threshold exists for Germany at present, incremental cost-effectiveness results of less than €20 000 per LYS for the treatment with clopidogrel can be assumed to be acceptable for German third party payers.     

Review of the cost of diabetes complications in Australia,Canada, France,Germany, Italy and Spain

ABSTRACT

Objectives: To provide a comprehensive source document on previously published cost data for diabetic complications in Australia, Canada, France, Germany, Italy and Spain for use in a peer-reviewed, validated diabetes model.

Methods: A search for published cost of diabetes complications data was performed in peer-reviewed journals listed in PubMed and health economic conference proceedings from 1994 to March 2005. Where country specific data were not available, we referred to government websites and local cost experts. All costs were inflated to 2003 Euros (€). Major complication costs are presented.

Results: First year costs of non-fatal myocardial infarction varied between €19?277 in Spain and €12?292 in Australia. In subsequent years of treatment, this range was €1226 (France) to €203 (Australia). Angina costs were similar across all four countries: €1716 in Australia; €2218 in Canada; €2613 in France; €3342 in Germany; €2297 in Italy; and €2207 in Spain. Event costs of non-fatal stroke were higher in Canada (€23?173) than in other countries (Australia €13?443; France €11?754; Germany €19?399; Italy €6583; Spain €4638). Event costs of end-stage renal disease varied depending on the type of dialysis: in Australia (€17?188–27?552); Canada (€33?811–58?159); France (€24?608–56?487); Germany (€46?296–68?175); Italy (€43?075–56?717); and Spain (€28?370–32?706). Lower extremity amputation costs were: €18?547 (Australia); €17?130 (Canada); €31?998 (France); €22?096 (Germany); €10?177 (Italy); and €14?787 (Spain).

Conclusions: Overall, our search showed costs are well documented in Australia, Canada, France and Germany, but revealed a paucity of data for Spain and Italy. Spanish costs, collected by contacting local experts and from government reports, generally appeared to be lower for treating cardiovascular complications than in other countries. Italian costs reported in the literature were primarily hospitalization costs derived from diagnosis-related groups, and therefore likely to misrepresent the cost of specific complications. Additional research is required to document complication costs in Spain and Italy. Australian and German values were collected primarily by referring to diagnostic related group (DRG) tariffs and, as a result, there may be a need for future economic evaluations measuring the accuracy of the costs and resource utilization in the reported values. These cost data are essential to create models of diabetes that are able to accurately simulate the cumulative costs associated with the progression of the disease and its complications.     

Treatment patterns and associated costs for genital warts in Italy

ABSTRACT

Objective: Genital warts are caused by human papillomavirus (HPV), principally types 6 and 11, and are highly contagious. This study assessed treatment patterns and costs of management of genital warts in Italy.

Research design and methods: This was a retrospective, observational study conducted among gynaecologists, dermatologists, and specialists at sexually transmitted disease clinics in Italy. Resource-use data related to genital warts were collected for patients at risk in the age range 14–64 years examined during 2005. Unit costs were assigned to resource use to provide estimates of the direct, indirect and total costs per case of genital warts.

Results: Twenty-eight investigators enrolled 341 patients aged 15–64 years, including 194 (56.9%), 81 (23.7%) and 66 (19.4%) patients with newly diagnosed, recurrent and resistant genital warts, respectively. Most patients (333/341; 97.7%) had at least one outpatient visit, while 43 (12.6%) patients were hospitalised, including 39 patients without an overnight stay (day-hospital cases, 11.4%). Self-applied medication was prescribed for 124 (36.4%) patients. Most outpatient cases (267/333; 80.2%) underwent an office-based procedure. Mean annual direct medical costs per patient, which were funded predominantly by the Italian National Health Service (there was some patient co-payment), were €242 for men and €332 for women. When productivity losses were included, mean total annual costs were €325 for men and €464 for women.

Conclusions: This is the first study of treatment patterns and costs for genital warts in Italy. Treatment patterns differ in some respects from those observed in other European countries, but costs generally appear similar. Despite the limitations of physician selection bias and over-representation of North Italy in the patient sample, the findings of this study may be useful in estimating the cost-effectiveness of introducing a quadrivalent HPV vaccination programme in Italy.     

Cost-effectiveness analysis of escitalopram: a new SSRI in the first-line treatment of major depressive disorder in Austria

SUMMARY

Objectives: To compare the cost-effectiveness of escitalopram, a new selective serotonin reuptake inhibitor (SSRI), with (generic) citalopram in the first-line treatment of major depressive disorder (MDD) in Austria.

Methods: A two-path decision analytic model with a 6-month horizon was adapted to the Austrian setting using Austrian clinical guidelines. All patients (aged ≥ 18?years) started at the primary care path and were referred to specialist care in the secondary care path in case of insufficient response. Model inputs included drug-specific probabilities from head-to-head trial data, literature and expert opinion. The main outcome measure was success (i.e., remission defined as Montgomery–Åsberg Depression Rating Scale (MADRS) score ≤ 12) and costs of treatment (i.e., drug costs and medical care). The analysis was performed from the Austrian societal and Social Healthcare Insurance System (SHIS) perspectives. The Human Capital approach was used to estimate the societal costs of lost productivity.

Results: Treatment with escitalopram yielded lower expected cost and greater effectiveness compared with citalopram. The expected success rate was higher for escitalopram (64.5%) compared to citalopram (59.1%). From the SHIS perspective, the total expected cost per successfully treated patient was lower (€115) for escitalopram (€608) compared with citalopram (€723). From the societal perspective, these expected costs were €3034 and €3269 respectively. Sensitivity analyses on unit costs and probabilities demonstrated the robustness of the results. From the societal perspective, escitalopram remained the dominant treatment option, even at a cost of €0 for (generic) citalopram.

Conclusion: Escitalopram is a cost-effective alternative compared to (generic) citalopram in the first-line treatment of MDD in Austria.     

Economic analysis of a multicentre,randomised, phase III trial comparing FOLFOXIRI with FOLFIRI in patients with metastatic colorectal cancer in Greece

ABSTRACT

Introduction: An economic evaluation of the irinotecan, leucovorin, 5-fluorouracil (FOLFIRI) combination versus the irinotecan, oxaliplatin, leucovorin, 5-fluorouracil (FOLFOXIRI) regimen in patients with metastatic colorectal cancer was performed in the context of a randomised phase III study.

Methods: The trial did not find any differences in efficacy and, therefore, a cost-minimisation analysis was undertaken. Treatment cost accounts for the administration of first and second line chemotherapy, for concomitant medications, for laboratory and other examinations and hospitalisations due to treatment side effects. Unit prices used reflect 2006 and are common among NHS hospitals in Greece.

Results: The mean total cost of therapy in the FOLFOXIRI group (€18?344, 95% CI: €16?951–€19?776), was significantly higher than the FOLFIRI group (€12?201, 95% CI: €11?011–€13?427). Mean chemotherapy cost of the FOLFOXIRI group (€9016; 95% CI: €8338–€9669) was significantly higher than that of the FOLFIRI group (€4830; 95% CI: €4435–€5231). The next largest component of cost involves second line drugs, where the average cost per patient was €3306 (95% CI: €2479–€4237) in the FOLFIRI group and €3996 (95% CI: €3196–€4892) in the FOLFOXIRI group. The cost of hospitalisations was €1814 (95% CI: €1672–€1954) in the first group and €2663 (95% CI: €2469–€2859) in the second. The rest of the components represent a small part of the total cost and there are no differences in the two groups.

Conclusion: The combination of irinotecan, leucovorin, 5-fluorouracil has the same effectiveness as the combination of irinotecan, oxaliplatin, leucovorin, 5-fluorouracil in patients with metastatic colorectal cancer, nonetheless it is associated with a much lower overall treatment cost and it should be the preferred treatment regimen in this context.     

Medical resource utilization among community-acquired pneumonia patients initially treated with levofloxacin 750 mg daily versus ceftriaxone 1000 mg plus azithromycin 500 mg daily: A US-based study*

ABSTRACT

Objective: The 2007 American Thoracic Society/Infectious Diseases Society of America (ATS/IDSA) guidelines recommend that community-acquired pneumonia (CAP) patients admitted to hospital wards initially receive respiratory fluoroquinolone monotherapy or β-lactam plus macrolide combination therapy. There is little evidence as to which regimen is preferred, or if differences in medical resource utilization exist between therapies. Thus, the authors compared length of hospital stay (LOS) and length of intravenous antibiotic therapy (LOIV) for patients who received initial levofloxacin 750?mg daily versus ceftriaxone 1000?mg plus azithromycin 500?mg daily (‘combination therapy’).

Research design and methods: Adult hospital CAP cases from January 2005 to December 2007 were identified by principal discharge diagnosis code. Patients with a chest infiltrate and medical notes indicative of CAP were included. Direct intensive care unit admits and healthcare-associated cases were excluded. A propensity score technique was used to balance characteristics associated with initial antimicrobial therapy using multivariable regression to derive the scores. Propensity score categories, defined as propensity score quintiles, rather than propensity scores themselves, were used in the least squares regression model to assess the impact of LOS and LOIV.

Results: A total of 495 patients from six hospitals met study criteria. Of these, 313 (63%) received levofloxacin and 182 (37%) received combination therapy. Groups were similar with respect to age, sex, most comorbidities, presenting signs and symptoms, and Pneumonia Severity Index (PSI) risk class. Patients on combination therapy were more likely to have heart failure and receive pre-admission antibiotics. Adjusted least squares mean (±SE) LOS and LOIV were shorter with levofloxacin versus combination therapy: LOS, 4.6?±?0.17 vs. 5.4?±?0.22 days, p?<?0.01; and LOIV, 3.6?±?0.17 vs. 4.8?±?0.21 days, p?<?0.01. Results for PSI risk class III or IV patients were: LOS, 5.0?±?0.30 vs. 5.9?±?0.37 days, p?=?0.07; and LOIV, 3.7?±?0.33 vs. 5.2?±?0.39 days, p?<?0.01. Due to the retrospective study design, limited sample size, and scope (single health-network), the authors encourage replication of this study in other data sources.

Conclusions: Given the LOS and LOIV reductions of 0.8 and 1.2 days, respectively, utilization of levofloxacin 750?mg daily for CAP patients admitted to the medical floor has the potential to result in substantial cost savings for US hospitals.     

莫西沙星治疗老年患者社区获得性肺炎的疗效

目的观察莫西沙星治疗老年患者社区获得性肺炎（CAP）的疗效及安全性。方法选择本院老年患者80例,随机分成莫西沙星组（实验组）40例和头孢曲松联合左氧氟沙星组（对照组）40例。结果实验组总有效率95%、对照组总有效率77.5%,两组比较有统计学差异（P〈0.05）。实验组的不良反应发生率7.5%,对照组的不良反应发生率10.0%,两组比较差异无统计学意义（P〉0.05）。结论莫西沙星治疗老年CAP安全、有效。     

Moxifloxacin versus levofloxacin for treatment of acute rhinosinusitis: a retrospective database analysis of treatment duration,outcomes, and charges

ABSTRACT

Objective: Antibiotics are clinically indicated for acute bacterial rhinosinusitis, but they may be prescribed inappropriately. This retrospective study examined how labeled recommendations for duration of moxifloxacin and levofloxacin treatment of acute bacterial rhinosinusitis compare with real-world practice, and compared the failure and recurrence rates, and associated charges.

Methods and main outcome measures: The PharMetrics Patient-Centric claims database was searched over a 3‐year period for episodes of acute rhinosinusitis treated within 5 days with moxifloxacin or levofloxacin. The duration of antibiotic treatment prescribed was compared with the labeled recommendation. Failure rates (a second antibiotic claim to treat acute rhinosinusitis within 30 days of the first claim), recurrence rates (subsequent antibiotic claims to treat any rhinosinusitis more than 30 days after the original or second [in the case of failure] claim), and treatment charges from the perspective of the payer (health insurer) were also compared using multivariate analysis.

Results: The initial duration prescribed of moxifloxacin was shorter than for levofloxacin (–1.65 days, p < 0.0001), reflecting the shorter labeled recommendation (10 days versus 10–14 days). The durations of monotherapy (–2.06 days, p < 0.0001) and of all antibiotic treatment (–1.97 days, p < 0.0001) were also significantly shorter for episodes treated initially with moxifloxacin. The odds ratio for treatment failure (0.718; 95% confidence interval = 0.598–0.863; p = 0.0004) and the hazard ratio for recurrence (0.652; p = 0.0005) were both significantly lower for moxifloxacin than for levofloxacin, and resulted in lower total treatment charges (–$37.94 ± 13.65; p = 0.0055).

Conclusion: The shorter treatment durations seen for moxifloxacin in this database of real-world care reflect the label-recommended duration for acute rhinosinusitis. Despite this shorter duration of therapy, moxifloxacin resulted in better outcomes than levofloxacin in terms of the risk of treatment failure and recurrence. In addition, the total charges were lower for patients treated with moxifloxacin.