BackgroundSystemic hypertension often accompanies chronic renal failure and can accelerate its progression to end-stage renal disease (ESRD). Adjunctive moxonidine appeared to have benefits versus adjunctive nitrendipine, in a randomised double-blind six-month trial in hypertensive patients with advanced renal failure. To understand the longer term effects and costs of moxonidine, a decision analytic model was developed and a cost-effectiveness analysis performed.MethodsA Markov model was used to extrapolate results from the trial over three years. All patients started in a non-ESRD state. After each cycle, patients with a glomerular filtration rate below 15 ml/min had progressed to an ESRD state.The cost-effectiveness analysis was based on the Dutch healthcare perspective. The main outcome measure was incremental cost per life-year gained. The percentage of patients progressing to ESRD and cumulative costs were also compared after three years. In the base case analysis, all patients with ESRD received dialysis.ResultsThe model predicted that after three years, 38.9% (95%CI 31.8–45.8) of patients treated with nitrendipine progressed to ESRD compared to 7.5% (95%CI 3.5–12.7) of patients treated with moxonidine. Treatment with standard antihypertensive therapy and adjunctive moxonidine was predicted to reduce the number of ESRD cases by 81% over three years compared to adjunctive nitrendipine.The cumulative costs per patient were significantly lower in the moxonidine group €9,858 (95% CI 5,501–16,174) than in the nitrendipine group €37,472 (95% CI 27,957–49,478).The model showed moxonidine to be dominant compared to nitrendipine, increasing life-years lived by 0.044 (95%CI 0.020–0.070) years and at a cost-saving of €27,615 (95%CI 16,894–39,583) per patient.Probabilistic analyses confirmed that the moxonidine strategy was dominant over nitrendipine in over 98.9% of cases. The cumulative 3-year costs and LYL continued to favour the moxonidine strategy in all sensitivity analyses performed.ConclusionTreatment with standard antihypertensive therapy and adjunctive moxonidine in hypertensive patients with advanced renal failure was predicted to reduce the number of new ESRD cases over three years compared to adjunctive nitrendipine. The model showed that adjunctive moxonidine could increase life-years lived and provide long term cost savings.
BACKGROUND: Atrial Fibrillation (AF) is the most frequent type of arrhythmia. Termination of acute AF is generally undertaken in a hospital setting. Available drugs for termination of acute AF have severe side effects and complicated dose regimens. There is a need for new drugs with a high conversion rate, favourable safety profile and easier dosing. OBJECTIVES: To describe the characteristics and hospital treatment patterns of patients with AF. To investigate the requirements for an improved cost‐effective anti‐arrhythmic therapy. METHODS: A database was used containing aggregated and anonymised diagnostic information, hospital experience (e.g., length of stay), and demographic data for over 80 million inpatient episodes in the UK over ten years. The database contains 28,524 hospital admissions of patients (65 and over) with a diagnosis of AF during 1999/2000. 53.3% are female, with mean length of stay (LOS) 6.1 days; 46.7% are male with LOS 4.3 days. Controlling for age, the gender LOS difference is significant (p < 0.01). RESULTS: Comorbid Conditions. 17.5% of AF patients also had a diagnosis of chronic ischaemic heart disease (IHD), a further 7.5% had myocardial ischaemia, and 19.5%, congestive heart failure. Furthermore, 24.2% of CHF patients and 16.9% of all angina patients also had clinically significant AF. Cardioversion. Cardioversion (defibrillation) is used when pharmacological therapy fails to terminate acute AF. However, significant numbers (35%) of cardioversion procedures were undertaken on an elective day case basis. We are currently investigating and will report on the resource consequences in acute AF. CONCLUSIONS: There is a clear unmet medical need for improved anti‐arrhythmic drugs. Using the dataset, we identify two potentially cost‐effective possibilities for improved anti‐arrhythmic treatment: an agent which can simultaneously demonstrate effectiveness in associated cardiovascular conditions such as IHD or CHF; or an agent reducing the need for cardioversion in acute AF.
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