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Margherio SM, Evans SW, Monopoli WJ, Langberg JM. Cost-Effectiveness of a Training Intervention for Adolescents with ADHD. JOURNAL OF CLINICAL CHILD AND ADOLESCENT PSYCHOLOGY : THE OFFICIAL JOURNAL FOR THE SOCIETY OF CLINICAL CHILD AND ADOLESCENT PSYCHOLOGY, AMERICAN PSYCHOLOGICAL ASSOCIATION, DIVISION 53 2023; 52:819-833. [PMID: 33630716 DOI: 10.1080/15374416.2021.1875323] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
OBJECTIVE The aim of this study was to examine the costs and cost-effectiveness of a school-based training intervention delivered at varying levels of intensity with adolescents with attention-deficit/hyperactivity disorder (ADHD). Costs were examined in relation to post-treatment and 6-month follow-up effects of the Challenging Horizons Program (CHP), a training intervention for adolescents with ADHD. METHOD A total of 326 middle-school students (71% male; 77% White) with ADHD were randomized to an after-school version of the CHP (CHP-AS), a less-intensive mentoring version (CHP-M), or routine community care. Detailed time logs were maintained throughout the study and were used to estimate costs associated with each condition. Student grade point average (GPA) and parent-rated ADHD symptoms and organization skills were collected at post-treatment and 6-month follow-up. RESULTS The cost analysis revealed that CHP-AS was more costly per student than CHP-M, both in terms of overall costs and direct expenses to the school. However, CHP-AS was less costly per hour of intervention provided to the youth than CHP-M. Incremental cost-effectiveness ratios revealed that CHP-M may be the more cost-effective option for post-treatment effects, yet CHP-AS may be the more cost-effective option in the long term for sustained gains in organization skills and GPA. CONCLUSIONS This study provides stakeholders important information to make decisions regarding allocation of finite monetary resources to meet their prioritized goals.
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DeFouw ER, Owens JS, Margherio SM, Evans S. Supporting Teachers’ Use of Classroom Management Strategies via Different School-Based Consultation Models: Which Is More Cost-Effective for Whom? SCHOOL PSYCHOLOGY REVIEW 2022. [DOI: 10.1080/2372966x.2022.2087476] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/17/2022]
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Dijk HH, Wessels LM, Constanti M, van den Hoofdakker BJ, Hoekstra PJ, Groenman AP. Cost-Effectiveness and Cost Utility of Treatment of Attention-Deficit/Hyperactivity Disorder: A Systematic Review. J Child Adolesc Psychopharmacol 2021; 31:578-596. [PMID: 34705525 DOI: 10.1089/cap.2021.0068] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
Objectives: This systematic review provides an overview of full economic evaluations of attention-deficit/hyperactivity disorder (ADHD) treatments, evaluates their outcomes, and highlights gaps in the literature. Data Sources: Electronic databases were searched for full economic evaluations of ADHD treatments for children, adolescents, or adults published in English or Dutch. Results: Twenty-nine studies met the inclusion criteria. Almost all studies that compared medication or psychosocial treatment to no treatment, placebo, or care as usual indicated that medication and psychosocial treatment were cost-effective compared to the control group. Stimulant treatment appeared to be cost-effective for the treatment of ADHD in children and adolescents. Only few studies focus on treatments in adults and psychosocial treatments and the number of studies with long time horizons and without industry funding is limited. Conclusions: Despite the rising interest in cost-effectiveness, this systematic review shows that more cost-effectiveness research of higher quality is warranted to aid in the optimal use of available treatments and resources for individuals with ADHD. Specifically, more studies should focus on treatments in adults and psychosocial treatments, and more studies with long time horizons and without industry funding are warranted. Nevertheless, we can conclude that treating ADHD is generally cost-effective compared to no treatment. PROSPERO: CRD42017060074. Available from: https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=60074.
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Affiliation(s)
- Hermien H Dijk
- Faculty of Economics and Business, University of Groningen, Groningen, The Netherlands.,Department of Child and Adolescent Psychiatry, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands.,Accare Child Study Center
| | - Lisa M Wessels
- Department of Child and Adolescent Psychiatry, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands.,Accare Child Study Center
| | - Margaret Constanti
- National Guideline Centre, Royal College of Physicians, London, United Kingdom
| | - Barbara J van den Hoofdakker
- Department of Child and Adolescent Psychiatry, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands.,Accare Child Study Center
| | - Pieter J Hoekstra
- Department of Child and Adolescent Psychiatry, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands.,Accare Child Study Center
| | - Annabeth P Groenman
- Department of Child and Adolescent Psychiatry, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands.,Accare Child Study Center
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Sibley MH, Coxe SJ, Page TF, Pelham WE, Yeguez CE, LaCount PA, Barney S. Four-Year Follow-Up of High versus Low Intensity Summer Treatment for Adolescents with ADHD. JOURNAL OF CLINICAL CHILD AND ADOLESCENT PSYCHOLOGY 2020; 51:750-763. [PMID: 33210938 DOI: 10.1080/15374416.2020.1833734] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
OBJECTIVE Despite an emergence of psychosocial treatments for adolescent ADHD, their long-term effects are unknown. METHOD We examine four-year outcomes of a randomized controlled trial (N = 218) comparing high-intensity (HI; 412 h, $4,373 per participant) versus low-intensity (LI; 24 h, $97 per participant) skills-based summer intervention delivered to adolescents with ADHD at two secondary school transitions (6th/9th grade). Quantitative and qualitative analyses evaluated group×time and group×grade×time effects on 4-year outcomes. RESULTS Relative to LI, a single dose of HI had modest but lasting effects on teen organization skills (d =.40) and ADHD symptoms (9th grade only: d =.27 to.31) at 4-year follow-up. There was no long-term incremental effect of HI (vs. LI) for parent-teen conflict, GPA, or parent use of contingency management. Treatment appeared most effective when delivered to older adolescents (i.e., 9th versus 6th grade), suggesting the long-term impact of ADHD treatment may increase with age. Qualitative data corroborated that the primary long-term benefit of HI (vs. LI) treatment was to organization skills; many of the remaining perceived benefits were to parent and teen psychological variables (i.e., increased self-esteem, self-awareness, parental optimism). HI offered no incremental benefit to long-term educational or clinical service utilization or costs. CONCLUSIONS Modest therapeutic benefits of adolescent ADHD treatment are maintained long term. However, HI treatment did not impact outcomes that could defray the intervention's high costs ($4,373) compared to LI treatment ($97).
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Affiliation(s)
- Margaret H Sibley
- Department of Psychiatry & Behavioral Sciences, University of Washington School of Medicine.,Center for Child Health, Behavior, and Development, Seattle Children's Research Institute
| | - Stefany J Coxe
- Department of Psychology, Florida International University
| | - Timothy F Page
- Department of Psychology, Florida International University
| | | | | | - Patrick A LaCount
- Center for Child Health, Behavior, and Development, Seattle Children's Research Institute
| | - Samantha Barney
- Center for Child Health, Behavior, and Development, Seattle Children's Research Institute
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Dakin H, Gray A. Which interactions matter in economic evaluations? A systematic review and simulation study. BMC Med Res Methodol 2020; 20:109. [PMID: 32380948 PMCID: PMC7203889 DOI: 10.1186/s12874-020-00978-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2019] [Accepted: 04/13/2020] [Indexed: 01/23/2023] Open
Abstract
BACKGROUND We aimed to assess the magnitude of interactions in costs, quality-adjusted life-years (QALYs) and net benefits within a sample of published economic evaluations of factorial randomised controlled trials (RCTs), evaluate the impact that different analytical methods would have had on the results and compare the performance of different criteria for identifying which interactions should be taken into account. METHODS We conducted a systematic review of full economic evaluations conducted alongside factorial RCTs and reviewed the methods used in different studies, as well as the incidence, magnitude, statistical significance, and type of interactions observed within the trials. We developed the interaction-effect ratio as a measure of the magnitude of interactions relative to main effects. For those studies reporting sufficient data, we assessed whether changing the form of analysis to ignore or include interactions would have changed the conclusions. We evaluated how well different criteria for identifying which interactions should be taken into account in the analysis would perform in practice, using simulated data generated to match the summary statistics of the studies identified in the review. RESULTS Large interactions for economic endpoints occurred frequently within the 40 studies identified in the review, although interactions rarely changed the conclusions. CONCLUSIONS Simulation work demonstrated that in analyses of factorial RCTs, taking account of all interactions or including interactions above a certain size (regardless of statistical significance) minimised the opportunity cost from adopting treatments that do not in fact have the highest true net benefit.
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Affiliation(s)
- Helen Dakin
- Health Economics Research Centre, Nuffield Department of Population Health, University of Oxford, Old Road Campus, Headington, Oxford, OX3 7LF UK
| | - Alastair Gray
- Health Economics Research Centre, Nuffield Department of Population Health, University of Oxford, Old Road Campus, Headington, Oxford, OX3 7LF UK
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Coles EK, Pelham WE, Fabiano GA, Gnagy EM, Burrows-MacLean L, Wymbs BT, Chacko A, Walker KS, Wymbs F, Robb Mazzant J, Garefino A, Hoffman MT, Massetti GM, Page TF, Waschbusch DA, Waxmonsky JG, Pelham WE. Randomized Trial of First-Line Behavioral Intervention to Reduce Need for Medication in Children with ADHD. JOURNAL OF CLINICAL CHILD AND ADOLESCENT PSYCHOLOGY 2019; 49:673-687. [PMID: 31411903 DOI: 10.1080/15374416.2019.1630835] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
Abstract
A study conducted in an analogue summer treatment setting showed that when concurrently receiving behavioral intervention, many children with Attention-Deficit Hyperactivity Disorder (ADHD) did not need medication or maximized responsiveness at very low doses. The present study followed participants in that summer study into the subsequent school year to investigate whether the same pattern would extend to the natural school and home settings. There were 127 unmedicated children with ADHD between the ages of 5 and 13 who were randomly assigned to receive or not receive behavioral consultation (BC) at the start of the school year. Children were evaluated by teachers and parents each week to determine if central nervous system stimulant treatment was needed. Children who received BC were approximately half as likely those who did not (NoBC) to initiate medication use each week at school or home and used lower doses when medicated at school. This produced a 40% reduction in total methylphenidate exposure over the course of the school year. BC and NoBC groups did not significantly differ on end-of-year teacher or parent ratings of behavior, which were positive. Moreover, BC and NoBC groups did not significantly differ in cost of treatment; although children in the BC condition accrued additional costs via the BC, these costs were offset by the associated delay and reduction in medication use. Results add to a growing literature suggesting that the use of low-intensity behavioral intervention as a first-line treatment reduces or eliminates the need for medication in children with ADHD.
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Affiliation(s)
- Erika K Coles
- Center for Children and Families, Florida International University
| | | | - Gregory A Fabiano
- Department of Counseling, School, and Educational Psychology, State University of New York at Buffalo
| | | | | | | | - Anil Chacko
- Department of Applied Psychology, New York University
| | | | | | | | | | - Martin T Hoffman
- Department of Pediatrics, State University of New York at Buffalo
| | - Greta M Massetti
- Department of Psychology, State University of New York at Buffalo
| | - Timothy F Page
- Department of Health Policy and Management, Florida International University
| | - Daniel A Waschbusch
- Department of Psychiatry, Pennsylvania State University Milton S. Hershey Medical Center
| | - James G Waxmonsky
- Department of Psychiatry, Pennsylvania State University Milton S. Hershey Medical Center
| | - William E Pelham
- Center for Children and Families, Florida International University
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Bee P, Pedley R, Rithalia A, Richardson G, Pryjmachuk S, Kirk S, Bower P. Self-care support for children and adolescents with long-term conditions: the REfOCUS evidence synthesis. HEALTH SERVICES AND DELIVERY RESEARCH 2018. [DOI: 10.3310/hsdr06030] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023] Open
Abstract
BackgroundSelf-care support (e.g. education, training, peer/professional support) is intended to enhance the self-care capacities of children and young people, while simultaneously reducing the financial burden facing health-care systems.ObjectivesTo determine which models of self-care support for long-term conditions (LTCs) are associated with significant reductions in health utilisation and costs without compromising outcomes for children and young people.DesignSystematic review with meta-analysis.PopulationChildren and young people aged 0–18 years with a long-term physical or mental health condition (e.g. asthma, depression).InterventionSelf-care support in health, social care, educational or community settings.ComparatorUsual care.OutcomesGeneric/health-related quality of life (QoL)/subjective health symptoms and health service utilisation/costs.DesignRandomised/non-randomised trials, controlled before-and-after studies, and interrupted time series designs.Data sourcesMEDLINE, EMBASE, PsycINFO, Cumulative Index to Nursing and Allied Health Literature, ISI Web of Science, NHS Economic Evaluation Database, The Cochrane Library, Health Technology Assessment database, Paediatric Economic Database Evaluation, IDEAS, reference scanning, targeted author searches and forward citation searching. All databases were searched from inception to March 2015.MethodsWe conducted meta-analyses, simultaneously plotting QoL and health utilisation effects. We conducted subgroup analyses for evidence quality, age, LTC and intervention (setting, target, delivery format, intensity).ResultsNinety-seven studies reporting 114 interventions were included. Thirty-seven studies reported adequate allocation concealment. Fourteen were UK studies. The vast majority of included studies recruited children and young people with asthma (n = 66, 68%). Four per cent of studies evaluated ‘pure’ self-care support (delivered through health technology without additional contact), 23% evaluated facilitated self-care support (≤ 2 hours’/four sessions’ contact), 65% were intensively facilitated (≥ 2 hours’/four sessions’ contact) and 8% were case management (≥ 2 hours’ support with multidisciplinary input). Self-care support was associated with statistically significant, minimal benefits for QoL [effect size (ES) –0.17, 95% confidence interval (CI) –0.23 to –0.11], but lacked clear benefit for hospital admissions (ES –0.05, 95% CI –0.12 to 0.03). This finding endured across intervention intensities and LTCs. Statistically significant, minimal reductions in emergency use were observed (ES –0.11, 95% CI –0.17 to –0.04). The total cost analysis was limited by the small number of data. Subgroup analyses revealed statistically significant, minimal reductions in emergency use for children aged ≤ 13 years (ES –0.10, 95% CI –0.17 to –0.04), children and young people with asthma (ES –0.12, 95% CI –0.18 to –0.06) and children and young people receiving ≥ 2 hours per four sessions of support (ES –0.10, 95% CI –0.17 to –0.03). Preliminary evidence suggested that interventions that include the child or young person, and deliver some content individually, may optimise QoL effects. Face-to-face delivery may help to maximise emergency department effects. Caution is required in interpreting these findings.LimitationsIdentification of optimal models of self-care support is challenged by the size and nature of evidence available. The emphasis on meta-analysis meant that a minority of studies with incomplete but potentially relevant data were excluded.ConclusionsSelf-care support is associated with positive but minimal effects on children and young people’s QoL, and minimal, but potentially important, reductions in emergency use. On current evidence, we cannot reliably conclude that self-care support significantly reduces health-care costs.Future workResearch is needed to explore the short- and longer-term effects of self-care support across a wider range of LTCs.Study registrationThis study is registered as PROSPERO CRD42014015452.FundingThe National Institute for Health Research Health Services and Delivery Research programme.
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Affiliation(s)
- Penny Bee
- Division of Nursing, Midwifery and Social Work, University of Manchester, Manchester Academic Health Science Centre, Manchester, UK
| | - Rebecca Pedley
- Division of Nursing, Midwifery and Social Work, University of Manchester, Manchester Academic Health Science Centre, Manchester, UK
| | - Amber Rithalia
- Division of Nursing, Midwifery and Social Work, University of Manchester, Manchester Academic Health Science Centre, Manchester, UK
| | | | - Steven Pryjmachuk
- Division of Nursing, Midwifery and Social Work, University of Manchester, Manchester Academic Health Science Centre, Manchester, UK
| | - Susan Kirk
- Division of Nursing, Midwifery and Social Work, University of Manchester, Manchester Academic Health Science Centre, Manchester, UK
| | - Peter Bower
- National Institute for Health Research School for Primary Care Research, University of Manchester, Manchester Academic Health Science Centre, Manchester, UK
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Becker SP, Schindler DN, Luebbe AM, Tamm L, Epstein JN. Psychometric Validation of the Revised Child Anxiety and Depression Scales-Parent Version (RCADS-P) in Children Evaluated for ADHD. Assessment 2017; 26:811-824. [PMID: 29029564 DOI: 10.1177/1073191117735886] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/18/2023]
Abstract
Children with attention-deficit/hyperactivity disorder (ADHD) frequently experience comorbid internalizing symptoms. The Revised Child Anxiety and Depression Scales-Parent Version (RCADS-P) is a frequently used measure of anxiety and depression in children, though its psychometric properties remain unexamined in children referred for ADHD specifically. The present study evaluated the RCADS-P in 372 children (age 7-12 years; 68% male) referred for evaluation at an ADHD specialty clinic (89% met criteria for ADHD). In addition to the RCADS-P, parents completed the Vanderbilt ADHD Diagnostic Rating Scale and Child Behavior Checklist and were administered the Kiddie Schedule for Affective Disorders and Schizophrenia for School-Age Children semistructured diagnostic interview. Teacher ratings were available for approximately half of the sample. Factor structure, reliability, convergent/discriminant validity, and sensitivity/specificity were examined. Results supported the six-factor structure of the RCADS-P. The RCADS-P demonstrated adequate internal consistency as well as convergent and discriminant validity with other parent ratings and, to a somewhat lesser extent, teacher ratings. Children with an internalizing diagnosis had higher RCADS-P scores than children without an internalizing diagnosis. Finally, the RCADS-P had good-to-excellent diagnostic efficiency, and a total sum score of 25 had excellent sensitivity and fair specificity. Findings provide psychometric support for the RCADS-P in children with ADHD.
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Affiliation(s)
- Stephen P Becker
- 1 Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA.,2 University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Dana N Schindler
- 1 Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | | | - Leanne Tamm
- 1 Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA.,2 University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Jeffery N Epstein
- 1 Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA.,2 University of Cincinnati College of Medicine, Cincinnati, OH, USA
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Casadei G, Cartabia M, Reale L, Costantino MA, Bonati M. Italian regional health service costs for diagnosis and 1-year treatment of ADHD in children and adolescents. Int J Ment Health Syst 2017; 11:33. [PMID: 28465719 PMCID: PMC5410029 DOI: 10.1186/s13033-017-0140-8] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/07/2017] [Accepted: 04/12/2017] [Indexed: 11/10/2022] Open
Abstract
The main aim of this study was to estimate the costs associated with diagnostic assessment and 1-year therapy in children and adolescents enrolled in 18 ADHD reference centres. Data concerning 1887 children and adolescents from the mandatory ADHD registry database during the 2012–2014 period were analysed. The overall diagnostic and treatment costs per patient amounts to €574 and €830, respectively. The ADHD centre, the school as sender, and the time to diagnosis constitute cost drivers. Non-pharmacological therapy resulted as being more expensive for patients concomitantly treated with drugs (€929) compared to those treated with psychological interventions alone (€590; p = 0.006). This study gives the first and reliable estimate of the costs associated with both diagnosis and treatment of ADHD in Italy. Although costs associated with mental disorders are difficult to estimate, continuing efforts are need to define costs and resources to guarantee appropriate care, also for ADHD.
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Affiliation(s)
- Gianluigi Casadei
- CESAV-"Angelo e Angela Valenti" Centre for Health Economics, Department of Public Health, IRCCS-Istituto di Ricerche Farmacologiche "Mario Negri", Via Giuseppe La Masa, 19, 20156 Milan, Italy
| | - Massimo Cartabia
- Laboratory for Mother and Child Health, Department of Public Health, IRCCS-Istituto di Ricerche Farmacologiche "Mario Negri", Milan, Italy
| | - Laura Reale
- Laboratory for Mother and Child Health, Department of Public Health, IRCCS-Istituto di Ricerche Farmacologiche "Mario Negri", Milan, Italy
| | - Maria Antonella Costantino
- Child and Adolescent Neuropsychiatric Unit, IRCCS Foundation Ca' Granda, Ospedale Maggiore Policlinico, Milan, Italy
| | - Maurizio Bonati
- Laboratory for Mother and Child Health, Department of Public Health, IRCCS-Istituto di Ricerche Farmacologiche "Mario Negri", Milan, Italy
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Page TF, Fabiano GA, Greiner AR, Gnagy EM, Pelham WE, Hart K, Coxe S, Waxmonsky JG, Pelham WE. Comparative Cost Analysis of Sequential, Adaptive, Behavioral, Pharmacological, and Combined Treatments for Childhood ADHD. JOURNAL OF CLINICAL CHILD AND ADOLESCENT PSYCHOLOGY : THE OFFICIAL JOURNAL FOR THE SOCIETY OF CLINICAL CHILD AND ADOLESCENT PSYCHOLOGY, AMERICAN PSYCHOLOGICAL ASSOCIATION, DIVISION 53 2016; 45:416-27. [PMID: 26808137 PMCID: PMC4930413 DOI: 10.1080/15374416.2015.1055859] [Citation(s) in RCA: 41] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
We conducted a cost analysis of the behavioral, pharmacological, and combined interventions employed in a sequential, multiple assignment, randomized, and adaptive trial investigating the sequencing and enhancement of treatment for children with attention deficit hyperactivity disorder (ADHD; Pelham et al., 201X; N = 146, 76% male, 80% Caucasian). The quantity of resources expended on each child's treatment was determined from records that listed the type, date, location, persons present, and duration of all services provided. The inputs considered were the amount of physician time, clinician time, paraprofessional time, teacher time, parent time, medication, and gasoline. Quantities of these inputs were converted into costs in 2013 USD using national wage estimates from the Bureau of Labor Statistics, the prices of 30-day supplies of prescription drugs from the national Express Scripts service, and mean fuel prices from the Energy Information Administration. Beginning treatment with a low-dose/intensity regimen of behavior modification (large-group parent training) was less costly for a school year of treatment ($961) than beginning treatment with a low dose of stimulant medication ($1,669), regardless of whether the initial treatment was intensified with a higher "dose" or if the other modality was added. Outcome data from the parent study (Pelham et al., 201X) found equivalent or superior outcomes for treatments beginning with low-intensity behavior modification compared to intervention beginning with medication. Combined with the present analyses, these findings suggest that initiating treatment with behavior modification rather than medication is the more cost-effective option for children with ADHD.
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Richardson M, Moore DA, Gwernan-Jones R, Thompson-Coon J, Ukoumunne O, Rogers M, Whear R, Newlove-Delgado TV, Logan S, Morris C, Taylor E, Cooper P, Stein K, Garside R, Ford TJ. Non-pharmacological interventions for attention-deficit/hyperactivity disorder (ADHD) delivered in school settings: systematic reviews of quantitative and qualitative research. Health Technol Assess 2016; 19:1-470. [PMID: 26129788 DOI: 10.3310/hta19450] [Citation(s) in RCA: 37] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND Attention-deficit/hyperactivity disorder (ADHD) is a neurodevelopmental disorder characterised by age-inappropriate levels of inattention, impulsivity and hyperactivity. School can be particularly challenging for children with ADHD. Few reviews have considered non-pharmacological interventions in school settings. OBJECTIVES To assess the effectiveness of non-pharmacological interventions delivered in school settings for pupils with, or at risk of, ADHD and to explore the factors that may enhance, or limit, their delivery. DATA SOURCES Twenty electronic databases (including PsycINFO, MEDLINE, EMBASE, Education Resources Information Centre, The Cochrane Library and Education Research Complete) were searched from 1980 to February-August 2013. Three separate searches were conducted for four systematic reviews; they were supplemented with forward and backwards citation chasing, website searching, author recommendations and hand-searches of key journals. REVIEW METHODS The systematic reviews focused on (1) the effectiveness of school-based interventions for children with or at risk of ADHD; (2) quantitative research that explores attitudes towards school-based non-pharmacological interventions for pupils with ADHD; (3) qualitative research investigating the attitudes and experiences of children, teachers, parents and others using ADHD interventions in school settings; and (4) qualitative research exploring the experience of ADHD in school among pupils, their parents and teachers more generally. Methods of synthesis included a random-effects meta-analysis, meta-regression and narrative synthesis for review 1, narrative synthesis for review 2 and meta-ethnography and thematic analysis for reviews 3 and 4. RESULTS For review 1, 54 controlled trials met the inclusion criteria. For the 36 meta-analysed randomised controlled trials, beneficial effects (p < 0.05) were observed for several symptom and scholastic outcomes. Mean weighted effect sizes ranged from very small (d + < 0.20) to large (d + ≥ 0.80), but substantial heterogeneity in effect size estimates across studies was reported. Moderator analyses were not able to clarify which intervention features were linked with effectiveness. For review 2, 28 included studies revealed that educators' attitudes towards interventions ranged in positivity. Most interventions were rated positively or neutrally across different studies. The only intervention that consistently recorded positive attitudes from educators was daily report cards. For review 3, 33 studies met the inclusion criteria. Key findings included tensions regarding the preferred format of interventions, particularly how structured interventions were and the extent to which they are tailored to the child with ADHD. There were mixed views about the impact of interventions, although it was clear that interventions both influence and are influenced by the relationships held by children with ADHD and participants' attitudes towards school and ADHD. For review 4, 34 studies met the inclusion criteria. Key findings included the importance of causal attributions that teachers, parents and pupils made about ADHD symptoms, the decisions teachers made about treatment, the self-perceptions pupils developed about themselves, the role of the classroom environment and stigma in aggravating ADHD symptoms, and the significant barrier to treatment posed by the common presence of conflict in relationships between pupils-teachers, parents-teachers and pupils-peers in relation to ADHD. An overarching synthesis of the four reviews highlighted the importance of the context affecting interventions. It suggested that ADHD psychoeducation and relationship-building skills are potential implications for interventions. LIMITATIONS The breadth of both interventions and outcomes in the reviewed studies presented a challenge for categorisation, analysis and interpretation in reviews 1-3. Across reviews, relatively few studies were conducted in the UK, limiting the applicability of findings to UK education. In reviews 1 and 2, the poor methodological quality of some included studies was identified as a barrier to establishing effectiveness or comparing attitudes. In review 3 the descriptive analysis used by the majority of studies constrained theorising during synthesis. Studies in review 4 lacked detail regarding important issues like gender, pupil maturity and school level. CONCLUSION Findings suggest some beneficial effects of non-pharmacological interventions for ADHD used in school settings, but substantial heterogeneity in effect sizes was seen across studies. The qualitative reviews demonstrate the importance of the context in which interventions are used. Future work should consider more rigorous evaluation of interventions, as well as focus on what works, for whom and in which contexts. Gaps in current research present opportunities for the development and testing of standardised tools to describe interventions, agreement on gold-standard outcome measures assessing ADHD behaviour and testing a range of potential moderators alongside intervention trials. STUDY REGISTRATION This study is registered as PROSPERO CRD42011001716. FUNDING The National Institute for Health Research Health Technology Assessment programme.
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Affiliation(s)
| | - Darren A Moore
- Evidence Synthesis & Modelling for Health Improvement, University of Exeter Medical School, Exeter, UK
| | - Ruth Gwernan-Jones
- Evidence Synthesis & Modelling for Health Improvement, University of Exeter Medical School, Exeter, UK
| | - Jo Thompson-Coon
- National Institute for Health Research (NIHR) Collaboration for Leadership in Applied Health Research and Care South West Peninsula (PenCLAHRC), University of Exeter Medical School, Exeter, UK
| | - Obioha Ukoumunne
- National Institute for Health Research (NIHR) Collaboration for Leadership in Applied Health Research and Care South West Peninsula (PenCLAHRC), University of Exeter Medical School, Exeter, UK
| | - Morwenna Rogers
- National Institute for Health Research (NIHR) Collaboration for Leadership in Applied Health Research and Care South West Peninsula (PenCLAHRC), University of Exeter Medical School, Exeter, UK
| | - Rebecca Whear
- National Institute for Health Research (NIHR) Collaboration for Leadership in Applied Health Research and Care South West Peninsula (PenCLAHRC), University of Exeter Medical School, Exeter, UK
| | - Tamsin V Newlove-Delgado
- National Institute for Health Research (NIHR) Collaboration for Leadership in Applied Health Research and Care South West Peninsula (PenCLAHRC), University of Exeter Medical School, Exeter, UK
| | - Stuart Logan
- National Institute for Health Research (NIHR) Collaboration for Leadership in Applied Health Research and Care South West Peninsula (PenCLAHRC), University of Exeter Medical School, Exeter, UK
| | - Christopher Morris
- Peninsula Cerebra Research Unit (PenCRU), University of Exeter Medical School, Exeter, UK
| | - Eric Taylor
- Institute of Psychiatry, King's College London, London, UK
| | - Paul Cooper
- Centre for Special Educational Needs and Inclusive Education (CSENIE), Hong Kong Institute of Education, Hong Kong, China
| | - Ken Stein
- National Institute for Health Research (NIHR) Collaboration for Leadership in Applied Health Research and Care South West Peninsula (PenCLAHRC), University of Exeter Medical School, Exeter, UK
| | - Ruth Garside
- The European Centre for Environment and Human Health (ECEHH), University of Exeter Medical School, Truro, UK
| | - Tamsin J Ford
- Child Health Group, University of Exeter Medical School, Exeter, UK
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Hinshaw SP, Arnold LE. ADHD, Multimodal Treatment, and Longitudinal Outcome: Evidence, Paradox, and Challenge. WILEY INTERDISCIPLINARY REVIEWS. COGNITIVE SCIENCE 2015; 6:39-52. [PMID: 25558298 PMCID: PMC4280855 DOI: 10.1002/wcs.1324] [Citation(s) in RCA: 63] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/27/2014] [Revised: 08/31/2014] [Accepted: 09/18/2014] [Indexed: 12/14/2022]
Abstract
Given major increases in the diagnosis of attention-deficit hyperactivity disorder (ADHD) and in rates of medication for this condition, we carefully examine evidence for effects of single versus multimodal (i.e., combined medication and psychosocial/behavioral) interventions for ADHD. Our primary data source is the Multimodal Treatment Study of Children with ADHD (MTA), a 14-month, randomized clinical trial in which intensive behavioral, medication, and multimodal treatment arms were contrasted with one another and with community intervention (treatment-as-usual), regarding outcome domains of ADHD symptoms, comorbidities, and core functional impairments. Although initial reports emphasized the superiority of well-monitored medication for symptomatic improvement, reanalyses and reappraisals have highlighted (a) the superiority of combination treatment for composite outcomes and for domains of functional impairment (e.g., academic achievement, social skills, parenting practices); (b) the importance of considering moderator and mediator processes underlying differential patterns of outcome, including comorbid subgroups and improvements in family discipline style during the intervention period; (c) the emergence of side effects (e.g., mild growth suppression) in youth treated with long-term medication; and (d) the diminution of medication's initial superiority once the randomly assigned treatment phase turned into naturalistic follow-up. The key paradox is that whereas ADHD clearly responds to medication and behavioral treatment in the short term, evidence for long-term effectiveness remains elusive. We close with discussion of future directions and a call for greater understanding of relevant developmental processes in the attempt to promote optimal, generalized, and lasting treatments for this important and impairing neurodevelopmental disorder.
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Affiliation(s)
- Stephen P. Hinshaw
- Department of Psychology, Tolman Hall, University of California, Berkeley CA 94720
| | - L. Eugene Arnold
- Department of Psychiatry, 395E McCampbell Hall, 1581 Dodd Dr., Ohio State University, Columbus, OH 43210
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Beecham J. Annual research review: Child and adolescent mental health interventions: a review of progress in economic studies across different disorders. J Child Psychol Psychiatry 2014; 55:714-32. [PMID: 24580503 PMCID: PMC4657502 DOI: 10.1111/jcpp.12216] [Citation(s) in RCA: 81] [Impact Index Per Article: 8.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 01/17/2014] [Indexed: 11/30/2022]
Abstract
BACKGROUND Resources for supporting children and adolescents with psychiatric disorders continue to be scarce. Economics research can identify current patterns of expenditure, and help inform allocation of treatment and support resources between competing needs or uses. SCOPE AND METHODS The aim was to identify the costs of supporting children and adolescents, the economic impacts of childhood psychiatric disorders in adulthood and any new evidence on the cost-effectiveness of interventions. An electronic search of databases (including PubMed, Medline and Psychinfo) identified peer-reviewed journal articles published between 2005 and 2012. FINDINGS Sixty-seven papers provided data on support and treatment costs now or in the future, or cost-effectiveness analyses of services. Half the articles came from the United States. Most articles focussed on autism spectrum disorder (ASD; 23 articles), attention deficit hyperactivity disorder (ADHD; n = 15), conduct disorder (CD; n = 7), and anxiety or depression (n = 8). CONCLUSION Only 14 studies used a cost perspective wider than health care; most included education costs (n = 11), but only five included costs to the justice system. The number of studies estimating costs to the family has increased, particularly for children with autism spectrum disorder (ASD). In the United Kingdom, support costs for children and adolescents with conduct disorder (CD) appear to be lower than for those with attention deficit hyperactivity disorder (ADHD), although for the United States, the opposite may be true. Support costs for children and adolescents with ASD may be higher than both CD and ADHD. However, there were many differences between the samples and the methods employed making comparisons between studies difficult. Outcomes in adulthood include negative impacts on (mental) health, quality of life, public sector services, employment status and income. The evidence base is improving for child and adolescent psychiatric disorders, although only one full cost-effectiveness analysis was identified since the previous review published in 2012. However, we still do not know enough about the economic implications of support and treatment for specific disorders.
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Affiliation(s)
- Jennifer Beecham
- Personal Social Services Research Unit, University of KentCanterbury, UK
- London School of Economics and Political ScienceCanterbury, UK
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14
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Braun S, Russo L, Zeidler J, Linder R, Hodgkins P. Descriptive Comparison of Drug Treatment–Persistent, –Nonpersistent, and Nondrug Treatment Patients With Newly Diagnosed Attention Deficit/Hyperactivity Disorder in Germany. Clin Ther 2013; 35:673-85. [DOI: 10.1016/j.clinthera.2013.03.017] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2012] [Revised: 03/20/2013] [Accepted: 03/26/2013] [Indexed: 11/25/2022]
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Ungar M, Ghazinour M, Richter J. Annual Research Review: What is resilience within the social ecology of human development? J Child Psychol Psychiatry 2013; 54:348-66. [PMID: 23215898 DOI: 10.1111/jcpp.12025] [Citation(s) in RCA: 238] [Impact Index Per Article: 21.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
BACKGROUND The development of Bronfenbrenner's bio-social-ecological systems model of human development parallels advances made to the theory of resilience that progressively moved from a more individual (micro) focus on traits to a multisystemic understanding of person-environment reciprocal processes. METHODS This review uses Bronfenbrenner's model and Ungar's social-ecological interpretation of four decades of research on resilience to discuss the results of a purposeful selection of studies of resilience that have been done in different contexts and cultures. RESULTS An ecological model of resilience can, and indeed has been shown to help researchers of resilience to conceptualize the child's social and physical ecologies, from caregivers to neighbourhoods, that account for both proximal and distal factors that predict successful development under adversity. Three principles emerged from this review that inform a bio-social-ecological interpretation of resilience: equifinality (there are many proximal processes that can lead to many different, but equally viable, expressions of human development associated with well-being); differential impact (the nature of the risks children face, their perceptions of the resources available to mitigate those risks and the quality of the resources that are accessible make proximal processes more or less influential to children's development); and contextual and cultural moderation (different contexts and cultures provide access to different processes associated with resilience as it is defined locally). CONCLUSION As this review shows, using this multisystemic social-ecological theory of resilience can inform a deeper understanding of the processes that contribute to positive development under stress. It can also offer practitioners and policy makers a broader perspective on principles for the design and implementation of effective interventions.
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Outcome domains in child mental health research since 1996: have they changed and why does it matter? J Am Acad Child Adolesc Psychiatry 2012; 51. [PMID: 23200282 PMCID: PMC3513697 DOI: 10.1016/j.jaac.2012.09.004] [Citation(s) in RCA: 41] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
OBJECTIVE Child mental health treatment and services research yields more immediate public health benefit when they focus on outcomes of relevance to a broader group of stakeholders. We reviewed all experimental studies of child and adolescent treatment and service effectiveness published in the last 15 years (1996-2011) and compared the distribution and types of outcome domains to a prior review that focused on studies from the prior 15 years (1980-1995). METHOD Studies were included if they focused on children from birth to 18 years of age with specific or general psychiatric conditions, employed randomized designs, and examined intervention effects with a six-month or longer post-treatment assessment in treatment studies or a 6-month or longer post-baseline assessment for services studies. Two hundred (n=200) studies met criteria. Reported outcome measures were coded into conceptual categories drawn from the 1980-1995 review. RESULTS There was a five-fold increase in the total number of studies (38 versus 200) across the two 15-year time periods, with the largest increase in the number of studies that focused on consumer-oriented outcomes (from eight to 47 studies, an almost sixfold increase); two new domains, parent symptoms and health-related outcomes, were identified. The majority of studies (more than 95%) continued to focus on symptoms and diagnoses as an outcome. Impact ratings were higher among studies examining four or more outcomes versus one to two outcomes in all categories with the exception of Posttraumatic Stress Disorder. CONCLUSIONS Given major shifts in health care policy affecting mental health services, the emergence of health and parent-related outcomes as well as greater attention to consumer perspectives parallels emerging priorities in health care and can enhance the relevance of child outcome studies for implementation in the real world.
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Becker SP, Luebbe AM, Langberg JM. Co-occurring Mental Health Problems and Peer Functioning Among Youth with Attention-Deficit/Hyperactivity Disorder: A Review and Recommendations for Future Research. Clin Child Fam Psychol Rev 2012; 15:279-302. [PMID: 22965872 DOI: 10.1007/s10567-012-0122-y] [Citation(s) in RCA: 75] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Affiliation(s)
- Stephen P Becker
- Department of Psychology, Miami University, Oxford, OH 45056, USA.
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Sonuga-Barke EJS, Fairchild G. Neuroeconomics of attention-deficit/hyperactivity disorder: differential influences of medial, dorsal, and ventral prefrontal brain networks on suboptimal decision making? Biol Psychiatry 2012; 72:126-33. [PMID: 22560046 DOI: 10.1016/j.biopsych.2012.04.004] [Citation(s) in RCA: 84] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/01/2011] [Revised: 03/19/2012] [Accepted: 04/05/2012] [Indexed: 12/31/2022]
Abstract
Psychiatric neuroeconomics offers an alternative approach to understanding mental disorders by studying the way disorder-related neurobiological alterations constrain economic agency, as revealed through decisions about choices between future goods. In this article, we apply this perspective to understand suboptimal decision making in attention-deficit/hyperactivity disorder (ADHD) by integrating recent advances in the neuroscience of decision making and studies of the pathophysiology of ADHD. We identify three brain networks as candidates for further study and develop specific hypotheses about how these could be implicated in ADHD. First, we postulate that altered patterns of connectivity within a network linking medial prefrontal cortex and posterior cingulate cortex (i.e., the default mode network) disrupts ordering of utilities, prospection about desired future states, setting of future goals, and implementation of aims. Second, we hypothesize that deficits in dorsal frontostriatal networks, including the dorsolateral prefrontal cortex and dorsal striatum, produce executive dysfunction-mediated impairments in the ability to compare outcome options and make choices. Third, we propose that dopaminergic dysregulation in a ventral frontostriatal network encompassing the orbitofrontal cortex, ventral striatum, and amygdala disrupts processing of cues of future utility, evaluation of experienced outcomes (feedback), and learning of associations between cues and outcomes. Finally, we extend this perspective to consider three contemporary themes in ADHD research.
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Affiliation(s)
- Edmund J S Sonuga-Barke
- Institute for Disorders of Impulse & Attention, School of Psychology, University of Southampton, Southampton, United Kingdom.
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19
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Wu EQ, Hodgkins P, Ben-Hamadi R, Setyawan J, Xie J, Sikirica V, Du EX, Yan SY, Erder MH. Cost effectiveness of pharmacotherapies for attention-deficit hyperactivity disorder: a systematic literature review. CNS Drugs 2012; 26:581-600. [PMID: 22712698 DOI: 10.2165/11633900-000000000-00000] [Citation(s) in RCA: 41] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/02/2022]
Abstract
BACKGROUND Attention-deficit hyperactivity disorder (ADHD) is a common psychiatric disorder that impairs the quality of life for patients and their families and is associated with considerable direct and indirect costs. Pharmacotherapies for ADHD, including stimulants and non-stimulants, are often used to treat patients with ADHD. However, the costs, effectiveness and adverse effects of these agents vary. Therefore, information regarding the cost effectiveness of different pharmacological treatments is needed to better inform payers in the allocation of limited resources. OBJECTIVES The objectives of this study were to conduct a systematic literature review of economic evaluations of pharmacotherapies for ADHD treatments and to assess the cost effectiveness of different interventions based on the existing studies. METHODS A systematic literature review of economic evaluations of pharmacotherapies for ADHD was conducted in MEDLINE, the National Health Services (NHS) Economic Evaluation database and EMBASE. For inclusion in this review, studies had to compare two or more ADHD interventions with at least one pharmacotherapy, assess both costs and outcomes, and be conducted between 1990 and 2011 in North America, Europe, Australia or New Zealand. Studies were excluded if they were not original research, were presented only as conference proceedings or abstracts or did not report costs associated with specific interventions. The study quality was assessed using the British Medical Journal (BMJ) health economics checklist. The literature search, data extraction and quality assessment were performed by one author and independently checked for accuracy by a second author. Discrepancies were resolved by consensus and referring to the original article. If necessary, a third reviewer was consulted. RESULTS The initial search returned 93 citations from MEDLINE, 10 from the NHS Economic Evaluation database and 377 from EMBASE. Thirteen papers met the inclusion/exclusion criteria and were included in the review. Based on the BMJ checklist, all these studies were considered to be of sufficient quality to be included in the literature review, but they varied substantially in target population, methodology and effectiveness measures. Identified pharmacotherapies were cost effective compared with no treatment, placebo, behavioural therapy or community care among children and adolescents with ADHD. Studies comparing non-stimulants with stimulants and amfetamine with methylphenidate stimulants showed inconsistent findings. A limited number of studies indicated that methylphenidate Osmotic-controlled Release Oral delivery System (OROS) was cost effective compared with short-acting methylphenidate. There were no published studies on the cost effectiveness of pharmacotherapy in the adult ADHD population, comparing stimulants, non-stimulants or adjuvant therapy. There is limited evidence on the long-term cost effectiveness of pharmacotherapies. CONCLUSIONS Among children and adolescents with ADHD, there was consistent evidence that pharmacotherapies are cost effective compared with no treatment or behavioural therapy. Adequate data are lacking to draw conclusions regarding the relative cost effectiveness of different pharmacological agents. More economic evaluations with standardized methods, such as effectiveness measures and cost components, are warranted. To better inform payers about the economic value of existing medications, future studies should also consider identifying subgroups that may have heterogeneous responses to different treatments, including analyses of recently approved treatments (e.g. lisdexamfetamine, guanfacine extended-release and clonidine extended-release) and expanding the time horizon to incorporate long-term outcomes.
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Affiliation(s)
- Eric Q Wu
- Analysis Group, Inc., Boston, MA, USA.
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20
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Contopoulos-Ioannidis DG, Seto I, Hamm MP, Thomson D, Hartling L, Ioannidis JPA, Curtis S, Constantin E, Batmanabane G, Klassen T, Williams K. Empirical evaluation of age groups and age-subgroup analyses in pediatric randomized trials and pediatric meta-analyses. Pediatrics 2012; 129 Suppl 3:S161-84. [PMID: 22661763 DOI: 10.1542/peds.2012-0055j] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND An important step toward improvement of the conduct of pediatric clinical research is the standardization of the ages of children to be included in pediatric trials and the optimal age-subgroups to be analyzed. METHODS We set out to evaluate empirically the age ranges of children, and age-subgroup analyses thereof, reported in recent pediatric randomized clinical trials (RCTs) and meta-analyses. First, we screened 24 RCTs published in Pediatrics during the first 6 months of 2011; second, we screened 188 pediatric RCTs published in 2007 in the Cochrane Central Register of Controlled Trials; third, we screened 48 pediatric meta-analyses published in the Cochrane Database of Systematic Reviews in 2011. We extracted information on age ranges and age-subgroups considered and age-subgroup differences reported. RESULTS The age range of children in RCTs published in Pediatrics varied from 0.1 to 17.5 years (median age: 5; interquartile range: 1.8-10.2) and only 25% of those presented age-subgroup analyses. Large variability was also detected for age ranges in 188 RCTs from the Cochrane Central Register of Controlled Trials, and only 28 of those analyzed age-subgroups. Moreover, only 11 of 48 meta-analyses had age-subgroup analyses, and in 6 of those, only different studies were included. Furthermore, most of these observed differences were not beyond chance. CONCLUSIONS We observed large variability in the age ranges and age-subgroups of children included in recent pediatric trials and meta-analyses. Despite the limited available data, some age-subgroup differences were noted. The rationale for the selection of particular age-subgroups deserves further study.
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Affiliation(s)
- Despina G Contopoulos-Ioannidis
- Department of Pediatrics, Division of Infectious Diseases, Stanford Prevention Research Center, Stanford University School of Medicine, Stanford, California 94305, USA.
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Kilian R, Losert C, Park AL, McDaid D, Knapp M. Cost-Effectiveness Analysis in Child and Adolescent Mental Health Problems: An Updated Review of Literature. INTERNATIONAL JOURNAL OF MENTAL HEALTH PROMOTION 2012. [DOI: 10.1080/14623730.2010.9721825] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
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Robb JA, Sibley MH, Pelham WE, Foster EM, Molina BS, Gnagy EM, Kuriyan AB. The Estimated Annual Cost of ADHD to the U.S. Education System. SCHOOL MENTAL HEALTH 2011; 3:169-177. [PMID: 25110528 PMCID: PMC4123753 DOI: 10.1007/s12310-011-9057-6] [Citation(s) in RCA: 82] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
The purpose of this study was to examine and monetize the educational outcomes of students with ADHD. Data were examined from the Pittsburgh ADHD Longitudinal Study (PALS), a follow-up study of children diagnosed with ADHD in childhood and recontacted for follow-up in adolescence and young adulthood. A comprehensive educational history was obtained for all participants from Kindergarten through 12th grade. Annual economic impact was derived from costs incurred through special education placement, grade retention, and disciplinary incidents. Results indicated that, as compared to students without ADHD, students with ADHD incurred a higher annual cost to the U.S. Education system. Specifically, a student with ADHD incurred an average annual incremental cost to society of $5,007, as compared to $318 for students in the comparison group. These results suggest that prevention and intervention strategies are greatly needed to offset the large financial impact of educating youth with ADHD.
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Affiliation(s)
- Jessica A. Robb
- Center for Children and Families, Department of Psychology, Florida International University, Miami, FL
| | - Margaret H. Sibley
- Center for Children and Families, Department of Psychology, Florida International University, Miami, FL
- Department of Psychology, State University of New York at Buffalo, Buffalo, NY
| | - William E. Pelham
- Center for Children and Families, Department of Psychology, Florida International University, Miami, FL
| | - E. Michael Foster
- School of Public Health, University of North Carolina, Chapel Hill, Chapel Hill, NC
| | - Brooke S.G. Molina
- Department of Psychiatry and Psychology, University of Pittsburgh, Pittsburgh, PA
| | - Elizabeth M. Gnagy
- Center for Children and Families, Department of Psychology, Florida International University, Miami, FL
| | - Aparajita B. Kuriyan
- Center for Children and Families, Department of Psychology, Florida International University, Miami, FL
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Larson K, Russ SA, Kahn RS, Halfon N. Patterns of comorbidity, functioning, and service use for US children with ADHD, 2007. Pediatrics 2011; 127:462-70. [PMID: 21300675 PMCID: PMC3065146 DOI: 10.1542/peds.2010-0165] [Citation(s) in RCA: 340] [Impact Index Per Article: 26.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
Abstract
OBJECTIVE To determine patterns of comorbidity, functioning, and service use for US children with attention-deficit/hyperactivity disorder (ADHD). METHODS Bivariate and multivariable cross-sectional analyses were conducted on data from the 2007 National Survey of Children's Health on 61 779 children ages 6 to 17 years, including 5028 with ADHD. RESULTS Parent-reported diagnosed prevalence of ADHD was 8.2%. Children with ADHD were more likely to have other mental health and neurodevelopmental conditions. Parents reported that 46% of children with ADHD had a learning disability versus 5% without ADHD, 27% vs 2% had a conduct disorder, 18% vs 2% anxiety, 14% vs 1% depression, and 12% vs 3% speech problems (all P < .05). Most children with ADHD had at least 1 comorbid disorder: 33% had 1, 16% had 2, and 18% had 3 or more. The risk for having 3 or more comorbidities was 3.8 times higher for poor versus affluent children (30% vs 8%). Children with ADHD had higher odds of activity restriction (odds ratio: 4.14 [95% confidence interval: 3.34-5.15]), school problems (odds ratio: 5.18 [95% confidence interval: 4.47-6.01]), grade repetition, and poor parent-child communication, whereas social competence scores were lower and parent aggravation higher. Functioning declined in a stepwise fashion with increasing numbers of comorbidities, and use of health and educational services and need for care coordination increased. CONCLUSIONS Clinical management of ADHD must address multiple comorbid conditions and manage a range of adverse functional outcomes. Therapeutic approaches should be responsive to each child's neurodevelopmental profile, tailored to their unique social and family circumstances, and integrated with educational, mental health and social support services.
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Affiliation(s)
- Kandyce Larson
- UCLA Center for Healthier Children, Families, and Communities, 10990 Wilshire Blvd, Suite 900, Los Angeles, CA 90024, USA.
| | - Shirley A. Russ
- UCLA Center for Healthier Children, Families, and Communities, Los Angeles, California; ,Department of Academic Primary Care Pediatrics, Cedars-Sinai Medical Center, Los Angeles, California
| | - Robert S. Kahn
- Division of General and Community Pediatrics, Cincinnati Children's Hospital Medical Center, University of Cincinnati College of Medicine, Cincinnati, Ohio; and
| | - Neal Halfon
- UCLA Center for Healthier Children, Families, and Communities, Los Angeles, California; ,Department of Pediatrics, David Geffen School of Medicine, University of California, Los Angeles; ,Department of Health Services, School of Public Health, University of California, Los Angeles, California
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Schlander M, Trott GE, Schwarz O. [The health economics of attention deficit hyperactivity disorder in Germany. Part 2: Therapeutic options and their cost-effectiveness]. DER NERVENARZT 2010; 81:301-14. [PMID: 19936695 DOI: 10.1007/s00115-009-2889-8] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
Attention deficit hyperactivity disorder (ADHD) has been associated with a continuous increase of health care utilization and thus expenditures. This raises the issue of cost-effectiveness of health care provided for patients with ADHD. Comparative health economic evaluations generate relevant insights and typically report incremental cost-effectiveness ratios (ICERs) of alternatives versus an established standard. Typically, results of cost-effectiveness analyses (CEAs) are reported in terms of incremental cost-effectiveness ratios (ICERs). International evaluations, as well specific adaptations to Germany, indicate an acceptable to attractive cost-effectiveness--according to currently used international benchmarks--of an intense medication management strategy based on stimulants, primarily methylphenidate, with ICERs ranging from 20,000 EUR to 37,000 EUR per quality-adjusted life year (QALY) gained. Economic modeling studies also suggest cost-effectiveness of long-acting modified-release preparations of methylphenidate, owing to improved treatment compliance associated with simplified once daily administration schemes. Atomoxetine, in contrast, appears economically inferior compared to long-acting stimulants, given its higher acquisition costs and at best equal clinical effectiveness. There are currently no data supporting the cost-effectiveness of psychotherapeutic or behavioral interventions. Economic evaluations, which have been published to date, are generally limited by time horizons of up to 1 year and by their prevailing focus on ADHD core symptom improvement only. Therefore, further research into the cost-effectiveness of ADHD treatment strategies seems warranted.
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Affiliation(s)
- M Schlander
- Institute for Innovation & Valuation in Health Care (InnoValHC), An der Ringkirche 4, 65197 Wiesbaden.
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Semi-parametric regression as a tool for assessing moderation: an analysis of the Fast Track intervention. HEALTH SERVICES AND OUTCOMES RESEARCH METHODOLOGY 2010. [DOI: 10.1007/s10742-010-0064-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
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Foreman DM. The Impact of Governmental Guidance on the Time Taken to Receive a Prescription for Medication for ADHD in England. Child Adolesc Ment Health 2010; 15:12-17. [PMID: 32847212 DOI: 10.1111/j.1475-3588.2009.00526.x] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
The National Health Service in England has deployed guidance from the National Institute of Clinical Excellence (NICE) to assist practitioners in the diagnosis and treatment of Attention Deficit Hyperactivity Disorder (ADHD) but, though the number of prescriptions has risen since its introduction, the impact of the guidance on prescribing practice has not been studied. Clinic records of all open ADHD cases (296) in three English Child and Adolescent Mental Health Services were examined. The time from referral to either prescription or data collection was extracted for a survival analysis. It was hypothesised that NICE guidance, clinic, patient and referral characteristics would all influence the speed and likelihood of prescription. Following the introduction of NICE guidance, the median time to start prescribing medication fell from 1262 to 526 days: the minimum realistic time to complete a routine assessment was approximately 70 days. Overall, 70% were prescribed medication. Most of the wait was after face-to-face appointments at the clinic had been initiated. Waiting times differed between clinics and shorter waits were likely for older children and those referred from an educational source. While the introduction of NICE guidance has increased the rate of prescription, the time taken before prescription suggests that the tendency in England is still to postpone treatment by medication. The reasons for this require further research.
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Affiliation(s)
- David M Foreman
- Child and Adolescent Mental Health Service, Nobles Hospital, Strang, Braddan, Isle of Man, IM4 4RJ, UK. E-mail:
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Affiliation(s)
- Diane E May
- Department of Psychiatry, University of Nebraska Medical Center, Omaha, Nebraska 68198-5581, USA
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Hong J, Dilla T, Arellano J. A modelled economic evaluation comparing atomoxetine with methylphenidate in the treatment of children with attention-deficit/hyperactivity disorder in Spain. BMC Psychiatry 2009; 9:15. [PMID: 19366449 PMCID: PMC2674033 DOI: 10.1186/1471-244x-9-15] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/30/2008] [Accepted: 04/14/2009] [Indexed: 11/16/2022] Open
Abstract
BACKGROUND Attention Deficit/Hyperactivity Disorder (ADHD) is a neurobehavioural disorder, affecting 3-6% of school age children and adolescents in Spain. Methylphenidate (MPH), a mild stimulant, had long been the only approved medication available for ADHD children in Spain. Atomoxetine is a non-stimulant alternative in the treatment of ADHD with once-a-day oral dosing. This study aims to estimate the cost-effectiveness of atomoxetine compared to MPH. In addition, atomoxetine is compared to 'no medication' for patient populations who are ineligible for MPH (i.e. having stimulant-failure experience or co-morbidities precluding stimulant medication). METHODS An economic model with Markov processes was developed to estimate the costs and benefits of atomoxetine versus either MPH or 'no medication'. The incremental cost per quality-adjusted life-year (QALY) was calculated for atomoxetine relative to the comparators. The Markov process incorporated 14 health states, representing a range of outcomes associated with treatment options. Utility values were obtained from the utility valuation survey of 83 parents of children with ADHD. The clinical data were based on a thorough review of controlled clinical trials and other clinical literature, and validated by international experts. Costs and outcomes were estimated using Monte Carlo simulation over a 1-year duration, with costs estimated from the perspective of the National Health Service in Spain. RESULTS For stimulant-naive patients without contra-indications to stimulants, the incremental costs per QALY gained for atomoxetine were euro 34,308 (compared to an immediate-release MPH) and euro 24,310 (compared to an extended-release MPH). For those patients who have stimulant-failure experience or contra-indications to stimulants, the incremental costs per QALY gained of atomoxetine compared to 'no medication' were euro 23,820 and euro 23,323, respectively. CONCLUSION The economic evaluation showed that atomoxetine is an effective alternative across a range of ADHD populations and offers value-for money in the treatment of ADHD.
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Affiliation(s)
- Jihyung Hong
- LSE Health, London School of Economics, London, UK.
| | - Tatiana Dilla
- Eli Lilly and Company, S.A, Alcobendas (Madrid), Spain
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Wehmeier PM, Schacht A, Rothenberger A. Change in the direct cost of treatment for children and adolescents with hyperkinetic disorder in Germany over a period of four years. Child Adolesc Psychiatry Ment Health 2009; 3:3. [PMID: 19175910 PMCID: PMC2654853 DOI: 10.1186/1753-2000-3-3] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/18/2008] [Accepted: 01/28/2009] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND In many developed countries, the treatment of hyperkinetic disorder (or ADHD) consumes a considerable amount of resources. The primary aim of this study was to determine change in the direct cost of treatment for children and adolescents with hyperkinetic disorder in Germany over time, and compare the cost with the cost of treatment for two physical disorders: epilepsy and asthma. METHODS The German Federal Statistical Office provided data on the direct cost of treating hyperkinetic disorder, epilepsy and asthma in Germany for 2002, 2004, and 2006. The direct costs of treatment incurred by hyperkinetic disorder in these years were compared with those incurred by epilepsy and asthma. RESULTS The total direct cost of treatment for the hyperkinetic disorder was euro 177 million in 2002, euro 234 million in 2004, and euro 341 million in 2006. The largest proportion of the cost was incurred by the age group < 15 years: euro 158 million in 2002, euro 205 million in 2004, and euro 287 million in 2006. The direct cost of treatment for epilepsy in this age group was a total of euro 157 million in 2002, euro 155 million in 2004, and euro 155 million in 2006. For asthma, the total direct cost of treatment in this age group was euro 266 million in 2002, euro 257 million in 2004, and euro 272 million in 2006. CONCLUSION The direct cost of treatment for hyperkinetic disorder in the age group < 15 years increased considerably between 2002 and 2006. Over the same period of time and for the same age group, expenditure for epilepsy and asthma was more or less constant. The increase in expenditure for the treatment of hyperkinetic disorder may be due to increasing demand for diagnostic and therapeutic services and improved availability of such services. The study is limited by the difficulty of obtaining consistent data on the direct cost of treatment for both physical and psychiatric disorders in Germany.
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Affiliation(s)
- Peter M Wehmeier
- Medical Department, Lilly Deutschland GmbH, Bad Homburg, Germany.
| | | | - Aribert Rothenberger
- Department of Child and Adolescent Psychiatry, University of Göttingen, Göttingen, Germany
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Reeves G, Anthony B. Multimodal treatments versus pharmacotherapy alone in children with psychiatric disorders: implications of access, effectiveness, and contextual treatment. Paediatr Drugs 2009; 11:165-9. [PMID: 19445545 PMCID: PMC5312750 DOI: 10.2165/00148581-200911030-00002] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/02/2022]
Abstract
Practice guidelines for the treatment of youth with mental health problems tend to endorse integrating psychopharmacologic treatment with psychosocial interventions, such as psychotherapy and parent skills training. However, poor access to pediatric mental health specialists and inadequate training of primary care physicians in psychosocial interventions make it difficult for families to receive this standard of care. Large pediatric randomized, multicenter trials, including the Multimodal Treatment Study of ADHD (attention deficit hyperactivity disorder) [MTA] and the Treatment for Adolescents with Depression Study (TADS), have begun to identify specific advantages of multimodal treatment compared with psychopharmacology alone. Advantages of combined treatment include improvement of both symptoms and family functioning. More research is needed to determine effective and appropriate multimodal interventions for complex and severe pediatric mental illness. Advantages of multimodal treatment must be balanced with the treatment burden on the family system.
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Affiliation(s)
- Gloria Reeves
- Child and Adolescent Psychiatry Division, University of Maryland, Baltimore, Maryland, USA.
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Pelham WE, Fabiano GA. Evidence-based psychosocial treatments for attention-deficit/hyperactivity disorder. JOURNAL OF CLINICAL CHILD AND ADOLESCENT PSYCHOLOGY 2008; 37:184-214. [PMID: 18444058 DOI: 10.1080/15374410701818681] [Citation(s) in RCA: 449] [Impact Index Per Article: 28.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
Pelham, Wheeler, and Chronis (1998) reviewed the treatment literature on attention-deficit/hyperactivity disorder (ADHD) and concluded behavioral parent training (BPT) and behavioral classroom management (BCM) were well-established treatments for children with ADHD. This review updates and extends the finding of the prior review. Studies conducted since the 1998 review were identified and coded based on standard criteria, and effect sizes were calculated where appropriate. The review reinforces the conclusions of Pelham, Wheeler, and Chronis regarding BPT and BCM. Further, the review shows that intensive peer-focused behavioral interventions implemented in recreational settings (e.g., summer programs) are also well-established. The results of this update are discussed in the context of the existing treatment literature on ADHD. Implications for practice guidelines are suggested, as are directions for future research.
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Affiliation(s)
- William E Pelham
- State University of New York at Buffalo, Center for Children and Families, Buffalo, NY 14214, USA.
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Schlander M. Is NICE infallible? A qualitative study of its assessment of treatments for attention-deficit/hyperactivity disorder (ADHD). Curr Med Res Opin 2008; 24:515-35. [PMID: 18186971 DOI: 10.1185/030079908x260808] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
BACKGROUND Conclusions of the recent NICE technology appraisal of treatments for attention-deficit/hyperactivity disorder (ADHD) differ from recommendations by other Health Technology Assessment (HTA) agencies, such as the Scottish Medicines Consortium (CMS) and the Australian Pharmaceutical Benefits Advisory Committee (PBAC). NICE did not identify differences on grounds of clinical effectiveness between treatment options studied and issued technology guidance based on clinical profiles of compounds and on drug acquisition costs. The aim of the present study was to explore the robustness of NICE assessment methods when addressing a complex clinical problem such as the evaluation of ADHD treatment strategies. This robustness will be of interest to international policy-makers, given the widespread perception of NICE as a role model for the implementation of HTAs including economic evaluation. METHODS A qualitative case study was performed to critically appraise the technology assessment report (AR) underlying NICE conclusions, including a systematic search for and analysis of relevant literature. RESULTS The AR produced on behalf of NICE was found to exhibit a range of anomalies. Search criteria were not applied consistently, and the available clinical evidence was not used optimally; selection of clinical endpoints and clinical trials for analysis were idiosyncratic. The primary cost-effectiveness model relied on six short-term studies only, and secondary extensions combined heterogeneous study designs and different clinical endpoints. Neither the distinction between efficacy and effectiveness nor the role of treatment compliance in ADHD was addressed adequately. Long-term extensions of the model were impaired by use of inappropriate discount rates and absence of consideration of long-term sequelae associated with ADHD. CONCLUSION A review of the literature strongly suggests that the NICE assessment of ADHD treatment strategies was incomplete and likely prone to bias. It is concluded that NICE did not adequately accommodate a complex clinical decision problem. Although the present qualitative case study of one assessment cannot, and was not designed to, invalidate the NICE approach to economic evaluation of healthcare programs, this observation may have potentially far-reaching implications for the generalizability of NICE-like approaches.
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Affiliation(s)
- Michael Schlander
- Institute for Innovation & Valuation in Health Care (InnoVal HC), Eschborn, Germany.
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Is stacking intervention components cost-effective? An analysis of the Incredible Years program. J Am Acad Child Adolesc Psychiatry 2007; 46:1414-24. [PMID: 18049291 DOI: 10.1097/chi.0b013e3181514c8a] [Citation(s) in RCA: 53] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVE Research demonstrates that interventions targeting multiple settings within a child's life are more effective in treating or preventing conduct disorder. One such program is the Incredible Years Series, which comprises three treatment components, each focused on a different context and type of daily social interaction that a child encounters. This article explores the cost-effectiveness of stacking multiple intervention components versus delivering single intervention components. METHOD The data involved 459 children, ages 3 to 8, who participated in clinical trials of the Incredible Years Series. Children randomized to one of six treatment conditions received one or more of the three following program components: a child-based program, a parent training program, and a teacher-based program instructing teachers in classroom management and in the delivery of a classroom-based social skills curriculum. RESULTS Per-child treatment costs and child behavior outcomes (observer and teacher reported) were used to generate cost-effectiveness acceptability curves; results suggest that stacking intervention components is likely cost-effective, at least for willingness to pay above $3,000 per child treated. CONCLUSIONS Economic data may be used to compare competing intervention formats. In the case of this program, providing multiple intervention components was cost-effective.
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Schlander M. Long-acting medications for the hyperkinetic disorders. A note on cost-effectiveness. Eur Child Adolesc Psychiatry 2007; 16:421-9. [PMID: 17401606 DOI: 10.1007/s00787-007-0615-2] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 02/06/2007] [Indexed: 01/05/2023]
Abstract
New long-acting medications for attention-deficit/ hyperactivity disorder (ADHD) have become available, which combine certain advantages over conventional short-acting drugs with higher acquisition costs. Choices between these drugs should thus be driven by their clinical profiles and by an acceptable balance of increased costs and additional benefits. Accordingly, the notion of relative cost-effectiveness should be central to recommendations about the use of these drugs in practice. A recent technology assessment on behalf of the National Institute for Health and Clinical Excellence (NICE) did not identify differences between compounds in terms of clinical efficacy and described drug cost as the major driver of cost-effectiveness. The underlying economic model was restricted to a cost-utility analysis that used only a fraction of the available clinical evidence base and did not address the distinction between efficacy and effectiveness. Cost-effectiveness evaluations including the potential impact of improved treatment compliance indicate a relatively more attractive cost-effectiveness of long-acting medications than suggested by the NICE assessment. These evaluations provide health economic support to treatment recommendations recently published by the European Network for Hyperkinetic Disorders. Limitations of currently available economic evaluations include their short time horizon, and future research should assess treatment effects on long-term sequelae associated with ADHD.
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Affiliation(s)
- Michael Schlander
- Institute for Innovation & Valuation in Health Care, Eschborn, Germany.
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