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


METHODS
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).


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


METHODS
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.


METHODS
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).


METHODS
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 euro800 for home treatment and euro752 for outpatient treatment, showing an incremental cost per patient of euro48 (95% CI euro-77 to euro174). The average total costs by one year after the end of phototherapy were euro1272 and euro1148 respectively (difference euro124, 95% CI euro-155 to euro403). 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 euro9276 and euro4646 respectively, both amounts well below the normally accepted standard of euro20 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 euro20 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.


BACKGROUND
Current Controlled Trials ISRCTN83025173 and Clinicaltrials.gov NCT00150930.
Koek
Mayke B G
MB
Department of Dermatology/Allergology (G02.124), University Medical Center Utrecht, Heidelberglaan 100, 3584 CX Utrecht, Netherlands. author@koek.com
Sigurdsson
Vigfús
V
van Weelden
Huib
H
Steegmans
Paul H A
PH
Bruijnzeel-Koomen
Carla A F M
CA
Buskens
Erik
E
D000328:Adult; D017281:Cost of Illness; D003362:Cost-Benefit Analysis; D006295:Health Resources / Q000706:statistics & numerical data; D006699:Home Care Services / Q000191:economics; D006801:Humans; D008875:Middle Aged; D011565:Psoriasis / Q000191:economics / Q000532:radiotherapy*; D019057:Quality-Adjusted Life Years; D016037:Single-Blind Method; D016896:Treatment Outcome; D014467:Ultraviolet Therapy / Q000191:economics*
Br J Dermatol. 2006 Apr;154(4):701-11
16536814
J Am Acad Dermatol. 1981 May;4(5):584-91
7240467
Expert Opin Pharmacother. 2003 Sep;4(9):1525-33
12943482
Dermatologica. 1978;157(4):238-44
357213
Aliment Pharmacol Ther. 1998 Sep;12(9):919-23
9768536
Br J Dermatol. 2002 Nov;147(5):957-65
12410707
J Dermatolog Treat. 2006;17(6):359-61
17853310
Br J Dermatol. 2005 Apr;152(4):597-615
15840088
J Health Econ. 2002 Mar;21(2):271-92
11939242
Ned Tijdschr Geneeskd. 1993 Dec 4;137(49):2525-6
8272137
Health Policy. 1990 Dec;16(3):199-208
10109801
Semin Dermatol. 1992 Dec;11(4):284-6
1493091
J Dermatol. 1999 Apr;26(4):210-5
10343464
Cutis. 1985 Feb;35(2):127-8, 130
3979098
Health Econ. 2004 Sep;13(9):873-84
15362179
J Am Acad Dermatol. 1993 Jul;29(1):73-7
8315080
J Am Acad Dermatol. 2008 Oct;59(4):577-81
18619709
J Am Acad Dermatol. 1982 Mar;6(3):355-62
7068964
Dermatology. 2001;202(1):38-43
11244227
J Invest Dermatol. 1996 Jan;106(1):183-6
8592072
Manag Care Interface. 2006 Jan;19(1):33-6, 39
16453993
Int J Technol Assess Health Care. 1996 Summer;12(3):405-15
8840661
J Invest Dermatol. 1994 Jun;102(6):967-9
8006462
Br J Dermatol. 1997 Sep;137(3):327-30
9349324
Arch Dermatol. 2008 Sep;144(9):1224-5
18794474
Br J Dermatol. 2004 Aug;151(2):283-97
15327535
Arch Dermatol. 1998 Dec;134(12):1591-6
9875199
Cutis. 1996 Jul;58(1):71-3
8823554
Health Econ. 2005 May;14(5):435-43
15497201
Cutis. 2001 Nov;68(5):345-7
11766120
Health Econ. 2004 May;13(5):405-15
15127421
BMJ. 2009 May 07;338:b1542
19423623
BMJ. 2009 May 07;338:b607
19423624
Br J Dermatol. 1979 Jul;101(1):13-6
475982
BMC Med Res Methodol. 2006 Aug 01;6:39
16882343