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Economic evaluation of the OSAC randomised controlled trial: oral corticosteroids for non-asthmatic adults with acute lower respiratory tract infection in primary care

Research output: Contribution to journalArticle

Original languageEnglish
JournalBMJ Open
DateAccepted/In press - 15 Oct 2019

Abstract

Objective
To estimate the costs and outcomes associated with treating non-asthmatic (nor suffering from other lung-disease) adults presenting to primary care with acute lower respiratory tract infection (ALRTI) with oral corticosteroids compared with placebo.

Design
Cost-consequence analysis alongside a randomised controlled trial. Perspectives included the healthcare provider, patients, and productivity losses associated with time off-work.

Setting
Fifty-four NHS general practices in England.

Participants
398 adults attending NHS primary practices with ALRTI but no asthma or other chronic lung disease, followed up for 28 days.

Interventions
2x20mg oral prednisolone daily for five days versus matching placebo tablets.

Outcome measures
Quality-adjusted life years using the EQ-5D-5L measured weekly; duration and severity of symptom. Direct and indirect resources related to the disease and its treatment were also collected. Outcomes were measured for the 28-day follow up.

Results
198 (50%) patients received the intervention (prednisolone) and 200 (50%) received placebo. NHS costs were dominated by primary care contacts, higher with placebo than with prednisolone (£13.11 vs £10.38) but without evidence of a difference (95% CI: -£3.05 to £8.52). The trial medication cost of £1.96 per patient would have been recouped in prescription charges of £4.30 per patient overall (55% participants would have paid £7.85), giving an overall mean ‘profit’ to the NHS of £7.00 (95% CI: £0.50 to £17.08) per patient. There was a QALY gain of 0.03 (95% CI: 0.01 to 0.05) equating to half a day of perfect health favouring the prednisolone patients; there was no difference in duration of cough or severity of symptoms.

Conclusions
The use of prednisolone for non-asthmatic adults with ALRTI, provided small gains in quality of life and cost savings driven by prescription charges. Considering the results of the economic evaluation and possible side effects of corticosteroids, the short-term benefits may not outweigh the long term harms.

Strengths and limitations of this study
· The economic evaluation was part of a rigorously conducted multicentre randomised controlled trial, involving a representative population of patients not thought to need immediate antibiotic treatment.
· The economic evaluation included the perspectives of patients and time off work as well as the NHS.
· Low levels of missing cost and outcome data, with EQ-5D observations from multiple time points, achieving an accurate profile of patient health-related quality of life over the period of the illness.
· The analysis was thorough and included multiple imputation of missing data and extensive sensitivity analysis.

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