Patient-centred endpoints in economic evaluations of gastro-oesophageal reflux disease.

AIM: To perform a systematic review of the economic literature on gastro-oesophageal reflux disease to evaluate (a) the use of patient-centred effectiveness end-points, or (b) the use of patient-centred economic end-points, and the influence of these end-points on the outcome of the model. METHODS: Three electronic databases (EMBASE, BIOSIS and Medline) were used, together with a manual search of meeting abstracts for relevant articles. The quality of the studies was determined by the Drummond criteria. RESULTS: Our initial search identified 179 articles and a manual search revealed 78 abstracts and articles. A total of 47 studies (36 fully published articles and 11 abstracts) met the seven Drummond criteria for inclusion in our evaluation. CONCLUSIONS: This systematic review demonstrates that many of the published economic evaluations available today take the perspective of the third-party payer and focus on pharmaceutical costs relevant to the third-party payer. Our study also demonstrates that there are a number of costs of illness determinations, such that pharmaceutical costs account for only a small proportion of the total costs of managing gastro-oesophageal reflux disease. Future economic analyses should consider an evaluation of the patient's desire for complete symptom relief by including cost-utility assessments or willingness to pay data.

Angiotensin converting enzyme (ACE) inhibitors and heart failure. The consequences of underprescribing.

Heart failure (HF) is a common and expensive cardiovascular disease, in economic terms as well as in lives lost. Angiotensin converting enzyme (ACE) inhibitors have been shown to significantly reduce mortality and hospitalisation in HF. However, recent surveys show that the prescription rate of ACE inhibitors for HF is far below what is considered to be optimal. Furthermore, prescribed dosages are usually lower than those recommended based on evidence from clinical trials. This article estimates the consequences, both economic and human, of underprescribing ACE inhibitors in patients with HF. The indication for prescribing an ACE inhibitor varies, and clinical trials have included different categories of patients; it is inappropriate to assess costs in all eligible patients without taking these factors into account. Therefore, we analysed the data with respect to 4 different groups: (i) asymptomatic left ventricular systolic dysfunction (LVSD)--an early stage leading to chronic HF; (ii) chronic HF; and post-myocardial infarction (MI) LVSD differentiated into (iii) post-MI asymptomatic LVSD and (iv) post-MI chronic HF. We also estimated the cost effectiveness of adding an ACE inhibitor to the treatment of patients with HF for whom an ACE inhibitor is not currently prescribed. If only patient populations in which large trials have shown a significant effect of ACE inhibition on mortality are included in the analysis (i.e. excluding asymptomatic patients with LVSD), increasing the number of Swedish patients receiving an ACE inhibitor could save in excess of 3700 lives each year, in addition to reducing the annual number of hospitalisations by 8400. The additional cost would be 101.5 million Swedish kronor (SEK), a cost per life saved of SEK27 200. Chronic HF is the most cost-effective patient population to treat, generating cost savings under certain assumptions. A further 6700 hospitalisations can be avoided should the use of ACE inhibitors be extended to asymptomatic patients with LVSD. Increasing dosages to those used in the large clinical trials may generate additional savings in lives and hospitalisations. In conclusion, the use of ACE inhibitors in HF and LVSD has clearly been proven to be cost effective, and compares favourably with the cost effectiveness of treating hypertension or hypercholesterolaemia. At present, however, ACE inhibitors are not optimally utilised. Given the increasingly constrained resources for healthcare, every effort should be made to increase the use of cost-effective treatments, such as ACE inhibitors in chronic HF and post-MI LVSD.

[What is the effect of lowering the arterial blood pressure on the quality of life? An auxiliary study to the HOT (Hypertension Optimal Treatment) trial]. / Quelle influence l'abaissement de la pression artérielle a-t-il sur la qualité de vie? Une étude auxiliaire de l'essai HOT (Hypertension Optimal Treatment).

Nine hundred and twenty-two hypertensive patients were included in a substudy to the hypertension optimal (HOT) study which aimed to investigate the impact on quality of life of lowering the pressure and of intensified therapy. Patients were randomised to three diastolic BPs (DBPs) levels, i.e. < or = 90 mmHg, < or = 85 mmHg and < or = 80 mmHg. Seven hundred and eighty one patients completed both baseline and follow-up questionnaires after 6 months (intention to treat, ITT, population), while 610 patients were included in a per protocol (PP) analysis. The lower the DBP achieved, the greater the improvement in well-being (p < 0.05). The increase in well-being from baseline to 6 months was significant in target groups < or = 80 mmHg (p < 0.01) and < or = 85 mmHg (p < 0.05). Cardiac symptoms and dizziness improved in all groups but the sex life score deteriorated in the < or = 80 and < or = 85 mmHg groups in male patients. Headaches were reduced in all groups (p < 0.001), while swollen ankles (p < 0.001), and dry cough in the < or = 80 mmHg group (p < 0.001) increased. Despite a slight increase in subjective symptoms, more intensive antihypertensive therapy was still associated with improvements in patients' well-being.

The health care costs of heart failure in Sweden.

AIM: Heart failure is a common and serious condition requiring extensive health care resources. The aim of this study is to estimate the total treatment costs of heart failure in Sweden. METHODS AND RESULTS: The study is a prevalence-based cost-of-illness study. It includes costs of institutional care (hospitals and nursing homes), outpatient care, surgery and drugs. The costs are estimated based on official Swedish statistics, and on various clinical and epidemiological studies. The results are expressed in 1996 prices. The total annual treatment costs for heart failure are approximately Swedish kronor (SEK) 2000-2600 million, or nearly 2% of the Swedish health care budget. Institutional care is the single largest component, amounting to SEK 1300-1900 million, or about 65-75% of the costs of heart failure treatment. CONCLUSIONS: The results from this study indicate that heart failure is a costly condition. Efforts to develop effective management programmes that can reduce the need for expensive institutional care, without a negative impact on quality of life, morbidity and mortality, should be given high priority.

Does lowering the blood pressure improve the mood? Quality-of-life results from the Hypertension Optimal Treatment (HOT) study.

Nine-hundred-and-twenty-two hypertensive patients were included in a substudy to the Hypertension Optimal Treatment study, which aimed to investigate the impact on quality of life of lowering the pressure and of intensified therapy. Seven-hundred-and-eighty-one patients completed both baseline and follow-up questionnaires (intention-to-treat population), while 610 patients were included in a per protocol analysis. Patients were randomized to three diastolic BP levels (DBPs), i.e. < or =90 mmHg, < or =85 mmHg and < or =80 mmHg. Two self-administered validated questionnaires, the Psychological General Well-Being index and the Subjective Symptoms Assessment Profile (SSA-P) were completed at baseline and after 6 months. The lower the DBP achieved, the greater the improvement in well-being (p < 0.05). The increase in well-being from baseline to 6 months was significant in target groups < or =80 mmHg (p < 0.01) and < or =85 mmHg (p < 0.05). The SSA-P domains, cardiac symptoms and dizziness improved in all groups but the sex life score deteriorated in the < or =80 and < or =85 mmHg groups in male patients. In all target groups, headaches were reduced (p < 0.001), while swollen ankles (p < 0.001) and dry cough in the < or =80 mmHg group (p < 0.001) increased. Although more intensive antihypertensive therapy is associated with a slight increase in subjective symptoms, it is nonetheless still associated with improvements in patients' well-being.