Cost-Effectiveness of Eltrombopag versus Romiplostim for the Treatment of Chronic Immune Thrombocytopenia in England and Wales

Objective: To evaluate the cost-effectiveness of eltrombopag compared with romiplostim as a treatment for chronic immune thrombocytopenia (cITP) in patients who are splenectomized or ineligible for splenectomy and are treatment refractory in England and Wales. Methods: A Markov cohort model in which patients were administered a sequence of treatments was used to predict long-term outcomes associated with each treatment. The model was informed by data from the eltrombopag clinical trial program and the available literature. The analysis was conducted from the perspective of the United Kingdom National Health Service, and a lifetime time horizon was used. Deterministic and probabilistic sensitivity analyses were performed. Results: Eltrombopag dominated romiplostim (i.e., eltrombopag was as effective as but less costly than romiplostim) in both splenectomized and non-splenectomized patients, assuming a class effect for the two treatments. Eltrombopag also dominated romiplostim in the majority of deterministic sensitivity analyses with the exception of when indirect efficacy estimates were incorporated into the model. In this analysis, eltrombopag no longer dominated romiplostim but remained cost-effective versus romiplostim at a willingness-to-pay threshold of £20,000 per quality-adjusted life-year (QALY). Probabilistic sensitivity analysis demonstrated that there was a 99% and 92% chance of eltrombopag being cost-effective at a cost-effectiveness threshold of £20,000/QALY in splenectomized and non-splenectomized patients, respectively. Conclusions: Results of this study demonstrate that eltrombopag is cost-effective when compared to romiplostim as a treatment for cITP, representing good value for the United Kingdom National Health Service

Predictors of early death in female patients with breast cancer in the UK: a cohort study.

Objective To identify factors predicting early death in women with breast cancer. Design Cohort study. Setting 29 trusts across seven cancer networks in the North Thames area. Participants 15 037 women with primary breast cancer diagnosed between January 1996 and December 2005. Methods Logistic regression analyses to determine predictors of early death and factors associated with lack of surgical treatment. Main exposures Age at diagnosis, mode of presentation, ethnicity, disease severity, comorbidities, treatment and period of diagnosis in relation to the Cancer Plan (the NHS's strategy in 2000 for investment in and reform of cancer services). Main outcome measures Death from any cause within 1 year of diagnosis, and receipt of surgical treatment. Results By 31 December 2006, 4765 women had died, 980 in the year after diagnosis. Older age and disease severity independently predicted early death. Women over 80 were more likely to die early than women under 50 (OR 8.05, 95% CI 5.96 to 10.88). Presence of distant metastases on diagnosis increased the odds of early death more than eightfold (OR 8.41, 95% CI 6.49 to 10.89). Two or more recorded comorbidities were associated with a nearly fourfold increase. There was a significant decrease in odds associated with surgery (OR 0.29, 95% CI 0.24 to 0.35). Independently of disease severity and comorbidities, women over 70 were less likely than those under 50 to be treated surgically and this was even more pronounced in those aged over 80 (OR 0.09, 95% CI 0.07 to 0.10). Other factors independently associated with a reduced likelihood of surgery included a non-screening presentation, non-white ethnicity and additional comorbidities. Conclusions These findings may partially explain the survival discrepancies between the UK and other European countries in female patients with breast cancer. The study identifies a group of women with a particularly poor prognosis for whom interventions aiming at early detection may be targeted

Assessment of acute pain in children:Development of evidence-based guidelines

Aim: Detecting children's pain in a healthcare setting can be improved by facilitating pain expression in ways that are appropriate to the child's cognitive development and that can be recognised by their carers. To ensure up-to-date guidance on assessing pain in children, the Royal College of Nursing undertook an evidence-based update of pain assessment guidelines, initially published in 2000. Methods: Following systematic review of the psychometric testing literature, a two-stage critical appraisal process was developed to derive a list of robust tools that could be recommended for use in a variety of settings to assess the intensity of a child's acute pain. Studies were appraised on the basis of their relevance to this topic and according to prespecified quality criteria. Tools were assessed for inclusion in guideline recommendations according to minimum validity and reliability thresholds. Results: Overall the quality of literature was poor, limited by small samples, lack of control groups, unblinded raters and convenience sampling. Twenty-four tools are recommended for use with infants and verbal children without cognitive impairment, 11 of which are purely self-report tools. Eight tools are recommended for use with neonates, some of which require concurrent physiological measures. Four tools are considered valid for use in children with cognitive impairment. All of these tools had shown reliability and validity according to the criteria established for this review. Conclusion: The tools are presented in user-friendly tables that include a guide to their key features and the setting and age groups in which they have been validated. They are accompanied by good practice recommendations from experts and recommendations relating to timing and triggers for pain assessment. These outputs are some of those associated with the full guidelines and supporting material published on the Royal College of Nursing website (http://www.rcn.org.uk/childrenspainguideline).</p