Estimation of a Relative Risk Effect Size when Using Continuous Outcomes Data: An Application of Methods in the Prevention of Major Depression and Eating Disorders

Psychiatric disorders and comorbidity in women with Turner Syndrome: a retrospective national cohort study

Turner syndrome (TS) is a genetic condition characterized by partial or complete monosomy X. A reduced life expectancy has been shown in TS, depending on an increased risk of aortic dissection, and ischemic heart disease. Studies covering the occurrence of psychiatric conditions are sparse within TS. Several case reports describe concomitant TS and neuropsychiatric abnormalities that may represent a pathogenetic link to genetics, as well as feature correlates of TS. The aim of this study was to determine the presence, and the frequency of psychiatric diagnosis in women with TS in a Swedish cohort followed during 25 years' time. Statistics from the entire female population in Sweden of corresponding age was used as reference. Data were retrieved from clinical examinations and validated from the National Board of Health and Welfare registries for women with TS (n = 487), aged 16 to 84 years, with respect to mental health disorders. The most common diagnoses in TS were mood and anxiety disorders. There was no increase in psychiatric diagnosis within the group with time, nor correlation to specific karyotype or somatic comorbidity as congenital heart disease and hypothyroidism, hormonal treatment, or childbirth. In addition, the frequency of psychiatric diagnosis in TS was lower than in the population-based data. Further investigations are needed in the view of the fact that women with Turner syndrome should not be burdened with more severe diagnoses.

The Modeled Cost-Effectiveness of a Prevention Program Targeting Both Eating Disorders and High BMI

OBJECTIVE

Prevention programs for eating disorders (EDs) and high body index mass (BMI) have the potential to reduce the onset of these interconnected public health concerns. However, it remains unclear whether routine implementation of such programs would be cost-effective. This study aims to determine the cost-effectiveness of an intervention that aims to prevent both ED and high BMI.

METHOD

A Markov model was developed to evaluate the incremental cost-effectiveness of a targeted school-based program, Healthy Weight, that aims to prevent both EDs and high BMI among Australian adolescents with body image concerns (aged 15-18 years), versus a "no intervention" comparator. A cost-utility analysis was conducted from a "healthcare and education" sector perspective with costs (measured in 2019 Australian dollars) and health impacts modeled over the lifetime of the target population. An incremental cost-effectiveness ratio (ICER), expressed as cost per health-adjusted life year (HALY) gained, was calculated. Sensitivity analyses were done to test model assumptions.

RESULTS

The mean intervention cost and HALYs gained were AUD$2.13 million (95% CI, AUD$1.83-2.43 million) and 146 (95% CI, 90-209), respectively. With healthcare cost-savings (AUD$3.97 million) included, the intervention was predicted to be cost-saving (AUD$1.83 million; 95% CI, AUD$0.51-3.21 million). Primary findings were robust to extensive sensitivity analyses.

DISCUSSION

The Healthy Weight intervention is likely to represent good value-for-money. To ensure the successful implementation of this program at the population level, further research on its feasibility and acceptability among schools and the wider community is required.

School-based socio-emotional learning programs to prevent depression, anxiety and suicide among adolescents: a global cost-effectiveness analysis

AIMS

Preventing the occurrence of depression/anxiety and suicide during adolescence can lead to substantive health gains over the course of an individual person's life. This study set out to identify the expected population-level costs and health impacts of implementing universal and indicated school-based socio-emotional learning (SEL) programs in different country contexts.

METHODS

A Markov model was developed to examine the effectiveness of delivering universal and indicated school-based SEL programs to prevent the onset of depression/anxiety and suicide deaths among adolescents. Intervention health impacts were measured in healthy life years gained (HLYGs) over a 100-year time horizon. Country-specific intervention costs were calculated and denominated in 2017 international dollars (2017 I$) under a health systems perspective. Cost-effectiveness findings were subsequently expressed in terms of I$ per HLYG. Analyses were conducted on a group of 20 countries from different regions and income levels, with final results aggregated and presented by country income group - that is, low and lower middle income countries (LLMICs) and upper middle and high-income countries (UMHICs). Uncertainty and sensitivity analyses were conducted to test model assumptions.

RESULTS

Implementation costs ranged from an annual per capita investment of I$0.10 in LLMICs to I$0.16 in UMHICs for the universal SEL program and I$0.06 in LLMICs to I$0.09 in UMHICs for the indicated SEL program. The universal SEL program generated 100 HLYGs per 1 million population compared to 5 for the indicated SEL program in LLMICs. The cost per HLYG was I$958 in LLMICS and I$2,006 in UMHICs for the universal SEL program and I$11,123 in LLMICs and I$18,473 in UMHICs for the indicated SEL program. Cost-effectiveness findings were highly sensitive to variations around input parameter values involving the intervention effect sizes and the disability weight used to estimate HLYGs.

CONCLUSIONS

The results of this analysis suggest that universal and indicated SEL programs require a low level of investment (in the range of I$0.05 to I$0.20 per head of population) but that universal SEL programs produce significantly greater health benefits at a population level and therefore better value for money (e.g., less than I$1,000 per HLYG in LLMICs). Despite producing fewer population-level health benefits, the implementation of indicated SEL programs may be justified as a means of reducing population inequalities that affect high-risk populations who would benefit from a more tailored intervention approach.

Cost-effectiveness of an indicated preventive intervention for depression in adolescents: a model to support decision making

BACKGROUND

Adolescent depression has negative health and economic outcomes in the short- and long-term. Indicated preventive interventions, in particular group based cognitive behavioural therapy (GB-CBT), are effective in preventing depression in adolescents with subsyndromal depression. However, little is known about the cost-effectiveness of these interventions.

METHODS

A Markov cohort model was used to conduct cost-effectiveness analyses comparing a GB-CBT indicated preventive intervention for depression, to a no-intervention option in a Swedish setting. Taking a time horizon of 5- and 10 years, incremental differences in societal costs and health benefits expressed as differences in the proportion of cases of depression prevented, and as quality adjusted life years (QALYs) gained were estimated. Through univariate and probabilistic sensitivity analyses, the robustness of the results was explored. Costs, presented in 2018 USD, and effects were discounted at a yearly rate of 3%.

RESULTS

The base-case analysis showed that GB-CBT indicated preventive intervention incurred lower costs, prevented a larger proportion of cases of depression and generated higher QALYs compared to the no-intervention option for both time horizons. Offering the intervention was even a cost saving strategy and demonstrated a probability of being cost-effective of over 95%. In the sensitivity analyses, these results were robust to the modelling assumptions.

LIMITATIONS

The study considered a homogeneous cohort and assumed a constant annual decay rate of the relative treatment effect.

CONCLUSIONS

GB-CBT indicated preventive interventions for depression in adolescence can generate good value for money compared to leaving adolescents with subsyndromal depression untreated.

Quantificational evaluation of the resolving power of qualitative biomarkers with different cardinal numbers based on a magnitude-standardized index

Biomarkers are used for clinical diagnostic purposes, but existing indexes exhibit limitations in terms of the resolving power of biomarkers. This paper proposes a new index, the magnitude-standardized index (MSI), to describe the quantitative variations and resolving powers of different biomarkers. In MSI analysis models, variation scales for ratios and differences are considered simultaneously, and a higher MSI value implies a stronger risk or effect for a biological factor. We explain the rationale for the MSI via hybrid and geometric methods and verify its efficacy through simulation experiments. Our results indicate that the MSI is superior to the Youden index and odds ratio for describing resolving power. When two biomarkers with similar Youden index values, odds ratios, or MSI values but different positive test rates (or cardinal numbers) were combined, all three index values increased; however, only the MSI value remained relatively stable. For a very small cardinal number, such as that of a single nucleotide polymorphism, the MSI value is at most half of the maximum value (0.5), allowing comparisons between MSI values for biomarkers with different cardinal numbers. The MSI can thus provide a better quantifiable evaluation of the resolving power of biomarkers with different cardinal numbers.

Uptake of methodological advances for synthesis of continuous and time-to-event outcomes would maximize use of the evidence base

Objective

The objective of the study is to establish how often continuous and time-to-event outcomes are synthesized in health technology assessment (HTA), the statistical methods and software used in their analysis and how often evidence synthesis informs decision models.

Study Design and Setting

This is a review of National Institute of Health Research HTA reports, National Institute for Health and Care Excellence (NICE) technology appraisals, and NICE guidelines reporting quantitative meta-analysis or network meta-analysis of at least one continuous or time-to-event outcome published from April 01, 2018 to March 31, 2019.

Results

We identified 47 eligible articles. At least one continuous or time-to-event outcome was synthesized in 51% and 55% of articles, respectively. Evidence synthesis results informed decision models in two-thirds of articles. The review and expert knowledge identified five areas where methodology is available for improving the synthesis of continuous and time-to-event outcomes: i) outcomes reported on multiple scales, ii) reporting of multiple related outcomes, iii) appropriateness of the additive scale, iv) reporting of multiple time points, and v) nonproportional hazards. We identified three anticipated barriers to the uptake and implementation of these methods: i) statistical expertise, ii) software, and iii) reporting of trials.

Conclusion

Continuous and time-to-event outcomes are routinely reported in HTA. However, increased uptake of methodological advances could maximize the evidence base used to inform the decision making process.

An Angle Compared Index with Hybrid of Changes in the Ratio and Amplitude for Quantitative Evaluation of Disease Risk, Biological Function, and Biomarker Efficacy

Objective

The purpose of this study was to describe variations of different cardinal frequency by using angle compared index (ACI).

Methods

The basic principle of the analysis model is to comprehensively consider changes in both the ratio and absolute value as follows: ACI = arctan {Pd⁎(1-Pc) / [Pc⁎(1-Pd)]} + arctan (Pd - Pc) - 45, where Pd represent percentage of disease occurrence in disease group and Pc represent that in control group. The range of ACI was (0~90). Thus, ACIs from different cardinal frequency are comparable.

Results

When biomarkers with similar ratio value, absolute value, or ACI but different positive frequencies were combined, although three indexes (ratio value, absolute value, or ACI) increased after two single biomarkers were combined, only ACI increased with similar amplitudes after two single biomarkers with the same ACI at different positive frequencies were combined.

Conclusion

The ACI provides a better understanding power of biomarker and may be a relatively good index for evaluating the complex events represented by different cardinal frequency from new systems.