Bryce A Kiberd, Kailash K Jindal
Abstract
Objective - To examine the conditions necessary to make screening for microalbuminuria in patients with insulin dependent diabetes mellitus cost effective.
Design - This economic evaluation compared two strategies designed to prevent the development of end stage renal disease in patients with insulin dependent diabetes with disease for five years. Strategy A, screening for microalbuminuria as currently recommended, was compared with strategy B, a protocol in which patients were screened for hypertension and macroproteinuria.
Intervention - Patients identified in both strategies were treated with an angiotensin converting enzyme inhibitor.
Setting - Computer simulation.
Main outcome measures - Strategy costs and quality adjusted life years (QALYs).
Results - The model predicted that strategy A would produce an additional 0.00967 QALYs at a present value cost of $261.53 (1990 US$) per patient (or an incremental cost/QALY of $27041.69) over strategy B. The incremental cost/QALY for strategy A over B was sensitive to several variables. If the positive predictive value of screening for microalbuminuria (impact of false label and unnecessary treatment) is less than 0.72, the effect of treatment to delay progression from microalbuminuria to macroproteinuria is less than 1.6 years, the cumulative incidence of diabetic nephropathy falls to less than 20%, or more than 64% of patients demonstrate hypertension at the onset of microalbuminuria, then the incremental costs/QALY will exceed $75,000.
Conclusions - Whether microalbuminuria surveillance in this population is cost effective requires more information. Being aware of the costs, recommendation pitfalls, and gaps in our knowledge should help focus our efforts to provide cost effective care to this population.
Department of Medicine Dalhousie University Halifax Nova Scotia Canada Bryce A Kiberd associate professor of medicine Kailash K Jindal associate professor of medicine
Correspondence to: Professor Kiberd, 5077 RC Dickson Building, Victoria General Hospital, Halifax, Nova Scotia, Canada B3H 2Y9.
Allison Lee, Peter Thomas, Lena Cupidore, Beryl Serjeant, Graham Serjeant
Abstract
Objective - To examine whether simple interventions in a sickle cell clinic improve survival in sickle cell disease.
Design - Survival curve analysis and hazard ratios in a cohort study followed from birth.
Setting - MRC Laboratories (Jamaica) at the University of the West Indies, and Victoria Jubilee Hospital, Kingston, Jamaica.
Subjects - 315 patients with homozygous sickle cell disease detected during the screening of 100,000 consecutive non-operative deliveries between June 1973 and December 1981 at the main government maternity hospital, Kingston, Jamaica.
Interventions - Prophylactic penicillin to prevent pneumococcal septicaemia, parental education in early diagnosis of acute splenic sequestration, close monitoring in sickle cell clinic.
Main outcome measures - Survival.
Results - Survival appeared to improve, the log rank test for trend comparing the first, second, and last third of the study reaching borderline significance (P equals 0.05). Combined deaths from acute splenic sequestration and pneumococcal septicaemia-meningitis declined significantly (test for trend,P equals 0.02).
Conclusion - Early diagnosis and simple prophylactic measures significantly reduce deaths associated with homozygous sickle cell disease.
MRC Laboratories (Jamaica) University of the West Indies Kingston Jamaica Allison Lee medical student Peter Thomas statistician Lena Cupidore nurse practitioner Beryl Serjeant chief technologist Graham Serjeant director
Correspondence to: Professor G Serjeant.
A J Lees on behalf of the Parkinson's Disease Research Group of the United Kingdom
Abstract
Objective - To compare effectiveness of levodopa and levodopa combined with selegiline in treating early, mild Parkinson's disease.
Design - Open, long term, prospective randomised trial.
Setting - 93 hospitals throughout United Kingdom.
Subjects - 520 patients with early Parkinson's disease who were not receiving dopaminergic treatment.
Interventions - Treatment with levodopa and dopa decarboxylase inhibitor (arm 1) or levodopa and decarboxylase inhibitor in combination with selegiline (arm 2).
Main outcome measures - Assessments of serial disability, frequency and severity of adverse events, and deaths from all causes.
Results - After average of 5.6 years' follow up, mortality ratio in arm 2 compared with arm 1 was 1.57 (95% confidence interval 1.09 to 2.30), and difference in survival between the two arms was significant (log rank test, P equals 0.015). Hazard ratio adjusted for age and sex was 1.49 (1.02 to 2.16), and after adjustment for other baseline factors it increased to 1.57 (1.07 to 2.31). Patients in arm 1 had slightly worse disability scores than those in arm 2, but differences were not significant. Functionally disabling peak dose dyskinesias and on/off fluctuations were more frequent in arm 2 than arm 1. During the trial the dose of levodopa required to produce optimum motor control steadily increased in arm 1 (median daily dose 375 mg at 1 year and 625 mg at 4 years), but median dose in arm 2 did not change (375 mg).
Conclusion - Levodopa in combination with selegiline seemed to confer no clinical benefit over levodopa alone in treating early, mild Parkinson's disease. Moreover, mortality was significantly higher with combination treatment, casting doubts on its chronic use in Parkinson's disease.
Parkinson's Disease Research Group of the United Kingdom National Hospital for Neurology and Neurosurgery London WC1N 3BG A J Lees honorary secretary
P Hanlon, J McEwen, L Carey, H Gilmour, C Tannahill, A Tannahill, M Kelly
Abstract
Objectives - To determine the effectiveness of a health check and assess any particular benefits resulting from feedback of plasma cholesterol concentration or coronary risk score, or both.
Design - Randomised controlled trial in two Glasgow work sites.
Subjects - 1,632 employees (89% male) aged 20 to 65 years.
Interventions - At the larger work site, (a) health education; (b) health education and feedback on cholesterol concentration; (c) health education and feedback on risk score; (d) health education with feedback on cholesterol concentration and risk score (full health check); (e) no health intervention (internal control) . At the other work site there was no health intervention (external control).
Main outcome measures - Changes in Dundee risk score, plasma cholesterol concentration, diastolic blood pressure, body mass index, and self reported behaviours (smoking, exercise, alcohol intake, and diet) in comparison with internal and external control groups.
Results - Comparisons between the full health check and the internal control groups showed a small difference (0.13 mmol/I) in the change in mean cholesterol concentration (95% confidence interval 0.02 to 0.22, P equals 0.02) but no significant differences for changes in Dundee risk score (P equals 0.21), diastolic blood pressure (P equals 0.71), body mass index (P equals 0.16), smoking (P equals 1.00), or exercise (P equals 0.41). Significant differences between the two groups were detected for changes in self reported consumption of alcohol (41% in group with full health check v 17% in internal control group, P equals 0.001), fruit and vegetables (24% v 12%, P is less than 0.001), and fat (30% v 9%, P is less than 0 .001). Comparison of all groups showed no advantage from feedback of cholesterol concentration or risk score, or both.
Conclusions - The health check only had a small effect on reversible coronary risk. It was effective in influencing self reported alcohol consumption and diet. Feedback on cholesterol concentration and on risk score did not provide additional motivation for a change in behaviour.
Department of Public Health University of Glasgow Glasgow G12 8RZ P Hanlon senior lecturer in public health J McEwen professor of public health H Gilmour senior lecturer in statisticsHealth Promotion Department Greater Glasgow Health Board Glasgow G2 4JT L Carey senior researcher C Tannahill head of health promotion
Health Education Board for Scotland Edinburgh EH10 4SG A Tannahill general manager
University of Greenwich London SE9 2HB M Kelly professor of social sciences
Correspondence to: Dr Hanlon.