title: Cost-effectiveness analysis of three different combinations of inhalers for severe and very severe chronic obstructive pulmonary disease patients at a tertiary care teaching hospital of South India.
abstract: BACKGROUND
  This study aims at simplifying the practical patient management and offers some general indications for pharmacotherapeutic choice by the implementation of (Global Initiative for Chronic Lung Disease) guidelines. This study was designed to evaluate the clinical and economic consequences of salmeterol/fluticasone (SF), formoterol/budesonide (FB), and formoterol/fluticasone (FF) in severe and very severe chronic obstructive pulmonary disease (COPD) patients.
  
  
  OBJECTIVE
  The aim was to find out the most cost-effective drug combination between the three combinations (SF/FB/FF) in COPD patients.
  
  
  METHODS
  A prospective observational comparative study (cost-effectiveness analysis), in which 90 severe (30 ≤ forced expiratory volume in 1 s [FEV1] <50% predicted) and very severe (FEV1 < 30% predicted) COPD patients (outpatients/inpatients) who are prescribed with any one of the following combinations (SF/FB/FF) were selected. In our study, we have divided 90 COPD patients into three groups (Group I, Group II, and Group III) each group consisting of 30 patients. Group I was prescribed with medication SF, Group II with medication FB, and Group III with medication FF. We used five different parameters such as spirometry test (mean FEV1 initial and final visit), number of symptom-free days (SFDs), number of moderate and severe exacerbations, Number of days of hospitalization and direct, indirect, and total cost to assess the cost-effectiveness of SF/FB/FF. Comparison of cost and effects was done during the period of 6 months of using SF/FB/FF.
  
  
  RESULTS
  The average FEV1 for Group I, Group II, and Group III subjects at initial visit was 33.47%, 33.73%, and 33.20% and was increased to 36.60%, 35.8%, and 33.4%, respectively. A 3% increment in FEV1 was reported for Group I subjects (SF) and was highly significant statistically (t = -8.833, P = 0.000) at 95% CI. For Group II subjects (FB), a 2% increment in FEV1 was reported and was highly significant statistically (t = -9.001, P = 0.000) at 95% CI. For Group III (FF) subjects 0.2% increment in FEV1. The overall mean total cost for Group I, Group II, and Group III subjects during the 6 months period was found to be Rs. 29,725/-, Rs. 32,602/- and Rs. 37,155/-. Incremental cost-effectiveness of FB versus SF was Rs. 37,781/- per avoided exacerbation and Rs. 661/-per SFD.
  
  
  CONCLUSIONS
  This study highlights the favorable therapeutic performance of combined inhaled bronchodilators and corticosteroids (SF/FB/FF), thus suggesting that healthcare costs would be also affected positively. Results from our study showed that SF and FB were the most effective strategies in the treatment of COPD, with a slight clinical superiority of SF. The FF strategy was not much effective (i.e. associated with fewer outcomes and higher costs).
authors.affiliation: Department of Pharmacy Practice and PharmD, Deccan School of Pharmacy, Jawaharlal Nehru Technological University, Hyderabad, Telangana, India.
authors.forename: Mohammed
authors.initials: M
authors.lastname: Altaf
authors.affiliation: Department of Pharmacy Practice and PharmD, Deccan School of Pharmacy, Jawaharlal Nehru Technological University, Hyderabad, Telangana, India.
authors.forename: Ayesha Mubeen
authors.initials: AM
authors.lastname: Zubedi
authors.affiliation: Department of Pharmacy Practice and PharmD, Deccan School of Pharmacy, Jawaharlal Nehru Technological University, Hyderabad, Telangana, India.
authors.forename: Fareesa
authors.initials: F
authors.lastname: Nazneen
authors.affiliation: Department of Pharmacy Practice and PharmD, Deccan School of Pharmacy, Jawaharlal Nehru Technological University, Hyderabad, Telangana, India.
authors.forename: Shaik
authors.initials: S
authors.lastname: Kareemulla
authors.affiliation: Department of Pharmacy Practice and PharmD, Deccan School of Pharmacy, Jawaharlal Nehru Technological University, Hyderabad, Telangana, India.
authors.forename: Syed Amir
authors.initials: SA
authors.lastname: Ali
authors.affiliation: Department of Pulmonology, Deccan College of Medical Sciences, Hyderabad, Telangana, India.
authors.forename: N M
authors.initials: NM
authors.lastname: Aleemuddin
authors.affiliation: Department of Physiology, Deccan College of Medical Sciences, Hyderabad, Telangana, India.
authors.forename: Md Abdul
authors.initials: MA
authors.lastname: Hannan Hazari
keywords: Bronchodilators; cost-effectiveness; inhaled corticosteroids; severe and very severe chronic obstructive pulmonary disease; symptom-free day