Care Get Got Health Into It It Mess Take We Will

Background  Recent studies have suggested a possible association between pneumonia and the use of inhaled corticosteroids. We aimed to ascertain the risk of pneumonia with long-term inhaled corticosteroid use among patients with chronic obstructive pulmonary disease (COPD).

Methods  We performed systematic searches with no date restrictions through June 30, 2008, of MEDLINE, EMBASE, the Cochrane Database of Systematic Reviews, regulatory documents, and trial registries. We included randomized controlled trials of any inhaled corticosteroid vs a control treatment for COPD, with at least 24 weeks of follow-up and reporting of pneumonia as an adverse event. Outcomes evaluated included any pneumonia, serious pneumonia, pneumonia-related mortality, and overall mortality.

Results  Eighteen randomized controlled trials (n = 16 996) with 24 to 156 weeks of follow-up were included after a detailed screening of 97 articles. Inhaled corticosteroids were associated with a significantly increased risk of any pneumonia (relative risk [RR], 1.60; 95% confidence interval [CI], 1.33-1.92 [P < .001]; I² = 16%) and serious pneumonia (1.71; 1.46-1.99 [P < .001]; I² = 0%) but without a significantly increased risk of pneumonia-related mortality (1.27; 0.80-2.03 [P = .31]; I² = 0%) or overall mortality (0.96; 0.86-1.08 [P = .51]; I² = 0%). Inhaled corticosteroids were associated with a significantly increased risk of serious pneumonia when compared with placebo (RR, 1.81; 95% CI, 1.44-2.29 [P < .001]) or when the combination of inhaled corticosteroids and long-acting β-agonists was compared with long-acting β-agonists (1.68; 1.20-2.34 [P = .002]).

Conclusion  Among patients with COPD, inhaled corticosteroid use for at least 24 weeks is associated with a significantly increased risk of serious pneumonia, without a significantly increased risk of death.

Background  Evidence from cost-effective smoking cessation programs is scarce. This study determined the cost-effectiveness of 3 smoking cessation strategies as provided by general practitioners (GPs) in Germany.

Methods  In a cluster-randomized smoking cessation trial, rates and intervention costs for 577 smoking patients of 82 GPs were followed up for 12 months. Three smoking cessation treatments were tested: (1) GP training plus GP remuneration for each abstinent patient, (2) GP training plus cost-free nicotine replacement medication and/or bupropion hydrochloride for the patient, and (3) a combination of both strategies. Smoking abstinence at 12 months was the primary outcome used to calculate incremental cost-effectiveness ratios and net monetary benefits.

Results  Intervention 1 was not effective compared with treatment as usual (TAU). Interventions 2 and 3 each proved to be cost-effective compared separately with TAU. When applying a 95% level of certainty of cost-effectiveness against TAU, 9.80 or 6.96, respectively, had to be paid for each additional 1% of patients abstinent at 12 months (maximum willingness to pay). That means that in intervention 2, 92.12 per patient in the program must be invested to gain 1 additional quitter (as opposed to 39.10 paid per patient during the trial). In intervention 2, the cost was 82.82, as opposed to 50.04. Neither of these 2 cost-effective treatments proved to be superior to the other. The cost-effectiveness of both treatments was stable against TAU in sensitivity analyses. (The exchange rate from October 1, 2003, was used; 1 = $1.17.)

Conclusions  Both treatments have a high potential to reduce smoking-related morbidity at a low cost. It is highly recommended that they be implemented as a routine service offered by GPs because in many countries, health insurance plans currently do not fund nicotine replacement therapy.