Analysis of referrals to a multi-disciplinary breast cancer genetics clinic: practical and economic considerations.

Analysis of activity was undertaken in an established regional clinic providing risk assessment, counselling, screening and management for women with a family history of breast or ovarian cancer. The objectives were to determine: (1) how closely the route and pattern of referrals matched official guidelines (2) whether the previously recorded socio-economic imbalance among clinic clientele persisted and (3) the economic and practical consequences of committing resources to verification and extension of reported family histories. The findings were: (1) after some years of operation, the proportion of referrals direct from primary care had increased from less than 50% to over 75%, with a concomitant slight decrease in overall referral rate; (2) the socio-economic distribution of patients referred had become less selective and (3) extension and verification of reported family histories led to a redistribution of risk categories, increasing the proportion of referrals judged to be in the "low risk" category, from 25% (based on referral letter alone) to 41% (at the end of the process). The costs associated with this approach are offset by the savings generated and it allows specialised counselling and screening services to be targeted more efficiently.

An economic evaluation of a European cohort from a multinational trial of linezolid versus teicoplanin in serious Gram-positive bacterial infections: the importance of treatment setting in evaluating treatment effects.

In a recent multinational trial, hospital resource use and total cost of treatment were compared between linezolid and teicoplanin for severe Gram-positive bacterial infections among 227 European hospitalised patients. The results show that the linezolid group had a 3.2-day (6.3 for linezolid versus 9.5 for teicoplanin groups) shorter mean intravenous antibiotic treatment duration. Certain baseline variables, particularly the inpatient location at enrolment and the presence of outpatient/home parenteral antibiotic therapy (OHPAT), had substantial effects on length of stay (LOS) and cost of treatment. After adjusting for the between-treatment difference in these two variables and other baseline variables, the results showed non-significant shorter LOS and lower mean total cost of treatment for the linezolid group among patients with no access to OHPAT.

Use of quality adjusted life years and life years gained as benchmarks in economic evaluations: a critical appraisal.

Researchers have grappled with various ways of placing the results of an economic evaluation in the appropriate context. One of the most common methods is to relate the results of a study to an appropriate benchmark (commonly, dollars 50,000 per QALY in the US or pounds sterling 30,000 per QALY in the UK). This paper examines the foundation for these cut-off points and critiques their use by researchers. Although it is difficult to establish an appropriate benchmark this paper notes that reference points may be too low based on published data. Further, the inconsistent application of benchmarks, and differences in the calculation of a value of a statistical life, will lead to an inefficient allocation of health care resources.

Modelling therapeutic strategies in the treatment of osteoarthritis: an economic evaluation of meloxicam versus diclofenac and piroxicam.

OBJECTIVE: To assess the economic efficiency of meloxicam, a cyclo-oxygenase (COX)-2 selective inhibitor, versus diclofenac and piroxicam in the UK for the treatment of patients with osteoarthritis and the impact on the NHS budget of substituting nonselective NSAIDs with meloxicam. Methods and perspective: A decision analytical model was used to compare the effects of 4 weeks' treatment of osteoarthritis with meloxicam (7.5 mg/day), diclofenac (100 mg/day) and piroxicam (20 mg/day). The decision tree was derived by combining best practice and clinical reality. Analysis was from the NHS perspective. The study considered only the direct costs. These included costs for drug acquisition and management of all adverse events, both serious gastrointestinal events requiring hospitalisation, and non-serious events that required maintenance. Resource use and treatment costs were obtained from local and published sources. A range of sensitivity analyses was carried out. RESULTS: Based on two 4-week large-scale trials, the Meloxicam Large-scale International Study Safety Assessment (MELISSA) and Safety and Efficacy Large-scale Evaluation of COX-inhibiting Therapies (SELECT) trials, and a decision analytical model, the findings suggested that meloxicam had the lowest cost per patient ( pound 30 versus pound 35 for piroxicam and pound 51 for diclofenac [costs presented as 1998 values except for drug costs which were in 2000 values]). The results of the Monte Carlo probabilistic sensitivity analysis, using 4000 samples, suggested that meloxicam was the optimal strategy in the drug treatment of patients with osteoarthritis compared with nonselective NSAIDs both individually and as a group. The cost savings were due to lower levels of serious adverse events accompanied by fewer days in intensive care units and shorter overall duration of hospital stay observed with meloxicam compared with diclofenac and piroxicam in the 4-week trials. CONCLUSIONS: Based on the 4-week trial period, meloxicam was predicted to be the lowest cost drug therapy, and thus the optimal drug therapy, in the management of patients with osteoarthritis compared with nonselective NSAIDs such as diclofenac and piroxicam. Applying the cost savings per patient derived from the model, switching patients from piroxicam and diclofenac to meloxicam would indicate a cost saving of over pound 25 million per annum. Models such as this can facilitate better clinical guidance and is a useful way of assessing treatment outcomes.

An econometric analysis of screening and treatment of patients with suspected Chlamydia.

Chlamydia trachomatis is probably the most common sexually transmitted disease in the Western industrialised countries with devastating consequences. However, it is an infection that can be so easily treated. There are over 50 million new cases occurring each year. In the United States chlamydia is seen as the most common and costly of the bacterial sexually transmitted diseases (STD), with approximately 4 million new cases occurring each year at an estimated total cost of $2.4 billion. The characteristic of this infection is its difficulty of detection that promotes its spread and making its prediction rather complex. Chlamydial infections are commonly asymptomatic or cause mild or non-specific symptoms and signs, which are not easily detected. Approximately 70% of women with endocervical infections and up to 50% of men with urethral infections are asymptomatic and thus not likely to seek medical care. Chlamydia has become known as the "silent epidemic". It is the more frequently identifiable single cause of pelvic inflammatory disease (PID), occurring in an estimated 15-40% of women. The primary objective of the study was to identify factors and quantify their contribution to the risk of being infected with Chlamydia and to construct an easy to use friendly method for early detection. The importance of developing some means of early detection is vital and previous studies suggest that selective screening might be one solution. A logit model was fitted to three broad variables: behavioural, patients' characteristics, and signs/symptoms noted by patient. The age of the women, the number of sexual partners over the past year, previous history of sexually transmitted disease, the use of barrier contraception and patients' and their partners' signs and symptoms were found to be among the most important variables. Such a model should allow patients who are in a high-risk category, allowing appropriate treatment.