A Cost-Effectiveness Analysis of “Test” versus “Treat” Patients Hospitalized with Suspected Influenza in Hong Kong

BACKGROUND: Seasonal and 2009 H1N1 influenza viruses may cause severe diseases and result in excess hospitalization and mortality in the older and younger adults, respectively. Early antiviral treatment may improve clinical outcomes. We examined potential outcomes and costs of test-guided versus empirical treatment in patients hospitalized for suspected influenza in Hong Kong. METHODS: We designed a decision tree to simulate potential outcomes of four management strategies in adults hospitalized for severe respiratory infection suspected of influenza: "immunofluorescence-assay" (IFA) or "polymerase-chain-reaction" (PCR)-guided oseltamivir treatment, "empirical treatment plus PCR" and "empirical treatment alone". Model inputs were derived from literature. The average prevalence (11%) of influenza in 2010-2011 (58% being 2009 H1N1) among cases of respiratory infections was used in the base-case analysis. Primary outcome simulated was cost per quality-adjusted life-year (QALY) expected (ICER) from the Hong Kong healthcare providers' perspective. RESULTS: In base-case analysis, "empirical treatment alone" was shown to be the most cost-effective strategy and dominated the other three options. Sensitivity analyses showed that "PCR-guided treatment" would dominate "empirical treatment alone" when the daily cost of oseltamivir exceeded USD18, or when influenza prevalence was <2.5% and the predominant circulating viruses were not 2009 H1N1. Using USD50,000 as the threshold of willingness-to-pay, "empirical treatment alone" and "PCR-guided treatment" were cost-effective 97% and 3% of time, respectively, in 10,000 Monte-Carlo simulations. CONCLUSIONS: During influenza epidemics, empirical antiviral treatment appears to be a cost-effective strategy in managing patients hospitalized with severe respiratory infection suspected of influenza, from the perspective of healthcare providers in Hong Kong

Pharmacogenetics of warfarin in a paediatric population: time in therapeutic range, initial and stable dosing and adverse effects

Warfarin is used in paediatric populations, but dosing algorithms incorporating pharmacogenetic data have not been developed for children. Previous studies have produced estimates of the effect of polymorphisms in Cytochrome P450 2C9 (CYP2C9) and vitamin K epoxide reductase complex subunit 1 (VKORC1) on stable warfarin dosing, but data on time in therapeutic range, initial dosing and adverse effects are limited. Participants (n=97) were recruited, and routine clinical data and salivary DNA samples were collected from all participants and analysed for CYP2C9*2, *3 and VKORC1-1639 polymorphisms.VKORC1 -1639 was associated with a greater proportion of the first 6 months’ treatment time spent within the target International Normalised Ratio (INR) range, accounting for an additional 9.5% of the variance in the proportion of time. CYP2C9*2 was associated with a greater likelihood of INR values exceeding the target range during the initiation of treatment (odds ratio (OR; per additional copy) 4.18, 95% confidence interval (CI) 1.42, 12.34). CYP2C9*2 and VKORC1-1639 were associated with a lower dose requirement, and accounted for almost 12% of the variance in stable dose. VKORC1-1639 was associated with an increased likelihood of mild bleeding complications (OR (heterozygotes vs homozygotes) 4.53, 95% CI 1.59, 12.93). These data show novel associations between VKORC1-1639 and CYP2C9*2 and INR values in children taking warfarin, as well as replicating previous findings with regard to stable dose requirements. The development of pharmacogenomic dosing algorithms for children using warfarin has the potential to improve clinical care in this population

The all-powerful and 'happy' drug: The use of steroids among primary care doctors in Hong Kong

Background: Steroids are commonly used, but their prescribing pattern and factors associated with their use in the primary care setting are largely unknown. Methods: Using diagnosis and drug data obtained from logbooks submitted by participants in the Diploma in Family Medicine course between 1999 and 2004, we selected and analysed all patients with a prescription of steroid as well as conditions in which it was prescribed. Factors, relating to patients or doctors, which could be associated with steroid prescription were recorded for both the prescribed and the non-prescribed groups. The results were compared using chi-square tests. Results: Steroids were prescribed in 7·1% of all patient encounters, of which dermatological and respiratory diseases were the most two common conditions. Upper respiratory tract infections accounted for a third of all respiratory diseases in which steroid was prescribed. Female or 'minor' patients (OR 1·16, 95% CI 1·01-1·32 and 1·16, 1·00-1·36 respectively) were more likely to be given a steroid and younger doctors (1·52, 1·25-1·86) were more likely to prescribe them. Conclusion: Some patterns of poor prescribing practice were demonstrated in this study. Campaigns by professional bodies may improve prescribing among our community doctors and effective public education programmes are needed to modify the health beliefs and expectations of the general public. © 2006 Blackwell Publishing Ltd.link_to_subscribed_fulltex

The cost-effectiveness of an outreach clinical model in the management and prevention of gonorrhea and chlamydia among Chinese female sex workers in Hong Kong

Background: Social marginalization and stigmatization in usual medical care setting may refrain female sex workers (FSWs) from seeking usual medical care for sexually transmitted infections in Hong Kong. Goal: To evaluate the cost-effectiveness of using an outreach approach for treatment and prevention of gonorrhea and chlamydia among FSWs. Study Design: A decision tree was designed to simulate the outcomes of 2 alternatives: (1) outreach service providing treatment of gonorrhea and chlamydia and counseling to FSWs (outreach arm) and (2) no outreach service (control arm). Five tiers of outcomes were estimated for each study arm: (1) total direct medical cost, (2) number of FSWs infected with gonorrhea, (3) number of new cases of gonorrhea in clients transmitted by FSWs, (4) number of FSWs infected with chlamydia, and (5) number of new cases of chlamydia in clients transmitted by FSWs. Clinical inputs were estimated from literature, and cost analysis was conducted from the perspective of a public health organization. Results: Compared to the control group, the marginal savings per new case of infection averted (marginal cost divided by marginal cases of infection) of the outreach group were $10,988 (US dollars) per case of gonorrhea averted in FSWs,$685 per case of gonorrhea averted in clients, $9643 per case of chlamydia averted in FSWs, and$220 per case of chlamydia averted in clients ($1 = 7.8 Hong Kong dollars). Conclusions: An outreach clinic is potentially less costly and more effective in preventing transmission of gonorrhea and chlamydia between FSWs and their clients in Hong Kong. Copyright © 2006, American Sexually Transmitted Diseases Association All rights reserved.link_to_subscribed_fulltex

Atypical antipsychotic therapy for treatment of schizophrenia in Hong Kong Chinese patients - A cost analysis

Obiective: To evaluate the direct medical cost of atypical antipsychotic therapy for schizophrenia among Hong Kong Chinese patients and to identify factors affecting the cost of treatment. Methods: In this retrospective database analysis, patient data were retrieved from three Hong Kong public hospitals. Patients aged ≥ 18 years who received an initial prescription for olanzapine, risperidone, quetiapme or amisulpride between April 1 and September 30, 2003; and had an ICD-10-coded diagnosis of schizophrenia were included. Patient data were collected for a maximum duration of 1 year before and after treatment initiation. Primary outcome measures were the schizophrenia-related direct medical costs. Demographic and clinical factors were analyzed by multiple regression analysis to identify influential factors for the cost of atypical antipsychotic therapy. Results: A total of 325 patient records were reviewed and 82 patients were included in the analysis. Cost per patient per month for clinic visits (US$67 ± 41 versus US$ 78 ± 41), medications (US$8 ± 12 versus US$ 97 ± 83), and the total cost per patient per month (US$314 ± 898 versus US$ 431 ± 914) increased significantly after treatment initiation (US$1 = HK$ 7.8). Previous duration of hospitalization (RR = 1.00, 95% CI= 1.00 - 1.01), history of substance abuse (RR = 1.26, 95% CI = 1.05 - 1.52) and use of depot antipsychotics (RR = 1.22, 95% CI = 1.05 - 1.42) were associated with higher cost of atypical antipsychotic therapy. Conclusion: The total direct medical cost increased significantly after initiation of atypical antipsychotic therapy in a cohort of Chinese patients with schizophrenia. History of drug abuse, use of depot antipsychotics and prior duration of hospitalization were positive predictors of cost of therapy. ©2007 Dustri-Verlag Dr. K. Feistle.link_to_subscribed_fulltex

Cost-effectiveness analysis of influenza and pneumococcal vaccination for Hong Kong elderly in long-term care facilities

Background: To compare cost and quality-adjusted life-years (QALYs) gained by influenza vaccination with or without pneumococcal vaccination in the elderly living in long-term care facilities (LTCFs). Methods: Cost-effectiveness analysis based on Markov modelling over 5 years, from a Hong Kong public health provider's perspective, on a hypothetical cohort of LTCF residents aged ≥65 years. Benefit-cost ratio (BCR) and net present value (NPV) of two vaccination strategies versus no vaccination were estimated. The cost and QALYs gained by two vaccination strategies were compared by Student's t-test in probabilistic sensitivity analysis (10 000 Monte Carlo simulations). Results: Both vaccination strategies had high BCRs and NPVs (6.39 and US$334 for influenza vaccination; 5.10 and US$332 for influenza plus pneumococcal vaccination). In base case analysis, the two vaccination strategies were expected to cost less and gain higher QALYs than no vaccination. In probabilistic sensitivity analysis, the cost of combined vaccination and influenza vaccination was significantly lower (p<0.001) than the cost of no vaccination. Both vaccination strategies gained significantly higher (p<0.001) QALYs than no vaccination. The QALYs gained by combined vaccination were significantly higher (p=0.030) than those gained by influenza vaccination alone. The total cost of combined vaccination was significantly lower (p=0.011) than that of influenza vaccination. Conclusion: Influenza vaccination with or without pneumococcal vaccination appears to be less costly with higher QALYs gained than no vaccination, over a 5-year period, for elderly people living in LTCFs from the perspective of a Hong Kong public health organisation. Combined vaccination was more likely to gain higher QALYs with lower total cost than influenza vaccination alone.link_to_subscribed_fulltex