Improving the cost-effectiveness of a healthcare system for depressive disorders by implementing telemedicine: a health economic modeling study

Alleviating the burden of depression: a simulation study on the impact of mental health services

AIMS

Depressive disorders are ranked as the single leading cause of disability worldwide. Despite immense efforts, there is no evidence of a global reduction in the disease burden in recent decades. The aim of the study was to determine the public health impact of the current service system (status quo), to quantify its effects on the depression-related disease burden and to identify the most promising strategies for improving healthcare for depression on the population level.

METHODS

A Markov model was developed to quantify the impact of current services for depression (including prevention, treatment and aftercare interventions) on the total disease burden and to investigate the potential of alternative scenarios (e.g., improved reach or improved treatment effectiveness). Parameter settings were derived from epidemiological information and treatment data from the literature. Based on the model parameters, 10,000,000 individual lives were simulated for each of the models, based on monthly transition rates between dichotomous health states (healthy vs. diseased). Outcome (depression-related disease burden) was operationalized as the proportion of months spent in depression.

RESULTS

The current healthcare system alleviates about 9.5% (95% confidence interval [CI]: 9.2%-9.7%) of the total disease burden related to depression. Chronic cases cause the majority (83.2%) of depression-related burden. From a public health perspective, improving the reach of services holds the largest potential: Maximum dissemination of prevention (26.9%; CI: 26.7%-27.1%) and treatment (26.5%; CI: 26.3%-26.7%) would result in significant improvements on the population level.

CONCLUSIONS

The results confirm an urgent need for action in healthcare for depression. Extending the reach of services is not only more promising but also probably more achievable than increasing their effectiveness. Currently, the system fails to address the prevention and treatment of chronic cases. The large proportion of the disease burden associated with chronic courses highlights the need for improved treatment policies and clinical strategies for this group (e.g., disease management and adaptive or personalized interventions). The model complements the existing literature by providing a new perspective on the depression-related disease burden and the complex interactions between healthcare services and the lifetime course.

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

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.

Towards Green and Sustainable Healthcare: A Literature Review and Research Agenda for Green Leadership in the Healthcare Sector

The health sector is one of the keys to sustainable development. Although it is directly related to only one Sustainable Development Goal (Goal 3, "Ensuring a healthy life and promoting well-being at all ages"), the sector itself, which aims to protect health, is paradoxically at the same time the main emitter of environmental pollutants that have a negative impact on health itself. Therefore, sustainability has become a key priority for health sector organizations, and leadership in this area is essential at all levels. Scientific research plays a particular role here, helping to more clearly define the links between environmental sustainability and the health effects of a polluted environment and climate change as well as indicating the direction of actions needed and disseminating good practices that can help accelerate the adoption of efforts towards climate neutrality and sustainable development of health sector organizations. The aim of this article is to present the current state of the art and future research scenarios in the field of green and sustainable healthcare through a literature review by using the Preferred Reporting Items for Systematic Reviews Meta-Analyses (PRISMA) method to perform a bibliometric analysis of papers published in 2012-2022. The Web of Science Core Collection (WoSCC) database is used for this purpose. A total of 144 papers are included for analysis, categorized based on eight fields: author(s), title, year of publication, country, journal, scientific category, and number of citations. Based on the results, themes for future research on green leadership in the healthcare sector are identified and recommended.

A Telehealth and Telepsychiatry Economic Cost Analysis Framework: Scoping Review

Introduction: Despite a good evidence base for telepsychiatry (TP), economic cost analyses are infrequent and vary in quality. Methods: A scoping review was conducted based on the research question, "From the perspective of an economic cost analysis for telehealth and telepsychiatry, what are the most meaningful ways to ensure a study/intervention improved clinical care, provided value to participants, had population level impact, and is sustainable?" The search in seven databases focused on keywords in four concept areas: (1) economic cost analysis, (2) evaluation, (3) telehealth and telepsychiatry, and (4) quantifiable health status outcomes. The authors reviewed the full-text articles based on the inclusion (Medical Subject Headings [MeSH] of the keywords) and exclusion criteria. Results: Of a total of 2,585 potential references, a total of 99 articles met the inclusion criteria. The evaluation of telehealth and TP has focused on access, quality, patient outcomes, feasibility, effectiveness, outcomes, and cost. Cost-effectiveness, cost-benefit, and other analytic models are more common with telehealth than TP studies, and these studies show favorable clinical, quality of life, and economic impact. A standard framework for economic cost analysis should include: an economist for planning, implementation, and evaluation; a tool kit or guideline; comprehensive analysis (e.g., cost-effectiveness or cost-benefit) with an incremental cost-effectiveness ratio; measures for health, quality of life, and utility outcomes for populations; methods to convert outcomes into economic benefits (e.g., monetary, quality of adjusted life year); broad perspective (e.g., societal perspective); sensitivity analysis for uncertainty in modeling; and adjustments for differential timing (e.g., discounting and future costs). Conclusions: Technology assessment and economic cost analysis-such as effectiveness and implementation science approaches-contribute to clinical, training, research, and other organizational missions. More research is needed with a framework that enables comparisons across studies and meta-analyses.

Modelling in economic evaluation of mental health prevention: current status and quality of studies

Background

The present study aimed to identify and critically appraise the quality of model-based economic evaluation studies in mental health prevention.

Methods

A systematic search was performed on MEDLINE, EMBASE, EconLit, PsycINFO, and Web of Science. Two reviewers independently screened for eligible records using predefined criteria and extracted data using a pre-piloted data extraction form. The 61-item Philips Checklist was used to critically appraise the studies. Systematic review registration number: CRD42020184519.

Results

Forty-nine studies were eligible to be included. Thirty studies (61.2%) were published in 2015–2021. Forty-seven studies were conducted for higher-income countries. There were mainly cost-utility analyses (n = 31) with the dominant primary outcome of quality-adjusted life year. The most common model was Markov (n = 26). Most of the studies were conducted from a societal or health care perspective (n = 37). Only ten models used a 50-year time horizon (n = 2) or lifetime horizon (n = 8). A wide range of mental health prevention strategies was evaluated with the dominance of selective/indicate strategy and focusing on common mental health problems (e.g., depression, suicide). The percentage of the Philip checkilst’s criteria fulfilled by included studies was 69.3% on average and ranged from 43.3 to 90%. Among three domains of the Philip checklist, criteria on the model structure were fulfilled the most (72.1% on average, ranging from 50.0% to 91.7%), followed by the data domain (69.5% on average, ranging from 28.9% to 94.0%) and the consistency domain (54.6% on average, ranging from 20.0% to 100%). The practice of identification of ‘relevant’ evidence to inform model structure and inputs was inadequately performed. The model validation practice was rarely reported.

Conclusions

There is an increasing number of model-based economic evaluations of mental health prevention available to decision-makers, but evidence has been limited to the higher-income countries and the short-term horizon. Despite a high level of heterogeneity in study scope and model structure among included studies, almost all mental health prevention interventions were either cost-saving or cost-effective. Future models should make efforts to conduct in the low-resource context setting, expand the time horizon, improve the evidence identification to inform model structure and inputs, and promote the practice of model validation.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12913-022-08206-9.

Telehealth Visits After Shoulder Surgery: Higher Patient Satisfaction and Lower Costs

Introduction:

Studies comparing the cost of in-person and virtual care are lacking. The goal of this study was threefold (1) to compare the cost of telemedicine visits with in-person clinic visits after common shoulder surgeries, (2) to measure the safety, and (3) to evaluate patient experience with telemedicine visits.

Methods:

The In-Person Visit cohort (N = 25) and the telemedicine cohort (Virtual Visit cohort, N = 24) were selected from patients undergoing routine follow-up of common shoulder procedures. Time-driven activity-based costing was used to determine costs associated with each episode of care. Patient complications, satisfaction, convenience, and technical difficulties associated with telehealth were recorded.

Results:

The average Virtual Visit was 54.1% less costly and 87.8% shorter than the In-Person Visit ($49 versus $107 per patient, 8.6 versus 70.1 minutes per patient, P < 0.01, respectively). One complication was missed in the Virtual Visit cohort, later captured by an in-person visit. All patients in the Virtual Visit cohort reported that the virtual visit was safe and convenient and showed high levels of satisfaction.

Discussion:

Virtual visits for postoperative care of patients undergoing shoulder surgery are associated with decreased costs and high ratings of convenience and satisfaction. Postoperative complications may be more challenging to diagnose virtually.

Telemedicine as a Tool to Improve Medicine Adherence in Patients with Affective Disorders - A Systematic Literature Review

Affective disorders are a common psychological impairment. A major problem with respect to treatment is medication non-adherence. eHealth interventions are already widely used in the treatment of patients living with affective disorders. The aim of this systematic literature review is to obtain the current scientific evidence to eHealth as a tool to improve medication adherence in patients with affective disorders. A systematic search was performed across PubMed, Cochrane Library, Web of Science and PsycInfo. Studies in English and German published between 2007 and 2020 were included. The review followed the PRISMA guidelines and were performed with the CADIMA online tool. A total of 17 articles were included in this review. Eleven studies were randomized controlled trials, two were controlled clinical trials, and four had a pre-/post-design. Three different types of interventions could be identified: internet-based self-management programs (n=4), multi-faceted interventions addressing different dimensions of medication adherence (n=4), and single-faceted interventions (n=9) comprising four mobile interventions and five telehealth interventions. Eleven interventions addressed patients with (comorbid) depressions and six addressed patients with bipolar disorders. Six interventions showed a statistically significant positive effect on medication adherence. None of the studies showed a statistically significant negative effect. All interventions which had a statistically significant positive effect on medication adherence involved personal contacts between therapists and patients. All included eHealth interventions are at least as effective as control conditions and seems to be effective for patients with depression as well as with bipolar disorders. Personal contacts seem to improve the effectiveness of eHealth interventions. eHealth interventions are an effective way to improve medication adherence in patients with affective disorders. In rural or underserved regions, eHealth can supplement usual care interventions on medication adherence by expanding access. More analyses are needed in order to understand determinants for the effectiveness of eHealth interventions on medication adherence enhancement.

Telemedicine for healthcare: Capabilities, features, barriers, and applications

Regular hospital visits can be expensive, particularly in rural areas, due to travel costs. In the era of the Covid-19 Pandemic, where physical interaction becomes risky, people prefer telemedicine. Fortunately, medical visits can be reduced when telemedicine services are used through video conferencing or other virtual technologies. Thus, telemedicine saves both the patient's and the health care provider time and the cost of the treatment. Furthermore, due to its fast and advantageous characteristics, it can streamline the workflow of hospitals and clinics. This disruptive technology would make it easier to monitor discharged patients and manage their recovery. As a result, it is sufficient to state that telemedicine can create a win-win situation. This paper aims to explore the significant capabilities, features with treatment workflow, and barriers to the adoption of telemedicine in Healthcare. The paper identifies seventeen significant applications of telemedicine in Healthcare. Telemedicine is described as a medical practitioner to diagnose and treat patients in a remote area. Using health apps for scheduled follow-up visits makes doctors and patients more effective and improves the probability of follow-up, reducing missing appointments and optimising patient outcomes. Patients should have an accurate medical history and show the doctor any prominent rashes, bruises, or other signs that need attention through the excellent quality audio-video system. Further, practitioners need file management and a payment gateway system. Telemedicine technologies allow patients and doctors both to review the treatment process. However, this technology supplements physical consultation and is in no way a substitute for a physical consultation. Today this technology is a safe choice for patients who cannot go to the doctor or sit at home, especially during a pandemic.

Health-economic evaluation of psychological interventions for depression prevention: Systematic review

Psychological interventions have been proven to be effective to prevent depression, however, little is known on the cost-effectiveness of psychological interventions for the prevention of depression in various populations. A systematic review was conducted using PubMed, PsycINFO, Web of Science, Embase, Cochrane Central Register of Controlled Trials, Econlit, NHS Economic Evaluations Database, NHS Health Technology Assessment and OpenGrey up to January 2021. Only health-economic evaluations based on randomized controlled trials of psychological interventions to prevent depression were included. Independent evaluators selected studies, extracted data and assessed the quality using the Consensus on Health Economic Criteria and the Cochrane Risk of Bias Tool. Twelve trial-based economic evaluations including 5929 participants from six different countries met the inclusion criteria. Overall, the quality of most economic evaluations was considered good, but some studies have some risk of bias. Setting the willingness-to-pay upper limit to US$40,000 (2018 prices) for gaining one quality adjusted life year (QALY), eight psychological preventive interventions were likely to be cost-effective compared to care as usual. The likelihood of preventive psychological interventions being more cost-effective than care as usual looks promising, but more economic evaluations are needed to bridge the many gaps that remain in the evidence-base. ETHICS: As this systematic review is based on published data, approval from the local ethics committee was not required.

Contextual assessment: evaluating a novel self-guided online therapeutic assessment

BACKGROUND

Paper introduces Conflict Analysis (CA), an online self-guided therapeutic assessment. CA combines a diagnostic self-report scale with narrative exercises and self-analytical tasks. CA automatically generates detailed diagnostic records and frameworks for changes.

OBJECTIVE

To evaluate therapeutic and diagnostic benefits associated with CA over time.

METHODS

This online study compared CA over 2 weeks on outcome measures predicting psychotherapy outcome. Novel scale measuring perceived diagnostic benefit and perceived therapeutic benefit was delivered at post and follow-up. Cohort (n = 59, average age = 35, 50% female) was either in therapy or interested to start therapy in near future.

RESULTS

Repeated-measure ANOVAs suggest that scores significantly changed on measures predicting negative affect, depression, performance and appearance self-esteem, insight, and growth initiative. Agreement rates on items measuring perceived diagnostic and therapeutic benefits were at least 74.5% for both post and follow-up.

CONCLUSIONS

Evidence supports further exploration of CA as a self-guided diagnostic and therapeutic resource.Key pointsResults demonstrate feasibility and utility of online self-guided therapeutic assessment.Described model is associated with increased perceived diagnostic and therapeutic benefits.Described model illustrates therapeutic benefits over time.Results demonstrate that even self-guided assessment can have therapeutic implications.

Cost-effectiveness evidence of mental health prevention and promotion interventions: A systematic review of economic evaluations

BACKGROUND

The prevention of mental disorders and promotion of mental health and well-being are growing fields. Whether mental health promotion and prevention interventions provide value for money in children, adolescents, adults, and older adults is unclear. The aim of the current study is to update 2 existing reviews of cost-effectiveness studies in this field in order to determine whether such interventions are cost-effective.

METHODS AND FINDINGS

Electronic databases (including MEDLINE, PsycINFO, CINAHL, and EconLit through EBSCO and Embase) were searched for published cost-effectiveness studies of prevention of mental disorders and promotion of mental health and well-being from 2008 to 2020. The quality of studies was assessed using the Quality of Health Economic Studies Instrument (QHES). The protocol was registered with PROSPERO (# CRD42019127778). The primary outcomes were incremental cost-effectiveness ratio (ICER) or return on investment (ROI) ratio across all studies. A total of 65 studies met the inclusion criteria of a full economic evaluation, of which, 23 targeted children and adolescents, 35 targeted adults, while the remaining targeted older adults. A large number of studies focused on prevention of depression and/or anxiety disorders, followed by promotion of mental health and well-being and other mental disorders. Although there was high heterogeneity in terms of the design among included economic evaluations, most studies consistently found that interventions for mental health prevention and promotion were cost-effective or cost saving. The review found that targeted prevention was likely to be cost-effective compared to universal prevention. Screening plus psychological interventions (e.g., cognitive behavioural therapy [CBT]) at school were the most cost-effective interventions for prevention of mental disorders in children and adolescents, while parenting interventions and workplace interventions had good evidence in mental health promotion. There is inconclusive evidence for preventive interventions for mental disorders or mental health promotion in older adults. While studies were of general high quality, there was limited evidence available from low- and middle-income countries. The review was limited to studies where mental health was the primary outcome and may have missed general health promoting strategies that could also prevent mental disorder or promote mental health. Some ROI studies might not be included given that these studies are commonly published in grey literature rather than in the academic literature.

CONCLUSIONS

Our review found a significant growth of economic evaluations in prevention of mental disorders or promotion of mental health and well-being over the last 10 years. Although several interventions for mental health prevention and promotion provide good value for money, the varied quality as well as methodologies used in economic evaluations limit the generalisability of conclusions about cost-effectiveness. However, the finding that the majority of studies especially in children, adolescents, and adults demonstrated good value for money is promising. Research on cost-effectiveness in low-middle income settings is required.

TRIAL REGISTRATION

PROSPERO registration number: CRD42019127778.

Scaling Up Maternal Mental healthcare by Increasing access to Treatment (SUMMIT) through non-specialist providers and telemedicine: a study protocol for a non-inferiority randomized controlled trial

BACKGROUND

Depression and anxiety impact up to 1 in 5 pregnant and postpartum women worldwide. Yet, as few as 20% of these women are treated with frontline interventions such as evidence-based psychological treatments. Major barriers to uptake are the limited number of specialized mental health treatment providers in most settings, and problems with accessing in-person care, such as childcare or transportation. Task sharing of treatment to non-specialist providers with delivery on telemedicine platforms could address such barriers. However, the equivalence of these strategies to specialist and in-person models remains unproven.

METHODS

This study protocol outlines the Scaling Up Maternal Mental healthcare by Increasing access to Treatment (SUMMIT) randomized trial. SUMMIT is a pragmatic, non-inferiority test of the comparable effectiveness of two types of providers (specialist vs. non-specialist) and delivery modes (telemedicine vs. in-person) of a brief, behavioral activation (BA) treatment for perinatal depressive and anxiety symptoms. Specialists (psychologists, psychiatrists, and social workers with ≥ 5 years of therapy experience) and non-specialists (nurses and midwives with no formal training in mental health care) were trained in the BA protocol, with the latter supervised by a BA expert during treatment delivery. Consenting pregnant and postpartum women with Edinburgh Postnatal Depression Scale (EPDS) score of ≥ 10 (N = 1368) will be randomized to one of four arms (telemedicine specialist, telemedicine non-specialist, in-person specialist, in-person non-specialist), stratified by pregnancy status (antenatal/postnatal) and study site. The primary outcome is participant-reported depressive symptoms (EPDS) at 3 months post-randomization. Secondary outcomes are maternal symptoms of anxiety and trauma symptoms, perceived social support, activation levels and quality of life at 3-, 6-, and 12-month post-randomization, and depressive symptoms at 6- and 12-month post-randomization. Primary analyses are per-protocol and intent-to-treat. The study has successfully continued despite the COVID-19 pandemic, with needed adaptations, including temporary suspension of the in-person arms and ongoing randomization to telemedicine arms.

DISCUSSION

The SUMMIT trial is expected to generate evidence on the non-inferiority of BA delivered by a non-specialist provider compared to specialist and telemedicine compared to in-person. If confirmed, results could pave the way to a dramatic increase in access to treatment for perinatal depression and anxiety.

TRIAL REGISTRATION

ClinicalTrials.gov NCT04153864 . Registered on November 6, 2019.

PTSD Coach Online-Arabic: A Randomized Controlled Pilot Trial to Examine Feasibility, Acceptability, and Preliminary Effectiveness

The Egyptian Revolution of 2011 resulted in high-level exposure to sociopolitical violence, placing a large burden on the mental health care system that cannot be effectively met given the small number of available providers in Egypt. We conducted a nonblinded, randomized controlled pilot trial of an online, self-directed tool for managing posttraumatic stress symptoms (PTSS). The study aimed to evaluate the feasibility, acceptability, and preliminary effectiveness of the PTSD Coach Online-Arabic. Trauma-exposed Egyptian adults with clinically significant PTSS (N = 87; intervention group: n = 41) completed assessments at baseline, weekly over the treatment period, posttest, and 3-month follow-up. Of participants who completed weekly surveys, 88.9% used the program; 22.0% of participants reported regular, weekly use. Most tools received good likeability and perceived benefit scores, but lower perceived benefit scores on three tools suggest that some content may require additional adaptation. Intent-to-treat analyses using multilevel modeling with multiple imputation to account for missing data were conducted. Effect sizes for PTSS were below the cutoff for small effects at posttest, d = -0.14, but demonstrated a small positive effect at 3-months, d = -0.25. There was a small positive effect of treatment on anxiety at posttest, d = -0.37, and a medium effect at 3-month follow-up, d = -0.49. Treatment effects for depressed mood were below the cutoff for small effects at posttest and 3-months, ds = -0.14 and -0.18. These findings suggest that the PTSD Coach Online-Arabic may be a promising supplemental resource for support in this setting.

New Concepts and Technological Resources in Patient Education and Asthma Self-Management

Asthma is a chronic disease that is associated with significant morbidity and mortality. In general, the use of technology resources or electronic health (e-health) has been shown to have beneficial effects on patients with asthma. E-health can impact a broad section of patients and can be cost-effective and associated with high patient satisfaction. E-health may enable remote delivery of care, as well as timely access to health care, which are some of the common challenges faced by patients with asthma. Web-based asthma self-management systems have been found to improve quality of life, self-reported asthma symptoms, lung function, reduction in asthma symptoms/exacerbations, and self-reported adherence for adults. Social media is commonly being used as a platform to disseminate information on asthma to increase public awareness. It can facilitate asthma self-management in a patient friendly manner and has shown to improve asthma control test scores as well as self-esteem. Text massages reminders can increase awareness regarding asthma treatment and control, thus potentially can improve adherence to medications and asthma outcome. Mobile health applications can support asthma self-management, improve a patient's quality of life, promote medication adherence, and potentially reduce the overall costs for asthma care. Inhaler trackers have shown to be beneficial to asthma outcome in various populations by improving adherence to asthma medications. Barriers such as physician financial reimbursement as well as licensing for rendering tele-healthcare services are important concerns. Other limitations of using technology resources in health care are related to liability, professionalism, and ethical issues such as breach of patient confidentiality and privacy. Additionally, there may be less face-to-face interaction and care of the patient when e-health is used.

Design of a health-economic Markov model to assess cost-effectiveness and budget impact of the prevention and treatment of depressive disorder

Background/objective: To describe the design of 'DepMod,' a health-economic Markov model for assessing cost-effectiveness and budget impact of user-defined preventive interventions and treatments in depressive disorders.Methods: DepMod has an epidemiological layer describing how a cohort of people can transition between health states (sub-threshold depression, first episode of mild, moderate or severe depression (partial) remission, recurrence, death). Superimposed on the epidemiological layer, DepMod has an intervention layer consisting of a reference scenario and alternative scenario comparing the effectiveness and cost-effectiveness of a user-defined package of preventive interventions and psychological and pharmacological treatments of depression. Results are presented in terms of quality-adjusted life years (QALYs) gained and healthcare expenditure. Costs and effects can be modeled over 5 years and are subjected to probabilistic sensitivity analysis.Results: DepMod was used to assess the cost-effectiveness of scaling up preventive interventions for treating people with subclinical depression, which showed that there is an 82% probability that scaling up prevention is cost-effective given a willingness-to-pay threshold of €20,000 per QALY.Conclusion: DepMod is a Markov model that assesses the cost-utility and budget impact of different healthcare packages aimed at preventing and treating depression and is freely available for academic purposes upon request at the authors.

The impact of telemental health use on healthcare costs among commercially insured adults with mental health conditions

OBJECTIVE

To determine the impact of telemental health (TMH) use on total healthcare costs and mental health (MH)-related costs paid by a third party among adults with mental health conditions (MHC).

METHOD

This study employed a pre-post design with a non-equivalent control group. The cohort comprised adults with MHCs identified using diagnosis codes from de-identified claims data of the Optum Clinformatics DataMart (2010 January 01 to 2017 June 30). We identified mental health (MH) service users and TMH users (N = 348) based on procedure codes. Non-users (N = 238,595) were defined as those who only used in-person MH services. A Difference-in-Differences (DID) analysis was performed within a multivariable two-part model (TPM) framework to examine the impact of TMH use on adjusted standardized costs (2018 US $) of all healthcare services and MH services. Patient-level and state-level factors were adjusted in TPM.

RESULTS

TMH use was associated with significantly higher MH-related costs [Marginal effect = $461.3, 95% confidence interval: $142.4-$780.2] and an excess of $370 increase in MH-related costs at follow-up as compared to baseline. However, TMH use was not associated with an increase in total third-party healthcare costs nor with changes in total costs from baseline to follow-up.

CONCLUSIONS

Despite having a higher likelihood of MH services use and MH-related costs, TMH users did not have higher total costs as compared to adults using only in-person MH services. Our findings suggest that TMH can increase access to MH care without increasing total healthcare costs among adults with MHC. Future studies exploring whether TMH use can lead to cost-savings over a longer period are warranted.

Sleeve Gastrectomy Compared with Gastric Bypass for Morbidly Obese Patients with End Stage Renal Disease: a Decision Analysis

INTRODUCTION

The use of bariatric surgery has increased for morbidly obese patients with end stage renal disease (ESRD) for whom listing on the waitlist is often restricted until a certain BMI threshold is achieved. Effective weight loss for this population improves access to life-saving renal transplantation. However, it is unclear whether sleeve gastrectomy (SG) vs Roux-en-Y gastric bypass (RYGB) is a more effective therapy for these patients.

METHODS

A decision analytic Markov state transition model was created to simulate the life of morbidly obese patients with ESRD who were deemed ineligible to be waitlisted for renal transplantation unless they achieved a BMI less than 35 kg/m². Life expectancy following weight management (MWM), RYGB, and SG were estimated. Base case patients were defined as having a pre-intervention BMI of 45 kg/m². Sensitivity analysis of initial BMI was performed. Markov parameters were extracted from literature review.

RESULTS

RYGB improved survival compared with SG and MWM. RYGB patients had higher rates of transplantation, leading to improved mean long-term survival. Base case patients who underwent RYGB gained 1.3 additional years of life compared with patient's who underwent SG and 2.6 additional years of life compared with MWM.

CONCLUSIONS

RYGB improves access to renal transplantation and thereby increases long-term survival compared with SG and MWM. The use of SG may be incongruent with the goal of improving access to renal transplantation for morbidly obese patients.

[The Importance of Social Exchange for Internet-based Eating Disorder Prevention]

The Importance of Social Exchange for Internet-based Eating Disorder Prevention Internet-based interventions have the potential to complement routine care mental health services. Yet, dissemination and implementation into routine care is challenging and often fails. From a public health point of view, facilitating access to care and dissemination of prevention have great potential to reduce eating disorder related suffering in the general population. In order to exploit that potential effective strategies to involve users in internet-based prevention are of utmost importance. User-behaviors of N = 980 predominantly female (80 %) participants with an average age of 19.4 years (SD = 7.0) of an internet-based intervention for the prevention of eating disorders (ProYouth) were analyzed. Specifically, differences in users' pathways between early and late phases of participation were compared in order to identify patterns of program utilization that are associated with elevated adherence. During their first login, users explore all modules of the platform. Enduring participation is characterized by increased usage of the modules that offer social exchange with other participants, i. e. the forums and the chat. Static modules, e. g., psychoeducation, are rarely accessed after the first login. Additionally, enduring users were more often female, older, and displayed higher levels of psychological impairment (ps < .001). The results support the relevance of social exchange for the adherence in internet-based interventions for the prevention of eating disorders.

A systematic review of electronic mental health interventions for Indigenous youth: Results and recommendations

Electronic health interventions involve health services delivered using the Internet and related communication technologies. These services can be particularly relevant for Indigenous populations who often have differential access to health-care services compared to general populations, especially within rural and remote areas. As the popularity of electronic health interventions grows, there is an increased need for evidence-based recommendations for the effective use of these technologies. The current study is a systematic review of peer-reviewed and available grey literature with the aim of understanding outcomes of electronic health interventions for mental health concerns among Indigenous people. Studies used electronic health technologies for substance use treatment or prevention, suicide prevention, parenting supports, goal setting and behaviour change and consultation services. Various technological platforms were used across interventions, with both novel and adapted intervention development. Most studies provided qualitative results, with fewer studies focusing on quantitative outcomes. Some preliminary results from the engagement of Indigenous individuals with electronic health services has been demonstrated, but further research is needed to confirm these results. Identified barriers and facilitators are identified from the reviewed literature. Recommendations for future development of electronic health interventions for Indigenous youth are provided.

Early use of telepsychotherapy in resident continuity clinics-our experience and a review of literature

Telepsychotherapy is an underutilized tool in training programs, and use of telepsychiatry often occurs in the later years of residency. This study evaluates the feasibility of early exposure to telepsychotherapy in residency continuity clinics and reviews the existing literature on the use of telemedicine in the training of psychiatrists. Feedback from the participating residents and patients was used to determine the benefit of such a training curriculum. The results of the feedback and evidence from the review of literature indicate that the early use of telepsychotherapy should be employed in psychiatric training.

A cost analysis comparing telepsychiatry to in-person psychiatric outreach and patient travel reimbursement in Northern Ontario communities

Introduction

Residents of Northern Ontario have limited access to local psychiatric care. To address this, three program models exist: (1) telepsychiatry; (2) psychiatrists traveling to underserved areas; and (3) reimbursing patients for travel to a psychiatrist. Evidence shows that telepsychiatry has comparable outcomes to in-person consultations. The objective of this study was to determine the cost difference between programs.

Methods

A cost-minimization analysis estimating cost per visit from a public healthcare payer economic costing perspective was conducted. Data on fixed and variable costs were obtained. Evidence-based assumptions were made where relevant. Base-case scenarios and a break-even analysis were completed, as well as deterministic and probabilistic sensitivity analyses, to explore the effects of parameter variability on program costs.

Results

Costs per visit were lowest in telepsychiatry (CAD$360) followed by traveling physicians (CAD$558) and patient reimbursement (CAD$620). Among the 100,000 Monte Carlo simulations, results showed telepsychiatry was the least costly program in 71.2% of the simulations, while the reimbursement and outreach programs were least costly in 15.1% and 13.7% of simulations, respectively. The break-even analysis found telepsychiatry was the least costly program after an annual patient visit threshold of approximately 76 visits (compared to traveling psychiatrists) and 126 visits (compared to reimbursed patients).

Discussion

Our analyses support telepsychiatry as the least costly program. These results have important implications for program planning, including the prioritization of telepsychiatry, increased integration of telepsychiatry with other modalities of outreach psychiatry, and limiting use of the patient remuneration program to where medically necessary, to reduce overall cost.

Cost-effectiveness, cost-utility and the budget impact of antidepressants versus preventive cognitive therapy with or without tapering of antidepressants

BACKGROUND

As depression has a recurrent course, relapse and recurrence prevention is essential.AimsIn our randomised controlled trial (registered with the Nederlands trial register, identifier: NTR1907), we found that adding preventive cognitive therapy (PCT) to maintenance antidepressants (PCT+AD) yielded substantial protective effects versus antidepressants only in individuals with recurrent depression. Antidepressants were not superior to PCT while tapering antidepressants (PCT/-AD). To inform decision-makers on treatment allocation, we present the corresponding cost-effectiveness, cost-utility and budget impact.

METHOD

Data were analysed (n = 289) using a societal perspective with 24-months of follow-up, with depression-free days and quality-adjusted life years (QALYs) as health outcomes. Incremental cost-effectiveness ratios were calculated and cost-effectiveness planes and cost-effectiveness acceptability curves were derived to provide information about cost-effectiveness. The budget impact was examined with a health economic simulation model.

RESULTS

Mean total costs over 24 months were €6814, €10 264 and €13 282 for AD+PCT, antidepressants only and PCT/-AD, respectively. Compared with antidepressants only, PCT+AD resulted in significant improvements in depression-free days but not QALYs. Health gains did not significantly favour antidepressants only versus PCT/-AD. High probabilities were found that PCT+AD versus antidepressants only and antidepressants only versus PCT/-AD were dominant with low willingness-to-pay thresholds. The budget impact analysis showed decreased societal costs for PCT+AD versus antidepressants only and for antidepressants only versus PCT/-AD.

CONCLUSIONS

Adding PCT to antidepressants is cost-effective over 24 months and PCT with guided tapering of antidepressants in long-term users might result in extra costs. Future studies examining costs and effects of antidepressants versus psychological interventions over a longer period may identify a break-even point where PCT/-AD will become cost-effective.Declaration of interestC.L.H.B. is co-editor of PLOS One and receives no honorarium for this role. She is also co-developer of the Dutch multidisciplinary clinical guideline for anxiety and depression, for which she receives no remuneration. She is a member of the scientific advisory board of the National Insure Institute, for which she receives an honorarium, although this role has no direct relation to this study. C.L.H.B. has presented keynote addresses at conferences, such as the European Psychiatry Association and the European Conference Association, for which she sometimes receives an honorarium. She has presented clinical training workshops, some including a fee. She receives royalties from her books and co-edited books and she developed preventive cognitive therapy on the basis of the cognitive model of A. T. Beck. W.A.N. has received grants from the Netherlands Organisation for Health Research and Development and the European Union and honoraria and speakers' fees from Lundbeck and Aristo Pharma, and has served as a consultant for Daleco Pharma.

The cost-utility of stepped-care algorithms according to depression guideline recommendations - Results of a state-transition model analysis

BACKGROUND

Evidence-based clinical guidelines for major depressive disorder (MDD) recommend stepped-care strategies for sequencing evidence-based treatments conditional on treatment outcomes. This study aims to evaluate the cost-effectiveness of stepped care as recommended by the multidisciplinary clinical guideline vis-à-vis usual care in the Netherlands.

METHODS

Guideline-congruent care as described in stepped-care algorithms for either mild MDD or moderate and severe MDD was compared with usual care in a health-economic state-transition simulation model. Incremental costs per QALY gained were estimated over five years from a healthcare perspective.

RESULTS

For mild MDD, the cost-utility analysis showed a 67% likelihood of better health outcomes against lower costs, and 33% likelihood of better outcomes against higher costs, implying dominance of guideline-congruent stepped care. For moderate and severe MDD, the cost-utility analysis indicated a 67% likelihood of health gains at higher costs following the stepped-care approach and 33% likelihood of health gains at lower costs, with a mean ICER of about €3,200 per QALY gained. At a willingness to pay threshold of €20,000 per QALY, the stepped-care algorithms for both mild MDD and moderate or severe MDD is deemed cost-effective compared to usual care with a greater than 95% probability.

LIMITATIONS

The findings of our decision-analytic modelling are limited by the accuracy and availability of the underlying evidence. This hampers taking into account all individual differences relevant to optimise treatment to individual needs.

CONCLUSIONS

It is highly likely that guideline-congruent stepped care for MDD is cost-effective compared to usual care. Our findings support current guideline recommendations.

An economic cost analysis of an expanding, multi-state behavioural telehealth intervention

Introduction

In this paper the economic costs associated with a growing, multi-state telepsychiatry intervention serving rural American Indian/Alaska Native populations were compared to costs of travelling to provide/receive in-person treatment.

Methods

Telepsychiatry costs were calculated using administrative, information-technology, equipment and technology components, and were compared to travel cost models. Both a patient travel and a psychiatrist travel model were estimated utilising ArcGIS software and unit costs gathered from literature and government sources. Cost structure and sensitivity analysis was also calculated by varying modeling parameters and assumptions.

Results and Discussion

It is estimated that per-session costs were $93.90, $183.34, and $268.23 for telemedicine, provider-travel, and patient-travel, respectively. Restricting the analysis to satellite locations with a larger number of visits reduced telemedicine per-patient encounter costs (50 or more visits: $83.52; 100 or more visits: $80.41; and 150 or more visits: $76.25). The estimated cost efficiencies of telemedicine were more evident for highly rural communities. Finally, we found that a multi-state centre was cheaper than each state operating independently.

Conclusions

Consistent with previous research, this study provides additional evidence of the economic efficiency associated with telemedicine interventions for rural American Indian/Alaska Native populations. Our results suggest that there are economies of scale in providing behavioural telemedicine and that bigger, multi-state telemedicine centres have lower overall costs compared to smaller, state-level centres. Additionally, results suggest that telemedicine structures with a higher number of per-satellite patient encounters have lower costs, and telemedicine centres delivering care to highly rural populations produce greater economic benefits.

Mobile and traditional cognitive behavioral therapy programs for generalized anxiety disorder: A cost-effectiveness analysis

Background

Generalized anxiety disorder (GAD) is a debilitating mental health illness that affects approximately 3.1% of U.S. adults and can be treated with cognitive behavioral therapy (CBT). With the emergence of digital health technologies, mobile CBT may be a cost-effective way to deliver care. We developed an analysis framework to quantify the cost-effectiveness of internet-based CBT for individuals with GAD. As a case study, we examined the potential value of a new mobile-delivered CBT program for GAD.

Methods

We developed a Markov model of GAD health states combined with a detailed economic analysis for a cohort of adults with GAD in the U.S. In our case study, we used pilot program efficacy data to evaluate a mobile CBT program as either prevention or treatment only and compared the strategies to traditional CBT and no CBT. Traditional CBT efficacy was estimated from clinical trial results. We calculated discounted incremental costs and quality-adjusted life-years (QALYs) over the cohort lifetime.

Case study results

In the base case, for a cohort of 100,000 persons with GAD, we found that mobile CBT is cost-saving. It leads to a gain of 34,108 QALYs and 81,492 QALYs and a cost reduction of $2.23 billion and $4.54 billion when compared to traditional CBT and no CBT respectively. Results were insensitive to most model inputs and mobile CBT remained cost-saving in almost all scenarios.

Limitations

The case study was conducted for illustrative purposes and used mobile CBT efficacy data from a small pilot program; the analysis should be re-conducted once robust efficacy data is available. The model was limited in its ability to measure the effectiveness of CBT in combination with pharmacotherapy.

Conclusions

Mobile CBT may lead to improved health outcomes at lower costs than traditional CBT or no intervention and may be effective as either prevention or treatment.

Prevention of Adolescent Depression in Primary Care: Barriers and Relational Work Solutions

BACKGROUND AND PURPOSE

Depression affects millions of adolescents in the United States each year. This population may benefit from targeted preventive interventions. We sought to understand the internal factors that affect the ability of healthcare organizations to implement an intervention that involves mental health screening and depression prevention treatment of at-risk adolescents in primary care settings.

METHODS

From November 2011 to July 2016 we conducted a study of the implementation of a multisite (N=30) phase 3 randomized clinical trial of an Internet-based depression prevention intervention program (CATCH-IT). We describe the prevalence of internal barriers on the screening and enrollment process by reporting REACH (the proportion of target audience exposed to the intervention).

RESULTS

A total of 369 adolescents were randomized into the intervention or control program. Mean REACH values for the study clinics were 0.216 for screening and 0.181 for enrollment to CATCH-IT. Mean REACH enrollment lost due to internal barriers was 0.233. This translated to 4,691 adolescents lost at screening and 2,443 adolescents lost at enrollment due to internal barriers.

CONCLUSION

We propose a model of the implementation process that emphasizes the importance of positive relational work that assists in overcoming internal barriers to REACH. We also provide implications for policy and practice.

Return on investment of public health interventions: a systematic review

BACKGROUND

Public sector austerity measures in many high-income countries mean that public health budgets are reducing year on year. To help inform the potential impact of these proposed disinvestments in public health, we set out to determine the return on investment (ROI) from a range of existing public health interventions.

METHODS

We conducted systematic searches on all relevant databases (including MEDLINE; EMBASE; CINAHL; AMED; PubMed, Cochrane and Scopus) to identify studies that calculated a ROI or cost-benefit ratio (CBR) for public health interventions in high-income countries.

RESULTS

We identified 2957 titles, and included 52 studies. The median ROI for public health interventions was 14.3 to 1, and median CBR was 8.3. The median ROI for all 29 local public health interventions was 4.1 to 1, and median CBR was 10.3. Even larger benefits were reported in 28 studies analysing nationwide public health interventions; the median ROI was 27.2, and median CBR was 17.5.

CONCLUSIONS

This systematic review suggests that local and national public health interventions are highly cost-saving. Cuts to public health budgets in high income countries therefore represent a false economy, and are likely to generate billions of pounds of additional costs to health services and the wider economy.

Complaint-Directed Mini-Interventions for Depressive Complaints: A Randomized Controlled Trial of Unguided Web-Based Self-Help Interventions

Background

Prevention of depression is important due to the substantial burden of disease associated with it. To this end, we developed a novel, brief, and low-threshold Web-based self-help approach for depressive complaints called complaint-directed mini-interventions (CDMIs). These CDMIs focus on highly prevalent complaints that are demonstrably associated with depression and have a substantial economic impact: stress, sleep problems, and worry.

Objective

The aim was to evaluate the effectiveness of the Web-based self-help CDMIs in a sample of adults with mild-to-moderate depressive symptoms compared to a wait-list control group.

Methods

A two-armed randomized controlled trial was conducted. An open recruitment strategy was used. Participants were randomized to either the Web-based CDMIs or the no-intervention wait-list control group. The CDMIs are online, unguided, self-help interventions, largely based on cognitive behavioral techniques, which consist of 3 to 4 modules with up to 6 exercises per module. Participants are free to choose between the modules and exercises. Assessments, using self-report questionnaires, took place at baseline and at 3 and 6 months after baseline. The control group was given access to the intervention following the 3-month assessment. The primary goal of the CDMIs is to reduce depressive complaints. The primary outcome of the study was a reduction in depressive complaints as measured by the Inventory of Depressive Symptomatology Self-Report (IDS-SR). Secondary outcomes included reductions in stress, worry, sleep problems, and anxiety complaints, and improvements in well-being. Data were analyzed using linear mixed models.

Results

In total, 329 participants enrolled in the trial, of which 165 were randomized to the intervention group and 164 to the control group. Approximately three-quarters of the intervention group actually created an account. Of these participants, 91.3% (116/127) logged into their chosen CDMI at least once during the 3-month intervention period (median 3, range 0-166). After 3 months, there was a significant reduction in depressive symptomatology for participants in the intervention group compared to participants in the wait-list control group (reduction in depression: mean –4.47, 95% CI –6.54 to –2.40; Cohen d=–0.70). Furthermore, significant effects were observed for sleep problems, worry, anxiety, and well-being, with effect sizes ranging from –0.29 to –0.40. The intervention did not significantly reduce stress. At 6-month follow-up, the improvements in the intervention group were generally sustained.

Conclusions

This study shows that the online self-help CDMIs have a positive impact on various mental health outcomes. Future research should focus on which specific strategies may boost adherence, and increase the reach of the CDMIs among people with low socioeconomic status.

ClinicalTrial

Netherlands Trial Register (NTR): NTR4612; http://www.trialregister.nl/trialreg/admin/rctview.asp?TC=4612 (Archived by WebCite at http://www.webcitation.org/6n4PVYddM)

Preventing Depression in Adults With Subthreshold Depression: Health-Economic Evaluation Alongside a Pragmatic Randomized Controlled Trial of a Web-Based Intervention

Background

Psychological interventions for the prevention of depression might be a cost-effective way to reduce the burden associated with depressive disorders.

Objective

To evaluate the cost-effectiveness of a Web-based guided self-help intervention to prevent major depressive disorder (MDD) in people with subthreshold depression (sD).

Methods

A pragmatic randomized controlled trial was conducted with follow-up at 12 months. Participants were recruited from the general population via a large statutory health insurance company and an open access website. Participants were randomized to a Web-based guided self-help intervention (ie, cognitive-behavioral therapy and problem-solving therapy assisted by supervised graduate students or health care professionals) in addition to usual care or to usual care supplemented with Web-based psycho-education (enhanced usual care). Depression-free years (DFYs) were assessed by blinded diagnostic raters using the telephone-administered Structured Clinical Interview for DSM-IV Axis Disorders at 6- and 12-month follow-up, covering the period to the previous assessment. Costs were self-assessed through a questionnaire. Costs measured from a societal and health care perspective were related to DFYs and quality-adjusted life years (QALYs).

Results

In total, 406 participants were enrolled in the trial. The mean treatment duration was 5.84 (SD 4.37) weeks. On average, participants completed 4.93 of 6 sessions. Significantly more DFYs were gained in the intervention group (0.82 vs 0.70). Likewise, QALY health gains were in favor of the intervention, but only statistically significant when measured with the more sensitive SF-6D. The incremental per-participant costs were €136 (£116). Taking the health care perspective and assuming a willingness-to-pay of €20,000 (£17,000), the intervention’s likelihood of being cost-effective was 99% for gaining a DFY and 64% or 99% for gaining an EQ-5D or a SF-6D QALY.

Conclusions

Our study supports guidelines recommending Web-based treatment for sD and adds that this not only restores health in people with sD, but additionally reduces the risk of developing a MDD. Offering the intervention has an acceptable likelihood of being more cost-effective than enhanced usual care and could therefore reach community members on a wider scale.

Trial registration

German Clinical Trials Register: DRKS00004709; http://www.drks.de/DRKS00004709 (Archived by WebCite at http://www.webcitation.org/6kAZVUxy9)

Prevention of Mental Health Disorders Using Internet- and Mobile-Based Interventions: A Narrative Review and Recommendations for Future Research

Although psychological interventions might have a tremendous potential for the prevention of mental health disorders (MHD), their current impact on the reduction of disease burden is questionable. Possible reasons include that it is not practical to deliver those interventions to the community en masse due to limited health care resources and the limited availability of evidence-based interventions and clinicians in routine practice, especially in rural areas. Therefore, new approaches are needed to maximize the impact of psychological preventive interventions. Limitations of traditional prevention programs could potentially be overcome by providing Internet- and mobile-based interventions (IMIs). This relatively new medium for promoting mental health and preventing MHD introduces a fresh array of possibilities, including the provision of evidence-based psychological interventions that are free from the restraints of travel and time and allow reaching participants for whom traditional opportunities are not an option. This article provides an introduction to the subject and narratively reviews the available evidence for the effectiveness of IMIs with regard to the prevention of MHD onsets. The number of randomized controlled trials that have been conducted to date is very limited and so far it is not possible to draw definite conclusions about the potential of IMIs for the prevention of MHD for specific disorders. Only for the indicated prevention of depression there is consistent evidence across four different randomized trial trials. The only trial on the prevention of general anxiety did not result in positive findings in terms of eating disorders (EDs), effects were only found in post hoc subgroup analyses, indicating that it might be possible to prevent ED onset for subpopulations of people at risk of developing EDs. Future studies need to identify those subpopulations likely to profit from preventive. Disorders not examined so far include substance use disorders, bipolar disorders, stress-related disorders, phobic disorders and panic disorder, obsessive-compulsive disorder, impulse-control disorders, somatic symptom disorder, and insomnia. In summary, there is a need for more rigorously conducted large scale randomized controlled trials using standard clinical diagnostic instruments for the selection of participants without MHD at baseline and the assessment of MHD onset. Subsequently, we discuss future directions for the field in order to fully exploit the potential of IMI for the prevention of MHD.

Skills and knowledge of informatics, and training needs of hospital pharmacists in Thailand: A self-assessment survey

OBJECTIVE

Because hospital pharmacists have to deal with large amounts of health information and advanced information technology in practice, they must possess adequate skills and knowledge of informatics to operate efficiently. However, most current pharmacy curricula in Thailand barely address the principles and skills concerned with informatics, and Thai pharmacists usually acquire computer literacy and informatics skills through personal-interest training and self-study. In this study, we aimed to assess the skills and knowledge of informatics and the training needs of hospital pharmacists in Thailand, in order to improve curricular and professional development.

METHOD

A self-assessment postal survey of 73 questions was developed and distributed to the pharmacy departments of 601 hospitals throughout the country. Practicing hospital pharmacists were requested to complete and return the survey voluntarily.

RESULTS

Within the 3 months of the survey period, a total of 805 out of 2002 surveys were returned. On average, respondents rated themselves as competent or better in the skills of basic computer operation, the Internet, information management, and communication. Understandably, they rated themselves at novice level for information technology and database design knowledge/skills, and at advanced beginner level for project, risk, and change management skills. Respondents believed that skills and knowledge of informatics were highly necessary for their work, and definitely needed training.

CONCLUSION

Thai hospital pharmacists were confident in using computers and the Internet. They realized and appreciated their lack of informatics knowledge and skills, and needed more training. Pharmacy curricula and training should be developed accordingly.

Review of key telepsychiatry outcomes

AIM

To conduct a review of the telepsychiatry literature.

METHODS

We conducted a systematic search of the literature on telepsychiatry using the search terms, "telepsychiatry", "telemental health", "telecare", "telemedicine", "e-health", and "videoconferencing". To meet criteria for inclusion, studies had to: (1) be published in a peer-reviewed journal after the year 2000; (2) be written in English; (3) use videoconferencing technology for the provision of mental health assessment or treatment services; and (4) use an adequately-powered randomized controlled trial design in the case of treatment outcome studies. Out of 1976 studies identified by searches in PubMed (Medline database), Ovid medline, PsychInfo, Embase, and EBSCO PSYCH, 452 met inclusion criteria. Studies that met all inclusion criteria were organized into one of six categories: (1) satisfaction; (2) reliability; (3) treatment outcomes; (4) implementation outcomes; (5) cost effectiveness; and (6) and legal issues. All disagreements were resolved by reassessing study characteristics and discussion.

RESULTS

Overall, patients and providers are generally satisfied with telepsychiatry services. Providers, however, tend to express more concerns about the potentially adverse of effects of telepsychiatry on therapeutic rapport. Patients are less likely to endorse such concerns about impaired rapport with their provider. Although few studies appropriately employ non-inferiority designs, the evidence taken together suggests that telepsychiatry is comparable to face-to-face services in terms of reliability of clinical assessments and treatment outcomes. When non-inferiority designs were appropriately used, telepsychiatry performed as well as, if not better than face-to-face delivery of mental health services. Studies using both rudimentary and more sophisticated methods for evaluating cost-effectiveness indicate that telepsychiatry is not more expensive than face-to-face delivery of mental health services and that telepsychiatry is actually more cost-effective in the majority of studies reviewed. Notwithstanding legal concerns about loss of confidentiality and limited capacity to respond to psychiatric emergencies, we uncovered no published reports of these adverse events in the use of telepsychiatry.

CONCLUSION

A large evidence base supports telepsychiatry as a delivery method for mental health services. Future studies will inform optimal approaches to implementing and sustaining telepsychiatry services.

Rethinking cost-effectiveness in the era of zero healthcare spending growth

Background

The global economic crisis imposes severe restrictions on healthcare budgets, limiting the coverage of new interventions, even when they are cost-effective. Our objective was to develop a tool that can assist decision-makers in comparing the impact of medical intervention alternatives on the entire target population, under a pre-specified budget constraint.

Methods

We illustrated the tool by using a target population of 1,000 patients, and a budget constraint of $1,000,000. We compared two intervention alternatives: the current practice that costs $1,000 and adds 0.5 quality-adjusted-life-years (QALYs) per patient and a new technology that costs 100 % more, and provides 20 % more QALYs per patient. We also developed a formula for defining the maximum premium price for a higher-cost/higher-effectiveness intervention that can justify its adoption under a constrained budget.

Results

Using the new therapy will add 300 QALYs, compared to 500 QALYS when using the lower-cost, lower-effective intervention, despite a favorable incremental cost-effectiveness ratio (ICER) of $10,000. The maximum price for the higher-efficacy therapy that will preserve the target population outcomes is 20 % higher than the lower-cost therapy.

Conclusions

Although an intervention associated with higher costs and higher efficacy may have an acceptable ICER, it could provide inferior outcomes in the target population under budget constraints, depending on the relative effectiveness and costs of the interventions. The cost premium that can be justified for a higher-efficacy intervention is directly correlated to its effectiveness premium. Using the proposed tool may assist decision-makers in improving overall healthcare outcomes, especially in times of economic downturn.

e-CBT (myCompass), Antidepressant Medication, and Face-to-Face Psychological Treatment for Depression in Australia: A Cost-Effectiveness Comparison

Background

The economic cost of depression is becoming an ever more important determinant for health policy and decision makers. Internet-based interventions with and without therapist support have been found to be effective options for the treatment of mild to moderate depression. With increasing demands on health resources and shortages of mental health care professionals, the integration of cost-effective treatment options such as Internet-based programs into primary health care could increase efficiency in terms of resource use and costs.

Objective

Our aim was to evaluate the cost-effectiveness of an Internet-based intervention (myCompass) for the treatment of mild-to-moderate depression compared to treatment as usual and cognitive behavior therapy in a stepped care model.

Methods

A decision model was constructed using a cost utility framework to show both costs and health outcomes. In accordance with current treatment guidelines, a stepped care model included myCompass as the first low-intervention step in care for a proportion of the model cohort, with participants beginning from a low-intensity intervention to increasing levels of treatment. Model parameters were based on data from the recent randomized controlled trial of myCompass, which showed that the intervention reduced symptoms of depression, anxiety, and stress and improved work and social functioning for people with symptoms in the mild-to-moderate range.

Results

The average net monetary benefit (NMB) was calculated, identifying myCompass as the strategy with the highest net benefit. The mean incremental NMB per individual for the myCompass group was AUD 1165.88 compared to treatment as usual and AUD 522.58 for the cognitive behavioral therapy model.

Conclusions

Internet-based interventions can provide cost-effective access to treatment when provided as part of a stepped care model. Widespread dissemination of Internet-based programs can potentially reduce demands on primary and tertiary services and reduce unmet need.

Developing a roadmap for the translation of e-mental health services for depression

OBJECTIVE

e-Mental health services have been shown to be effective and cost-effective for the treatment of depression. However, to have optimal impact in reducing the burden of depression, strategies for wider reach and uptake are needed.

METHOD

A review was conducted to assess the evidence supporting use of e-mental health programmes for treating depression. From the review, models of dissemination and gaps in translation were identified, with a specific focus on characterising barriers and facilitators to uptake within the Australian healthcare context. Finally, recommendations for promoting the translation of e-mental health services in Australia were developed.

RESULTS

There are a number of effective and cost-effective e-health applications available for treating depression in community and clinical settings. Four primary models of dissemination were identified: unguided, health service-supported, private ownership and clinically guided. Barriers to translation include clinician reluctance, consumer awareness, structural barriers such as funding and gaps in the translational evidence base.

CONCLUSION

Key strategies for increasing use of e-mental health programmes include endorsement of e-mental health services by government entities, education for clinicians and consumers, adequate funding of e-mental health services, development of an accreditation system, development of translation-focused activities and support for further translational research. The impact of these implementation strategies is likely to include economic gains, reductions in disease burden and greater availability of more interventions for prevention and treatment of mental ill-health complementary to existing health and efficient evidence-based mental health services.

Economic Evaluation of Pediatric Telemedicine Consultations to Rural Emergency Departments

BACKGROUND

Comprehensive economic evaluations have not been conducted on telemedicine consultations to children in rural emergency departments (EDs).

OBJECTIVE

We conducted an economic evaluation to estimate the cost, effectiveness, and return on investment (ROI) of telemedicine consultations provided to health care providers of acutely ill and injured children in rural EDs compared with telephone consultations from a health care payer prospective.

METHODS

We built a decision model with parameters from primary programmatic data, national data, and the literature. We performed a base-case cost-effectiveness analysis (CEA), a probabilistic CEA with Monte Carlo simulation, and ROI estimation when CEA suggested cost-saving. The CEA was based on program effectiveness, derived from transfer decisions following telemedicine and telephone consultations.

RESULTS

The average cost for a telemedicine consultation was $3641 per child/ED/year in 2013 US dollars. Telemedicine consultations resulted in 31% fewer patient transfers compared with telephone consultations and a cost reduction of $4662 per child/ED/year. Our probabilistic CEA demonstrated telemedicine consultations were less costly than telephone consultations in 57% of simulation iterations. The ROI was calculated to be 1.28 ($4662/$3641) from the base-case analysis and estimated to be 1.96 from the probabilistic analysis, suggesting a $1.96 return for each dollar invested in telemedicine. Treating 10 acutely ill and injured children at each rural ED with telemedicine resulted in an annual cost-savings of $46,620 per ED.

LIMITATIONS

Telephone and telemedicine consultations were not randomly assigned, potentially resulting in biased results.

CONCLUSIONS

From a health care payer perspective, telemedicine consultations to health care providers of acutely ill and injured children presenting to rural EDs are cost-saving (base-case and more than half of Monte Carlo simulation iterations) or cost-effective compared with telephone consultations.

Depression care management for adults older than 60 years in primary care clinics in urban China: a cluster-randomised trial

BACKGROUND

China's national health policy classifies depression as a chronic disease that should be managed in primary care settings. In some high-income countries use of chronic disease management principles and primary care-based collaborative-care models have improved outcomes for late-life depression; however, this approach has not yet been tested in China. We aimed to assess whether use of a collaborative-care depression care management (DCM) intervention could improve outcomes for Chinese adults with depression aged 60 years and older.

METHODS

Between Jan 17, 2011, [corrected] and Nov 30, 2013, we did a cluster-randomised trial in patients from primary care centre clinics in Shangcheng district of Hangzhou city in eastern China. We randomly assigned (1:1) clinics to either DCM (involving training for physicians in use of treatment guidelines, training for primary care nurses to function as care managers, and consultation with psychiatrists as support) or to give enhanced care as usual to all eligible patients aged 60 years and older with major depressive disorder. Clinics were chosen randomly for inclusion from all primary care clinics in the district by computer algorithm and then randomly allocated depression care interventions remotely by computer algorithm. Physicians, study personnel, and patients were not masked to clinic assignment. Our primary outcome was difference in Hamilton Depression Rating Scale (HAMD) score using data for clusters at baseline and 3, 6, and 12 month follow-up in a mixed-effects model of the intention-to-treat population. We originally aimed to analyse outcomes at 24 months, however the difference between groups at 12 months was large and funding was insufficient to continue to 24 months, therefore we decided to end the trial at 12 months. This trial is registered with ClinicalTrials.gov, number NCT01287494.

FINDINGS

Of 34 primary care clinics in Shangcheng district, 16 were randomly chosen. We randomly assigned eight clinics to the DCM intervention (164 patients enrolled) and eight primary care clinics to enhanced care as usual (162 patients). There were no major differences in baseline demographic and clinical variables between the groups of patients for each intervention. Over the 12 months, patients in clinics assigned to DCM had a significantly greater reduction in HAMD score than did those in practices assigned to enhanced care as usual (estimated between group difference -6·5 [95% CI -7·1 to -5·9]; Cohen's d 0·8 [95% CI 0·8-0·9]; p<0·0001). The intercluster correlation for change in HAMD total score was 0·07 (95% CI 0·06-0·08). There were no study-related adverse events in either group.

INTERPRETATION

Clinical outcomes of Chinese adults older than 60 years who had major depression were improved when their primary care clinic used DCM. Primary care-based collaborative management of depression is promising to address this pressing public health need in China.

FUNDING

National Institutes of Health, Program for New Century Excellent Talents in Universities of China, Ministry of Education, China.

Cost-utility and cost-effectiveness studies of telemedicine, electronic, and mobile health systems in the literature: a systematic review

OBJECTIVE

A systematic review of cost-utility and cost-effectiveness research works of telemedicine, electronic health (e-health), and mobile health (m-health) systems in the literature is presented.

MATERIALS AND METHODS

Academic databases and systems such as PubMed, Scopus, ISI Web of Science, and IEEE Xplore were searched, using different combinations of terms such as "cost-utility" OR "cost utility" AND "telemedicine," "cost-effectiveness" OR "cost effectiveness" AND "mobile health," etc. In the articles searched, there were no limitations in the publication date.

RESULTS

The search identified 35 relevant works. Many of the articles were reviews of different studies. Seventy-nine percent concerned the cost-effectiveness of telemedicine systems in different specialties such as teleophthalmology, telecardiology, teledermatology, etc. More articles were found between 2000 and 2013. Cost-utility studies were done only for telemedicine systems.

CONCLUSIONS

There are few cost-utility and cost-effectiveness studies for e-health and m-health systems in the literature. Some cost-effectiveness studies demonstrate that telemedicine can reduce the costs, but not all. Among the main limitations of the economic evaluations of telemedicine systems are the lack of randomized control trials, small sample sizes, and the absence of quality data and appropriate measures.

Blended vs. face-to-face cognitive behavioural treatment for major depression in specialized mental health care: study protocol of a randomized controlled cost-effectiveness trial

BACKGROUND

Depression is a prevalent disorder, associated with a high disease burden and substantial societal, economic and personal costs. Cognitive behavioural treatment has been shown to provide adequate treatment for depression. By offering this treatment in a blended format, in which online and face-to-face treatment are combined, it might be possible to reduce the number of costly face-to-face sessions required to deliver the treatment protocol. This could improve the cost-effectiveness of treatment, while maintaining clinical effects. This protocol describes the design of a pilot study for the evaluation of the feasibility, acceptability and cost-effectiveness of blended cognitive behavioural therapy for patients with major depressive disorder in specialized outpatient mental health care.

METHODS/DESIGN

In a randomized controlled trial design, adult patients with major depressive disorder are allocated to either blended cognitive behavioural treatment or traditional face-to-face cognitive behavioural treatment (treatment as usual). We aim to recruit one hundred and fifty patients. Blended treatment will consist of ten face-to-face and nine online sessions provided alternately on a weekly basis. Traditional cognitive behavioural treatment will consist of twenty weekly sessions. Costs and effects are measured at baseline and after 10, 20 and 30 weeks. Evaluations are directed at cost-effectiveness (with depression severity and diagnostic status as outcomes), and cost-utility (with costs per quality adjusted life year, QALY, as outcome). Costs will encompass health care uptake costs and productivity losses due to absence from work and lower levels of efficiency while at work. Other measures of interest are mastery, working alliance, treatment preference at baseline, depressive cognitions, treatment satisfaction and system usability.

DISCUSSION

The results of this pilot study will provide an initial insight into the feasibility and acceptability of blended cognitive behavioural treatment in terms of clinical and economic outcomes (proof of concept) in routine specialized mental health care settings, and an indication as to whether a well-powered clinical trial of blended cognitive behavioural treatment for depression in routine practice would be advisable. This will be determined based on the perspective of various stakeholders including patients, mental health service providers and health insurers. Strengths and limitations of the study are discussed.

TRIAL REGISTRATION

Netherlands Trial Register NTR4650 . Registered 18 June 2014.

The empirical foundations of telemedicine interventions for chronic disease management

The telemedicine intervention in chronic disease management promises to involve patients in their own care, provides continuous monitoring by their healthcare providers, identifies early symptoms, and responds promptly to exacerbations in their illnesses. This review set out to establish the evidence from the available literature on the impact of telemedicine for the management of three chronic diseases: congestive heart failure, stroke, and chronic obstructive pulmonary disease. By design, the review focuses on a limited set of representative chronic diseases because of their current and increasing importance relative to their prevalence, associated morbidity, mortality, and cost. Furthermore, these three diseases are amenable to timely interventions and secondary prevention through telemonitoring. The preponderance of evidence from studies using rigorous research methods points to beneficial results from telemonitoring in its various manifestations, albeit with a few exceptions. Generally, the benefits include reductions in use of service: hospital admissions/re-admissions, length of hospital stay, and emergency department visits typically declined. It is important that there often were reductions in mortality. Few studies reported neutral or mixed findings.

Efficacy and cost-effectiveness of a web-based intervention with mobile phone support to treat depressive symptoms in adults with diabetes mellitus type 1 and type 2: design of a randomised controlled trial

BACKGROUND

A diagnosis of diabetes mellitus types 1 or 2 doubles the odds of a comorbid depressive disorder. The combined diseases have a wide range of adverse outcomes, such as a lower quality of life, poorer diabetes outcomes and increased healthcare utilisation. Diabetes patients with depression can be treated effectively with psychotherapy, but access to psychological care is limited. In this study we will examine the efficacy and cost-effectiveness of a newly developed web-based intervention (GET.ON Mood Enhancer Diabetes) for people with diabetes and comorbid depressive symptoms.

METHODS/DESIGN

A two-arm randomised controlled trial will be conducted. Adults with diabetes (type 1 or type 2) with increased depression scores (> 22 on the German version of the Center for Epidemiological Studies Depression Scale (CES-D)) will be included. Eligible participants will be recruited through advertisement in diabetes patient journals and via a large-scale German health insurance company. The participants will be randomly assigned to either a 6-week minimally guided web-based self-help program or an online psychoeducation program on depression. The study will include 260 participants, which will enable us to detect a statistically significant difference with a group effect size of d = 0.35 at a power of 80% and a significance level of p = 0.05. The primary outcome measure will be the level of depression as assessed by the CES-D. The secondary outcome measures will be: diabetes-specific emotional distress, glycaemic control, self-management behaviour and the participants' satisfaction with the intervention. Online self-assessments will be collected at baseline and after a 2 months period, with additional follow-up measurements 6 and 12 months after randomisation. The data will be analysed on an intention-to-treat basis and per protocol. In addition, we will conduct an economic evaluation from a societal perspective.

DISCUSSION

If this intervention is shown to be cost-effective, it has considerable potential for implementing psychological care for large numbers of people with diabetes and comorbid depression in routine practice and improve health outcomes.

TRIAL REGISTRATION

German Clinical Trial Register (DRKS): DRKS00004748.