scholarly journals The clinical effectiveness and cost-effectiveness of treat-to-target strategies in rheumatoid arthritis: a systematic review and cost-effectiveness analysis

2017 ◽  
Vol 21 (71) ◽  
pp. 1-258 ◽  
Author(s):  
Allan Wailoo ◽  
Emma S Hock ◽  
Matt Stevenson ◽  
Marrissa Martyn-St James ◽  
Andrew Rawdin ◽  
...  
Keyword(s):  
Systematic Review ◽  
Cost Effectiveness ◽  
Usual Care ◽  
Clinical Effectiveness ◽  
Cost Effective ◽  
Treat To Target ◽  
Treatment Protocols ◽  
Remission Rates ◽  
Established Disease ◽  
Target Treatment

Background Treat to target (TTT) is a broad concept for treating patients with rheumatoid arthritis (RA). It involves setting a treatment target, usually remission or low disease activity (LDA). This is often combined with frequent patient assessment and intensive and rapidly adjusted drug treatment, sometimes based on a formal protocol. Objective To investigate the clinical effectiveness and cost-effectiveness of TTT compared with routine care. Data sources Databases including EMBASE and MEDLINE were searched from 2008 to August 2016. Review methods A systematic review of clinical effectiveness was conducted. Studies were grouped according to comparisons made: (1) TTT compared with usual care, (2) different targets and (3) different treatment protocols. Trials were subgrouped by early or established disease populations. Study heterogeneity precluded meta-analyses. Narrative synthesis was undertaken for the first two comparisons, but was not feasible for the third. A systematic review of cost-effectiveness was also undertaken. No model was constructed as a result of the heterogeneity among studies identified in the clinical effectiveness review. Instead, conclusions were drawn on the cost-effectiveness of TTT from papers relating to these studies. Results Sixteen clinical effectiveness studies were included. They differed in terms of treatment target, treatment protocol (where one existed) and patient visit frequency. For several outcomes, mixed results or evidence of no difference between TTT and conventional care was found. In early disease, two studies found that TTT resulted in favourable remission rates, although the findings of one study were not statistically significant. In established disease, two studies showed that TTT may be beneficial in terms of LDA at 6 months, although, again, in one case the finding was not statistically significant. The TICORA (TIght COntrol for RA) trial found evidence of lower remission rates for TTT in a mixed population. Two studies reported cost-effectiveness: in one, TTT dominated usual care; in the other, step-up combination treatments were shown to be cost-effective. In 5 of the 16 studies included the clinical effectiveness review, no cost-effectiveness conclusion could be reached, and in one study no conclusion could be drawn in the case of patients denoted low risk. In the remaining 10 studies, and among patients denoted high risk in one study, cost-effectiveness was inferred. In most cases TTT is likely to be cost-effective, except where biological treatment in early disease is used initially. No conclusions could be drawn for established disease. Limitations TTT refers not to a single concept, but to a range of broad approaches. Evidence reflects this. Studies exhibit substantial heterogeneity, which hinders evidence synthesis. Many included studies are at risk of bias. Future work Future studies comparing TTT with usual care must link to existing evidence. A consistent definition of remission in studies is required. There may be value in studies to establish the importance of different elements of TTT (the setting of a target, the intensive use of drug treatments and protocols pertaining to those drugs and the frequent assessment of patients). Conclusion In early RA and studies of mixed early and established RA populations, evidence suggests that TTT improves remission rates. In established disease, TTT may lead to improved rates of LDA. It remains unclear which element(s) of TTT (the target, treatment protocols or increased frequency of patient visits) drive these outcomes. Future trials comparing TTT with usual care and/or different TTT targets should use outcomes comparable with existing literature. Remission, defined in a consistent manner, should be the target of choice of future studies. Study registration This study is registered as PROSPERO CRD42015017336. Funding The National Institute for Health Research Health Technology Assessment programme.

scholarly journals Clinical effectiveness and cost-effectiveness of a multifaceted podiatry intervention for falls prevention in older people: a multicentre cohort randomised controlled trial (the REducing Falls with ORthoses and a Multifaceted podiatry intervention trial)

2017 ◽  
Vol 21 (24) ◽  
pp. 1-198 ◽  
Author(s):  
Sarah Cockayne ◽  
Sara Rodgers ◽  
Lorraine Green ◽  
Caroline Fairhurst ◽  
Joy Adamson ◽  
...  
Keyword(s):  
Cost Effectiveness ◽  
Usual Care ◽  
Incidence Rate ◽  
Primary Outcome ◽  
Controlled Trial ◽  
Intervention Group ◽  
Clinical Effectiveness ◽  
Cost Effective ◽  
Falls Prevention ◽  
Randomised Controlled

BackgroundFalls are a serious cause of morbidity and cost to individuals and society. Evidence suggests that foot problems and inappropriate footwear may increase the risk of falling. Podiatric interventions could help reduce falls; however, there is limited evidence regarding their clinical effectiveness and cost-effectiveness.ObjectivesTo determine the clinical effectiveness and cost-effectiveness of a multifaceted podiatry intervention for preventing falls in community-dwelling older people at risk of falling, relative to usual care.DesignA pragmatic, multicentred, cohort randomised controlled trial with an economic evaluation and qualitative study.SettingNine NHS trusts in the UK and one site in Ireland.ParticipantsIn total, 1010 participants aged ≥ 65 years were randomised (intervention,n = 493; usual care,n = 517) via a secure, remote service. Blinding was not possible.InterventionsAll participants received a falls prevention leaflet and routine care from their podiatrist and general practitioner. The intervention also consisted of footwear advice, footwear provision if required, foot orthoses and foot- and ankle-strengthening exercises.Main outcome measuresThe primary outcome was the incidence rate of falls per participant in the 12 months following randomisation. The secondary outcomes included the proportion of fallers and multiple fallers, time to first fall, fear of falling, fracture rate, health-related quality of life (HRQoL) and cost-effectiveness.ResultsThe primary analysis consisted of 484 (98.2%) intervention and 507 (98.1%) usual-care participants. There was a non-statistically significant reduction in the incidence rate of falls in the intervention group [adjusted incidence rate ratio 0.88, 95% confidence interval (CI) 0.73 to 1.05;p = 0.16]. The proportion of participants experiencing a fall was lower (50% vs. 55%, adjusted odds ratio 0.78, 95% CI 0.60 to 1.00;p = 0.05). No differences were observed in key secondary outcomes. No serious, unexpected and related adverse events were reported. The intervention costs £252.17 more per participant (95% CI –£69.48 to £589.38) than usual care, was marginally more beneficial in terms of HRQoL measured via the EuroQoL-5 Dimensions [mean quality-adjusted life-year (QALY) difference 0.0129, 95% CI –0.0050 to 0.0314 QALYs] and had a 65% probability of being cost-effective at the National Institute for Health and Care Excellence threshold of £30,000 per QALY gained. The intervention was generally acceptable to podiatrists and trial participants.LimitationsOwing to the difficulty in calculating a sample size for a count outcome, the sample size was based on detecting a difference in the proportion of participants experiencing at least one fall, and not the primary outcome. We are therefore unable to confirm if the trial was sufficiently powered for the primary outcome. The findings are not generalisable to patients who are not receiving podiatry care.ConclusionsThe intervention was safe and potentially effective. Although the primary outcome measure did not reach significance, a lower fall rate was observed in the intervention group. The reduction in the proportion of older adults who experienced a fall was of borderline statistical significance. The economic evaluation suggests that the intervention could be cost-effective.Future workFurther research could examine whether or not the intervention could be delivered in group sessions, by physiotherapists, or in high-risk patients.Trial registrationCurrent Controlled Trials ISRCTN68240461.FundingThis project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full inHealth Technology Assessment; Vol. 21, No. 24. See the NIHR Journals Library website for further project information.

scholarly journals Low-dose computed tomography for lung cancer screening in high-risk populations: a systematic review and economic evaluation

2018 ◽  
Vol 22 (69) ◽  
pp. 1-276 ◽  
Author(s):  
Tristan Snowsill ◽  
Huiqin Yang ◽  
Ed Griffin ◽  
Linda Long ◽  
Jo Varley-Campbell ◽  
...  
Keyword(s):  
Lung Cancer ◽  
Cost Effectiveness ◽  
Usual Care ◽  
Cancer Mortality ◽  
Meta Analysis ◽  
Lung Cancer Screening ◽  
Lung Cancer Mortality ◽  
Clinical Effectiveness ◽  
Cost Effective ◽  
Cochrane Library

BackgroundDiagnosis of lung cancer frequently occurs in its later stages. Low-dose computed tomography (LDCT) could detect lung cancer early.ObjectivesTo estimate the clinical effectiveness and cost-effectiveness of LDCT lung cancer screening in high-risk populations.Data sourcesBibliographic sources included MEDLINE, EMBASE, Web of Science and The Cochrane Library.MethodsClinical effectiveness – a systematic review of randomised controlled trials (RCTs) comparing LDCT screening programmes with usual care (no screening) or other imaging screening programmes [such as chest X-ray (CXR)] was conducted. Bibliographic sources included MEDLINE, EMBASE, Web of Science and The Cochrane Library. Meta-analyses, including network meta-analyses, were performed. Cost-effectiveness – an independent economic model employing discrete event simulation and using a natural history model calibrated to results from a large RCT was developed. There were 12 different population eligibility criteria and four intervention frequencies [(1) single screen, (2) triple screen, (3) annual screening and (4) biennial screening] and a no-screening control arm.ResultsClinical effectiveness – 12 RCTs were included, four of which currently contribute evidence on mortality. Meta-analysis of these demonstrated that LDCT, with ≤ 9.80 years of follow-up, was associated with a non-statistically significant decrease in lung cancer mortality (pooled relative risk 0.94, 95% confidence interval 0.74 to 1.19). The findings also showed that LDCT screening demonstrated a non-statistically significant increase in all-cause mortality. Given the considerable heterogeneity detected between studies for both outcomes, the results should be treated with caution. Network meta-analysis, including six RCTs, was performed to assess the relative clinical effectiveness of LDCT, CXR and usual care. The results showed that LDCT was ranked as the best screening strategy in terms of lung cancer mortality reduction. CXR had a 99.7% probability of being the worst intervention and usual care was ranked second. Cost-effectiveness – screening programmes are predicted to be more effective than no screening, reduce lung cancer mortality and result in more lung cancer diagnoses. Screening programmes also increase costs. Screening for lung cancer is unlikely to be cost-effective at a threshold of £20,000/quality-adjusted life-year (QALY), but may be cost-effective at a threshold of £30,000/QALY. The incremental cost-effectiveness ratio for a single screen in smokers aged 60–75 years with at least a 3% risk of lung cancer is £28,169 per QALY. Sensitivity and scenario analyses were conducted. Screening was only cost-effective at a threshold of £20,000/QALY in only a minority of analyses.LimitationsClinical effectiveness – the largest of the included RCTs compared LDCT with CXR screening rather than no screening. Cost-effectiveness – a representative cost to the NHS of lung cancer has not been recently estimated according to key variables such as stage at diagnosis. Certain costs associated with running a screening programme have not been included.ConclusionsLDCT screening may be clinically effective in reducing lung cancer mortality, but there is considerable uncertainty. There is evidence that a single round of screening could be considered cost-effective at conventional thresholds, but there is significant uncertainty about the effect on costs and the magnitude of benefits.Future workClinical effectiveness and cost-effectiveness estimates should be updated with the anticipated results from several ongoing RCTs [particularly the NEderlands Leuvens Longkanker Screenings ONderzoek (NELSON) screening trial].Study registrationThis study is registered as PROSPERO CRD42016048530.FundingThe National Institute for Health Research Health Technology Assessment programme.

scholarly journals The clinical effectiveness and cost-effectiveness of second-eye cataract surgery: a systematic review and economic evaluation

2014 ◽  
Vol 18 (68) ◽  
pp. 1-206 ◽  
Author(s):  
Geoff Frampton ◽  
Petra Harris ◽  
Keith Cooper ◽  
Andrew Lotery ◽  
Jonathan Shepherd
Keyword(s):  
Quality Of Life ◽  
Systematic Review ◽  
Cost Effectiveness ◽  
Cataract Surgery ◽  
Patient Reported Outcomes ◽  
Clinical Effectiveness ◽  
Cost Effective ◽  
Eye Surgery ◽  
Patient Reported

BackgroundElective cataract surgery is the most commonly performed surgical procedure in the NHS. In bilateral cataracts, the eye with greatest vision impairment from cataract is operated on first. First-eye surgery can improve vision and quality of life. However, it is unclear whether or not cataract surgery on the second eye provides enough incremental benefit to be considered clinically effective and cost-effective.ObjectiveTo conduct a systematic review of clinical effectiveness and analysis of cost-effectiveness of second-eye cataract surgery in England and Wales, based on an economic model informed by systematic reviews of cost-effectiveness and quality of life.Data sourcesTwelve electronic bibliographic databases, including MEDLINE, EMBASE, Web of Science, The Cochrane Library and the Centre for Reviews and Dissemination databases were searched from database inception to April 2013, with searches updated in July 2013. Reference lists of relevant publications were also checked and experts consulted.Review methodsTwo reviewers independently screened references, extracted and checked data from the included studies and appraised their risk of bias. Based on the review of cost-effectiveness, a de novo economic model was developed to estimate the cost-effectiveness of second-eye surgery in bilateral cataract patients. The model is based on changes in quality of life following second-eye surgery and includes post-surgical complications.ResultsThree randomised controlled trials (RCTs) of clinical effectiveness, three studies of cost-effectiveness and 10 studies of health-related quality of life (HRQoL) met the inclusion criteria for the systematic reviews and, where possible, were used to inform the economic analysis. Heterogeneity of studies precluded meta-analyses, and instead data were synthesised narratively. The RCTs assessed visual acuity, contrast sensitivity, stereopsis and several measures of HRQoL. Improvements in binocular visual acuity and contrast sensitivity were small and unlikely to be of clinical significance, but stereopsis was improved to a clinically meaningful extent following second-eye surgery. Studies did not provide evidence that second-eye surgery significantly affected HRQoL, apart from an improvement in the mental health component of HRQoL in one RCT. In the model, second-eye surgery generated 0.68 incremental quality-adjusted life-years with an incremental cost-effectiveness ratio of £1964. Model results were most sensitive to changes in the utility gain associated with second-eye surgery, but otherwise robust to changes in parameter values. The probability that second-eye surgery is cost-effective at willingness-to-pay thresholds of £10,000 and £20,000 is 100%.LimitationsClinical effectiveness studies were all conducted more than 9 years ago. Patients had good vision pre surgery which may not represent all patients eligible for second-eye surgery. For some vision-related patient-reported outcomes and HRQoL measures, thresholds for determining important clinical effects are either unclear or have not been determined.ConclusionsSecond-eye cataract surgery is generally cost-effective based on the best available data and under most assumptions. However, more up-to-date data are needed. A well-conducted RCT that reflects current populations and enables the estimation of health state utility values would be appropriate. Guidance is required on which vision-related, patient-reported outcomes are suitable for assessing effects of cataract surgery in the NHS and how these measures should be interpreted clinically.Study registrationThis project is registered as PROSPERO CRD42013004211.FundingThis project was funded by the National Institute for Health Research Health Technology Assessment programme.

Cost-effectiveness of interventions to support self-care: A systematic review

2005 ◽  
Vol 21 (4) ◽  
pp. 423-432 ◽  
Author(s):  
Gerry Richardson ◽  
Hugh Gravelle ◽  
Helen Weatherly ◽  
Gill Ritchie
Keyword(s):  
Systematic Review ◽  
Cost Effectiveness ◽  
Self Care ◽  
Clinical Effectiveness ◽  
Cost Effective ◽  
Current Evidence ◽  
Economic Evaluations ◽  
Current Evidence Base ◽  
Care Support

Objectives: Interventions to support patient self-care of their condition aim to improve patient health and reduce health service costs. Consequently, they have attracted considerable policy interest. There is some evidence of clinical effectiveness but less attention has been paid to whether these interventions are cost-effective. This study examines the quality and quantity of existing evidence of the cost-effectiveness.Methods: A systematic review was carried out to assess the extent and quality of economic evaluations of self-care support interventions. Thirty-nine economic evaluations were assessed against a quality checklist developed to reflect the special features of these interventions.Results: The majority of the studies claimed that self-care support interventions were cost-effective or cost saving. The overall quality of economic evaluations was poor because of flaws in study designs, especially a narrow definition of relevant costs and short follow-up periods.Conclusions: The current evidence base does not support any general conclusion that self-care support interventions are cost-effective, but ongoing trials may provide clearer evidence.

Clinical effectiveness and cost-effectiveness of implantable cardioverter defibrillators for arrhythmias: A systematic review and economic evaluation

2007 ◽  
Vol 23 (1) ◽  
pp. 63-70 ◽  
Author(s):  
Jackie Bryant ◽  
Hakan Brodin ◽  
Emma Loveman ◽  
Andrew Clegg
Keyword(s):  
Systematic Review ◽  
Cost Effectiveness ◽  
Cardiac Death ◽  
Clinical Effectiveness ◽  
Cost Effective ◽  
Controlled Trials ◽  
Implantable Cardioverter Defibrillators ◽  
Inclusion Criteria ◽  
Randomized Controlled ◽  
Cardioverter Defibrillators

Objectives:The clinical effectiveness and cost-effectiveness of implantable cardioverter defibrillators (ICD) for arrhythmias was assessed.Methods:A systematic review of the literature of systematic reviews and randomized controlled trials that reported mortality outcomes associated with implantable cardioverter defibrillators compared with antiarrhythmic drug therapy in people at risk of sudden cardiac death due to arrhythmias was undertaken. Economic evaluations were also sought. Inclusion criteria, data extraction, and quality assessment were undertaken by standard methodology. A decision analytic model was constructed using best available evidence to determine cost-effectiveness in a UK setting.Results:Eight randomized controlled trials, two systematic reviews, and a meta-analysis met the inclusion criteria and were of variable quality. Evidence suggests that ICDs reduce mortality in both secondary and primary prevention, although the magnitude of benefit depends on baseline risk for sudden cardiac death. Incremental cost per quality-adjusted life year ranged from £52,000 ($98,000) to over £200,000 ($379,000), depending on mortality risk and assumptions made.Conclusions:Evidence suggests that ICDs reduce total mortality but may be cost-effective only in some subgroups of patients at high risk of ventricular arrhythmias. Further research is needed on risk stratification of patients in whom ICDs are most likely to be clinically and cost-effective.

scholarly journals A systematic review of the clinical effectiveness and cost-effectiveness of pharmacological and psychological interventions for the management of obsessive–compulsive disorder in children/adolescents and adults

2016 ◽  
Vol 20 (43) ◽  
pp. 1-392 ◽  
Author(s):  
Petros Skapinakis ◽  
Deborah Caldwell ◽  
William Hollingworth ◽  
Peter Bryden ◽  
Naomi Fineberg ◽  
...  
Keyword(s):  
Systematic Review ◽  
Cost Effectiveness ◽  
Children And Adolescents ◽  
Statistical Significance ◽  
Clinical Effectiveness ◽  
Cost Effective ◽  
Behavioural Therapy ◽  
Psychological Interventions ◽  
Obsessive Compulsive ◽  
Compulsive Disorder

BackgroundObsessive–compulsive disorder (OCD) is a relatively common and disabling condition.ObjectivesTo determine the clinical effectiveness, acceptability and cost-effectiveness of pharmacological and psychological interventions for the treatment of OCD in children, adolescents and adults.Data sourcesWe searched the Cochrane Collaboration Depression, Anxiety and Neurosis Trials Registers, which includes trials from routine searches of all the major databases. Searches were conducted from inception to 31 December 2014.Review methodsWe undertook a systematic review and network meta-analysis (NMA) of the clinical effectiveness and acceptability of available treatments. Outcomes for effectiveness included mean differences in the total scores of the Yale–Brown Obsessive–Compulsive Scale or its children’s version and total dropouts for acceptability. For the cost-effectiveness analysis, we developed a probabilistic model informed by the results of the NMA. All analyses were performed using OpenBUGS version 3.2.3 (members of OpenBUGS Project Management Group; seewww.openbugs.net).ResultsWe included 86 randomised controlled trials (RCTs) in our systematic review. In the NMA we included 71 RCTs (54 in adults and 17 in children and adolescents) for effectiveness and 71 for acceptability (53 in adults and 18 in children and adolescents), comprising 7643 and 7942 randomised patients available for analysis, respectively. In general, the studies were of medium quality. The results of the NMA showed that in adults all selective serotonin reuptake inhibitors (SSRIs) and clomipramine had greater effects than drug placebo. There were no differences between SSRIs, and a trend for clomipramine to be more effective did not reach statistical significance. All active psychological therapies had greater effects than drug placebo. Behavioural therapy (BT) and cognitive therapy (CT) had greater effects than psychological placebo, but cognitive–behavioural therapy (CBT) did not. BT and CT, but not CBT, had greater effects than medications, but there are considerable uncertainty and methodological limitations that should be taken into account. In children and adolescents, CBT and BT had greater effects than drug placebo, but differences compared with psychological placebo did not reach statistical significance. SSRIs as a class showed a trend for superiority over drug placebo, but the difference did not reach statistical significance. However, the superiority of some individual drugs (fluoxetine, sertraline) was marginally statistically significant. Regarding acceptability, all interventions except clomipramine had good tolerability. In adults, CT and BT had the highest probability of being most cost-effective at conventional National Institute for Health and Care Excellence thresholds. In children and adolescents, CBT or CBT combined with a SSRI were more likely to be cost-effective. The results are uncertain and sensitive to assumptions about treatment effect and the exclusion of trials at high risk of bias.LimitationsThe majority of psychological trials included patients who were taking medications. There were few studies in children and adolescents.ConclusionsIn adults, psychological interventions, clomipramine, SSRIs or combinations of these are all effective, whereas in children and adolescents, psychological interventions, either as monotherapy or combined with specific SSRIs, were more likely to be effective. Future RCTs should improve their design, in particular for psychotherapy or combined interventions.Study registrationThe study is registered as PROSPERO CRD42012002441.Funding detailsThe National Institute for Health Research Health Technology Assessment programme.

scholarly journals Acupuncture for chronic pain and depression in primary care: a programme of research

2017 ◽  
Vol 5 (3) ◽  
pp. 1-316 ◽  
Author(s):  
Hugh MacPherson ◽  
Andrew Vickers ◽  
Martin Bland ◽  
David Torgerson ◽  
Mark Corbett ◽  
...  
Keyword(s):  
Chronic Pain ◽  
Cost Effectiveness ◽  
Usual Care ◽  
Research Programme ◽  
Clinical Effectiveness ◽  
Cost Effective ◽  
Evidence Base ◽  
Sham Acupuncture ◽  
Osteoarthritis Of The Knee ◽  
High Quality

BackgroundThere has been an increase in the utilisation of acupuncture in recent years, yet the evidence base is insufficiently well established to be certain about its clinical effectiveness and cost-effectiveness. Addressing the questions related to the evidence base will reduce uncertainty and help policy- and decision-makers with regard to whether or not wider access is appropriate and provides value for money.AimOur aim was to establish the most reliable evidence on the clinical effectiveness and cost-effectiveness of acupuncture for chronic pain by drawing on relevant evidence, including recent high-quality trials, and to develop fresh evidence on acupuncture for depression. To extend the evidence base we synthesised the results of published trials using robust systematic review methodology and conducted a randomised controlled trial (RCT) of acupuncture for depression.Methods and resultsWe synthesised the evidence from high-quality trials of acupuncture for chronic pain, consisting of musculoskeletal pain related to the neck and low back, osteoarthritis of the knee, and headache and migraine, involving nearly 18,000 patients. In an individual patient data (IPD) pairwise meta-analysis, acupuncture was significantly better than both sham acupuncture (p < 0.001) and usual care (p < 0.001) for all conditions. Using network meta-analyses, we compared acupuncture with other physical therapies for osteoarthritis of the knee. In both an analysis of all available evidence and an analysis of a subset of better-quality trials, using aggregate-level data, we found acupuncture to be one of the more effective therapies. We developed new Bayesian methods for analysing multiple individual patient-level data sets to evaluate heterogeneous continuous outcomes. An accompanying cost-effectiveness analysis found transcutaneous electrical nerve stimulation (TENS) to be cost-effective for osteoarthritis at a threshold of £20,000 per quality-adjusted life-year when all trials were synthesised. When the analysis was restricted to trials of higher quality with adequate allocation concealment, acupuncture was cost-effective. In a RCT of acupuncture or counselling compared with usual care for depression, in which half the patients were also experiencing comorbid pain, we found acupuncture and counselling to be clinically effective and acupuncture to be cost-effective. For patients in whom acupuncture is inappropriate or unavailable, counselling is cost-effective.ConclusionWe have provided the most robust evidence from high-quality trials on acupuncture for chronic pain. The synthesis of high-quality IPD found that acupuncture was more effective than both usual care and sham acupuncture. Acupuncture is one of the more clinically effective physical therapies for osteoarthritis and is also cost-effective if only high-quality trials are analysed. When all trials are analysed, TENS is cost-effective. Promising clinical and economic evidence on acupuncture for depression needs to be extended to other contexts and settings. For the conditions we have investigated, the drawing together of evidence on acupuncture from this programme of research has substantially reduced levels of uncertainty. We have identified directions for further research. Our research also provides a valuable basis for considering the potential role of acupuncture as a referral option in health care and enabling providers and policy-makers to make decisions based on robust sources of evidence.Trial registrationCurrent Controlled Trials ISRCTN63787732.FundingThe National Institute for Health Research Programme Grants for Applied Research programme.

scholarly journals A systematic review, evidence synthesis and meta-analysis of quantitative and qualitative studies evaluating the clinical effectiveness, the cost-effectiveness, safety and acceptability of interventions to prevent postnatal depression

2016 ◽  
Vol 20 (37) ◽  
pp. 1-414 ◽  
Author(s):  
C Jane Morrell ◽  
Paul Sutcliffe ◽  
Andrew Booth ◽  
John Stevens ◽  
Alison Scope ◽  
...  
Keyword(s):  
Cost Effectiveness ◽  
Usual Care ◽  
Postnatal Depression ◽  
Postnatal Care ◽  
Evidence Synthesis ◽  
Clinical Effectiveness ◽  
Cost Effective ◽  
Considerable Uncertainty ◽  
Cognitive Behavioural ◽  
The Cost

BackgroundPostnatal depression (PND) is a major depressive disorder in the year following childbirth, which impacts on women, their infants and their families. A range of interventions has been developed to prevent PND.ObjectivesTo (1) evaluate the clinical effectiveness, cost-effectiveness, acceptability and safety of antenatal and postnatal interventions for pregnant and postnatal women to prevent PND; (2) apply rigorous methods of systematic reviewing of quantitative and qualitative studies, evidence synthesis and decision-analytic modelling to evaluate the preventive impact on women, their infants and their families; and (3) estimate cost-effectiveness.Data sourcesWe searched MEDLINE, EMBASE, Science Citation Index and other databases (from inception to July 2013) in December 2012, and we were updated by electronic alerts until July 2013.Review methodsTwo reviewers independently screened titles and abstracts with consensus agreement. We undertook quality assessment. All universal, selective and indicated preventive interventions for pregnant women and women in the first 6 postnatal weeks were included. All outcomes were included, focusing on the Edinburgh Postnatal Depression Scale (EPDS), diagnostic instruments and infant outcomes. The quantitative evidence was synthesised using network meta-analyses (NMAs). A mathematical model was constructed to explore the cost-effectiveness of interventions contained within the NMA for EPDS values.ResultsFrom 3072 records identified, 122 papers (86 trials) were included in the quantitative review. From 2152 records, 56 papers (44 studies) were included in the qualitative review. The results were inconclusive. The most beneficial interventions appeared to be midwifery redesigned postnatal care [as shown by the mean 12-month EPDS score difference of –1.43 (95% credible interval –4.00 to 1.36)], person-centred approach (PCA)-based and cognitive–behavioural therapy (CBT)-based intervention (universal), interpersonal psychotherapy (IPT)-based intervention and education on preparing for parenting (selective), promoting parent–infant interaction, peer support, IPT-based intervention and PCA-based and CBT-based intervention (indicated). Women valued seeing the same health worker, the involvement of partners and access to several visits from a midwife or health visitor trained in person-centred or cognitive–behavioural approaches. The most cost-effective interventions were estimated to be midwifery redesigned postnatal care (universal), PCA-based intervention (indicated) and IPT-based intervention in the sensitivity analysis (indicated), although there was considerable uncertainty. Expected value of partial perfect information (EVPPI) for efficacy data was in excess of £150M for each population. Given the EVPPI values, future trials assessing the relative efficacies of promising interventions appears to represent value for money.LimitationsIn the NMAs, some trials were omitted because they could not be connected to the main network of evidence or did not provide EPDS scores. This may have introduced reporting or selection bias. No adjustment was made for the lack of quality of some trials. Although we appraised a very large number of studies, much of the evidence was inconclusive.ConclusionsInterventions warrant replication within randomised controlled trials (RCTs). Several interventions appear to be cost-effective relative to usual care, but this is subject to considerable uncertainty.Future work recommendationsSeveral interventions appear to be cost-effective relative to usual care, but this is subject to considerable uncertainty. Future research conducting RCTs to establish which interventions are most clinically effective and cost-effective should be considered.Study registrationThis study is registered as PROSPERO CRD42012003273.FundingThe National Institute for Health Research Health Technology Assessment programme.

PP09 Cost-Effectiveness Of Chronic Obstructive Pulmonary Disease Management

2019 ◽  
Vol 35 (S1) ◽  
pp. 38-39
Author(s):  
Thomas Plunkett ◽  
Paul Carty ◽  
Michelle O'Neill ◽  
Patricia Harrington ◽  
Susan M Smith ◽  
...  
Keyword(s):  
Systematic Review ◽  
Chronic Obstructive Pulmonary Disease ◽  
Cost Effectiveness ◽  
Usual Care ◽  
Pulmonary Disease ◽  
Cost Effective ◽  
Cochrane Library ◽  
Chronic Obstructive ◽  
Obstructive Pulmonary Disease ◽  
The Cost

IntroductionTo inform the development of a national clinical guideline for Chronic Obstructive Pulmonary Disease (COPD), prioritized by the National Clinical Effectiveness Committee in Ireland, a systematic review was conducted to examine the cost-effectiveness of pulmonary rehabilitation programs (PRPs), outreach programs (OPs), and long-term oxygen therapy (LTOT), compared with usual care.MethodsMedline, Embase, the Cochrane Library and grey literature sources were searched up to 19 June 2018. Studies evaluating cost-effectiveness published post-2008 in English were included. Screening, data extraction, and quality assessment using the Consensus Health Economic Criteria and International Society for Pharmacoeconomics questionnaires were conducted independently by two reviewers. Costs were converted to 2017 Irish Euro using consumer price indices for health and purchasing power parity.ResultsFrom 8,661 articles identified, seven studies (one comparing both PRPs and LTOT) were included (PRPs: five; OPs: one; LTOT: two). PRP cost-utility analyses (n = 4) reported conflicting results due to considerable heterogeneity in program and study design, with incremental cost-effectiveness ratios (ICERs) ranging between EUR 12,391 and EUR 509,122 per quality adjusted life-year (QALY) gained. The remaining study investigated hospitalizations avoided and found outpatient and community-based PRPs to be dominant, while home-based PRP produced an ICER of EUR 1,913. OPs were found to be less costly, but also less effective. However, the results of the underpinning trial were neither statistically nor clinically significant. LTOT was found to be cost-effective, with ICERs of EUR 17,603 and EUR 26,936 per QALY gained.ConclusionsApplying a willingness-to-pay threshold of EUR 45,000 per QALY gained, this systematic review found that, compared with usual care, there is inconsistent but generally favorable evidence for PRPs, no clear evidence for the cost-effectiveness of OPs, and that LTOT is likely to be cost-effective. However, there was a lack of methodologically robust studies included in the review and most were not directly transferable to the Irish context.

scholarly journals P88 Intensive management in moderate established rheumatoid arthritis: the titrate trial

Rheumatology ◽  
2020 ◽  
Vol 59 (Supplement_2) ◽  
Author(s):  
Elena Nikiphorou ◽  
on behalf of the ◽  
TITRATE Programme Investigators
Keyword(s):  
Rheumatoid Arthritis ◽  
Cost Effectiveness ◽  
Motivational Interviewing ◽  
Standard Care ◽  
Cost Effective ◽  
Treat To Target ◽  
Intensive Management ◽  
Remission Rates ◽  
Interviewing Techniques

Abstract Background Intensive management (IM) using treat-to-target principles has been shown to be effective in many trials of early rheumatoid arthritis (RA) in patients with high disease activity levels. There is no trial evidence that this approach benefits patients with moderately active RA - a dominant group in clinics. We tested the hypothesis that IM increases remission rates in established moderate RA patients (DAS28-ESR 3.2-5.1) receiving stable conventional synthetic disease modifying drugs (csDMARDs) compared to standard care (SC). IM comprised of: (a)monthly clinical assessments; (b)treat-to-target titrated medication including biologics; (c)psycho-social support delivered by trained nurses and other practitioners in motivational interviewing techniques. Methods A multicentre individually randomised trial compared IM (using combination DMARDs, depot steroid, biologics in non-responders, alongside supportive care using motivational interviewing techniques from trained nurses) to standard care (SC) patients receiving their usual clinical care. The primary outcome was 12-months remission by DAS28-ESR. Secondary outcomes: alternative remission assessments, disability via the health assessment questionnaire (HAQ), pain, fatigue, erosive progression and harm. Multivariable logistic and linear regression compared treatment approaches under intention-to-treat with multiple imputation for missing data. Cost, quality-adjusted life years (QALYs) from the EQ-5D-5L instrument mapped to EQ5D-3L, and incremental cost-effectiveness ratios (ICERs) were calculated, for within trial period. Results 459 patients were screened and 335 randomised (168 IM; 167 SC); 303(90%) gave 12-month outcome measures. 139(83%) IM patients attended sessions. At 12 months IM significantly increased DAS28-ESR remissions compared to SC (32% vs 18%, p = 0.004) and other remission assessments. IM increased DAS28-ESR low disease activity (48% vs 32%, p = 0.005). Clinically important reductions in HAQ were seen in patients who achieved remission following IM (mean change at 12-months -0.40; 95% confidence intervals -0.57,-0.22), as well as improvements in both fatigue and pain. There was a minimal increase in erosive damage over 12 months in both groups. Serious adverse events (IM = 15 vs SC = 11) and other adverse events (114 IM,151 SC) were similar between groups. The base case ICER was £43,972 (€51,474) with a probability of being cost effective at £30,000/€35,000 of 0.17. The ICER fell to £29,363 (€24,384) after including patients’ personal costs and lost working time with a probability IM is cost-effective of 0.5 at UK willing to pay thresholds. This estimate was based on the historic prices of biologics and the probability is higher when current drug acquisition costs are applied. Conclusion IM by trained nurses in motivational interviewing techniques is clinically effective in moderate established RA, achieving more remission without increasing harm. It also gave clinically important improvement in pain and fatigue. There is a strong case to adopt this approach in routine practice as increasing remission rates may improve long-term outcomes, reduce future biologic prescribing and thereby improve long term cost-effectiveness. Disclosures E. Nikiphorou None.

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