Development of an online well-being intervention for young people: an evaluation protocol

BACKGROUND

Research has shown that improving well-being using positive mental health interventions can be useful for predicting and preventing mental illness. Implementing online interventions may be an effective way to reach young people, given their familiarity with technology.

OBJECTIVE

This study will assess the effectiveness of a website called the "Online Wellbeing Centre (OWC)," designed for the support and improvement of mental health and well-being in young Australians aged between 16 and 25 years. As the active component of the study, the OWC will introduce a self-guided app recommendation service called "The Toolbox: The best apps for your brain and body" developed by ReachOut.com. The Toolbox is a responsive website that serves as a personalized, ongoing recommendation service for technology-based tools and apps to improve well-being. It allows users to personalize their experience according to their individual needs.

METHODS

This study will be a two-arm, randomized controlled trial following a wait-list control design. The primary outcome will be changes in psychological well-being measured by the Mental Health Continuum Short Form. The secondary outcomes will be drawn from a subsample of participants and will include depression scores measured by the Center for Epidemiologic Studies Depression Scale, and quality of life measured by the Assessment of Quality of Life-four dimensions (AQOL-4D) index. Cost-effectiveness analysis will be conducted based on a primary outcome of cost per unique visit to the OWC. Utility-based outcomes will also be incorporated into the analysis allowing a secondary outcome to be cost per quality-adjusted life year gained (based on the AQOL-4D values). Resource use associated with both the intervention and control groups will be collected using a customized questionnaire. Online- and community-based recruitment strategies will be implemented, and the effectiveness of each approach will be analyzed. Participants will be recruited from the general Australian population and randomized online. The trial will last for 4 weeks.

RESULTS

Small but clinically significant increases in well-being symptoms are expected to be detected in the intervention group compared with the control group.

CONCLUSIONS

If this intervention proves to be effective, it will have an impact on the future design and implementation of online-based well-being interventions as a valid and cost-effective way to support mental health clinical treatment. Findings regarding recruitment effectiveness will also contribute to developing better ways to engage this population in research.

CLINICALTRIAL

This study is registered in the Australian New Zealand Clinical Trials Registry (ANZCTR): ACTRN12614000710628.

A systematic review and economic evaluation of subcutaneous and sublingual allergen immunotherapy in adults and children with seasonal allergic rhinitis

BACKGROUND

Severe allergic rhinitis uncontrolled by conventional medication can substantially affect quality of life. Immunotherapy involves administering increasing doses of a specific allergen, with the aim of reducing sensitivity and symptomatic reactions. Recent meta-analyses have concluded that both subcutaneous immunotherapy (SCIT) and sublingual immunotherapy (SLIT) are more effective than placebo in reducing symptoms. It is uncertain which route of administration is more effective and whether or not treatment is cost-effective.

OBJECTIVE

To determine the comparative clinical effectiveness and cost-effectiveness of SCIT and SLIT for seasonal allergic rhinitis in adults and children.

DATA SOURCES

Electronic databases {MEDLINE, EMBASE, The Cochrane Library [Cochrane Central Register of Controlled Trials (CENTRAL)], NHS Economic Evaluation Database (NHS EED)} and trial registries (from inception up to April 2011).

REVIEW METHODS

Standard systematic review methods were used for study selection, data extraction and quality assessment. Double-blind randomised, placebo-controlled trials of SCIT or SLIT, or of SCIT compared with SLIT, and economic evaluations were included. Meta-analysis and indirect comparison meta-analysis and meta-regression were carried out. A new economic model was constructed to estimate cost-utility.

RESULTS

Meta-analyses found statistically significant effects for SCIT and SLIT compared with placebo across a number of outcome measures and for the vast majority of subgroup analyses (type and amount of allergen, duration of treatment). There was less evidence for children, but some results in favour of SLIT were statistically significant. Indirect comparisons did not provide conclusive results in favour of either SCIT or SLIT. Economic modelling suggested that, when compared with symptomatic treatment (ST), both SCIT and SLIT may become cost-effective at a threshold of £20,000-30,000 per quality-adjusted life-year (QALY) from around 6 years, or 5 years for SCIT compared with SLIT (NHS and patient perspective).

LIMITATIONS

It is uncertain to what extent changes in the outcome measures used in the trials translate into clinically meaningful benefits. Cost-effectiveness estimates are based on a simple model, limited data and a number of assumptions, and should be seen as indicative only.

CONCLUSIONS

A benefit from both SCIT and SLIT compared with placebo has been consistently demonstrated, but the extent of this effectiveness in terms of clinical benefit is unclear. Both SCIT and SLIT may be cost-effective compared with ST from around 6 years (threshold of £20,000-30,000 per QALY). Further research is needed to establish the comparative effectiveness of SCIT compared with SLIT and to provide more robust cost-effectiveness estimates.

FUNDING

The National Institute for Health Research Health Technology Assessment programme.

How important is health status in defining quality of life for older people? An exploratory study of the views of older South Australians

BACKGROUND

Cost-effectiveness analyses of interventions for older adults have traditionally focused on health status. However, there is increasing recognition of the need to develop new instruments to capture quality of life in a broader sense in the face of age-associated increasing frailty and declining health status, particularly in the economic evaluation of aged and social care interventions that may have positive benefits beyond health.

OBJECTIVE

To explore the relative importance of health and broader quality of life domains for defining quality of life from the perspective of older South Australians.

METHODS

Older adults (n=21) from a day rehabilitation facility in Southern Adelaide, South Australia attended one of two audio-recorded focus groups. A mixed methods (qualitative and quantitative) study design was adopted. The study included three main components. First was a general group discussion on quality of life and the factors of importance in defining quality of life. Second was a structured ranking exercise in which individuals were asked to rank domains from the brief Older People's Quality of Life (OPQOL-brief) questionnaire and Adult Social Care Outcomes Toolkit (ASCOT) in order of importance. Third, participants were asked to self-complete the EuroQol five-dimension (EQ-5D), a measure of health status, and two broader quality-of-life measures: the OPQOL-brief and ASCOT.

RESULTS

Mean scores on the EQ-5D, OPQOL-brief and ASCOT were 0.71 (standard deviation [SD] 0.20, range 0.06-1.00), 54.6 (SD 5.5, range 38-61) and 0.87 (SD 0.13, range 0.59-1.00), respectively, with higher scores reflecting better ratings. EQ-5D scores were positively associated with OPQOL-brief (Spearman's Rho: 0.730; p<0.01), but not ASCOT. Approximately half (52.4%) of the participants ranked either 'health' or 'psychological and emotional well-being' as the domain most important to their quality of life. However, one-third (33.3%) of the total sample ranked a non-health domain from the ASCOT or OPQOL-brief (safety, dignity, independence) as the most important contributing factor to their overall quality of life. Qualitative analysis of focus group transcripts supported the high value of both health-related (health, psychological well-being) and social (independence, safety) domains to quality of life.

CONCLUSIONS

Older adults value both health and social domains as important to their overall quality of life. Future economic evaluations of health, community and aged-care services for older adults should include assessment of both health-related and broader aspects of quality of life.

Telemonitoring and self-management in the control of hypertension (TASMINH2): a cost-effectiveness analysis

AIMS

Self-monitoring and self-titration of antihypertensives (self-management) is a novel intervention which improves blood pressure control. However, little evidence exists regarding the cost-effectiveness of self-monitoring of blood pressure in general and self-management in particular. This study aimed to evaluate whether self-management of hypertension was cost-effective.

DESIGN AND METHODS

A cohort Markov model-based probabilistic cost-effectiveness analysis was undertaken extrapolating to up to 35 years from cost and outcome data collected from the telemonitoring and self-management in hypertension trial (TASMINH2). Self-management of hypertension was compared with usual care in terms of lifetime costs, quality adjusted life years and cost-effectiveness using a UK Health Service perspective. Sensitivity analyses examined the effect of different time horizons and reduced effectiveness over time from self-management.

RESULTS

In the long-term, when compared with usual care, self-management was more effective by 0.24 and 0.12 quality adjusted life years (QALYs) gained per patient for men and women, respectively. The resultant incremental cost-effectiveness ratio for self-management was £1624 per QALY for men and £4923 per QALY for women. There was at least a 99% chance of the intervention being cost-effective for both sexes at a willingness to pay threshold of £20,000 per QALY gained. These results were robust to sensitivity analyses around the assumptions made, provided that the effects of self-management lasted at least two years for men and five years for women.

CONCLUSION

Self-monitoring with self-titration of antihypertensives and telemonitoring of blood pressure measurements not only reduces blood pressure, compared with usual care, but also represents a cost-effective use of health care resources.

The impact of using different tariffs to value EQ-5D health state descriptions: an example from a study of acute cough/lower respiratory tract infections in seven countries

When using the EQ-5D in European cross-national studies, there is no consensus over whether the European value set (EVS), country specific value sets (CVS) or UK value set (UKVS) should be used. Data on health outcomes were collected in 7 countries. EQ-5D index scores were generated for each country using all three value sets. QALYs gained over 4 weeks based on EQ-5D scores were also generated in order to investigate the implications for cost-utility analysis. EQ-5D scores obtained using the EVS were similar to values obtained using the CVS and UKVS in all countries. CVS-based EQ-5D scores were on average associated with a smaller baseline-to-week 4 change/improvement in all countries (except in Wales and Belgium) while UKVS-based EQ-5D scores showed the largest improvement over the same period for every country. With regards to cost-utility analysis, the results suggest that in most countries (with the exception of Belgium and Finland), using different tariffs to value EQ-5D would not have made a difference to the decisions based on the results of cost-utility analysis.

Mapping utility scores from the Barthel index

PURPOSE

It is not always possible to collect utility-based outcome data, like EQ-5D, needed for conducting economic evaluations in populations of older people. Sometimes, information on other non-utility outcome measures may have been collected. This paper examines the possibility of mapping the EQ-5D from a non-utility-based outcome, the Barthel index.

METHODS

Data for 1,189 UK intermediate care patients were used. Ordinary least squares (OLS), censored least absolute deviations (CLAD) estimator and multinomial logistic (ML) models were used. The mean absolute error (MAE) and root-mean-squared error (RMSE) were used to estimate the predictive accuracy of eight regression models. Validation of primary models was carried out on random samples of data collected at admission and discharge.

RESULTS

Models where the EQ-5D was entered as a continuous dependent variable and Barthel dimensions used as explanatory variables performed better. CLAD performed best on MAE and OLS on the RMSE, while the ML performed the worst on both measures. The CLAD predicted EQ-5D scores that matched the observed values more closely than the OLS.

CONCLUSIONS

It is possible to reasonably predict that the EQ-5D from the Barthel using regression methods and the CLAD model (4) is recommended.

Targets and self-management for the control of blood pressure in stroke and at risk groups (TASMIN-SR): protocol for a randomised controlled trial

Background

Self-monitoring of hypertension with self-titration of antihypertensives (self-management) results in lower systolic blood pressure for at least one year. However, few people in high risk groups have been evaluated to date and previous work suggests a smaller effect size in these groups. This trial therefore aims to assess the added value of self-management in high risk groups over and above usual care.

Methods/Design

The targets and self-management for the control of blood pressure in stroke and at risk groups (TASMIN-SR) trial will be a pragmatic primary care based, unblinded, randomised controlled trial of self-management of blood pressure (BP) compared to usual care. Eligible patients will have a history of stroke, coronary heart disease, diabetes or chronic kidney disease and will be recruited from primary care. Participants will be individually randomised to either usual care or self-management. The primary outcome of the trial will be difference in office SBP between intervention and control groups at 12 months adjusted for baseline SBP and covariates. 540 patients will be sufficient to detect a difference in SBP between self-management and usual care of 5 mmHg with 90% power. Secondary outcomes will include self-efficacy, lifestyle behaviours, health-related quality of life and adverse events. An economic analysis will consider both within trial costs and a model extrapolating the results thereafter. A qualitative analysis will gain insights into patients’ views, experiences and decision making processes.

Discussion

The results of the trial will be directly applicable to primary care in the UK. If successful, self-management of blood pressure in people with stroke and other high risk conditions would be applicable to many hundreds of thousands of individuals in the UK and beyond.

Trial Registration

ISRCTN87171227

The inclusion of informal care in applied economic evaluation: a review

OBJECTIVE

Theory and guidelines advocating the inclusion of informal care in economic evaluation have, in recent years, been accompanied by developments in the methods for capturing the costs and outcomes related to informal care. The objective of this study was to review applied economic evaluations to identify the methods used for, and implications of, including informal care in practice.

METHODS

Searches of key databases were conducted to identify all full economic evaluations incorporating costs or outcomes relating to informal care. Information was extracted by using a standard template from all studies meeting the inclusion criteria.

RESULTS

Thirty economic evaluations were identified that included informal care. Twenty-five of these studies costed carers' time input and 17 measured outcomes for carers. The reported cost-effectiveness of interventions was altered by including informal care, in some cases changing the key conclusions for health care funding.

CONCLUSIONS

Theory and methods development around informal care are yet to significantly permeate the applied literature; however, the results suggest that some funding priorities may change if they were to do so. The development of 1) a reference case for including informal care; 2) sensitivity analysis for contentious issues; and 3) a statement for the reason for excluding informal care, if this is deemed appropriate, may help to improve the way that informal care is included in economic evaluations in the future.

Do the methods used to analyse missing data really matter? An examination of data from an observational study of Intermediate Care patients

Background

Missing data is a common statistical problem in healthcare datasets from populations of older people. Some argue that arbitrarily assuming the mechanism responsible for the missingness and therefore the method for dealing with this missingness is not the best option—but is this always true? This paper explores what happens when extra information that suggests that a particular mechanism is responsible for missing data is disregarded and methods for dealing with the missing data are chosen arbitrarily.

Regression models based on 2,533 intermediate care (IC) patients from the largest evaluation of IC done and published in the UK to date were used to explain variation in costs, EQ-5D and Barthel index. Three methods for dealing with missingness were utilised, each assuming a different mechanism as being responsible for the missing data: complete case analysis (assuming missing completely at random—MCAR), multiple imputation (assuming missing at random—MAR) and Heckman selection model (assuming missing not at random—MNAR). Differences in results were gauged by examining the signs of coefficients as well as the sizes of both coefficients and associated standard errors.

Results

Extra information strongly suggested that missing cost data were MCAR. The results show that MCAR and MAR-based methods yielded similar results with sizes of most coefficients and standard errors differing by less than 3.4% while those based on MNAR-methods were statistically different (up to 730% bigger). Significant variables in all regression models also had the same direction of influence on costs. All three mechanisms of missingness were shown to be potential causes of the missing EQ-5D and Barthel data. The method chosen to deal with missing data did not seem to have any significant effect on the results for these data as they led to broadly similar conclusions with sizes of coefficients and standard errors differing by less than 54% and 322%, respectively.

Conclusions

Arbitrary selection of methods to deal with missing data should be avoided. Using extra information gathered during the data collection exercise about the cause of missingness to guide this selection would be more appropriate.

Rituximab for the treatment of relapsed/refractory chronic lymphocytic leukaemia

This paper presents a summary of the evidence review group (ERG) report on the clinical effectiveness and cost-effectiveness of rituximab with chemotherapy compared to chemotherapy only for the treatment of relapsed/refractory chronic lymphocytic leukaemia (CLL) based on the manufacturer's submission to the National Institute for Health and Clinical Excellence (NICE) as part of the single technology appraisal (STA) process. Evidence was available in the form of one open-label, ongoing, unpublished randomised controlled trial (RCT), REACH (Rituximab in the Study of Relapsed Chronic Lymphocytic Leukemia), conducted by the manufacturer, which compared rituximab with a fludarabine and cyclophosphamide combination (R-FC) to fludarabine and cyclophosphamide (FC) only. REACH was scheduled to run for 8 years; however, the data provided were immature, with a median observation time at the time of data analysis of 2.1 years. REACH provided evidence of prolonged progression free survival with R-FC compared to FC (10 months, investigators' data), but no evidence of an overall survival benefit with R-FC. Patients refractory to fludarabine and with prior rituximab exposure were excluded from REACH and no controlled studies were identified by the ERG for these patient groups. The ERG had concerns about the structure of the economic model submitted by the manufacturer, which did not allow improvement in quality of life from treatment while in a progressed state. The manufacturer's model further assumed a divergence in cumulative deaths between the R-FC and FC treatment arms from the outset, which did not accord with observed data from REACH. When the survival advantage was removed, the manufacturer's base-case incremental cost-effectiveness ratio (ICER) changed from 15,593 pounds to between 40,000 pounds and 42,000 pounds per quality-adjusted life-year (QALY). With no survival advantage, the ICER became sensitive to changes in utility. There was no good empirical evidence on the utility of CLL patients in different states. Allowing for the possibility of a survival advantage with rituximab (although not supported by current evidence), the ERG performed further modelling, which found that rituximab would be cost-effective at 20,000 pounds/QALY (30,000 pounds/QALY) if a reduction in survival advantage relative to the manufacturer's base case of 40% (80%) was assumed. The guidance issued by NICE in July 2010 as a result of the STA recommends rituximab with FC for people with relapsed or refractory chronic lymphocytic leukaemia, except when the condition is refractory to fludarabine or where there has been previous treatment with rituximab.

Rituximab for the treatment of relapsed/refractory chronic lymphocytic leukaemia

This paper presents a summary of the evidence review group (ERG) report on the clinical effectiveness and cost-effectiveness of rituximab with chemotherapy compared to chemotherapy only for the treatment of relapsed/refractory chronic lymphocytic leukaemia (CLL) based on the manufacturer’s submission to the National Institute for Health and Clinical Excellence (NICE) as part of the single technology appraisal (STA) process. Evidence was available in the form of one open-label, ongoing, unpublished randomised controlled trial (RCT), REACH (Rituximab in the Study of Relapsed Chronic Lymphocytic Leukemia), conducted by the manufacturer, which compared rituximab with a fludarabine and cyclophosphamide combination (R-FC) to fludarabine and cyclophosphamide (FC) only. REACH was scheduled to run for 8 years; however, the data provided were immature, with a median observation time at the time of data analysis of 2.1 years. REACH provided evidence of prolonged progression free survival with R-FC compared to FC (10 months, investigators’ data), but no evidence of an overall survival benefit with R-FC. Patients refractory to fludarabine and with prior rituximab exposure were excluded from REACH and no controlled studies were identified by the ERG for these patient groups. The ERG had concerns about the structure of the economic model submitted by the manufacturer, which did not allow improvement in quality of life from treatment while in a progressed state. The manufacturer’s model further assumed a divergence in cumulative deaths between the R-FC and FC treatment arms from the outset, which did not accord with observed data from REACH. When the survival advantage was removed, the manufacturer’s base-case incremental cost-effectiveness ratio (ICER) changed from £15,593 to between £40,000 and £42,000 per quality-adjusted life-year (QALY). With no survival advantage, the ICER became sensitive to changes in utility. There was no good empirical evidence on the utility of CLL patients in different states. Allowing for the possibility of a survival advantage with rituximab (although not supported by current evidence), the ERG performed further modelling, which found that rituximab would be cost-effective at £20,000/QALY (£30,000/QALY) if a reduction in survival advantage relative to the manufacturer’s base case of 40% (80%) was assumed. The guidance issued by NICE in July 2010 as a result of the STA recommends rituximab with FC for people with relapsed or refractory chronic lymphocytic leukaemia, except when the condition is refractory to fludarabine or where there has been previous treatment with rituximab.

The relationship between staff skill mix, costs and outcomes in intermediate care services

Background

The purpose of this study was to assess the relationship between skill mix, patient outcomes, length of stay and service costs in older peoples' intermediate care services in England.

Methods

We undertook multivariate analysis of data collected as part of the National Evaluation of Intermediate Care Services. Data were analysed on between 337 and 403 older people admitted to 14 different intermediate care teams. Independent variables were the numbers of different types of staff within a team and the ratio of support staff to professionally qualified staff within teams. Outcome measures include the Barthel index, EQ-5D, length of service provision and costs of care.

Results

Increased skill mix (raising the number of different types of staff by one) is associated with a 17% reduction in service costs (p = 0.011). There is weak evidence (p = 0.090) that a higher ratio of support staff to qualified staff leads to greater improvements in EQ-5D scores of patients.

Conclusions

This study provides limited evidence on the relationship between multidisciplinary skill mix and outcomes in intermediate care services.

Telemonitoring and self-management in the control of hypertension (TASMINH2): a randomised controlled trial

BACKGROUND

Control of blood pressure is a key component of cardiovascular disease prevention, but is difficult to achieve and until recently has been the sole preserve of health professionals. This study assessed whether self-management by people with poorly controlled hypertension resulted in better blood pressure control compared with usual care.

METHODS

This randomised controlled trial was undertaken in 24 general practices in the UK. Patients aged 35-85 years were eligible for enrolment if they had blood pressure more than 140/90 mm Hg despite antihypertensive treatment and were willing to self-manage their hypertension. Participants were randomly assigned in a 1:1 ratio to self-management, consisting of self-monitoring of blood pressure and self-titration of antihypertensive drugs, combined with telemonitoring of home blood pressure measurements or to usual care. Randomisation was done by use of a central web-based system and was stratified by general practice with minimisation for sex, baseline systolic blood pressure, and presence or absence of diabetes or chronic kidney disease. Neither participants nor investigators were masked to group assignment. The primary endpoint was change in mean systolic blood pressure between baseline and each follow-up point (6 months and 12 months). All randomised patients who attended follow-up visits at 6 months and 12 months and had complete data for the primary outcome were included in the analysis, without imputation for missing data. This study is registered as an International Standard Randomised Controlled Trial, number ISRCTN17585681.

FINDINGS

527 participants were randomly assigned to self-management (n=263) or control (n=264), of whom 480 (91%; self-management, n=234; control, n=246) were included in the primary analysis. Mean systolic blood pressure decreased by 12.9 mm Hg (95% CI 10.4-15.5) from baseline to 6 months in the self-management group and by 9.2 mm Hg (6.7-11.8) in the control group (difference between groups 3.7 mm Hg, 0.8-6.6; p=0.013). From baseline to 12 months, systolic blood pressure decreased by 17.6 mm Hg (14.9-20.3) in the self-management group and by 12.2 mm Hg (9.5-14.9) in the control group (difference between groups 5.4 mm Hg, 2.4-8.5; p=0.0004). Frequency of most side-effects did not differ between groups, apart from leg swelling (self-management, 74 patients [32%]; control, 55 patients [22%]; p=0.022).

INTERPRETATION

Self-management of hypertension in combination with telemonitoring of blood pressure measurements represents an important new addition to control of hypertension in primary care.

FUNDING

Department of Health Policy Research Programme, National Coordinating Centre for Research Capacity Development, and Midlands Research Practices Consortium.

Rapid testing for group B streptococcus during labour: a test accuracy study with evaluation of acceptability and cost-effectiveness

OBJECTIVE

To determine the accuracy, acceptability and cost-effectiveness of polymerase chain reaction (PCR) and optical immunoassay (OIA) rapid tests for maternal group B streptococcal (GBS) colonisation at labour.

DESIGN

A test accuracy study was used to determine the accuracy of rapid tests for GBS colonisation of women in labour. Acceptability of testing to participants was evaluated through a questionnaire administered after delivery, and acceptability to staff through focus groups. A decision-analytic model was constructed to assess the cost-effectiveness of various screening strategies.

SETTING

Two large obstetric units in the UK.

PARTICIPANTS

Women booked for delivery at the participating units other than those electing for a Caesarean delivery.

INTERVENTIONS

Vaginal and rectal swabs were obtained at the onset of labour and the results of vaginal and rectal PCR and OIA (index) tests were compared with the reference standard of enriched culture of combined vaginal and rectal swabs.

MAIN OUTCOME MEASURES

The accuracy of the index tests, the relative accuracies of tests on vaginal and rectal swabs and whether test accuracy varied according to the presence or absence of maternal risk factors.

RESULTS

PCR was significantly more accurate than OIA for the detection of maternal GBS colonisation. Combined vaginal or rectal swab index tests were more sensitive than either test considered individually [combined swab sensitivity for PCR 84% (95% CI 79-88%); vaginal swab 58% (52-64%); rectal swab 71% (66-76%)]. The highest sensitivity for PCR came at the cost of lower specificity [combined specificity 87% (95% CI 85-89%); vaginal swab 92% (90-94%); rectal swab 92% (90-93%)]. The sensitivity and specificity of rapid tests varied according to the presence or absence of maternal risk factors, but not consistently. PCR results were determinants of neonatal GBS colonisation, but maternal risk factors were not. Overall levels of acceptability for rapid testing amongst participants were high. Vaginal swabs were more acceptable than rectal swabs. South Asian women were least likely to have participated in the study and were less happy with the sampling procedure and with the prospect of rapid testing as part of routine care. Midwives were generally positive towards rapid testing but had concerns that it might lead to overtreatment and unnecessary interference in births. Modelling analysis revealed that the most cost-effective strategy was to provide routine intravenous antibiotic prophylaxis (IAP) to all women without screening. Removing this strategy, which is unlikely to be acceptable to most women and midwives, resulted in screening, based on a culture test at 35-37 weeks' gestation, with the provision of antibiotics to all women who screened positive being most cost-effective, assuming that all women in premature labour would receive IAP. The results were sensitive to very small increases in costs and changes in other assumptions. Screening using a rapid test was not cost-effective based on its current sensitivity, specificity and cost.

CONCLUSIONS

Neither rapid test was sufficiently accurate to recommend it for routine use in clinical practice. IAP directed by screening with enriched culture at 35-37 weeks' gestation is likely to be the most acceptable cost-effective strategy, although it is premature to suggest the implementation of this strategy at present.

Costs and health outcomes of intermediate care: results from five UK case study sites

The objectives of this study were to explore the costs and outcomes associated with different types of intermediate care (IC) services, and also to examine the characteristics of patients receiving such services. Five UK case studies of 'whole systems' of IC were used, with data collected on a sample of consecutive IC episodes between January 2003 and January 2004. Statistical differences in costs and outcomes associated with different IC services and patient groups were explored. Factors associated with variation in IC episode outcomes (EuroQol EQ-5D and Barthel Index) were explored using an econometric framework. Data were available for 2253 episodes of IC. In terms of Department of Health criteria, a large proportion of patients (up to 47% of those for whom data were available) in this study were inappropriately admitted to IC services. As regards service function, compared to supported discharge, admission avoidance services were associated with both lower costs and greater health and functional gains. These gains appear to be driven, in part, by illness severity (more dependent patients tended to gain most benefit). In addition, these gains appear to be larger where the admission was appropriate. Our work suggests a need for the development and application of robust and reliable clinical criteria for admission to IC, and close co-operation between hospital and community service providers over selection of patients and targeting of IC and acute care services to meet defined clinical need.