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SD4: QUALITY OF LIFE ASSESSMENT AS A NEW OUTCOME MEASURE IN CLINICAL PRACTICE
368
Abstracts
women who choose to deliver at home relative to women who choose to deliver in hospital. This study has wider implications in demonstrating the application of a technique that can be used to ascertain the utility or value attached to attributes or characteristics associated with the process of health care.
SD2
GENERICS ONLY OR GENERICS AND EFFICIENT DRUGS? Bendahan G, Benaque A Direcció d’Atenció Primària Eixample, Institut Català de la Salut, Barcelona, Spain BACKGROUND: During 98 several strategies have been implemented to increase the prescription of efficient (ED) and generic (GD) drugs. In Catalonia to improve the generics’ use, economic incentives have been offered to some Primary Care Teams. Although the general practitioners (GP) in our study were not included in this incentive’s project, they received the intervention presented in this study. OBJECTIVE: To evaluate an intervention to implement ED and GD in a Primary Care District in Barcelona. METHODS Type of study: Pre-post intervention with control group. Setting and period: Drug prescription follow up of the primary care district (296.000 inhabitants) and Catalonia (control group) during 97, 98 and January-March 99. Information source: Catalan Institut of Health’s pharmaceutical computerised system. Intervention: Design of a sheet of paper with information about 1) prices of different drugs for a same active principle, including those drugs responsible for higher pharmaceutical cost and with ED 2) all generic drugs on the market and how to prescribe them. In January 98, it was distributed to all GP. Variables: Number and price of the drugs of 18 active principle and savings obtained. RESULTS: The savings obtained prescribing ED of omeprazole, enalapril and nimodipino during the period 99– 97 have increased a 182% in the district versus 103% in Catalonia. The % of GD is also greater in our district: Ranitidina 24% vs. 14%, Captopril 13,2% vs. 8,6%, Aciclovir 14,8% vs. 11.8%; Alprazolam 8.2% vs. 5% Fluoxetina 3,73% vs. 2,7%. During January-March 99, our district saved 69 millions (pesetas), 90% by prescribing ED and 10% by generics. CONCLUSION: The GP collaboration and an instrument with updated information and easy to use have allowed to achieve a higher percentage of ED and GD prescription in our district. To rationalise drug’s prescription, it is necessary to take into account the ED.
SD3
USING ECONOMIC INFORMATION IN HOSPITAL FORMULARY DECISION-MAKING Späth HM1,2, Ferdjaoui N1,2, Carrère MO1,2 1 GRESAC, Lyon, France; 2Université Lyon, Lyon, France
OBJECTIVES: Over the last 15 years pharmacoeconomics research has grown rapidly, but little is known about the actual use of economic information by health-care decision-makers. We conducted a literature review of papers addressing the use of economic information in drug selection for hospital formularies to determine its role in decision-making, the barriers that prevent its use and the importance of these barriers. METHODS: Five bibliographic databases were searched: (1) Medline (2) Embase (3) Pascal (4) NHS Economic Evaluation Database, and (5) International Pharmaceutical Abstracts, from 1991 to 1998. In addition a manual search of the journal PharmacoEconomics and of the reference sections of all retrieved papers was performed. To appraise and summarise the publications we used a 7point checklist. RESULTS: We assessed 34 papers. Case studies based on personal observations were reported in 27 (79%) papers, surveys in 5 (15%) and literature reviews in 2 (6%). Input that were reported to have a greater impact on decisions than economic information were: (1) the efficacy and safety of drugs (mentioned in 100% of the papers) (2) dosage and administration procedures (50%) (3) quality of life considerations (32%), and (4) clinical experience of practitioners (29%). The most important of the seven identified barriers to the use of economic information in decision-making were: (1) lack of credibility of economic evaluations (65%) (2) economic data did not apply to the setting of the decision-makers (62%) (3) decision-makers had no expertise in appraising economic information (59%) (4) decision-makers did not have economic information and it was not possible to collect it (47%), and (5) lack of collaboration between producers of economic information and decision-makers (41%). CONCLUSIONS: The current use of economic information is limited compared with its potential use. More research is needed to determine decision-maker’s needs for economic information and to identify incentives to take this into account.
SD4
QUALITY OF LIFE ASSESSMENT AS A NEW OUTCOME MEASURE IN CLINICAL PRACTICE Pratheepawanit N, Salek M, Finlay I, Luscombe D Medicines Research Unit, Welsh School of Pharmacy and University of Wales College of Medicine, Cardiff, UK OBJECTIVES: To assess the practicality of routine measurement of patients’ quality of life during an outpatient palliative care clinic. METHOD: The study was a prospective evaluation of palliative care services provided at an outpatient clinic at Velindre NHS Trust, Cardiff. During a one-year period of the study, patients’ self-report of quality of life was implemented into the routine care. Each patient was asked to complete the revised McGill Quality of Life Questionnaire (MQOL) in the waiting room pre-consultation. After each consultation, doctors recorded their comments on the pa-
369
Abstracts tients’ responses to MQOL that had been helpful in their decision making and the interventions arising from that process. RESULTS: The total of 348 consultations took place during the study period; 274 consultations had the MQOL forms completed. This was accounted for 127 patients. There were 46 male and 81 female with mean age of 59 years old (range 26–85). 66 patients (52%) attended the clinic for the first time. Of these 66 new patients, 31 (47%) had a record of the MQOL on their subsequent visits. Compared with the first visits, the results show the quality of life had improved in every domain (i.e., physical symptoms, physical wellbeing, psychological and existential domains) on their subsequent visits. The overall quality of life score in particular was significantly improved during the follow-up visits (P 0.05). Considering the use of the MQOL, 101 (37%) consultations had a record of doctors’ comments on utilizing the quality of life information and the majority (95%) indicated the MQOL as being useful during consultations, particularly information related to physical symptoms, psychological and existential domains. CONCLUSIONS: The findings support the practicality of quality of life assessment in clinical practice and its value as an outcome measure and monitoring tool of palliative care services in this population. ECONOMIC & OUTCOMES STUDY RESULTS OF ENDOCRINE DISORDERS
ED1
COST-EFFECTIVENESS OF INTENSIVE METFORMIN VERSUS CONVENTIONAL THERAPY FOR OBESE PATIENTS WITH TYPE 2 DIABETES Palmer AJ1, Sendi PP1, Gozzoli V1, Brandt A1, Spinas GA2 1 IMIB, Institute for Medical Informatics and Biostatistics, Riehen, Switzerland; 2Division of Endocrinology and Diabetes, University Hospital, Zürich, Switzerland OBJECTIVES: The clinical results of the metformin substudy of the United Kingdom Prospective Diabetes Study (UKPDS) were combined with published cost data through modeling techniques, allowing a cost-effectiveness analysis of the management of obese type 2 diabetes patients with either conventional therapy or intensive therapy with metformin from the NHS perspective. METHODS: Occurrence of diabetes-related complications were simulated using a Markov model. Probabilities for complications were taken from the UKPDS, and costs were retrieved from published sources. Total direct costs and mortality over an 11-year period were determined for patients randomized to either conventional therapy or intensive therapy with metformin. Incremental costs per life year gained for metformin versus conventional therapy were calculated. Extensive sensitivity analysis was performed. RESULTS: Mean (SD) costs per patient over the 11 year follow-up period (discounted at 5% per annum) were £4043
(10’987) and £3613 (12’122) for patients randomized to either conventional or intensive therapy with metformin, respectively. Intensive therapy with metformin led to a 0.21 life years gained (discounted at 5% p.a.), and therefore dominated conventional therapy, with lower costs and increased life expectancy. Outcomes were most sensitive to variations in the acquisition cost of metformin. Changes in event rates and costs related to myocardial infarction, renal failure and stroke also had an important impact. CONCLUSIONS: Within the limitations of the modeling study, intensive therapy with metformin is cost saving and improves life expectancy in obese type 2 diabetes in the UK setting. These findings should be confirmed by the economic study performed alongside the UKPDS.
ED2
COST-EFFECTIVENESS OF ACROMEGALY TREATMENTS Wilson LS1, Shin JL2, Ezzat S2 1 Department of Pharmacy, University of California, San Francisco, CA, USA; 2Department of Medicine, University of Toronto, Toronto, Ontario, Canada OBJECTIVES: Acromegaly is a chronic disease with increased morbidity and mortality. For this and other pituitary tumors, the treatment choice changes between surgical or medical. The new generation of somatostatin analogues resulted in a recent challenge in attitude towards the traditional dominant role of pituitary surgery, but costs of medical treatment are a concern. We conducted a costeffectiveness analysis comparing surgical treatment alone with combinations of surgical and medical treatments and comparing new and old formulations of medical treatment. METHODS: We evaluated retrospectively 53 patients with acromegaly who underwent pituitary trans-sphenoid surgery alone or in addition to medical therapy. Outcomes were analyzed as person months spent in different health state outcomes, defined according to Growth Hormone and Insulin-like growth factor-I levels. We used a decision analytic modeling approach and included cost per added year in a cured health state and cost per life year saved comparing surgery only with either the addition of medical treatment to all those non cured, or to all post surgery patients. RESULTS: Patients spent as much as 65% of time in noncured health states. The average annual cost of acromegaly treatment was $8,700. The cost-effectiveness ratio of treating patients with microadenomas or macroadenomas and persistent disease following surgery was $30,733 and $35,892 respectively per added year spent in a cured state. New somatostatin formulations had little effect on the overall results. The cost per life year saved was approximately $32,000. The results were cost-effective over a wide range of costs and outcomes. CONCLUSION: Medical management of acromegaly is cost-effective providing further justification for more aggressive treatment of patients with persistently active postoperative disease.
Abstracts
women who choose to deliver at home relative to women who choose to deliver in hospital. This study has wider implications in demonstrating the application of a technique that can be used to ascertain the utility or value attached to attributes or characteristics associated with the process of health care.
SD2
GENERICS ONLY OR GENERICS AND EFFICIENT DRUGS? Bendahan G, Benaque A Direcció d’Atenció Primària Eixample, Institut Català de la Salut, Barcelona, Spain BACKGROUND: During 98 several strategies have been implemented to increase the prescription of efficient (ED) and generic (GD) drugs. In Catalonia to improve the generics’ use, economic incentives have been offered to some Primary Care Teams. Although the general practitioners (GP) in our study were not included in this incentive’s project, they received the intervention presented in this study. OBJECTIVE: To evaluate an intervention to implement ED and GD in a Primary Care District in Barcelona. METHODS Type of study: Pre-post intervention with control group. Setting and period: Drug prescription follow up of the primary care district (296.000 inhabitants) and Catalonia (control group) during 97, 98 and January-March 99. Information source: Catalan Institut of Health’s pharmaceutical computerised system. Intervention: Design of a sheet of paper with information about 1) prices of different drugs for a same active principle, including those drugs responsible for higher pharmaceutical cost and with ED 2) all generic drugs on the market and how to prescribe them. In January 98, it was distributed to all GP. Variables: Number and price of the drugs of 18 active principle and savings obtained. RESULTS: The savings obtained prescribing ED of omeprazole, enalapril and nimodipino during the period 99– 97 have increased a 182% in the district versus 103% in Catalonia. The % of GD is also greater in our district: Ranitidina 24% vs. 14%, Captopril 13,2% vs. 8,6%, Aciclovir 14,8% vs. 11.8%; Alprazolam 8.2% vs. 5% Fluoxetina 3,73% vs. 2,7%. During January-March 99, our district saved 69 millions (pesetas), 90% by prescribing ED and 10% by generics. CONCLUSION: The GP collaboration and an instrument with updated information and easy to use have allowed to achieve a higher percentage of ED and GD prescription in our district. To rationalise drug’s prescription, it is necessary to take into account the ED.
SD3
USING ECONOMIC INFORMATION IN HOSPITAL FORMULARY DECISION-MAKING Späth HM1,2, Ferdjaoui N1,2, Carrère MO1,2 1 GRESAC, Lyon, France; 2Université Lyon, Lyon, France
OBJECTIVES: Over the last 15 years pharmacoeconomics research has grown rapidly, but little is known about the actual use of economic information by health-care decision-makers. We conducted a literature review of papers addressing the use of economic information in drug selection for hospital formularies to determine its role in decision-making, the barriers that prevent its use and the importance of these barriers. METHODS: Five bibliographic databases were searched: (1) Medline (2) Embase (3) Pascal (4) NHS Economic Evaluation Database, and (5) International Pharmaceutical Abstracts, from 1991 to 1998. In addition a manual search of the journal PharmacoEconomics and of the reference sections of all retrieved papers was performed. To appraise and summarise the publications we used a 7point checklist. RESULTS: We assessed 34 papers. Case studies based on personal observations were reported in 27 (79%) papers, surveys in 5 (15%) and literature reviews in 2 (6%). Input that were reported to have a greater impact on decisions than economic information were: (1) the efficacy and safety of drugs (mentioned in 100% of the papers) (2) dosage and administration procedures (50%) (3) quality of life considerations (32%), and (4) clinical experience of practitioners (29%). The most important of the seven identified barriers to the use of economic information in decision-making were: (1) lack of credibility of economic evaluations (65%) (2) economic data did not apply to the setting of the decision-makers (62%) (3) decision-makers had no expertise in appraising economic information (59%) (4) decision-makers did not have economic information and it was not possible to collect it (47%), and (5) lack of collaboration between producers of economic information and decision-makers (41%). CONCLUSIONS: The current use of economic information is limited compared with its potential use. More research is needed to determine decision-maker’s needs for economic information and to identify incentives to take this into account.
SD4
QUALITY OF LIFE ASSESSMENT AS A NEW OUTCOME MEASURE IN CLINICAL PRACTICE Pratheepawanit N, Salek M, Finlay I, Luscombe D Medicines Research Unit, Welsh School of Pharmacy and University of Wales College of Medicine, Cardiff, UK OBJECTIVES: To assess the practicality of routine measurement of patients’ quality of life during an outpatient palliative care clinic. METHOD: The study was a prospective evaluation of palliative care services provided at an outpatient clinic at Velindre NHS Trust, Cardiff. During a one-year period of the study, patients’ self-report of quality of life was implemented into the routine care. Each patient was asked to complete the revised McGill Quality of Life Questionnaire (MQOL) in the waiting room pre-consultation. After each consultation, doctors recorded their comments on the pa-
369
Abstracts tients’ responses to MQOL that had been helpful in their decision making and the interventions arising from that process. RESULTS: The total of 348 consultations took place during the study period; 274 consultations had the MQOL forms completed. This was accounted for 127 patients. There were 46 male and 81 female with mean age of 59 years old (range 26–85). 66 patients (52%) attended the clinic for the first time. Of these 66 new patients, 31 (47%) had a record of the MQOL on their subsequent visits. Compared with the first visits, the results show the quality of life had improved in every domain (i.e., physical symptoms, physical wellbeing, psychological and existential domains) on their subsequent visits. The overall quality of life score in particular was significantly improved during the follow-up visits (P 0.05). Considering the use of the MQOL, 101 (37%) consultations had a record of doctors’ comments on utilizing the quality of life information and the majority (95%) indicated the MQOL as being useful during consultations, particularly information related to physical symptoms, psychological and existential domains. CONCLUSIONS: The findings support the practicality of quality of life assessment in clinical practice and its value as an outcome measure and monitoring tool of palliative care services in this population. ECONOMIC & OUTCOMES STUDY RESULTS OF ENDOCRINE DISORDERS
ED1
COST-EFFECTIVENESS OF INTENSIVE METFORMIN VERSUS CONVENTIONAL THERAPY FOR OBESE PATIENTS WITH TYPE 2 DIABETES Palmer AJ1, Sendi PP1, Gozzoli V1, Brandt A1, Spinas GA2 1 IMIB, Institute for Medical Informatics and Biostatistics, Riehen, Switzerland; 2Division of Endocrinology and Diabetes, University Hospital, Zürich, Switzerland OBJECTIVES: The clinical results of the metformin substudy of the United Kingdom Prospective Diabetes Study (UKPDS) were combined with published cost data through modeling techniques, allowing a cost-effectiveness analysis of the management of obese type 2 diabetes patients with either conventional therapy or intensive therapy with metformin from the NHS perspective. METHODS: Occurrence of diabetes-related complications were simulated using a Markov model. Probabilities for complications were taken from the UKPDS, and costs were retrieved from published sources. Total direct costs and mortality over an 11-year period were determined for patients randomized to either conventional therapy or intensive therapy with metformin. Incremental costs per life year gained for metformin versus conventional therapy were calculated. Extensive sensitivity analysis was performed. RESULTS: Mean (SD) costs per patient over the 11 year follow-up period (discounted at 5% per annum) were £4043
(10’987) and £3613 (12’122) for patients randomized to either conventional or intensive therapy with metformin, respectively. Intensive therapy with metformin led to a 0.21 life years gained (discounted at 5% p.a.), and therefore dominated conventional therapy, with lower costs and increased life expectancy. Outcomes were most sensitive to variations in the acquisition cost of metformin. Changes in event rates and costs related to myocardial infarction, renal failure and stroke also had an important impact. CONCLUSIONS: Within the limitations of the modeling study, intensive therapy with metformin is cost saving and improves life expectancy in obese type 2 diabetes in the UK setting. These findings should be confirmed by the economic study performed alongside the UKPDS.
ED2
COST-EFFECTIVENESS OF ACROMEGALY TREATMENTS Wilson LS1, Shin JL2, Ezzat S2 1 Department of Pharmacy, University of California, San Francisco, CA, USA; 2Department of Medicine, University of Toronto, Toronto, Ontario, Canada OBJECTIVES: Acromegaly is a chronic disease with increased morbidity and mortality. For this and other pituitary tumors, the treatment choice changes between surgical or medical. The new generation of somatostatin analogues resulted in a recent challenge in attitude towards the traditional dominant role of pituitary surgery, but costs of medical treatment are a concern. We conducted a costeffectiveness analysis comparing surgical treatment alone with combinations of surgical and medical treatments and comparing new and old formulations of medical treatment. METHODS: We evaluated retrospectively 53 patients with acromegaly who underwent pituitary trans-sphenoid surgery alone or in addition to medical therapy. Outcomes were analyzed as person months spent in different health state outcomes, defined according to Growth Hormone and Insulin-like growth factor-I levels. We used a decision analytic modeling approach and included cost per added year in a cured health state and cost per life year saved comparing surgery only with either the addition of medical treatment to all those non cured, or to all post surgery patients. RESULTS: Patients spent as much as 65% of time in noncured health states. The average annual cost of acromegaly treatment was $8,700. The cost-effectiveness ratio of treating patients with microadenomas or macroadenomas and persistent disease following surgery was $30,733 and $35,892 respectively per added year spent in a cured state. New somatostatin formulations had little effect on the overall results. The cost per life year saved was approximately $32,000. The results were cost-effective over a wide range of costs and outcomes. CONCLUSION: Medical management of acromegaly is cost-effective providing further justification for more aggressive treatment of patients with persistently active postoperative disease.