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Zanganeh M, Belcher J, Fotheringham J, Coyle D, Lindley EJ, Keane DF, Caskey FJ, Dasgupta I, Davenport A, Farrington K, Mitra S, Ormandy P, Wilkie M, Macdonald JH, Solis-Trapala I, Sim J, Davies SJ, Andronis L. Cost-effectiveness of bioimpedance-guided fluid management in patients undergoing haemodialysis: the BISTRO RCT. Health Technol Assess 2024:1-45. [PMID: 39325432 DOI: 10.3310/jypr4287] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/27/2024] Open
Abstract
Background The BioImpedance Spectroscopy to maintain Renal Output randomised controlled trial investigated the effect of bioimpedance spectroscopy added to a standardised fluid management protocol on the risk of anuria and preservation of residual kidney function (primary trial outcomes) in incident haemodialysis patients. Despite the economic burden of kidney disease, the cost-effectiveness of using bioimpedance measurements to guide fluid management in haemodialysis is not known. Objectives To assess the cost-effectiveness of bioimpedance-guided fluid management against current fluid management without bioimpedance. Design Within-trial economic evaluation (cost-utility analysis) carried out alongside the open-label, multicentre BioImpedance Spectroscopy to maintain Renal Output randomised controlled trial. Setting Thirty-four United Kingdom outpatient haemodialysis centres, both main and satellite units, and their associated inpatient hospitals. Participants Four hundred and thirty-nine adult haemodialysis patients with > 500 ml urine/day or residual glomerular filtration rate > 3 ml/minute/1.73 m2. Intervention The study intervention was the incorporation of bioimpedance technology-derived information about body composition into the clinical assessment of fluid status in patients with residual kidney function undergoing haemodialysis. Bioimpedance measurements were used in conjunction with usual clinical judgement to set a target weight that would avoid excessive fluid depletion at the end of a dialysis session. Main outcome measures The primary outcome measure of the BioImpedance Spectroscopy to maintain Renal Output economic evaluation was incremental cost per additional quality-adjusted life-year gained over 24 months following randomisation. In the main (base-case) analysis, this was calculated from the perspective of the National Health Service and Personal Social Services. Sensitivity analyses explored the impact of different scenarios, sources of resource use data and value sets. Results The bioimpedance-guided fluid management group was associated with £382 lower average cost per patient (95% CI -£3319 to £2556) and 0.043 more quality-adjusted life-years (95% CI -0.019 to 0.105) compared with the current fluid management group, with neither values being statistically significant. The probability of bioimpedance-guided fluid management being cost-effective was 76% and 83% at commonly cited willingness-to-pay threshold of £20,000 and £30,000 per quality-adjusted life-year gained, respectively. The results remained robust to a series of sensitivity analyses. Limitations The missing data level was high for some resource use categories collected through case report forms, due to COVID-19 disruptions and a significant dropout rate in the informing BioImpedance Spectroscopy to maintain Renal Output trial. Conclusions Compared with current fluid management, bioimpedance-guided fluid management produced a marginal reduction in costs and a small improvement in quality-adjusted life-years. Results from both the base-case and sensitivity analyses suggested that use of bioimpedance is likely to be cost-effective. Future work Future work exploring the association between primary outcomes and longer-term survival would be useful. Should an important link be established, and relevant evidence becomes available, it would be informative to determine whether and how this might affect longer-term costs and benefits associated with bioimpedance-guided fluid management. Funding details This article presents independent research funded by the National Institute for Health and Care Research (NIHR) Health Technology Assessment programme as award number HTA 14/216/01 (NIHR136142).
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Affiliation(s)
- Mandana Zanganeh
- Centre for Health Economics at Warwick, University of Warwick, Coventry, UK
| | | | - James Fotheringham
- School of Health and Related Research, University of Sheffield, Sheffield, UK
- Sheffield Kidney Institute, Sheffield Teaching Hospitals NHS Trust, Sheffield, UK
| | - David Coyle
- NIHR Devices for Dignity, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
| | | | - David F Keane
- CÚRAM SFI Research Centre for Medical Devices, University of Galway, Galway, Ireland
| | - Fergus J Caskey
- Population Health Sciences, University of Bristol, Bristol, UK
| | - Indranil Dasgupta
- Renal Medicine, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
- Warwick Medical School, University of Warwick, Coventry, UK
| | - Andrew Davenport
- UCL Department of Renal Medicine, Royal Free Hampstead NHS Trust, University College, London, UK
| | - Ken Farrington
- Renal Medicine, East & North Hertfordshire NHS Trust, Hertfordshire, UK
| | - Sandip Mitra
- Manchester Academic Health Sciences Centre (MAHSC), Manchester University Hospitals and University of Manchester, Manchester, UK
| | - Paula Ormandy
- School of Health and Society, University of Salford, Manchester, UK
| | - Martin Wilkie
- Sheffield Kidney Institute, Sheffield Teaching Hospitals NHS Trust, Sheffield, UK
| | - Jamie H Macdonald
- Institute for Applied Human Physiology, Bangor University, Bangor, UK
| | | | - Julius Sim
- School of Medicine, Keele University, Keele, UK
| | | | - Lazaros Andronis
- Centre for Health Economics at Warwick, University of Warwick, Coventry, UK
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Walter JR, Barnhart KT, Koelper NC, Santoro NF, Zhang H, Thomas TR, Huang H, Harvie HS. Cost-effectiveness analysis of expectant vs active management for treatment of persistent pregnancies of unknown location. Am J Obstet Gynecol 2024; 231:328.e1-328.e11. [PMID: 38552817 DOI: 10.1016/j.ajog.2024.03.035] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2023] [Revised: 03/08/2024] [Accepted: 03/24/2024] [Indexed: 04/28/2024]
Abstract
BACKGROUND Persistent pregnancies of unknown location are defined by abnormally trending serum human chorionic gonadotropin with nondiagnostic ultrasound. There is no consensus on optimal management. OBJECTIVE This study aimed to assess the cost-effectiveness of 3 primary management strategies for persistent pregnancies of unknown location: (1) expectant management, (2) empirical 2-dose methotrexate, and (3) uterine evacuation followed by methotrexate, if indicated. STUDY DESIGN This was a prospective economic evaluation performed concurrently with the Expectant versus Active Management for Treatment of Persistent Pregnancies of Unknown Location multicenter randomized trial that was conducted from July 2014 to June 2019. Participants were randomized 1:1:1 to expectant management, 2-dose methotrexate, or uterine evacuation. The analysis was from the healthcare sector perspective with a 6-week time horizon after randomization. Costs were expressed in 2018 US dollars. Effectiveness was measured in quality-adjusted life years and the rate of salpingectomy. Incremental cost-effectiveness ratios and cost-effectiveness acceptability curves were generated. Sensitivity analyses were performed to assess the robustness of the analysis. RESULTS Methotrexate had the lowest mean cost ($875), followed by expectant management ($1085) and uterine evacuation ($1902) (P=.001). Expectant management had the highest mean quality-adjusted life years (0.1043), followed by methotrexate (0.1031) and uterine evacuation (0.0992) (P=.0001). The salpingectomy rate was higher for expectant management than for methotrexate (9.4% vs 1.2%, respectively; P=.02) and for expectant management than for uterine evacuation (9.4% vs 8.1%, respectively; P=.04). Uterine evacuation, with the highest costs and the lowest quality-adjusted life years, was dominated by both expectant management and methotrexate. In the base case analysis, expectant management was not cost-effective compared with methotrexate at a willingness to pay of $150,000 per quality-adjusted life year given an incremental cost-effectiveness ratio of $175,083 per quality-adjusted life year gained (95% confidence interval, -$1,666,825 to $2,676,375). Threshold analysis demonstrated that methotrexate administration would have to cost $214 (an increase of $16 or 8%) to favor expectant management. Moreover, expectant management would be favorable in lower-risk patient populations with rates of laparoscopic surgical management for ectopic pregnancy not exceeding 4% of pregnancies of unknown location. Based on the cost-effectiveness acceptability curves, the probability of expectant management being cost-effective compared with methotrexate at a willingness to pay of $150,000 per quality-adjusted life year gained was 50%. The results were dependent on the cost of surgical intervention and the expected rate of methotrexate failure. CONCLUSION The management of pregnancies of unknown location with a 2-dose methotrexate protocol may be cost-effective compared with expectant management and uterine evacuation. Although uterine evacuation was dominated, expectant management vs methotrexate results were sensitive to modest changes in treatment costs of both methotrexate and surgical management.
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Affiliation(s)
- Jessica R Walter
- Division of Reproductive Endocrinology and Infertility, Department of Obstetrics and Gynecology, Northwestern University, Chicago, IL.
| | - Kurt T Barnhart
- Division of Reproductive Endocrinology and Infertility, Department of Obstetrics and Gynecology, University of Pennsylvania, Philadelphia, PA
| | - Nathanael C Koelper
- Division of Reproductive Endocrinology and Infertility, Department of Obstetrics and Gynecology, University of Pennsylvania, Philadelphia, PA
| | - Nanette F Santoro
- Divisions of Reproductive Endocrinology and Infertility and Reproductive Sciences, Department of Obstetrics and Gynecology, University of Colorado, Aurora, CO
| | - Heping Zhang
- Department of Biostatistics, Yale University School of Public Health, New Haven, CT
| | - Tracey R Thomas
- Division of Reproductive Endocrinology and Infertility, Department of Obstetrics and Gynecology, University of Pennsylvania, Philadelphia, PA
| | - Hao Huang
- Department of Biostatistics, Yale University School of Public Health, New Haven, CT
| | - Heidi S Harvie
- Urogynecology and Pelvic Reconstructive Surgery, Department of Obstetrics and Gynecology, University of Pennsylvania, Philadelphia, PA; Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, PA
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3
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Bray G, Moncrieff J, Priebe S, Marston L, Lewis G, Haynes N, Pinfold V, Johnson S, Hunter RM. Cost-Utility Analysis of Antipsychotic Reduction and Discontinuation in Patients With Long-Term Schizophrenia and Psychosis in English Mental Health Trusts: The RADAR Study. VALUE IN HEALTH : THE JOURNAL OF THE INTERNATIONAL SOCIETY FOR PHARMACOECONOMICS AND OUTCOMES RESEARCH 2024:S1098-3015(24)02800-6. [PMID: 39127250 DOI: 10.1016/j.jval.2024.07.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/29/2024] [Revised: 07/22/2024] [Accepted: 07/25/2024] [Indexed: 08/12/2024]
Abstract
OBJECTIVES The current recommended treatment for patients with recurrent episodes of schizophrenia and related conditions is antipsychotic medication. However, many antipsychotic users remain functionally impaired and experience serious physical and mental side effects. This study aims to assess the cost-effectiveness of a gradual antipsychotic reduction and discontinuation strategy compared with maintenance treatment over 24 months from mental health services, health and social care, and societal perspectives. METHODS Nineteen mental health trusts recruited patients to the Research into Antipsychotic Discontinuation and Reduction (RADAR) randomized controlled trial. Quality-adjusted life-years were calculated from patient-reported EQ-5D-5L, with years of full capability calculated from the patient-reported ICECAP-A. Mental health services use and medication was collected from medical records. Other resource use and productivity loss was collected using self-completed questionnaires. Costs were calculated from published sources. RESULTS A total of 253 participants were randomized: 126 assigned to antipsychotic dose reduction and 127 to maintenance. There were no significant differences between arms in total costs for any perspectives. There were no significant difference in quality-adjusted life-years (-0.035; 95% CI: -0.123 to 0.052), whereas years of full capability were significantly lower in the reduction arm compared with the maintenance arm (baseline-adjusted difference: -0.103; 95% CI: -0.192 to -0.014). The reduction strategy was dominated by maintenance for all analyses and was not likely to be cost-effective. CONCLUSIONS It is unlikely that gradual antipsychotic reduction and discontinuation strategy is cost-effective compared with maintenance over 2-years for patients with schizophrenia and other recurrent psychotic disorders who are on long-term antipsychotics.
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Affiliation(s)
- George Bray
- Office of Health Economics, London, England, UK
| | - Joanna Moncrieff
- Division of Psychiatry, University College London and North East London NHS Foundation Trust, London, England, UK
| | - Stefan Priebe
- Unit for Social and Community Psychiatry, Queen Mary University of London, London, England, UK
| | - Louise Marston
- Research Department of Primary Care and Population Health, University College London, London, England, UK
| | - Glyn Lewis
- Division of Psychiatry, University College London and North East London NHS Foundation Trust, London, England, UK
| | - Nadia Haynes
- Research and Development Department, North East London NHS Foundation Trust, London, England, UK
| | | | - Sonia Johnson
- Division of Psychiatry, University College London and North East London NHS Foundation Trust, London, England, UK
| | - Rachael Maree Hunter
- Research Department of Primary Care and Population Health, University College London, London, England, UK.
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Kiamouri A, Angeli M, Krommidas C, Digelidis N, Karatrantou K. Tennis Coaches' Self-Determined Motivation and Achievement Goals: Links between Coach-Created Motivational Climate, Work Engagement, and Well-Being. Behav Sci (Basel) 2024; 14:681. [PMID: 39199077 PMCID: PMC11352129 DOI: 10.3390/bs14080681] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2024] [Revised: 08/03/2024] [Accepted: 08/05/2024] [Indexed: 09/01/2024] Open
Abstract
Tennis coaches display significant influence, catalyzing changes in athlete performance, motivation, and overall well-being. Research on coaches' motivations and their impact on coaching style, work, and well-being is limited, especially in individual sports like tennis. Based on self-determination (SDT) and achievement goal (AGT) theories, the aim of the present study was to examine the relationships of coaches' self-determined motivation (intrinsic, extrinsic, and amotivation), basic psychological needs satisfaction (autonomy, relatedness, and competence), and achievement goals (self-improvement-SI, self-enhancement-SE, self-transcendence-ST) with their coach-created empowering-disempowering motivational climate, work engagement, and well-being (subjective vitality). Participants were 106 tennis coaches from Greece (66 males and 40 females), with an average age of 41.30 ± 12.54 years and coaching experience ranging from six months to 40 years. Data was collected through online questionnaires. Correlation analysis revealed that intrinsic and extrinsic motivation, satisfaction of the three basic psychological needs, and achievement goals were found to be positively related to an empowering climate, work engagement, and subjective vitality. Coaches' amotivation was positively related to a disempowering climate. Multiple regression analyses showed that autonomy and ST achievement goals significantly predicted tennis coaches' empowering motivational climate, while none of the independent variables were significant predictors of the disempowering motivational climate. Additionally, intrinsic motivation and ST goal significantly predicted tennis coaches' work engagement, while autonomy and ST goal significantly predicted their subjective vitality. It is advisable for forthcoming coach education initiatives to consider these findings as an additional justification for tennis coaches to incorporate multiple perspectives into their coaching methodologies.
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Affiliation(s)
| | | | | | | | - Konstantina Karatrantou
- Department of Physical Education & Sport Science, University of Thessaly, 42100 Trikala, Greece; (A.K.); (M.A.); (C.K.); (N.D.)
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Pilz da Cunha G, Coupé VMH, Zonderhuis BM, Bonjer HJ, Erdmann JI, Kazemier G, Besselink MG, Swijnenburg RJ. Healthcare cost expenditure for robotic versus laparoscopic liver resection: a bottom-up economic evaluation. HPB (Oxford) 2024; 26:971-980. [PMID: 38853074 DOI: 10.1016/j.hpb.2024.05.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/25/2024] [Revised: 05/22/2024] [Accepted: 05/27/2024] [Indexed: 06/11/2024]
Abstract
BACKGROUND Minimally invasive liver surgery (MILS) is increasingly performed via the robot-assisted approach but may be associated with increased costs. This study is a post-hoc comparison of healthcare cost expenditure for robotic liver resection (RLR) and laparoscopic liver resection (LLR) in a high-volume center. METHODS In-hospital and 30-day postoperative healthcare costs were calculated per patient in a retrospective series (October 2015-December 2022). RESULTS Overall, 298 patients were included (143 RLR and 155 LLR). Benefits of RLR were lower conversion rate (2.8% vs 12.3%, p = 0.002), shorter operating time (167 min vs 198 min, p = 0.044), and less blood loss (50 mL vs 200 mL, p < 0.001). Total per-procedure costs of RLR (€10260) and LLR (€9931) were not significantly different (mean difference €329 [95% bootstrapped confidence interval (BCI) €-1179-€2120]). Lower costs with RLR due to shorter surgical and operating room time were offset by higher disposable instrumentation costs resulting in comparable intraoperative costs (€5559 vs €5247, mean difference €312 [95% BCI €-25-€648]). Postoperative costs were similar for RLR (€4701) and LLR (€4684), mean difference €17 [95% BCI €-1357-€1727]. When also considering purchase and maintenance costs, RLR resulted in higher total per-procedure costs. DISCUSSION In a high-volume center, RLR can have similar per-procedure cost expenditure as LLR when disregarding capital investment.
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Affiliation(s)
- Gabriela Pilz da Cunha
- Amsterdam UMC, Location University of Amsterdam, Department of Surgery, Amsterdam, the Netherlands; Cancer Center Amsterdam, Amsterdam, the Netherlands
| | - Veerle M H Coupé
- Amsterdam UMC, Location University of Amsterdam, Department of Epidemiology and Biostatistics, Amsterdam, the Netherlands
| | - Barbara M Zonderhuis
- Cancer Center Amsterdam, Amsterdam, the Netherlands; Amsterdam UMC, Location Vrije Universiteit, Department of Surgery, Amsterdam, the Netherlands
| | - H Jaap Bonjer
- Cancer Center Amsterdam, Amsterdam, the Netherlands; Amsterdam UMC, Location Vrije Universiteit, Department of Surgery, Amsterdam, the Netherlands
| | - Joris I Erdmann
- Cancer Center Amsterdam, Amsterdam, the Netherlands; Amsterdam UMC, Location Vrije Universiteit, Department of Surgery, Amsterdam, the Netherlands
| | - G Kazemier
- Cancer Center Amsterdam, Amsterdam, the Netherlands; Amsterdam UMC, Location Vrije Universiteit, Department of Surgery, Amsterdam, the Netherlands
| | - Marc G Besselink
- Amsterdam UMC, Location University of Amsterdam, Department of Surgery, Amsterdam, the Netherlands; Cancer Center Amsterdam, Amsterdam, the Netherlands
| | - Rutger-Jan Swijnenburg
- Amsterdam UMC, Location University of Amsterdam, Department of Surgery, Amsterdam, the Netherlands; Cancer Center Amsterdam, Amsterdam, the Netherlands; Amsterdam UMC, Location Vrije Universiteit, Department of Surgery, Amsterdam, the Netherlands.
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6
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Pickering AN, Zhao X, Sileanu FE, Lovelace EZ, Rose L, Schwartz AL, Hale JA, Schleiden LJ, Gellad WF, Fine MJ, Thorpe CT, Radomski TR. Care cascades following low-value cervical cancer screening in dually enrolled Veterans. J Am Geriatr Soc 2024; 72:2091-2099. [PMID: 38721922 PMCID: PMC11226371 DOI: 10.1111/jgs.18956] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2024] [Revised: 04/08/2024] [Accepted: 04/18/2024] [Indexed: 06/02/2024]
Abstract
BACKGROUND Veterans dually enrolled in the Veterans Health Administration (VA) and Medicare commonly experience downstream services as part of a care cascade after an initial low-value service. Our objective was to characterize the frequency and cost of low-value cervical cancer screening and subsequent care cascades among Veterans dually enrolled in VA and Medicare. METHODS This retrospective cohort study used VA and Medicare administrative data from fiscal years 2015 to 2019. The study cohort was comprised of female Veterans aged >65 years and at low risk of cervical cancer who were dually enrolled in VA and Medicare. Within this cohort, we compared differences in the rates and costs of cascade services related to low-value cervical cancer screening for Veterans who received and did not receive screening in FY2018, adjusting for baseline patient- and facility-level covariates using inverse probability of treatment weighting. RESULTS Among 20,972 cohort-eligible Veterans, 494 (2.4%) underwent low-value cervical cancer screening with 301 (60.9%) initial screens occurring in VA and 193 (39%) occurring in Medicare. Veterans who were screened experienced an additional 26.7 (95% CI, 16.4-37.0) cascade services per 100 Veterans compared to those who were not screened, contributing to $2919.4 (95% CI, -265 to 6104.7) per 100 Veterans in excess costs. Care cascades consisted predominantly of subsequent cervical cancer screening procedures and related outpatient visits with low rates of invasive procedures and occurred in both VA and Medicare. CONCLUSIONS Veterans dually enrolled in VA and Medicare commonly receive related downstream tests and visits as part of care cascades following low-value cervical cancer screening. Our findings demonstrate that to fully capture the extent to which individuals are subject to low-value care, it is important to examine downstream care stemming from initial low-value services across all systems from which individuals receive care.
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Affiliation(s)
- Aimee N Pickering
- Center for Health Equity Research and Promotion (CHERP), VA Pittsburgh Healthcare System, Pittsburgh, Pennsylvania, USA
- Division of General Internal Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - Xinhua Zhao
- Center for Health Equity Research and Promotion (CHERP), VA Pittsburgh Healthcare System, Pittsburgh, Pennsylvania, USA
| | - Florentina E Sileanu
- Center for Health Equity Research and Promotion (CHERP), VA Pittsburgh Healthcare System, Pittsburgh, Pennsylvania, USA
| | - Elijah Z Lovelace
- Center for Health Equity Research and Promotion (CHERP), VA Pittsburgh Healthcare System, Pittsburgh, Pennsylvania, USA
| | - Liam Rose
- Health Economics Resource Center (HERC), VA Palo Alto Healthcare System, Palo Alto, California, USA
| | - Aaron L Schwartz
- Center for Health Equity Research and Promotion (CHERP), Crescenz VA Medical Center, Philadelphia, Pennsylvania, USA
- Division of General Internal Medicine, Department of Medical Ethics and Health Policy, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Jennifer A Hale
- Center for Health Equity Research and Promotion (CHERP), VA Pittsburgh Healthcare System, Pittsburgh, Pennsylvania, USA
| | - Loren J Schleiden
- Center for Health Equity Research and Promotion (CHERP), VA Pittsburgh Healthcare System, Pittsburgh, Pennsylvania, USA
| | - Walid F Gellad
- Center for Health Equity Research and Promotion (CHERP), VA Pittsburgh Healthcare System, Pittsburgh, Pennsylvania, USA
- Division of General Internal Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - Michael J Fine
- Center for Health Equity Research and Promotion (CHERP), VA Pittsburgh Healthcare System, Pittsburgh, Pennsylvania, USA
- Division of General Internal Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - Carolyn T Thorpe
- Center for Health Equity Research and Promotion (CHERP), VA Pittsburgh Healthcare System, Pittsburgh, Pennsylvania, USA
- Division of Pharmaceutical Outcomes and Policy, University of North Carolina at Chapel Hill Eshelman School of Pharmacy, Chapel Hill, North Carolina, USA
| | - Thomas R Radomski
- Center for Health Equity Research and Promotion (CHERP), VA Pittsburgh Healthcare System, Pittsburgh, Pennsylvania, USA
- Division of General Internal Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
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Crawford MJ, Leeson VC, Evans R, Goulden N, Weaver T, Trumm A, Barrett BM, Khun-Thompson F, Pandya SP, Saunders KE, Lamph G, Woods D, Smith H, Greenall T, Nicklin V, Barnicot K. Clinical effectiveness and cost-effectiveness of Structured Psychological Support for people with probable personality disorder in mental health services in England: study protocol for a randomised controlled trial. BMJ Open 2024; 14:e086593. [PMID: 38925701 PMCID: PMC11202761 DOI: 10.1136/bmjopen-2024-086593] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/18/2024] [Accepted: 06/12/2024] [Indexed: 06/28/2024] Open
Abstract
INTRODUCTION Evidence-based psychological treatments for people with personality disorder usually involve attending group-based sessions over many months. Low-intensity psychological interventions of less than 6 months duration have been developed, but their clinical effectiveness and cost-effectiveness are unclear. METHODS AND ANALYSIS This is a multicentre, randomised, parallel-group, researcher-masked, superiority trial. Study participants will be aged 18 and over, have probable personality disorder and be treated by mental health staff in seven centres in England. We will exclude people who are: unwilling or unable to provide written informed consent, have a coexisting organic or psychotic mental disorder, or are already receiving psychological treatment for personality disorder or on a waiting list for such treatment. In the intervention group, participants will be offered up to 10 individual sessions of Structured Psychological Support. In the control group, participants will be offered treatment as usual plus a single session of personalised crisis planning. The primary outcome is social functioning measured over 12 months using total score on the Work and Social Adjustment Scale (WSAS). Secondary outcomes include mental health, suicidal behaviour, health-related quality of life, patient-rated global improvement and satisfaction, and resource use and costs. The primary analysis will compare WSAS scores across the 12-month period using a general linear mixed model adjusting for baseline scores, allocation group and study centre on an intention-to-treat basis. In a parallel process evaluation, we will analyse qualitative data from interviews with study participants, clinical staff and researchers to examine mechanisms of impact and contextual factors. ETHICS AND DISSEMINATION The study complies with the Helsinki Declaration II and is approved by the London-Bromley Research Ethics Committee (IRAS ID 315951). Study findings will be published in an open access peer-reviewed journal; and disseminated at national and international conferences. TRIAL REGISTRATION NUMBER ISRCTN13918289.
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Affiliation(s)
| | | | | | | | - Tim Weaver
- Department of Mental Health & Social Work, Middlesex University, London, UK
| | - Aile Trumm
- Department of Mental Health & Social Work, Middlesex University, London, UK
| | | | | | | | | | - Gary Lamph
- School of Nursing and Midwifery, Keele University, Keele, UK
| | - David Woods
- Derbyshire Healthcare NHS Foundation Trust, Derby, UK
| | - Harriet Smith
- Avon and Wiltshire Mental Health Partnership NHS Trust, Bath, UK
| | - Toby Greenall
- Lincolnshire Community Health Services NHS Trust, Lincoln, UK
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Benz F, Grolig L, Hannibal S, Buntrock C, Cuijpers P, Domschke K, Ebert DD, Ell J, Janneck M, Jenkner C, Johann AF, Josef A, Kaufmann M, Koß A, Mallwitz T, Mergan H, Morin CM, Riemann D, Riper H, Schmid SR, Smit F, Spille L, Steinmetz L, Van Someren EJW, Spiegelhalder K, Lehr D. Investigating non-inferiority of internet-delivered versus face-to-face cognitive behavioural therapy for insomnia (CBT-I): a randomised controlled trial (iSleep well). Trials 2024; 25:371. [PMID: 38858707 PMCID: PMC11163861 DOI: 10.1186/s13063-024-08214-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2024] [Accepted: 05/30/2024] [Indexed: 06/12/2024] Open
Abstract
BACKGROUND Insomnia is a highly prevalent disorder associated with numerous adverse health outcomes. Cognitive behavioural therapy for insomnia (CBT-I) is recommended as first-line treatment by clinical guidelines but is accessible to only a minority of patients suffering from insomnia. Internet-delivered CBT-I (iCBT-I) could contribute to the widespread dissemination of this first-line treatment. As there is insufficient evidence regarding non-inferiority, this study directly aims to compare therapist-guided internet-delivered versus face-to-face CBT-I in terms of insomnia severity post-treatment. Furthermore, a health-economic evaluation will be conducted, and potential benefits and disadvantages of therapist-guided iCBT-I will be examined. METHODS This study protocol describes a randomised controlled two-arm parallel-group non-inferiority trial comparing therapist-guided iCBT-I with face-to-face CBT-I in routine clinical care. A total of 422 patients with insomnia disorder will be randomised and treated at 16 study centres throughout Germany. Outcomes will be assessed at baseline, 10 weeks after randomisation (post), and 6 months after randomisation (follow-up). The primary outcome is insomnia severity measured using the Insomnia Severity Index. Secondary outcomes include depression-related symptoms, quality of life, fatigue, physical activity, daylight exposure, adverse events related to treatment, and a health-economic evaluation. Finally, potential moderator variables and several descriptive and exploratory outcomes will be assessed (e.g. benefits and disadvantages of internet-delivered treatment). DISCUSSION The widespread implementation of CBT-I is a significant healthcare challenge. The non-inferiority of therapist-guided iCBT-I versus face-to-face CBT-I will be investigated in an adequately powered sample in routine clinical care, with the same therapeutic content and same level of therapist qualifications provided with both interventions. If this trial demonstrates the non-inferiority of therapist-guided iCBT-I, healthcare providers may be more confident recommending this treatment to their patients, contributing to the wider dissemination of CBT-I. TRIAL REGISTRATION Trial registration number in the German Clinical Trials Register: DRKS00028153 ( https://drks.de/search/de/trial/DRKS00028153 ). Registered on 16th May 2023.
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Affiliation(s)
- F Benz
- Department of Psychiatry and Psychotherapy, Medical Center - University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany.
| | - L Grolig
- Department of Health Psychology and Applied Biological Psychology, Institute of Sustainability Psychology, Leuphana University of Lüneburg, Lüneburg, Germany
| | - S Hannibal
- Department of Health Psychology and Applied Biological Psychology, Institute of Sustainability Psychology, Leuphana University of Lüneburg, Lüneburg, Germany
| | - C Buntrock
- Institute of Social Medicine and Health Systems Research, Medical Faculty, Otto-von-Guericke-University, Magdeburg, Germany
| | - P Cuijpers
- Department of Clinical, Neuro and Developmental Psychology, Amsterdam Public Health Research Institute, Vrije Universiteit Amsterdam, Amsterdam, Netherlands
- Babeș-Bolyai University, International Institute for Psychotherapy, Cluj-Napoca, Romania
| | - K Domschke
- Department of Psychiatry and Psychotherapy, Medical Center - University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - D D Ebert
- Psychology & Digital Mental Health Care, Department of Health Sciences, Technical University Munich, Munich, Germany
| | - J Ell
- Department of Psychiatry and Psychotherapy, Medical Center - University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - M Janneck
- Institute for Interactive Systems, Department of Electrical Engineering and Computer Science, Technische Hochschule Lübeck, Lübeck, Germany
| | - C Jenkner
- Clinical Trials Unit, Medical Center, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - A F Johann
- Department of Psychiatry and Psychotherapy, Medical Center - University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
- Institute of Medical Psychology and Medical Sociology, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - A Josef
- Clinical Trials Unit, Medical Center, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - M Kaufmann
- Clinical Trials Unit, Medical Center, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - A Koß
- Clinical Trials Unit, Medical Center, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - T Mallwitz
- Institute for Interactive Systems, Department of Electrical Engineering and Computer Science, Technische Hochschule Lübeck, Lübeck, Germany
| | - H Mergan
- Institute for Interactive Systems, Department of Electrical Engineering and Computer Science, Technische Hochschule Lübeck, Lübeck, Germany
| | - C M Morin
- École de Psychologie, Centre d'étude des troubles du sommeil, Centre de recherche CERVO/Brain Research Center, Université Laval, Québec, Canada
| | - D Riemann
- Department of Psychiatry and Psychotherapy, Medical Center - University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - H Riper
- Department of Clinical, Neuro and Developmental Psychology, Amsterdam Public Health Research Institute, Vrije Universiteit Amsterdam, Amsterdam, Netherlands
- Amsterdam UMC, Department of Psychiatry, Amsterdam Public Health Research Institute, Amsterdam, Netherlands
| | - S R Schmid
- Department of Psychiatry and Psychotherapy, Medical Center - University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - F Smit
- Department of Clinical, Neuro and Developmental Psychology, Amsterdam Public Health Research Institute, Vrije Universiteit Amsterdam, Amsterdam, Netherlands
- Department of Epidemiology and Biostatistics, Amsterdam Public Health Research Institute, Amsterdam University Medical Centers, Location VUmc, Amsterdam, the Netherlands
- Centre of Health-Economic Evaluation, Trimbos Institute (Netherlands Institute of Mental Health and Addiction), Utrecht, the Netherlands
| | - L Spille
- Department of Psychiatry and Psychotherapy, Medical Center - University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - L Steinmetz
- Department of Psychiatry and Psychotherapy, Medical Center - University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - E J W Van Someren
- Department of Sleep and Cognition, Netherlands Institute for Neuroscience, Royal Netherlands Academy of Arts and Sciences, Amsterdam, the Netherlands
| | - K Spiegelhalder
- Department of Psychiatry and Psychotherapy, Medical Center - University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - D Lehr
- Department of Health Psychology and Applied Biological Psychology, Institute of Sustainability Psychology, Leuphana University of Lüneburg, Lüneburg, Germany
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9
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Seow-En I, Tan IEH, Zheng V, Wu J, Zhao Y, Ang KA, Au MKH, Tan EJKW. A retrospective cohort study of intra-corporeal versus extra-corporeal anastomosis for right hemicolectomy with cost-effectiveness analysis. Tech Coloproctol 2024; 28:66. [PMID: 38850445 DOI: 10.1007/s10151-024-02944-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/10/2024] [Accepted: 05/15/2024] [Indexed: 06/10/2024]
Abstract
BACKGROUND We aimed to compare outcomes and cost effectiveness of extra-corporeal anastomosis (ECA) versus intra-corporeal anastomosis (ICA) for laparoscopic right hemicolectomy using the National Surgical Quality Improvement Programme data. METHODS Patients who underwent elective laparoscopic right hemicolectomy for colon cancer from January 2018 to December 2022 were identified. Non-cancer diagnoses, emergency procedures or synchronous resection of other organs were excluded. Surgical characteristics, peri-operative outcomes, long-term survival and hospitalisation costs were compared. Incremental cost-effectiveness ratio (ICER) was used to evaluate cost-effectiveness. RESULTS A total of 223 patients (175 ECA, 48 ICA) were included in the analysis. Both cohorts exhibited comparable baseline patient, comorbidity, and tumour characteristics. Distribution of pathological TMN stage, tumour largest dimension, total lymph node harvest and resection margin lengths were statistically similar. ICA was associated with a longer median operative duration compared with ECA (255 min vs. 220 min, P < 0.001). There was a quicker time to gastrointestinal recovery, with a shorter median hospital stay in the ICA group (4.0 versus 5.0 days, P = 0.001). Overall complication rates were comparable. ICA was associated with a higher surgical procedure cost (£6301.57 versus £4998.52, P < 0.001), but lower costs for ward accommodation (£1679.05 versus £2420.15, P = 0.001) and treatment (£3774.55 versus £4895.14, P = 0.009), with a 4.5% reduced overall cost compared with ECA. The ICER of -£3323.58 showed ICA to be more cost effective than ECA, across a range of willingness-to-pay thresholds. CONCLUSION ICA in laparoscopic right hemicolectomy is associated with quicker post-operative recovery and may be more cost effective compared with ECA, despite increased operative costs.
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Affiliation(s)
- I Seow-En
- Department of Colorectal Surgery, Singapore General Hospital, Outram Road, 169608, Singapore.
| | - I E-H Tan
- Group Finance Analytics, Singapore Health Services, Singapore, Singapore
| | - V Zheng
- Yong Loo Lin School of Medicine, National University of Singapore, Medical Drive, 117597, Singapore
| | - J Wu
- Department of Colorectal Surgery, Singapore General Hospital, Outram Road, 169608, Singapore
| | - Y Zhao
- Group Finance Analytics, Singapore Health Services, Singapore, Singapore
| | - K A Ang
- Finance, Singapore General Hospital, Outram Road, 169608, Singapore
| | - M K H Au
- Group Finance Analytics, Singapore Health Services, Singapore, Singapore
- Finance, SingHealth Community Hospitals, Singapore, Singapore
- Regional Health System and Strategic Finance, Singapore Health Services, Singapore, Singapore
| | - E J K W Tan
- Department of Colorectal Surgery, Singapore General Hospital, Outram Road, 169608, Singapore
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10
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Lappe L, Hertzberg C, Knake S, Knuf M, von Podewils F, Willems LM, Kovac S, Zöllner JP, Sauter M, Kurlemann G, Mayer T, Bertsche A, Marquard K, Meyer S, Schäfer H, Thiels C, Zukunft B, Schubert-Bast S, Reese JP, Rosenow F, Strzelczyk A. A multicenter, matched case-control analysis comparing burden of illness among patients with tuberous sclerosis complex related epilepsy, generalized idiopathic epilepsy, and focal epilepsy in Germany. Neurol Res Pract 2024; 6:29. [PMID: 38812055 PMCID: PMC11138101 DOI: 10.1186/s42466-024-00323-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2024] [Accepted: 04/15/2024] [Indexed: 05/31/2024] Open
Abstract
BACKGROUND Depending on the underlying etiology and epilepsy type, the burden of disease for patients with seizures can vary significantly. This analysis aimed to compare direct and indirect costs and quality of life (QoL) among adults with tuberous sclerosis complex (TSC) related with epilepsy, idiopathic generalized epilepsy (IGE), and focal epilepsy (FE) in Germany. METHODS Questionnaire responses from 92 patients with TSC and epilepsy were matched by age and gender, with responses from 92 patients with IGE and 92 patients with FE collected in independent studies. Comparisons were made across the main QoL components, direct costs (patient visits, medication usage, medical equipment, diagnostic procedures, ancillary treatments, and transport costs), indirect costs (employment, reduced working hours, missed days), and care level costs. RESULTS Across all three cohorts, mean total direct costs (TSC: €7602 [median €2620]; IGE: €1919 [median €446], P < 0.001; FE: €2598 [median €892], P < 0.001) and mean total indirect costs due to lost productivity over 3 months (TSC: €7185 [median €11,925]; IGE: €3599 [median €0], P < 0.001; FE: €5082 [median €2981], P = 0.03) were highest among patients with TSC. The proportion of patients with TSC who were unemployed (60%) was significantly larger than the proportions of patients with IGE (23%, P < 0.001) or FE (34%, P = P < 0.001) who were unemployed. Index scores for the EuroQuol Scale with 5 dimensions and 3 levels were significantly lower for patients with TSC (time-trade-off [TTO]: 0.705, visual analog scale [VAS]: 0.577) than for patients with IGE (TTO: 0.897, VAS: 0.813; P < 0.001) or FE (TTO: 0.879, VAS: 0.769; P < 0.001). Revised Epilepsy Stigma Scale scores were also significantly higher for patients with TSC (3.97) than for patients with IGE (1.48, P < 0.001) or FE (2.45, P < 0.001). Overall Quality of Life in Epilepsy Inventory-31 items scores was significantly lower among patients with TSC (57.7) and FE (57.6) than among patients with IGE (66.6, P = 0.004 in both comparisons). Significant differences between patients with TSC and IGE were also determined for Neurological Disorder Depression Inventory for Epilepsy (TSC: 13.1; IGE: 11.2, P = 0.009) and Liverpool Adverse Events Profile scores (TSC: 42.7; IGE: 37.5, P = 0.017) with higher score and worse results for TSC patients in both questionnaires. CONCLUSIONS This study is the first to compare patients with TSC, IGE, and FE in Germany and underlines the excessive QoL burden and both direct and indirect cost burdens experienced by patients with TSC.
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Affiliation(s)
- Lisa Lappe
- Goethe-University Frankfurt, Epilepsy Center Frankfurt Rhine-Main, Department of Neurology, University Hospital Frankfurt, Theodor-Stern-Kai 7, 60596, Frankfurt am Main, Germany
- Center for Personalized Translational Epilepsy Research (CePTER), Goethe-University Frankfurt, Frankfurt am Main, Germany
| | | | - Susanne Knake
- Epilepsy Center Hessen and Department of Neurology, Philipps-University Marburg, Marburg, Germany
| | - Markus Knuf
- Department of Pediatrics, Klinikum Worms, Worms, Germany
- Department of Pediatrics, University Medicine Mainz, Mainz, Germany
| | - Felix von Podewils
- Department of Neurology, Epilepsy Center, University Medicine Greifswald, Greifswald, Germany
| | - Laurent M Willems
- Goethe-University Frankfurt, Epilepsy Center Frankfurt Rhine-Main, Department of Neurology, University Hospital Frankfurt, Theodor-Stern-Kai 7, 60596, Frankfurt am Main, Germany
- Center for Personalized Translational Epilepsy Research (CePTER), Goethe-University Frankfurt, Frankfurt am Main, Germany
| | - Stjepana Kovac
- Department of Neurology with Institute of Translational Neurology, University Münster, Münster, Germany
| | - Johann Philipp Zöllner
- Goethe-University Frankfurt, Epilepsy Center Frankfurt Rhine-Main, Department of Neurology, University Hospital Frankfurt, Theodor-Stern-Kai 7, 60596, Frankfurt am Main, Germany
- Center for Personalized Translational Epilepsy Research (CePTER), Goethe-University Frankfurt, Frankfurt am Main, Germany
| | - Matthias Sauter
- Klinikum Kempten, Klinikverbund Allgäu, Kempten/Allgäu, Germany
| | | | | | - Astrid Bertsche
- Department of Neuropediatrics, University Hospital for Children and Adolescents, Greifswald, Germany
| | - Klaus Marquard
- Department of Pediatric Neurology, Psychosomatics and Pain Management, Klinikum Stuttgart, Stuttgart, Germany
| | - Sascha Meyer
- Department of General Pediatrics and Neonatology, Franz-Lust Klinik für Kinder und Jugendliche, Karlsruhe, Germany
| | - Hannah Schäfer
- Department of Nephrology, Klinikum rechts der Isar, Technische Universität München, Munich, Germany
| | - Charlotte Thiels
- Division of Nephrology, Medizinische Klinik und Poliklinik IV, Klinikum der LMU München - Innenstadt, Munich, Germany
- Department of Neuropediatrics and Pediatric Epileptology, University Hospital of Ruhr University Bochum, Bochum, Germany
| | - Bianca Zukunft
- Department of Nephrology and Internal Intensive Care, Charité - University Medicine Berlin, Berlin, Germany
| | - Susanne Schubert-Bast
- Goethe-University Frankfurt, Epilepsy Center Frankfurt Rhine-Main, Department of Neurology, University Hospital Frankfurt, Theodor-Stern-Kai 7, 60596, Frankfurt am Main, Germany
- Center for Personalized Translational Epilepsy Research (CePTER), Goethe-University Frankfurt, Frankfurt am Main, Germany
- Goethe-University Frankfurt, Department of Neuropediatrics, University Hospital Frankfurt, Frankfurt am Main, Germany
| | - Jens-Peter Reese
- Institute of Clinical Epidemiology and Biometry, University of Würzburg, Würzburg, Germany
| | - Felix Rosenow
- Goethe-University Frankfurt, Epilepsy Center Frankfurt Rhine-Main, Department of Neurology, University Hospital Frankfurt, Theodor-Stern-Kai 7, 60596, Frankfurt am Main, Germany
- Center for Personalized Translational Epilepsy Research (CePTER), Goethe-University Frankfurt, Frankfurt am Main, Germany
| | - Adam Strzelczyk
- Goethe-University Frankfurt, Epilepsy Center Frankfurt Rhine-Main, Department of Neurology, University Hospital Frankfurt, Theodor-Stern-Kai 7, 60596, Frankfurt am Main, Germany.
- Center for Personalized Translational Epilepsy Research (CePTER), Goethe-University Frankfurt, Frankfurt am Main, Germany.
- Epilepsy Center Hessen and Department of Neurology, Philipps-University Marburg, Marburg, Germany.
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11
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Jiang X, Yang D, Feng L, Zhu Y, Wang M, Feng Y, Bai C, Fang H. Contrastive learning with token projection for Omicron pneumonia identification from few-shot chest CT images. Front Med (Lausanne) 2024; 11:1360143. [PMID: 38756944 PMCID: PMC11096503 DOI: 10.3389/fmed.2024.1360143] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2023] [Accepted: 04/05/2024] [Indexed: 05/18/2024] Open
Abstract
Introduction Deep learning-based methods can promote and save critical time for the diagnosis of pneumonia from computed tomography (CT) images of the chest, where the methods usually rely on large amounts of labeled data to learn good visual representations. However, medical images are difficult to obtain and need to be labeled by professional radiologists. Methods To address this issue, a novel contrastive learning model with token projection, namely CoTP, is proposed for improving the diagnostic quality of few-shot chest CT images. Specifically, (1) we utilize solely unlabeled data for fitting CoTP, along with a small number of labeled samples for fine-tuning, (2) we present a new Omicron dataset and modify the data augmentation strategy, i.e., random Poisson noise perturbation for the CT interpretation task, and (3) token projection is utilized to further improve the quality of the global visual representations. Results The ResNet50 pre-trained by CoTP attained accuracy (ACC) of 92.35%, sensitivity (SEN) of 92.96%, precision (PRE) of 91.54%, and the area under the receiver-operating characteristics curve (AUC) of 98.90% on the presented Omicron dataset. On the contrary, the ResNet50 without pre-training achieved ACC, SEN, PRE, and AUC of 77.61, 77.90, 76.69, and 85.66%, respectively. Conclusion Extensive experiments reveal that a model pre-trained by CoTP greatly outperforms that without pre-training. The CoTP can improve the efficacy of diagnosis and reduce the heavy workload of radiologists for screening of Omicron pneumonia.
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Affiliation(s)
- Xiaoben Jiang
- School of Information Science and Technology, East China University of Science and Technology, Shanghai, China
| | - Dawei Yang
- Department of Pulmonary and Critical Care Medicine, Zhongshan Hospital, Fudan University, Shanghai, China
- Shanghai Engineering Research Center of Internet of Things for Respiratory Medicine, Shanghai, China
- Department of Pulmonary and Critical Care Medicine, Zhongshan Hospital (Xiamen), Fudan University, Xiamen, Fujian, China
| | - Li Feng
- Department of Nursing, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Yu Zhu
- School of Information Science and Technology, East China University of Science and Technology, Shanghai, China
| | - Mingliang Wang
- Department of Anesthesiology, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Yinzhou Feng
- Department of Pulmonary and Critical Care Medicine, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Chunxue Bai
- Department of Pulmonary and Critical Care Medicine, Zhongshan Hospital, Fudan University, Shanghai, China
- Shanghai Engineering Research Center of Internet of Things for Respiratory Medicine, Shanghai, China
| | - Hao Fang
- Department of Anesthesiology, Zhongshan Hospital, Fudan University, Shanghai, China
- Department of Anesthesiology, Shanghai Geriatric Medical Center, Shanghai, China
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12
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Nowak-Gospodarowicz I, Gospodarowicz M, Rękas M. Factors influencing medical expenditures in patients with unresolved facial palsy and pharmacoeconomic analysis of upper eyelid lid loading with gold and platinum weights compared to tarsorrhaphy. HEALTH ECONOMICS REVIEW 2024; 14:30. [PMID: 38676777 PMCID: PMC11055228 DOI: 10.1186/s13561-024-00506-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/05/2023] [Accepted: 04/08/2024] [Indexed: 04/29/2024]
Abstract
There are no standards in diagnostic and therapeutic approaches to eye care in incomplete eyelid closure due to unresolved facial palsy (FP). Loading of the upper eyelid (UELL) with gold weights (GWs) or platinum chains (PCs) is a highly effective procedure for the correction of lagophthalmos. Despite this, the procedure is used infrequently in our country because of the relatively high price of the implant and the lack of reimbursement. The aim of this research was to assess the factors influencing medical expenditures in this group of patients and to analyze utility costs for the UELL procedure with the use of GW and PC compared to tarsorrhaphy.Material and methods The costs of 88 surgical procedures (40 GWs, 11 PCs and 37 tarsorrhaphies) and medical expenditures before and after surgery were calculated based on reporting of materials, staff salaries and the SF-36 questionnaire. Distribution quartiles of the cost per QALY measure (dependent variable) was assessed via an ordered logistic regression model with eight explanatory variables.Results The calculated total cost of the surgery was US$209 for tarsorrhaphy, US$758 for UELL with a GW and US$1,676 for UELL with a PC. Bootstrapped costs per QALY values (CUI) in 88% of cases were below the US$100,000 cutoff. Etiology and duration of facial palsy and presence of Bell's phenomenon were factors that significantly influenced the CUI. Patient gender and age, history of previous eyelid surgery, and presence of corneal sensation were found to be not significant (p > 0.1). Calculated ICER for GW was US$1,241.74/1QALY and ICER for PC was US$13,181.05/1QALY compared to tarsorrhaphy.Conclusions Eye protection in patients with FP should be a crucial element of health policy. Findings suggest UELL procedure with a GW or a PC to be a cost-effective procedure with GW being the most cost-effective.
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Affiliation(s)
- Izabela Nowak-Gospodarowicz
- Department of Ophthalmology, Military Institute of Medicine - National Research Institute, 128 Szaserow St, 04-141, Warsaw, Poland.
| | - Marcin Gospodarowicz
- Institute of Banking, Warsaw School of Economics, Niepodległości 162, 02-554, Warsaw, Poland
| | - Marek Rękas
- Department of Ophthalmology, Military Institute of Medicine - National Research Institute, 128 Szaserow St, 04-141, Warsaw, Poland
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13
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Zelionkaitė I, Gaižauskaitė R, Uusberg H, Uusberg A, Ambrasė A, Derntl B, Grikšienė R. The levonorgestrel-releasing intrauterine device is related to early emotional reactivity: An ERP study. Psychoneuroendocrinology 2024; 162:106954. [PMID: 38241970 DOI: 10.1016/j.psyneuen.2023.106954] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/07/2023] [Revised: 11/17/2023] [Accepted: 12/30/2023] [Indexed: 01/21/2024]
Abstract
Despite the evidence of altered emotion processing in oral contraceptive (OC) users, the impact of hormonal intrauterine devices (IUD) on emotional processing remains unexplored. Our study aimed to investigate how behavioural performance and event-related potentials (ERPs) linked with emotion reactivity and its regulation are associated with hormonal profiles of women using different types of hormonal contraception and naturally cycling women. Women using OCs (n = 25), hormonal IUDs (n = 33), and naturally cycling women in their early follicular (NCF, n = 33) or mid-luteal (NCL, n = 28) phase of the menstrual cycle were instructed to view emotional pictures (neutral, low and high negativity) and use cognitive reappraisal to up- or down-regulate negative emotions, while their electroencephalogram was recorded. Participants rated perceived negativity after each picture and their emotional arousal throughout the task. Saliva samples were collected to assess levels of 17β-estradiol, progesterone, and testosterone. As expected, emotional arousal increased throughout the task and correlated positively with perceived negativity. Perceived negativity and the amplitudes of the middle (N2/P3) and later (LPP) latency ERP components increased with increasing stimuli negativity. Emotion regulation modulated perceived negativity and the amplitudes of very late ERP components (parietal and frontal LPP). Moreover, IUD-users showed a higher negative amplitude of the frontal N2 in comparison to all three other groups, with the most consistent differences during up-regulation. Finally, testosterone correlated positively with the N2 peak in IUD-users and NCL women. Overall, our findings suggest that IUD-use and testosterone might be related to altered preconscious processing during the emotion regulation task requiring attention to the stimulus. The study underscores the need for additional research into how different hormonal contraceptives are linked to socio-emotional functioning.
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Affiliation(s)
- Ingrida Zelionkaitė
- Department of Neurobiology and Biophysics, Vilnius University, Saulėtekio ave. 7, 10257, Vilnius, Lithuania.
| | - Rimantė Gaižauskaitė
- Department of Neurobiology and Biophysics, Vilnius University, Saulėtekio ave. 7, 10257, Vilnius, Lithuania
| | - Helen Uusberg
- Institute of Psychology, University of Tartu, Ülikooli 18, 50090, Tartu, Estonia
| | - Andero Uusberg
- Institute of Psychology, University of Tartu, Ülikooli 18, 50090, Tartu, Estonia
| | - Aistė Ambrasė
- Department of Psychiatry and Psychotherapy, Women's Mental Health & Brain Function, Tübingen Center for Mental Health, University of Tübingen, Calwerstraße 14, 72016, Tübingen, Germany
| | - Birgit Derntl
- Department of Psychiatry and Psychotherapy, Women's Mental Health & Brain Function, Tübingen Center for Mental Health, University of Tübingen, Calwerstraße 14, 72016, Tübingen, Germany; DZPG (German Center for Mental Health), Partner site Tübingen, Germany
| | - Ramunė Grikšienė
- Department of Neurobiology and Biophysics, Vilnius University, Saulėtekio ave. 7, 10257, Vilnius, Lithuania
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14
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Dinh NTT, de Graaff B, Campbell JA, Jose MD, Burgess J, Saunder T, Kitsos A, Wells C, Palmer AJ. Creating an interactive map visualising the geographic variations of the burden of diabetes to inform policymaking: An example from a cohort study in Tasmania, Australia. Aust N Z J Public Health 2024; 48:100109. [PMID: 38429224 DOI: 10.1016/j.anzjph.2023.100109] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2023] [Revised: 08/16/2023] [Accepted: 11/07/2023] [Indexed: 03/03/2024] Open
Abstract
OBJECTIVES To visualise the geographic variations of diabetes burden and identify areas where targeted interventions are needed. METHODS Using diagnostic criteria supported by hospital codes, 51,324 people with diabetes were identified from a population-based dataset during 2004-2017 in Tasmania, Australia. An interactive map visualising geographic distribution of diabetes prevalence, mortality rates, and healthcare costs in people with diabetes was generated. The cluster and outlier analysis was performed based on statistical area level 2 (SA2) to identify areas with high (hot spot) and low (cold spot) diabetes burden. RESULTS There were geographic variations in diabetes burden across Tasmania, with highest age-adjusted prevalence (6.1%), excess cost ($2627), and annual costs per person ($5982) in the West and Northwest. Among 98 SA2 areas, 16 hot spots and 25 cold spots for annual costs, and 10 hot spots and 10 cold spots for diabetes prevalence were identified (p<0.05). 15/16 (94%) and 6/10 (60%) hot spots identified were in the West and Northwest. CONCLUSIONS We have developed a method to graphically display important diabetes outcomes for different geographical areas. IMPLICATIONS FOR PUBLIC HEALTH The method presented in our study could be applied to any other diseases, regions, and countries where appropriate data are available to identify areas where interventions are needed to improve diabetes outcomes.
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Affiliation(s)
- Ngan T T Dinh
- Menzies Institute for Medical Research, University of Tasmania, Tasmania, Australia; Thai Nguyen University of Medicine and Pharmacy, Thai Nguyen University, Thai Nguyen, Vietnam. https://twitter.com/@NganDin46229988
| | - Barbara de Graaff
- Menzies Institute for Medical Research, University of Tasmania, Tasmania, Australia
| | - Julie A Campbell
- Menzies Institute for Medical Research, University of Tasmania, Tasmania, Australia
| | - Matthew D Jose
- School of Medicine, University of Tasmania, Tasmania, Australia; Australia and New Zealand Dialysis and Transplant Registry (ANZDATA), South Australia, Australia
| | - John Burgess
- School of Medicine, University of Tasmania, Tasmania, Australia; Department of Endocrinology, Royal Hobart Hospital, Tasmania, Australia
| | - Timothy Saunder
- School of Medicine, University of Tasmania, Tasmania, Australia
| | - Alex Kitsos
- School of Medicine, University of Tasmania, Tasmania, Australia
| | | | - Andrew J Palmer
- Menzies Institute for Medical Research, University of Tasmania, Tasmania, Australia.
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15
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Halder GE, Guo F, Harvie H, White AB, Caldwell L, Giles DL, Bilagi D, Rogers RG. Cost Effectiveness of Additional Preoperative Telephone Call to Increase Surgical Preparedness: Analysis of a Randomized Clinical Trial. Int Urogynecol J 2024; 35:527-536. [PMID: 38189853 DOI: 10.1007/s00192-023-05719-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2023] [Accepted: 12/09/2023] [Indexed: 01/09/2024]
Abstract
INTRODUCTION AND HYPOTHESIS There is a need for cost effective interventions that increase surgical preparedness in urogynecology. METHODS We performed an ancillary prospective economic evaluation of the Telehealth Intervention to Increase Patient Preparedness for Surgery (TIPPS) Trial, a randomized multicenter trial that evaluated the impact of a preoperative telehealth call on surgical preparedness in women undergoing urogynecologic surgery. A within-trial analysis from the health care sector and societal perspective was performed. Cost-effectiveness was computed from health care sector and societal perspectives, with an 8-week time horizon. RESULTS A total of 126 women were included in our analysis. QALYs gained were similar between groups (telehealth 0.1414 + 0.0249; usual care 0.1409 + 0.0179). The cumulative mean per-person costs at 8 weeks from the healthcare sector perspective were telehealth call: $8696 +/- 3341; usual care: $8473 +/- 3118 (p = 0.693) and from the societal perspective were telehealth call: $11,195 + 5191; usual care: $11,213 +/- 4869 (p = 0.944). The preoperative telehealth call intervention was not cost effective from the health care sector perspective with an ICER of $460,091/QALY (95%CI -$7,382,608/QALY, $7,673,961) using the generally accepted maximum willingness to pay threshold of $150,000/QALY (Neumann et al. N Engl J Med. 371(9):796-7, 2014). From the societal perspective, because incremental costs per QALY gained were negative $-35,925/QALY (95%CI, -$382,978/QALY, $317,226), results suggest that preoperative telehealth call dominated usual care. CONCLUSIONS A preoperative telehealth call is cost effective from the society perspective. CLINICAL TRIAL REGISTRATION Registered with http://ClinicalTrials.gov . Date of registration: March 26, 2019 Date of initial participant enrollment: June 5, 2019 URL: https://clinicaltrials.gov/ct2/show/record/NCT03890471 Clinical trial identification number: NCT03890471.
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Affiliation(s)
- Gabriela E Halder
- Department of Women's Health, The University of Texas Austin Dell Medical School, Austin, TX, USA.
- Division of Urogynecology, Department of Obstetrics and Gynecology, The University of Texas Medical Branch, Galveston, TX, USA.
| | - Fangjian Guo
- Division of Population and Preventive Health, Department of Obstetrics & Gynecology, The University of Texas Medical Branch at Galveston, Galveston, TX, USA
- Center for Interdisciplinary Research in Women's Health, School of Medicine, The University of Texas Medical Branch at Galveston, Galveston, TX, USA
| | - Heidi Harvie
- Department of Obstetrics and Gynecology, Perelman School of Medicine, The University of Pennsylvania, Philadelphia, PA, USA
- The Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, PA, USA
| | - Amanda B White
- Department of Women's Health, The University of Texas Austin Dell Medical School, Austin, TX, USA
| | - Lauren Caldwell
- Department of Women's Health, The University of Texas Austin Dell Medical School, Austin, TX, USA
| | - Dobie L Giles
- Division of Female Pelvic Medicine and Reconstructive Surgery, Department of Obstetrics and Gynecology, The University of Wisconsin-Maddison, Maddison, WI, USA
| | - Daksha Bilagi
- Department of Women's Health, The University of Texas Austin Dell Medical School, Austin, TX, USA
| | - Rebecca G Rogers
- Department of Women's Health, The University of Texas Austin Dell Medical School, Austin, TX, USA
- Department of Obstetrics and Gynecology, Albany Medical Center, Albany, NY, USA
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Hasselgren K, Henriksson M, Røsok BI, Larsen PN, Sparrelid E, Lindell G, Schultz NA, Bjørnbeth BA, Isaksson B, Rizell M, Larsson AL, Sandström P, Björnsson B. Health Economic Evaluation of Patients With Colorectal Liver Metastases Randomized to ALPPS or TSH: Analysis From the LIGRO Trial. ANNALS OF SURGERY OPEN 2024; 5:e367. [PMID: 38883960 PMCID: PMC11175926 DOI: 10.1097/as9.0000000000000367] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2022] [Accepted: 10/28/2023] [Indexed: 06/18/2024] Open
Abstract
Objective This is a preplanned, health economic evaluation from the LIGRO trial. One hundred patients with colorectal liver metastases (CRLM) and standardized future liver remnant <30% were randomized to associating liver partition and portal vein ligation for staged hepatectomy (ALPPS) or two-staged hepatectomy (TSH). Summary Background Data TSH, is an established method in advanced CRLM. ALPPS has emerged providing improved resection rate and survival. The health care costs and health outcomes, combining health-related quality of life (HRQoL) and survival into quality-adjusted life years (QALYs), of ALPPS and TSH have not previously been evaluated and compared. Methods Costs and QALYs were compared from treatment start up to 2 years. Costs are estimated from resource use, including all surgical interventions, length of stay after interventions, diagnostic procedures and chemotherapy, and applying Swedish unit costs. QALYs were estimated by combining survival and HRQoL data, the latter being assessed with EQ-5D 3L. Estimated costs and QALYs for each treatment strategy were combined into an incremental cost-effectiveness ratio (ICER). Nonparametric bootstrapping was used to assess the joint distribution of incremental costs and QALYs. Results The mean cost difference between ALPPS and TSH was 12,662€, [95% confidence interval (CI): -10,728-36,051; P = 0.283]. Corresponding mean difference in life years and QALYs was 0.1296 (95% CI: -0.12-0.38; P = 0.314) and 0.1285 (95% CI: -0.11-0.36; P = 0.28), respectively. The ICER was 93,186 and 92,414 for QALYs and life years as outcomes, respectively. Conclusions Based on the 2-year data, the cost-effectiveness of ALPPS is uncertain. Further research, exploring cost and health outcomes beyond 2 years is needed.
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Affiliation(s)
- Kristina Hasselgren
- From the Division of surgery, Department of Biomedical and Clinical Sciences, Linköping University, Linköping, Sweden
| | - Martin Henriksson
- Centre for Medical Technology Assessment, Department of Medical and Health Sciences, Linköping University, Linköping, Sweden
| | - Bård I Røsok
- Department of Hepato-Pancreato-Biliary Surgery, Oslo University Hospital, Oslo, Norway
| | - Peter N Larsen
- Department of Surgical Gastroenterology and Transplantation, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
| | - Ernesto Sparrelid
- Department of Clinical Science, Intervention and Technology, Division of Surgery, Karolinska Institutet, Karolinska University Hospital, Stockholm, Sweden
| | - Gert Lindell
- Department of Surgery, Skane University Hospital, Lund, Sweden
| | - Nicolai A Schultz
- Department of Surgical Gastroenterology and Transplantation, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
| | - Bjorn A Bjørnbeth
- Department of Hepato-Pancreato-Biliary Surgery, Oslo University Hospital, Oslo, Norway
| | - Bengt Isaksson
- Department of Surgery, Akademiska University Hospital, Uppsala, Sweden
| | - Magnus Rizell
- Department of Transplantation and Liver Surgery, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Anna Lindhoff Larsson
- From the Division of surgery, Department of Biomedical and Clinical Sciences, Linköping University, Linköping, Sweden
| | - Per Sandström
- From the Division of surgery, Department of Biomedical and Clinical Sciences, Linköping University, Linköping, Sweden
| | - Bergthor Björnsson
- From the Division of surgery, Department of Biomedical and Clinical Sciences, Linköping University, Linköping, Sweden
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17
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Carrie S, Fouweather T, Homer T, O'Hara J, Rousseau N, Rooshenas L, Bray A, Stocken DD, Ternent L, Rennie K, Clark E, Waugh N, Steel AJ, Dooley J, Drinnan M, Hamilton D, Lloyd K, Oluboyede Y, Wilson C, Gardiner Q, Kara N, Khwaja S, Leong SC, Maini S, Morrison J, Nix P, Wilson JA, Teare MD. Effectiveness of septoplasty compared to medical management in adults with obstruction associated with a deviated nasal septum: the NAIROS RCT. Health Technol Assess 2024; 28:1-213. [PMID: 38477237 PMCID: PMC11017631 DOI: 10.3310/mvfr4028] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/14/2024] Open
Abstract
Background The indications for septoplasty are practice-based, rather than evidence-based. In addition, internationally accepted guidelines for the management of nasal obstruction associated with nasal septal deviation are lacking. Objective The objective was to determine the clinical effectiveness and cost-effectiveness of septoplasty, with or without turbinate reduction, compared with medical management, in the management of nasal obstruction associated with a deviated nasal septum. Design This was a multicentre randomised controlled trial comparing septoplasty, with or without turbinate reduction, with defined medical management; it incorporated a mixed-methods process evaluation and an economic evaluation. Setting The trial was set in 17 NHS secondary care hospitals in the UK. Participants A total of 378 eligible participants aged > 18 years were recruited. Interventions Participants were randomised on a 1: 1 basis and stratified by baseline severity and gender to either (1) septoplasty, with or without turbinate surgery (n = 188) or (2) medical management with intranasal steroid spray and saline spray (n = 190). Main outcome measures The primary outcome was the Sino-nasal Outcome Test-22 items score at 6 months (patient-reported outcome). The secondary outcomes were as follows: patient-reported outcomes - Nasal Obstruction Symptom Evaluation score at 6 and 12 months, Sino-nasal Outcome Test-22 items subscales at 12 months, Double Ordinal Airway Subjective Scale at 6 and 12 months, the Short Form questionnaire-36 items and costs; objective measurements - peak nasal inspiratory flow and rhinospirometry. The number of adverse events experienced was also recorded. A within-trial economic evaluation from an NHS and Personal Social Services perspective estimated the incremental cost per (1) improvement (of ≥ 9 points) in Sino-nasal Outcome Test-22 items score, (2) adverse event avoided and (3) quality-adjusted life-year gained at 12 months. An economic model estimated the incremental cost per quality-adjusted life-year gained at 24 and 36 months. A mixed-methods process evaluation was undertaken to understand/address recruitment issues and examine the acceptability of trial processes and treatment arms. Results At the 6-month time point, 307 participants provided primary outcome data (septoplasty, n = 152; medical management, n = 155). An intention-to-treat analysis revealed a greater and more sustained improvement in the primary outcome measure in the surgical arm. The 6-month mean Sino-nasal Outcome Test-22 items scores were -20.0 points lower (better) for participants randomised to septoplasty than for those randomised to medical management [the score for the septoplasty arm was 19.9 and the score for the medical management arm was 39.5 (95% confidence interval -23.6 to -16.4; p < 0.0001)]. This was confirmed by sensitivity analyses and through the analysis of secondary outcomes. Outcomes were statistically significantly related to baseline severity, but not to gender or turbinate reduction. In the surgical and medical management arms, 132 and 95 adverse events occurred, respectively; 14 serious adverse events occurred in the surgical arm and nine in the medical management arm. On average, septoplasty was more costly and more effective in improving Sino-nasal Outcome Test-22 items scores and quality-adjusted life-years than medical management, but incurred a larger number of adverse events. Septoplasty had a 15% probability of being considered cost-effective at 12 months at a £20,000 willingness-to-pay threshold for an additional quality-adjusted life-year. This probability increased to 99% and 100% at 24 and 36 months, respectively. Limitations COVID-19 had an impact on participant-facing data collection from March 2020. Conclusions Septoplasty, with or without turbinate reduction, is more effective than medical management with a nasal steroid and saline spray. Baseline severity predicts the degree of improvement in symptoms. Septoplasty has a low probability of cost-effectiveness at 12 months, but may be considered cost-effective at 24 months. Future work should focus on developing a septoplasty patient decision aid. Trial registration This trial is registered as ISRCTN16168569 and EudraCT 2017-000893-12. Funding This award was funded by the National Institute for Health and Care Research (NIHR) Health Technology Assessment programme (NIHR award ref: 14/226/07) and is published in full in Health Technology Assessment; Vol. 28, No. 10. See the NIHR Funding and Awards website for further award information.
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Affiliation(s)
- Sean Carrie
- Ear, Nose and Throat Department, Freeman Hospital, Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, UK
- Honorary affiliation with Population Health Sciences Institute, Newcastle University, Newcastle upon Tyne, UK
| | - Tony Fouweather
- Population Health Sciences Institute, Newcastle University, Newcastle upon Tyne, UK
| | - Tara Homer
- Population Health Sciences Institute, Newcastle University, Newcastle upon Tyne, UK
| | - James O'Hara
- Ear, Nose and Throat Department, Freeman Hospital, Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, UK
| | - Nikki Rousseau
- Leeds Institute of Clinical Trials Research, University of Leeds, Leeds, UK
| | - Leila Rooshenas
- Bristol Population Health Science Institute, University of Bristol, Bristol, UK
| | - Alison Bray
- Honorary affiliation with Population Health Sciences Institute, Newcastle University, Newcastle upon Tyne, UK
- Northern Medical Physics and Clinical Engineering, Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, UK
| | - Deborah D Stocken
- Leeds Institute of Clinical Trials Research, University of Leeds, Leeds, UK
| | - Laura Ternent
- Population Health Sciences Institute, Newcastle University, Newcastle upon Tyne, UK
| | - Katherine Rennie
- Newcastle Clinical Trials Unit, Newcastle University, Newcastle upon Tyne, UK
| | - Emma Clark
- Newcastle Clinical Trials Unit, Newcastle University, Newcastle upon Tyne, UK
| | - Nichola Waugh
- Newcastle Clinical Trials Unit, Newcastle University, Newcastle upon Tyne, UK
| | - Alison J Steel
- Newcastle Clinical Trials Unit, Newcastle University, Newcastle upon Tyne, UK
| | - Jemima Dooley
- Centre for Academic Primary Care, University of Bristol, Bristol, UK
| | - Michael Drinnan
- Honorary affiliation with Population Health Sciences Institute, Newcastle University, Newcastle upon Tyne, UK
- Northern Medical Physics and Clinical Engineering, Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, UK
| | - David Hamilton
- Population Health Sciences Institute, Newcastle University, Newcastle upon Tyne, UK
| | - Kelly Lloyd
- Leeds Institute of Clinical Trials Research, University of Leeds, Leeds, UK
| | - Yemi Oluboyede
- Population Health Sciences Institute, Newcastle University, Newcastle upon Tyne, UK
| | - Caroline Wilson
- Bristol Population Health Science Institute, University of Bristol, Bristol, UK
| | - Quentin Gardiner
- Ear, Nose and Throat Department, Ninewells Hospital, NHS Tayside, Dundee, UK
| | - Naveed Kara
- Ear, Nose and Throat Department, Darlington Memorial Hospital, County Durham and Darlington NHS Foundation Trust, Durham, UK
| | - Sadie Khwaja
- Ear, Nose and Throat Department, Manchester Royal Infirmary, Manchester University Foundation NHS Trust, Manchester, UK
| | - Samuel Chee Leong
- Ear, Nose and Throat Department, Aintree Hospital, Aintree University Hospitals NHS Foundation Trust, Liverpool, UK
| | - Sangeeta Maini
- Ear, Nose and Throat Department, Aberdeen Royal Infirmary, NHS Grampian, Aberdeen, UK
| | | | - Paul Nix
- Ear, Nose and Throat Department, Leeds General Infirmary, Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | - Janet A Wilson
- Population Health Sciences Institute, Newcastle University, Newcastle upon Tyne, UK
| | - M Dawn Teare
- Population Health Sciences Institute, Newcastle University, Newcastle upon Tyne, UK
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18
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Casetta C, Santosh P, Bayley R, Bisson J, Byford S, Dixon C, Drake RJ, Elvins R, Emsley R, Fung N, Hayes D, Howes O, James A, James K, Jones R, Killaspy H, Lennox B, Marchant L, McGuire P, Oloyede E, Rogdaki M, Upthegrove R, Walters J, Egerton A, MacCabe JH. CLEAR - clozapine in early psychosis: study protocol for a multi-centre, randomised controlled trial of clozapine vs other antipsychotics for young people with treatment resistant schizophrenia in real world settings. BMC Psychiatry 2024; 24:122. [PMID: 38355533 PMCID: PMC10865566 DOI: 10.1186/s12888-023-05397-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/04/2023] [Accepted: 11/22/2023] [Indexed: 02/16/2024] Open
Abstract
BACKGROUND Clozapine is an antipsychotic drug with unique efficacy, and it is the only recommended treatment for treatment-resistant schizophrenia (TRS: failure to respond to at least two different antipsychotics). However, clozapine is also associated with a range of adverse effects which restrict its use, including blood dyscrasias, for which haematological monitoring is required. As treatment resistance is recognised earlier in the illness, the question of whether clozapine should be prescribed in children and young people is increasingly important. However, most research to date has been in older, chronic patients, and evidence regarding the efficacy and safety of clozapine in people under age 25 is lacking. The CLEAR (CLozapine in EARly psychosis) trial will assess whether clozapine is more effective than treatment as usual (TAU), at the level of clinical symptoms, patient rated outcomes, quality of life and cost-effectiveness in people below 25 years of age. Additionally, a nested biomarker study will investigate the mechanisms of action of clozapine compared to TAU. METHODS AND DESIGN This is the protocol of a multi-centre, open label, blind-rated, randomised controlled effectiveness trial of clozapine vs TAU (any other oral antipsychotic monotherapy licenced in the British National Formulary) for 12 weeks in 260 children and young people with TRS (12-24 years old). AIM AND OBJECTIVES The primary outcome is the change in blind-rated Positive and Negative Syndrome Scale scores at 12 weeks from baseline. Secondary outcomes include blind-rated Clinical Global Impression, patient-rated outcomes, quality of life, adverse effects, and treatment adherence. Patients will be followed up for 12 months and will be invited to give consent for longer term follow-up using clinical records and potential re-contact for further research. For mechanism of action, change in brain magnetic resonance imaging (MRI) biomarkers and peripheral inflammatory markers will be measured over 12 weeks. DISCUSSION The CLEAR trial will contribute knowledge on clozapine effectiveness, safety and cost-effectiveness compared to standard antipsychotics in young people with TRS, and the results may guide future clinical treatment recommendation for early psychosis. TRIAL REGISTRATION ISRCTN Number: 37176025, IRAS Number: 1004947. TRIAL STATUS In set-up. Protocol version 4.0 01/08/23. Current up to date protocol available here: https://fundingawards.nihr.ac.uk/award/NIHR131175# /.
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Affiliation(s)
- C Casetta
- Institute of Psychiatry, Psychology & Neuroscience, King's College London, London, UK.
- South London and Maudsley NHS Foundation Trust, London, UK.
| | - P Santosh
- Institute of Psychiatry, Psychology & Neuroscience, King's College London, London, UK
- South London and Maudsley NHS Foundation Trust, London, UK
| | - R Bayley
- Institute of Psychiatry, Psychology & Neuroscience, King's College London, London, UK
| | - J Bisson
- Division of Psychological Medicine and Clinical Neurosciences, Cardiff University, Cardiff, UK
| | - S Byford
- Institute of Psychiatry, Psychology & Neuroscience, King's College London, London, UK
| | - C Dixon
- Wonford House Hospital, Devon Partnership NHS Trust, Exeter, UK
| | - R J Drake
- Division of Psychology & Mental Health, University of Manchester, Manchester, UK
- Greater Manchester Mental Health NHS Foundation Trust, Manchester, UK
| | - R Elvins
- Manchester University Hospitals NHS Foundation Trust, Manchester, UK
| | - R Emsley
- Institute of Psychiatry, Psychology & Neuroscience, King's College London, London, UK
| | - N Fung
- Birmingham Women's and Children's NHS Foundation Trust, Birmingham, UK
| | - D Hayes
- South London and Maudsley NHS Foundation Trust, London, UK
| | - O Howes
- Institute of Psychiatry, Psychology & Neuroscience, King's College London, London, UK
| | - A James
- Department of Psychiatry, University of Oxford, Oxford, UK
| | - K James
- Institute of Psychiatry, Psychology & Neuroscience, King's College London, London, UK
| | - R Jones
- Birmingham and Solihull Mental Health Foundation Trust, Birmingham, UK
| | - H Killaspy
- Division of Psychiatry, University College London, London, UK
| | - B Lennox
- Department of Psychiatry, University of Oxford, Oxford, UK
| | - L Marchant
- Institute of Psychiatry, Psychology & Neuroscience, King's College London, London, UK
| | - P McGuire
- Department of Psychiatry, University of Oxford, Oxford, UK
| | - E Oloyede
- Institute of Psychiatry, Psychology & Neuroscience, King's College London, London, UK
- South London and Maudsley NHS Foundation Trust, London, UK
| | - M Rogdaki
- Institute of Psychiatry, Psychology & Neuroscience, King's College London, London, UK
- South London and Maudsley NHS Foundation Trust, London, UK
| | - R Upthegrove
- Institute for Mental Health, University of Birmingham, Birmingham, UK
- Birmingham Early Intervention Service, Birmingham Womens and Childrens NHS Foundation Trust, Birmingham, UK
| | - J Walters
- Division of Psychological Medicine and Clinical Neurosciences, Cardiff University, Cardiff, UK
| | - A Egerton
- Institute of Psychiatry, Psychology & Neuroscience, King's College London, London, UK
| | - J H MacCabe
- Institute of Psychiatry, Psychology & Neuroscience, King's College London, London, UK
- South London and Maudsley NHS Foundation Trust, London, UK
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19
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Chen F, Chen Y, Jiang X, Li X, Ning H, Hu M, Jiang W, Zhang N, Feng H, Yan P. Impact of hearing loss on cognitive function in community-dwelling older adults: serial mediation of self-rated health and depressive anxiety symptoms. Front Aging Neurosci 2023; 15:1297622. [PMID: 38155735 PMCID: PMC10753014 DOI: 10.3389/fnagi.2023.1297622] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2023] [Accepted: 11/27/2023] [Indexed: 12/30/2023] Open
Abstract
Background Hearing loss can exacerbate cognitive decline; therefore, exploring the mechanisms through which hearing loss affects cognitive function is crucial. The current study aimed to investigate the impact of hearing loss on cognitive function and the mediating role played by self-rated health and depressive anxiety symptoms. Methods Using stratified whole-group random sampling, the study employed a cross-sectional design and included 624 participants aged ≥65 years from three communities in Urumqi, China. Cognitive function was assessed using the Mini-Mental State Examination. Hearing function and self-rated health were determined by self-report. The 15-item Geriatric Depression Scale and the 7-item Generalized Anxiety Disorder Scale were used to assess depressive anxiety symptoms. Serial mediation analysis was performed using AMOS 26.0. Results Hearing loss can not only negatively affect cognitive function in older adults directly (direct effect = -0.106; SE = 0.045; 95% confidence interval (CI): -0.201 to -0.016), but also indirectly affect the relationship between hearing loss and cognitive function through self-rated health and depressive anxiety symptoms. The results of the serial mediation analysis showed that the total indirect effect of self-rated health and depressive anxiety symptoms was -0.115 (95% CI: -0.168 to -0.070), and the total effect of the model was -0.221 (95% CI: -0.307 to -0.132), with the total indirect effect accounting for 52.04% of the total effect of the model. Conclusion Our study discovered that there is a partial mediation of the relationship between hearing loss and cognitive function by self-rated health and depressive anxiety symptoms. It is suggested that by enhancing self-rated health and ensuring good mental health, the decline in cognitive function among older adults with hearing loss can be delayed.
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Affiliation(s)
- Fenghui Chen
- Xiangya Nursing School, Central South University, Changsha, China
- Nursing School, Xinjiang Medical University, Urumqi, China
| | - Yingying Chen
- Nursing School, Xinjiang Medical University, Urumqi, China
| | - Xin Jiang
- Nursing School, Xinjiang Medical University, Urumqi, China
| | - Xiaoyang Li
- Xiangya Nursing School, Central South University, Changsha, China
| | - Hongting Ning
- Xiangya Nursing School, Central South University, Changsha, China
| | - Mingyue Hu
- Xiangya Nursing School, Central South University, Changsha, China
| | - Wenxin Jiang
- Nursing School, Xinjiang Medical University, Urumqi, China
| | - Nan Zhang
- Nursing School, Xinjiang Medical University, Urumqi, China
| | - Hui Feng
- Xiangya Nursing School, Central South University, Changsha, China
| | - Ping Yan
- Nursing School, Xinjiang Medical University, Urumqi, China
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20
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Wilson JA, Fouweather T, Stocken DD, Homer T, Haighton C, Rousseau N, O'Hara J, Vale L, Wilson R, Carnell S, Wilkes S, Morrison J, Ah-See K, Carrie S, Hopkins C, Howe N, Hussain M, Lindley L, MacKenzie K, McSweeney L, Mehanna H, Raine C, Whelan RS, Sullivan F, von Wilamowitz-Moellendorff A, Teare D. Tonsillectomy compared with conservative management in patients over 16 years with recurrent sore throat: the NATTINA RCT and economic evaluation. Health Technol Assess 2023; 27:1-195. [PMID: 38204203 PMCID: PMC11017150 DOI: 10.3310/ykur3660] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2024] Open
Abstract
Background The place of tonsillectomy in the management of sore throat in adults remains uncertain. Objectives To establish the clinical effectiveness and cost-effectiveness of tonsillectomy, compared with conservative management, for tonsillitis in adults, and to evaluate the impact of alternative sore throat patient pathways. Design This was a multicentre, randomised controlled trial comparing tonsillectomy with conservative management. The trial included a qualitative process evaluation and an economic evaluation. Setting The study took place at 27 NHS secondary care hospitals in Great Britain. Participants A total of 453 eligible participants with recurrent sore throats were recruited to the main trial. Interventions Patients were randomised on a 1 : 1 basis between tonsil dissection and conservative management (i.e. deferred surgery) using a variable block-stratified design, stratified by (1) centre and (2) severity. Main outcome measures The primary outcome measure was the total number of sore throat days over 24 months following randomisation. The secondary outcome measures were the number of sore throat episodes and five characteristics from Sore Throat Alert Return, describing severity of the sore throat, use of medications, time away from usual activities and the Short Form questionnaire-12 items. Additional secondary outcomes were the Tonsil Outcome Inventory-14 total and subscales and Short Form questionnaire-12 items 6 monthly. Evaluation of the impact of alternative sore throat patient pathways by observation and statistical modelling of outcomes against baseline severity, as assessed by Tonsil Outcome Inventory-14 score at recruitment. The incremental cost per sore throat day avoided, the incremental cost per quality-adjusted life-year gained based on responses to the Short Form questionnaire-12 items and the incremental net benefit based on costs and responses to a contingent valuation exercise. A qualitative process evaluation examined acceptability of trial processes and ramdomised arms. Results There was a median of 27 (interquartile range 12-52) sore throats over the 24-month follow-up. A smaller number of sore throats was reported in the tonsillectomy arm [median 23 (interquartile range 11-46)] than in the conservative management arm [median 30 (interquartile range 14-65)]. On an intention-to-treat basis, there were fewer sore throats in the tonsillectomy arm (incident rate ratio 0.53, 95% confidence interval 0.43 to 0.65). Sensitivity analyses confirmed this, as did the secondary outcomes. There were 52 episodes of post-operative haemorrhage reported in 231 participants undergoing tonsillectomy (22.5%). There were 47 re-admissions following tonsillectomy (20.3%), 35 relating to haemorrhage. On average, tonsillectomy was more costly and more effective in terms of both sore throat days avoided and quality-adjusted life-years gained. Tonsillectomy had a 100% probability of being considered cost-effective if the threshold for an additional quality-adjusted life year was £20,000. Tonsillectomy had a 69% probability of having a higher net benefit than conservative management. Trial processes were deemed to be acceptable. Patients who received surgery were unanimous in reporting to be happy to have received it. Limitations The decliners who provided data tended to have higher Tonsillectomy Outcome Inventory-14 scores than those willing to be randomised implying that patients with a higher burden of tonsillitis symptoms may have declined entry into the trial. Conclusions The tonsillectomy arm had fewer sore throat days over 24 months than the conservative management arm, and had a high probability of being considered cost-effective over the ranges considered. Further work should focus on when tonsillectomy should be offered. National Trial of Tonsillectomy IN Adults has assessed the effectiveness of tonsillectomy when offered for the current UK threshold of disease burden. Further research is required to define the minimum disease burden at which tonsillectomy becomes clinically effective and cost-effective. Trial registration This trial is registered as ISRCTN55284102. Funding This award was funded by the National Institute for Health and Care Research (NIHR) Health Technology Assessment programme (NIHR award ref: 12/146/06) and is published in full in Health Technology Assessment; Vol. 27, No. 31. See the NIHR Funding and Awards website for further award information.
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Affiliation(s)
- Janet A Wilson
- Population Health Sciences Institute, Newcastle University, Newcastle upon Tyne, UK
| | - Tony Fouweather
- Population Health Sciences Institute, Newcastle University, Newcastle upon Tyne, UK
| | - Deborah D Stocken
- Leeds Institute of Clinical Trials Research, University of Leeds, Leeds, UK
| | - Tara Homer
- Population Health Sciences Institute, Newcastle University, Newcastle upon Tyne, UK
| | - Catherine Haighton
- Department of Social Work, Education and Community Wellbeing, Northumbria University, Newcastle upon Tyne, UK
| | - Nikki Rousseau
- Leeds Institute of Clinical Trials Research, University of Leeds, Leeds, UK
| | - James O'Hara
- Ear, Nose and Throat Department, Newcastle Upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, UK
| | - Luke Vale
- Population Health Sciences Institute, Newcastle University, Newcastle upon Tyne, UK
| | - Rebecca Wilson
- Newcastle Clinical Trials Unit, Newcastle University, Newcastle upon Tyne, UK
| | - Sonya Carnell
- Newcastle Clinical Trials Unit, Newcastle University, Newcastle upon Tyne, UK
| | - Scott Wilkes
- School of Medicine, Faculty of Health Sciences and Wellbeing, University of Sunderland, Sunderland, UK
| | | | - Kim Ah-See
- Department of Otolaryngology Head and Neck Surgery, NHS Grampian, Aberdeen, UK
| | - Sean Carrie
- Ear, Nose and Throat Department, Newcastle Upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, UK
| | - Claire Hopkins
- Ear, Nose and Throat and Head and Neck Department, Guy's and St Thomas' NHS Foundation Trust, London, UK
| | - Nicola Howe
- Newcastle Clinical Trials Unit, Newcastle University, Newcastle upon Tyne, UK
| | | | | | - Kenneth MacKenzie
- Department of Ear, Nose and Throat Surgery, NHS Greater Glasgow and Clyde, Glasgow, UK
| | - Lorraine McSweeney
- Population Health Sciences Institute, Newcastle University, Newcastle upon Tyne, UK
| | - Hisham Mehanna
- Institute of Head and Neck Studies and Education, University of Birmingham, Birmingham, UK
| | - Christopher Raine
- Ear, Nose and Throat Department, Bradford Teaching Hospitals NHS Foundation Trust, Bradford, UK
| | - Ruby Smith Whelan
- Newcastle Clinical Trials Unit, Newcastle University, Newcastle upon Tyne, UK
| | - Frank Sullivan
- Population and Behavioural Science Division, School of Medicine, University of St Andrews, St Andrews, UK
| | | | - Dawn Teare
- Population Health Sciences Institute, Newcastle University, Newcastle upon Tyne, UK
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Singla DR, de Oliveira C, Murphy SM, Patel V, Charlebois J, Davis WN, Dennis CL, Kim JJ, Kurdyak P, Lawson A, Meltzer-Brody S, Mulsant BH, Schoueri-Mychasiw N, Silver RK, Tschritter D, Vigod SN, Byford S. Protocol for an economic evaluation of scalable strategies to improve mental health among perinatal women: non-specialist care delivered via telemedicine vs. specialist care delivered in-person. BMC Psychiatry 2023; 23:817. [PMID: 37940930 PMCID: PMC10634150 DOI: 10.1186/s12888-023-05318-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/23/2023] [Accepted: 10/27/2023] [Indexed: 11/10/2023] Open
Abstract
BACKGROUND Perinatal depression affects an estimated 1 in 5 women in North America during the perinatal period, with annualized lifetime costs estimated at $20.6 billion CAD in Canada and over $45.9 billion USD in the US. Access to psychological treatments remains limited for most perinatal women suffering from depression and anxiety. Some barriers to effective care can be addressed through task-sharing to non-specialist providers and through telemedicine platforms. The cost-effectiveness of these strategies compared to traditional specialist and in-person models remains unknown. This protocol describes an economic evaluation of non-specialist providers and telemedicine, in comparison to specialist providers and in-person sessions within the ongoing Scaling Up Maternal Mental healthcare by Increasing access to Treatment (SUMMIT) trial. METHODS The economic evaluation will be undertaken alongside the SUMMIT trial. SUMMIT is a pragmatic, randomized, non-inferiority trial across five North American study sites (N = 1,226) of the comparable effectiveness of two types of providers (specialist vs. non-specialist) and delivery modes (telemedicine vs. in-person) of a behavioural activation treatment for perinatal depressive and anxiety symptoms. The primary economic evaluation will be a cost-utility analysis. The outcome will be the incremental cost-effectiveness ratio, which will be expressed as the additional cost required to achieve an additional quality-adjusted life-year, as assessed by the EuroQol 5-Dimension 5-Level instrument. A secondary cost-effectiveness analysis will use participants' depressive symptom scores. A micro-costing analysis will be conducted to estimate the resources/costs required to implement and sustain the interventions; healthcare resource utilization will be captured via self-report. Data will be pooled and analysed using uniform price and utility weights to determine cost-utility across all trial sites. Secondary country-specific cost-utility and cost-effectiveness analyses will also be completed. Sensitivity analyses will be conducted, and cost-effectiveness acceptability-curves will be generated, in all instances. DISCUSSION Results of this study are expected to inform key decisions related to dissemination and scale up of evidence-based psychological interventions in Canada, the US, and possibly worldwide. There is potential impact on real-world practice by informing decision makers of the long-term savings to the larger healthcare setting in services to support perinatal women with common mental health conditions.
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Affiliation(s)
- Daisy R Singla
- Institute for Mental Health Policy Research, Campbell Family Mental Health Research Institute, Centre for Addiction and Mental Health, Toronto, Canada.
- Department of Psychiatry, Temerty Faculty of Medicine, University of Toronto, Toronto, Canada.
- Lunenfeld-Tanenbaum Research Institute, Sinai Health, Toronto, Canada.
| | - Claire de Oliveira
- Institute for Mental Health Policy Research, Campbell Family Mental Health Research Institute, Centre for Addiction and Mental Health, Toronto, Canada
- Institute of Health Policy, Management and Evaluation, Dalla Lana School of Public Health, University of Toronto, Toronto, Canada
- ICES, Toronto, Canada
| | - Sean M Murphy
- Department of Population Health Sciences, Weill Cornell Medical College, New York, NY, USA
| | - Vikram Patel
- Department of Global Health and Social Medicine, Harvard Medical School, Boston, USA
- Department of Global Health and Population, Harvard Chan School of Public Health, Boston, USA
| | | | | | - Cindy-Lee Dennis
- Department of Psychiatry, Temerty Faculty of Medicine, University of Toronto, Toronto, Canada
- Lunenfeld-Tanenbaum Research Institute, Sinai Health, Toronto, Canada
- Lawrence S. Bloomberg Faculty of Nursing, University of Toronto, Toronto, Canada
| | - J Jo Kim
- Department of Obstetrics & Gynecology, NorthShore University HealthSystem, Evanston, USA
| | - Paul Kurdyak
- Institute for Mental Health Policy Research, Campbell Family Mental Health Research Institute, Centre for Addiction and Mental Health, Toronto, Canada
- Department of Psychiatry, Temerty Faculty of Medicine, University of Toronto, Toronto, Canada
- ICES, Toronto, Canada
| | - Andrea Lawson
- Institute for Mental Health Policy Research, Campbell Family Mental Health Research Institute, Centre for Addiction and Mental Health, Toronto, Canada
| | - Samantha Meltzer-Brody
- Department of Psychiatry, School of Medicine, University of North Carolina, Chapel Hill, USA
| | - Benoit H Mulsant
- Institute for Mental Health Policy Research, Campbell Family Mental Health Research Institute, Centre for Addiction and Mental Health, Toronto, Canada
- Department of Psychiatry, Temerty Faculty of Medicine, University of Toronto, Toronto, Canada
| | | | - Richard K Silver
- Department of Obstetrics & Gynecology, NorthShore University HealthSystem, Evanston, USA
- Department of Obstetrics and Gynecology, University of Chicago Pritzker School of Medicine, Chicago, USA
| | - Dana Tschritter
- Lunenfeld-Tanenbaum Research Institute, Sinai Health, Toronto, Canada
| | - Simone N Vigod
- Department of Psychiatry, Temerty Faculty of Medicine, University of Toronto, Toronto, Canada
- Women's College Hospital, Toronto, Canada
| | - Sarah Byford
- King's Health Economics, Institute of Psychiatry, Psychology & Neuroscience, King's College London, London, UK
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22
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Chaibekava KV, Scheenen AJC, Lettink A, Smits LJM, Langenveld J, Laar RVD, Peeters B, Joosten S, Verstappen ML, Dirksen CD, Nieuwenhuijze MJ, Scheepers HCJ. Continuous care during labor by maternity care assistants in the Netherlands vs care-as-usual: a randomized controlled trial. Am J Obstet Gynecol MFM 2023; 5:101168. [PMID: 37742999 DOI: 10.1016/j.ajogmf.2023.101168] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2023] [Accepted: 09/20/2023] [Indexed: 09/26/2023]
Abstract
BACKGROUND Continuous support during labor has many benefits including lower use of obstetrical interventions. However, implementation remains limited. Insights into birth outcomes and peripartum costs are essential to assess whether continuous care by a maternity care assistant is a potentially (cost) effective program to provide for all women. OBJECTIVE Continuous care during labor, provided by maternity care assistants, will reduce the use of epidural analgesia and peripartum costs owing to a reduction in interventions. STUDY DESIGN This was a randomized controlled trial comparing continuous support during labor (intervention group) with care-as-usual (control group) with prespecified intention-to-treat and per-protocol analyses. The primary outcome was epidural analgesia use. The secondary outcomes were use of other analgesia, referrals from midwife- to obstetrician-led care, modes of birth, hospital stay, sense of control (evaluated with the Labor Agentry Scale), maternal and neonatal adverse outcomes and peripartum costs. Data were collected using questionnaires. Anticipating incomplete adherence to providing continuous care, both intention-to-treat and per-protocol analyses were planned. Peripartum costs were estimated using a healthcare perspective. Mean costs per woman and cost differences between the intervention and control group were calculated. RESULTS The population consisted of 1076 women with 54 exclusions and 30 discontinuations, leaving 992 women to be analyzed (515 continuous care and 477 care-as-usual). Intention-to-treat analyses showed statistically nonsignificant differences between the intervention and control group for epidural use (relative risk, 0.88; 95% confidence interval, 0.74-1.04; P=.14) and peripartum costs (mean difference, € 185.83; 95% confidence interval, -€ 204.22 to € 624.54). Per-protocol analyses showed statistically significant decreases in epidural analgesia (relative risk, 0.64; 95% confidence interval, 0.48-0.84; P=.001), other analgesia (relative risk, 0.59; 95% confidence interval, 0.37-0.94; P=.02), cesarean deliveries (relative risk, 0.53; 95% confidence interval, 0.29-0.95; P=.03) and increase in spontaneous vaginal births (relative risk, 1.09; 95% confidence interval, 1.01-1.18; P=.001) in the intervention group, but difference in total peripartum costs remained statistically nonsignificant (mean difference, € 246.55; 95% confidence interval, -€ 539.14 to € 13.50). CONCLUSION If the provision of continuous care given by maternity care assistants during labor can be secured, continuous care leads to more vaginal births and less epidural use, pain medication, and cesarean deliveries while not leading to a difference in peripartum costs compared with care-as-usual.
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Affiliation(s)
- Karina V Chaibekava
- Department of Obstetrics & Gynecology, Maastricht University Medical Center, Maastricht, The Netherlands (Mses Chaibekava and Scheenan and Dr Scheepers); GROW-School for Oncology and Developmental Biology, Maastricht University, Maastricht, The Netherlands (Ms Chaibekava and Dr Scheepers).
| | - Amber J C Scheenen
- Department of Obstetrics & Gynecology, Maastricht University Medical Center, Maastricht, The Netherlands (Mses Chaibekava and Scheenan and Dr Scheepers)
| | - Adrie Lettink
- Department of Obstetrics & Gynecology, Maastricht University Medical Center, Maastricht, The Netherlands (Dr Lettink)
| | - Luc J M Smits
- Department of Epidemiology, Faculty of Health, Medicine and Life Sciences, Maastricht University, Maastricht, The Netherlands (Dr Smits)
| | - Josje Langenveld
- Department of Obstetrics & Gynecology, Zuyderland Medical Center, Heerlen, The Netherlands (Dr Langenveld)
| | - Rafli Van De Laar
- Department of Obstetrics & Gynecology, VieCuri Medical Center, Venlo, The Netherlands (Dr Van De Laar)
| | - Babette Peeters
- Cicogna Kraamzorg, Gulpen, The Netherlands (Mses Peeters and Joosten)
| | - Sanne Joosten
- Cicogna Kraamzorg, Gulpen, The Netherlands (Mses Peeters and Joosten)
| | | | - Carmen D Dirksen
- Department Clinical Epidemiology and Medical Technology Assessment, Care And Public Health Research Institute, Maastricht University Medical Center, Maastricht, The Netherlands (Dr Dirksen)
| | - Marianne J Nieuwenhuijze
- Research Center for Midwifery Science, Zuyd University, Maastricht, The Netherlands (Dr Nieuwenhuijze); and Care and Public Health Research Institute, Maastricht University, Maastricht, The Netherlands (Dr Nieuwenhuijze)
| | - Hubertina C J Scheepers
- Department of Obstetrics & Gynecology, Maastricht University Medical Center, Maastricht, The Netherlands (Mses Chaibekava and Scheenan and Dr Scheepers); GROW-School for Oncology and Developmental Biology, Maastricht University, Maastricht, The Netherlands (Ms Chaibekava and Dr Scheepers)
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23
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Ben ÂJ, van Dongen JM, Finch AP, Alili ME, Bosmans JE. To what extent does the use of crosswalks instead of EQ-5D value sets impact reimbursement decisions?: a simulation study. THE EUROPEAN JOURNAL OF HEALTH ECONOMICS : HEPAC : HEALTH ECONOMICS IN PREVENTION AND CARE 2023; 24:1253-1270. [PMID: 36371791 PMCID: PMC10533624 DOI: 10.1007/s10198-022-01539-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/02/2022] [Accepted: 10/05/2022] [Indexed: 06/16/2023]
Abstract
PURPOSE Inconsistent results have been found on the impact of using crosswalks versus EQ-5D value sets on reimbursement decisions. We sought to further investigate this issue in a simulation study. METHODS Trial-based economic evaluation data were simulated for different conditions (depression, low back pain, osteoarthritis, cancer), severity levels (mild, moderate, severe), and effect sizes (small, medium, large). For all 36 scenarios, utilities were calculated using 3L and 5L value sets and crosswalks (3L to 5L and 5L to 3L crosswalks) for the Netherlands, the United States, and Japan. Utilities, quality-adjusted life years (QALYs), incremental QALYs, incremental cost-effectiveness ratios (ICERs), and probabilities of cost-effectiveness (pCE) obtained from values sets and crosswalks were compared. RESULTS Differences between value sets and crosswalks ranged from -0.33 to 0.13 for utilities, from -0.18 to 0.13 for QALYs, and from -0.01 to 0.08 for incremental QALYs, resulting in different ICERs. For small effect sizes, at a willingness-to-pay of €20,000/QALY, the largest pCE difference was found for moderate cancer between the Japanese 5L value set and 5L to 3L crosswalk (difference = 0.63). For medium effect sizes, the largest difference was found for mild cancer between the Japanese 3L value set and 3L to 5L crosswalk (difference = 0.06). For large effect sizes, the largest difference was found for mild osteoarthritis between the Japanese 3L value set and 3L to 5L crosswalk (difference = 0.08). CONCLUSION The use of crosswalks instead of EQ-5D value sets can impact cost-utility outcomes to such an extent that this may influence reimbursement decisions.
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Affiliation(s)
- Ângela Jornada Ben
- Department of Health Sciences, Faculty of Science, Vrije Universiteit Amsterdam, Amsterdam Public Health Research Institute, Van der Boechorststraat 7, 1081 BT, Amsterdam, The Netherlands.
| | - Johanna M van Dongen
- Department of Health Sciences, Faculty of Science, Vrije Universiteit Amsterdam, Amsterdam Public Health Research Institute, Van der Boechorststraat 7, 1081 BT, Amsterdam, The Netherlands
| | - Aureliano Paolo Finch
- EuroQol Office, EuroQol Research Foundation, Marten Meesweg 107, 3068 AV, Rotterdam, The Netherlands
| | - Mohamed El Alili
- Department of Health Sciences, Faculty of Science, Vrije Universiteit Amsterdam, Amsterdam Public Health Research Institute, Van der Boechorststraat 7, 1081 BT, Amsterdam, The Netherlands
| | - Judith E Bosmans
- Department of Health Sciences, Faculty of Science, Vrije Universiteit Amsterdam, Amsterdam Public Health Research Institute, Van der Boechorststraat 7, 1081 BT, Amsterdam, The Netherlands
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Snyman JR, Gumedze F, Jones ESW, Alaba OA, Tsabedze N, Vira A, Ntusi NAB. Comparing Cardiovascular Outcomes and Costs of Perindopril-, Enalapril- or Losartan-Based Antihypertensive Regimens in South Africa: Real-World Medical Claims Database Analysis. Adv Ther 2023; 40:5076-5089. [PMID: 37730949 PMCID: PMC10567948 DOI: 10.1007/s12325-023-02641-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2023] [Accepted: 08/09/2023] [Indexed: 09/22/2023]
Abstract
INTRODUCTION Differences in class or molecule-specific effects between renin-angiotensin-aldosterone system (RAAS) inhibitors have not been conclusively demonstrated. This study used South African data to assess clinical and cost outcomes of antihypertensive therapy with the three most common RAAS inhibitors: perindopril, losartan and enalapril. METHODS Using a large, South African private health insurance claims database, we identified patients with a hypertension diagnosis in January 2015 receiving standard doses of perindopril, enalapril or losartan, alone or in combination with other agents. From claims over the subsequent 5 years, we calculated the risk-adjusted rate of the composite primary outcome of myocardial infarction, ischaemic heart disease, heart failure or stroke; rate of all-cause mortality; and costs per life per month (PLPM), with adjustments based on demographic characteristics, healthcare plan and comorbidity. RESULTS Overall, 32,857 individuals received perindopril, 16,693 losartan and 13,939 enalapril. Perindopril-based regimens were associated with a significantly lower primary outcome rate (205 per 1000 patients over 5 years) versus losartan (221; P < 0.0001) or enalapril (223; P < 0.0001). The risk-adjusted all-cause mortality rate was lower with perindopril than enalapril (100 vs. 139 deaths per 1000 patients over 5 years; P = 0.007), but not losartan (100 vs. 94; P = 0.650). Mean (95% confidence interval) overall risk-adjusted cost PLPM was Rands (ZAR) 1342 (87-8973) for perindopril, ZAR 1466 (104-9365) for losartan (P = 0.0044) and ZAR 1540 (77-10,546) for enalapril (P = 0.0003). CONCLUSION In South African individuals with private health insurance, a perindopril-based antihypertensive regimen provided better clinical and cost outcomes compared with other regimens.
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Affiliation(s)
| | - Freedom Gumedze
- Department of Statistical Sciences, University of Cape Town, Cape Town, South Africa
| | - Erika S W Jones
- Division of Nephrology and Hypertension, Department of Medicine, University of Cape Town and Groote Schuur Hospital, Cape Town, South Africa
| | - Olufunke A Alaba
- Health Economics Unit, School of Public Health and Family Medicine, University of Cape Town, Cape Town, South Africa
| | - Nqoba Tsabedze
- Division of Cardiology, Department of Internal Medicine, School of Clinical Medicine, Faculty of Health Sciences, University of the Witwatersrand and The Charlotte Maxeke Johannesburg Academic Hospital, Johannesburg, South Africa
| | - Alykhan Vira
- Quantium Health South Africa, Johannesburg, South Africa
| | - Ntobeko A B Ntusi
- Division of Cardiology, Department of Medicine, University of Cape Town and Groote Schuur Hospital, J46.53, Old Main Building, Main Road, Observatory, Cape Town, 7925, South Africa.
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Goense L, van der Sluis PC, van der Horst S, Tagkalos E, Grimminger PP, van Dijk W, Ruurda JP, van Hillegersberg R. Cost analysis of robot-assisted versus open transthoracic esophagectomy for resectable esophageal cancer. Results of the ROBOT randomized clinical trial. EUROPEAN JOURNAL OF SURGICAL ONCOLOGY 2023; 49:106968. [PMID: 37423873 DOI: 10.1016/j.ejso.2023.06.020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2022] [Revised: 05/09/2023] [Accepted: 06/22/2023] [Indexed: 07/11/2023]
Abstract
BACKGROUND The previously published ROBOT trial demonstrated that robot assisted minimally invasive esophagectomy (RAMIE) is associated with a lower percentage of postoperative complications compared to open esophagectomy (OTE) for patients with esophageal cancer. The implications of these results on healthcare costs are important given the increased attention for cost-reduction in healthcare. Therefore the aim of this study was to report the hospital costs of RAMIE compared to OTE as treatment for esophageal cancer. METHODS The ROBOT trial randomized 112 patients with esophageal cancer between RAMIE and OTE through January 2012 and August 2016 in a single tertiary care academic centre in the Netherlands. The primary outcome of the current study was hospital costs from the day of esophagectomy until 90 days after discharge based on Time-Driven Activity-Based Costing methodology. Secondary outcomes included the incremental cost-effectiveness ratio per complication prevented and risk factors for increased hospital costs. RESULTS Of the 112 included patients, 109 patients underwent an esophagectomy, of whom 54 RAMIE and 55 OTE. The mean total hospital costs were comparable between RAMIE €40211 and OTE €39495 (mean difference €-715; bias-corrected and accelerated confidence interval € -14831 to 14783, p = 0.932). At a willingness-to-pay threshold of €20.000 to €25.000 (i.e. estimated additional costs to the hospital to treat patients with a complication) RAMIE had a probability 62%-70% of being cost effective to prevent postoperative complications. In multivariable regression analysis, major postoperative complications were the main driver of hospital costs after esophagectomy (€31839, p = 0.009). CONCLUSION In this randomized trial RAMIE resulted in fewer postoperative complications compared to OTE without increasing total hospital costs.
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Affiliation(s)
- Lucas Goense
- Department of Surgery, University Medical Center Utrecht, Utrecht, the Netherlands.
| | - Pieter C van der Sluis
- Department of Surgery, University Medical Center Utrecht, Utrecht, the Netherlands; Department of General-, Visceral- and Transplant Surgery, University Medical Center of the Johannes Gutenberg University, Mainz, Germany
| | - Sylvia van der Horst
- Department of Surgery, University Medical Center Utrecht, Utrecht, the Netherlands
| | - Evangelos Tagkalos
- Department of General-, Visceral- and Transplant Surgery, University Medical Center of the Johannes Gutenberg University, Mainz, Germany
| | - Peter P Grimminger
- Department of General-, Visceral- and Transplant Surgery, University Medical Center of the Johannes Gutenberg University, Mainz, Germany
| | | | - Jelle P Ruurda
- Department of Surgery, University Medical Center Utrecht, Utrecht, the Netherlands
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26
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Deshpande A, Walker R, Schulte R, Pallotta AM, Tereshchenko LG, Hu B, Kadri SS, Klompas M, Rothberg MB. Reducing antimicrobial overuse through targeted therapy for patients with community-acquired pneumonia: a study protocol for a cluster-randomized factorial controlled trial (CARE-CAP). Trials 2023; 24:595. [PMID: 37716990 PMCID: PMC10505312 DOI: 10.1186/s13063-023-07615-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2023] [Accepted: 08/30/2023] [Indexed: 09/18/2023] Open
Abstract
BACKGROUND Community-acquired pneumonia (CAP) is a significant public health concern and a leading cause of hospitalization and inpatient antimicrobial use in the USA. However, determining the etiologic pathogen is challenging because traditional culture methods are slow and insensitive, leading to prolonged empiric therapy with extended-spectrum antibiotics (ESA) that contributes to increased hospital length of stay, and antimicrobial resistance. Two potential ways to reduce the exposure to ESA are (a) rapid diagnostic assays that can provide accurate results within hours, obviating the need for empiric therapy, and (b) de-escalation following negative bacterial cultures in clinically stable patients. METHODS We will conduct a large pragmatic 2 × 2 factorial cluster-randomized controlled trial across 12 hospitals in the Cleveland Clinic Health System that will test these two approaches to reducing the use of ESA in adult patients (age ≥ 18 years) with CAP. We will enroll over 12,000 patients and evaluate the independent and combined effects of routine use of rapid diagnostic testing at admission and pharmacist-led de-escalation after 48 h for clinically stable patients with negative cultures vs usual care. We hypothesize that both approaches will reduce days on ESA. Our primary outcome is the duration of exposure to ESA therapy, a key driver of antimicrobial resistance. Secondary outcomes include detection of respiratory viruses, treatment with anti-viral medications, positive pneumococcal urinary antigen test, de-escalation by 72 h from admission, re-escalation to ESA after de-escalation, total duration of any antibiotic, 14-day in-hospital mortality, intensive care unit transfer after admission, healthcare-associated C. difficile infection, acute kidney injury, total inpatient cost, and hospital length-of-stay. DISCUSSION Our study aims to determine whether identifying an etiological agent early and pharmacist-led de-escalation (calling attention to negative cultures) can safely reduce the use of ESA in patients with CAP. If successful, our findings should lead to better antimicrobial stewardship, as well as improved patient outcomes and reduced healthcare costs. Our findings may also inform clinical guidelines on the optimal management of CAP. TRIAL REGISTRATION ClinicalTrials.gov NCT05568654 . Registered on October 4, 2022.
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Affiliation(s)
- Abhishek Deshpande
- Center for Value-Based Care Research, Primary Care Institute, Cleveland Clinic, Cleveland, OH, USA.
- Department of Infectious Disease, Cleveland Clinic, Cleveland, OH, USA.
| | - Ramara Walker
- Department of Pharmacy, Cleveland Clinic, Cleveland, OH, USA
| | - Rebecca Schulte
- Department of Quantitative Health Sciences, Cleveland Clinic, Cleveland, OH, USA
| | | | | | - Bo Hu
- Department of Quantitative Health Sciences, Cleveland Clinic, Cleveland, OH, USA
| | - Sameer S Kadri
- Critical Care Medicine Department, National Institutes of Health Clinical Center, Bethesda, MD, USA
| | - Michael Klompas
- Department of Population Medicine, Harvard Medical School and Harvard Pilgrim Health Care Institute, Boston, MA, USA
- Department of Medicine, Brigham and Women's Hospital, Boston, MA, USA
| | - Michael B Rothberg
- Center for Value-Based Care Research, Primary Care Institute, Cleveland Clinic, Cleveland, OH, USA
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Moran JL, Duke GJ, Santamaria JD, Linden A. Modelling of intensive care unit (ICU) length of stay as a quality measure: a problematic exercise. BMC Med Res Methodol 2023; 23:207. [PMID: 37710162 PMCID: PMC10500937 DOI: 10.1186/s12874-023-02028-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/24/2022] [Accepted: 09/01/2023] [Indexed: 09/16/2023] Open
Abstract
BACKGROUND Intensive care unit (ICU) length of stay (LOS) and the risk adjusted equivalent (RALOS) have been used as quality metrics. The latter measures entail either ratio or difference formulations or ICU random effects (RE), which have not been previously compared. METHODS From calendar year 2016 data of an adult ICU registry-database (Australia & New Zealand Intensive Care Society (ANZICS) CORE), LOS predictive models were established using linear (LMM) and generalised linear (GLMM) mixed models. Model fixed effects quality-metric formulations were estimated as RALOSR for LMM (geometric mean derived from log(ICU LOS)) and GLMM (day) and observed minus expected ICU LOS (OMELOS from GLMM). Metric confidence intervals (95%CI) were estimated by bootstrapping; random effects (RE) were predicted for LMM and GLMM. Forest-plot displays of ranked quality-metric point-estimates (95%CI) were generated for ICU hospital classifications (metropolitan, private, rural/regional, and tertiary). Robust rank confidence sets (point estimate and 95%CI), both marginal (pertaining to a singular ICU) and simultaneous (pertaining to all ICU differences), were established. RESULTS The ICU cohort was of 94,361 patients from 125 ICUs (metropolitan 16.9%, private 32.8%, rural/regional 6.4%, tertiary 43.8%). Age (mean, SD) was 61.7 (17.5) years; 58.3% were male; APACHE III severity-of-illness score 54.6 (25.7); ICU annual patient volume 1192 (702) and ICU LOS 3.2 (4.9). There was no concordance of ICU ranked model predictions, GLMM versus LMM, nor for the quality metrics used, RALOSR, OMELOS and site-specific RE for each of the ICU hospital classifications. Furthermore, there was no concordance between ICU ranking confidence sets, marginal and simultaneous for models or quality metrics. CONCLUSIONS Inference regarding adjusted ICU LOS was dependent upon the statistical estimator and the quality index used to quantify any LOS differences across ICUs. That is, there was no "one best model"; thus, ICU "performance" is determined by model choice and any rankings thereupon should be circumspect.
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Affiliation(s)
- John L Moran
- Department of Intensive Care Medicine, The Queen Elizabeth Hospital, Woodville, Australia.
| | - Graeme J Duke
- Department of Intensive Care, Eastern Health, Box Hill, Australia
| | - John D Santamaria
- Department of Critical Care Medicine, St Vincent's Hospital (Melbourne), Fitzroy, Australia
| | - Ariel Linden
- Linden Consulting Group, LLC, San Francisco, CA, USA
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Chen BK, Dunsiger SI, Pinto BM. Cost-effectiveness of peer-delivered physical activity promotion and maintenance programs for initially sedentary breast cancer survivors. Transl Behav Med 2023; 13:683-693. [PMID: 37155603 PMCID: PMC10496440 DOI: 10.1093/tbm/ibad026] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/10/2023] Open
Abstract
The evidence for the survival and health benefits of physical activity (PA) among cancer survivors is well documented. However, it has been challenging to maintain PA among cancer survivors. To evaluate the cost-effectiveness of peer support to encourage maintenance of moderate-to-vigorous physical activity (MVPA) among breast cancer survivors. Participants were randomized into Reach Plus Message (weekly text/email messages), Reach Plus Phone (monthly phone calls) or Reach Plus (a self-monitoring intervention) over 6 months after an initial adoption phase. We calculated the incremental cost-effectiveness ratios (ICER) in terms of quality-adjusted years life years (QALYs) and self-reported MVPA, from the payer's budgetary and societal perspectives over 1 year. Intervention costs were collected via time logs from the trainers and peer coaches, and participant costs from the participants via surveys. For our sensitivity analyses, we bootstrapped costs and effects to construct cost-effectiveness planes and acceptability curves. The intervention that provides weekly messages from peer coaches has an ICER of $14,446 per QALY gained and $0.95 per extra minute of MVPA per day over Reach Plus. Reach Plus Message has a 49.8% and 78.5% probability of cost-effectiveness respectively when decision makers are willing to pay approximately $25,000 per QALY and $10 per additional minute of MVPA. Reach Plus Phone, which requires tailored monthly telephone calls, costs more than Reach Plus Message but yields less QALY and self-reported MVPA at 1 year. Reach Plus Message may be a viable and cost-effective intervention strategy to maintain MVPA among breast cancer survivors.
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Affiliation(s)
- Brian K Chen
- Department of Health Services Policy and Management, University of South Carolina, Arnold School of Public Health, 915 Green Street Suite 354, Columbia, SC 29208, USA
| | - Shira I Dunsiger
- Center for Health Promotion and Health Equity, Department of Behavioral and Social Sciences, Brown University, Box G-121-8 Providence, RI 02912, USA
| | - Bernardine M Pinto
- Biobehavioral Health & Nursing Science, College of Nursing, University of South Carolina, 1601 Greene Street, Room 302B, Columbia, SC 29208, USA
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Morton M, Wilson N, Homer TM, Simms L, Steel A, Maier R, Wason J, Ternent L, Abouhajar A, Allen M, Joyce R, Hildreth V, Lakey R, Cherlin S, Walker A, Devereux G, Chalmers JD, Hill AT, Haworth C, Hurst JR, De Soyza A. Dual bronchodilators in Bronchiectasis study (DIBS): protocol for a pragmatic, multicentre, placebo-controlled, three-arm, double-blinded, randomised controlled trial studying bronchodilators in preventing exacerbations of bronchiectasis. BMJ Open 2023; 13:e071906. [PMID: 37562935 PMCID: PMC10423789 DOI: 10.1136/bmjopen-2023-071906] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/27/2023] [Accepted: 07/08/2023] [Indexed: 08/12/2023] Open
Abstract
INTRODUCTION Bronchiectasis is a long-term lung condition, with dilated bronchi, chronic inflammation, chronic infection and acute exacerbations. Recurrent exacerbations are associated with poorer clinical outcomes such as increased severity of lung disease, further exacerbations, hospitalisations, reduced quality of life and increased risk of death. Despite an increasing prevalence of bronchiectasis, there is a critical lack of high-quality studies into the disease and no treatments specifically approved for its treatment. This trial aims to establish whether inhaled dual bronchodilators (long acting beta agonist (LABA) and long acting muscarinic antagonist (LAMA)) taken as either a stand-alone therapy or in combination with inhaled corticosteroid (ICS) reduce the number of exacerbations of bronchiectasis requiring treatment with antibiotics during a 12 month treatment period. METHODS This is a multicentre, pragmatic, double-blind, randomised controlled trial, incorporating an internal pilot and embedded economic evaluation. 600 adult patients (≥18 years) with CT confirmed bronchiectasis will be recruited and randomised to either inhaled dual therapy (LABA+LAMA), triple therapy (LABA+LAMA+ICS) or matched placebo, in a 2:2:1 ratio (respectively). The primary outcome is the number of protocol defined exacerbations requiring treatment with antibiotics during the 12 month treatment period. ETHICS AND DISSEMINATION Favourable ethical opinion was received from the North East-Newcastle and North Tyneside 2 Research Ethics Committee (reference: 21/NE/0020). Results will be disseminated in peer-reviewed publications, at national and international conferences, in the NIHR Health Technology Assessments journal and to participants and the public (using lay language). TRIAL REGISTRATION NUMBER ISRCTN15988757.
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Affiliation(s)
- Miranda Morton
- Newcastle Clinical Trials Unit, Newcastle University, Newcastle upon Tyne, UK
| | - Nina Wilson
- Population Health Sciences Institute, Newcastle University Faculty of Medical Sciences, Newcastle upon Tyne, UK
| | - Tara Marie Homer
- Health Economics Group, Newcastle University, Newcastle upon Tyne, UK
| | - Laura Simms
- Newcastle Clinical Trials Unit, Newcastle University, Newcastle upon Tyne, UK
| | - Alison Steel
- Newcastle Clinical Trials Unit, Newcastle University, Newcastle upon Tyne, UK
| | - Rebecca Maier
- Newcastle Clinical Trials Unit, Newcastle University, Newcastle upon Tyne, UK
| | - James Wason
- Population Health Sciences Institute, Newcastle University Faculty of Medical Sciences, Newcastle upon Tyne, UK
| | - Laura Ternent
- Health Economics Group, Newcastle University, Newcastle upon Tyne, UK
| | - Alaa Abouhajar
- Newcastle Clinical Trials Unit, Newcastle University, Newcastle upon Tyne, UK
| | - Maria Allen
- The Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, UK
| | - Richard Joyce
- Newcastle Clinical Trials Unit, Newcastle University, Newcastle upon Tyne, UK
| | - Victoria Hildreth
- Newcastle Clinical Trials Unit, Newcastle University, Newcastle upon Tyne, UK
| | - Rachel Lakey
- Newcastle Clinical Trials Unit, Newcastle University, Newcastle upon Tyne, UK
| | - Svetlana Cherlin
- Population Health Sciences Institute, Newcastle University Faculty of Medical Sciences, Newcastle upon Tyne, UK
| | - Adam Walker
- The Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, UK
| | - Graham Devereux
- Department of Clinical Sciences, Liverpool School of Tropical Medicine, Liverpool, UK
| | - James D Chalmers
- Molecular and Clinical Medicine, School of Medicine, University of Dundee, Dundee, UK
| | - Adam T Hill
- Centre for Inflammation research, The University of Edinburgh, Edinburgh, UK
| | | | - John R Hurst
- Academic Unit of Respiratory Medicine, UCL Medical School, London, UK
| | - Anthony De Soyza
- Population Health Sciences Institute, Newcastle University Faculty of Medical Sciences, Newcastle upon Tyne, UK
- The Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, UK
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Monk-Cunliffe J, Kadra-Scalzo G, Finamore C, Dale O, Khondoker M, Barrett B, Shetty H, Hayes RD, Moran P. Defining severity of personality disorder using electronic health records: short report. BJPsych Open 2023; 9:e137. [PMID: 37524373 PMCID: PMC10486230 DOI: 10.1192/bjo.2023.509] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/21/2022] [Revised: 05/24/2023] [Accepted: 05/25/2023] [Indexed: 08/02/2023] Open
Abstract
Severity of personality disorder is an important determinant of future health. However, this key prognostic variable is not captured in routine clinical practice. Using a large clinical data-set, we explored the predictive validity of items from the Health of Nation Outcome Scales (HoNOS) as potential indicators of personality disorder severity. For 6912 patients with a personality disorder diagnosis, we examined associations between HoNOS items relating to core personality disorder symptoms (self-harm, difficulty in interpersonal relationships, performance of occupational and social roles, and agitation and aggression) and future health service use. Compared with those with no self-harm problem, the total healthcare cost was 2.74 times higher (95% CI 1.66-4.52; P < 0.001) for individuals with severe to very severe self-harm problems. Other HoNOS items did not demonstrate clear patterns of association with service costs. Self-harm may be a robust indicator of the severity of personality disorder, but further replication work is required.
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Affiliation(s)
- Jonathan Monk-Cunliffe
- Centre for Academic Mental Health, Department of Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
| | - Giouliana Kadra-Scalzo
- Department of Psychological Medicine, Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, UK
| | - Chloe Finamore
- Research Unit, The Cassel Hospital, West London NHS Trust, Richmond, UK
| | - Oliver Dale
- Research Unit, The Cassel Hospital, West London NHS Trust, Richmond, UK
| | | | - Barbara Barrett
- Department of Psychological Medicine, Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, UK
| | - Hitesh Shetty
- Department of Psychological Medicine, Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, UK
| | - Richard D. Hayes
- Department of Psychological Medicine, Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, UK
| | - Paul Moran
- Centre for Academic Mental Health, Department of Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
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Wilson JA, O'Hara J, Fouweather T, Homer T, Stocken DD, Vale L, Haighton C, Rousseau N, Wilson R, McSweeney L, Wilkes S, Morrison J, MacKenzie K, Ah-See K, Carrie S, Hopkins C, Howe N, Hussain M, Mehanna H, Raine C, Sullivan F, von Wilamowitz-Moellendorff A, Teare MD. Conservative management versus tonsillectomy in adults with recurrent acute tonsillitis in the UK (NATTINA): a multicentre, open-label, randomised controlled trial. Lancet 2023; 401:2051-2059. [PMID: 37209706 DOI: 10.1016/s0140-6736(23)00519-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/02/2022] [Revised: 02/03/2023] [Accepted: 03/02/2023] [Indexed: 05/22/2023]
Abstract
BACKGROUND Tonsillectomy is regularly performed in adults with acute tonsillitis, but with scarce evidence. A reduction in tonsillectomies has coincided with an increase in acute adult hospitalisation for tonsillitis complications. We aimed to assess the clinical effectiveness and cost-effectiveness of conservative management versus tonsillectomy in patients with recurrent acute tonsillitis. METHODS This pragmatic multicentre, open-label, randomised controlled trial was conducted in 27 hospitals in the UK. Participants were adults aged 16 years or older who were newly referred to secondary care otolaryngology clinics with recurrent acute tonsillitis. Patients were randomly assigned (1:1) to receive tonsillectomy or conservative management using random permuted blocks of variable length. Stratification by recruiting centre and baseline symptom severity was assessed using the Tonsil Outcome Inventory-14 score (categories defined as mild 0-35, moderate 36-48, or severe 49-70). Participants in the tonsillectomy group received elective surgery to dissect the palatine tonsils within 8 weeks after random assignment and those in the conservative management group received standard non-surgical care during 24 months. The primary outcome was the number of sore throat days collected during 24 months after random assignment, reported once per week with a text message. The primary analysis was done in the intention-to-treat (ITT) population. This study is registered with the ISRCTN registry, 55284102. FINDINGS Between May 11, 2015, and April 30, 2018, 4165 participants with recurrent acute tonsillitis were assessed for eligibility and 3712 were excluded. 453 eligible participants were randomly assigned (233 in the immediate tonsillectomy group vs 220 in the conservative management group). 429 (95%) patients were included in the primary ITT analysis (224 vs 205). The median age of participants was 23 years (IQR 19-30), with 355 (78%) females and 97 (21%) males. Most participants were White (407 [90%]). Participants in the immediate tonsillectomy group had fewer days of sore throat during 24 months than those in the conservative management group (median 23 days [IQR 11-46] vs 30 days [14-65]). After adjustment for site and baseline severity, the incident rate ratio of total sore throat days in the immediate tonsillectomy group (n=224) compared with the conservative management group (n=205) was 0·53 (95% CI 0·43 to 0·65; <0·0001). 191 adverse events in 90 (39%) of 231 participants were deemed related to tonsillectomy. The most common adverse event was bleeding (54 events in 44 [19%] participants). No deaths occurred during the study. INTERPRETATION Compared with conservative management, immediate tonsillectomy is clinically effective and cost-effective in adults with recurrent acute tonsillitis. FUNDING National Institute for Health Research.
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Affiliation(s)
- Janet A Wilson
- Population Health Sciences Institute, Newcastle University, Newcastle upon Tyne, UK
| | - James O'Hara
- Population Health Sciences Institute, Newcastle University, Newcastle upon Tyne, UK; Ear, Nose, and Throat Department, Newcastle Upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, UK. james.o'
| | - Tony Fouweather
- Population Health Sciences Institute, Newcastle University, Newcastle upon Tyne, UK
| | - Tara Homer
- Population Health Sciences Institute, Newcastle University, Newcastle upon Tyne, UK
| | - Deborah D Stocken
- Leeds Institute of Clinical Trials Research, University of Leeds, Leeds, UK
| | - Luke Vale
- Population Health Sciences Institute, Newcastle University, Newcastle upon Tyne, UK
| | - Catherine Haighton
- Department of Social Work, Education, and Community Wellbeing, Northumbria University, Newcastle upon Tyne, UK
| | - Nikki Rousseau
- Leeds Institute of Clinical Trials Research, University of Leeds, Leeds, UK
| | - Rebecca Wilson
- Newcastle Clinical Trials Unit, Newcastle University, Newcastle upon Tyne, UK
| | - Lorraine McSweeney
- Population Health Sciences Institute, Newcastle University, Newcastle upon Tyne, UK
| | - Scott Wilkes
- School of Medicine Faculty of Health Sciences and Wellbeing, University of Sunderland, Sunderland, UK
| | | | - Kenneth MacKenzie
- Department of Ear, Nose, and Throat Surgery, NHS Greater Glasgow and Clyde, Glasgow, UK
| | - Kim Ah-See
- Department of Otolaryngology Head and Neck Surgery, NHS Grampian, Aberdeen, UK
| | - Sean Carrie
- Ear, Nose, and Throat Department, Newcastle Upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, UK
| | - Claire Hopkins
- Ear, Nose and Throat Department and Head and Neck Department, Guy's and St Thomas' NHS Foundation Trust, London, UK
| | - Nicola Howe
- Newcastle Clinical Trials Unit, Newcastle University, Newcastle upon Tyne, UK
| | | | - Hisham Mehanna
- Institute of Head and Neck Studies and Education, University of Birmingham, Birmingham, UK
| | - Christopher Raine
- Ear, Nose, and Throat Department, Bradford Teaching Hospitals NHS Foundation Trust, Bradford, UK
| | - Frank Sullivan
- Population and Behavioural Science Division, School of Medicine, University of St Andrews, St Andrews, UK
| | | | - M Dawn Teare
- Population Health Sciences Institute, Newcastle University, Newcastle upon Tyne, UK
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Koufaki MI, Fragoulakis V, Díaz-Villamarín X, Karamperis K, Vozikis A, Swen JJ, Dávila-Fajardo CL, Vasileiou KZ, Patrinos GP, Mitropoulou C. Economic evaluation of pharmacogenomic-guided antiplatelet treatment in Spanish patients suffering from acute coronary syndrome participating in the U-PGx PREPARE study. Hum Genomics 2023; 17:51. [PMID: 37287029 DOI: 10.1186/s40246-023-00495-3] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2023] [Accepted: 05/24/2023] [Indexed: 06/09/2023] Open
Abstract
BACKGROUND Cardiovascular diseases and especially Acute Coronary Syndrome (ACS) constitute a major health issue impacting millions of patients worldwide. Being a leading cause of death and hospital admissions in many European countries including Spain, it accounts for enormous amounts of healthcare expenditures for its management. Clopidogrel is one of the oldest antiplatelet medications used as standard of care in ACS. METHODS In this study, we performed an economic evaluation study to estimate whether a genome-guided clopidogrel treatment is cost-effective compared to conventional one in a large cohort of 243 individuals of Spanish origin suffering from ACS and treated with clopidogrel. Data were derived from the U-PGx PREPARE clinical trial. Effectiveness was measured as survival of individuals while study data on safety and efficacy, as well as on resource utilization associated with each adverse drug reaction were used to measure costs to treat these adverse drug reactions. A generalized linear regression model was used to estimate cost differences for both study groups. RESULTS Based on our findings, PGx-guided treatment group is cost-effective. PGx-guided treatment demonstrated to have 50% less hospital admissions, reduced emergency visits and almost 13% less ADRs compared to the non-PGx approach with mean QALY 1.07 (95% CI, 1.04-1.10) versus 1.06 (95% CI, 1.03-1.09) for the control group, while life years for both groups were 1.24 (95% CI, 1.20-1.26) and 1.23 (95% CI, 1.19-1.26), respectively. The mean total cost of PGx-guided treatment was 50% less expensive than conventional therapy with clopidogrel [€883 (95% UI, €316-€1582), compared to €1,755 (95% UI, €765-€2949)]. CONCLUSION These findings suggest that PGx-guided clopidogrel treatment represents a cost-effective option for patients suffering from ACS in the Spanish healthcare setting.
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Affiliation(s)
- Margarita-Ioanna Koufaki
- Laboratory of Pharmacogenomics and Individualized Therapy, Department of Pharmacy, University of Patras School of Health Sciences, Patras, Greece
| | - Vasileios Fragoulakis
- The Golden Helix Foundation, 91 Waterloo Road, Capital Tower 6th Floor, London, SE1 9RT, UK
| | | | - Kariofyllis Karamperis
- Laboratory of Pharmacogenomics and Individualized Therapy, Department of Pharmacy, University of Patras School of Health Sciences, Patras, Greece
- The Golden Helix Foundation, 91 Waterloo Road, Capital Tower 6th Floor, London, SE1 9RT, UK
| | - Athanassios Vozikis
- Laboratory of Health Economics and Management (LabHEM), Economics Department, University of Piraeus, Piraeus, Greece
| | - Jesse J Swen
- Leiden University Medical Center, Leiden, The Netherlands
| | - Cristina L Dávila-Fajardo
- Clinical Pharmacy Department, Hospital Universitario Virgen de las Nieves, Instituto de Investigación Biosanitaria (ibs.Granada), Granada, Spain
| | - Konstantinos Z Vasileiou
- Laboratory of Pharmacogenomics and Individualized Therapy, Department of Pharmacy, University of Patras School of Health Sciences, Patras, Greece
| | - George P Patrinos
- Laboratory of Pharmacogenomics and Individualized Therapy, Department of Pharmacy, University of Patras School of Health Sciences, Patras, Greece
- Department of Genetics and Genomics, College of Medicine and Health Sciences, United Arab Emirates University, Al-Ain, Abu Dhabi, United Arab Emirates
- Zayed Center for Health Sciences, United Arab Emirates University, Al-Ain, Abu Dhabi, United Arab Emirates
| | - Christina Mitropoulou
- The Golden Helix Foundation, 91 Waterloo Road, Capital Tower 6th Floor, London, SE1 9RT, UK.
- Department of Genetics and Genomics, College of Medicine and Health Sciences, United Arab Emirates University, Al-Ain, Abu Dhabi, United Arab Emirates.
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Starke F, Sikora A, Stegmann R, Knebel L, Buntrock C, de Rijk A, Houkes I, Szycik GR, Unger HP, Schumacher JO, Stark H, Hauth I, Holzapfel C, Borgolte A, Schneller C, Unterschemmann SL, Paetow W, Jung AL, Berking M, Zimmermann J, Wegewitz U. Evaluating a multimodal, clinical and work-directed intervention (RTW-PIA) to support sustainable return to work among employees with mental disorders: study protocol of a multicentre, randomised controlled trial. BMC Psychiatry 2023; 23:380. [PMID: 37254157 DOI: 10.1186/s12888-023-04753-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/17/2023] [Accepted: 04/05/2023] [Indexed: 06/01/2023] Open
Abstract
BACKGROUND Mental disorders (MDs) are one of the leading causes for workforce sickness absence and disability worldwide. The burden, costs and challenges are enormous for the individuals concerned, employers and society at large. Although most MDs are characterised by a high risk of relapse after treatment or by chronic courses, interventions that link medical-psychotherapeutic approaches with work-directed components to facilitate a sustainable return to work (RTW) are rare. This protocol describes the design of a study to evaluate the (cost-)effectiveness and implementation process of a multimodal, clinical and work-directed intervention, called RTW-PIA, aimed at employees with MDs to achieve sustainable RTW in Germany. METHODS The study consists of an effectiveness, a health-economic and a process evaluation, designed as a two-armed, multicentre, randomised controlled trial, conducted in German psychiatric outpatient clinics. Sick-listed employees with MDs will receive either the 18-month RTW-PIA treatment in conjunction with care as usual, or care as usual only. RTW-PIA consists of a face-to-face individual RTW support, RTW aftercare group meetings, and web-based aftercare. Assessments will be conducted at baseline and 6, 12, 18 and 24 months after completion of baseline survey. The primary outcome is the employees´ achievement of sustainable RTW, defined as reporting less than six weeks of working days missed out due to sickness absence within 12 months after first RTW. Secondary outcomes include health-related quality of life, mental functioning, RTW self-efficacy, overall job satisfaction, severity of mental illness and work ability. The health-economic evaluation will be conducted from a societal and public health care perspective, as well as from the employer's perspective in a cost-benefit analysis. The design will be supplemented by a qualitative effect evaluation using pre- and post-interviews, and a multimethod process evaluation examining various predefined key process indicators from different stakeholder perspectives. DISCUSSION By applying a comprehensive, multimethodological evaluation design, this study captures various facets of RTW-PIA. In case of promising results for sustainable RTW, RTW-PIA may be integrated into standard care within German psychiatric outpatient clinics. TRIAL REGISTRATION The study was prospectively registered with the German Clinical Trials Register ( DRKS00026232 , 1 September 2021).
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Affiliation(s)
- Fiona Starke
- Division 3 Work and Health, Unit 3.5 Evidence-based Occupational Health, Workplace Health Management, Federal Institute for Occupational Safety and Health (BAuA), Nöldnerstr. 40-42, Berlin, 10317, Germany.
- Department of Social Medicine, Faculty of Health, Medicine and Life Sciences, CAPHRI Care and Public Health Research Institute, Maastricht University, P.O. Box 616, Maastricht, 6200 MD, The Netherlands.
| | - Alexandra Sikora
- Division 3 Work and Health, Unit 3.5 Evidence-based Occupational Health, Workplace Health Management, Federal Institute for Occupational Safety and Health (BAuA), Nöldnerstr. 40-42, Berlin, 10317, Germany
| | - Ralf Stegmann
- Division 3 Work and Health, Unit 3.5 Evidence-based Occupational Health, Workplace Health Management, Federal Institute for Occupational Safety and Health (BAuA), Nöldnerstr. 40-42, Berlin, 10317, Germany
| | - Leonie Knebel
- Division 3 Work and Health, Unit 3.5 Evidence-based Occupational Health, Workplace Health Management, Federal Institute for Occupational Safety and Health (BAuA), Nöldnerstr. 40-42, Berlin, 10317, Germany
| | - Claudia Buntrock
- Institute of Social Medicine and Health Systems Research, Faculty of Medicine, Otto-Von-Guericke University Magdeburg (OVGU), Leipziger Str. 44, 39120, Magdeburg, Germany
- Department of Clinical Psychology and Psychotherapy, Institute of Psychology, Friedrich-Alexander-Universität Erlangen-Nürnberg (FAU), Nägelsbachstr. 25a, 91052, Erlangen, Germany
| | - Angelique de Rijk
- Department of Social Medicine, Faculty of Health, Medicine and Life Sciences, CAPHRI Care and Public Health Research Institute, Maastricht University, P.O. Box 616, Maastricht, 6200 MD, The Netherlands
| | - Inge Houkes
- Department of Social Medicine, Faculty of Health, Medicine and Life Sciences, CAPHRI Care and Public Health Research Institute, Maastricht University, P.O. Box 616, Maastricht, 6200 MD, The Netherlands
| | - Gregor R Szycik
- Department of Psychiatry, Social Psychiatry and Psychotherapy, Hanover Medical School, Podbielskistr. 162, Hanover, OE7110, Germany
| | - Hans-Peter Unger
- Department of Psychiatry, Psychotherapy and Psychosomatics, Centre for Mental Health, Asklepios Clinic Harburg, Eißendorfer Pferdeweg 52, Hamburg, 21075, Germany
| | - Jan Ole Schumacher
- Department of Psychiatry, Psychotherapy and Psychosomatics, Centre for Mental Health, Asklepios Clinic Harburg, Eißendorfer Pferdeweg 52, Hamburg, 21075, Germany
| | - Heiko Stark
- Department of Psychiatry, Burghof-Clinic, Ritterstr. 19, 31737, Rinteln, Germany
| | - Iris Hauth
- Department of Psychiatry, Psychotherapy and Psychosomatics, Alexian St. Joseph-Hospital Berlin-Weissensee, Gartenstr. 1, 13088, Berlin, Germany
| | | | - Anna Borgolte
- Department of Psychiatry, Social Psychiatry and Psychotherapy, Hanover Medical School, Podbielskistr. 162, Hanover, OE7110, Germany
| | - Carlotta Schneller
- Department of Psychiatry, Psychotherapy and Psychosomatics, Alexian St. Joseph-Hospital Berlin-Weissensee, Gartenstr. 1, 13088, Berlin, Germany
| | | | - Wiebke Paetow
- Department of Psychiatry, Psychotherapy and Psychosomatics, Centre for Mental Health, Asklepios Clinic Harburg, Eißendorfer Pferdeweg 52, Hamburg, 21075, Germany
| | - Anna Lena Jung
- Clinic Wittgenstein, Sählingsstr. 60, 57319, Bad Berleburg, Germany
| | - Matthias Berking
- Department of Clinical Psychology and Psychotherapy, Institute of Psychology, Friedrich-Alexander-Universität Erlangen-Nürnberg (FAU), Nägelsbachstr. 25a, 91052, Erlangen, Germany
| | - Johannes Zimmermann
- Department of Psychology, University of Kassel, Holländische Str. 36-38, 34127, Kassel, Germany
| | - Uta Wegewitz
- Division 3 Work and Health, Unit 3.5 Evidence-based Occupational Health, Workplace Health Management, Federal Institute for Occupational Safety and Health (BAuA), Nöldnerstr. 40-42, Berlin, 10317, Germany
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Johansen K, Lindhoff Larsson A, Lundgren L, Gasslander T, Hjalmarsson C, Sandström P, Lyth J, Henriksson M, Björnsson B. Laparoscopic distal pancreatectomy is more cost-effective than open resection: results from a Swedish randomized controlled trial. HPB (Oxford) 2023:S1365-182X(23)00138-7. [PMID: 37198071 DOI: 10.1016/j.hpb.2023.04.021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/16/2022] [Revised: 02/21/2023] [Accepted: 04/30/2023] [Indexed: 05/19/2023]
Abstract
BACKGROUND Laparoscopic distal pancreatectomy is being implemented worldwide. The aim of this study was to perform a cost-effectiveness analysis from a health care perspective. METHODS This cost-effectiveness analysis was based on the randomized controlled trial LAPOP, where 60 patients were randomized to open or laparoscopic distal pancreatectomy. For the follow-up of two years, resource use from a health care perspective was recorded, and health-related quality of life was assessed using the EQ-5D-5L. The per-patient mean cost and quality-adjusted life years (QALYs) were compared using nonparametric bootstrapping. RESULTS Fifty-six patients were included in the analysis. The mean health care costs were lower, €3863 (95% CI: -€8020 to €385), for the laparoscopic group. Postoperative quality of life improved with laparoscopic resection and resulted in a gain in QALYs of 0.08 (95% CI: -0.09 to 0.25). The laparoscopic group had lower costs and improved QALYs in 79% of bootstrap samples. With a cost-per-QALY threshold of €50 000, 95.4% of the bootstrap samples were in favour of laparoscopic resection. CONCLUSION Laparoscopic distal pancreatectomy is associated with numerically lower health care costs and improvements in QALYs compared with the open approach. The results support the ongoing transition from open to laparoscopic distal pancreatectomies.
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Affiliation(s)
- Karin Johansen
- Department of Surgery in Linköping and Department of Biomedical and Clinical Sciences, Linköping University, Linköping, Sweden
| | - Anna Lindhoff Larsson
- Department of Surgery in Linköping and Department of Biomedical and Clinical Sciences, Linköping University, Linköping, Sweden
| | - Linda Lundgren
- Department of Surgery in Linköping and Department of Biomedical and Clinical Sciences, Linköping University, Linköping, Sweden
| | - Thomas Gasslander
- Department of Surgery in Linköping and Department of Biomedical and Clinical Sciences, Linköping University, Linköping, Sweden
| | | | - Per Sandström
- Department of Surgery in Linköping and Department of Biomedical and Clinical Sciences, Linköping University, Linköping, Sweden
| | - Johan Lyth
- Centre for Medical Technology Assessment, Department of Health, Medicine and Caring Sciences, Linköping University, Sweden
| | - Martin Henriksson
- Centre for Medical Technology Assessment, Department of Health, Medicine and Caring Sciences, Linköping University, Sweden
| | - Bergthor Björnsson
- Department of Surgery in Linköping and Department of Biomedical and Clinical Sciences, Linköping University, Linköping, Sweden.
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Shearer J, Metrebian N, Weaver T, Goldsmith K, Strang J, Pilling S, Mitcheson L, Day E, Dunn J, Glasper A, Akhtar S, Bajaria J, Charles V, Desai R, Haque F, Little N, McKechnie H, Mosler F, Mutz J, Poovendran D, Byford S. The Cost-Effectiveness of Financial Incentives to Achieve Heroin Abstinence in Individuals With Heroin Use Disorder Starting New Treatment Episodes: A Cluster Randomized Trial-Based Economic Evaluation. VALUE IN HEALTH : THE JOURNAL OF THE INTERNATIONAL SOCIETY FOR PHARMACOECONOMICS AND OUTCOMES RESEARCH 2023; 26:658-665. [PMID: 36509367 DOI: 10.1016/j.jval.2022.11.021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/26/2021] [Revised: 09/14/2022] [Accepted: 11/17/2022] [Indexed: 05/03/2023]
Abstract
OBJECTIVES Cost-effectiveness analysis of two 12-week contingency management (CM) schedules targeting heroin abstinence or attendance at weekly keyworker appointments for opioid agonist treatment compared with treatment as usual (TAU). METHODS A cost-effectiveness analysis was conducted alongside a cluster randomized trial of 552 patients from 34 clusters (drug treatment clinics) randomly allocated 1:1:1 to opioid agonist treatment plus weekly keyworker appointments with (1) CM targeted at heroin abstinence (CM abstinence), (2) CM targeted at on-time attendance at weekly appointments (CM attendance), or (3) no CM (TAU). The primary cost-effectiveness analysis at 24 weeks after randomization took a societal cost perspective with effects measured in heroin-negative urine samples. RESULTS At 24 weeks, mean differences in weekly heroin-negative urine results compared with TAU were 0.252 (95% confidence interval [CI] -0.397 to 0.901) for CM abstinence and 0.089 (95% CI -0.223 to 0.402) for CM attendance. Mean differences in costs were £2562 (95% CI £32-£5092) for CM abstinence and £317 (95% CI -£882 to £1518) for CM attendance. Incremental cost-effectiveness ratios were £10 167 per additional heroin-free urine for CM abstinence and £3562 for CM attendance with low probabilities of cost-effectiveness of 3.5% and 36%, respectively. Results were sensitive to timing of follow-up for CM attendance, which dominated TAU (better outcomes, lower costs) at 12 weeks, with an 88.4% probability of being cost-effective. Probability of cost-effectiveness remained low for CM abstinence (8.6%). CONCLUSIONS Financial incentives targeted toward heroin abstinence and treatment attendance were not cost-effective over the 24-week follow-up. Nevertheless, CM attendance was cost-effective over the treatment period (12 weeks), when participants were receiving keyworker appointments and incentives.
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Affiliation(s)
- James Shearer
- King's Health Economics, Institute of Psychiatry, Psychology & Neuroscience, King's College London, London, England, UK.
| | - Nicola Metrebian
- Addictions Department, Institute of Psychiatry, Psychology & Neuroscience, King's College London, London, England, UK
| | - Tim Weaver
- Faculty of Health, Social Care and Education, Middlesex University, London, England, UK
| | - Kimberley Goldsmith
- Department of Biostatistics & Health Informatics, Institute of Psychiatry, Psychology & Neuroscience, King's College London, London, England, UK
| | - John Strang
- Addictions Department, Institute of Psychiatry, Psychology & Neuroscience, King's College London, London, England, UK
| | | | - Luke Mitcheson
- South London and Maudsley NHS Foundation Trust, London, England, UK
| | - Ed Day
- Institute for Mental Health, University of Birmingham, Birmingham, England, UK
| | - John Dunn
- Camden and Islington NHS Foundation Trust, London, England, UK
| | - Anthony Glasper
- Sussex Partnership NHS Foundation Trust, London, England, UK
| | - Shabana Akhtar
- Birmingham & Solihull Mental Health NHS Foundation Trust, London, England, UK
| | - Jalpa Bajaria
- CRN North West London, Imperial College Healthcare NHS Trust, London, England, UK
| | - Vikki Charles
- Addictions Department, Institute of Psychiatry, Psychology & Neuroscience, King's College London, London, England, UK
| | - Roopal Desai
- ADAPT Lab, Research Department of Clinical, Educational and Health Psychology, University College London, London, England, UK
| | - Farjana Haque
- National Addiction Centre, Institute of Psychiatry, Psychology & Neuroscience, King's College London, London, England, UK
| | | | | | - Franziska Mosler
- Unit for Social and Community Psychiatry, Queen Mary University of London, London, England, UK
| | - Julian Mutz
- Addictions Department, Institute of Psychiatry, Psychology & Neuroscience, King's College London, London, England, UK
| | - Dilkushi Poovendran
- Centre for Mental Health, Division of Brain Sciences, Imperial College London, London, England, UK
| | - Sarah Byford
- King's Health Economics, Institute of Psychiatry, Psychology & Neuroscience, King's College London, London, England, UK
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Lowenstein LM, Shih YCT, Minnix J, Lopez-Olivo MA, Maki KG, Kypriotakis G, Leal VB, Shete SS, Fox J, Nishi SP, Cinciripini PM, Volk RJ. A protocol for a cluster randomized trial of care delivery models to improve the quality of smoking cessation and shared decision making for lung cancer screening. Contemp Clin Trials 2023; 128:107141. [PMID: 36878389 PMCID: PMC10164095 DOI: 10.1016/j.cct.2023.107141] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2022] [Revised: 02/16/2023] [Accepted: 03/01/2023] [Indexed: 03/07/2023]
Abstract
BACKGROUND Patients eligible for lung cancer screening (LCS) are those at high risk of lung cancer due to their smoking histories and age. While screening for LCS is effective in lowering lung cancer mortality, primary care providers are challenged to meet beneficiary eligibility for LCS from the Centers for Medicare & Medicaid Services, including a patient counseling and shared decision-making (SDM) visit with the use of patient decision aid(s) prior to screening. METHODS We will use an effectiveness-implementation type I hybrid design to: 1) identify effective, scalable smoking cessation counseling and SDM interventions that are consistent with recommendations, can be delivered on the same platform, and are implemented in real-world clinical settings; 2) examine barriers and facilitators of implementing the two approaches to delivering smoking cessation and SDM for LCS; and 3) determine the economic implications of implementation by assessing the healthcare resources required to increase smoking cessation for the two approaches by delivering smoking cessation within the context of LCS. Providers from different healthcare organizations will be randomized to usual care (providers delivering smoking cessation and SDM on site) vs. centralized care (smoking cessation and SDM delivered remotely by trained counselors). The primary trial outcomes will include smoking abstinence at 12-weeks and knowledge about LCS measured at 1-week after baseline. CONCLUSION This study will provide important new evidence about the effectiveness and feasibility of a novel care delivery model for addressing the leading cause of lung cancer deaths and supporting high-quality decisions about LCS. CLINICALTRIALS GOV PROTOCOL REGISTRATION NCT04200534 TRIAL REGISTRATION: ClinicalTrials.govNCT04200534.
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Affiliation(s)
- Lisa M Lowenstein
- Departments of Health Services Research, The University of Texas MD Anderson Cancer Center, Houston, TX, USA.
| | - Ya-Chen Tina Shih
- Departments of Health Services Research, The University of Texas MD Anderson Cancer Center, Houston, TX, USA.
| | - Jennifer Minnix
- Behavioral Science, The University of Texas MD Anderson Cancer Center, Houston, TX, USA.
| | - Maria A Lopez-Olivo
- Departments of Health Services Research, The University of Texas MD Anderson Cancer Center, Houston, TX, USA.
| | - Kristin G Maki
- Departments of Health Services Research, The University of Texas MD Anderson Cancer Center, Houston, TX, USA.
| | - George Kypriotakis
- Behavioral Science, The University of Texas MD Anderson Cancer Center, Houston, TX, USA.
| | - Viola B Leal
- Departments of Health Services Research, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Sanjay S Shete
- Biostatistics, The University of Texas MD Anderson Cancer Center, Houston, TX, USA.
| | - James Fox
- Pulmonary & Critical Care Medicine, The University of Texas Health East Texas, Tyler, TX, USA.
| | - Shawn P Nishi
- Pulmonary & Critical Care Medicine, The University of Texas Medical Branch, Galveston, TX, USA.
| | - Paul M Cinciripini
- Behavioral Science, The University of Texas MD Anderson Cancer Center, Houston, TX, USA.
| | - Robert J Volk
- Departments of Health Services Research, The University of Texas MD Anderson Cancer Center, Houston, TX, USA.
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Schorling E, Lick S, Steinberg P, Brüggemann DA. Health care utilizations and costs of Campylobacter enteritis in Germany: A claims data analysis. PLoS One 2023; 18:e0283865. [PMID: 37018288 PMCID: PMC10075411 DOI: 10.1371/journal.pone.0283865] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2022] [Accepted: 03/19/2023] [Indexed: 04/06/2023] Open
Abstract
OBJECTIVE The number of reported cases of Campylobacter enteritis (CE) remains on a high level in many parts of the world. The aim of this study was to analyze the health care utilizations and direct and indirect costs of CE and sequelae of patients insured by a large health insurance with 26 million members in Germany. METHODS Claims data of insurants with at least one CE diagnosis in 2017 (n = 13,150) were provided, of which 9,945 were included in the analysis of health care utilizations and costs. If medical services were not diagnosis-linked, CE-associated costs were estimated in comparison to up to three healthy controls per CE patient. Indirect costs were calculated by multiplying the work incapacities by the average labor costs. Total costs of CE in Germany were extrapolated by including all officially reported CE cases in 2017 using Monte Carlo simulations. RESULTS Insurants showed a lower rate of 56 CE diagnoses per 100,000 than German surveillance data for 2017, but with a similar age, gender and regional distribution. Of those CE cases, 6.3% developed post-infectious reactive arthritis, Guillain-Barré syndrome (GBS), inflammatory bowel disease (IBD) and/or irritable bowel syndrome (IBS). Health care utilizations differed depending on CE severity, age and gender. Average CE-specific costs per patient receiving outpatient care were € 524 (95% CI 495-560) over a 12-month period, whereas costs per hospitalized CE case amounted to € 2,830 (2,769-2,905). The analyzed partial costs of sequelae ranged between € 221 (IBS) and € 22,721 (GBS) per patient per 12 months. Total costs of CE and sequelae extrapolated to Germany 2017 ranged between € 74.25 and € 95.19 million, of which 10-30% were due to sequelae. CONCLUSION CE is associated with a substantial economic burden in Germany, also due to care-intensive long-lasting sequelae. However, uncertainties remain as to the causal relationship of IBD and IBS after CE.
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Affiliation(s)
- Elisabeth Schorling
- Department of Safety and Quality of Meat, Max Rubner-Institut, Federal Research Institute of Nutrition and Food, Kulmbach, Bavaria, Germany
| | - Sonja Lick
- Department of Safety and Quality of Meat, Max Rubner-Institut, Federal Research Institute of Nutrition and Food, Kulmbach, Bavaria, Germany
| | - Pablo Steinberg
- Max Rubner-Institut, Federal Research Institute of Nutrition and Food, Karlsruhe, Baden-Württemberg, Germany
| | - Dagmar Adeline Brüggemann
- Department of Safety and Quality of Meat, Max Rubner-Institut, Federal Research Institute of Nutrition and Food, Kulmbach, Bavaria, Germany
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Höglinger M, Wirth B, Carlander M, Caviglia C, Frei C, Rhomberg B, Rohrbasser A, Trottmann M, Eichler K. Impact of a diabetes disease management program on guideline-adherent care, hospitalization risk and health care costs: a propensity score matching study using real-world data. THE EUROPEAN JOURNAL OF HEALTH ECONOMICS : HEPAC : HEALTH ECONOMICS IN PREVENTION AND CARE 2023; 24:469-478. [PMID: 35716315 PMCID: PMC10060321 DOI: 10.1007/s10198-022-01486-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 10/16/2021] [Accepted: 05/25/2022] [Indexed: 06/15/2023]
Abstract
OBJECTIVE To evaluate the impact of a DMP for patients with diabetes mellitus in a Swiss primary care setting. METHODS In a prospective observational study, we compared diabetes patients in a DMP (intervention group; N = 538) with diabetes patients receiving usual care (control group; N = 5050) using propensity score matching with entropy balancing. Using a difference-in-difference (DiD) approach, we compared changes in outcomes from baseline (2017) to 1-year (2017/18) and to 2-year follow-up (2017/19). Outcomes included four measures for guideline-adherent diabetes care, hospitalization risk, and health care costs. RESULTS We identified a positive impact of the DMP on the share of patients fulfilling all measures for guideline-adherent care [DiD 2017/18: 7.2 percentage-points, p < 0.01; 2017/19: 8.4 percentage-points, p < 0.001]. The hospitalization risk was lower in the intervention group in both years, but only statistically significant in the 1-year follow-up [DiD 2017/18: - 5.7 percentage-points, p < 0.05; 2017/19: - 3.9 percentage points, n.s.]. The increase in health care costs was smaller in the intervention than in the control group [DiD 2017/18: CHF - 852; 2017/19: CHF - 909], but this effect was not statistically significant. CONCLUSION The DMP under evaluation seems to exert a positive impact on the quality of diabetes care, reflected in the increase in the measures for guideline-adherent care and in a reduction of the hospitalization risk in the intervention group. It also might reduce health care costs, but only a longer follow-up will show whether the observed effect persists over time.
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Affiliation(s)
- Marc Höglinger
- Health Services Research, Winterthur Institute of Health Economics, Zurich University of Applied Sciences, Gertrudstrasse 15, CH-8401, Winterthur, Switzerland.
| | - Brigitte Wirth
- Health Services Research, Winterthur Institute of Health Economics, Zurich University of Applied Sciences, Gertrudstrasse 15, CH-8401, Winterthur, Switzerland
| | - Maria Carlander
- Health Services Research, Winterthur Institute of Health Economics, Zurich University of Applied Sciences, Gertrudstrasse 15, CH-8401, Winterthur, Switzerland
| | | | | | | | - Adrian Rohrbasser
- Medbase Health Care Provider, Winterthur, Switzerland
- Institute of Primary Health Care (BIHAM), University of Bern, Bern, Switzerland
| | | | - Klaus Eichler
- Health Services Research, Winterthur Institute of Health Economics, Zurich University of Applied Sciences, Gertrudstrasse 15, CH-8401, Winterthur, Switzerland
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Kempeneers MA, Issa Y, Bruno MJ, van Santvoort HC, Besselink MG, Boermeester MA, Dijkgraaf MG. Cost-effectiveness of Early Surgery Versus Endoscopy-first Approach for Painful Chronic Pancreatitis in the ESCAPE Trial. Ann Surg 2023; 277:e878-e884. [PMID: 35129523 DOI: 10.1097/sla.0000000000005240] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE Economic evaluation of early surgery compared to the endoscopy-first approach in CP. BACKGROUND In patients with painful CP and a dilated main pancreatic duct, early surgery, as compared with an endoscopy-first approach, leads to more pain reduction with fewer interventions. However, it is unknown if early surgery is more cost-effective than the endoscopy-first approach. METHODS The multicenter Dutch ESCAPE trial randomized patients with CP and a dilated main pancreatic duct between early surgery (surgery within 6 weeks) or the endoscopy-first approach in 30 centers (April 2011-September 2016). Healthcare utilization was prospectively recorded up to 18 months after randomization. Unit costs of resources were determined, and cost-effectiveness and cost-utility analyses were performed from societal and healthcare perspectives. Primary outcomes were the costs per unit decrease on the Izbicki pain score and per gained quality-adjusted life-year. RESULTS In total, 88 patients were included in the analysis, with 44 patients randomized to each group. Total costs were lower in the early surgery group but did not reach statistical significance (mean difference €-4,815 (95% bias-corrected and accelerated confidence interval €-13,113 to €3411; P = 0.25). Early surgery had a probability percentage of 88.4% of being more cost-effective than the endoscopy-first approach at a willingness-to-pay threshold of €0 per day per unit decrease on the Izbicki pain score. The probability percentage per additional gained quality-adjusted life-year was 75.7% at a willingness-to-pay threshold of €50,000. CONCLUSION In patients with painful CP and a dilated main pancreatic duct, early surgery was more cost-effective than the endoscopy-first approach.
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Affiliation(s)
- Marinus A Kempeneers
- Department of Surgery, Amsterdam Gastroenterology Endocrinology Metabolism, Amsterdam UMC, University of Amsterdam, Amsterdam, the Netherlands
| | - Yama Issa
- Department of Surgery, Amsterdam Gastroenterology Endocrinology Metabolism, Amsterdam UMC, University of Amsterdam, Amsterdam, the Netherlands
- Department of Surgery, Gelre Hospital, Apeldoorn, the Netherlands
| | - Marco J Bruno
- Department of Gastroenterology and Hepatology, Erasmus MC, University Medical Center, Rotterdam, the Netherlands
| | - Hjalmar C van Santvoort
- Department of Surgery, St Antonius Hospital, Nieuwegein, the Netherlands
- Department of Surgery, University Medical Center Utrecht, Utrecht, the Netherlands
| | - Marc G Besselink
- Department of Surgery, Amsterdam Gastroenterology Endocrinology Metabolism, Amsterdam UMC, University of Amsterdam, Amsterdam, the Netherlands
| | - Marja A Boermeester
- Department of Surgery, Amsterdam Gastroenterology Endocrinology Metabolism, Amsterdam UMC, University of Amsterdam, Amsterdam, the Netherlands
| | - Marcel G Dijkgraaf
- Department of Epidemiology and Data Science, Amsterdam Public Health, Amsterdam UMC, University of Amsterdam, the Netherlands
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Masiano SP, Kawende B, Ravelomanana NLR, Green TL, Dahman B, Thirumurthy H, Kimmel AD, Yotebieng M. Economic costs and cost-effectiveness of conditional cash transfers for the uptake of services for the prevention of vertical HIV transmissions in a resource-limited setting. Soc Sci Med 2023; 320:115684. [PMID: 36696797 PMCID: PMC9975037 DOI: 10.1016/j.socscimed.2023.115684] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2022] [Revised: 12/06/2022] [Accepted: 01/13/2023] [Indexed: 01/15/2023]
Abstract
BACKGROUND Prevention of mother-to-child transmission (PMTCT) is critical for halting the HIV epidemic. However, innovative approaches to improve PMTCT uptake may be resource-intensive. We examined the economic costs and cost-effectiveness of conditional cash transfers (CCTs) for the uptake of PMTCT services in the Democratic Republic of Congo. METHODS We leveraged data from a randomized controlled trial of CCTs (n = 216) versus standard PMTCT care alone (standard of care (SOC), n = 217). Economic cost data came from multiple sources, with costs analyzed from the societal perspective and reported in 2016 international dollars (I$). Effectiveness outcomes included PMTCT uptake (i.e., accepting all PMTCT visits and services) and retention (i.e., in HIV care at six weeks post-partum). Generalized estimating equations estimated effectiveness (relative risk) and incremental costs, with incremental effectiveness reported as the number of women needing CCTs for an additional PMTCT uptake or retention. We evaluated the cost-effectiveness of the CCTs at various levels of willingness-to-pay and assessed uncertainty using deterministic sensitivity analysis and cost-effectiveness acceptability curves. RESULTS Mean costs per participant were I$516 (CCTs) and I$431 (SOC), representing an incremental cost of I$85 (95% CI: 59, 111). PMTCT uptake was more likely for CCTs vs SOC (68% vs 53%, p < 0.05), with seven women needing CCTs for each additional PMTCT service uptake; twelve women needed CCTs for an additional PMTCT retention. The incremental cost-effectiveness of CCTs vs SOC was I$595 (95% CI: I$550, I$638) for PMTCT uptake and I$1028 (95% CI: I$931, I$1125) for PMTCT retention. CCTs would be an efficient use of resources if society's willingness-to-pay for an additional woman who takes up PMTCT services is at least I$640. In the worst-case scenario, the findings remained relatively robust. CONCLUSIONS Given the relatively low cost of the CCTs, policies supporting CCTs may decrease onward HIV transmission and expedite progress toward ending the epidemic.
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Affiliation(s)
- Steven P Masiano
- Department of Health Behavior and Policy, Virginia Commonwealth University School of Medicine, Richmond, VA, 23219, USA; Department of Quantitative Health Sciences, Lerner Research Institute, Cleveland Clinic, Cleveland, OH, 44195, USA.
| | - Bienvenu Kawende
- The University of Kinshasa, School of Public Health, Kinshasa, Democratic Republic of the Congo, The
| | - Noro Lantoniaina Rosa Ravelomanana
- The University of Kinshasa, School of Public Health, Kinshasa, Democratic Republic of the Congo, The; Albert Einstein College of Medicine, Department of Medicine, Division of General Internal Medicine, 3300 Kossuth Ave, Bronx, NY, 10467, USA
| | - Tiffany L Green
- Department of Health Behavior and Policy, Virginia Commonwealth University School of Medicine, Richmond, VA, 23219, USA; Departments of Population Health Sciences and Obstetrics and Gynecology, University of Wisconsin School of Medicine and Public Health, Madison, WI, USA
| | - Bassam Dahman
- Department of Health Behavior and Policy, Virginia Commonwealth University School of Medicine, Richmond, VA, 23219, USA
| | - Harsha Thirumurthy
- Medical Ethics and Health Policy, Perelman School of Medicine, University of Pennsylvania, USA; Center for Health Incentives and Behavioral Economics, University of Pennsylvania, USA
| | - April D Kimmel
- Department of Health Behavior and Policy, Virginia Commonwealth University School of Medicine, Richmond, VA, 23219, USA.
| | - Marcel Yotebieng
- The University of Kinshasa, School of Public Health, Kinshasa, Democratic Republic of the Congo, The; Albert Einstein College of Medicine, Department of Medicine, Division of General Internal Medicine, 3300 Kossuth Ave, Bronx, NY, 10467, USA
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Sifakaki M, Gkiouras K, Lindqvist HM, Marakis G, Petropoulou A, Donini LM, Bogdanos DP, Grammatikopoulou MG. Orthorexia Nervosa Practices in Rheumatoid Arthritis: The DORA Study. Nutrients 2023; 15:nu15030713. [PMID: 36771419 PMCID: PMC9919523 DOI: 10.3390/nu15030713] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2022] [Revised: 01/23/2023] [Accepted: 01/28/2023] [Indexed: 02/03/2023] Open
Abstract
Medical nutrition therapy (MNT) is an indisputable component of the multidisciplinary therapeutic approach in rheumatoid arthritis (RA). Previous research has suggested that in chronic disease where nutrition is an important effector of prognosis, healthy dietary choices might take an unhealthy turn, with patients developing disordered eating in the form of orthorexia nervosa (ON). ON is characterized by a pathological preoccupation with "healthy", "pure" eating, associated with restrictive dietary patterns, nutrient deficiencies and worsening disease outcomes. The aim of the present cross-sectional study was to evaluate ON tendencies in a sample of adult patients with RA. A total of 133 patients with RA were recruited, and completed the ORTO-15 questionnaire for the assessment of ON tendencies. Most of the patients were overweight/obese (53.4%). The results revealed ON tendencies in the sample, with the median ORTO-15 score reaching 36 (IQR: 33-39). Greater ON tendencies were associated with the female gender, and lowered ON tendencies with increasing age and body mass index. The present findings highlight the need for health professional awareness regarding the problem of ON in patients with RA and the importance of screening patients.
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Affiliation(s)
- Maria Sifakaki
- Department of Nutritional Sciences & Dietetics, Faculty of Health Sciences, International Hellenic University, Alexander Campus, P.O. Box 141, GR-57400 Thessaloniki, Greece
| | - Konstantinos Gkiouras
- Unit of Immunonutrition and Clinical Nutrition, Department of Rheumatology and Clinical Immunology, Faculty of Medicine, School of Health Sciences, University of Thessaly, Biopolis, GR-41110 Larissa, Greece
| | - Helen M. Lindqvist
- Department of Internal Medicine and Clinical nutrition, Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, 40530 Gothenburg, Sweden
| | - Georgios Marakis
- Nutrition and Food Standards Unit, Hellenic Food Authority, 124 Kifisias Avenue & Iatridou 2, GR-11526 Athens, Greece
| | - Anastasia Petropoulou
- Department of Nutritional Sciences & Dietetics, Faculty of Health Sciences, International Hellenic University, Alexander Campus, P.O. Box 141, GR-57400 Thessaloniki, Greece
| | - Lorenzo M. Donini
- Department of Experimental Medicine, Sapienza University, 00185 Rome, Italy
| | - Dimitrios P. Bogdanos
- Unit of Immunonutrition and Clinical Nutrition, Department of Rheumatology and Clinical Immunology, Faculty of Medicine, School of Health Sciences, University of Thessaly, Biopolis, GR-41110 Larissa, Greece
| | - Maria G. Grammatikopoulou
- Unit of Immunonutrition and Clinical Nutrition, Department of Rheumatology and Clinical Immunology, Faculty of Medicine, School of Health Sciences, University of Thessaly, Biopolis, GR-41110 Larissa, Greece
- Correspondence:
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Hinze V, Ford T, Gjelsvik B, Byford S, Cipriani A, Montero-Marin J, Ganguli P. Service use and costs in adolescents with pain and suicidality: a cross-sectional study. EClinicalMedicine 2023; 55:101778. [PMID: 36712889 PMCID: PMC9874333 DOI: 10.1016/j.eclinm.2022.101778] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/01/2022] [Revised: 11/17/2022] [Accepted: 11/22/2022] [Indexed: 12/15/2022] Open
Abstract
Background Persistent/recurrent pain for more than three months and suicidality (suicide and self-harm related thoughts and behaviours) are serious and co-occurring health problems in adolescence, underscoring the need for targeted support. However, little is known about service use and costs in adolescents with pain-suicidality comorbidity, compared to those with either problem alone. This study aimed to shed light on service use and costs in adolescents with pain and/or suicidality, and the role of individual and school characteristics. Methods We analysed cross-sectional, pre-intervention data from a large cluster randomised controlled trial, collected between 2017 and 2019 on a representative sample of 8072 adolescents (55% female; aged 11-15 years; 76% white) in 84 schools in the UK. We explored service use settings, covering health, social, educational settings, and medication for mental health problems over three months. Data were analysed using descriptive statistics and two-part hurdle models to obtain odds ratios (ORs) and incident rate ratios (IRRs). Findings 9% of adolescents reported comorbidity between pain and suicidality, 11% only suicidality, 13% only pain, and 66% neither pain nor suicidality. Approximately 55% of adolescents used services, especially general practitioner visits, outpatient appointments for injuries and contacts with a school nurse or pharmacist. Compared to adolescents with neither pain nor suicidality: (i) adolescents with pain (OR 3.79, 95% CI 2.63-5.48), suicidality (1.68, 1.12-2.51), and pain-suicidality comorbidity (2.35, 1.26-4.41) were more likely to use services and (ii) if services were used, they were more likely to have higher total costs (Pain: IRR 1.25, 95% CI 1.11-1.42; Suicidality: 1.27, 1.11-1.46; Comorbidity: 1.57, 1.34-1.85). Interpretation In our study, adolescents with pain and suicidality reported increased contact with health, social, and educational services, which could provide an opportunity for suicide prevention. Given the diversity of identified settings, multi-sector suicide prevention strategies are paramount. Funding Wellcome Trust [WT104908/Z/14/Z; WT107496/Z/15/Z]; Stiftung Oskar-Helene-Heim.
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Affiliation(s)
- Verena Hinze
- Department of Psychiatry, University of Oxford, Oxford, UK
- Oxford Precision Psychiatry Lab, NIHR Oxford Health Biomedical Research Centre, Oxford, UK
| | - Tamsin Ford
- Department of Psychiatry, University of Cambridge, Hershel Smith Building, Robinson Way, Cambridge Biomedical Campus, Cambridge CB2 0SZ, UK
| | - Bergljot Gjelsvik
- Department of Psychiatry, University of Oxford, Oxford, UK
- Department of Psychology, University of Oslo, Oslo, Norway
| | - Sarah Byford
- King’s College London, King’s Health Economics, Institute of Psychiatry, Psychology and Neuroscience, De Crespigny Park, London, UK
| | - Andrea Cipriani
- Department of Psychiatry, University of Oxford, Oxford, UK
- Oxford Precision Psychiatry Lab, NIHR Oxford Health Biomedical Research Centre, Oxford, UK
- Oxford Health NHS Foundation Trust, Warneford Hospital, Oxford, UK
| | - Jesus Montero-Marin
- Department of Psychiatry, University of Oxford, Oxford, UK
- Teaching, Research & Innovation Unit, Parc Sanitari Sant Joan de Déu, Sant Boi de Llobregat, Spain
| | - Poushali Ganguli
- King’s College London, King’s Health Economics, Institute of Psychiatry, Psychology and Neuroscience, De Crespigny Park, London, UK
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Jalali A, Tamimi RM, McPherson SM, Murphy SM. Econometric Issues in Prospective Economic Evaluations Alongside Clinical Trials: Combining the Nonparametric Bootstrap With Methods That Address Missing Data. Epidemiol Rev 2022; 44:67-77. [PMID: 36104860 PMCID: PMC10362933 DOI: 10.1093/epirev/mxac006] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2021] [Revised: 08/09/2022] [Accepted: 09/07/2022] [Indexed: 12/29/2022] Open
Abstract
Prospective economic evaluations conducted alongside clinical trials have become an increasingly popular approach in evaluating the cost-effectiveness of a public health initiative or treatment intervention. These types of economic studies provide improved internal validity and accuracy of cost and effectiveness estimates of health interventions and, compared with simulation or decision-analytic models, have the advantage of jointly observing health and economics outcomes of trial participants. However, missing data due to incomplete response or patient attrition, and sampling uncertainty are common concerns in econometric analysis of clinical trials. Missing data are a particular problem for comparative effectiveness trials of substance use disorder interventions. Multiple imputation and inverse probability weighting are 2 widely recommended methods to address missing data bias, and the nonparametric bootstrap is recommended to address uncertainty in predicted mean cost and effectiveness between trial interventions. Although these methods have been studied extensively by themselves, little is known about how to appropriately combine them and about the potential pitfalls and advantages of different approaches. We provide a review of statistical methods used in 29 economic evaluations of substance use disorder intervention identified from 4 published systematic reviews and a targeted search of the literature. We evaluate how each study addressed missing data bias, whether the recommended nonparametric bootstrap was used, how these 2 methods were combined, and conclude with recommendations for future research.
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Affiliation(s)
- Ali Jalali
- Correspondence to Dr. Ali Jalali, Department of Population Health Sciences, Weill Cornell Medicine, 425 East 61st Street, Suite 301, New York, NY 10065 (e-mail: )
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Kim NY, Park JH, Park J, Kwak N, Choi SM, Park YS, Lee CH, Cho J. Effect of chlorhexidine Mouthrinse on prevention of microbial contamination during EBUS-TBNA: a randomized controlled trial. BMC Cancer 2022; 22:1334. [PMID: 36539736 PMCID: PMC9764697 DOI: 10.1186/s12885-022-10442-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2022] [Accepted: 12/12/2022] [Indexed: 12/24/2022] Open
Abstract
BACKGROUND Although endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) is a minimally invasive procedure, fatal infectious complications have been reported. However, adequate preventive strategies have not been determined. We aimed to investigate the effect of chlorhexidine mouthrinse on the prevention of microbial contamination during EBUS-TBNA. METHODS In this single-center, assessor-blinded, parallel-group randomized controlled trial, we randomly assigned adult participants undergoing EBUS-TBNA using a convex probe to gargle for 1 minute with 100 mL of 0.12% chlorhexidine gluconate before EBUS-TBNA or to receive usual care (no chlorhexidine mouthrinse). Aspiration needle wash samples were collected immediately after completion of EBUS-TBNA by instilling sterile saline into the used needle. The primary outcome was colony forming unit (CFU) counts per mL of needle wash samples in aerobic cultures. Secondary outcomes were CFU counts per mL of needle wash samples in anaerobic cultures, fever within 24 hours after EBUS-TBNA, and infectious complications within 4 weeks after EBUS-TBNA. RESULTS From January 2021 to June 2021, 106 patients received either chlorhexidine mouthrinse (n = 51) or usual care (n = 55). The median CFU counts of needle wash samples in aerobic cultures were not significantly different in the two groups (10 CFU/mL vs 20 CFU/mL; P = 0.70). There were no significant differences between the groups regarding secondary outcomes, including median CFU counts in anaerobic cultures (P = 0.41) and fever within 24 hours after EBUS-TBNA (11.8% vs 5.6%, P = 0.31). There were no infectious complications within 4 weeks in both groups. CONCLUSIONS Chlorhexidine mouthrinse did not reduce CFU counts in needle wash samples of EBUS-TBNA. TRIAL REGISTRATION ClinicalTrials.gov, NCT04718922 . Registered on 22/01/2021.
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Affiliation(s)
- Na Young Kim
- grid.412484.f0000 0001 0302 820XDivision of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Seoul National University Hospital, Seoul, Republic of Korea
| | - Jae Hyeon Park
- grid.412484.f0000 0001 0302 820XDepartment of Laboratory Medicine, Seoul National University Hospital, Seoul, Republic of Korea ,grid.31501.360000 0004 0470 5905Department of Laboratory Medicine, Seoul National University College of Medicine, Seoul, Republic of Korea
| | - Jimyung Park
- grid.412484.f0000 0001 0302 820XDivision of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Seoul National University Hospital, Seoul, Republic of Korea
| | - Nakwon Kwak
- grid.412484.f0000 0001 0302 820XDivision of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Seoul National University Hospital, Seoul, Republic of Korea ,grid.31501.360000 0004 0470 5905Department of Internal Medicine, Seoul National University College of Medicine, 101 Daehak-ro, Jongno-gu, Seoul, 03080 Republic of Korea
| | - Sun Mi Choi
- grid.412484.f0000 0001 0302 820XDivision of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Seoul National University Hospital, Seoul, Republic of Korea ,grid.31501.360000 0004 0470 5905Department of Internal Medicine, Seoul National University College of Medicine, 101 Daehak-ro, Jongno-gu, Seoul, 03080 Republic of Korea
| | - Young Sik Park
- grid.412484.f0000 0001 0302 820XDivision of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Seoul National University Hospital, Seoul, Republic of Korea
| | - Chang-Hoon Lee
- grid.412484.f0000 0001 0302 820XDivision of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Seoul National University Hospital, Seoul, Republic of Korea
| | - Jaeyoung Cho
- grid.412484.f0000 0001 0302 820XDivision of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Seoul National University Hospital, Seoul, Republic of Korea ,grid.31501.360000 0004 0470 5905Department of Internal Medicine, Seoul National University College of Medicine, 101 Daehak-ro, Jongno-gu, Seoul, 03080 Republic of Korea
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Abas M, Mangezi W, Nyamayaro P, Jopling R, Bere T, McKetchnie SM, Goldsmith K, Fitch C, Saruchera E, Muronzie T, Gudyanga D, Barrett BM, Chibanda D, Hakim J, Safren SA, O'Cleirigh C. Task-sharing with lay counsellors to deliver a stepped care intervention to improve depression, antiretroviral therapy adherence and viral suppression in people living with HIV: a study protocol for the TENDAI randomised controlled trial. BMJ Open 2022; 12:e057844. [PMID: 36576191 PMCID: PMC9723911 DOI: 10.1136/bmjopen-2021-057844] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/07/2022] Open
Abstract
INTRODUCTION Non-adherence to antiretroviral therapy (ART) is the main cause of viral non-suppression and its risk is increased by depression. In countries with high burden of HIV, there is a lack of trained professionals to deliver depression treatments. This paper describes the protocol for a 2-arm parallel group superiority 1:1 randomised controlled trial, to test the effectiveness and cost effectiveness of the TENDAI stepped care task-shifted intervention for depression, ART non-adherence and HIV viral suppression delivered by lay interventionists. METHODS AND ANALYSIS Two hundred and ninety people living with HIV aged ≥18 years with probable depression (Patient Health Questionnaire=>10) and viral non-suppression (≥ 1000 HIV copies/mL) are being recruited from HIV clinics in towns in Zimbabwe. The intervention group will receive a culturally adapted 6-session psychological treatment, Problem-Solving Therapy for Adherence and Depression (PST-AD), including problem-solving therapy, positive activity scheduling, skills to cope with stress and poor sleep and content to target barriers to non-adherence to ART. Participants whose score on the Patient Health Questionnaire-9 remains ≥10, and/or falls by less than 5 points, step up to a nurse evaluation for possible antidepressant medication. The control group receives usual care for viral non-suppression, consisting of three sessions of adherence counselling from existing clinic staff, and enhanced usual care for depression in line with the WHO Mental Health Gap intervention guide. The primary outcome is viral suppression (<1000 HIV copies/mL) at 12 months post-randomisation. ETHICS AND DISSEMINATION The study and its tools were approved by MRCZ/A/2390 in Zimbabwe and RESCM-18/19-5580 in the UK. Study findings will be shared through the community advisory group, conferences and open access publications. TRIAL REGISTRATION NUMBER NCT04018391.
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Affiliation(s)
- Melanie Abas
- Section of Epidemiology, Health Services and Population Research Department, King's College London, London, UK
| | - Walter Mangezi
- Department of Primary Health Care Sciences, Unit of Mental Health, University of Zimbabwe, Harare, Zimbabwe
| | - Primrose Nyamayaro
- Department of Primary Health Care Sciences, Unit of Mental Health, University of Zimbabwe, Harare, Zimbabwe
| | - Rebecca Jopling
- Section of Epidemiology, Health Services and Population Research Department, King's College London, London, UK
| | - Tarisai Bere
- Department of Primary Health Care Sciences, Unit of Mental Health, University of Zimbabwe, Harare, Zimbabwe
| | - Samantha M McKetchnie
- Department of Psychiatry, Massachusetts General Hospital, Boston, Massachusetts, USA
- The Fenway Institute, Fenway Health, Boston, Massachusetts, USA
| | - Kimberley Goldsmith
- Department of Biostatistics and Health Informatics, King's College London, London, UK
| | - Calvin Fitch
- Department of Psychiatry, Massachusetts General Hospital, Boston, Massachusetts, USA
- The Fenway Institute, Fenway Health, Boston, Massachusetts, USA
| | - Emily Saruchera
- Department of Primary Health Care Sciences, Unit of Mental Health, University of Zimbabwe, Harare, Zimbabwe
| | - Thabani Muronzie
- Department of Primary Health Care Sciences, Unit of Mental Health, University of Zimbabwe, Harare, Zimbabwe
| | - Denford Gudyanga
- Department of Primary Health Care Sciences, Unit of Mental Health, University of Zimbabwe, Harare, Zimbabwe
| | - Barbara M Barrett
- Health Service and Population Research Department, Institute Of Psychiatry, Psychology and Neuroscience, King's College London, London, UK
| | - Dixon Chibanda
- Department of Psychiatry, University of Zimbabwe, Harare, Zimbabwe
- Centre for Global Mental Health, London School of Hygiene and Tropical Medicine, London, UK
| | - James Hakim
- Medical School Clinical Research Centre, University of Zimbabwe, Harare, Zimbabwe
| | - Steven A Safren
- Department of Psychology, University of Miami, Coral Gables, Florida, USA
| | - Conall O'Cleirigh
- Department of Psychiatry, Massachusetts General Hospital, Boston, Massachusetts, USA
- The Fenway Institute, Fenway Health, Boston, Massachusetts, USA
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46
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Pickering AN, Zhao X, Sileanu FE, Lovelace EZ, Rose L, Schwartz AL, Oakes AH, Hale JA, Schleiden LJ, Gellad WF, Fine MJ, Thorpe CT, Radomski TR. Assessment of Care Cascades Following Low-Value Prostate-Specific Antigen Testing Among Veterans Dually Enrolled in the US Veterans Health Administration and Medicare Systems. JAMA Netw Open 2022; 5:e2247180. [PMID: 36520431 PMCID: PMC9856440 DOI: 10.1001/jamanetworkopen.2022.47180] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/18/2022] [Accepted: 10/31/2022] [Indexed: 12/23/2022] Open
Abstract
Importance Older US veterans commonly receive health care outside of the US Veterans Health Administration (VHA) through Medicare, which may increase receipt of low-value care and subsequent care cascades. Objective To characterize the frequency, cost, and source of low-value prostate-specific antigen (PSA) testing and subsequent care cascades among veterans dually enrolled in the VHA and Medicare and to determine whether receiving a PSA test through the VHA vs Medicare is associated with more downstream services. Design, Setting, and Participants This retrospective cohort study used VHA and Medicare administrative data from fiscal years (FYs) 2017 to 2018. The study cohort consisted of male US veterans dually enrolled in the VHA and Medicare who were aged 75 years or older without a history of prostate cancer, elevated PSA, prostatectomy, radiation therapy, androgen deprivation therapy, or a urology visit. Data were analyzed from December 15, 2020, to October 20, 2022. Exposures Receipt of low-value PSA testing. Main Outcomes and Measures Differences in the use and cost of cascade services occurring 6 months after receipt of a low-value PSA test were assessed for veterans who underwent low-value PSA testing in the VHA and Medicare compared with those who did not, adjusted for patient- and facility-level covariates. Results This study included 300 393 male US veterans at risk of undergoing low-value PSA testing. They had a mean (SD) age of 82.6 (5.6) years, and the majority (264 411 [88.0%]) were non-Hispanic White. Of these veterans, 36 459 (12.1%) received a low-value PSA test through the VHA, which was associated with 31.2 (95% CI, 29.2 to 33.2) additional cascade services per 100 veterans and an additional $24.5 (95% CI, $20.8 to $28.1) per veteran compared with the control group. In the same cohort, 17 981 veterans (5.9%) received a PSA test through Medicare, which was associated with 39.3 (95% CI, 37.2 to 41.3) additional cascade services per 100 veterans and an additional $35.9 (95% CI, $31.7 to $40.1) per veteran compared with the control group. When compared directly, veterans who received a PSA test through Medicare experienced 9.9 (95% CI, 9.7 to 10.1) additional cascade services per 100 veterans compared with those who underwent testing within the VHA. Conclusions and Relevance The findings of this cohort study suggest that US veterans dually enrolled in the VHA and Medicare commonly experienced low-value PSA testing and subsequent care cascades through both systems in FYs 2017 and 2018. Care cascades occurred more frequently through Medicare compared with the VHA. These findings suggest that low-value PSA testing has substantial downstream implications for patients and may be especially challenging to measure when care occurs in multiple health care systems.
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Affiliation(s)
- Aimee N. Pickering
- Center for Health Equity Research and Promotion, Veterans Affairs Pittsburgh Healthcare System, Pittsburgh, Pennsylvania
- Division of General Internal Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Xinhua Zhao
- Center for Health Equity Research and Promotion, Veterans Affairs Pittsburgh Healthcare System, Pittsburgh, Pennsylvania
| | - Florentina E. Sileanu
- Center for Health Equity Research and Promotion, Veterans Affairs Pittsburgh Healthcare System, Pittsburgh, Pennsylvania
| | - Elijah Z. Lovelace
- Center for Health Equity Research and Promotion, Veterans Affairs Pittsburgh Healthcare System, Pittsburgh, Pennsylvania
| | - Liam Rose
- Health Economics Resource Center, Veterans Affairs Palo Alto Healthcare System, Palo Alto, California
| | - Aaron L. Schwartz
- Center for Health Equity Research and Promotion, Crescenz Veterans Affairs Medical Center, Philadelphia, Pennsylvania
- Division of General Internal Medicine, Department of Medical Ethics Health Policy, University of Pennsylvania, Philadelphia
| | - Allison H. Oakes
- Center for Health Equity Research and Promotion, Veterans Affairs Pittsburgh Healthcare System, Pittsburgh, Pennsylvania
- Trilliant Health, Birmingham, Alabama
| | - Jennifer A. Hale
- Center for Health Equity Research and Promotion, Veterans Affairs Pittsburgh Healthcare System, Pittsburgh, Pennsylvania
| | - Loren J. Schleiden
- Center for Health Equity Research and Promotion, Veterans Affairs Pittsburgh Healthcare System, Pittsburgh, Pennsylvania
| | - Walid F. Gellad
- Center for Health Equity Research and Promotion, Veterans Affairs Pittsburgh Healthcare System, Pittsburgh, Pennsylvania
- Division of General Internal Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Michael J. Fine
- Center for Health Equity Research and Promotion, Veterans Affairs Pittsburgh Healthcare System, Pittsburgh, Pennsylvania
- Division of General Internal Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Carolyn T. Thorpe
- Center for Health Equity Research and Promotion, Veterans Affairs Pittsburgh Healthcare System, Pittsburgh, Pennsylvania
- Division of Pharmaceutical Outcomes and Policy, Eshelman School of Pharmacy, University of North Carolina, Chapel Hill
| | - Thomas R. Radomski
- Center for Health Equity Research and Promotion, Veterans Affairs Pittsburgh Healthcare System, Pittsburgh, Pennsylvania
- Division of General Internal Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
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47
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Dinh NTT, de Graaff B, Campbell JA, Jose MD, John B, Saunder T, Kitsos A, Wiggins N, Palmer AJ. Costs of major complications in people with and without diabetes in Tasmania, Australia. AUST HEALTH REV 2022; 46:667-678. [PMID: 36375176 DOI: 10.1071/ah22180] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2022] [Accepted: 10/21/2022] [Indexed: 11/16/2022]
Abstract
Objective We set out to estimate healthcare costs of diabetes complications in the year of first occurrence and the second year, and to quantify the incremental costs of diabetes versus non-diabetes related to each complication. Methods In this cohort study, people with diabetes (n = 45 378) and their age/sex propensity score matched controls (n = 90 756) were identified from a linked dataset in Tasmania, Australia between 2004 and 2017. Direct costs (including hospital, emergency room visits and pathology costs) were calculated from the healthcare system perspective and expressed in 2020 Australian dollars. The average-per-patient costs and the incremental costs in people with diabetes were calculated for each complication. Results First-year costs when the complications occurred were: dialysis $78 152 (95% CI 71 095, 85 858), lower extremity amputations $63 575 (58 290, 68 688), kidney transplant $48 487 (33 862, 68 283), non-fatal myocardial infarction $30 827 (29 558, 32 197), foot ulcer/gangrene $29 803 (27 183, 32 675), ischaemic heart disease $29 160 (26 962, 31 457), non-fatal stroke $27 782 (26 285, 29 354), heart failure $27 379 (25 968, 28 966), kidney failure $24 904 (19 799, 32 557), angina pectoris $18 430 (17 147, 19 791), neuropathy $15 637 (14 265, 17 108), nephropathy $15 133 (12 285, 18 595), retinopathy $14 775 (11 798, 19 199), transient ischaemic attack $13 905 (12 529, 15 536), vitreous hemorrhage $13 405 (10 241, 17 321), and blindness/low vision $12 941 (8164, 19 080). The second-year costs ranged from 16% (ischaemic heart disease) to 74% (dialysis) of first-year costs. Complication costs were 109-275% higher than in people without diabetes. Conclusions Diabetes complications are costly, and the costs are higher in people with diabetes than without diabetes. Our results can be used to populate diabetes simulation models and will support policy analyses to reduce the burden of diabetes.
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Affiliation(s)
- Ngan T T Dinh
- Health Economics Research Group, Menzies Institute for Medical Research, University of Tasmania, Tas., Australia; and Thai Nguyen University of Medicine and Pharmacy, Thai Nguyen University, Thai Nguyen, Vietnam
| | - Barbara de Graaff
- Health Economics Research Group, Menzies Institute for Medical Research, University of Tasmania, Tas., Australia
| | - Julie A Campbell
- Health Economics Research Group, Menzies Institute for Medical Research, University of Tasmania, Tas., Australia
| | - Matthew D Jose
- School of Medicine, University of Tasmania, Tas., Australia; and Australia and New Zealand Dialysis and Transplant Registry (ANZDATA), SA, Australia
| | - Burgess John
- School of Medicine, University of Tasmania, Tas., Australia; and Department of Endocrinology, Royal Hobart Hospital, Tas., Australia
| | | | - Alex Kitsos
- School of Medicine, University of Tasmania, Tas., Australia
| | - Nadine Wiggins
- Tasmanian Data Linkage Unit, Menzies Institute for Medical Research, University of Tasmania, Tas., Australia
| | - Andrew J Palmer
- Health Economics Research Group, Menzies Institute for Medical Research, University of Tasmania, Tas., Australia
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Nagendra D, Gutman SM, Koelper NC, Loza-Avalos SE, Sonalkar S, Schreiber CA, Harvie HS. Medical management of early pregnancy loss is cost-effective compared with office uterine aspiration. Am J Obstet Gynecol 2022; 227:737.e1-737.e11. [PMID: 35780811 PMCID: PMC10302401 DOI: 10.1016/j.ajog.2022.06.054] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2022] [Revised: 06/17/2022] [Accepted: 06/26/2022] [Indexed: 11/18/2022]
Abstract
BACKGROUND Early pregnancy loss, also referred to as miscarriage, is common, affecting approximately 1 million people in the United States annually. Early pregnancy loss can be treated with expectant management, medications, or surgical procedures-strategies that differ in patient experience, effectiveness, and cost. One of the medications used for early pregnancy loss treatment, mifepristone, is uniquely regulated by the Food and Drug Administration. OBJECTIVE This study aimed to compare the cost-effectiveness from the healthcare sector perspective of medical management of early pregnancy loss, using the standard of care medication regimen of mifepristone and misoprostol, with that of office uterine aspiration. STUDY DESIGN We developed a decision analytical model to compare the cost-effectiveness of early pregnancy loss treatment with medical management with that of office uterine aspiration. Data on medical management came from the Pregnancy Failure Regimens randomized clinical trial, and data on uterine aspiration came from the published literature. The analysis was from the healthcare sector perspective with a 30-day time horizon. Costs were in 2018 US dollars. Effectiveness was measured in quality-adjust life-years gained and the rate of complete gestational sac expulsion with no additional interventions. Our primary outcome was the incremental cost per quality-adjust life-year gained. Sensitivity analysis was performed to identify the key uncertainties. RESULTS Mean per-person costs were higher for uterine aspiration than for medical management ($828 [95% confidence interval, $789-$868] vs $661 [95% confidence interval, $556-$766]; P=.004). Uterine aspiration more frequently led to complete gestational sac expulsion than medical management (97.3% vs 83.8%; P=.0001); however, estimated quality-adjust life-years were higher for medical management than for uterine aspiration (0.082 [95% confidence interval, 0.8148-0.08248] vs 0.079 [95% confidence interval, 0.0789-0.0791]; P<.0001). Medical management dominated uterine aspiration, with lower costs and higher confidence interval. The probability that medical management is cost-effective relative to uterine aspiration is 97.5% for all willingness-to-pay values of ≥$5600/quality-adjust life-year. Sensitivity analysis did not identify any thresholds that would substantially change outcomes. CONCLUSION Although office-based uterine aspiration more often results in treatment completion without further intervention, medical management with mifepristone pretreatment costs less and yields similar quality-adjust life-years, making it an attractive alternative. Our findings provided evidence that increasing access to mifepristone and eliminating unnecessary restrictions will improve early pregnancy care.
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Affiliation(s)
- Divyah Nagendra
- Department of Obstetrics and Gynecology, Cambridge Health Alliance, Cambridge, MA; Department of Obstetrics and Gynecology, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA
| | - Sarah M Gutman
- Department of Obstetrics and Gynecology, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA.
| | - Nathanael C Koelper
- Department of Obstetrics and Gynecology, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA
| | - Sandra E Loza-Avalos
- Department of Obstetrics and Gynecology, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA
| | - Sarita Sonalkar
- Department of Obstetrics and Gynecology, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA; Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, PA
| | - Courtney A Schreiber
- Department of Obstetrics and Gynecology, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA; Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, PA
| | - Heidi S Harvie
- Department of Obstetrics and Gynecology, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA; Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, PA
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49
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Bouchillon BC, Stewart PA. Computer games, trust, and immediacy: Role-playing as immigrants in the South. COMPUTERS IN HUMAN BEHAVIOR 2022. [DOI: 10.1016/j.chb.2022.107571] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
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50
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Haal S, Guman MSS, de Brauw LM, Schouten R, van Veen RN, Fockens P, Gerdes VEA, Voermans RP, Dijkgraaf MGW. Cost-effectiveness of ursodeoxycholic acid in preventing new-onset symptomatic gallstone disease after Roux-en-Y gastric bypass surgery. Br J Surg 2022; 109:1116-1123. [PMID: 35979609 PMCID: PMC10364680 DOI: 10.1093/bjs/znac273] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2022] [Revised: 07/13/2022] [Accepted: 07/15/2022] [Indexed: 08/02/2023]
Abstract
BACKGROUND The aim was to evaluate the cost-effectiveness and cost-utility of ursodeoxycholic acid (UDCA) prophylaxis for the prevention of symptomatic gallstone disease after Roux-en-Y gastric bypass (RYGB) in patients without gallstones before surgery. METHODS Data from a multicentre, double-blind, randomized placebo-controlled superiority trial were used. Patients scheduled for laparoscopic RYGB or sleeve gastrectomy were randomized to receive 900 mg UDCA or placebo for 6 months. Indicated by the clinical report, prophylactic prescription of UDCA was evaluated economically against placebo from a healthcare and societal perspective for the subgroup of patients without gallstones before surgery who underwent RYGB. Volumes and costs of in-hospital care, out-of-hospital care, out-of-pocket expenses, and productivity loss were assessed. Main outcomes were the costs per patient free from symptomatic gallstone disease and the costs per quality-adjusted life-year (QALY). RESULTS Patients receiving UDCA prophylaxis were more likely to remain free from symptomatic gallstone disease (relative risk 1.06, 95 per cent c.i. 1.02 to 1.11; P = 0.002) compared with patients in the placebo group. The gain in QALYs, corrected for a baseline difference in health utility, was 0.047 (95 per cent bias-corrected and accelerated (Bca) c.i. 0.007 to 0.088) higher (P = 0.022). Differences in costs were -€356 (95 per cent Bca c.i. €-1573 to 761) from a healthcare perspective and -€1392 (-3807 to 917) from a societal perspective including out-of-pocket expenses and productivity loss, both statistically non-significant, in favour of UDCA prophylaxis. The probability of UDCA prophylaxis being cost-effective was at least 0.872. CONCLUSION UDCA prophylaxis after RYGB in patients without gallstones before surgery was cost-effective.
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Affiliation(s)
- Sylke Haal
- Correspondence to: Sylke Haal, Department of Gastroenterology and Hepatology, Amsterdam UMC, University of Amsterdam, PO Box 22660, 1100 DD Amsterdam, the Netherlands (e-mail: )
| | - Maimoena S S Guman
- Department of Internal Medicine, Spaarne Gasthuis, Hoofddorp, the Netherlands
- Department of Internal and Vascular Medicine, Amsterdam UMC, University of Amsterdam, Amsterdam Gastroenterology Endocrinology Metabolism, Amsterdam, the Netherlands
| | | | - Ruben Schouten
- Department of Surgery, Flevohospital, Almere, the Netherlands
| | | | - Paul Fockens
- Department of Gastroenterology and Hepatology, Amsterdam UMC, University of Amsterdam, Amsterdam Gastroenterology Endocrinology Metabolism, Amsterdam, the Netherlands
| | - Victor E A Gerdes
- Department of Internal Medicine, Spaarne Gasthuis, Hoofddorp, the Netherlands
- Department of Internal and Vascular Medicine, Amsterdam UMC, University of Amsterdam, Amsterdam Gastroenterology Endocrinology Metabolism, Amsterdam, the Netherlands
| | - Rogier P Voermans
- Department of Gastroenterology and Hepatology, Amsterdam UMC, University of Amsterdam, Amsterdam Gastroenterology Endocrinology Metabolism, Amsterdam, the Netherlands
| | - Marcel G W Dijkgraaf
- Department of Epidemiology and Data Science, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
- Amsterdam Public Health, Methodology, Amsterdam, the Netherlands
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