Using N-of-1 trials to improve patient management and save costs

Paul A. Scuffham, Griffith University
Jane Nikles, University of Queensland
Geoffrey K. Mitchell, University of Queensland
Michael J. Yelland, Griffith University
Norma Vine, Australian Red Cross Blood Service
Christopher J. Poulos, Port Kembla Hospital
Peter I. Pillans, Princess Alexandra Hospital
Guy Bashford, Port Kembla Hospital
Chris Del Mar, Bond University
Philip J. Schluter, Auckland University of Technology
Paul Glasziou, Oxford University

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Accepted Version.

Scuffham, P.A., Nikles, J., Mitchell, G.K., Yelland, M.J., Vine, N., Poulos, C.J., Pillans, P.I., Bashford, G., Del Mar, C., Schluter, P.J. & Glasziou, P. (2010). Using N-of-1 trials to improve patient management and save costs. Journal of general internal medicine, 25(9), 906-913.

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© Copyright Society of General Internal Medicine, 2010.

Abstract

BACKGROUND: N-of-1 trials test treatment effectiveness within an individual patient.

OBJECTIVE: To assess (i) the impact of three different N-of-1 trials on both clinical and economic outcomes over 12 months and (ii) whether the use of N-of-1 trials to target patients' access to high-cost drugs might be cost-effective in Australia.

DESIGN: Descriptive study of management change, persistence, and costs summarizing three N-of-1 trials.

PARTICIPANTS: Volunteer patients with osteoarthritis, chronic neuropathic pain or ADHD whose optimal choice of treatment was uncertain.

INTERVENTIONS: Double-blind cyclical alternative medications for the three conditions.

MEASURES: Detailed resource use, treatment and health outcomes (response) data collected by postal and telephone surveys immediately before and after the trial and at 3, 6 and 12 months. Estimated costs to the Australian healthcare system for the pre-trial vs. 12 months post-trial.

RESULTS: Participants persisting with the joint patient-doctor decision 12 months after trial completion were 32% for osteoarthritis, 45% for chronic neuropathic pain and 70% for the ADHD trials. Cost-offsets were obtained from reduced usage of non-optimal drugs, and reduced medical consultations. Drug costs increased for the chronic neuropathic pain and ADHD trials due to many patients being on either low-cost or no pharmaceuticals before the trial.

CONCLUSIONS: N-of-1 trials are an effective method to identify optimal treatment in patients in whom disease management is uncertain. Using this evidence-based approach, patients and doctors tend to persist with optimal treatment resulting in cost-savings. N-of-1 trials are clinically acceptable and may be an effective way of rationally prescribing some expensive long-term medicines.