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AIMS: To estimate the cost effectiveness of continuous subcutaneous insulin infusion (CSII) compared with multiple daily injections (MDI) for patients using insulin pumps.
METHODS: We constructed a Markov model to estimate the costs and outcomes for patients with insulin-dependent diabetes (IDDM) treated with CSII using an insulin pump compared with MDI. Key parameters were obtained from the published scientific literature. The primary outcome was quality-adjusted life years (QALYs). Monte Carlo simulations were undertaken for 10 000 hypothetical patients over 8 years of monthly cycles (the expected life of a pump).
RESULTS: Over an 8-year period an average patient could expect to gain 0.48 [standard deviation (sd) 0.20] QALYs using CSII compared with MDI. The additional cost over 8 years for this gain was pounds 5462 (sd pounds 897). The incremental cost per QALY was pounds 11,461 (sd pounds 3656). CSII was most cost-effective in patients who had more than two severe hypoglycaemic events per year and who required admission to hospital at least once every year. Cases where CSII might be not economically viable are cases where diabetes is well controlled with few severe hypoglycaemic events. Results were most sensitive to the number of hypoglycaemic events per patient and the utility weights used to estimate QALYs.
CONCLUSION: CSII is a worthwhile investment when targeted to those who might benefit most.
No abstract available
Advice on how to access the best available online sources of research evidence on clinical and cost effectiveness published in three recent issues of Effectiveness Matters is reviewed.
BACKGROUND: Type 2 diabetes is characterized by insulin resistance and the progressive loss of islet beta-cell function. Although the former is already established at diagnosis and changes little thereafter, beta-cell function continues to decline, leading to secondary failure of anti-hyperglycaemic therapies.
AIM: To develop a quantitative model of the process of beta-cell function decay over time, using trial data.
DESIGN: Re-analysis of published data.
METHODS: The results of the Belfast Diet Study were re-analysed. Assuming patients are diagnosed at different stages in the disease process, time displacement of data was used to obtain a bi-partite spline model describing loss of insulin secretion over a 6-year period.
RESULTS: The model was developed combining two phases, in which a long slow gradual loss of beta-cell function leads to a crisis in metabolic regulation, precipitating a much more rapid decay phase. This paradigm was consistent with a previous non-linear model of beta-cell mass regulation.
DISCUSSION: This model may have important implications for targeting appropriate therapy to patients in each phase: delaying or avoiding full clinical type 2 diabetes in the first phase; and preventing the development of diabetic complications in the second phase.
No abstract available
BACKGROUND AND AIMS: To compare the cost-effectiveness of adding rosiglitazone 8 mg versus maximal dose sulphonylurea to metformin for obese patients failing to control HbA1c on metformin monotherapy.
MATERIALS AND METHODS: DiDACT is an established economic model of the long-term complications of type 2 diabetes. The model follows a cohort of 1,000 patients (410 male and 590 female) through multiple stages of microvascular and macrovascular disease. Inpatient, outpatient, and medication costs are included. Failure of glycaemic control was defined as HbA1c = 8.0%. The cohort has BMIs of 38 and 43 kg/m2 for males and females as per 2000 NHIS data using the Center for Disease Control's definition for obesity. Population demographics were taken from National Health and Nutrition Examination Survey III. Costs and outcomes were discounted at 3% per annum.
RESULTS: For males, adding rosiglitazone was estimated to increase total quality of life years (QALYs) by 94 and increase total life years by 53.5, compared with adding sulphonylurea. For females, adding rosiglitazone was estimated to increase total QALYs by 140 and increase total life years by 62. Costs per additional QALY were $38,838 in males and $39,539 in females.
CONCLUSIONS: The cost-effectiveness of a rosiglitazone plus metformin combination is comparable with other regularly prescribed interventions (such as statins in the cardiovascular area). These results illustrate that adding rosiglitazone to metformin may lead to long-term benefits in obese patients.
OBJECTIVE: Outcomes in healthcare technology reviews now increasingly include cost as well as effectiveness. The aim of this study is to report the findings and implications of a survey regarding the usefulness of NHS Economic Evaluation Database (NHS EED) structured abstracts within this process.
METHODS: Postal survey of lead authors of Technology Assessment Reviews (TARs) commissioned by the UK's National Institute for Clinical Excellence. The questionnaire investigated the usefulness of NHS EED regarding: search strategy, data extraction, quality assessment, and requirement for new modeling studies. Qualitative data were requested, including opinions regarding NHS EED.
RESULTS: NHS EED was used in 90% of all identified reviews (n = 46). The questionnaire response rate was 57%. The percentage of scores 3 or above, 2 or below, or N/A were, respectively: search strategy = 60%, 22%, 17%; data extraction = 26%, 26%, 48%; quality assessment = 30%, 22%, 48%; requirement for new modeling studies = 22%, 26%, 52%. The results were expanded upon in the qualitative data from the respondents.
CONCLUSIONS: Where several economic evaluations had been published NHS EED was utilized and valued as an independent source, and was highly useful to non-economists. However, those undertaking TARs also used confidential data from company submissions and cost data for studies not critiqued on NHS EED. More standardization and use of quality checklists in reviews of economic studies is clearly needed. The findings will help in developing and improving NHS EED in its role of providing health outcomes and economic evidence in TARs
