Abstract

INTRODUCTION: Recent clinical trial results have demonstrated that, in patients with type 2 diabetes, second-line treatment of rosiglitazone in combination with metformin can lead to significant improvements in the control of fasting plasma glucose/glycosylated haemoglobin A1c (HbA1c) after the failure of metformin monotherapy. Our objective was to assess the cost-effectiveness of the use of rosiglitazone in combination with metformin in overweight and obese patients with type 2 diabetes in the UK, failing to maintain glycaemic control with metformin monotherapy compared with conventional care using metformin in combination with sulfonylurea.

METHODS: The Diabetes Decision Analysis of Cost - type 2 (DiDACT) model, an established long-term economic model of type 2 diabetes, which projects the relationship between treatment and HbA1c over extended periods, was used to determine the health outcomes and economic impact for matched age and sex cohorts of 1000 patients with type 2 diabetes. The perspective was that of the UK National Health Service and all costs were in UK pounds sterling.

RESULTS: Treatment with rosiglitazone in combination with metformin provides better glycaemic control over the remaining lifetime of patients than metformin and sulfonylurea combination therapy. Patients treated with rosiglitazone combination therapy were predicted to have a longer life expectancy, gaining 123 and 140 additional life years per 1000 patients in the obese and overweight cohorts, respectively. Improvements in morbidity and a delay in the start of insulin therapy resulted in a projected improvement in quality of life. These effects combine with projected improved survival to yield 131 and 209 additional quality-adjusted life-years (QALYs) per 1000 patients in the obese and overweight cohorts, respectively. Discounted incremental cost-effectiveness ratios were estimated at £16 700 per QALY gained for the obese cohort and £11 600 per QALY gained for the overweight cohort.

CONCLUSION: The model predicts that rosiglitazone in combination with metformin is a cost-effective treatment in the UK for both obese and overweight patients failing on metformin monotherapy, compared with conventional therapy using metformin in combination with sulfonylurea.

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Abstract

OBJECTIVE: To assess the cost effectiveness of post-acute care for older people in a locality based community hospital compared with a department for care of elderly people in a district general hospital, which admits patients aged over 76 years with acute medical conditions.

DESIGN: Cost effectiveness analysis within a randomised controlled trial.

SETTING: Community hospital and district general hospital in Yorkshire, England.

PARTICIPANTS: 220 patients needing rehabilitation after an acute illness for which they required admission to hospital.

INTERVENTIONS: Multidisciplinary care in the district general hospital or prompt transfer to the community hospital.

MAIN OUTCOME MEASURES: EuroQol EQ-5D scores transformed into quality adjusted life years (QALYs), and health and social service costs over six months from randomisation.

RESULTS: The mean QALY score for the community hospital group was marginally non-significantly higher than that for the district general hospital group (0.38 v 0.35) at six months after recruitment. The mean (standard deviation) costs per patient of the health and social services resources used were similar for both groups: community hospital group 7233 pounds sterling (euros 10,567; 13,341 dollars) (5031 pounds sterling), district general hospital group 7351 pounds sterling(6229 pounds sterling), and these findings were robust to several sensitivity analyses. The incremental cost effectiveness ratio for community hospital care dominated. A cost effectiveness acceptability curve, based on bootstrapped simulations, suggests that at a willingness to pay threshold of 10,000 pounds sterling per QALY, 51% of community hospital cases will be cost effective, which rises to 53% of cases when the threshold is 30,000 pounds sterling per QALY.

CONCLUSION: Post-acute care for older people in a locality based community hospital is of similar cost effectiveness to that of an elderly care department in a district general hospital.

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Abstract

OBJECTIVE: The researchers sought to assess whether the widely used 1994 Cochrane Highly Sensitive Search Strategy (HSSS) for randomized controlled trials (RCTs) in MEDLINE could be improved in terms of sensitivity, precision, or parsimony.

METHODS: A gold standard of 1,347 RCT records and a comparison group of 2,400 non-trials were randomly selected from MEDLINE. Terms occurring in at least 1% of RCT records were identified. Fifty percent of the RCT and comparison group records were randomly selected, and the ability of the terms to discriminate RCTs from nontrial records was determined using logistic regression. The best performing combinations of terms were tested on the remaining records and in MEDLINE.

RESULTS: The best discriminating term was ''Clinical Trial'' (Publication Type). In years where the Cochrane assessment of MEDLINE records had taken place, the strategies identified few additional unindexed records of trials. In years where Cochrane assessment has yet to take place, ''Randomized Controlled Trial'' (Publication Type) proved highly sensitive and precise. Adding six more search terms identified further, unindexed trials at reasonable levels of precision and with sensitivity almost equal to the Cochrane HSSS.

CONCLUSIONS: Most reports of RCTs in MEDLINE can now be identified easily using ''Randomized Controlled Trial'' (Publication Type). More sensitive searches can be achieved by a brief strategy, the Centre for Reviews and Dissemination/Cochrane Highly Sensitive Search Strategy (2005 revision).

Abstract

The effectiveness of rosuvastatin in improving lipid measurements and achieving guideline target levels in patients has been demonstrated in short-term randomised clinical trials. The Framingham Heart Study has provided some of the strongest evidence in establishing the relationship between risk factors such as smoking, hypertension and cholesterol and events from cardiovascular disease and subsequent mortality. Using Framingham risk equations for coronary heart disease, we used a Markov model to extrapolate beyond short-term trial evidence to calculate the cost-effectiveness of cholesterol-lowering therapy in 55-year-old men and women, with an initial total cholesterol: high-density lipoprotein cholesterol (TC:HDL) ratio of 5.5 and an untreated expected survival (under adjusted Framingham risk equations) of 17 years (men) and 19 years (women). After titration, cholesterol-lowering therapy reduced the weighted average TC:HDL ratio to 3.4 (rosuvastatin), 3.7 (atorvastatin), 3.9 (simvastatin), 4.1 (fluvastatin) and 4.2 (pravastatin). In comparison with no treatment, rosuvastatin produced the greatest health gain (0.71 quality-adjusted life-years [QALYS]) and pravastatin the smallest (0.42). In the base case analysis, rosuvastatin dominated atorvastatin and delivered additional benefits at the cost of £9,735 per QALY for men in comparison with generic simvastatin. Sensitivity analysis showed a high probability of rosuvastatin being cost-effective under conditions of uncertainty.