Cost effectiveness of combined spa–exercise therapy in ankylosing spondylitis: A randomized controlled trial

Objective

To evaluate the cost effectiveness and cost utility of a 3‐week course of combined spa therapy and exercise therapy in addition to standard treatment consisting of antiinflammatory drugs and weekly group physical therapy in ankylosing spondylitis (AS) patients.

Methods

A total of 120 Dutch outpatients with AS were randomly allocated into 3 groups of 40 patients each. Group 1 was treated in a spa resort in Bad Hofgastein, Austria; group 2 in a spa resort in Arcen, The Netherlands. The control group stayed at home and continued their usual activities and standard treatment during the intervention weeks. After the intervention, all patients followed weekly group physical therapy. The total study period was 40 weeks. Effectiveness of the intervention was assessed by functional ability using the Bath Ankylosing Spondylitis Function Index (BASFI). Utilities were measured with the EuroQoL (EQ‐5D_utility). A time‐integrated summary score defined the clinical effects (BASFI‐area under the curve [AUC]) and utilities (EQ‐5D_utility‐AUC) over time. Both direct (health care and non‐health care) and indirect costs were included. Resource utilization and absence from work were registered weekly by the patients in a diary. All costs were calculated from a societal perspective.

Results

A total of 111 patients completed the diary. The between‐group difference for the BASFI‐AUC was 1.0 (95% confidence interval [95% CI] 0.4–1.6; P = 0.001) for group 1 versus controls, and 0.6 (95% CI 0.1–1.1; P = 0.020) for group 2 versus controls. The between‐group difference for EQ‐5D_utility‐AUC was 0.17 (95% CI 0.09–0.25; P < 0.001) for group 1 versus controls, and 0.08 (95% CI 0.00–0.15; P = 0.04) for group 2 versus controls. The mean total costs per patient (including costs for spa therapy) in Euros (€) during the study period were €3,023 for group 1, €3,240 for group 2, and €1,754 for the control group. The incremental cost‐effectiveness ratio per unit effect gained in functional ability (0–10 scale) was €1,269 (95% CI 497–3,316) for group 1, and €2,477 (95% CI 601–12,098) for group 2. The costs per quality‐adjusted life year gained were €7,465 (95% CI 3,294–14,686) for group 1, and €18,575 (95% CI 3,678–114,257) for group 2.

Conclusion

Combined spa–exercise therapy besides standard treatment with drugs and weekly group physical therapy is more effective and shows favorable cost‐effectiveness and cost‐utility ratios compared with standard treatment alone in patients with AS.

     

临床护理路径在单操作孔胸腔镜肺叶切除术围手术期患者中的应用效果

目的探讨临床护理路径在单操作孔胸腔镜肺叶切除术围手术期患者中的应用效果。方法选择因肺部疾病接受单操作孔胸腔镜肺叶切除手术治疗的围手术期住院患者200例。按人院时间分为实验组和对照组,各100例。对照组实施常规护理,实验组按临床护理路径实施护理。对两组患者平均住院日、术后平均住院时间、胸腔引流管留置时间、住院平均费用、患者满意度等方面进行比较。结果实验组患者的平均住院日、术后平均住院时间及住院平均费用均低于对照组（P〈0．01或P〈0．05）,患者满意度高于对照组（P〈0．01）。结论l临床护理路径作为一种科学的医疗护理模式,可使患者获得最佳的医疗护理服务,缩短住院日,降低住院费用,提高患者的满意度。     

If you try to stop smoking,should we pay for it? The cost–utility of reimbursing smoking cessation support in the Netherlands

Background Smoking cessation can be encouraged by reimbursing the costs of smoking cessation support (SCS). The short‐term efficiency of reimbursement has been evaluated previously. However, a thorough estimate of the long‐term cost–utility is lacking. Objectives To evaluate long‐term effects of reimbursement of SCS. Methods Results from a randomized controlled trial were extrapolated to long‐term outcomes in terms of health care costs and (quality adjusted) life years (QALY) gained, using the Chronic Disease Model. Our first scenario was no reimbursement. In a second scenario, the short‐term cessation rates from the trial were extrapolated directly. Sensitivity analyses were based on the trial's confidence intervals. In the third scenario the additional use of SCS as found in the trial was combined with cessation rates from international meta‐analyses. Results Intervention costs per QALY gained compared to the reference scenario were approximately €1200 extrapolating the trial effects directly, and €4200 when combining the trial's use of SCS with the cessation rates from the literature. Taking all health care effects into account, even costs in life years gained, resulted in an estimated incremental cost–utility of €4500 and €7400, respectively. In both scenarios costs per QALY remained below €16 000 in sensitivity analyses using a life‐time horizon. Conclusions Extrapolating the higher use of SCS due to reimbursement led to more successful quitters and a gain in life years and QALYs. Accounting for overheads, administration costs and the costs of SCS, these health gains could be obtained at relatively low cost, even when including costs in life years gained. Hence, reimbursement of SCS seems to be cost‐effective from a health care perspective.     

Treatment for life for severe haemophilia A– A cost‐utility model for prophylaxis vs. on‐demand treatment

Prophylaxis has been established as the treatment of choice in children with haemophilia and its continuation into the adult years has been shown to decrease morbidity throughout life. The cost of factor therapy has made the option questionable in cost‐effectiveness studies. The role of prophylaxis in pharmacokinetic dosage and tolerization against inhibitor formation were used to model the cost utility of prophylaxis vs. on‐demand (OD) therapy over a lifetime horizon in severe haemophilia A. The model was applied to a single provider national health system exemplified by the United Kingdom's National Health Service and a third party provider in the United States. The incremental cost‐effectiveness ratio (ICER) was estimated and compared to threshold values used by payer agencies to guide reimbursement decisions. A cost per quality‐adjusted life year (QALY) was also estimated for Sweden. Prophylaxis was dominant over OD treatment in the UK. The model resulted in an ICER – $68 000 – within the range of treatments reimbursed in the USA. In Sweden, a cost/QALY of SEK 1.1 million was also within the range of reimbursed treatments in that country. Dosage‐ and treatment‐induced inhibitor incidence were the most important variables in the model. Subject to continuing clinical evidence of the effectiveness of pharmacokinetic dosage and the role of prophylaxis in decreasing inhibitor incidence, treatment for life with prophylaxis is a cost‐effective therapy, using current criteria for the reimbursement of health care technologies in a number of countries.     

A Method for Evaluating the Economic Efficiency of HIV Behavioral Risk Reduction Interventions

To maximize the impact of public spending on HIV prevention, program managers, community planning groups, and other decision makers need accurate information on the economic efficiency (i.e., the relative balance between costs and consequences) of alternative HIV prevention strategies. This paper describes a technique for evaluating the economic efficiency of HIV behavioral risk reduction interventions within a cost–utility analytic framework. To determine the cost-effectiveness of the intervention, standardized values of the lifetime cost of treating HIV/AIDS and the number of quality-adjusted life years lost when someone becomes infected with HIV are combined with information about overall program costs and a model-based estimate of the number of infections averted by the intervention. The use of a standardized economic evaluation methodology for HIV prevention research, such as that proposed here, enhances cross-study comparability and thereby facilitates informed resource allocation decision making.     

Health utilities and psychometric quality of life in patients with early- and late-stage hepatitis C virus infection

Background and Aim: Hepatitis C virus (HCV) infection is associated with impairment in health‐related quality of life (HRQOL). The purpose of this study was to evaluate HRQOL across the HCV disease spectrum using preference‐based (utility) and non‐preference‐based (psychometric) methods, adjusting for sociodemographic factors and co‐morbidity. Methods: Hepatitis C virus patients (n = 751) were recruited from several tertiary care settings in Vancouver, Canada for this observational, cross‐sectional cohort study. Patients completed the Health Utilities Index Mark 2/3, a self‐administered time trade‐off utility instrument, and the Hepatitis Quality of Life Questionnaire (SF‐36 with HCV‐specific items). We examined the association between HRQOL and disease stage using linear regression adjusting for age, education, marital status, income, and co‐morbidities. Results: Utility scores were low across disease stage and instrument, ranging from 0.51 to 0.80. On the SF‐36, the mean Physical Component Summary score ranged from 37.2 to 49.2 across disease stage, and the Mental Component Summary score ranged from 39.7 to 45.7 (United States norms = 50). In general, patients with viral clearance had the highest scores, and those with late‐stage disease (cirrhosis, liver cancer) had the lowest. Multivariable linear regression showed that the effect of disease stage was modest overall. Increasing age, lower income, unattached marital status, and high comorbidity were strongly associated with impairment in HRQOL. Conclusions: The effect of stage of disease on HRQOL is modest, although viral clearance is associated with higher HRQOL. HCV patients' HRQOL is strongly associated with concomitant illness and sociodemographic factors.     

Cost‐utility analysis of idelalisib in combination with rituximab in relapsed or refractory chronic lymphocytic leukaemia

Objective

To evaluate the incremental cost‐utility ratio (ICUR) of idelalisib in combination with rituximab (IR) versus rituximab monotherapy (R) in the treatment of patients with relapsed or refractory (R/R) chronic lymphocytic leukaemia (CLL), from the Spanish National Health System (NHS) perspective.

Methods

A partitioned survival Markov model for a lifetime horizon (30 years) was developed to estimate costs (€, 2016) and quality‐adjusted life years (QALY) with IR and R. Initial cohort included patients with CLL receiving a second or subsequent line (2L) of treatment with IR or R. Survival data were based on CLL clinical trial. Drug, administration, monitoring, adverse events and clinical management of CLL costs were included in the model. Costs and outcomes were discounted using a 3% annually. Deterministic and probabilistic sensitivity analyses (PSA) were performed.

Results

Compared to R, 2L IR treatment resulted in QALY gain of 3.147 (4.965 versus 1.818). Total costs were €118 254 for IR versus €23 874 for R. ICUR was €29 990/QALY gained with IR versus R. In the PSA, IR was cost‐effective in 78% of iterations using a threshold of €45 000/QALY.

Conclusion

IR can be considered a cost‐effective treatment compared to R, in the treatment of R/R CLL patients for the Spanish NHS.