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Sodium-glucose cotransporter 2 inhibitors have been shown to reduce cardiovascular events but are currently not used as the first-line therapy. This study was conducted to evaluate the cost-effectiveness of first-line empagliflozin plus metformin versus metformin monotherapy among Australians with type 2 diabetes mellitus (T2DM) and existing cardiovascular disease (CVD).A Markov model with 1-year cycles and a 5-year time horizon was constructed to simulate the occurrence of recurrent cardiovascular events among Australians aged 50 to 84 years with T2DM and CVD. Efficacy results were derived from the Empagliflozin Cardiovascular Outcome Event Trial in Type 2 Diabetes Mellitus Patients-Removing Excess Glucose trial. Costs and utilities were drawn from published sources. The evaluation adopted both health care and societal perspectives, with the latter ascribing the Australian government's "value of statistical life year" (A$213 000) to each year lived by a person. Future outcomes were discounted at 5% annually. Sensitivity analyses were conducted to enhance the robustness of conclusions.Compared with metformin monotherapy, first-line empagliflozin plus metformin reduced overall cardiovascular events by 0.82% and overall deaths by 7.72% over 5 years. There were 0.2 years of life saved per person and 0.16 quality-adjusted life years gained, at a net health care cost of A$4408. These equated to incremental cost-effectiveness ratios of A$22 076 per year of life saved and A$28 244 per quality-adjusted life year gained. The gains in the value of statistical life year equated to A$42 530 per person, meaning that from a societal perspective, the intervention was cost-saving.First-line empagliflozin plus metformin may represent a cost-effective strategy for the management of T2DM and CVD in Australia.

Objective: The aim was to project the health and economic outcomes of cardiovascular disease (CVD) among people with type 2 diabetes from Australian public healthcare and societal perspectives over the next decade. Methods: A dynamic multistate model with yearly cycles was developed to project cardiovascular events among Australians with type 2 diabetes aged 40–89 years from 2022 to 2031. CVD risk (myocardial infarction [MI] and stroke) in the type 2 diabetes population was estimated using the 2013 pooled cohort equation, and recurrent cardiovascular event rates in the type 2 diabetes with established CVD population were obtained from the global Reduction of Atherothrombosis for Continued Health (REACH) registry. Costs and utilities were derived from published sources. Outcomes included fatal and non-fatal MI and stroke, years of life lived, quality-adjusted life years (QALYs), total healthcare costs, and total productivity losses. The annual discount rate was 5%, applied to outcomes and costs. Results: Between 2022 and 2031, a total of 83,618 non-fatal MIs (95% uncertainty interval [UI] 83,170–84,053) and 58,774 non-fatal strokes (95% UI 58,458–59,013) were projected. Total years of life lived and QALYs (discounted) were projected to be 9,549,487 (95% UI 9,416,423–9,654,043) and 6,632,897 (95% UI 5,065,606–7,591,679), respectively. Total healthcare costs and total lost productivity costs (discounted) were projected to be 9.59 billion Australian dollars (AU$) (95% UI 1.90–30.45 billion) and AU$9.07 billion (95% UI 663.53 million–33.19 billion), respectively. Conclusions: CVD in people with type 2 diabetes will substantially impact the Australian healthcare system and society over the next decade. Future work to investigate different strategies to optimize the control of risk factors for the prevention and treatment of CVD in type 2 diabetes in Australia is warranted.

This was a first-time evaluation that sought to analyze the cost-effectiveness of oral paracetamol and intravenous (IV) indomethacin as alternatives to ibuprofen for PDA in neonates. Decision-analytic, literature-based, economic simulation models were constructed, to follow up the use and consequences of oral/IV ibuprofen versus IV indomethacin, and oral/IV ibuprofen versus oral paracetamol, as first-line therapies for PDA closure. Model outcomes of interest were 'success', defined as PDA closure with/without adverse events, or 'failure' due to no response to the first course of treatment, death or premature discontinuation of therapy due to AEs. Oral ibuprofen is dominant/cost-effective over IV indomethacin in 97.9% of simulated cases, but oral paracetamol was 75.2% dominant/cost-effective over oral ibuprofen. Against IV ibuprofen, IV indomethacin was 55.3% dominant/cost-effective, whereas oral paracetamol was dominant/cost-effective in 98.5% of the cases. Sensitivity analyses confirmed the robustness of the study results. For PDA closure, while IV indomethacin was cost-effective against IV ibuprofen, oral paracetamol was cost-effective against both oral and IV ibuprofen.

Background Patients having CYP2C19 loss-of-function alleles and receiving clopidogrel are at higher risk of adverse cardiovascular outcomes. Ticagrelor is an effective antiplatelet that is unaffected by the CYP2C19 polymorphism. The main aim of the current research is to evaluate the cost-effectiveness among CYP2C19 genotype-guided therapy, universal ticagrelor, and universal clopidogrel after a percutaneous coronary intervention (PCI). Methods A two-part decision-analytic model, including a one-year model and a 20-year follow-up Markov model, was created to follow the use of (i) universal clopidogrel, (ii) universal ticagrelor, and (iii) genotype-guided antiplatelet therapy. Outcome measures were the incremental cost-effectiveness ratio (ICER, cost/success) and incremental cost-utility ratio (ICUR, cost/quality-adjusted life years [QALY]). Therapy success was defined as survival without myocardial infarction, stroke, cardiovascular death, stent thrombosis, and no therapy discontinuation because of adverse events, i.e. major bleeding and dyspnea. The model was based on a multivariate analysis, and a sensitivity analysis confirmed the robustness of the model outcomes, including against variations in drug acquisition costs. Results Against universal clopidogrel, genotype-guided therapy was cost-effective over the one-year duration (ICER, USD 6102 /success), and dominant over the long-term. Genotype-guided therapy was dominant against universal ticagrelor over the one-year duration, and cost-effective over the long term (ICUR, USD 1383 /QALY). Universal clopidogrel was dominant over ticagrelor for the short term, and cost-effective over the long-term (ICUR, USD 10,616 /QALY). Conclusion CYP2C19 genotype-guided therapy appears to be the preferred antiplatelet strategy, followed by universal clopidogrel, and then universal ticagrelor for post-PCI patients in Qatar.

Background In line with global trends, cancer incidence and mortality may have decreased for specific types of cancer in Qatar. However, the cancer-related burden on patients, healthcare systems, and the economy is expected to expand; thus, cancer remains a significant public healthcare issue in Qatar. Qatar’s free access to cancer care represents a considerable economic burden. Ensuring the best utilization of financial resources in the healthcare sector is important to provide unified and fair access to cancer care for all patients. Experts from the Qatar Oncology Health Economics Expert Panel (Q-OHEP) aimed to establish a consistent and robust base for evaluating oncology/hematology medications; involve patients’ insights to accelerate access to cutting-edge medications; increase the value of cancer care; and reach a consensus for using cost-effective strategies and efficient methodologies in cancer treatment. Methods The Q-OHEP convened on 30 November 2021 for a 3-hour meeting to discuss cancer management, therapeutics, and health economics in Qatar, focusing on four domains: (1) regulatory, (2) procurement, (3) treatment, and (4) patients. Discussions, guided by a moderator, focused on a list of suggested open-ended questions. Results Some of the salient recommendations included the development of a formal, fast-track, preliminary approval pathway for drugs needed by patients with severe disease or in critical condition; and encouraging and promoting the conduct of local clinical trials and real-world observational studies using existing registry data. The Q-OHEP also recommended implementing a forecast system using treatment center data based on the supply/demand of formulary oncology drugs to detect treatment patterns, estimate needs, expedite procurement, and prevent shortages/delays. Furthermore, the panel discussed the needs to define value concerning cancer treatment in Qatar, implement value-based models for reimbursement decision-making such as health technology assessment and multiple-criteria decision analysis, and promote patient education and involvement/feedback in developing and implementing cancer management guidelines. Conclusion Herein, we summarize the first Q-OHEP consensus recommendations, which aim to provide a solid basis for evaluating, registering, and approving new cancer medications to accelerate patient access to novel cancer treatments in Qatar; promote/facilitate the adoption and collection of patient-reported outcomes; and implement value-based cancer care in Qatar.

Although previous cost‐effectiveness evaluations of sacubitril/valsartan have demonstrated cardiovascular and economic benefits in heart failure patients with reduced ejection fraction (HFrEF), whether sacubitril/valsartan is cost-effective for reducing the need for implantable cardioverter-defibrillator (ICD) implantation and the risk of death in ICD‐eligible patients has not been investigated in patients with HFrEF. Herein, we evaluated the cost-effectiveness of sacubitril/valsartan versus standard of care in reducing the need for ICD implantation and the death rate in HFrEF. A Markov model was developed from the Qatari hospital perspective, comprised of ‘survival’ and ‘death’ health states, and was based on 1-monthly Markovian cycles, a 20-years follow-up horizon, and a 3% discount rate. The model inputs were obtained from the literature and local sources. Sacubitril/valsartan resulted in a relative increase of 0.04 quality-adjusted life year (QALY) and 0.67 years of life lived (YLL)/person, with an incremental cost increase of QAR13,952 (USD3,832). Sacubitril/valsartan was associated with incremental cost effectiveness ratio of QAR341,113 (USD93,687)/QALYs gained and QAR24,431 (USD6,710)/YLL. Sensitivity analyses confirmed robustness, with the cost-effectiveness maintained in ≥96.5% of simulated cases. To conclude, sacubitril/valsartan is a cost-effective alternative to standard care against QALY gained and YLL in reducing the need for an ICD therapy and the rate of death among ICD-eligible HFrEF patients.

Ibuprofen and paracetamol (acetaminophen) are very commonly used for analgesia and pain. In 2020, the US FDA gave its first approval of a fixed-dose combination (FDC) of the two drugs in the same tablet for postoperative pain. There has been no quantitative, summative analysis of the FDC effect size measures against postoperative pain in adults. Similar analyses exist, but only in pediatric patients. This was the first meta-analysis to compare the efficacy and safety outcomes of the ibuprofen/paracetamol FDC against placebo, administered postoperatively, for moderate to severe pain relief in adults. The MEDLINE, EMBASE, and Cochrane CENTRAL databases, in addition to the grey literature, were searched for clinical trials until April 2020, to identify comparative literature studies of the ibuprofen/paracetamol FDC in acute postoperative pain in adults. No restrictions on doses, formulations (oral, intravenous), and underlying type of surgery were applied. Independent reviewers performed the study selection, data extraction, and the risk-of-bias and quality-of-evidence assessments based on the Cochrane criteria. The outcome measures of interest in the meta-analysis were ≥ 50% pain relief , need for rescue medications, and occurrence of adverse drug events. Statistical analyses using a random-effects model were performed, at a statistical significance of p

Background The impact of midazolam on the overall performance of morphine therapy for pain in ventilated neonates with respiratory distress syndrome (RDS) has never been investigated. Objective This study is a clinical and economic analysis of morphine monotherapy versus morphine plus midazolam in ventilated infants with RDS. Methods A decision-analytic model from the hospital perspective was developed to follow the consequences of the use of the study drugs. Clinical and resource utilization data were extracted based on a retrospective cohort study of 104 neonates with RDS receiving morphine alone versus in combination with midazolam at the main neonatal intensive care unit (NICU) in Qatar, from 2014 to 2019. Primary outcome measures were the analgesia success rate, via the Premature Infant Pain Profile scale, and overall costs of therapies. Multivariate statistical analyses confirmed no significant variations in baseline characteristics between study groups. Results With 0.05 significance and 80% power, morphine had a higher rate of successful analgesia (65.4 vs. 34.6%; risk ratio 1.91; 95% confidence interval 1.11–3.28; p = 0.019). Overall costs were also in favor of morphine compared with its combination with midazolam, with cost savings of 40,959 Qatari Riyal ($US11,222), year 2019/20 values. The Monte Carlo analyses confirmed the economic advantage of morphine alone in 100% of cases and demonstrated that it is not sensitive to uncertainties in study model inputs. Conclusions Morphine monotherapy enabled enhanced pain relief over its combination with midazolam in the NICU, at a reduced overall cost. Morphine alone, therefore, seems to be a dominant analgesia strategy. Electronic supplementary material The online version of this article (10.1007/s40272-020-00432-0) contains supplementary material, which is available to authorized users.

Aim: To conduct a systematic overview of systematic reviews (SRs) and randomized clinical trials (RCTs) on surfactant therapy in neonatal meconium aspiration syndrome. Methods: We searched EMBASE, PROQUEST and PubMed to summarize the different effects of surfactant lung lavage and bolus surfactant therapies in neonates with meconium aspiration syndrome. Results: With a total of 1377 patients, three SRs and two RCTs were included in analysis. Surfactant effectiveness was concluded by low-quality SRs, with high risk of bias, which was contradicted by high-quality SRs, with low risk of bias. In SRs, the surfactant lung lavage reduced mortality, need for extracorporeal membrane oxygenation and hospitalization, while the bolus surfactant did not. In recent high-quality RCTs, however, the two modalities did not significantly differ. Conclusion: The evidence on surfactant effectiveness and its method of administration is sparse and inconsistent.

Although studies of nonstatin lipid-lowering therapies have demonstrated cardiovascular benefits; whether these benefits provide good value has not been evaluated in type 2 diabetes mellitus patients. A systematic review was performed to include studies on the cost-effectiveness of non-statin lipid-lowering therapies in type 2 diabetes mellitus patients with/without cardiovascular disease. Thirteen studies were included; ezetimibe (n = 8), proprotein convertase subtilisin/kexin type 9 inhibitors (n = 4), fenofibrate (n = 2), nicotinic acid (n = 1), extended-release niacin/laropiprant (n = 1), and icosapent ethyl (n = 1). Six studies considered ezetimibe + statin to be a cost-effective compared to statins monotherapy, three studies suggested that proprotein convertase subtilisin/kexin type 9inhibitors + statins were not cost-effective compared to statin + ezetimibe. Fenofibrate was a cost-effective either as monotherapy or combined with a statin compared to statin or fenofibrate monotherapy. Nicotinic acid and proprotein convertase subtilisin/kexin type 9 compared to statin monotherapy were also cost-effective. Icosapent ethyl was cost-effective compared to standard care but not using the wholesale acquisition cost.

This study answers the question of whether the health care costs of managing COVID-19 in preexisting cardiovascular diseases (CVD) patients increased or decreased as a consequence of evidence-based efforts to optimize the initial COVID-19 management protocol in a CVD group of patients. A retrospective cohort study was conducted in preexisting CVD patients with COVID-19 in Hamad Medical Corporation, Qatar. From the health care perspective, only direct medical costs were considered, adjusted to their 2021 values. The impact of revising the protocol was a reduction in the overall costs in non-critically ill patients from QAR15,447 (USD 4243) to QAR4337 (USD 1191) per patient, with an economic benefit of QAR11,110 (USD 3051). In the critically ill patients, however, the cost increased from QAR202,094 (USD 55,505) to QAR292,856 (USD 80,433) per patient, with added cost of QAR90,762 (USD 24,928). Overall, regardless of critical care status, the optimization of the initial COVID-19 protocols in patients with preexisting CVD did not reduce overall health care costs, but increased it by QAR80,529 (USD 22,117) per patient.

Background: Clinical pharmacists play a key role in ensuring the optimum use of cancer medicines. Yet, the economic benefit of this role has never been assessed in Qatar. Aim: To evaluate the overall economic impact of clinical pharmacist interventions in the main cancer care setting in Qatar. Methods: From the public healthcare perspective, this was an analysis of the total economic benefit and a cost-benefit analysis of the clinical pharmacy interventions. As a study sample size, patient records in March 2018, July/August 2018, and January 2019 were retrospectively reviewed at the National Center for Cancer Care & Research (NCCCR), Qatar. The total benefit from interventions was the total of the cost avoidance due to preventable adverse drug events (ADEs) plus the cost savings associated with therapeutic interventions. The interventions cost was based on salary and increased cost due to therapeutic interventions. The cost-benefit analysis results were presented via net benefit and benefit‐to‐cost ratio measures. Results : Total of 1,352 interventions occurred during the 3-month follow-up period. The total benefit was QAR 196,010,360 (USD53,834,206), constituting cost avoidance of QAR 194,764,534 (USD 53,492,040) and cost savings of QAR 1,245,826 (USD 342,166), mostly due to recommending additional medications and the medication dose reduction. The benefit-to-cost ratio was 174:1 and the annual net benefit was QAR 779,539,440 (USD 214,100,351). Sensitivity analyses confirmed the robustness of results. Conclusion: The clinical pharmacist intervention is a cost-beneficial practice in the NCCCR setting, associated with ADEs prevention and substantial economic benefits, including relative to the interventions cost.

Background The economic benefit of the clinical pharmacist's role in ensuring the optimum use of medicines is potentially considerable, particularly when it comes to cancer management. We sought to evaluate the overall economic impact of clinical pharmacist interventions in the main cancer setting in Qatar. Methods The total economic benefit of the clinical pharmacy interventions were analyzed from the public hospital perspective. Patient records in March 2018, July/August 2018, and January 2019 were retrospectively reviewed at the National Center for Cancer Care and Research, Qatar. The total benefit from interventions was the total cost avoidance due to preventable adverse drug events plus any cost savings associated with therapeutic-based resource use. Sensitivity analyses confirmed the results’ robustness and increased generalizability. Results A total of 1352 interventions based on 281 patients were analyzed. The majority of the drug-related problems were related to the appropriateness of therapy, followed by dosing and administration. The total population benefit over the 3-months study period was QAR 4,879,185 (USD 1,336,763), constituting cost avoidance of QAR 4,234,012 (USD 1,160,003) and negative resource-use cost savings of −QAR 645,174 (−USD 176,760). Projected annual overall benefit was QAR 14,355,354 (USD 3,932,974). The increase in resource use with therapies was mostly because of the addition of other medications. Cost avoidance was mostly driven by recommending additional medications and discontinuation of medications. The uncertainty analysis demonstrated the robustness of outcomes. Conclusions The clinical pharmacist intervention increased resource use and its cost. In overall, however, taking avoided cost of adverse drug events in consideration, it is an economically beneficial practice in the National Center for Cancer Care and Research setting, associated with adverse drug events prevention and substantial economic benefits.

Background Thrombus load in STEMI patients remains a challenge in practice. It aggravates coronary obstruction leading to impaired myocardial perfusion, worsened cardiac function, and adverse clinical outcomes. Various strategies have been advocated to reduce thrombus burden. Objectives This meta-analysis aimed to evaluate the effectiveness of intracoronary-administered thrombolytics or glycoprotein IIb/IIIa inhibitors (GPI) in comparison with aspiration thrombectomy (AT) as an adjunct to percutaneous coronary intervention (PCI) among patients presenting with ST-segment elevation myocardial infarction (STEMI). Methods A comprehensive literature search for randomized trials that compared intracoronary-administered thrombolytics or GPI with AT in STEMI patients who underwent PCI, was conducted using various databases (e.g., MEDLINE, EMBASE, CENTRALE). Primary outcome was procedural measures (e.g., TIMI flow grade 3, TIMI myocardial perfusion grade (TMPG) 3, Myocardial blush grade (MBG) 2/3, ST-segment resolution (STR)). Results Twelve randomized trials enrolled 1,466 patients: 696 were randomized to intracoronary-administered pharmacological interventions and 553 to AT. Patients randomized to PCI alone were excluded. Thrombolytics significantly improved TIMI flow grade 3 (odds ratio = 3.71, 95% CI: 1.85–7.45), complete STR (odds ratio = 3.64, 95% CI: 1.60–8.26), and TMPG 3 (odds ratio = 5.31, 95% CI: 2.48–11.36). Thrombolytics significantly reduced major adverse cardiovascular events (MACE) (odds ratio = 0.29, 95% CI: 0.13–0.65) without increasing bleeding risk. Trial sequential analysis assessment confirmed the superiority of thrombolytics for the primary outcome. Intracoronary GPI, either alone or combined with AT, did not improve procedural or clinical outcomes. Conclusions Compared with AT, intracoronary-administered thrombolytics significantly improved myocardial perfusion and MACE in STEMI patients.

Introduction: Vancomycin is commonly used for the treatment of complicated infections caused by methicillin-resistant Staphylococcus aureus. The impact of vancomycin therapeutic drug monitoring (TDM) quality indices on clinical outcomes has not been previously explored. Objectives: This study aims to relate routine vancomycin TDM service quality indices to clinical effectiveness outcomes and to develop a pragmatic vancomycin-specific TDM quality assessment tool that can be used in quality audits. Methods: A retrospective chart review was conducted on adult non-dialysis vancomycin TDM records documented between January 2014 and October 2016 in three tertiary care hospitals under Hamad Medical Corporation (HMC) in Qatar. Evidence-based criteria and pilot-testing were applied to develop a quality assessment tool. The appropriateness of vancomycin TDM service and clinical outcomes were simultaneously evaluated. Results: A 13-criterion vancomycin TDM quality assessment tool was developed and used to evaluate 208 TDM records involving 99 patients. The indications for TDM requests were judged appropriate in 77.4% (n = 161) of the records. However, most of the blood samples were deemed to be incorrectly timed (70.7%, n = 147). Inappropriate vancomycin TDM practices compared with appropriate practices were associated with lower therapeutic cure (47.3% vs 75%, P-value =.009). Conclusions: Vancomycin TDM requests were justified at HMC. However, inappropriate practices were associated with suboptimal clinical outcomes, signifying the importance of routine quality audits using rigorous evaluation tools. The developed tool can be used to determine setting-specific deficiencies in routine vancomycin TDM practices. 2020 Pharmacotherapy Publications, Inc. This study was funded by Qatar University, Student Grant (QUST-CPH-SPR-14/15-12). Scopus

Background Mechanically ventilated patients with respiratory disorders may require sedatives, such as opioids. Objectives To define methodological trends, gaps, and the reporting quality of the comparative clinical and economic evaluations of fentanyl and morphine in ventilated patients in the intensive care unit. Methods We conducted a literature review of the MEDLINE, Embase, OVID, ScienceDirect, Springer Link, and EconLit databases, comparing studies in the management of ventilated patients with respiratory disorders in the intensive care unit using either fentanyl or morphine, or both. We assessed the methodological aspects of the literature characteristics and trends of, for example, modeling, data sources, cost calculation, and data analysis, appraising the quality of reporting via the CONsolidated Standards Of Reporting Trials, STrengthening the Reporting of OBservational studies in Epidemiology, and the Consolidated Health Economic Evaluation Reporting Standards checklists. Results Among 1327 articles, 33 (comprising 22 in adults, 8 in neonates, and 3 in pediatrics) met the inclusion criteria. No head-to-head morphine versus fentanyl evaluations explicitly confined to subjects with respiratory conditions were undertaken. Studies relied on various scales to measure the sedation level as a primary study outcome, limiting the comparability of study conclusions. Seven articles of adults were identified to be economic studies from the hospital perspective. On the basis of different endpoints, the same sedation regimen performed differently in various studies. None of the randomized controlled trials, observational cohorts, or pharmacoeconomics studies met most of the assessed reporting quality criteria. Conclusions Our review identified poor reporting quality and high heterogeneity of methods used, potentially limiting the degree to which studies could be interpreted, decisions could be influenced, and findings could be generalized.

Rationale, aims, and objectives Clinical pharmacy services are vital in the prevention of adverse drug events (ADEs) in clinical practice, extending beyond the hospital to chronic disease management in outpatient settings. This study sought to evaluate the cost benefit of a clinical pharmacy intervention in resolving treatment-related problems (TRPs) among hospital outpatients with chronic diseases. Methods From the hospital system perspective, the cost-benefit analysis was based on a randomized clinical trial in the general outpatients of the major hospital in Jordan. Eligible patients were randomly assigned to either an intervention or a control group. TRPs were identified in both study groups, but interventions were delivered only to the intervention group via a home medication management review (HMMR) by a clinical pharmacist. A follow-up in both groups took place 3 months after recruitment. The total economic benefit was the sum of (a) cost savings due to intervention and (b) cost avoidance associated with preventable ADEs. The primary outcome measures were the net benefit and benefit-to-cost ratio with the clinical pharmacist-based HMMR. Results In both groups, 158 TRPs were identified, and 79 interventions were provided in the study group. The monthly cost of intervention was JD764 (US $1078), and the total monthly benefit was JD4570 (US $6444), leading to a benefit-to-cost ratio of 5.98 and an annual net benefit of JD45 669 (US $64 393). Sensitivity analyses confirmed the robustness of results. Conclusion The RCT-based cost-benefit evaluation provided evidence-based insight into the economic benefit of a clinical pharmacist-provided HMMR for preventing ADEs in the general chronic diseases outpatients. This intervention method against the TRPs among outpatients is cost beneficial and offers substantial cost savings to the health care hospital payer in Jordan.

It has been speculated that out-of-hospital cardiac arrest (OHCA) patients’ survival might be improved by implementing extracorporeal cardiopulmonary resuscitation (ECPR) before arrival to hospital. Therefore, we sought to assess the cost-effectiveness of OH-ECPR versus in-hospital (IH)-ECPR in OHCA patients in Qatar. From the hospital perspective, a conventional decision-analytic model was constructed to follow up the clinical and economic consequences of OH-ECPR versus IH-ECPR in a simulated OHCA population over one year. The primary outcome was the survival at discharge after arrest as well as the overall direct healthcare costs of managing OHCA patients. The robustness of this model was evaluated via sensitivity analyses. The OH-ECPR yielded 16% survival at discharge after arrest compared to 7% with IH-ECPR, [risk ratio (RR)=0.91; 95% CI 0.79 to 1.06; P = 0.26]. Incorporating the uncertainty associated with this survival rate, and based on the estimated willingness to pay threshold in Qatar, the OH-ECPR was cost-effective with an incremental cost-effectiveness ratio of QAR 464,589 (USD 127,634). Sensitivity and uncertainty analyses confirmed the robustness of the study outcome. This is the first cost-effectiveness evaluation of OH-ECPR versus IH-ECPR in OHCA patients. OH-ECPR is potentially an economically acceptable resuscitative strategy in Qatar. Open access funding was provided by the Qatar National Library.

Background. Describe the design, delivery and impact of a course delivered in an undergraduate pharmacy program with students whose first language is not English. The aim of this course is to develop pharmacy students’ scientific writing, peer assessment and critical appraisal skills. Methods. The course is offered in the final year of an undergraduate pharmacy program. In this course, students wrote two structured pharmacy review articles (PRA) based on assigned scientific research articles and peer assessed each others’ written PRAs. Students also critically appraised scientific research articles on a weekly basis, completed one pre-journal club written reflective critique based on a assigned scientific research article and moderated one journal club session. Results. Course rubrics were developed and validated by the course coordinators. A survey that was administered to students enrolled in the course identified that 85% of the students perceived that they gained adequate writing skills in the course. More than 70% of the students indicated they had the necessary skills to evaluate their peers’ written assessments and 93% felt comfortable providing and receiving feedback from peers. More than 90% of the students indicated that their understanding of the primary research articles assigned improved as a result of their contribution to the peer assessment process and writing of PRAs. Conclusion. This course improved students scientific writing, peer assessment and critical appraisal skills. Further practice is required to reinforce the skills learned and to strengthen the writing skills of students.

Islam Eljilany,1 Mohamed Elarref,2 Nabil Shallik,2– 5 Abdel-Naser Elzouki,6– 8 Loulia Bader,1 Ahmed El-Bardissy,9 Osama Abdelsamad,10 Daoud Al-Badriyeh,1 Larisa H Cavallari,11 Hazem Elewa1,10,12 1College of Pharmacy, QU Health, Qatar University, Doha, Qatar; 2Department of Anesthesia, Hamad General Hospital, Hamad Medical Corporation, Doha, Qatar; 3Department of Anesthesia, Faculty of Medicine, Tanta University, Tanta, Egypt; 4Department of Clinical Anesthesia, College of Medicine, Qatar University, Doha, Qatar; 5Department of Clinical Anesthesia, Weill Cornell Medical College, Doha, Qatar; 6Department of Medicine, Hamad General Hospital, Hamad Medical Corporation, Doha, Qatar; 7Department of Internal Medicine, College of Medicine, Qatar University, Doha, Qatar; 8Department of Internal Medicine, Weill Cornell Medical College, Doha, Qatar; 9Department of Pharmacy, Hamad General Hospital, Hamad Medical Corporation, Doha, Qatar; 10Department of Pharmacy, Al Wakra Hospital, Hamad Medical Corporation, Doha, Qatar; 11Department of Pharmacotherapy and Translation Research, Center for Pharmacogenomics and Precision Medicine, College of Pharmacy, University of Florida, Gainesville, FL, USA; 12Biomedical and Pharmaceutical Research Unit, QU Health, Qatar University, Doha, QatarCorrespondence: Hazem ElewaBiomedical and Pharmaceutical Research Unit, QU Health, Qatar University, P.O. Box 2713, Doha, QatarTel +974 66628838Fax +974 44035551Email Hazem.elewa@qu.edu.qaBackground: Annually, 10% of warfarin patients will likely need to stop warfarin prior to elective surgery to achieve a baseline international normalization ratio (INR) level (INR ≤ 1.2) at the time of the procedure. This study explores the influence of genetic and non-genetic factors on INR normalization in the Arab (major part of Near Eastern) population in preprocedural warfarin management.Methods: An observational prospective cohort study was designed to recruit Arab patients taking warfarin and scheduled for an elective procedure. Two INR readings were recorded. DNA extraction and genotyping of variants in CYP2C9*2, CYP2C9*3, CYP4F2*3, VKORC1*2, and FII (rs5896) and FVII (rs3093229) genes using real-time polymerase chain reaction were performed.Results: Data from 116 patients were included in the analysis. CYP2C9 and VKORC1 genetic variants carriers required lower maintenance dose compared to non-carriers. The analysis showed that ciprofloxacin, antiplatelet medications, and INR index (INR at visit 1) are the only factors associated with the INR decline rate. Also, the proportion of CYP2C9*3 carriers with normal INR (≤ 1.2) on the day of surgery was significantly lower than those with wild-type genotype (28% vs 60%, p=0.013). In addition, heparin bridging, INR target, and Sudanese nationality are significant predictors of INR normalization (≤ 1.2) on the day of the procedure.Conclusion: Despite the confirmed effect of genetic factors on warfarin maintenance dose, the study was not able to find a significant effect of any genetic factor on the rate of INR normalization possibly due to the small sample size. Index INR and interacting medications showed to be significant predictors of INR decline rate.Keywords: INR, periprocedural, pharmacogenetics, pharmacogenomics, warfarin

Aim: To systematically review ibuprofen, including versus indomethacin and paracetamol/acetaminophen, for the closure of patent ductus arteriosus (PDA). Methods: Pubmed, Embase, Cochrane and gray literature were searched to summarize ibuprofen outcomes in closure of PDA in published meta-analyses (MAs). Results: Seven MAs were included. Including high dose (HD) use, ibuprofen is equivalent/superior to indomethacin, and inferior/equivalent to paracetamol. Oral ibuprofen had higher efficacy than IV ibuprofen, including compared with indomethacin and paracetamol. Ibuprofen had safety advantages over indomethacin. Indomethacin and paracetamol had safety advantages over IV ibuprofen. HD of ibuprofen increases efficacy, but not toxicity. Conclusion: Evidence on ibuprofen effectiveness and safety, including the dosage forms, is limited by heterogeneity in doses and the levels of methods quality and risk of bias.

The warfarin peri-procedural management in Qatar is predominantly based on bridging (63%), compared to non-bridging. This study sought to perform a first-time cost analysis of current warfarin peri-procedural management practices, including a cost-effectiveness analysis (CEA) of predominant bridging vs predominant non-bridging practices. From the hospital perspective, a one-year decision-analytic model followed the cost and success consequences of the peri-procedural warfarin in a hypothetical cohort of 10,000 atrial fibrillation patients. Success was defined as survival with no adverse events. Outcome measures were the cost and success consequences of the 63% bridging (vs not-bridging) practice in the study setting, ie, Hamad Medical Corporation, Qatar, and the incremental cost-effectiveness ratio (ICER, cost/success) of the warfarin therapy when predominantly bridging based vs when predominantly non-bridging based. The model was based on Monte Carlo simulation, and sensitivity analyses were performed to confirm the robustness of the study conclusions. As per 63% bridging practices, the mean overall cost of peri-procedural warfarin management per patient was USD 3,260 (QAR 11,900), associated with an overall success rate of 0.752. Based on the CEA, predominant bridging was dominant (lower cost, higher effect) over the predominant non-bridging practice in 62.2% of simulated cases, with a cost-saving of up to USD 2,001 (QAR 7,303) at an average of USD 272 (QAR 993) and was cost-effective in 36.9% of cases. Being between cost-saving and cost-effective, compared to predominant non-bridging practices, the predominant use of bridging with warfarin seems to be a favorable strategy in atrial fibrillation patients.

The use of anticoagulant bridging remains controversial. This study was conducted to evaluate our warfarin periprocedural management in Qatar and investigate the associated clinical outcomes with such management.A prospective cohort study was designed to describe the periprocedural clinical practice in warfarin patients in Qatar and to compare clinical safety and efficacy outcomes between anticoagulant bridging and nonbridging.103 patients were recruited. Bridging occurred in 82% of the participants. No thromboembolic events were observed, while 39.1% of patients experienced bleeding events during the study period. The incidence of overall bleeding and major bleeding were numerically higher for bridging group compared to nonbridging but did not reach statistical significance ([30.6% vs 22.2%, P = 0.478] and [12.9% vs 5.6%, P = 0.375], respectively).Warfarin interruption and bridging are overwhelmingly used in warfarin-treated patients in Qatar. While bridging was numerically associated with increased bleeding events, there is no statistical difference in reported clinical events between bridging and nonbridging strategies.

Ibuprofen and paracetamol (acetaminophen) are very commonly used for analgesia and pain. In 2020, the US FDA gave its first approval of a fixed-dose combination (FDC) of the two drugs in the same tablet for postoperative pain. There has been no quantitative, summative analysis of the FDC effect size measures against postoperative pain in adults. Similar analyses exist, but only in pediatric patients.This was the first meta-analysis to compare the efficacy and safety outcomes of the ibuprofen/paracetamol FDC against placebo, administered postoperatively, for moderate to severe pain relief in adults.The MEDLINE, EMBASE, and Cochrane CENTRAL databases, in addition to the grey literature, were searched for clinical trials until April 2020, to identify comparative literature studies of the ibuprofen/paracetamol FDC in acute postoperative pain in adults. No restrictions on doses, formulations (oral, intravenous), and underlying type of surgery were applied. Independent reviewers performed the study selection, data extraction, and the risk-of-bias and quality-of-evidence assessments based on the Cochrane criteria. The outcome measures of interest in the meta-analysis were ≥ 50% pain relief , need for rescue medications, and occurrence of adverse drug events. Statistical analyses using a random-effects model were performed, at a statistical significance of p 0.05. The RevMan software was used for analysis. A trial sequential analysis (TSA) was conducted to assess how precise and conclusive the meta-analysis outcomes are.Seven double-blind, randomized controlled trials with 2947 participants were included. The FDC dose was at three different levels: 75-100 mg ibuprofen/250 mg paracetamol, 150-200 mg ibuprofen/500 mg paracetamol (FDA-approved dose level), and 292.5-400 mg ibuprofen/975-1000 mg paracetamol. The ≥ 50% pain relief outcome was more achieved with the FDC compared to placebo (risk ratio [RR] 2.60, 95% confidence interval [CI] 2.11-3.20, p 0.00001), as was the reduced need for rescue medications (RR 0.51, 95% CI 0.37-0.71, p 0.0001). While inconclusive based on TSA, the FDC was at the highest doses at least as well tolerated as placebo regarding the occurrence of adverse events, including severe, common, and treatment-related adverse events, as well as those that lead to discontinuation, but it was also significantly associated with lower rates of headache and nausea. Subgroup analyses confirmed that the efficacy and safety of the FDC were maintained regardless of doses and formulations. The sensitivity analysis confirmed outcomes against potential publication bias and identified sources of heterogeneity in analyses.The ibuprofen plus paracetamol FDC is conclusively an effective analgesic against placebo in acute postoperative, moderate to severe pain in adults. It is also superiorly well tolerated, including at the higher dose of 292.5-400 mg ibuprofen/975-1000 mg paracetamol; however, safety outcomes were inconclusive. Future studies need to confirm the safety of FDC and its benefits against other marketed analgesics in postoperative pain.

Background: Patients having CYP2C19 loss-of-function alleles and receiving clopidogrel are at higher risk of adverse cardiovascular outcomes. Ticagrelor is a more effective and expensive antiplatelet that is unaffected by the CYP2C19 polymorphism. The main aim of the current research is to evaluate the cost-effectiveness among CYP2C19 genotype-guided therapy, universal ticagrelor, and universal clopidogrel after a percutaneous coronary intervention (PCI). Methods: A two-part simulation model, including a one-year decision-analytic model and a 20-year followup Markov model, was created to follow the use of (i) universal clopidogrel, (ii) universal ticagrelor, and (iii) genotype-guided antiplatelet therapy. Outcome measures were the incremental cost-effectiveness ratio (ICER, cost/success) and incremental cost-utility ratio (ICUR, cost/qualityadjusted life years [QALY]). Therapy success was defined as survival without myocardial infarction, stroke, cardiovascular death, stent thrombosis, and no therapy discontinuation because of adverse events, i.e. major bleeding and dyspnea. The model was based on a multivariate analysis, and a sensitivity analysis confirmed the robustness of the model outcomes. Results: Against universal clopidogrel, genotype-guided therapy was cost-effective over the one-year duration (ICER, USD 6,102 /success), and dominant over the long-term. Genotype-guided therapy was dominant over universal ticagrelor over the one-year duration and cost-effective over the long term (ICUR, USD 1,383 /QALY). Universal clopidogrel was dominant over ticagrelor over the short term, and cost-effective over the long-term (ICUR, 10,616 /QALY). Conclusion: CYP2C19 genotype-guided therapy appears to be the preferred antiplatelet strategy, followed by universal clopidogrel, and then universal ticagrelor for post-PCI patients in Qatar.

It is estimated that 10–15% of oral anticoagulant (OAC) patients, would need to hold their OAC for scheduled surgery. Especially for warfarin, this process is complex and requires multi-layer risk assessment and decisions across different specialties. Clinical guidelines deliver broad recommendations in the area of warfarin management before surgery which can lead to different trends and practices among practitioners. To evaluate the current attitude, awareness, and practice among health care providers (HCPs) on warfarin periprocedural management. A multiple-choice questionnaire was developed, containing questions on demographics and professional information and was completed by187 HCPs involved in warfarin periprocedural management. The awareness median (IQR) score was moderate [64.28% (21.43)]. The level of awareness was associated with the practitioner’s specialty and degree of education (P = 0.009, 0.011 respectively). Practice leans to overestimate the need for warfarin discontinuation as well as the need for bridging. Participants expressed interest in using genetic tests to guide periprocedural warfarin management [median (IQR) score (out of 10) = 7 (5)]. In conclusion, the survey presented a wide variation in the clinical practice of warfarin periprocedural management. This study highlights that HCPs in Qatar have moderate awareness. We suggest tailoring an educational campaign or courses towards the identified gaps.

Sodium-glucose cotransporter 2 (SGLT2) inhibitors have shown to reduce cardiovascular events and mortality in patients with type 2 diabetes mellitus (T2DM), but they are currently not used as first-line therapy in clinical practice. This study sought to evaluate the cost-effectiveness of first-line empagliflozin plus standard care for patients with newly diagnosed T2DM and existing cardiovascular disease (CVD). A decision-analytic Markov model with one-year cycles and a lifetime time horizon was developed from the perspective of the Qatari healthcare system to compare first-line empagliflozin combined with metformin versus metformin monotherapy for patients aged 50 to 79 years with T2DM and existing CVD. Two health states were considered: ‘Alive with CVD and T2DM’ and ‘Dead’. Patients could experience non-fatal myocardial infarction, non-fatal stroke, hospitalization for heart failure, hospitalization for unstable angina, and cardiovascular or non-cardiovascular death. Model inputs were ascertained from published and publicly available sources in Qatar. Costs and outcomes were discounted at 3% per annum. Sensitivity analyses were conducted to evaluate parameter uncertainty. The model predicted that adding empagliflozin to current standard care led to additional 1.9 years of life saved (YoLS) and 1.5 quality-adjusted life year (QALYs) per person, and an incremental cost of QAR 56,869 (USD 15,619), which equated to an incremental cost-effectiveness ratio of QAR 30,675 (USD 8,425) per YoLS and QAR 39,245 (USD 10,779) per QALY. Sensitivity analyses showed the findings to be robust. First-line empagliflozin combined with metformin appears to be a cost-effective therapeutic option for patients with T2DM and CVD.