Cost effective treatments for menorrhagia
BMJ 2011; 342: d2202
What is the most cost-effective NHS treatment for menorrhagia? This study compared two types of endometrial ablative technique to hysterectomy and the levonorgestrel-releasing intra-uterine system (LING-IUS).
Using a complex economic analysis on four hypothetical cohorts of women, they sought to assess cost effectiveness based on incremental cost per quality adjusted life year (QALY). They found that hysterectomy is the preferred strategy for the first intervention for heavy menstrual bleeding.
Although hysterectomy is more expensive, it produces more QALYs relative to other remaining strategies and is likely to be considered cost effective. The incremental cost effectiveness ratio for hysterectomy compared with the LING-IUS is £1,440 per additional QALY.
The incremental cost effectiveness ratio for hysterectomy compared with second generation ablation is £970 per additional QALY.
The authors concluded that in light of the acceptable thresholds used by NICE, hysterectomy would be considered the preferred strategy for the treatment of heavy menstrual bleeding.
Atypical fracture risk with bisphosphonates is small
N Engl J Med 2011; 364: 1728-37
This study was triggered by conflicting results regarding the possible excess risk of atypical fractures of the femoral shaft associated with bisphosphonate use.
The study cohort consisted of 12,777 Swedish women aged 55 years or older who sustained a fracture of the femur in 2008. The researchers identified those who had a subtrochanteric or shaft fracture and found 59 patients with atypical fractures. The 59 case patients were also compared with 263 control patients who had ordinary subtrochanteric or shaft fractures.
The increase in absolute risk was five cases per 10,000 patient-years. A total of 78 per cent of the case patients and 10 per cent of the controls had received bisphosphonates.
The risk was independent of coexisting conditions and of concurrent use of other drugs with known effects on bone.
The duration of use influenced the risk.
After drug withdrawal, the risk diminished by 70 per cent per year since the last use. The researchers concluded that although there was a high prevalence of current bisphosphonate use among patients with atypical fractures, the absolute risk was small.
Keeping an eye on the cost of age-related macular degeneration (AMD) drugs
N Engl J Med 2011; doi:10.1056/NEJMoa1102673
Clinical trials have established the efficacy of ranibizumab for the treatment of neovascular AMD. In addition, bevacizumab is used off-label to treat AMD, despite the absence of similar supporting data.
The cost of the former is substantial while the cost of the latter is minimal. In a multicentre single-blind study, researchers randomly assigned 1,208 patients with AMD to receive intravitreal injections of ranibizumab or bevacizumab on either a monthly schedule or as needed with monthly evaluation.
The primary outcome was the mean change in visual acuity at one year. The results with regards to visual acuity were identical although there were more serious adverse events with bevacizumab, which was unexpected and the authors did note this requires further study.
Complementary and alternative medicine (CAM) intervention in heart failure
Arch Intern Med 2011; 171: 750-7
This study was based on the observation that meditative exercise may have benefits for patients with chronic systolic heart failure. A single-blind, multisite, parallel-group, RCT evaluated 100 outpatients with systolic heart failure (New York Heart Association class I-III, left ventricular ejection fraction 40 per cent).
A group-based 12-week t'ai chi exercise program (n = 50) or time-matched education (n = 50, control group) was conducted.
Outcome measures included exercise capacity (six-minute walk test and peak oxygen uptake) and disease-specific quality of life.
The results showed no difference between the groups in terms of the outcome measures except in the quality of life measure, where the t'ai chi group improved in exercise self-efficacy and mood scores.
This shows that CAM improves quality of life scores solely as a result of human contact and has no effect on disease processes.
- Dr Palmer is a former Hampshire GP currently working in Australia, and a member of our team who regularly review the journals
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