Type 2 diabetes (T2DM) results in a heavy burden on healthcare resources, and this burden is increasing due to a number of factors. By the nature of this chronic illness, mathematical modelling is the only method available to investigate the cost-effectiveness of new treatments in T2DM. To help populate and validate a new model of T2DM, this study was undertaken with the objective of quantifying hospital resource use as patients with and without diabetes approach death. Using the Cardiff Diabetes Database, mortality data from the Office of National Stistics for 1996 were linked to existing hospital records using probability matching techniques. Costs were attributed using a statistical costing technique (healthcare resource groups (HRGs)). Costs are UK 2000 prices. There were 4,394 deaths of which 412 (9.4%) were for patients with diabetes. In the year before death 380 (92%) DM+ patients with diabetes were admitted as an inpatient compared with 73% DM-, a relative rate of 1.27. Total inpatient costs were £12.2M ($20M) of which costs for patients with diabetes was £1.6M ($2.6M), accounting for 15.6% of revenue. This translates to a rate of £2.8M ($4.0M) per 100,000 population per year. The mean annual inpatient cost before death was £3,997 ($5,676) for DM+ compared with £2,656 ($3,772) for DM-. Mean annual outpatient costs ranged from £185 ($263: year minus 4) to £248 ($352: year minus 2) in DM+, and £91 ($129: year minus 4) to £116 ($165: year minus 2) in DM-. Mean annual outpatient costs associated with the care of people with diabetes are consistently higher: +80% at minus 1-year rising to +120% at minus three years. This study has demonstrated that the costs of inpatient care for all patients increases markedly in the final year of life. People with diabetes were found to be more financially costly, even in this stage of their care, than were people who did not have diabetes.
Increases in expenditure on medicines, above the level of increases in health care expenditure generally, are a feature of all Western health systems, including the UK's. This paper examines the causes of these increases in the UK. It reports on a study carried out by the Office of Health Economics, with technical assistance from the Department of Health, under the auspices of the Industry Strategy Group, a forum for joint discussion of matters of strategic interest to the pharmaceutical industry and the Government. The study shows that the position is complex - a number of different forces are at work. Analysis suggests that the largest effect is that of 'product mix', the prescribing of newer, more expensive medicines, followed by the 'volume effect', comprising growth in the number of prescription items and in the number of tablets per prescription. As the paper shows in examining growth in asthma prescribing, these effects are driven by innovation, morbidity, demography and changing treatment patterns. The detailed analysis presented in this paper provides important background for the current debate about NHS expenditure and the Government's own Comprehensive Spending Review. The paper concludes that expenditure on medicines can be expected to show continued real growth and take an increasing share of total NHS expenditure in the medium term. The challenge for the Government, pharmaceutical industry and medical profession is to ensure that we have and use medical advances offering genuine benefit to patients whilst seeking to ensure that all expenditure on medicines represents value for money for patients and the NHS as a whole.
The objective of this analysis was to assess the cost-effectiveness of achieving 'tight control' versus 'less tight control' of blood pressure, as defined in the UK Prospective Diabetics Study 38, in type II diabetic patients in the UK and Italy. The effect of including doxazosin in a 'tight control' combination therapy was analysed. Given doxazosin's positive impact on lipid levels in addition to its antihypertensive effect, it is hypothesised that treatment including doxazosin will reduce the incidence of macrovascular complications. For each country, a Markov model was constructed to simulate macrovascular outcomes of patients on various drug combinations. Transitional probabilities were based on the risk rates presented in UKPDS 38. Risk rates were adjusted for the ageing of the cohort and the lipid-lowering properties of doxazosin using Framingham risk equations. Incremental cost-effectiveness ratios ranged from 2224 Pounds to 4867 Pounds (US$3225-7057) per life-year saved for the UK and from L1.8-9.3 million (US$818-4159) per life-year saved for Italy. Doxazosin is a cost-effective agent when included in a combination therapy in the treatment of hypertension in the diabetic populations of the UK and Italy.
This study investigated the outcomes and management associated with stroke prevention treatments in patients with non-valvular atrial fibrillation (NVAF) in Europe. This analysis estimated persistence and adherence to treatment with VKA. We conducted an observational retrospective cohort study of patients with NVAF in the Longitudinal Patient Database (CEGEDIM) in France, Italy, the UK, Spain and Germany. The analysis included patients >=18 years old, with AF diagnosis, treated with VKA and without rheumatic valvular disease or prosthetic valves. Patients had to be in the database for >=1 year before date of 1stvisit during inclusion period (May 2010/April 2012). We estimated persistence (time to VKA discontinuation) as the time from first prescription to last prescription before discontinuation, defining discontinuation as switch or absence of renewal within 3 months, using the Kaplan-Meier method. We measured adherence to treatment by the Medication Possession Ratio (MPR) during the inclusion period. Median time to treatment discontinuation was 0.78 year in Germany (n=6,386), 1.00 year in Italy (n=8,774), 1.34 years in France (n=9,184), 1.99 years in Spain (n=7,526), and 1.92 years in the UK (n=7,731). Persistence at 5 years was 12% in Germany, 20% in Italy, 24% in France, 26% in Spain, and 25% in the UK. Concerning adherence the mean MPR was 0.54 in Spain, 0.56 in Italy, 0.57 in France, and 0.59 in Germany. There was insufficient data to estimate adherence in the UK. MPR >=0.80 is used to define good adherence. The results show adherence to treatment with VKA is low in the countries studied. Results were consistent across countries, which suggest that low adherence is not country specific. Low adherence to treatment with VKA can affect the maintenance of patients within recommended range of INR, and therefore may increase the risk of stroke.
In the context of the COVID-19 pandemic and overloaded hospitals, a central issue is the need to define reliable and consensual criteria for hospitalization or outpatient management in mild cases of COVID-19. Our aim was to define an easy-to-use clinical rule aiming to help emergency physicians in hospitalization or outpatient management decision-making for patients with suspected or confirmed SARS-CoV-2 infection (the HOME-CoV rule). The Delphi method was used to reach a consensus of a large panel of 51 experts: emergency physicians, geriatricians, infectious disease specialists, and ethical consultants. A preliminary list of eligible criteria was compiled based on a literature review. Four rounds of anonymized expert consultations were performed. The experts were asked to score each item as relevant, possibly relevant and non-relevant, as major or minor, and to choose the cut-off. They were also able make suggestions and remarks. Eight criteria constituting the HOME-CoV were selected: six correspond to the severity of clinical signs, one to the clinical course (clinically significant worsening within the last 24 h), and the last corresponds to the association of a severe comorbidity and an inadequate living context. Hospitalization is deemed necessary if a patient meets one or more of the criteria. In the end, 94.4% of the experts agreed with the defined rule. Thanks to the Delphi method, an absolute consensus was obtained of a large panel of experts on the HOME-CoV rule, a decision-making support mechanism for clinicians to target patients with suspected or confirmed COVID-19 requiring hospitalization.Trial registration: NCT04338841.
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