Narrowband-UVB treatment for psoriasis is highly economical and causes significant savings in cost for topical treatments K. Boswell,1 H. Cameron,1 J. West,1 C. Fleming,1 S. Ibbotson,1 R. Dawe,1,2 J. Foerster1 1University of Dundee, Medical School; and Department of Dermatology and Photobiology Unit, NHS Tayside, Dundee, U.K. 2National Managed Clinical Network for Phototherapy (Photonet), NHS Scotland, Dundee, U.K. British Journal of Dermatology. DOI: 10.1111/bjd.16716

Introduction What’s already known? NB-UVB is considered expensive. However, existing estimates of treatment costs are largely based on assumptions and do not consider treatment- associated savings.

Objective To define actual costs of NB-UVB incurred by the service provider, as well as treatment-associated cost savings.

Methods: Approach to data collection Validity: compile actually incurred cost, not estimates. Use actual fraction of each staff job plan allocated to phototherapy. Robustness: use data spanning 6 years to define extend of fluctuations. Generality: compile data separately for low-, medium-, large treatment sites to account for variability in individual staff performance, centre-size effects, local factors. Accuracy: list all direct and indirect costs. Comprehensiveness: list treatment-associated cost savings incurred through change in topical treatments.

Methods: Staff- and non-staff costs Primary staff (nurse): hours allocated to treatment administration, documentation, data entry, letter dictation, training, CPD. Data derived from salary scales detailed for each of 4 independent sites. Supporting staff: consultant /non-consultant supervision [hours per job plans], admin [hours allocated to staff to typing and appointment booking], photobiology technician. FEC staff costs: for all staff, include pension, N.I. for hours in job plan Equipment: purchasing price for NB-UVB cabinets, depreciation, average lifetime, replacement kit (bulbs). Med physics/ estate: maintenance, lamp calibration, cleaning, property maintenance, energy, and rates per sqm used by NHS.

Methods: Treatment – associated cost savings Previous data [Foerster, PLoS One, 2017]: Specific reduction of psoriasis-related topical prescriptions, but not unrelated prescriptions, in the 12-month interval after-, compared to 12- months before a course of NB-UVB. Itemize the respective costs using drug tariff.

Results: Cost incurred by NHS Tayside for NB-UVB between 2010 - 2015 Total: £253 ± 64 per course including all overheads One course: 29.7 ± 10.5 sessions One session: £8.50

Results: cost for topical psoriasis treatment in NHS Tayside 2010 – 2015 (n = 1749 patients)

Results: cost for topical psoriasis treatment in NHS Tayside 2010 – 2015 (n = 1749 patients)

Discussion Data represent averages across four separate treatment sites spanning 6 years, minimizing spurious fluctuations and local factors. Data include indirect staff cost and do not rely on estimates. Real NB-UVB cost (£257) and savings (£51) are in sharp contrast to figure used by NICE in Health Technology Appraisals (£1882) of comparator treatments. Real cost per session (£8.50) in sharp contrast to Tariff applied by NHS England (£74 for adults).

Limitations: Only NB-UVB but not PUVA / UVA1 analysed.1 Non-provider cost not analyzed (time off work for patients). No modelling of QALY performed. Data valid for UK-based hospital-based context. (Staff – hours tabulated for translation of cost into other economies. 1Data on PUVA cost: Dawe, R: . Phototherapy in the treatment of skin disease in Scotland, MD thesis, University of Glasgow, 2001, pp 85 to 89

Conclusions What does this study add? We present comprehensive direct and indirect actual cost incurred for NB-UVB by a provider serving a population of 420,000 over six years. Significant savings can be achieved due to the reduced need of topical treatment and delay / avoidance of 3d line systemic treatment. Data necessitate a review of cost figures used by NICE and in NHS Tariff.

The Research Team Colin Fleming Robert Dawe Jonathan West Heather Cameron Sally Ibbotson John Foerster Kirsty Boswell

Call for correspondence Why not join the debate on this article through our correspondence section? Rapid responses should not exceed 350 words, four references and one figure Further details can be found here