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Objectives Clinicians are told to use the number needed to treat (NNT) to compare the benefits of therapeutic strategies, and researchers are asked to report results this way, generally without considering differences among the studies from which these were derived. Methods The crude NNT currently advocated is compared to the NNT standardized for a common outcome, follow-up time, study population and comparator. An NNT model for cardiovascular disease is described as an example that addresses differences among studies of secondary prevention of cardiovascular disease. Crude NNTs are compared to those obtained from the model. Results Follow-up in the 18 trials identified varied from 1.0 to 6.2 years; rates of cardiovascular events in the untreated subgroups ranged from 4.8% to 45.9%. The crude NNTs were more variable (9.1–163.7) than those obtained from the model (9.1–75.2). The effect of standardization was substantial in some cases, with proportional changes ranging from a 91% decrease to a 223% increase. Conclusion Using an NNT model to account for differences in study design allows for more meaningful comparisons.

Background: Asthma exacerbations affect quality of life for children with asthma. A cost-utility analysis was performed alongside the PLEASANT clinical trial to assess the cost-effectiveness of a letter intervention in preventing and lessening exacerbations in school-aged children at the start of a new school term. The economic analysis relied on published literature for health utilities estimates as no patient reported outcome measures were collected in the trial. Objective: To identify preference-based utility values for children with day-to-day asthma symptoms (baseline utility) and children experiencing an asthma exacerbation, and to review the appropriateness of the utility values to be used in the PLEASANT economic analysis. Methods: A systematic review was performed in five electronic databases (Ovid MEDLINE, The Cochrane Library, EMBASE, ECONLIT and SCHARR Health Utilities Database) up to 5th July 2014 to identify studies that report preference-based utility values in children with asthma. Results were summarised narratively and utility data were assessed for quality, relevance to the economic analysis and compliance with the NICE reference case. Results: A total of 927 studies were identified from the search and 14 studies which met the inclusion criteria were included. Health utilities were elicited using various outcome measurements. EQ-5D was used in 5 studies (35.7%), HUI, PAHOM and direct valuation using vignettes were each reported in 2 studies (14.3%). Three (21.4%) studies estimated utility values from mapping between condition specific measures and the EQ-5D. None of the studies directly measured health utilities in children with asthma exacerbation using a preference-based measure. Conclusions: There is a lack of robust estimates on utility decrement in children with asthma exacerbation. Future studies in children with asthma should incorporate collection of health state utilities into the study design, taking into account the ethical and methodological considerations of quality-of-life assessment during exacerbation.

OBJECTIVES: An array of antidepressant agents are available in the treatment of geropsychiatric patients with depression. While most current agents, such as the selective serotonin reuptake inhibitors (SSRI's) (e.g., fluoxetine; sertraline) and agents acting upon both serotonin and norepinephrine (e.g., mirtazapine; venlaxafine), are reasonably effective in ameliorating depressive symptomatology, less is known about the impact of these agents on other common areas of deficit in older depressed patients, such as cognition. This study examines change in cognitive functioning in geropsychiatric patients (age 55 and older) with major depression (ICD-9-CM codes 296.20-296.36) treated with fluoxetine (n = 269), mirtazapine (n = 275), sertraline (n = 713), or venlaxafine (n = 259). METHODS: Data were obtained from the CQI+SM Outcomes Measurement System, a Joint Commission of Accredited Hospital Organizations (JCAHO) ORYX accepted performance improvement system, which tracked patients admitted to geropsychiatric inpatient programs in 111 general hospitals across 33 states between 1997–1999. Cognitive functioning was measured at admission and discharge using the Mini-Mental State Examination (MMSE) (Folstein, Folstein, & McHugh, 1975). A Medication Usage Questionnaire was used to track medications prescribed to patients just prior to admission and at discharge. One-way Analyses of Variance and if significant, Tukey's pairwise comparisons, were used to compare medication groups. RESULTS: At admission, patients exhibited moderate evidence of cognitive impairment (Mean MMSE score of 21 out of 30). Medication groups were indistinguishable on change scores in cognitive functioning from time of admission to discharge (average length of stay around 16 days). The average change score on the MMSE was 1.1 to 1.6 points, suggesting very mild improvement. CONCLUSIONS: Antidepressant agents in this analysis were associated with modest improvement in cognitive functioning as assessed by the MMSE. New treatment modalities that improve cognition along with depressive symptomatology in older patients would be beneficial.

OBJECTIVES: While most current antidepressant agents, such as SSRIs and dual action agents are reasonably effective in ameliorating depressive symptomatology in older patients, less is known about their impact on concurrent instrumental activities of daily living (IADL's). This study examines change in IADL's, such as the capacity to use the telephone, travel, shop, cook, do housework, handle money, or take medicine, from admission to three-month post-discharge follow-up in geropsychiatric patients (age 55 and older) with major depression (ICD-9-CM codes 296.20-296.36) treated with fluoxetine (n = 77), mirtazapine (n = 36), sertraline (n = 145), or venlaxafine (n = 56). METHODS: Data were obtained from the CQI+SM Outcomes Measurement System, which tracked patients admitted to geropsychiatric inpatient programs in 111 general hospitals across 33 states between 1997–1999. IADL's were measured by selected items from the Duke OARS Multidimensional Functional Assessment Questionnaire (Lawton & Brody, 1969). A Medication Usage Questionnaire was used to track medications prescribed. One-way Analyses of Variance and if significant, Tukey's pairwise comparisons were used to compare medication groups. RESULTS: At admission, patients exhibited moderate to severe inability to independently carry out IADL's (Mean score of 14 to 15 out of 21). Medication groups were indistinguishable on change scores in overall IADL's from time of admission to follow-up. On average, patients showed no change in their ability to carry out IADL's during this time period, despite an improvement in level of depression, as measured by the collateral version of the Geriatric Depression Scale (Nitcher, Burke, Roccaforte, & Wengel, 1993). CONCLUSIONS: Antidepressant agents in this analysis were associated with modest improvement in IADL's as assessed by the Duke OARS Multidemsional Functional Assessment in Older Adults. New treatment modalities that improve IADL's along with depressive symptomatology in older patients would be beneficial. Further controlled studies are needed to better understand these findings.

Addition of pravastatin to dietary advice has been shown by the West of Scotland Coronary Prevention Study (WOSCOPS) to prevent the transition from health to cardiovascular disease. METHODS: An economic analysis was coducted to assess the cost-effectiveness of primary prevention with pravastatin. Appropriate Canadian risk factor data were used in an exponential regression model derived from WOSCOPS data to estimate the rates at which Canadians transition to cardiovascular disease. The number of transitions avoided were valued in terms of cost savings to the Canadian health care system, as well as life years gained. Canadian cost (1996 CAD $1 =$0.72 US) were based on ICD-9-CM Ontario Case Cost Project inpatient hospital data and were discounted at 5% per annum beyond the first year. The difference between age and gender-specific Canadian life table survival and post-event survival obtained from Scottish linkage data was calculated to estimate life years gained. RESULTS: The prevention of 303 transitions to CVD, which implies 3,067 years of life gained, would be achieved if 10,000 Candian hypercholesterolaemic men started treatment. Based on these results, cost-effectiveness ratios of $10,113/LYG (undiscounted) and $24,223/LYG (discounted) were obtained. If only high-risk patients (defined by published consensus statements) are treated, the ratios drop to between $6,865 and $16,391. CONCLUSION: In light of published Canadian economic analysis guidelines, this constitutes strong evidence for adoption of primary prevention with pravastatin to avoid the clinical manifestations of CVD.

Most guidelines for economic analysis call for discounting of health benefits. This major methodological point has rapidly moved form debate to common practice. Yet, the powerful effect that discounting can have on an analysis means that it may become the dominant factor in a therapeutic decision. These grave implications should cause pharmacoeconomic analysts to take pause. This workshop will examine the implications of discounting, its rationale and counterpoints, in an effort to establish whether discounting of benefits is justified or not. Topics covered will be: The Basis for Discounting; The Logical Implications of Discounting; and Discounting: A New Approach. Pharmacoeconomics is a fast evolving field. New thought should continually be put into refining its methodology. Ultimately, the aim of this workshop is to take time to rethink the various issues that surround discounting of health benefits.