Estimating the true costs of splitting HIV antiretroviral drugs

Problem: A regional UK commissioning decision in 2010 mandated that when the component drugs of Combivir—a combination therapy for HIV—come off patent, doctors must prescribe the individual drugs instead. This was driven by a perception that the generic component drugs are cheaper in the immediate-term and so more efficient overall. As our pharmaceutical client’s HIV combination drug was soon to come off patent, they wanted to help commissioners understand the full healthcare costs of such a policy, to inform future decisions.

Approach: We worked with our client and clinicians in Nottingham University Hospital’s HIV clinic who had patient-level care data before and after the commissioning change. We planned the analysis and identified which costs would be used and which data were required.

Impact: Our work contributes to the evidence-base of the costs of prescribing patients a single dose therapy over multiple doses. It has changed people’s perceptions of the costs of treating long-term conditions with combination drugs, and helped commissioners to make policy decisions about mandating use of particular drugs whilst taking a holistic view of healthcare.



“Aquarius provided a professional yet personal level of support with our project. We found the statistical support invaluable, and felt that they went the extra mile to ensure the project went smoothly and on time.”

  • Dr Ruth Taylor, Consultant in Genitourinary Medicine, Nottingham University Hospitals NHS Trust


Related publications

 publication_iconTaylor R, Carlin E, Sadique Z, Ahmed I, Adams EJ. The financial and service implications of splitting fixed-dose antiretroviral drugs – a case study. Accepted Mar 2014, Int J STD AIDS


Understanding Idiopathic Pulmonary Fibrosis patient care delivery and costs

Problem: Idiopathic Pulmonary Fibrosis (IPF) is a chronic condition, often with poor prognosis. Although there are NICE guidelines for managing IPF patients, care has varied across England; it has depended on how a clinic’s services are set up and what local resources are available. Our clients wanted to support local specialist centres as they document how their clinics managed IPF patients, how local pathways varied from the NICE benchmark care, and estimate affordability of providing care to patients.

Approach: We generated a gold-standard benchmark pathway for IPF patients based on the NICE guidelines and published literature using our pathway mapping tool, Dots. With our client we designed and conducted structured interviews with clinicians and service managers to explore how their IPF patients are managed and map out local pathways and resource use. Finally, we estimated the costs of care and compared it to our benchmark national pathway using the Dots.

Impact: All of the clinics were given their results so they could understand how their IPF pathways compared to the benchmark and to other clinics, both clinically and in cost-wise. It is anticipated that results could inform the development of a national tariff, as the estimated costs of providing care was over 40% more than currently reimbursed.


Related publications

presentation_iconHill C, Nasr R, Fisher MI, et. al. 
Estimated cost and payment by results (PBR) tariff reimbursement for idiopathic pulmonary fibrosis services across 14 specialist providers in England. British Thoracic Society Winter Meeting, London UK. 5th December 2014 MRC-2731

Increased efficiency and improved treatment for stable HIV patients in England

Problem: There was no guidance in England on how frequently stable HIV patients should attend clinics for routine visits, how frequently they should receive their HIV drugs and whether or not it would be cost efficient for patients to collect their drugs from the hospital pharmacy (which incurs VAT) or receive them through a home delivery (with associated delivery cost).

Approach: We built a simple spreadsheet tool in Microsoft Excel to estimate which strategy was the most cost-efficient. Local data from St George’s hospital were obtained and analysed, and supplemented with nationally published data as inputs in the model. Results suggested that the most cost efficient way of delivering care was to see stable patients for routine visits every six months in clinic, and give them their drugs through home delivery every three months; this would also save the most drug wastage for example if patients needed to switch to a new drug regimen. Results suggested that this could save roughly £2000 per patient annually, and roughly £8 million if it were implemented across England to the 4000 HIV patients in 2012.

Impact: Results were given to the London HIV commissioners, published in a peer-reviewed journal, and the tool is available to healthcare professionals so that they can put in their local data to help them make better decisions about healthcare provision.



“It has been a pleasure to work with Dr Elisabeth Adams on our costing project for HIV home delivery of drugs. I have also worked with her on research related to the POPI study of chlamydia screening.

She has a very professional and thorough approach to her work, and is good at delivering to timelines. I can recommend her as a partner for future work.”

  • Dr Phillip Hay, Reader and Honorary Consultant, Sexual Health and HIV Medicine, St. George’s Hospital, London


Related publications

publication_iconAdams EJ, Ogden D, Ehrlich A, Hay P. Treatment for stable HIV patients in England: can we save costs and improve patient care? Journal of Health Services Research & Policy. Published online 29 Oct 2013, doi:10.1177/1355819613508176

Please contact us to request a version of the tool.

The true cost of treating invasive fungal infections in hospitals

Problem: Our client’s drug is recommended in most guidelines as a first line treatment for invasive fungal infections in immunocompromised patients. But because its acquisition cost can be comparatively high, health care purchasers have tended to favour its lower-cost competitors. To challenge this perception, our client wanted to know what the total healthcare costs were of treating patients with invasive fungal infection with its drug compared to alternatives, and to help customers understand the wider costs of patient management.

Approach: We took a two-pronged approach. First, we assembled a multidisciplinary team, to work closely with our client’s market access and medical teams in the UK, Ireland, and internationally. We reviewed the published evidence base of the side-effects, effectiveness and costs of its drug and its alternatives, and built a simple, user-friendly Excel tool that could be used with their customers to demonstrate the total treatment costs of theirs and competitors’ drugs. National data for the baseline values in the tool were used, but we incorporated a simple interface so that customers could use local patient data and costs for a personalised result.

Next, we worked with clinicians at Kings College Hospital NHS Foundation Trust to analyse data collected prospectively as part of a study of haematology patients receiving antifungal treatment in hospital. This patient level analysis explored the costs of antifungal and antibiotic drugs, diagnostic tests, and hospital stay. We found that the driver of costs was the underlying inpatient stay, which was much higher than the cost of antifungal drugs.

Impact: Our client’s sales team have reported that our tool has been integral in their work and as part of their evidence base. They can help their customers understand the total costs of different treatment strategies, and it has prompted several clinics to audit their own local data and then use it in the tool to estimate the impact of drug use on their overall costs. Results from the analysis at Kings College Hospital provided much needed evidence of the costs of care for IFD patients, which can be used to inform local and national tariffs. More generally, the project has helped raise awareness of the wider issues of cost, rather than focusing on the drug acquisition cost alone.



“Through working with Elisabeth and her team I have been able to develop excellent tools which have been relevant to our customers and valuable to our sales team. Aquarius is flexible to my needs and able to adapt their approach as situations and demands change. I have always found Elisabeth to be very knowledgeable and professional and I thoroughly enjoy the partnership we have developed. I would definitely recommend working with Aquarius!”

  • Manager, Market Access & Reimbursement, pharmaceutical company

“The Aquarius team conducted an analysis of individual patient data from our hospital. They were very proactive and responsive throughout our collaboration, and although we had quite complicated data, they delivered excellent results ending in a peer-reviewed publication.”

  • Dr Tony Pagliuca, Clinical and Transplant Director, Chair of DH BMT CRG, and Professor of Stem Cell Transplantation, King’s College Hospital NHS Foundation Trust
  • Dr M. Mansour Ceesay, Consultant Haematologist, King’s College Hospital NHS Foundation


Related publications

publication_iconCeesay MM, Sadique Z, Harris, R, Ehrlich A, Adams EJ, Pagliuca A. Prospective Evaluation Of The Cost Of Diagnosis And Treatment Of Invasive Fungal Disease In A Cohort Of Adult Haematology Patients In The United Kingdom. J Antimicrobial Chemotherapy. 2014; doi: 10.1093/jac/dku506.

presentation_iconAdams EJ, Kendall E, Horner J, Marsh R. Thinking critically about the value and cost of drugs: managing patients with invasive fungal disease. ECCMID 2015. 25 – 28 April 2015. Copenhagen, Denmark.