Lifetime cost effectiveness of a through-school nutrition and physical programme: Project Energize.

Project Energize, a multicomponent through-school physical activity and nutrition programme, is delivered to all primary school children in the Waikato region. The programme aim is to improve the overall health and reduce the rate of weight gain of all Waikato primary school children. An existing economic model was used to extrapolate the programme effects, initial costs, lifetime health treatment cost structures, quality-adjusted-life-years gained and increased life expectancy to the general and Maori child population of New Zealand. In March 2011, a sample of 2474 younger (7.58 ± 0.57 years, mean ± SD) and 2330 older (10.30 ± 0.51 years) children (36% Maori) attending Energize schools had body mass index measured and compared using mixed effect modelling with unEnergized comparison children from 2004 and 2006 from the same region. In 2011 the median body mass index reduction compared with the comparison younger children was -0.504 (90% CI -0.435 to -0.663) kg/m(2) and in the older children -0.551 (-0.456 to -0.789) kg/m(2). In 2010 there were 42,067 children attending Energize schools and in the same year NZ$1,891,175 was spent to deliver the programme; a cost of $44.96/child/year. Compared to the comparison children the increment in cost/quality-adjusted-life-year gained was $30,438 for the younger and $24,690 for the older children, and lower for Maori (younger $28,241, older $22,151) and for the middle socioeconomic status schools ($23,211, $17,891). Project Energize would improve quality and length of life and when compared with other obesity prevention programmes previously assessed with this model, it would be relatively cost-effective from the health treatment payer's perspective.

Disease status, patient quality of life and healthcare resource use for ulcerative colitis in the UK: an observational study.

BACKGROUND: Ulcerative colitis is a lifelong, chronic, relapsing-remitting disease. OBJECTIVE: To assess the relationship between ulcerative colitis disease status and patient quality of life, and to determine the impact of ulcerative colitis on healthcare costs and work productivity, in the UK. METHODS: Clinicians assessed 173 adult patients' current disease status at a single study visit using the partial Mayo (pMayo) instrument. Patients completed the Euro Quality of Life 5-dimension, 5-level (EQ-5D-5L) questionnaire, the Work Productivity and Activity Impairment (WPAI) questionnaire. Healthcare resource use was determined from questionnaires and from patients' medical charts. RESULTS: Patients in remission had a significantly higher EQ-5D-5L scores (mean (SD) 0.86 (0.15)) than patients with active disease (0.71 (0.20); p<0.001). Patients with mild disease had significantly higher mean (SD) EQ-5D-5L scores than patients with moderate/severe disease: 0.77 (0.11) and 0.66 (0.24), respectively (p<0.001). The mean percent productivity impairment was greater for patients with active disease than for patients in remission on all items of the WPAI questionnaire: 24.6% vs 1.8% for work time missed, 34.1% vs 12.9% for impairment while working, 40.8% vs 14.4% for overall work impairment and 42.7% vs 13.0% for activity impairment (p<0.001 for all comparisons). The mean (SD) total cost of healthcare for ulcerative colitis in the prior 3 months was £1211 (1588). CONCLUSIONS: When compared with patients in remission, patients with active ulcerative colitis have significantly worse quality of life and significantly more work impairment. The healthcare costs of ulcerative colitis are considerable.

Relationship between disease severity and quality of life and assessment of health care utilization and cost for ulcerative colitis in Australia: a cross-sectional, observational study.

BACKGROUND & AIMS: The burden of ulcerative colitis (UC) in relation to disease severity is not well documented. This study quantitatively evaluated the relationship between disease activity and quality of life (QoL), as well as health care utilization, cost, and work-related impairment associated with UC in an Australian population. METHODS: A cross-sectional, noninterventional, observational study was performed in patients with a wide range of disease severity recruited during routine specialist consultations. Evaluations included the Assessment of Quality of Life-8-dimension (AQoL-8D), EuroQol 5-dimension, 5-level (EQ-5D-5L), the disease-specific Inflammatory Bowel Disease Questionnaire (IBDQ), and the Work Productivity and Activity Impairment (WPAI) instrument. The 3-item Partial Mayo Score was used to assess disease severity. Health care resource utilization was assessed by chart review and patient questionnaires. RESULTS: In 175 patients, mean (SD) AQoL-8D and EQ-5D-5L scores were greater for patients in remission (0.80 [0.19] and 0.81 [0.18], respectively) than for patients with active disease (0.70 [0.20] and 0.72 [0.19], respectively, both Ps<0.001). IBDQ correlated with both AQoL-8D (r=0.73; P<0.0001) and EQ-5D-5L (0.69; P<0.0001). Mean 3-month UC-related health care cost per patient was AUD $2914 (SD=$3447 [mean for patients in remission=$1970; mild disease=$3736; moderate/severe disease=$4162]). Patients in remission had the least work and activity impairment. CONCLUSIONS: More severe UC disease was associated with poorer QoL. Substantial health care utilization, costs, and work productivity impairments were found in this sample of patients with UC. Moreover, greater disease activity was associated with greater health care costs and impairment in work productivity and daily activities.

Histology as a treatment effect modifier in advanced non-small cell lung cancer: a systematic review of the evidence.

BACKGROUND AND OBJECTIVE: We conducted a systematic review of prospective, randomized, controlled trials (RCT) to examine whether histology had a treatment modifying effect (TME) on the efficacy outcomes of chemotherapeutic agents in patients with advanced (stage IIIB-IV) non-small cell lung cancer (NSCLC). METHODS: Potentially pertinent publications were reviewed in full to determine if there was any TME by histology for overall survival (OS), progression-free survival (PFS) or treatment response rate (TRR). RESULTS: Data from three pemetrexed RCT, comparing (i) pemetrexed versus docetaxel, (ii) pemetrexed and cisplatin versus gemcitabine and cisplatin, and (iii) pemetrexed versus placebo, showed a statistically significant TME by histology for OS and PFS. One trial comparing pemetrexed and carboplatin versus gemcitabine and carboplatin found no significant associations between histology and OS. The results of this systematic review indicate that pemetrexed appears to have the most consistent treatment-by-histology interaction effect on the efficacy outcomes of chemotherapeutic agents in patients with advanced or metastatic NSCLC. Patients with non-squamous histology gain the greatest benefit from treatment with pemetrexed. Conversely, patients with squamous cell disease appeared to experience poorer OS when pemetrexed was compared with other active treatments, and similar OS when compared with placebo. Reproducible patterns of TME effect by histology with other chemotherapeutic agents are less clear. CONCLUSIONS: We consider that the historical approach to treating all NSCLC patients with the same chemotherapy regimen is now no longer acceptable.

A systematic review of the clinical effectiveness of 64-slice or higher computed tomography angiography as an alternative to invasive coronary angiography in the investigation of suspected coronary artery disease.

BACKGROUND: This systematic review summarized recent evidence pertaining to the clinical effectiveness of 64-slice or higher computed tomography angiography (CTA) in patients with suspected coronary artery disease (CAD). If CTA proves to be a successful diagnostic performance measure, it could prevent the use of invasive diagnostic procedures in some patients. This would provide multiple health and cost benefits, particularly for under resourced areas where invasive coronary angiography is not always available. METHODS: A systematic method of literature searching and selection was employed with searches limited to December 2006 to March 2009. Included studies were quality assessed using National Health and Medical Research Council (NHMRC) diagnostic levels of evidence and a modified Quality Assessment of Diagnostic Accuracy Studies (QUADAS) tool. Individual and pooled diagnostic performance measures were calculated using standard meta-analytic techniques at the patient, vessel and segment level. A positive result was defined as greater than or equal to 50% stenosis. RESULTS: Twenty-eight studies were included in the systematic review examining 3,674 patients. The primary meta-analysis at the patient-level indicated a sensitivity of 98.2% and specificity of 81.6%. The median (range) positive predictive value (PPV) was 90.5% (76%-100%) and negative predictive value (NPV) 99.0% (83%-100%). In all vessels, the pooled sensitivity was 94.9%, specificity 89.5%, and median (range) PPV 75.0% (53%-95%) and NPV 99.0% (93%-100%). At the individual artery level, overall diagnostic accuracy appeared to be slightly higher in the left main coronary artery and slightly lower in the left anterior descending and circumflex artery. In all segments, the sensitivity was 91.3%, specificity 94.0% and median (range) PPV 69.0% (44%-86%) and NPV 99.0% (98%-100%). CONCLUSIONS: The high sensitivity indicates that CTA can effectively identify the majority of patients with significant coronary artery stenosis. The high NPV at the patient, vessel and segment level establishes CTA as an effective non-invasive alternative to invasive coronary angiography (ICA) for the exclusion of stenosis.

A systematic review of the interobserver variability for histology in the differentiation between squamous and nonsquamous non-small cell lung cancer.

INTRODUCTION: The importance of identifying non-small cell lung cancer (NSCLC) histologic subtype has increased recently because of the development of target-specific chemotherapeutic agents. This systematic review was undertaken to examine the interobserver variability for histology in differentiating between subtypes of NSCLC, specifically the ability to differentiate squamous from nonsquamous histology. METHODS: A systematic literature search was undertaken to identify studies that evaluated the reproducibility of histologic diagnosis by pathologists in their reporting of NSCLC subtypes. Studies were screened using a priori defined eligibility criteria. The National Health and Medical Research Council diagnostic levels of evidence were applied and quality assessed using the Quality Assessment of Diagnostic Accuracy Studies tool. Data were extracted and reanalyzed to permit comparison of agreement in nonsquamous and squamous cell carcinoma by 2 × 2 tables. Percentage agreement and kappa statistics were calculated for each included study. RESULTS: Out of 1480 articles identified through the literature search, six were eligible for inclusion. The percentage agreement for all subtypes of NSCLC in the included studies ranged from 67.1 to 89.6% (κ, 0.42-0.84). Based on the primary reanalysis of data (reanalysis 1), agreement between pathologists in differentiating nonsquamous and squamous histology ranged from 77.0 to 94.2% (κ = 0.48-0.88) indicating a moderate to high level of agreement. CONCLUSION: The reasonably high agreement and kappa statistics for the included studies suggest that pathologists can reproducibly differentiate between nonsquamous and squamous NSCLC. This is clinically important in guiding oncologist decision making in choosing the most appropriate therapy for their patients.

Relationship between disease severity, quality of life and health-care resource use in a cross-section of Australian patients with Crohn's disease.

BACKGROUND AND AIM: New treatments for Crohn's disease are expensive and place economic strain upon health-care systems, and 'value-for-money' needs to be confirmed. This study aimed to correlate disease severity with health-related quality of life and with health-care resource use, to allow evaluation of the cost effectiveness of these treatments. METHODS: A cross-sectional, non-interventional, pharmacoeconomics study was performed with patients completing questionnaires comprising demographic, disease and health-care utilization questions, together with the disease-specific Inflammatory Bowel Disease Questionnaire (IBDQ) and the Assessment of Quality of Life (AQoL) multi-attribute utility instrument. The Crohn's Disease Activity Index (CDAI) was used to assess disease severity. RESULTS: 143 patients with a broad range of disease severity (CDAI 36-446, fistulae 23%) were recruited from referral centers. Stepwise regression analyses demonstrated a negative correlation between disease severity and both IBDQ and AQoL (both P < 0.0001). Age, gender and years since diagnosis did not impact upon either of the quality-of-life outcomes. Mean utility score for non-fistulizing patients with moderate-severe active disease (CDAI >/= 220) was 0.45, mild disease (CDAI 150-219) was 0.68 and for remission (CDAI < 150) was 0.77. Health-care resource utilization increased with increasing CDAI (P < 0.001), with hospital admissions being the largest component cost. Twenty-seven percent of patients (mean age 38 year) received a government benefit, 51% primarily due to their Crohn's disease. CONCLUSION: Crohn's disease severity correlates with poor quality of life. Utility scores determined will permit cost-utility analyses to be made in order to best allocate limited health resources.

Diagnosis of appendicitis in adults by ultrasonography or computed tomography: a systematic review and meta-analysis.

OBJECTIVES: The use of ultrasonography and computed tomography (CT) in the diagnosis of appendicitis in adult patients was compared. METHODS: Systematic review and meta-analysis of current evidence in two clinical situations: unselected nonpregnant, adult patients with symptoms of appendicitis, and more selective use in only those patients who still have an equivocal diagnosis subsequent to routine clinical investigations. RESULTS: Meta-analysis of eligible studies shows CT to have better sensitivity and specificity than ultrasound in both clinical situations. CONCLUSIONS: Application of these findings in clinical practice and/or policy would need to evaluate the better diagnostic performance of CT against its cost and availability. In addition, it is imperative that future studies be conducted in patient populations that are well-defined with respect to prior investigations. Sequelae of false-negative and false-positive diagnoses should also be evaluated.

Patient preference and willingness-to-pay for Humalog Mix25 relative to Humulin 30/70: a multicountry application of a discrete choice experiment.

OBJECTIVES: To assess preference and willingness-to-pay (WTP) for the insulin mixture Humalog Mix25 relative to Humulin 30/70, from the patients' perspective, the relative importance of individual treatment attributes was also determined. Differences among five European countries were investigated. METHODS: Two hundred and ninety patients with type 2 diabetes were recruited from five European countries. Of these, 235 were suitable for inclusion in the analysis. Their mean age was 51.3 years and, on average, patients had had diabetes for 11 years. A discrete-choice conjoint analysis was conducted using face-to-face interviews. Treatment attributes, such as timing of injections around meals, 2-hour postprandial control, effect of prandial dosing, frequency of nocturnal hypoglycemia, and cost, and levels were derived after a systematic review of all published comparative clinical trial data. Meta-analyses were undertaken where appropriate. RESULTS: Ninety percent (95% CI 86-93%) of patients would choose Humalog Mix25 over Humulin 30/70, at the same cost. On average, European subjects were willing to pay 111 euros per month more for Humalog Mix25 (95% CI 86.71-156.91 euros). The primary driver was the reduced risk of nocturnal hypoglycemic events, contributing 49% of WTP. The convenience of dosing immediately before the meal contributed 37%. Preference results were similar in all five countries, although WTP and sensitivity to increasing cost both varied. CONCLUSIONS: Patients in all countries showed a preference and WTP for Humalog Mix25 over Humulin 30/70. The main drivers of patient WTP may be of interest to pharmaceutical prescribers, manufacturers, and reimbursement agencies.

Community-acquired pneumonia mortality: a potential link to antibiotic prescribing trends in general practice.

BACKGROUND: Community prescribing of antibiotics has decreased substantially in the UK in recent years. We examine the association between pneumonia mortality and recent changes in community-based antibiotic prescribing for lower respiratory tract infections (LRTI). METHODS: Retrospective analysis of aggregated data for pneumonia mortality, influenza incidence, and antibiotic prescribing for LRTI in England and Wales during 12-week winter periods between 1993/94 and 1999/2000. RESULTS: Winter antibiotic prescribing for LRTI showed a 30.0% decline since 1995/96. Over the same period, there was a 50.6% increase in winter excess pneumonia mortality adjusted for influenza incidence. Negative binomial regression analysis showed that the incidence of influenza alone had a significant association with winter pneumonia mortality (P<0.001). The analysis also showed the reduction in antibiotic prescribing had a small but significant association with mortality (P<0.001), when simultaneously modelling for influenza incidence. CONCLUSIONS: Our findings suggest an association between recent reductions in antibiotic prescribing for LRTI in general practice and an increase in pneumonia mortality in England and Wales. This retrospective study of aggregate data represents the first attempt to assess the effect of limiting antibiotic prescribing on patient outcomes, and highlights the need to identify which patients benefit from antibiotic treatment for LRTI.