A cost-effectiveness analysis of calcipotriol plus betamethasone dipropionate aerosol foam versus gel for the topical treatment of plaque psoriasis.

BACKGROUND: Calcipotriol 50 µg/g and betamethasone 0.5 mg/g dipropionate (Cal/BD) aerosol foam formulation provides greater effectiveness and improved patient preference compared with traditional Cal/BD formulations for the topical treatment of plaque psoriasis. OBJECTIVE: To determine the cost-effectiveness of Cal/BD foam compared with Cal/BD gel from the Australian perspective. METHODS: A Markov model was developed to evaluate the cost-effectiveness of topical Cal/BD foam and gel for the treatment of people with plaque psoriasis. Treatment effectiveness, safety, and utilities were based on a randomized control trial, resource use was informed by expert opinion, and unit costs were obtained from public sources. Outcomes were reported in terms of 1-year costs, quality-adjusted life years, and incremental cost-effectiveness ratios. All costs were reported in 2017 Australian Dollars. RESULTS: The model showed that patients using Cal/BD foam had more QALYs and higher costs over 1 year compared with patients using Cal/BD gel, resulting in a cost of $13,609 per QALY gained at 4-weeks. When 4 weeks of Cal/BD foam was compared with 8 weeks of Cal/BD gel treatment, Cal/BD foam was $8 less expensive and resulted in 0.006 more QALYs gained. Sensitivity analyses showed that, compared with Cal/BD ointment, Cal/BD foam was associated with an incremental cost of $15,091 per QALY gained. CONCLUSION: Cal/BD foam is the most cost-effective Cal/BD formulation for the topical treatment of patients with plaque psoriasis.

Assessing New Technologies in Aerosol Medicine: Strengths and Limitations.

Aerosols are the mainstay of treatment for pulmonary diseases such as asthma, cystic fibrosis, and COPD. In addition, aerosols are also being used for systemic drug delivery. Patients need devices that are safe, reliable, portable, and easy to use; have few steps in their operation; help them keep track of the remaining doses; are not expensive; and provide age-appropriate positive reinforcement and feedback. Computational fluid dynamics, human factor sciences, and quality by design are now applied to device development. Matching patient, drug, and device remains a challenge. Formulary restrictions, the current status of the industry-academia relationship, and the need to use multiple platforms hinder the process. Patients and families need to participate in the selection of a device that is appropriate for them. Practitioners need comparative data to help them choose the right device. New devices and drugs can be compared with the existing technology using in vitro and in vivo methods (lung imaging, pharmacokinetic and pharmacodynamics studies). Drug manufacturers need to be able to justify coverage of new products by third-party payers by showing a positive cost/benefit relationship. Finally, post-market surveillance is necessary for old drugs with new devices or for new drugs and devices to ensure patient safety.

Aerosolised liposomal amphotericin B to prevent aspergillosis in acute myeloid leukaemia: Efficacy and cost effectiveness in real-life.

Chemotherapy-induced neutropenia can be complicated by invasive pulmonary aspergillosis (IPA). In 2008, liposomal amphotericin B (L-AmB) inhalation was shown to prevent IPA in a placebo-controlled trial. Patients with acute myeloid leukaemia (AML) are the subset of haematology patients at high risk for IPA. In 2008, L-AmB inhalation prophylaxis became the standard of care for all AML patients in Erasmus MC. In this study, the efficacy and cost effectiveness of L-AmB inhalation were evaluated in a prospective cohort of AML patients. In total, 127 consecutive AML patients received chemotherapy and prophylactically inhaled L-AmB during their first and second chemotherapy cycles; 108 patients treated for AML at the same sites from 2005-2008 served as controls. A standardised diagnostic protocol was used and probable/proven IPA served as the primary endpoint. Diagnostic and therapeutic costs were also comprehensively analysed and compared. A significant decrease in probable/proven IPA in the L-AmB inhalation group was observed (L-AmB 9.5% vs. controls 23.4%; P=0.0064). Systemic antifungal therapy given at any time during the entire AML therapy decreased from 52.8% to 29.9%. Per-patient equipment and drug costs for L-AmB inhalation (1292 €/patient) were more than compensated for by a decrease in costs for diagnostics and therapeutic voriconazole use (-1816 €/patient). No serious adverse events related to L-AmB inhalation were observed. In an unselected AML patient group, L-AmB inhalation resulted in a significant and substantial decrease in IPA and was cost saving. Now that azole resistance is more frequent, non-azole-based prophylaxis may become an attractive strategy.

An evaluation of retail outlets as part of a community prevention trial to reduce sales of harmful legal products to youth.

Communities across the nation have become increasingly concerned about inhalant use and use of harmful legal products among youth because of increasing prevalence rates and deleterious health consequences from abusing these products. The increasing concern of communities about inhaling and ingesting legal products has been coupled with increasing awareness and concern about ability of youth to access and abuse a variety of other legal retail products. There are few examples of scientifically designed community prevention projects that seek to reduce youth abuse of such legal products. This article describes a community prevention trial that is designed to reduce sales of inhalants and other harmful legal products to youth and demonstrates how the retailer component of the trial can be rigorously evaluated. It also shows how data from youth purchase attempts can complement survey data from retailers.

Malaria prevention in The Gambia: patterns of expenditure and determinants of demand at the household level.

OBJECTIVE: To provide a better understanding of (1) the amounts households in The Gambia spend on a wide variety of malaria prevention measures, (2) how expenditure fluctuates throughout the year and (3) the main determinants of expenditure. METHODS: A random sample of 1700 households from the Farafenni region were interviewed about their expenditure on malaria prevention over the past 2 weeks. Interviews were staggered over 12 months. Expenditure was measured for bed nets, treating and repairing bed nets, aerosols, coils, indoor spraying, smoke and other prevention strategies such as drinking herbs and cleaning the outside environment. Results Expenditure on bed nets, including treatment and repair, constituted only 10% of total expenditure on malaria prevention. Every fortnight, households spent an average of 8.40 Dalasis (D) on coils, 4.20 D on indoor sprays, 3.09 D on smoke and 3.06 D on aerosols, together making up 81% of total fortnightly expenditure. Of the 442 households that did not own a bed net, 68% said it was because they could not afford one. Every 2 months, the same households spent an average of US 5 dollars, the equivalent to the cost of an insecticide treated bed net, on other forms of prevention. Total expenditure was 42% higher during the wet season than for the rest of the year. For every month of the year, coils were the dominant form of prevention expenditure. Wealth, age, occupation of household head, location of residence and month of the year were significant determinants of prevention expenditure. CONCLUSIONS: Households in The Gambia spend considerable amounts on a range of malaria prevention products and activities throughout the year. Bed nets represent a relatively small proportion of this expenditure even though they are perceived to be the most efficient and effective method of malaria control. A more concerted effort is needed to develop appropriate targeting strategies to encourage bed net use especially for children <5 years of age. Equal emphasis should be given to addressing barriers to purchasing nets such as their relative high upfront cost.

A cost-effective and versatile xenon gas dispenser.

OBJECTIVE: To modify a commercial xenon gas dispenser so that two xenon unit-dose vials could be combined with a modified dispenser to deliver a recommended dose. METHOD: To maintain the same operating mechanism, changes were made only to the vial shield and the needle port of the original gas dispenser. The modified gas dispenser consisted of two puncture needles and two vial holders shielded with the same thickness of lead as the commercial dispenser. RESULTS: Our evaluation showed that the modified gas dispenser operated the same way as the commercial unit, and the average 133Xe residual activity in either one or two xenon unit-dose vials of the modified gas dispenser was not significantly different from that in one vial of the commercial xenon gas dispenser. CONCLUSION: The modified xenon gas dispenser allows the stock of xenon gas vials to be managed cost-effectively. The modified unit can be used to dispense two low-activity xenon gas vials to deliver a standard dose to a patient. Also, the modified gas dispenser can be used to combine different amounts of xenon activity in two unit-dose vials in order to customize the dose delivered to patients with special needs (e.g., obese patients). Our modified device can also function as a single-dose dispenser by placing an empty vial alongside the unit-dose vial of radioactive xenon gas.

[The impact of fusafungine on the prescription of antibiotics in the treatment of rhinopharyngitis]. / Impact de la fusafungine sur la prescription d'antibiotiques dans le traitement de la rhinopharyngite en France.

OBJECTIVE: The analysis in France, during the period 01/12/99 to 30/11/2000, of the prescription of systemic antibiotics in patients with rhinopharyngitis and of the variables statistically related to such prescriptions and the potential role of fusafungine in the form of a rhinopharyngeal spray. METHODS: A retrospective study, based on a panel of 1,010 general practitioners, in a cohort of 30,568 patients presenting with rhinopharyngitis. The fusafungine group consisted of 16,076 patients who had rhinopharyngitis and in whom fusafungine was prescribed. The control group consisted of 14,492 patients with rhinopharyngitis without prescription of fusafungine. The overall rate of antibiotic prescription was documented. A stepwise statistical analysis was conducted to specify the variables statistically associated with the prescription of a systemic antibiotic. The rate of prescription of a systemic antibiotic and the cost of the treatment were also compared within both groups. RESULTS: The overall rate of systemic antibiotic prescription was 52.9%, falling from 60.4% in the group without fusafungine down to 46.2% in the group with fusafungine (p<0.01) whichever the systemic antibiotic prescribed. The stepwise analysis documented various variables that appear to be related to the systemic antibiotic prescription. A saving of 0.7 euros per prescription was noted in the fusafungine group. CONCLUSION: Although various variables appear to influence systemic antibiotic prescription in patients with rhinopharyngitis, our study shows that prescription of fusafungine in spray from led to statistically significant reduction in systemic antibiotic prescription.

Malaria control--two years' use of insecticide-treated bednets compared with insecticide house spraying in KwaZulu-Natal.

OBJECTIVES: The objective of this study was to produce data indicating whether insecticide-treated bednets should replace insecticide house spraying as a malaria control method in South Africa. We report 2 years of preliminary data on malaria incidence comparing areas receiving insecticide-treated bednets and those subjected to house spraying in northern KwaZulu-Natal. DESIGN, SETTING AND SUBJECTS: In order to measure significant reductions in malaria incidence between the two interventions, a geographical information system (GIS) was used to identify and create seven pairs of geographical blocks (areas) in the malaria high-risk areas of Ndumu and Makanis in Ingwavuma magisterial district, KwaZulu-Natal. Individual blocks were then randomly allocated to either insecticide-treated bednets or house spraying with deltamethrin. Malaria cases were either routinely recorded by surveillance agents at home or were reported to the nearest health facility. RESULTS AND CONCLUSIONS: The results show that 2 years' use of insecticide-treated bednets by communities in Ndumu and Makanis, KwaZulu-Natal, significantly reduced the malaria incidence both in 1997 (rate ratio (RR) = 0.879, 95% confidence interval (CI) 0.80-0.95, P = 0.04) and in 1998 (RR = 0.667, CI 0.61-0.72, P = 0.0001). Using a t-test, these significant reductions were further confirmed by an assessment of the rate of change between 1996 and 1998, showing a 16% reduction in malaria incidence in blocks using treated bednets and an increase of 45% in sprayed areas (t = 2.534, P = 0.026 (12 df)). In order to decide whether bednets should replace house spraying in South Africa, we need more data on the efficacy of treated bednets, their long-term acceptability and the cost of the two interventions.

Assessing costs of aerosol therapy.

The large economic burden of asthma accentuates the need for economically sound treatment. Numerous studies report that the outcomes produced by nebulizers are equivalent to the outcomes produced by MDI/spacers in selected patients. Studies show that MDI/spacer use will probably result in substantial cost savings to hospitals. Although some patients will not be able to achieve the same outcomes with MDI/spacers as with nebulizers, Bowton et al and Orens et al showed that a large percentage of patients could be converted to the less costly MDI/spacer therapy without negative repercussions. Observation of current treatment practice indicates that hospitals have yet to capitalize on the economic benefits of replacing nebulizers with MDI/spacers. For example, original data from MARC indicate that only 5% of adults who present to an academic ED with acute asthma receive at least one beta agonist treatment via MDI. Studies that improve upon existing cost analyses may convince hospitals of the untapped savings potential. Investigation of barriers to MDI/spacer conversion, along with a compilation of successful strategies for this conversion, would be helpful. Taken together, such research could lead to increased beta agonist delivery via MDI/spacer and probable savings to the health care system.

The clinical effects and cost-avoidance of a change in perioperative bronchodilator use.

The clinical effects and financial impact of a change in prescribing habits from routine to occasional use of perioperative bronchodilators, following the presentation of drug information, were assessed retrospectively by comparing the outcomes of patients admitted for major thoracic surgery. Eighteen of 24 (75%) patients in Period A (prior to change) received salbutamol bronchodilator therapy versus 10 of 17 (59%) in Period B (following the change) (p = .448). Of the patients who did receive salbutamol aerosols, the mean dose in grams per patient was greater in Period A than in Period B (6.85 +/- 5.96 vs. 2.64 +/- 4.44 respectively p < 0.05). Two patients from Period A and one from Period B were receiving digoxin prior to admission. In the remaining patients, 5 of 22 (23%) in Period A and 1 of 16 (6%) in Period B developed atrial fibrillation requiring digoxin (p = .36). The proportion of patients with obstructive airways disease (OAD) who developed an arrhythmia was not different between the two groups. However, in those patients without OAD an arrhythmia was reported in 9 of 16 patients (56%) receiving salbutamol, versus only 1 of 11 (9%) of those not receiving it (p = 0.032). The number of days patients were hospitalized during Period A and Period B were 10.2 +/- 4.97 and 9.4 +/- 3.68 respectively (p = 0.85). A potential average cost-avoidance of $68.46 per patient could be realized with this new practice. We conclude that a change in prescribing habits had no adverse clinical outcome and resulted in a considerable cost-avoidance.