Effects of Losartan-based therapy on the incidence of end-stage renal disease and associated costs in type 2 diabetes mellitus: A retrospective cost-effectiveness analysis in the United Kingdom

AbstractBackground:In the Reduction of Endpoints in Non-Insulin-Dependent Diabetes Mellitus with the Angiotensin II Antagonist Losartan (RENAAL) study, the primary composite end point was the 2-fold increase in baseline serum creatinine concentration, the development of end-stage renal disease (ESRD), or death. The effects of losartan used for the prevention or delay of progression of diabetic nephropathy to ESRD were compared with those of conventional anti-hypertensive treatment (control) (calcium channel blockers, diuretics, α-blockers, β-blockers, and centrally acting agents), but not angiotensin-converting enzyme (ACE) inhibitors or angiotensin II antagonists (AIIAs), in 1513 adults with type 2 diabetes mellitus (DM-2) and nephropathy. Both treatment groups received conventional antihypertensive therapy (calcium channel blockers, diuretics, α-blockers, β-blockers, and/or centrally acting agents). ACE inhibitors and AIIAs were not allowed during the study period. The relative risk (RR) for composite outcome was 25% less, and the RR for ESRD was 28% less, in the losartantreated group compared with the control group.Objective:The aim of this retrospective cost-effectiveness analysis was to use data from the RENAAL study to determine the survival benefits and lifetime direct medical costs of a losartan-based regimen for the prevention of ESRD in patients with DM-2 and nephropathy in the setting of the UK National Health Service (NHS).Methods:This analysis used life-years saved as the effectiveness measure. The effect of losartan-based treatment on ESRD risk was confined to the trial period (3.5 years). However, survival and the lifetime direct medical costs of managing ESRD were projected beyond the trial period to incorporate the full effects of ESRD on survival and resource use. The effect of altering key variables was examined using 1-way sensitivity analyses.Results:ESRD-related costs were significantly lower in patients receiving losartan-based treatment compared with those in the control group (savings per patient, 7390 [95% CI, 11,366-3414; P< 0.001] [1 = US −$1.75]). Incorporation of the cost of losartan into the assessment found reduced net costs (savings per patient, 6622 [95% CI, 10,591-2653; P= 0.001]). The projected mean number of life years saved due to ESRD risk reduction with losartan was 0.44 years (95% CI, 0.16–0.71; P = 0.002). Losartan treatment was found to save costs in all cases, even if the cost of renal replacement therapy for patients with ESRD was reduced by 50%.Conclusion:In this retrospective cost-effectiveness analysis using data from the RENAAL study, losartan-based treatment for the prevention or delay of progression of diabetic nephropathy to ESRD in patients with DM-2 and nephropathy was found to be potentially cost saving compared with conventional anti-hypertensive therapy from the perspective of the UK NHS

Missing.... presumed at random: cost-analysis of incomplete data

When collecting patient-level resource use data for statistical analysis, for some patients and in some categories of resource use, the required count will not be observed. Although this problem must arise in most reported economic evaluations containing patient-level data, it is rare for authors to detail how the problem was overcome. Statistical packages may default to handling missing data through a so-called complete case analysis, while some recent cost-analyses have appeared to favour an available case approach. Both of these methods are problematic: complete case analysis is inefficient and is likely to be biased; available case analysis, by employing different numbers of observations for each resource use item, generates severe problems for standard statistical inference. Instead we explore imputation methods for generating replacement values for missing data that will permit complete case analysis using the whole data set and we illustrate these methods using two data sets that had incomplete resource use information

Nurse’s Knowledge of Early Ambulation of the Post Operative Patient and Complication Prevention: A Quality Improvement Project

Ambulation is the single most important nursing intervention in the prevention of postoperative complications. It is also a key component in maintaining optimal patient outcomes. Current literature has revealed that when ambulation is initiated early there is a marked decrease in pain, length of hospital admission, and overall complication rates. However, even with this depth of evidence early postoperative ambulation on the two surgical units at a teaching hospital in Rhode Island, patient ambulation continues to be inconsistent. The purpose of this quality improvement project is to improve nursing knowledge regarding early ambulation after surgery for the prevention of post-operative complications. This project utilized a pretest, educational in-service intervention, and posttest design. Seventeen out of a possible 22 surgical nurses participated in this project (N= 17, 77%). The educational in-service sessions combined information from an extensive literature review in the form of a 10-minute Power Point presentation. Pre and post tests were made up of 5 knowledge-based and 5 opinion-based questions. The mean scores for the pretest were 74% while the mean scores for the posttest were 95.2%. There was a 35% increase in overall scores following the educational intervention. APRNs play a pivotal role in establishing and implementing educational programs. This project aimed to recognize a need for ongoing education about postoperative ambulation for the surgical unit nurses. Educational programs about postoperative ambulation and complication prevention should be routinely incorporated in future trainings to ensure improved nursing knowledge and patient outcomes