Policy makers require information on costs related to inpatient and outpatient health services to inform resource allocation decisions.
Country data sets were gathered in 2008-2010 through literature ...reviews, website searches and a public call for cost data. Multivariate regression analysis was used to explore the determinants of variability in unit costs using data from 30 countries. Two models were designed, with the inpatient and outpatient models drawing upon 3407 and 9028 observations respectively. Cost estimates are produced at country and regional level, with 95% confidence intervals.
Inpatient costs across 30 countries are significantly associated with the type of hospital, ownership, as well as bed occupancy rate, average length of stay, and total number of inpatient admissions. Changes in outpatient costs are significantly associated with location, facility ownership and the level of care, as well as to the number of outpatient visits and visits per provider per day.
These updated WHO-CHOICE service delivery unit costs are statistically robust and may be used by analysts as inputs for economic analysis. The models can predict country-specific unit costs at different capacity levels and in different settings.
This study assesses Jordanian community pharmacists’ readiness and willingness to deliver vaccination services in their practice sites. Between February and April 2021, a self‐administered online ...questionnaire was distributed via social media, WhatsApp messages, and personal communication. The questionnaire targeted practicing community pharmacies. Descriptive and inferential data analysis was carried out. A total of 403 community pharmacists participated in the study. Almost 146 (36%) community pharmacists reported vaccinating patients in their practice sites. However, readiness assessment revealed that only 54 (13.4%) pharmacists received the required training and qualifications. Moreover, 33 (8.2%) study participants worked in adequately equipped and designed community pharmacies. Overall, surveyed participants held positive attitudes toward their involvement in vaccination services: 260 (64.5%) pharmacists were willing to vaccinate patients, and 227 (65.0%) out of unready, unqualified, participants were willing to get needed training and qualifications. According to study participants, regulatory and professional bodies (Ministry of Health, Jordan Pharmacists Association) are influential in supporting pharmacist‐vaccinators. Among the investigated factors, organizational structure and employment status were significantly associated with pharmacists’ readiness to deliver vaccination. This study revealed that further work is needed to increase pharmacists’ and pharmacies’ readiness to deliver vaccination services and that regulators should follow a more active approach in highlighting the importance of training and the impact of training in patients’ safety and satisfaction.
This figure briefly describes the study's population, design, and main outcomes.
Background
People with psoriasis live with other long‐term conditions (co‐morbidities) that affect their use of healthcare, but the scale of this is not well characterised.
Objectives
Estimate the ...concurrent prevalence of co‐morbidities known to affect the use of healthcare in people living with psoriasis in England.
Methods
A retrospective cohort study using linked data from the UK's Clinical Practice Research Datalink with Hospital Episode Statistics, Office for National Statistics mortality records, and Index of Multiple Deprivation 2010. A cohort of adults (≥18 years) with psoriasis was matched with a comparator cohort of individuals based on age, sex and registered general practice between April 2007 and December 2017. A predefined list of 21 co‐morbidities was selected from a published measure: the Cambridge Multimorbidity Index (CMI). Descriptive analysis describes prevalence with statistical tests (t tests; two‐sample proportions test) of difference for selected variables.
Results
The study cohort comprised 372,949 individuals (54,817 psoriasis; and 318,132 matched‐comparator). The calculated CMI general score was statistically higher at 0.54 (standard deviation: 0.9) for psoriasis compared with 0.39 (standard deviation: 0.75) for the matched comparator (t test; p < 0.001). A higher percentage (53.2%) of individuals within the psoriasis cohort had at least one co‐morbidity compared with 45.4% of individuals in the matched‐comparator cohort. The prevalence of 20 individual co‐morbidities was statistically significantly (two‐sample proportions test; p < 0.001) higher than in the matched‐comparator cohort.
Conclusions
Individuals living with psoriasis are more likely to live with multiple long‐term conditions that have developed at an earlier age compared with those without psoriasis. Knowing the characteristics for a higher prevalence of co‐morbidities in people living with psoriasis provides clinicians with the motivation to consider more holistic approaches to improve management and treatment, noting the importance of mental health alongside physical health, and enabling a conversation about the importance of making lifestyle changes.
This study estimated the concurrent prevalence of co‐morbidities known to affect use of healthcare in people living with psoriasis in England using a retrospective cohort (54,817 with psoriasis; 318,132 matched‐comparator). The prevalence of 20 individual co‐morbidities were statistically significantly (two‐sample proportions test; p < 0.001) higher than in the matched comparator‐cohort. Individuals living with psoriasis are more likely to live with multiple long‐term conditions that have developed at an earlier age compared with those without psoriasis.
Poor outcomes and high resource-use are observed for frail older people discharged from acute medical units. A specialist geriatric medical intervention, to facilitate Comprehensive Geriatric ...Assessment, was developed to reduce the incidence of adverse outcomes and associated high resource-use in this group in the post-discharge period.
To examine the costs and cost-effectiveness of a specialist geriatric medical intervention for frail older people in the 90 days following discharge from an acute medical unit, compared with standard care.
Economic evaluation was conducted alongside a two-centre randomised controlled trial (AMIGOS). 433 patients (aged 70 or over) at risk of future health problems, discharged from acute medical units within 72 hours of attending hospital, were recruited in two general hospitals in Nottingham and Leicester, UK. Participants were randomised to the intervention, comprising geriatrician assessment in acute units and further specialist management, or to control where patients received no additional intervention over and above standard care. Primary outcome was incremental cost per quality adjusted life year (QALY) gained.
We undertook cost-effectiveness analysis for 417 patients (intervention: 205). The difference in mean adjusted QALYs gained between groups at 3 months was -0.001 (95% confidence interval CI: -0.009, 0.007). Total adjusted secondary and social care costs, including direct costs of the intervention, at 3 months were £4412 (€5624, $6878) and £4110 (€5239, $6408) for the intervention and standard care groups, the incremental cost was £302 (95% CI: 193, 410) €385, $471. The intervention was dominated by standard care with probability of 62%, and with 0% probability of cost-effectiveness (at £20,000/QALY threshold).
The specialist geriatric medical intervention for frail older people discharged from acute medical unit was not cost-effective. Further research on designing effective and cost-effective specialist service for frail older people discharged from acute medical units is needed.
ISRCTN registry ISRCTN21800480 http://www.isrctn.com/ISRCTN21800480.
Celotno besedilo
Dostopno za:
DOBA, IZUM, KILJ, NUK, PILJ, PNG, SAZU, SIK, UILJ, UKNU, UL, UM, UPUK
One in three hospital acute medical admissions is of an older person with cognitive impairment. Their outcomes are poor and the quality of their care in hospital has been criticised. A specialist ...unit to care for older people with delirium and dementia (the Medical and Mental Health Unit, MMHU) was developed and then tested in a randomised controlled trial where it delivered significantly higher quality of, and satisfaction with, care, but no significant benefits in terms of health status outcomes at three months.
To examine the cost-effectiveness of the MMHU for older people with delirium and dementia in general hospitals, compared with standard care.
Six hundred participants aged over 65 admitted for acute medical care, identified on admission as cognitively impaired, were randomised to the MMHU or to standard care on acute geriatric or general medical wards. Cost per quality adjusted life year (QALY) gained, at 3-month follow-up, was assessed in trial-based economic evaluation (599/600 participants, intervention: 309). Multiple imputation and complete-case sample analyses were employed to deal with missing QALY data (55%).
The total adjusted health and social care costs, including direct costs of the intervention, at 3 months was £7714 and £7862 for MMHU and standard care groups, respectively (difference -£149 (95% confidence interval CI: -298, 4)). The difference in QALYs gained was 0.001 (95% CI: -0.006, 0.008). The probability that the intervention was dominant was 58%, and the probability that it was cost-saving with QALY loss was 39%. At £20,000/QALY threshold, the probability of cost-effectiveness was 94%, falling to 59% when cost-saving QALY loss cases were excluded.
The MMHU was strongly cost-effective using usual criteria, although considerably less so when the less acceptable situation with QALY loss and cost savings were excluded. Nevertheless, this model of care is worthy of further evaluation.
ClinicalTrials.gov NCT01136148.
Celotno besedilo
Dostopno za:
DOBA, IZUM, KILJ, NUK, PILJ, PNG, SAZU, SIK, UILJ, UKNU, UL, UM, UPUK
In persons with type 1 diabetes, intermittently scanned continuous glucose monitoring led to significantly lower glycated hemoglobin levels than participant monitoring with fingerstick testing.
ObjectiveTo examine the effectiveness of the New Medicine Service (NMS), a national community pharmacy service to support medicines-taking in people starting a new medicine for a long-term condition, ...compared with normal practice.MethodsPragmatic patient-level parallel randomised controlled trial, in 46 community pharmacies in England. Patients 1:1 block randomisation stratified by drug/disease group within each pharmacy. 504 participants (NMS: 251) aged 14 years and over, identified in the pharmacy on presentation of a prescription for asthma/chronic obstructive pulmonary disease, hypertension, type 2 diabetes or an anticoagulant/antiplatelet agent. NMS intervention: One consultation 7–14 days after presentation of prescription followed by another 14–21 days thereafter to identify problems with treatment and provide support if needed. Controls received normal practice. Adherence, defined as missing no doses without the advice of a medical professional in the previous 7 days, was assessed through patient self-report at 10 weeks. Intention-to-treat analysis was employed, with outcome adjusted for recruiting pharmacy, NMS disease category, age, sex and medication count. Cost to the National Health Service (NHS) was collected.ResultsAt 10 weeks, 53 patients had withdrawn and 443 (85%) patients were contacted successfully by telephone. In the unadjusted analysis of 378 patients still taking the initial medicine, 61% (95% CI 54% to 67%) and 71% (95% CI 64% to 77%) patients were adherent in the normal practice and NMS arms, respectively (p=0.04 for difference). In the adjusted intention-to-treat analysis, the OR for increased adherence was 1.67 (95% CI 1.06 to 2.62; p=0.027) in favour of the NMS arm. There was a general trend to reduced NHS costs, albeit, statistically non-significant, for the NMS intervention: saving £21 (95% CI −£59 to £100, p=0.128) per patient.ConclusionsThe NMS significantly increased the proportion of patients adhering to their new medicine by about 10%, compared with normal practice.Trial registration numbersClinicalTrials.gov trial reference number NCT01635361 (http://clinicaltrials.gov/ct2/show/NCT01635361). Current Controlled trials: trial reference number ISRCTN 23560818 (http://www.controlled-trials.com/ISRCTN23560818/; DOI 10.1186/ISRCTN23560818). UK Clinical Research Network (UKCRN) study 12494 (http://public.ukcrn.org.uk/Search/StudyDetail.aspx?StudyID=12494).
Acute Coronary Syndrome (ACS) is a condition with very high clinical burden and financial burden worldwide and in the UK. ACS is more common in populations with Type 2 Diabetes Mellitus(T2DM), due to ...the vascular complications that people with T2DM face. This fact results in increased occurrence of ACS compared to the general population. ACS management is complex in T2DM populations because of the additional need for glycaemic control. Oral antiplatelet medication (clopidogrel, aspirin) is among the most important treatments for the secondary prevention of ACS. New oral antiplatelet agents (ticagrelor, prasugrel) were compared as alternative treatments to clopidogrel in the general population. The new agents performed better than clopidogrel in terms of effectiveness and cost-effectiveness. The results of the effectivess of those agents in T2DM subgroups were available, but they were presented as an ad hoc analysis of the initial trials. This gap in research provided an opportunity for investigating effectiveness of antiplatelet medications in T2DM populations using real world data. This study investigated the economic impact of different antiplatelet regimens in people with T2DM post-ACS, from the perspective of the NHS in England. The study aimed to gain an understanding of the characteristics of people with T2DM prescribed antiplatelet medications for secondary prevention post-ACS (demographics, clinical outcomes, medication usage, medication adherence, healthcare resource used, and costs), explain the variation in those clinical outcomes and costs, and investigate the effectiveness and cost-effectiveness of antiplatelet regimens in this population. Using routinely collected data from the Clinical Practice Research Datalink (CPRD) and Hospital Episode Statistics (HES), a cohort study was carried out in order to investigate the effect of different antiplatelet regimens in patients with T2DM. Inverse probability treatment weights were obtained from propensity score models, and those weights were used to address the confounding that arised from the non-random assignment in antiplatelet regimens in the retrospectively observed data. The time to event analysis found that the newer antiplatelet medications had better results than aspirin-clopidogrel for the outcomes investigated. The time to reccurence of a major adverse cardiovascular event (MACE) in patients treated with aspirin-prasugrel was approximately 4.4 times longer Time Ratio (TR): 4.42; 95%CI: 1.73 to 11.28 compared to that of patients on aspirin-clopidogrel. No effect was found in patients who were prescribed aspirin-ticagrelor. Aspirin-prasugrel was associated with a 96% decrease in the hazard rate of stroke Hazard Ratio (HR): 0.04 ;95% CI: 0.01 to 0.32 and aspirin-ticagrelor with a 78% decrease Hazard Ratio (HR): 0.22 ;95% CI: 0.05 to 0.95 when compared with aspirin-clopidogrel. The time to recurrence of a bleeding event in patients on aspirin-ticagrelor was approximately 12 times longer compared to that of patients on aspirin-clopidogrel TR:11.89; 95%CI: 0.95 to 148.03. No effect in bleeding was found in patients who were prescribed aspirin-prasugrel. Patients on aspirin-ticagrelor and aspirin-prasugrel survived 2.6 times TR: 2.57;95% CI: 1.61 to 4.12 and 1.4 times longer TR: 1.43;95% CI: 1.01 to 2.06 compared to patients treated with aspirin-clopidogrel. The findings are in partial accordance with the literature around the effectiveness of newer antiplatelet agents versus aspirin-clopidogrel. The cost association analysis found that, on average, patients on aspirin-ticagrelor and aspirin-clopidogrel incur annually £6345 in total care health care costs. Patients on aspirin-prasugrel incurred 35% less costs (£4098). The adherence analysis found that the average proportion of days covered (PDC) for all regimens is high and above the cut-off point of 80%. Patients on dual antiplatelet therapy regimens started discontinuing their therapies after 180 days. For the groups of aspirin- ticagrelor and aspirin-prasugrel there where no patients continuing their prescription after 450 days. In the aspirin-clopidogrel group the number of patients with prescriptions lasting more than 450 days was decreasing and the number of patients continuing with therapy for more than 450 days and less than 720 days was very small. A decision analytical model was used to estimate the cost-effectiveness of alternative dual antiplatelet regimens and aspirin only. The analysis demonstrated that aspirin-ticagrelor generated more QALYs 0.67;95% CI:0.05 to 1.22 compared with aspirin only and costs £1459.96; 95% CI: -5797.66 to 10056.77 over the lifetime horizon. Aspirin-prasugrel and aspirin-clopidogrel were extendedly dominated. The probabilistic model estimated that aspirin-ticagrelor had the highest probability of being cost-effective for willingness to pay levels higher than £2000 per QALY. For a maximum willingness-to pay of £20000 per QALY the probability of cost-effectiveness was 90%. These findings were in accordance with similar studies for the general population. This study allowed for a head-to-head comparison of alternative antiplatelet regimens for T2DM patients who suffered an ACS. Study findings were relevant for England only and not UK wide, because of the linkage of primary and secondary care data. The time-to-event and the cost analyses, even though they were carried out with the use of doubly robust estimation methods, potentially did not sufficiently address some of the confounding. In the Markov model, it was not possible to use a more complex treatment pattern in the patients who were assigned in DAPT regimen, and that could result in the potential overestimation cost-effectiveness. Many T2DM patients were on monotherapy regimens for secondary prevention, even though this is not suggested in the clinical guidelines. Further investigation for this specific group is needed. T2DM patients who are on a DAPT regimen, tend to discontinue the treatment from the sixth month. This practice implication indicates the need for interventions that reduce DAPT discontinuation.
ObjectiveTo examine the effectiveness and cost-effectiveness of the community pharmacy New Medicine Service (NMS) at 26 weeks.MethodsPragmatic patient-level parallel randomised controlled trial in 46 ...English community pharmacies. 504 participants aged ≥14, identified in the pharmacy when presenting a prescription for a new medicine for predefined long-term conditions, randomised to receive NMS (n=251) or normal practice (n=253) (NMS intervention: 2 consultations 1 and 2 weeks after prescription presentation). Adherence assessed through patient self-report at 26-week follow-up. Intention-to-treat analysis employed. National Health Service (NHS) costs calculated. Disease-specific Markov models estimating impact of non-adherence combined with clinical trial data to calculate costs per extra quality-adjusted life-year (QALY; NHS England perspective).ResultsUnadjusted analysis: of 327 patients still taking the initial medicine, 97/170 (57.1%) and 103/157 (65.6%) (p=0.113) patients were adherent in normal practice and NMS arms, respectively. Adjusted intention-to-treat analysis: adherence OR 1.50 (95% CI 0.93 to 2.44, p=0.095), in favour of NMS. There was a non-significant reduction in 26-week NHS costs for NMS: −£104 (95% CI −£37 to £257, p=0.168) per patient. NMS generated a mean of 0.04 (95% CI −0.01 to 0.13) more QALYs per patient, with mean reduction in lifetime cost of −£113.9 (−1159.4, 683.7). The incremental cost-effectiveness ratio was −£2758/QALY (2.5% and 97.5%: −38 739.5, 34 024.2. NMS has an 89% probability of cost-effectiveness at a willingness to pay of £20 000 per QALY.ConclusionsAt 26-week follow-up, NMS was unable to demonstrate a statistically significant increase in adherence or reduction in NHS costs, which may be attributable to patient attrition from the study. Long-term economic evaluation suggested NMS may deliver better patient outcomes and reduced overall healthcare costs than normal practice, but uncertainty around this finding is high.Trial registration number NCT01635361, ISRCTN23560818, ISRCTN23560818, UKCRN12494.
Background
The English community pharmacy New Medicine Service (NMS) significantly increases patient adherence to medicines, compared with normal practice. We examined the cost effectiveness of NMS ...compared with normal practice by combining adherence improvement and intervention costs with the effect of increased adherence on patient outcomes and healthcare costs.
Methods
We developed Markov models for diseases targeted by the NMS (hypertension, type 2 diabetes mellitus, chronic obstructive pulmonary disease, asthma and antiplatelet regimens) to assess the impact of patients’ non-adherence. Clinical event probability, treatment pathway, resource use and costs were extracted from literature and costing tariffs. Incremental costs and outcomes associated with each disease were incorporated additively into a composite probabilistic model and combined with adherence rates and intervention costs from the trial. Costs per extra quality-adjusted life-year (QALY) were calculated from the perspective of NHS England, using a lifetime horizon.
Results
NMS generated a mean of 0.05 (95% CI 0.00–0.13) more QALYs per patient, at a mean reduced cost of −£144 (95% CI −769 to 73). The NMS dominates normal practice with a probability of 0.78 incremental cost-effectiveness ratio (ICER) −£3166 per QALY. NMS has a 96.7% probability of cost effectiveness compared with normal practice at a willingness to pay of £20,000 per QALY. Sensitivity analysis demonstrated that targeting each disease with NMS has a probability over 0.90 of cost effectiveness compared with normal practice at a willingness to pay of £20,000 per QALY.
Conclusions
Our study suggests that the NMS increased patient medicine adherence compared with normal practice, which translated into increased health gain at reduced overall cost.
Trial Registration
ClinicalTrials.gov Trial reference number NCT01635361 (
http://clinicaltrials.gov/ct2/show/NCT01635361
). Current Controlled trials: Trial reference number ISRCTN 23560818 (
http://www.controlled-trials.com/ISRCTN23560818/
; DOI
10.1186/ISRCTN23560818
). UK Clinical Research Network (UKCRN) study 12494 (
http://public.ukcrn.org.uk/Search/StudyDetail.aspx?StudyID=12494
).
Funding
Department of Health Policy Research Programme.
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