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Cost effectiveness of home ultraviolet B phototherapy for psoriasis: economic evaluation of a randomised controlled trial (PLUTO study)

BMJ 2010; 340 doi: https://doi.org/10.1136/bmj.c1490 (Published 20 April 2010) Cite this as: BMJ 2010;340:c1490
  1. Mayke B G Koek, epidemiologist, medical doctor1,
  2. Vigfús Sigurdsson, dermatologist1,
  3. Huib van Weelden, investigator photodermatology1,
  4. Paul H A Steegmans, dermatologist2,
  5. Carla A F M Bruijnzeel-Koomen, professor of dermatology/allergology1,
  6. Erik Buskens, professor of medical technology assessment34
  1. 1Department of Dermatology/Allergology (G02.124), University Medical Center Utrecht, Heidelberglaan 100, 3584 CX Utrecht, Netherlands
  2. 2Department of Dermatology, St Antonius Hospital, Koekoekslaan 1, 3435 CM Nieuwegein, Netherlands
  3. 3Department of Epidemiology, University Medical Center Groningen, University of Groningen, Hanzeplein 1, 9713 GZ Groningen, Netherlands
  4. 4Julius Centre for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht
  1. Correspondence to: M B G Koek author{at}koek.com
  • Accepted 5 January 2010

Abstract

Objective To assess the costs and cost effectiveness of phototherapy with ultraviolet B light provided at home compared with outpatient ultraviolet B phototherapy for psoriasis.

Design Cost utility, cost effectiveness, and cost minimisation analyses performed alongside a pragmatic randomised clinical trial (the PLUTO study) at the end of phototherapy (mean 17.6 weeks) and at one year after the end of phototherapy (mean 68.4 weeks).

Setting Secondary care, provided by a dermatologist in the Netherlands.

Participants 196 adults with psoriasis who were clinically eligible for narrowband (TL-01) ultraviolet B phototherapy were recruited from the dermatology departments of 14 hospitals and were followed until the end of phototherapy. From the end of phototherapy onwards, follow-up was continued for an unselected, consecutive group of 105 patients for one year after end of phototherapy.

Interventions Ultraviolet B phototherapy provided at home (intervention) and conventional outpatient ultraviolet B phototherapy (control) in a setting reflecting routine practice in the Netherlands. Both treatments used narrowband ultraviolet B lamps (TL-01).

Main outcome measures Total costs to society, quality adjusted life years (QALYs) as calculated using utilities measured by the EQ-5D questionnaire, and the number of days with a relevant treatment effect (≥50% improvement of the baseline self administered psoriasis area and severity index (SAPASI)).

Results Home phototherapy is at least as effective and safe as outpatient phototherapy, therefore allowing cost minimisation analyses (simply comparing costs). The average total costs by the end of phototherapy were €800 for home treatment and €752 for outpatient treatment, showing an incremental cost per patient of €48 (95% CI €−77 to €174). The average total costs by one year after the end of phototherapy were €1272 and €1148 respectively (difference €124, 95% CI €−155 to €403). Cost utility analyses revealed that patients experienced equal health benefits—that is, a gain of 0.296 versus 0.291 QALY (home v outpatient) by the end of phototherapy (difference 0.0052, −0.0244 to 0.0348) and 1.153 versus 1.126 QALY by one year after the end of phototherapy (difference 0.0267, −0.024 to 0.078). Incremental costs per QALY gained were €9276 and €4646 respectively, both amounts well below the normally accepted standard of €20 000 per QALY. Cost effectiveness analyses indicated that the mean number of days with a relevant treatment effect was 42.4 versus 55.3 by the end of phototherapy (difference −12.9, −23.4 to −2.4). By one year after the end of phototherapy the number of days with a relevant treatment effect were 216.5 and 210.4 respectively (6.1, −41.1 to 53.2), yielding an incremental cost of €20 per additional day with a relevant treatment effect.

Conclusions Home ultraviolet B phototherapy for psoriasis is not more expensive than phototherapy in an outpatient setting and proved to be cost effective. As both treatments are at least equally effective and patients express a preference for home treatment, the authors conclude that home phototherapy should be the primary treatment option for patients who are eligible for phototherapy with ultraviolet B light.

Trial registration Current Controlled Trials ISRCTN83025173 and Clinicaltrials.gov NCT00150930

Footnotes

  • We thank all participating patients who made this study possible. We thank Chantal Cornelis (research nurse) for coordinating the contacts with all the patients as well as with the participating hospitals and home care organisations. For the economic analysis, we thank Mart Janssen for his help with bootstrapping, and Wendy J Post for her work on the multilevel models used for extrapolation.

  • We thank all dermatologists, residents, and other contributing employees of the departments of dermatology of the following hospitals: UMC Utrecht, Hilversum Hospital, Academic Hospital Maastricht, Diakonessen Hospital Utrecht and Zeist, Meander Hospital Amersfoort, Groene Hart Hospital Gouda, AMC Amsterdam, Erasmus MC Rotterdam, VUmc Amsterdam, Gelre Hospital Apeldoorn, Reinier de Graaf Groep Delft and Voorburg, AntoniusMesosGroup Hospitals Utrecht, and Lucas Andreas Hospital Amsterdam. Similarly, we thank all employees of the participating home care organisations Medizorg, Farmadomo, and BEM.

  • Contributors: MBGK, EB, PHAS, VS, and CAFMB-K contributed to the study concept and design. MBGK, HvW, and Chantal Cornelis were involved in the acquisition of data, and HvW and Chantal Cornelis provided administrative, technical, and material support. MBGK, EB, VS, Mart Janssen, and Wendy J Post took part in the analysis and interpretation of the data. MBGKwas the overall study manager and drafted the manuscript. All authors revised the manuscript for important intellectual content and approved the final version for publication. VS is the guarantor.

  • Funding: This study was supported by grant 945-02-017 from the Netherlands Organisation for Health Research and Development (ZonMW). ZonMW had no role in the study design; collection, analysis, and interpretation of data; production of the manuscript; or the decision to submit the article for publication. The researchers are independent from the funders.

  • Competing interests: None declared.

  • Ethical approval: The institutional review board of the University Medical Center Utrecht approved the study (02/090-O).

  • Accepted 5 January 2010

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