A systematic review and meta-analysis of the evidence base for add-on treatment for patients with major depressive disorder who have not responded to antidepressant treatment: a European perspective.

Previous comparative reviews of add-on therapies for patients with major depressive disorder (MDD) with an inadequate response to antidepressants have not used meta-analytic techniques to compare different drug classes and have included non-licensed therapies. This meta-analysis reviewed all published peer-reviewed evidence for the efficacy of EU-licensed therapies in patients with MDD and an inadequate response to antidepressant monotherapy. Papers concerning randomized clinical trials (RCTs) were identified using criteria from the Cochrane Handbook for Systematic Reviews of Interventions. Add-on therapies reviewed were antidepressants, quetiapine XR, lithium, and S-adenosyl-l-methionine (SAMe). Seven RCTs that reported response and remission in a way that allowed quantitative analysis were included in this meta-analysis. Comparison of the different drug classes indicated that most interventions had similar efficacy. The likelihood of response was significantly greater with SAMe versus placebo and lithium and with quetiapine XR versus placebo. Most add-on interventions demonstrated comparable efficacy in patients with MDD and an inadequate response to initial antidepressants. However, there is currently a paucity of high-quality data regarding the use of add-on treatments in patients with MDD who are inadequate responders to antidepressants, with quetiapine XR presenting the most comprehensive evidence base to date.

Economic evaluation of fulvestrant 500 mg versus generic nonsteroidal aromatase inhibitors in patients with advanced breast cancer in the United Kingdom.

OBJECTIVE: The goal of this study was to examine the cost-effectiveness of fulvestrant 500 mg for the treatment of first progression or recurrence of advanced breast cancer in postmenopausal patients compared with generic nonsteroidal aromatase inhibitors (anastrozole and letrozole) in the United Kingdom. METHODS: A cost-utility model based on a time-in-state approach was used. Clinical effectiveness estimates used in the model were derived from a network meta-analysis for overall survival and serious adverse events. Overall survival was extrapolated by using a Weibull distribution, and progression-free survival (PFS) estimates were derived from a simultaneous network meta-analysis and extrapolation of PFS curves by using the log-normal distribution. Data on resource use, costs, and utilities were based on various sources, including expert opinion and published data. To explore uncertainty, 1-way and probability sensitivity analyses were conducted. The study was conducted from the perspective of the UK National Health Service, and costs are reported in 2010/2011 British pounds. RESULTS: The base case incremental cost-effectiveness ratio (ICER) for fulvestrant 500 mg versus letrozole was £34,528, with incremental costs of £14,383 and an incremental quality-adjusted life-year (QALY) of 0.417. Extended dominance occurred for anastrozole because the ICER for anastrozole versus letrozole was higher than the ICER for fulvestrant 500 mg versus anastrozole. Based on the probability sensitivity analyses, the probability that fulvestrant 500 mg was the most cost-effective treatment option was 3%, 20%, and 53% at a willingness-to-pay threshold of £20,000, £30,000, and £40,000 per QALY, respectively. According to the 1-way sensitivity analyses, the PFS estimates were the key drivers of the model results. CONCLUSIONS: Although fulvestrant 500 mg was found not to be a cost-effective option at a standard UK threshold of £20,000 to £30,000 per QALY, it may be relevant to apply a higher threshold due to the poor prognosis of patients with advanced breast cancer and the limited number of hormonal treatment options available for this stage of treatment. Certain subgroups may also benefit from fulvestrant as a treatment option; however, limited data are currently available to identify these subgroups.

Direct access by GPs to palliative nursing.

This article presents the results of a pilot study evaluating direct access by GPs to specialist community palliative nursing support without an intermediary visit from a medical consultant. GPs wishing to refer terminally ill patients to the community palliative care team were given access via either medical assessment or nursing assessment. Results showed that the overall referral rate to the service increased during the period of the study. In addition, the new service was well received by the GPs who used it. A large number of referrals (75%) requested support for the patient and family. This study contributes to the ongoing debate about the need to identify and define supportive interventions and the most appropriate providers of these.

Palliative care nursing in France: a personal perspective.

This article gives an account of a visit to palliative care services in France and identifies the benefits to be gained from the cross-fertilisation of ideas from a different European culture. Most of the challenging issues around terminal illness and death are experienced by the French, but palliative care provision has not been developed and established within the health-care system to the extent that it has in Britain. The role of the clinical nurse specialist (CNS) in palliative care in France closely matches the role of the palliative care CNS in Britain. Nurse-led community teams in France have the potential to develop specialist care practice in a way that will maximise the nursing role, enhance patient care and disseminate the principles of good practice.