Risk factors for gastrointestinal ulcers caused by nonsteroidal anti-inflammatory drugs (NSAIDs)

Thirteen million individuals in the United States take nonsteroidal anti-inflammatory drugs (NSAIDs) chronically for the relief of pain and inflammation caused by arthritis and related conditions. NSAIDs are valuable and in many cases essential to the management of arthritis pain. Long-term use of NSAIDs, however, can cause gastrointestinal (GI) ulcers and potentially life-threatening ulcer complications. Factors such as older age (greater than or equal to 60 years), a history of peptic ulcer disease, concomitant corticosterid use, cigarette smoking, alcohol use, and high dose or multiple NSAID therapy can increase the risk of GI damage and complications in the chronic NSAID user. Physician awareness of these risk factors is crucial so that the benefits and hazards of NSAID therapy in high-risk patients can be properly weighed. When the decision is made to prescribe NSAIDs, despite the presence of risk factors for NSAID-induced ulcers, patients should be closely monitored, and, in some cases, effective prophylaxis should be initiated. This is especially important since NSAID-induced gastrointestinal ulcers can be asymptomatic, causing serious ulcer complications without warning.     

Costs and Effects of Various Analgesic Treatments for Patients with Rheumatoid Arthritis and Osteoarthritis in The Netherlands

Objective:  To assess the balance between costs and upper gastrointestinal (GI) side effects of treatment with celecoxib, nonsteroidal antiinflammatory drugs (NSAIDs) alone, NSAID plus misoprostol, NSAID plus histamine-2 receptor antagonist (H₂RA), NSAID plus proton pump inhibitor (PPI), and Arthrotec in The Netherlands.
Methods:  A model was used to convene data from various sources on the probability of GI side effects and resource use. The probabilities of GI side effects for celecoxib and NSAIDs alone were derived from trial data. Calculations were based on 6 months of treatment, and were from a societal perspective. Distinction was made between low-, medium-, and high-risk patients. An extensive probabilistic sensitivity analysis was performed to address uncertainty.
Results:  Assuming an average patient, the total costs per 6 months of therapy were: celecoxib €255, NSAIDs alone €166, NSAID plus misoprostol €285, NSAID plus H₂RA €284, NSAID plus PPI €243, and Arthrotec €187. Treatment with celecoxib was associated with the lowest number of GI side effects and related deaths. Incremental costs per life-year saved for Arthrotec compared to NSAIDs alone were €5676 for all patients and €526 for medium-to-high-risk patients, whereas for high-risk patients, Arthrotec dominated NSAID alone. For celecoxib compared to Arthrotec, the incremental cost-effectiveness ratios (ICERs) were €56,667, €33,684, and €15,429, respectively.
Conclusion:  Assuming a limit of €20,000 per life-year gained, from an economic point of view, Arthrotec is the preferred treatment when all patients or medium-to-high-risk patients are considered. In high-risk patients, celecoxib is the preferred treatment strategy.     

Cost-effectiveness analysis of the use of celecoxib for the treatment of osteoarthritis

BACKGROUND: Non-steroidal anti-inflammatory drugs (NSAIDs), used for the treatment of osteoarthritis, can produce serious gastrointestinal (GI) adverse reactions.Celecoxib, a specific COX-2 inhibitor, has a proven efficacy equivalent to that of traditional NSAIDs with an improved tolerance and safety profile. OBJECTIVE: The objective of this study was to perform a cost-effectiveness analysis on the use of celecoxib versus traditional NSAIDs in the treatment of osteoarthritis. MATERIAL AND METHODS: This cost-effectiveness analysis was designed through a pharmacoeconomic model; each effectiveness unit was defined as each year of life gained after the ingestion of celecoxib or NSAIDs. The probability of different clinical results appearing was obtained from published articles and incorporated assumptions.Only direct medical costs were evaluated (medication, hospitalization, additional tests, analyses, extra visits, etc.) and other costs were excluded.The study perspective was the national health system and the time horizon chosen was 6 months. RESULTS: The additional cost for each year of life gained through the use of celecoxib compared with that of traditional NSAIDs amounted to 8017; (1,333,834 ptas). Sensitivity analysis demonstrated how these values were sensitive to changes in the costs of NSAIDs and gastroprotective agents as well as to the inclusion of younger population groups. CONCLUSION: Celecoxib can be considered as a cost-effective option in the treatment of osteoarthritis because its use prevents deaths and increases survival rate and the additional cost is reasonable and moderate compared with that of NSAIDs. Its efficiency increases in proportion to its use in younger patients and probably in those at high risk for developing GI complications.     

Cost-Effectiveness of Statins for Primary Prevention in Patients Newly Diagnosed with Type 2 Diabetes in The Netherlands

BackgroundStatins are lipid-lowering drugs that reduce the risk of cardiovascular events in patients with diabetes.ObjectivesThe objective of this study was to determine whether statin treatment for primary prevention in newly diagnosed type 2 diabetes is cost-effective, taking nonadherence, baseline risk, and age into account.MethodsA cost-effectiveness analysis was performed by using a Markov model with a time horizon of 10 years. The baseline 10-year cardiovascular risk was estimated in a Dutch population of primary prevention patients with newly diagnosed diabetes from the Groningen Initiative to Analyse Type 2 Diabetes Treatment (GIANTT) database, using the United Kingdom Prospective Diabetes Study risk engine. Statin adherence was measured as pill days covered in the IADB.nl pharmacy research database. Cost-effectiveness was measured in costs per quality-adjusted life-year (QALY) from the health care payers’ perspective.ResultsFor an average patient aged 60 years, the base case, statin treatment was highly cost-effective at €2245 per QALY. Favorable cost-effectiveness was robust in sensitivity analysis. Differences in age and 10-year cardiovascular risk showed large differences in cost-effectiveness from almost €100,000 per QALY to almost being cost saving. Treating all patients younger than 45 years at diabetes diagnosis was not cost-effective (weighted cost-effectiveness of almost €60,000 per QALY).ConclusionsDespite the nonadherence levels observed in actual practice, statin treatment is cost-effective for primary prevention in patients newly diagnosed with type 2 diabetes. Because of large differences in cost-effectiveness according to different risk and age groups, the efficiency of the treatment could be increased by targeting patients with relatively higher cardiovascular risk and higher ages.     

Targeted outreach hepatitis B vaccination program in high-risk adults: The fundamental challenge of the last mile

BackgroundThe aim of this study was to evaluate the cost-effectiveness of the on-going decentralised targeted hepatitis B vaccination program for behavioural high-risk groups operated by regional public health services in the Netherlands since 1-November-2002. Target groups for free vaccination are men having sex with men (MSM), commercial sex workers (CSW) and hard drug users (HDU). Heterosexuals with a high partner change rate (HRP) were included until 1-November-2007.MethodsBased on participant, vaccination and serology data collected up to 31-December-2012, the number of participants and program costs were estimated. Observed anti-HBc prevalence was used to estimate the probability of susceptible individuals per risk-group to become infected with hepatitis B virus (HBV) in their remaining life. We distinguished two time-periods: 2002–2006 and 2007–2012, representing different recruitment strategies and target groups. Correcting for observed vaccination compliance, the number of future HBV-infections avoided was estimated per risk-group. By combining these numbers with estimates of life-years lost, quality-of-life losses and healthcare costs of HBV-infections - as obtained from a Markov model-, the benefit of the program was estimated for each risk-group separately.ResultsThe overall incremental cost-effectiveness ratio of the program was €30,400/QALY gained, with effects and costs discounted at 1.5% and 4%, respectively. The program was more cost-effective in the first period (€24,200/QALY) than in the second period (€42,400/QALY). In particular, the cost-effectiveness for MSM decreased from €20,700/QALY to €47,700/QALY.Discussion and conclusionThis decentralised targeted HBV-vaccination program is a cost-effective intervention in certain unvaccinated high-risk adults. Saturation within the risk-groups, participation of individuals with less risky behaviour, and increased recruitment investments in the second period made the program less cost-effective over time. The project should therefore discus how to reduce costs per risk-group, increase effects or when to integrate the vaccination in regular healthcare.     

The Cost-Effectiveness of Different Hearing Screening Strategies for 50- to 70-Year-Old Adults: A Markov Model

ObjectiveTo assess the cost-effectiveness of screening 50- to 70-year-old adults for hearing loss in The Netherlands. We compared no screening, telephone screening, Internet screening, screening with a handheld screening device, and audiometric screening for various starting ages and a varying number of repeated screenings.MethodsThe costs per quality-adjusted life-year (QALY) for no screening and for 76 screening strategies were analyzed using a Markov model with cohort simulation for the year 2011. Screening was deemed to be cost-effective if the costs were less than €20,000/QALY.ResultsScreening with a handheld screening device and audiometric screening were generally more costly but less effective than telephone and Internet screening. Internet screening strategies were slightly better than telephone screening strategies. Internet screening at age 50 years, repeated at ages 55, 60, 65, and 70 years, was the most cost-effective strategy, costing €3699/QALY. At a threshold of €20,000/QALY, this strategy was with 100% certainty cost-effective compared with current practice and with 69% certainty the most cost-effective strategy among all strategies.ConclusionsThis study suggests that Internet screening at age 50 years, repeated at ages 55, 60, 65, and 70 years, is the optimal strategy to screen for hearing loss and might be considered for nationwide implementation.     

Cost-effectiveness of maternal immunization against neonatal invasive Group B Streptococcus in the Netherlands

BackgroundNeonatal invasive Group B Streptococcus (GBS) infection causes considerable disease burden in the Netherlands. Intrapartum antibiotic prophylaxis (IAP) prevents early-onset disease (EOD), but has no effect on late-onset disease (LOD). A potential maternal GBS vaccine could prevent both EOD and LOD by conferring immunity in neonates.ObjectiveExplore under which circumstances maternal vaccination against GBS would be cost-effective as an addition to, or replacement for the current risk factor-based IAP prevention strategy in the Netherlands.MethodsWe assessed the maximum cost-effective price per dose of a trivalent (serotypes Ia, Ib, and III) and hexavalent (additional serotypes II, IV, and V) GBS vaccine in addition to, or as a replacement for IAP. To project the prevented costs and disease burden, a decision tree model was developed to reflect neonatal GBS disease and long-term health outcomes among a cohort based on 169,836 live births in the Netherlands in 2017.ResultsUnder base-case conditions, maternal immunization with a trivalent vaccine would gain 186 QALYs and prevent more than €3.1 million in health care costs when implemented in addition to IAP. Immunization implemented as a replacement for IAP would gain 88 QALYs compared to the current prevention strategy, prevent €1.5 million in health care costs, and avoid potentially ~ 30,000 IAP administrations. The base-case results correspond to a maximum price of €58 per dose (vaccine + administration costs; using a threshold of €20,000/QALY). Expanding the serotype coverage to a hexavalent vaccine would only have a limited additional impact on the cost-effectiveness in the Netherlands.ConclusionsA maternal GBS vaccine could be cost-effective when implemented in addition to the current risk factor-based IAP prevention strategy in the Netherlands. Discontinuation of IAP would save costs and prevent antibiotic use, however, is projected to lead to a lower health gain compared to vaccination in addition to IAP.     

Evaluación económica de la inclusión en el calendario vacunal de 4CMenB (Bexsero®) en España

IntroductionBexsero® (4CMenB), meningococcal B vaccine, was licensed in Europe in 2013. In Spain, despite MenB being the most frequent cause of invasive meningococcal disease (IMD), Bexsero® is recommended and financed for patients at increased risk of IMD but is not financed by the NHS in the routine vaccination schedule.Objectiveto evaluate the cost-utility, epidemiological impact, and total costs of the introduction of 4CMenB into the vaccination schedule to help inform vaccine policy in Spain.MethodWe adapted a cost-utility analysis, a probabilistic decision-tree, to Spain. A cohort of new-born infants in 2015 was modelled with two dosages, using two different strategies: routine vaccination schedule with 4CMenB and non-vaccination. Costs were measured from a payer perspective and benefits were calculated in quality-adjusted life years (QALYs). A Monte Carlo analysis and 32 scenarios were performed to assess the robustness and the uncertainty of our results.ResultsWith the 3+1 dosage, routine vaccination prevented 54% of cases and deaths and an incremental cost-utility ratio (ICUR) of 351.389 €/QALY (95% confidence interval [95%CI]: 265,193-538,428) was estimated. The 2+1 dosage prevented 50% of cases and deaths, with an ICUR of 278.556 €/QALY (95%CI: 210,285-430,122).ConclusionsGiven the current incidence of invasive meningococcal disease in Spain and the information available from 4CMenB, our model shows that routine vaccination is not cost-effective at the current price. Only with a vaccine price of 1.45 € for the 3+1 schedule or 3.37 € for the 2+1 schedule could it be recommended based on efficiency criteria.     

The Optimality of Different Strategies for Supplemental Staging of Non–Small-Cell Lung Cancer: A Health Economic Decision Analysis

ObjectivesTo assess the expected costs and outcomes of alternative strategies for staging of lung cancer to inform a Danish National Health Service perspective about the most cost-effective strategy.MethodsA decision tree was specified for patients with a confirmed diagnosis of non–small-cell lung cancer. Six strategies were defined from relevant combinations of mediastinoscopy, endoscopic or endobronchial ultrasound with needle aspiration, and combined positron emission tomography-computed tomography with F18-fluorodeoxyglucose. Patients without distant metastases and central or contralateral nodal involvement (N2/N3) were considered to be candidates for surgical resection. Diagnostic accuracies were informed from literature reviews, prevalence and survival from the Danish Lung Cancer Registry, and procedure costs from national average tariffs. All parameters were specified probabilistically to determine the joint decision uncertainty. The cost-effectiveness analysis was based on the net present value of expected costs and life years accrued over a time horizon of 5 years.ResultsAt threshold values of around €30,000 for cost-effectiveness, it was found to be cost-effective to send all patients to positron emission tomography-computed tomography with confirmation of positive findings on nodal involvement by endobronchial ultrasound. This result appeared robust in deterministic sensitivity analysis. The expected value of perfect information was estimated at €52 per patient, indicating that further research might be worthwhile.ConclusionsThe policy recommendation is to make combined positron emission tomography-computed tomography and endobronchial ultrasound available for supplemental staging of patients with non–small-cell lung cancer. The effects of alternative strategies on patients’ quality of life, however, should be examined in future studies.     

Cost-Effectiveness Assessment of Monitoring Abiraterone Levels in Metastatic Castration-Resistant Prostate Cancer Patients

ObjectivesAbiraterone acetate is registered for the treatment of metastatic castration-sensitive and resistant prostate cancer (mCRPC). Treatment outcome is associated with plasma trough concentrations (C_min) of abiraterone. Patients with a plasma C_min below the target of 8.4 ng/mL may benefit from treatment optimization by dose increase or concomitant intake with food. This study aims to investigate the cost-effectiveness of monitoring abiraterone C_min in patients with mCRPC.MethodsA Markov model was built with health states progression-free survival, progressed disease, and death. The benefits of monitoring abiraterone C_min followed by a dose increase or food intervention were modeled via a difference in the percentage of patients achieving adequate C_min taking a healthcare payer perspective. Deterministic and probabilistic sensitivity analyses were performed to assess uncertainties and their impac to the incremental cost-effectiveness ratio (ICER).ResultsMonitoring abiraterone followed by a dose increase resulted in 0.149 incremental quality-adjusted life-years (QALYs) with €22 145 incremental costs and an ICER of €177 821/QALY. The food intervention assumed equal effects and estimated incremental costs of €7599, resulting in an ICER of €61 019/QALY. The likelihoods of therapeutic drug monitoring (TDM) with a dose increase or food intervention being cost-effective were 8.04%and 81.9%, respectively.ConclusionsMonitoring abiraterone followed by a dose increase is not cost-effective in patients with mCRPC from a healthcare payer perspective. Monitoring in combination with a food intervention is likely to be cost-effective. This cost-effectiveness assessment may assist decision making in future integration of abiraterone TDM followed by a food intervention into standard abiraterone acetate treatment practices of mCRPC patients.     

The Impact of Proton Pump Inhibitor Compliance on Health-Care Resource Utilization and Costs in Patients with Gastroesophageal Reflux Disease

ObjectiveStandard pharmacotherapy for patients with gastroesophageal reflux disease (GERD) includes treatment with proton pump inhibitors (PPIs). This study examined the effect of GERD patients' compliance with PPI therapy on health-care resource utilization and costs.MethodsThis was a retrospective study of more than 25 million managed care lives in the United States from January 2000 through February 2005. Administrative claims data were obtained from the National Managed Care Benchmarks database, developed by Integrated Health Care Information Solutions. GERD-diagnosed patients who had at least two PPI dispensings were extracted and grouped into two treatment categories based on their PPI medication possession ratio (MPR): compliant (MPR > 0.8) and noncompliant. A regression-based difference-in-differences approach was used to estimate the effect of compliance on the frequency and costs of inpatient and outpatient visits and pharmacy costs. Statistical controls included health plan type, patient age, baseline use of nonsteroidal antiinflammatory drugs, and comorbidities.ResultsOf the total 41,837 patients studied, 68% were compliant. On an annual, per-patient basis, PPI compliance resulted in 0.47 fewer outpatient visits (P = 0.040), 0.03 fewer inpatient visits (P = 0.015), and 0.47 fewer hospitalization days (P = 0.001) from the pre-PPI use period, compared to noncompliance. PPI therapy increased pharmacy costs for both groups, but the total annual health-care costs were reduced for both groups. Compliant patients experienced a greater decline in total cost from the pre-PPI period compared to noncompliant patients (declines of $3261 vs. $2406 per patient per year, P = 0.012).ConclusionsBoth health-care resource use and costs were reduced after initiation of PPI therapy. Additional reductions from the pre-PPI period were further observed by compliance with PPI therapy.     

Cost-Effectiveness of Quadrivalent Versus Trivalent Influenza Vaccination in the Dutch National Influenza Prevention Program

ObjectivesAs of 2019, quadrivalent influenza vaccine (QIV) has replaced trivalent influenza vaccine (TIV) in the national immunization program in The Netherlands. Target groups are individuals of 60+ years of age and those with chronic diseases. The objective was to estimate the incremental break-even price of QIV over TIV at a threshold of €20 000 per quality-adjusted life-year (QALY).MethodsAn age-structured compartmental dynamic model was adapted for The Netherlands to assess health outcomes and associated costs of vaccinating all individuals at higher risk for influenza with QIV instead of TIV over the seasons 2010 to 2018. Influenza incidence rates were derived from a global database. Other parameters (probabilities, QALYs and costs) were extracted from the literature and applied according to Dutch guidelines. A threshold of €20 000 per QALY was applied to estimate the incremental break-even prices of QIV versus TIV. Sensitivity analyses were performed to test the robustness of the model outcomes.ResultsRetrospectively, vaccination with QIV instead of TIV could have prevented on average 9500 symptomatic influenza cases, 2130 outpatient visits, 84 hospitalizations, and 38 deaths per year over the seasons 2010 to 2018. This translates into 385 QALYs and 398 life-years potentially gained. On average, totals of €431 527 direct and €2 388 810 indirect costs could have been saved each year.ConclusionUsing QIV over TIV during the influenza seasons 2010 to 2018 would have been cost-effective at an incremental price of maximally €3.81 (95% confidence interval, €3.26-4.31). Sensitivity analysis showed consistent findings on the incremental break-even price in the same range.     

Healthcare costs of diabetic foot disease in Italy: estimates for event and state costs

Objective

This study aimed to estimate healthcare costs of diabetic foot disease (DFD) in a large population-based cohort of people with type-2 diabetes (T2D) in the Tuscany region (Italy).

Data sources/study setting

Administrative healthcare data of Tuscany region, with 2018 as the base year.

Study design

Retrospective study assessing a longitudinal cohort of patients with T2D.

Data collection/extraction methods

Using administrative healthcare data, DFD were identified using the International Classification of Diseases, Ninth Revision, Clinical Modification codes.

Methods

We examined the annual healthcare costs of these clinical problems in patients with T2D between 2015 and 2018; moreover, we used a generalized linear model to estimate the total healthcare costs.

Principal findings

Between 2015 and 2018, patients with T2D experiencing DFD showed significantly higher average direct costs than patients with T2D without DFD (p < 0.0001). Among patients with T2D experiencing DFD, those who experienced complications either in 2015–2017 and in 2018 incurred the highest incremental costs (incremental cost of € 16,702) followed by those with complications in 2018 only (incremental cost of € 9,536) and from 2015 to 2017 (incremental cost of € 800).

Conclusions

DFD significantly increase healthcare utilization and costs among patients with TD2. Healthcare costs of DFD among patients with T2D are associated with the timing and frequency of DFD. These findings should increase awareness among policymakers regarding resource reallocation toward preventive strategies among patients with T2D.

     

Treating to Target with Etanercept in Rheumatoid Arthritis: Cost-Effectiveness of Dose Reductions When Remission Is Achieved

BackgroundCurrent management of rheumatoid arthritis (RA) focuses on inducing remission as early as possible to avoid lasting joint damage, and maintenance of remission has become important. A 12-month clinical trial in 834 patients with moderate RA investigated whether etanercept 50 mg/wk could be reduced to half dose or discontinued in patients who achieved low disease activity after 36 weeks.ObjectiveThe objective of this study was to estimate the cost-effectiveness of the three maintenance strategies.MethodsA Markov model integrated the three strategies from the clinical trial and extrapolated to 10 years using data from the Swedish RA registry. Assumed treatment strategies after the trial were similar in all three arms, with patients failing to maintain remission on half-dose etanercept or methotrexate alone switching to the full dose of etanercept and patients maintaining remission on full-dose etanercept allowed switching to half dose. Resource use and utilities were taken from an observational study. Results are presented as cost/quality-adjusted life-year (QALY) (both discounted 3%) in the societal perspective.ResultsThe cost/QALY gained with half-dose etanercept versus methotrexate ranged from €14,000 to €29,000: Longer simulations result in a higher cost/QALY, as the acquisition cost of etanercept increases. Half-dose etanercept technically dominates the full dose (lower costs [€?3000 to 6300] and similar effectiveness [0.007–0.011]).ConclusionsAlthough ultimately all three strategies explored achieve a similar outcome as all three continuously manage patients to maintain remission, it appears that a dose reduction is the most advantageous strategy in patients with moderate disease activity.     

Cardiovascular and gastrointestinal risks associated with selective and non-selective NSAIDs

There has been much discussion regarding the cardiovascular and gastrointestinal safety of traditional and COX-2 selective NSAIDs. The national and international guidelines differ in their recommendations. Selective COX-2 inhibitors seem to have a diminished risk for severe gastrointestinal complications in the short-term, but the long-term benefit has not yet been proven. In various studies, COX-2 selective NSAIDs have been associated with an increased risk of cardiovascular complications. This connection has been clearly demonstrated only for rofecoxib. Celecoxib seems to lead to an increased risk only at high dosages. However, more patients will have to be followed for a longer period to confirm these results. There is insufficient evidence that the COX-2 selective agents lead to more frequent cardiovascular complications than the traditional NSAIDs. In patients with an increased risk of gastrointestinal complications and no cardiovascular risk, there is no preference for either COX-2 selective NSAIDs or the combination of traditional NSAIDs and a proton pump inhibitor. If dyspepsia develops during the use of a traditional NSAID, then it seems more effective to add a proton-pump inhibitor to the traditional NSAID rather than replacing it by a COX-2 selective NSAID.     

The effect of alcohol abuse on the risk of NSAID-related gastrointestinal events

PURPOSE: Non-steroidal anti-inflammatory drugs (NSAIDs) are known to increase the risk of gastrointestinal (GI) complications. Excessive alcohol consumption may further increase this risk and the FDA is requiring warnings on over-the-counter (OTC) NSAIDs. Our objective is to evaluate the risk of NSAID-related GI events for persons with a history of alcohol abuse. METHODS: This case control study used data from Saskatchewan Health. Cases consisted of 1083 patients hospitalized for severe GI events, whereas the control group consisted of 14,754 persons without such hospitalizations. RESULTS: Five percent of cases and 1.9% of controls had a history of treatment for alcohol abuse. The presence of either NSAID use or a history of alcohol abuse led to an odds ratio (OR) of 2.9* for severe GI events, whereas the presence of both risk factors simultaneously led to an OR of 10.2* (additive would be 5.8). Similarly, the presence of ibuprofen and naproxen use, which are OTC in the USA, without alcohol abuse led to an OR of 1.9*, whereas alcohol abuse by itself led to an OR of 2.4*. The presence of both OTC NSAIDs and alcohol abuse simultaneously, led to an OR of 6.5 (additive would be 4.3). Thus with both risk factors present, the resulting risk ratio is greater than the additive risk of the separate risk factors. CONCLUSIONS: The Food and Drug Administration (FDA) warning concerns concurrent use of alcohol with NSAIDs, whereas the present study presents the effect of long term alcohol abuse. Further research is needed to separate these two issues to allow physicians to provide the best advice to their patients. *Statistically significant at p<0.05.     

Gastrointestinal side effects of non-steroidal anti-inflammatory drugs in high-risk patients--role of selective cyclooxygenase inhibitors

Non-steroidal anti-inflammatory drugs (NSAID) are the most widely used drugs in the world. Gastrointestinal (GI) side effects of NSAID have a significant economical impact (3-4% clinical GI event, and 1.5% serious/life threatening GI event/year). Selective cyclooxigenase-2 inhibitors (coxibs) are equally effective as non-selective NSAID with about 50% reduction of serious/life threatening GI events. Serious GI events are significantly less in high-risk patients (history of peptic ulcer disease, age over 65 years, treatment with anticoagulants), therefore the use of coxibs is cost-effective in these population. Most of patients with long-term NSAID therapy also require co-therapy with acid suppression or prostaglandin analogue, but coxibs may replace both. The treatment with coxibs in long-term NSAID users thus is cheaper then non-selective NSAID + co-therapy. Patients with GI adverse events during coxib therapy require co-therapy with acid suppression or prostaglandin analogue.     

Cost-Effectiveness of Reduced Waiting Time for Head and Neck Cancer Patients due to a Lean Process Redesign

BackgroundCompared with new technologies, the redesign of care processes is generally considered less attractive to improve patient outcomes. Nevertheless, it might result in better patient outcomes, without further increasing costs. Because early initiation of treatment is of vital importance for patients with head and neck cancer (HNC), these care processes were redesigned.ObjectivesThis study aimed to assess patient outcomes and cost-effectiveness of this redesign.MethodsAn economic (Markov) model was constructed to evaluate the biopsy process of suspicious lesion under local instead of general anesthesia, and combining computed tomography and positron emission tomography for diagnostics and radiotherapy planning. Patients treated for HNC were included in the model stratified by disease location (larynx, oropharynx, hypopharynx, and oral cavity) and stage (I–II and III–IV). Probabilistic sensitivity analyses were performed.ResultsWaiting time before treatment start reduced from 5 to 22 days for the included patient groups, resulting in 0.13 to 0.66 additional quality-adjusted life-years. The new workflow was cost-effective for all the included patient groups, using a ceiling ratio of €80,000 or €20,000. For patients treated for tumors located at the larynx and oral cavity, the new workflow resulted in additional quality-adjusted life-years, and costs decreased compared with the regular workflow. The health care payer benefited €14.1 million and €91.5 million, respectively, when individual net monetary benefits were extrapolated to an organizational level and a national level.ConclusionsThe redesigned care process reduced the waiting time for the treatment of patients with HNC and proved cost-effective. Because care improved, implementation on a wider scale should be considered.     

Don’t forget about the future: The impact of including future costs on the cost-effectiveness of adult pneumococcal conjugate vaccination with PCV13 in the Netherlands

BackgroundWhen vaccines increase longevity, vaccinated people may experience costs and benefits during added life-years. These future benefits and costs may include increased productivity as well as medical and non-medical costs. Such impacts should be considered in cost-effectiveness analyses (CEA) of vaccines but are often omitted. Here, we illustrate the impact of including future costs on the cost-effectiveness of vaccination against pneumococcus disease. We emphasize the relevance of differentiating cost estimates between risk groups.MethodsWe updated an existing Dutch CEA of vaccination against pneumococcus disease with the 13-valent pneumococcal conjugate vaccine (PCV13) to include all future medical and non-medical costs. We linked costs by age and risk with survival information and estimates of cases prevented per vaccination strategy based on the original study to calculate the impact of inclusion. Future medical costs were adjusted for relevant risk groups.ResultsFor the base-case strategy, the original incremental cost-effectiveness ratio (ICER) of PVC13 was €9,157 per quality adjusted life-year (QALY). Including all future medical costs increased the ICER to €28,540 per QALY. Also including future non-medical costs resulted in an ICER of €45,691 per QALY. The impact of future medical costs varied considerably per risk group and generally increased with age.Discussion and conclusionThis study showed a substantial effect of the inclusion of future costs on the ICER of vaccinating with PCV13. Especially when lives of people with underlying health conditions are extended, the impact of future medical costs is large. This inclusion may make vaccination a less attractive option, especially in relation to low thresholds as often applied for prevention. Although this raises important questions, ignoring these real future costs may lead to an inefficient use of healthcare resources. Our results may imply that prices for some vaccines need to be lowered to be cost-effective.