QALYs and mental health care

Examining how well economic evaluations capture the value of mental health

Health economics evidence informs health-care decision making, but the field has historically paid insufficient attention to mental health. Economic evaluations in health should define an appropriate scope for benefits and costs and how to value them. This Health Policy provides an overview of these processes and considers to what extent they capture the value of mental health. We suggest that although current practices are both transparent and justifiable, they have distinct limitations from the perspective of mental health. Most social value judgements, such as the exclusion of interindividual outcomes and intersectoral costs, diminish the value of improving mental health, and this reduction in value might be disproportionate compared with other types of health. Economic analyses might have disadvantaged interventions that improve mental health compared with physical health, but research is required to test the size of such differential effects and any subsequent effect on decision-making systems such as health technology assessment systems. Collaboration between health economics and the mental health sciences is crucial for achieving mental-physical health parity in evaluative frameworks and, ultimately, improving population mental health.

Assessment of health-related quality of life in individuals with depressive symptoms: validity and responsiveness of the EQ-5D-3L and the SF-6D

BACKGROUND

The EQ-5D and the SF-6D are examples of commonly used generic preference-based instruments for assessing health-related quality of life (HRQoL). However, their suitability for mental disorders has been repeatedly questioned.

OBJECTIVE

To assess the responsiveness and convergent validity of the EQ-5D-3L and SF-6D in patients with depressive symptoms.

METHODS

The data analyzed were from cardiac patients with depressive symptoms and were collected as part of the SPIRR-CAD (Stepwise Psychotherapy Intervention for Reducing Risk in Coronary Artery Disease) trial. The EQ-5D-3L and SF-6D were compared with the HADS (Hospital Anxiety and Depression Scale) and PHQ-9 (Patient Health Questionnaire) as disease-specific instruments. Convergent validity was assessed using Spearman's rank correlation. Effect sizes were calculated and ROC analysis was performed to determine responsiveness.

RESULTS

Data from 566 patients were analysed. The SF-6D correlated considerably better with the disease-specific instruments (|rs|= 0.63-0.68) than the EQ-5D-3L (|rs|= 0.51-0.56). The internal responsiveness of the SF-6D was in the upper range of a small effect (ES: - 0.44 and - 0.47), while no effect could be determined for the EQ-5D-3L. Neither the SF-6D nor the EQ-5D-3L showed acceptable external responsiveness for classifying patients' depressive symptoms as improved or not improved. The ability to detect patients whose condition has deteriorated was only acceptable for the EQ-5D-3L.

CONCLUSION

Overall, both the convergent validity and responsiveness of the SF-6D are better than those of the EQ-5D-3L in patients with depressive symptoms. The SF-6D appears, therefore, more recommendable for use in studies to evaluate interventions for this population.

Outcome measures for economic evaluations and cost-effectiveness analyses of interventions for people with intellectual disabilities: A methodological systematic review

BACKGROUND

Mainstream economic evaluations methods may not be appropriate to capture the range of effects triggered by interventions for people with intellectual disabilities. In this systematic review, we aimed to identify, assess and synthesise the arguments in the literature on how the effects of interventions for people with intellectual disabilities could be measured in economic evaluations.

METHOD

We searched for studies providing relevant arguments by running multi-database, backward, forward citation and grey literature searches. Following title/abstract and full-text screening, the arguments extracted from the included studies were summarised and qualitatively assessed in a narrative synthesis.

RESULTS

Our final analysis included three studies, with their arguments summarised in different methodological areas.

CONCLUSIONS

Based on the evidence, we suggest the use of techniques more attuned to the population with intellectual disabilities, such sensitive preference-based instruments to collect health states data, and mapping algorithms to obtain utility values.

Conceptualising 'Benefits Beyond Health' in the Context of the Quality-Adjusted Life-Year: A Critical Interpretive Synthesis

There is growing interest in extending the evaluative space of the quality-adjusted life-year framework beyond health. Using a critical interpretive synthesis approach, the objective was to review peer-reviewed literature that has discussed non-health outcomes within the context of quality-adjusted life-years and synthesise information into a thematic framework. Papers were identified through searches conducted in Web of Science, using forward citation searching. A critical interpretive synthesis allows for the development of interpretations (synthetic constructs) that go beyond those offered in the original sources. The final output of a critical interpretive synthesis is the synthesising argument, which integrates evidence from across studies into a coherent thematic framework. A concept map was developed to show the relationships between different types of non-health benefits. The critical interpretive synthesis was based on 99 papers. The thematic framework was constructed around four themes: (1) benefits affecting well-being (subjective well-being, psychological well-being, capability and empowerment); (2) benefits derived from the process of healthcare delivery; (3) benefits beyond the recipient of care (spillover effects, externalities, option value and distributional benefits); and (4) benefits beyond the healthcare sector. There is a wealth of research concerning non-health benefits and the evaluative space of the quality-adjusted life-year. Further dialogue and debate are necessary to address conceptual and normative challenges, to explore the societal willingness to sacrifice health for benefits beyond health and to consider the equity implications of different courses of action.

Lives and livelihoods: Estimates of the global mortality and poverty effects of the Covid-19 pandemic

We evaluate the global welfare consequences of increases in mortality and poverty generated by the Covid-19 pandemic. Increases in mortality are measured in terms of the number of years of life lost (LY) to the pandemic. Additional years spent in poverty (PY) are conservatively estimated using growth estimates for 2020 and two different scenarios for its distributional characteristics. Using years of life as a welfare metric yields a single parameter that captures the underlying trade-off between lives and livelihoods: how many PYs have the same welfare cost as one LY. Taking an agnostic view of this parameter, we compare estimates of LYs and PYs across countries for different scenarios. Three main findings arise. First, we estimate that, as of early June 2020, the pandemic (and the observed private and policy responses) had generated at least 68 million additional poverty years and 4.3 million years of life lost across 150 countries. The ratio of PYs to LYs is very large in most countries, suggesting that the poverty consequences of the crisis are of paramount importance. Second, this ratio declines systematically with GDP per capita: poverty accounts for a much greater share of the welfare costs in poorer countries. Finally, a comparison of these baseline results with mortality estimates in a counterfactual "herd immunity" scenario suggests that welfare losses would be greater in the latter in most countries.

Cost-effectiveness of Interventions for Chronic Fatigue Syndrome or Myalgic Encephalomyelitis: A Systematic Review of Economic Evaluations

INTRODUCTION

Chronic fatigue syndrome/myalgic encephalomyelitis (CFS/ME) has profound quality of life and economic consequences for individuals, their family, formal services and wider society. Little is known about which therapeutic interventions are more cost-effective.

OBJECTIVE

A systematic review was carried out to identify and critically appraise the evidence on the cost-effectiveness of CFS/ME interventions.

METHODS

The review protocol was prespecified (PROSPERO: CRD42018118731). Searches were carried out across two databases-MEDLINE (1946-2020) and EMBASE (1974-2020). Additional studies were identified by searching reference lists. Only peer-reviewed journal articles of full economic evaluations examining CFS/ME interventions were included. Trial- and/or model-based economic evaluations were eligible. Data extraction and screening were carried out independently by two reviewers. The methodological quality of the economic evaluation and trial were assessed using the Consensus Health Economic Criteria checklist (CHEC-list) and Risk of Bias-2 (RoB-2) tool, respectively. A narrative synthesis was used to summarise the economic evidence for interventions for adults and children in primary and secondary care settings.

RESULTS

Ten economic evaluations, all based on data derived from randomised controlled trials, met our eligibility criteria. Cognitive behavioural therapy (CBT) was evaluated across five studies, making it the most commonly evaluated intervention. There was evidence from three trials to support CBT as a cost-effective treatment option for adults; however, findings on CBT were not uniform, suggesting that cost-effectiveness may be context-specific. A wide array of other interventions were evaluated in adults, including limited evidence from two trials supporting the cost effectiveness of graded exercise therapy (GET). Just one study assessed intervention options for children. Our review highlighted the importance of informal care costs and productivity losses in the evaluation of CFS/ME interventions.

CONCLUSIONS

We identified a limited patchwork of evidence on the cost-effectiveness of interventions for CFS/ME. Evidence supports CBT as a cost-effective treatment option for adults; however, cost-effectiveness may depend on the duration and frequency of sessions. Limited evidence supports the cost effectiveness of GET. Key weaknesses in the literature included small sample sizes and short duration of follow-up. Further research is needed on pharmacological interventions and therapies for children.

Presentation and validation of the Abbreviated Self Completion Teen-Addiction Severity Index (ASC T-ASI): A preference-based measure for use in health-economic evaluations

Economic evaluations of new youth mental health interventions require preference-based outcome measures that capture the broad benefits these interventions can have for adolescents. The Abbreviated Self Completion Teen-Addiction Severity Index (ASC T-ASI) was developed to meet the need for such a broader measure. It assesses self reported problems in seven important domains of adolescents' lives, including school performance and family relationships, and is intended for use in economic evaluations of relevant interventions. The aim of the current study was to present the ASC T-ASI and examine its validity as well as its ability to distinguish between adolescents with and without problems associated with substance use and delinquency. The validation study was conducted in a sample of adolescents (n = 167) aged 12-18 years, who received in- or outpatient care in a youth mental health and (enclosed) care facility in the Netherlands. To examine its feasibility, test-retest reliability, and convergent validity, respondents completed the ASC T-ASI, as well as the EQ-5D-3L and SDQ at baseline and after a two-week interval using a counterbalanced method. The ASC T-ASI descriptive system comprises seven domains: substance use, school, work, family, social relationships, justice, and mental health, each expressing self reported problems on a five-point Likert scale (ranging from having 'no problem' to having a 'very large problem'). The majority of respondents (>70%) completed the ASC T-ASI within 10 minutes and appraised the questions as (very) easy and (very) comprehensible. Test-retest reliability was adequate (Kw values 0.26-0.55). Correlations with the supplementary measures were moderate to high (rs 0.30-0.50), suggesting convergent validity. The ASC T-ASI is a promising and valid measure for assessing self reported problems in important domains in adolescents' lives, allowing benefits beyond health and health-related quality of life to be included in economic evaluations of youth mental health interventions. Future studies of the ASC T-ASI should consider the comprehensiveness of its domains and sensitivity to change.

Problematic cost-utility analysis of interventions for behavior problems in children and adolescents

Cost–utility analyses are slowly becoming part of randomized control trials evaluating physical and mental health treatments and (preventive) interventions in child and adolescent development. The British National Institute of Health and Care Excellence, for example, insists on the use of gains in Quality Adjusted Life Years (QALYs) to compute the “value for money” of interventions. But what counts as a gain in quality of life? For one of the most widely used instruments, the EuroQol 5 Dimensions scale (EQ‐5D), QALYs are estimated by healthy individuals who provide utility scores for specific health states, assuming that the best life is a life without self‐experienced problems in five domains: mobility, self‐care, usual activities, pain/discomfort, and anxiety/depression. The worst imaginable outcome is defined as “a lot of problems” in each of these five domains. The impact of the individual's problems on the social network is not weighted, and important social–developmental domains (externalizing problems, social competence) are missing. Current cost–utility computations based on EQ‐5D favor physical health over mental health, and they rely on adult weights for child and adolescent quality of life. Thus, a level playing field is absent, and developmental expertise is sorely missing.

Sociocultural and economic aspects of quality of life measurement

Obtaining a level of consensus over the definition, construction and measurement of the concept of quality of life would allow for an improved degree of standardization in the assessment of clinical intervention for people with mental health problems. One of the many benefits of this standardization would be the ability to make valid and reliable comparisons between various interventions and across different groups or settings, which is of particular interest to economists. There are, however, a host of sociocultural issues that present fundamental obstacles to the satisfactory attainment of consensus over definitions and domains of quality of life. This paper considers the arguments pertinent to each of these two alternative perspectives, the economic and the sociocultural (or anthropological), and draws out the lessons that these perspectives — despite the apparent polarity that exists between them — can offer to the improved measurement of quality of life for those with mental health problems.

Homeless persons' experiences of health- and social care: A systematic integrative review

Homelessness is associated with high risks of morbidity and premature death. Many interventions aimed to improve physical and mental health exist, but do not reach the population of persons experiencing homelessness. Despite the widely reported unmet healthcare needs, more information about the barriers and facilitators that affect access to care for persons experiencing homelessness is needed. A systematic integrative review was performed to explore experiences and needs of health- and social care for persons experiencing homelessness. The following databases were searched: AMED, ASSIA, Academic Search Complete, CINAHL, Cochrane library, Nursing and Allied Database, PsycInfo, PubMed, Scopus and Web of Science Core Collection. Twenty-two studies met the inclusion criteria of empirical studies with adult persons experiencing homelessness, English language, and published 2008-2018. Fifty percent of the studies were of qualitative and quantitative design, respectively. Most studies (73%) were conducted in the United States (n=11) and Canada (n=5). The analysis resulted in three themes Unmet basic human needs, Interpersonal dimensions of access to care, and Structural and organizational aspects to meet needs. The findings highlight that persons in homelessness often must prioritize provision for basic human needs, such as finding shelter and food, over getting health- and social care. Bureaucracy and rigid opening hours, as well as discrimination and stigma, hinder these persons' access to health- and social care.

Economic value of protected areas via visitor mental health

We evaluate methods to calculate the economic value of protected areas derived from the improved mental health of visitors. A conservative global estimate using quality-adjusted life years, a standard measure in health economics, is US$6 trillion p.a. This is an order of magnitude greater than the global value of protected area tourism, and two to three orders greater than global aggregate protected area management agency budgets. Future research should: refine this estimate using more precise methods; consider interactions between health and conservation policies and budgets at national scales; and examine links between personalities and protected area experiences at individual scale.

The ReThink study: a 3-arm parallel randomized trial of cognitive bias modification, with and without adherence promotion, for adolescent anxiety disorder: trial design and protocol

BACKGROUND

Anxiety disorders are the most common mental health problem among youth, contribute to reduced quality of daily life, and are associated with high rates of comorbidity. However, treatment rates for anxiety are very low, causing a sizeable treatment gap. There is an immediate need to identify treatment interventions that are effective, affordable, and can be delivered easily to the youth population. Cognitive Bias Modification (CBM) is one potentially effective intervention that could reach youth on a large scale, especially when self-administered at home. Thus, we aim to assess the benefit of CBM to treat youth anxiety. Further, we aim to test whether adding an adherence promotion (AP) component to the CBM intervention can improve outcomes, and whether CBM delivered both with and without the AP component is cost effective.

METHODS

This is a 12-month randomized controlled trial (RCT) conducted within an existing healthcare system. Potentially eligible youth (ages 12 to 17) will be identified by reviewing the electronic health record (EHR) for clinical anxiety diagnoses, which are then confirmed via research interview. We aim to enroll 498 participants and randomize them 1:1:1 to one of three arms: Arm 1 is a Low-Ratio version of the CBM program (nearly identical to the other CBM versions, but minimally effective); Arm 2 is a High-Ratio "active" CBM program; and Arm 3 is the High-Ratio CBM program with an added AP component. Participants will complete assessments at baseline, 1-, 3-, 6- and 12-months post-baseline. Youth in all three arms will self-administer the CBM program at home and will be asked to complete twelve intervention sessions over a four-week period. Arm 3 participants (High-Ratio CBM + AP) will also receive up to four telephone calls from phone coaches during the intervention period to provide technical assistance, encouragement, and motivational enhancement to increase adherence. The primary clinical outcome will be anxiety remission at 6-month follow-up.

DISCUSSION

This study protocol describes the method and design for an RCT to test whether self-administered CBM both with and without adherence promotion can be an effective at-home treatment for anxious youth.

TRIAL REGISTRATION

ClinicalTrials.gov : NCT02156531, First Posted June 5, 2014.

Are acceptance and mindfulness-based interventions 'value for money'? Evidence from a systematic literature review

OBJECTIVES

Acceptance and mindfulness-based interventions (A/MBIs) are recommended for people with mental health conditions. Although there is a growing evidence base supporting the effectiveness of different A/MBIs for mental health conditions, the economic case for these interventions has not been fully explored. The aim of this systematic review was to identify and appraise all available economic evidence of A/MBIs for the management of mental health conditions.

METHODS

Eight electronic bibliographic databases (MEDLINE, MEDLINE In-Process & Other Non-Indexed Citations, EMBASE, Web of Science, NHS Economic Evaluation Database (EED), Database of Abstracts of Reviews of Effects (DARE), Health Technology Assessment (HTA) database, and EconLit) were searched for relevant economic evaluations published from each database's inception date until November 2017. Study selection, quality assessment, and data extraction were carried out according to published guidelines.

RESULTS

Ten relevant economic evaluations presented in 11 papers were identified. Seven of the included studies were full economic evaluations (i.e., costs and effects assessed), and three studies were partial economic evaluations (i.e., only costs were considered in the analysis). The A/MBIs that had been subjected to economic evaluation were acceptance and commitment therapy (ACT), dialectical behaviour therapy (DBT), mindfulness-based cognitive therapy (MBCT), and mindfulness-based stress reduction (MBSR). In terms of clinical presentations, the evaluation of cost-effectiveness of A/MBIs has been more focused on depression and emotional unstable personality disorder with three and four economic evaluations, respectively. Three out of seven full economic evaluations observed that A/MBIs were cost-effective for the management of mental health conditions. Nevertheless, the heterogeneity of included populations, interventions, and economic evaluation study types limits the extent to which firm conclusions can currently be made.

CONCLUSION

This first substantive review of economic evaluations of A/MBIs indicates that more research is needed before firm conclusions can be reached on the cost-effectiveness of A/MBIs for mental health conditions.

PRACTITIONER POINTS

The findings of the review provide information that may be relevant to mental health service commissioners and decision-makers as all economic evidence available on acceptance and mindfulness-based interventions for mental health conditions is summarized. Evidence relating to the cost-effectiveness and cost-saving potential of acceptance and mindfulness-based interventions is focused mainly on depression and emotional unstable personality disorder to date. Heterogeneity in the specific forms of acceptance and mindfulness-based interventions may limit generalizability of the findings. The number of health economic evaluations relating to acceptance and mindfulness-based interventions remains relatively small. Further research in this area is required.

Health-Related Quality of Life in People Living with Psychotic Illness and Factors Associated with Its Variation

OBJECTIVES

To establish whether the four-dimensional Assessment of Quality of Life (AQoL-4D) produces robust utility values in adults with psychotic illness, and identify health inequalities compared with the general population.

METHODS

The AQoL-4D was completed by 1613 individuals with an International Classification of Diseases, Tenth Revision, psychotic illness in the 2010 Australian National Survey of Psychosis. Utilities were assessed for this sample and 20 subgroups, and were compared with general population norms. Modified Cohen d was used as an index of effect size. Utilities were collapsed into 10 health-related quality-of-life (HRQOL) bands or decades.

RESULTS

HRQOL in people with psychotic illness was half of the maximum achievable utility (half-"full health") with a mean utility of 0.49 (95% confidence interval [CI] 0.48-0.51), and showing substantial variability across subgroups. Participants with essentially normal functioning had the highest mean utility (0.72; 95% CI 0.68-0.77), and those with very poor perceived mental health had the lowest (0.22; 95% CI 0.18-0.26). These subgroups showed the most variability. Negative symptoms also gave rise to substantial variation. Among diagnostic categories, only depressive psychosis had a large effect relative to delusional disorders. The distribution of utilities in people with psychotic illness differed markedly from that in the general population, with 6.8% versus 47.2% having values in the highest decade (>0.90-1.00). Utilities were lower in every age group in people with psychosis.

CONCLUSIONS

Profound HRQOL impacts are revealed by the AQoL-4D in people with psychotic illness, and marked variations in utilities were observed for key subjective and objective measures. We provide a suite of utility values for economic modeling studies and recommend the AQoL-4D for assessing HRQOL in people with psychotic illness.

A systematic review of health economic models and utility estimation methods in schizophrenia

INTRODUCTION

There is a growing need for economic evaluations describing the disease course, as well as the costs and clinical outcomes related to the treatment of schizophrenia.

AREAS COVERED

A systematic review on studies describing health economic models in schizophrenia and a targeted literature review on utility mapping algorithms in schizophrenia were carried out. Models found in the review were collated and assessed in detail according to their type and various other attributes. Fifty-nine studies were included in the review. Modeling techniques varied from simple decision trees to complex simulation models. The models used various clinical endpoints as value drivers, 47% of the models used quality-adjusted life years, and eight percent used disability-adjusted life years to measure benefits, while others applied various clinical outcomes. Most models considered patients switching between therapies, and therapeutic adherence, compliance or persistence. The targeted literature review identified four main approaches to map PANSS scores to utility values.

EXPERT COMMENTARY

Health economic models developed for schizophrenia showed great variability, with simulation models becoming more frequently used in the last decade. Using PANSS scores as the basis of utility estimations is justifiable.

Are Quality-Adjusted Life Years a Good Proxy Measure of Individual Capabilities?

BACKGROUND

There is a debate in the health economics literature concerning the most appropriate way of applying Amartya Sen's capability approach in economic evaluation studies. Some suggest that quality-adjusted life years (QALYs) alone are adequate while others argue that this approach is too narrow and that direct measures of capability wellbeing provide a more extensive application of Sen's paradigm.

OBJECTIVE

This paper empirically explores whether QALYs provide a good proxy for individual capabilities.

METHODS

Data is taken from a multinational cross-sectional survey of individuals with seven health conditions (asthma, arthritis, cancer, depression, diabetes, hearing loss, heart disease) and a healthy population. Each individual completed the ICECAP-A measure of capability wellbeing for adults and six health utility instruments that are used to generate QALYs, including EQ-5D and SF-6D. Primary analysis examines how well health utility instruments can explain variation in the ICECAP-A using ordinary least squares regression.

RESULTS

The findings show that all seven health conditions have a negative association on overall capability as measured by the ICECAP-A index. Inclusion of health utility instruments into separate regressions improves the predictive power of capability but on average, explains less than half of the variation in capability wellbeing. Individuals with arthritis appear to be less inhibited in terms of capability losses when accounting for health utility, yet those who have depression record significant reductions in capability relative to the healthy population even after accounting for the most commonly used health utility instruments.

CONCLUSION

The study therefore casts doubt on the ability of QALYs to act as a reliable proxy measure of individuals' capability.

Maximizing Health or Sufficient Capability in Economic Evaluation? A Methodological Experiment of Treatment for Drug Addiction

Conventional practice within the United Kingdom and beyond is to conduct economic evaluations with "health" as evaluative space and "health maximization" as the decision-making rule. However, there is increasing recognition that this evaluative framework may not always be appropriate, and this is particularly the case within public health and social care contexts. This article presents a methodological case study designed to explore the impact of changing the evaluative space within an economic evaluation from health to capability well-being and the decision-making rule from health maximization to the maximization of sufficient capability. Capability well-being is an evaluative space grounded on Amartya Sen's capability approach and assesses well-being based on individuals' ability to do and be the things they value in life. Sufficient capability is an egalitarian approach to decision making that aims to ensure everyone in society achieves a normatively sufficient level of capability well-being. The case study is treatment for drug addiction, and the cost-effectiveness of 2 psychological interventions relative to usual care is assessed using data from a pilot trial. Analyses are undertaken from a health care and a government perspective. For the purpose of the study, quality-adjusted life years (measured using the EQ-5D-5L) and years of full capability equivalent and years of sufficient capability equivalent (both measured using the ICECAP-A [ICEpop CAPability measure for Adults]) are estimated. The study concludes that different evaluative spaces and decision-making rules have the potential to offer opposing treatment recommendations. The implications for policy makers are discussed.

A Review of Economic Evaluations of Community Mental Health Care

The authors review the methodology and findings of economic evaluations of 42 community mental health care programs reported in the English-language literature between 1979 and 2003. There were three substantial methodological problems in the literature: costs were often not completely specified, the quality of econometric analysis was often low, and most evaluations failed to integrate cost and health outcome information. Well-conducted research shows that care in the community dominates hospital in-patient care, achieving better outcomes at lower or equal cost. It is less clear what types of community programs are most cost-effective. Future research should focus on identifying which types of community care are most cost effective and at what level of intensity they are most effective.

Impact of Treatment with Naloxegol for Opioid-Induced Constipation on Patients' Health State Utility

Introduction

Opioid-induced constipation (OIC) is the most common side effect of opioid treatment. Treatment for OIC typically involves a laxative. However, some patients have an inadequate response to these (laxative inadequate responders, or LIR). This has led to the development of treatments such as naloxegol. This analysis estimates the impact of naloxegol on the health state utility of LIR patients, examines if this utility impact is driven by the change in OIC status, and estimates the utility impact of relief of OIC.

Methods

The analysis was conducted using data from two 12-week randomized controlled trials, KODIAC 4 (ClinicalTrials.gov identifier, NCT01309841) and KODIAC 5 (ClinicalTrials.gov identifier, NCT01323790), plus KODIAC 7 (ClinicalTrials.gov identifier, NCT01395524), a 12-week extension to KODIAC 4. All were designed to assess the efficacy and safety of oral naloxegol (12.5 and 25 mg) compared to placebo. Health state utility data were collected through the EuroQol—five dimensions questionnaire (EQ-5D-3L). Descriptive analysis was undertaken to estimate how EQ-5D utility scores and EQ-5D domain responses varied with treatment, OIC status, and over time. A repeated measure mixed-effects model was used to predict the change from baseline in health state utility score over time.

Results

Compared with placebo, LIR patients treated with naloxegol 25 mg reported a 0.08 improvement in the EQ-5D overall score after 12 weeks of treatment. The analyses also suggest that change in OIC status is a key driver of the impact of OIC treatment on health state utility. When other factors are controlled, relieving OIC is associated with a 0.05 improvement in health state utility, although treatment with naloxegol is associated with an improvement in health state utility over and above the improvement in OIC status.

Conclusion

These analyses suggest that treatment with naloxegol improves patients’ health state utility; driven predominantly by the relief of patients’ constipation.

Funding

AstraZeneca.

Effectiveness and cost-effectiveness of a brief school-based group programme for parents of children at risk of ADHD: a cluster randomised controlled trial

BACKGROUND

National Institute for Health and Care Excellence guidelines recommend a stepped care approach for the identification and management of children with, or at risk of, attention-deficit/hyperactivity disorder (ADHD). We investigated the effectiveness, cost-effectiveness and acceptability of a group parenting intervention programme (+/- a teacher session) for children at risk of ADHD.

METHODS

In a three-arm cluster randomised controlled trial, 12 primary schools were randomly assigned to control, parent-only and combined (parent + teacher) intervention arms. Eligible children had high levels of parent-rated hyperactivity/inattention (n = 199). At 6 month follow-up, the primary outcome measure was the parent-completed Conners' Rating Scale - Revised (ADHD index). Secondary outcomes included the Conners' sub-scales (hyperactivity, cognitive problems/inattention and oppositional behaviour), the teacher-completed Conners' Rating Scale - Revised, child health-related quality of life, parental burden and parental mental health. The cost-effectiveness analyses reflected a health and personal social services perspective.

TRIAL REGISTRATION

ISRCTN87634685.

RESULTS

Follow-up data were obtained from 76 parents and 169 teachers. There was no effect of the parent-only (mean difference = -1.1, 95% CI -5.1,2.9; p = 0.57) or combined interventions (mean difference = -2.1, 95% CI -6.4,2.1; p = 0.31) on the ADHD index. The combined intervention was associated with reduced parent-reported hyperactivity symptoms (mean difference = -5.3; 95% CI -10.5,-0.01; p = 0.05) and the parent-only intervention with improved parental mental health (mean difference = -1.9; 95% CI -3.2,-0.5; p = 0.009). The incremental costs of the parent-only and the combined interventions were £73 and £123, respectively. Above a willingness-to-pay of £31 per one-point improvement in the ADHD index, the parent-only programme had the highest probability of cost-effectiveness. Participants found the interventions acceptable.

CONCLUSIONS

For children at risk of ADHD, this school-based parenting programme was not associated with improvement in core ADHD symptoms. Secondary analyses suggested a possible reduction in parent-reported hyperactivity and parental mental health problems. Future research should compare targeted interventions against watchful waiting and specialist referral.

Alternative approaches for assessing the socioeconomic benefits of medical devices: a systematic review

Many medical devices offer improvements over current care that may be difficult to assess using standard methods of economic benefit measurement such as the quality-adjusted life-year (QALY). The objective of this research was to explore the extent to which these benefits have been measured and valued by alternative approaches, such as willingness-to-pay studies or discrete choice experiments. We undertook a systematic review of the literature from 1996 to 2013 to identify empirical studies on the benefits of medical devices using the alternative methodologies. The search resulted in 2772 hits, of which 2016 were considered not relevant to the study and 76 were duplicates. After further examination, there were 30 relevant empirical studies, of which 18 were willingness-to-pay and 12 discrete choice experiments. This research demonstrates that while it is feasible to measure and value the attributes of devices using alternative approaches to standard quality-of-life measures, the literature is quite limited when compared with that for non-device technologies.

Economic evaluation of mental health interventions: an introduction to cost-utility analysis

Finite resources need to be allocated over an ever-increasing range of competing health policies and interventions. Economic evaluation has been developed as a methodology to inform decision makers on the efficiency of particular resource allocations. In this paper we summarize cost-utility analysis, one of the most widely-used forms of economic evaluation in healthcare. We discuss its main elements, interpretation, limitations and relevance to the domain of mental health.

Comprehensively Measuring Health-Related Subjective Well-Being: Dimensionality Analysis for Improved Outcome Assessment in Health Economics

BACKGROUND

Allocation of inevitably limited financial resources for health care requires assessment of an intervention's effectiveness. Interventions likely affect quality of life (QOL) more broadly than is measurable with commonly used health-related QOL utility scales. In line with the World Health Organization's definition of health, a recent Delphi procedure showed that assessment needs to put more emphasis on mental and social dimensions.

OBJECTIVE

To identify the core dimensions of health-related subjective well-being (HR-SWB) for a new, more comprehensive outcome measure.

METHODS

We formulated items for each domain of an initial Delphi-based set of 21 domains of HR-SWB. We tested these items in a large sample (N = 1143) and used dimensionality analyses to find a smaller number of latent factors.

RESULTS

Exploratory factor analysis suggested a five-factor model, which explained 65% of the total variance. Factors related to physical independence, positive affect, negative affect, autonomy, and personal growth. Correlations between the factors ranged from 0.19 to 0.59. A closer inspection of the factors revealed an overlap between the newly identified core dimensions of HR-SWB and the validation scales, but the dimensions of HR-SWB also seemed to reflect additional aspects. This shows that the dimensions of HR-SWB we identified go beyond the existing health-related QOL instruments.

CONCLUSIONS

We identified a set of five key dimensions to be included in a new, comprehensive measure of HR-SWB that reliably captures these dimensions and fills in the gaps of the existent measures used in economic evaluations.

The DEP-6D, a new preference-based measure to assess health states of dependency

In medical literature there are numerous multidimensional scales to measure health states for dependence in activities of daily living. However, these scales are not preference-based and are not able to yield QALYs. On the contrary, the generic preference-based measures are not sensitive enough to measure changes in dependence states. The objective of this paper is to propose a new dependency health state classification system, called DEP-6D, and to estimate its value set in such a way that it can be used in QALY calculations. DEP-6D states are described as a combination of 6 attributes (eat, incontinence, personal care, mobility, housework and cognition problems), with 3-4 levels each. A sample of 312 Spanish citizens was surveyed in 2011 to estimate the DEP-6D preference-scoring algorithm. Each respondent valued six out of the 24 states using time trade-off questions. After excluding those respondents who made two or more inconsistencies (6% out of the sample), each state was valued between 66 and 77 times. The responses present a high internal and external consistency. A random effect model accounting for main effects was the preferred model to estimate the scoring algorithm. The DEP-6D describes, in general, more severe problems than those usually described by means of generic preference-based measures. The minimum score predicted by the DEP-6D algorithm is -0.84, which is considerably lower than the minimum value predicted by the EQ-5D and SF-6D algorithms. The DEP-6D value set is based on community preferences. Therefore it is consistent with the so-called 'societal perspective'. Moreover, DEP-6D preference weights can be used in QALY calculations and cost-utility analysis.

The validity and responsiveness of the ICECAP-A capability-well-being measure in women with irritative lower urinary tract symptoms

Purpose

A desire to incorporate broader aspects of well-being in health economic evaluations has led to the development of the ICEpop CAPability measure for Adults (ICECAP-A). The ICECAP-A draws upon Amartya Sen’s capability approach and conceptualises well-being as the capability to achieve Stability, Attachment, Autonomy, Achievement, and Enjoyment. The aim of this study was to assess the psychometric performance of the ICECAP-A in a context where patient outcomes can extend beyond health-related quality of life.

Methods

Longitudinal data were collected for 478 women with symptoms of urinary frequency and urgency, with or without incontinence. Women were recruited across 22 hospitals in the UK and had a mean age of 55 (SD 14). The psychometric performance of the measure was evaluated in relation to the EuroQol Five-Dimension Questionnaire (EQ-5D-3L) and the International Consultation on Incontinence Questionnaire for Overactive Bladder (ICIQ-OAB) and involved an assessment of acceptability, construct validity, and responsiveness using parametric and nonparametric methods.

Results

ICECAP-A showed good convergence with the ICIQ-OAB with 20 out of 22 expected patterns of relationship confirmed. Findings suggested that the ICECAP-A has better discriminative properties than EQ-5D-3L and as good as those of the ICIQ-OAB, confirming expected associations with clinical and demographic factors. The ICECAP-A was more responsive than EQ-5D-3L and ICIQ-OAB to deteriorations of clinical symptoms. Improvements in symptoms were not valued as highly as deteriorations by either ICECAP-A or EQ-5D-3L.

Conclusions

The ICECAP-A is a valid and responsive measure capturing broad emotional and practical impacts of urinary symptoms on women’s well-being and could be considered for use in economic evaluations in this context.

Housing First Impact on Costs and Associated Cost Offsets: A Review of the Literature

OBJECTIVE

Housing First (HF) programs for people who are chronically or episodically homeless, combining rapid access to permanent housing with community-based, integrated treatment, rehabilitation and support services, are rapidly expanding in North America and Europe. Overall costs of services use by homeless people can be considerable, suggesting the potential for significant cost offsets with HF programs. Our purpose was to provide an updated literature review, from 2007 to the present, focusing specifically on the cost offsets of HF programs.

METHOD

A systematic review was performed on MEDLINE and PsycINFO as well as Google and the Homeless Hub for grey literature. Study characteristics and key findings were extracted from identified studies. Where available, impact on service cost associated with HF (increase or decrease) and net impact on overall costs, taking into account the cost of HF intervention, were noted.

RESULTS

Twelve published studies (4 randomized studies and 8 quasi-experimental) and 22 unpublished studies were retained. Shelter and emergency department costs decreased with HF, while impacts on hospitalization and justice costs are more ambiguous. Studies using a pre-post design reported a net decrease in overall costs with HF. In contrast, experimental studies reported a net increase in overall costs with HF.

CONCLUSIONS

While our review casts doubt on whether HF programs can be expected to pay for themselves, the certainty of significant cost offsets, combined with their benefits for participants, means that they represent a more efficient allocation of resources than traditional services.

Does convenience matter in health care delivery? A systematic review of convenience-based aspects of process utility

OBJECTIVES

To systematically review the existing literature on the value associated with convenience in health care delivery, independent of health outcomes, and to try to estimate the likely magnitude of any value found.

METHODS

A systematic search was conducted for previously published studies that reported preferences for convenience-related aspects of health care delivery in a manner that was consistent with either cost-utility analysis or cost-benefit analysis. Data were analyzed in terms of the methodologies used, the aspects of convenience considered, and the values reported.

RESULTS

Literature searches generated 4715 records. Following a review of abstracts or full-text articles, 27 were selected for inclusion. Twenty-six studies reported some evidence of convenience-related process utility, in the form of either a positive utility or a positive willingness to pay. The aspects of convenience valued most often were mode of administration (n = 11) and location of treatment (n = 6). The most common valuation methodology was a discrete-choice experiment containing a cost component (n = 15).

CONCLUSIONS

A preference for convenience-related process utility exists, independent of health outcomes. Given the diverse methodologies used to calculate it, and the range of aspects being valued, however, it is difficult to assess how large such a preference might be, or how it may be effectively incorporated into an economic evaluation. Increased consistency in reporting these preferences is required to assess these issues more accurately.

The estimation of utility weights in cost-utility analysis for mental disorders: a systematic review

OBJECTIVE

To systematically review approaches and instruments used to derive utility weights in cost-utility analyses (CUAs) within the field of mental disorders and to identify factors that may have influenced the choice of the approach.

METHODS

We searched the databases DARE (Database of Abstracts of Reviews of Effects), NHS EED (National Health Service Economic Evaluation Database), HTA (Health Technology Assessment), and PubMed for CUAs. Studies were included if they were full economic evaluations and reported quality-adjusted life-years as the health outcome. Study characteristics and instruments used to estimate utility weights were described and a logistic regression analysis was conducted to identify factors associated with the choice of either the direct (e.g. standard gamble) or the preference-based measure (PBM) approach (e.g. EQ-5D).

RESULTS

We identified 227 CUAs with a maximum in 2009, 2010, and 2012. Most CUAs were conducted in depression, dementia, or psychosis, and came from the US or the UK, with the EQ-5D being the most frequently used instrument. The application of the direct approach was significantly associated with depression, psychosis, and model-based studies. The PBM approach was more likely to be used in recent studies, dementia, Europe, and empirical studies. Utility weights used in model-based studies were derived from only a small number of studies.

LIMITATIONS

We only searched four databases and did not evaluate the quality of the included studies.

CONCLUSIONS

Direct instruments and PBMs are used to elicit utility weights in CUAs with different frequencies regarding study type, mental disorder, and country.

'Show me the money': improving the economic evaluation of mental health services

BACKGROUND

Compared with the United Kingdom, mental health services in Ireland are under-funded and under-developed. This may be partly due to the neglect of economic analyses concerning mental health services in Ireland, as few policy makers would invest in the sector without evidence that such investment represents 'value-for-money' economically. Aim The aim of this paper is to highlight how mental health services can conduct economic service evaluations that ultimately will drive the policy-making agenda and future governmental investment.

METHODS

A guide to the economic evaluation of mental health services, based on a narrative review of relevant policy documents and papers, in an Irish context.

RESULTS

Three types of economic analyses that can be undertaken within mental health services are outlined: (a) cost-benefit analysis, (b) cost-utility analysis and (c) cost-minimisation analysis. In addition, a newly formulated questionnaire (i.e. the 'EcoPsy 12') is presented.

CONCLUSIONS

Economic evaluations of mental health services can provide re-assurances to policy-makers that (much-needed) investment in such services is economically viable.

Testing the McSad depression specific classification system in patients with somatic conditions: validity and performance

Background

Valuations of depression are useful to evaluate depression interventions offered to patients with chronic somatic conditions. The only classification system to describe depression developed specifically for valuation purposes is the McSad, but it has not been used among somatic patients. The aim of this study was to test the construct validity of the McSad among diabetes and cancer patients and then to compare the McSad to the commonly used EuroQol – 5 Dimensions (EQ-5D^TM) classification system. The comparison was expected to shed light on their capacity to reflect the range of depression states experienced by somatic patients.

Methods

Cross-sectional data were collected online from 114 diabetes and 195 cancer patients; additionally, 241 cancer patients completed part of the survey on paper. Correlational analyses were performed to test the construct validity. Specifically, we hypothesized high correlations of the McSad domains with depression (Center for Epidemiological Studies Depression Scale (CES-D) and the Patient Health Questionnaire (PHQ-9)). We also expected low/moderate correlations with self-esteem (Rosenberg Self-Esteem scale - RSE) and extraversion (Eysenck Personality Questionnaire Extraversion scale - EPQ-e). Multiple linear regression analyses were run so that the proportion of variance in depression scores (CES-D, PHQ-9) explained by the McSad could be compared to the proportion explained by the EQ-5D classification system.

Results

As expected, among all patients groups, we found moderate to high correlations for the McSad domains with the CES-D (.41 to .70) and the PHQ-9 (.52 to .76); we also found low to moderate correlations with the RSE (-.21 to .-48) and the EPQ-e (.18 to .31). Linear regression analyses showed that the McSad explained a greater proportion of variance in depression (CES-D, PHQ-9) (Diabetes: 73%, 82%; Cancer: 72%, 72%) than the EQ-5D classification system (Diabetes: 47%, 59%; Cancer: 51%, 47%).

Conclusions

Findings support the construct validity of the McSad among patients with somatic conditions and demonstrate that it performs better than the EQ-5D classification system to reflect the range of depression states. For future valuation purposes, the McSad classification system could therefore be recommended to describe depression as experienced by patients with a chronic medical condition.

A validation of the ICECAP-O in a population of post-hospitalized older people in the Netherlands

BACKGROUND

Various healthcare and social services may impact not only health, but wellbeing as well. Such effects may be more fully captured by capability-wellbeing instruments than with Health-related Quality of Life (HrQol) instruments. The aim of this study is to validate the ICEpop (Investigating Choice Experiments for the Preferences of Older People) CAPability measure for Older people (ICECAP-O) capability wellbeing instrument in a population of post-hospitalized older people admitted to a hospital 3 months earlier.

METHODS

296 post-hospitalized older people in the Netherlands were interviewed 3 months after admission between September 2010 and January 2011. We investigated the convergent validity of the ICECAP-O and overall wellbeing measures (Cantril's ladder and Social Production Function: Instrument for Level of Well-being (SPF-IL)), as well as with various health measures (EQ5D, Katz-15 Instrumental Activities of Daily Living (IADL) scale, Geriatric Depression Scale (GDS) and the Medical Outcomes Study Short form (SF-20) social functioning dimension). Additionally, we assessed discriminant validity by comparing several relevant subgroups in our sample (based on age, depression, IADL dependency, living situation, etc.). We also investigated the relationship between overall wellbeing and the ICECAP-O, controlling for HrQol and background characteristics.

RESULTS

This study suggests that the ICECAP-O has good convergent validity with wellbeing measures as well as health measures and discriminates between various groups of post-hospitalized older people. Wellbeing measured by both Cantril's ladder and SPF-IL is associated with the ICECAP-O in a multivariate analysis controlling for HRQoL as well.

CONCLUSION

The ICECAP-O seems to be a valid instrument of capability-wellbeing in older, post-hospitalized people, showing good convergent validity with health and wellbeing instruments, and is able to discriminate between elderly with various health profiles. The ICECAP-O measure seems to capture both health and wellbeing. Therefore it is a promising instrument for assessing the outcomes of health and social services aimed at older people.

The use of a Cumulative Needs for Care Monitor for individual treatment v. care as usual for patients diagnosed with severe mental illness, a cost-effectiveness analysis from the health care perspective

AIMS

To study the systematic assessment of need for care and clinical parameters for use in treatment plans in patients diagnosed with severe mental illness.

METHODS

The Cumulative Needs for Care Monitor (CNCM) includes various validated instruments, such as the Camberwell Assessment of Need. A Markov-type cost-effectiveness model (health care perspective, 5-year time horizon) was used to compare CNCM with care as usual (CAU). Two studies were used to determine model parameters: a before–after study (n = 2155) and a matched-control study (n = 937).

RESULTS

The CNCM may lead to a gain in psychiatric functioning according to the models. CNCM patients remain in (outpatient) care, while CAU patients drop out more frequently. There is only a small difference in inpatient care. As a result, average costs per patient in the CNCM group are between €2809 (before–after model) and €5251 (matched-control model) higher. The iCER was between €45 127 and €57 839 per life year without psychiatric dysfunction gained.

CONCLUSIONS

CNCM may be only cost-effective when willingness to pay for a life year without psychiatric dysfunction is higher than €45 000. However, this result is highly sensitive to the level of psychiatric dysfunctioning in patients who do not receive care.

Estimating a preference-based index from the Clinical Outcomes in Routine Evaluation-Outcome Measure (CORE-OM): valuation of CORE-6D

Background. The Clinical Outcomes in Routine Evaluation–Outcome Measure (CORE-OM) is used to evaluate the effectiveness of psychological therapies in people with common mental disorders. The objective of this study was to estimate a preference-based index for this population using CORE-6D, a health state classification system derived from the CORE-OM consisting of a 5-item emotional component and a physical item, and to demonstrate a novel method for generating states that are not orthogonal. Methods. Rasch analysis was used to identify 11 emotional health states from CORE-6D that were frequently observed in the study population and are, thus, plausible (in contrast, conventional statistical design might generate implausible states). Combined with the 3 response levels of the physical item of CORE-6D, they generate 33 plausible health states, 18 of which were selected for valuation. A valuation survey of 220 members of the public in South Yorkshire, United Kingdom, was undertaken using the time tradeoff (TTO) method. Regression analysis was subsequently used to predict values for all possible states described by CORE-6D. Results. A number of multivariate regression models were built to predict values for the 33 health states of CORE-6D, using the Rasch logit value of the emotional state and the response level of the physical item as independent variables. A cubic model with high predictive value (adjusted R² = 0.990) was selected to predict TTO values for all 729 CORE-6D health states. Conclusion. The CORE-6D preference-based index will enable the assessment of cost-effectiveness of interventions for people with common mental disorders using existing and prospective CORE-OM data sets. The new method for generating states may be useful for other instruments with highly correlated dimensions.

Development of a self-report measure of capability wellbeing for adults: the ICECAP-A

PURPOSE

The benefits of health and social care are not confined to patient health alone and therefore broader measures of wellbeing may be useful for economic evaluation. This paper reports the development of a simple measure of capability wellbeing for adults (ICECAP-A).

METHODS

In-depth, informant-led, interviews to identify the attributes of capability wellbeing were conducted with 36 adults in the UK. Eighteen semi-structured, repeat interviews were carried out to develop a capability-based descriptive system for the measure. Informants were purposively selected to ensure variation in socio-economic status, age, sex, ethnicity and health. Data analysis was carried out inductively and iteratively alongside interviews, and findings were used to shape the questions in later interviews.

RESULTS

Five over-arching attributes of capability wellbeing were identified for the measure: "stability", "attachment", "achievement", "autonomy" and "enjoyment". One item, with four response categories, was developed for each attribute for the ICECAP-A descriptive system.

CONCLUSIONS

The ICECAP-A capability measure represents a departure from traditional health economics outcome measures, by treating health status as an influence over broader attributes of capability wellbeing. Further work is required to value and validate the attributes and test the sensitivity of the ICECAP-A to healthcare interventions.

The relationship among Mental Health Status (GHQ-12), Health Related Quality of Life (EQ-5D) and Health-State Utilities in a general population

Aim – To assess the relationship between mental health and health-related quality of life (HRQL) in the general population, and to map GHQ-12 as a screening test for population psychological distress to a generic health state measure (EQ-5D) in order to estimate health state values and allow deriving quality-adjusted life years. Methods – Relationship between mental health and HRQL was examined from the 2004 Canary Islands’ Health Survey. Participants were classified as probable psychiatric cases according to GHQ-12. HRQL was measured by the EQ-5D index. Multivariate lineal regression analysis was used to examine the association between mental health and HRQL adjusting by socio-demographic variables and comorbidities. A multivariate regression model was built from EQ-5D to estimate health states values using GHQ-12 as exposure. Results – EQ-5D index scores decreased as the GHQ-12 scores increased. Clinical and socio-demographic factors influenced HRQL without changing the overall trend for this negative relationship. The regression equation explained 43% of the variance. For estimation of utility scores, the model showed a high predictive capacity, with a mean forecast errors of 16%. Conclusions – HRQL progressively decreased when the probability of being a psychiatric case increased. Findings enable health state values to be derived from GHQ-12 scores for populations where utilities has not or cannot be measured directly.

Declaration of Interest: Authors declare no conflicts of interest. This work was supported by the Quality Plan for the National Health Service (Spanish Ministry of Health and Social Policy).

Viewpoint: Economic evaluation of package of care interventions employing clinical guidelines

Increasingly attention is shifting towards delivering essential packages of care, often based on clinical practice guidelines, as a means to improve maternal, child and newborn survival in low-income settings. Cost effectiveness analysis (CEA), allied to the evaluation of less complex intervention, has become an increasingly important tool for priority setting. Arguably such analyses should be extended to inform decisions around the deployment of more complex interventions. In the discussion, we illustrate some of the challenges facing the extension of CEA to this area. We suggest that there are both practical and methodological challenges to overcome when conducting economic evaluation for packages of care interventions that incorporate clinical guidelines. Some might be overcome by developing specific guidance on approaches, for example clarity in identifying relevant costs. Some require consensus on methods. The greatest challenge, however, lies in how to incorporate, as measures of effectiveness, process measures of service quality. Questions on which measures to use, how multiple measures might be combined, how improvements in one area might be compared with those in another and what value is associated with improvement in health worker practices are yet to be answered.

Using Rasch analysis to form plausible health states amenable to valuation: the development of CORE-6D from a measure of common mental health problems (CORE-OM)

PURPOSE

To describe a new approach for deriving a preference-based index from a condition specific measure that uses Rasch analysis to develop health states.

METHODS

The CORE-OM is a 34-item instrument monitoring clinical outcomes of people with common mental health problems. The CORE-OM is characterised by high correlation across its domains. Rasch analysis was used to reduce the number of items and response levels in order to produce a unidimensional measure and to generate a credible set of health states corresponding to different levels of symptom severity using the Rasch item threshold map.

RESULTS

The proposed methodology resulted in the development of CORE-6D, a 2-dimensional health state descriptive system consisting of a unidimensional 5-item emotional component (derived from Rasch analysis) and a physical symptom item. Inspection of the Rasch item threshold map of the emotional component helped identify a set of 11 plausible health states, which, combined with 3 physical symptom item levels, form 33 plausible health states that can be used for the valuation of the instrument, resulting in the development of a preference-based index.

CONCLUSIONS

This is a useful new approach to develop preference-based measures from existing instruments with high correlations across domains. The CORE-6D preference-based index will enable calculation of Quality-Adjusted Life Years in people with common mental health problems.

Evaluating willingness-to-pay thresholds for dementia caregiving interventions: application to the tailored activity program

OBJECTIVES

The study aims to apply willingness-to-pay (WTP) values derived from the literature to inform decision-makers of the cost-effectiveness of the Tailored Activity Program (TAP), an intervention proven to reduce caregiver burden.

METHODS

TAP and other caregiver interventions employ an individual perspective and non-quality-adjusted life-year (QALY) outcome measure where the primary objective is to determine caregiver burden from an individual perspective. Therefore, standard cost/QALY thresholds are not appropriate. To identify relevant WTP values, we searched for studies that: 1) were published in the past 5 years and used contingent valuation methodology to identify WTP; 2) assessed WTP for a dementia-related intervention requiring out-of-pocket expenditure; and 3) asked caregivers their WTP for an outcome related to reducing caregiver burden. Three studies were identified utilizing four WTP values. We also assessed potential financial savings that caregivers could achieve from purchasing TAP. To assess the probability of TAP being cost-effective, we built a Monte Carlo simulation to test the four WTP values applied to two TAP outcome measures: reduction in caregiver hours "on duty;" and "doing things."

RESULTS

  For outcome measure "on duty," WTP varied between $1.06/hour and $4.58/hour. For outcome measure "doing things," WTP varied between $2.21/hour and $9.57/hour. Applying the four identified WTP values from the literature to TAP outcomes resulted in TAP cost-effectiveness varying between 50% and 80% for both outcome measures.

CONCLUSIONS

When WTP data are not collected prospectively or conventional metrics cannot be applied, retrospectively assessing literature-derived WTP may be acceptable for informing decision-makers of potential cost-effectiveness of a proven program. Application of WTP to TAP shows potential cost-effectiveness that can be expected under the tested WTP scenarios.

Cost-effectiveness of an early intervention service for people with psychosis

BACKGROUND

There is concern that delaying treatment for psychosis may have a negative impact on its long-term course. A number of countries have developed early intervention teams but there is limited evidence regarding their cost-effectiveness.

AIMS

To compare the costs and cost-effectiveness of an early intervention service in London with standard care.

METHOD

Individuals in their first episode of psychosis (or those who had previously discontinued treatment) were recruited to the study. Clinical variables and costs were measured at baseline and then at 6- and 18-month follow-up. Information on quality of life and vocational outcomes were combined with costs to assess cost-effectiveness.

RESULTS

A total of 144 people were randomised. Total mean costs were 11,685 pounds sterling in the early intervention group and 14,062 pounds sterling in the standard care group, with the difference not being significant (95% CI -8128 pounds sterling to 3326 pounds sterling). When costs were combined with improved vocational and quality of life outcomes it was shown that early intervention would have a very high likelihood of being cost-effective.

CONCLUSIONS

Early intervention did not increase costs and was highly likely to be cost-effective when compared with standard care.

A review and critique of studies reporting utility values for schizophrenia-related health states

Economic evaluation of health technologies in the form of cost-utility analysis is increasingly advocated. The most common outcome measure in this type of analysis is the QALY. In order to estimate QALYs, appropriate utility values are required. The objective of this review was to identify and critique utility values for schizophrenia-related health states. A critical appraisal was performed on utility values for schizophrenia identified in the systematic literature review that informed the economic analysis of the updated edition of the National Institute for Health and Clinical Excellence (NICE) clinical guideline on schizophrenia for England and Wales. Seven studies reporting utility values for schizophrenia were identified. The studies employed a variety of methods for generating utility values. None of the reported sets of utility values for schizophrenia were generated using the EQ-5D, which is a measure widely used in cost-utility analysis and preferred by NICE. Nevertheless, the EQ-5D may be less sensitive in capturing aspects of health-related quality of life in patients with schizophrenia. A condition-specific preference-based instrument may be more appropriate than a generic measure to inform cost-utility analyses of interventions for schizophrenia.

Screening for postnatal depression in primary care: cost effectiveness analysis

OBJECTIVE

To evaluate the cost effectiveness of routine screening for postnatal depression in primary care.

DESIGN

Cost effectiveness analysis with a decision model of alternative methods of screening for depression, including standardised postnatal depression and generic depression instruments. The performance of screening instruments was derived from a systematic review and bivariate meta-analysis at a range of instrument cut points; estimates of other relevant parameters were derived from literature sources and relevant databases. A decision tree considered the full treatment pathway from the possible onset of postnatal depression through identification, treatment, and possible relapse.

SETTING

Primary care.

PARTICIPANTS

A hypothetical population of women assessed for postnatal depression either via routine care only or supplemented by use of formal identification methods six weeks postnatally, as recommended in recent guidelines.

MAIN OUTCOME MEASURES

Costs expressed in 2006-7 prices and impact on health outcomes expressed in terms of quality adjusted life years (QALYs). The time horizon of the analysis was one year.

RESULTS

The routine application of either postnatal or general depression questionnaires did not seem to be cost effective compared with routine care only. The Edinburgh postnatal depression scale (at a cut point of 16) had an incremental cost effectiveness ratio (ICER) of pound 41,103 (euro 45,398, $67,130) per QALY compared with routine care only. The ICER for all other strategies ranged from pound 49,928 to pound 272,463 per QALY versus routine care only, while the probability that no formal identification strategy was cost effective was 88% (59%) at a cost effectiveness threshold of pound 20,000 ( pound 30,000) per QALY. While sensitivity analysis indicated that the cost of managing incorrectly identified depression (false positive result) was an important driver of the model, formal identification approaches did not seem to be cost effective at any feasible estimate of this cost.

CONCLUSIONS

Formal identification methods for postnatal depression do not seem to represent value for money for the NHS. The major determinant of cost effectiveness seems to be the potential additional costs of managing women incorrectly diagnosed as depressed. Formal identification methods for postnatal depression do not currently satisfy the National Screening Committee's criteria for the adoption of a screening strategy as part of national health policy.

"Through a glass, darkly": the clinical and ethical implications of Munchausen syndrome

Patients who present repeatedly for care with medically unexplained symptoms raise challenges for the health system. One proposed strategy for dealing with such patients is the introduction of electronic medical records (EMRs) to identify these patients and thus limit the demands on resources their management involves. This measure may ultimately be appropriate but fails to consider equally critical core issues in psychiatric ethics. Identifying patients as "somatisers" invites a problematic relaxation of clinical vigilance, increasing the likelihood that an actual life-threatening medical problem will not be identified. Management of such patients requires regular, structured therapeutic contact with a skilled mental health clinician, that is independent of the patient's distress level. Psychiatric problems and medical problems are frequently seen as two distinct, unrelated categories. This is a false dichotomy, as mental health and physical health are interdependent. Given patient privacy considerations, EMRs would be unlikely to reveal the kind of sensitive mental health information needed for the identification and management of somatising patients in busy health systems. Cost-effective interventions for somatising patients' problematic behaviour, such as structured clinical intervention, antidepressant medication and cognitive behaviour therapy, are available at a fraction of the cost of EMR systems. Citing cost savings as a justification for violating the privacy of mental health patients compounds the manifest injustice these patients already face in the health system.

[Economic evaluation in health care]

Economic evaluation of healthcare programmes helps us to assure the efficient use of healthcare resources. Cost-minimisation analysis, cost-effectiveness analysis, cost-utility analysis and cost-benefit analysis are the most commonly applied evaluation types. They differ in how they measure outcomes of healthcare interventions. Several guidelines for conducting economic evaluations exist. Furthermore, checklists have been developed for systematic critical appraisal of economic evaluations. Even though economic evaluations increase the transparency of resource allocation decisions and make decision criteria more explicit, they do not replace public discussions on the availability of overall resources for the public health care system.

Relative cost-effectiveness of treatments for adolescent depression: 36-week results from the TADS randomized trial

OBJECTIVE

The cost-effectiveness of three active interventions for major depression in adolescents was compared after 36 weeks of treatment in the Treatment of Adolescents with Depression Study.

METHOD

Outpatients aged 12 to 18 years with a primary diagnosis of major depression participated in a randomized controlled trial conducted at 13 U.S. academic and community clinics from 2000 to 2004. Three hundred twenty-seven participants randomized to 1 of 3 active treatment arms, fluoxetine alone (n = 109), cognitive-behavioral therapy (n = 111) alone, or their combination (n = 107), were evaluated for a 3-month acute treatment and a 6-month continuation/maintenance treatment period. Costs of services received for the 36 weeks were estimated and examined in relation to the number of depression-free days and quality-adjusted life-years. Cost-effectiveness acceptability curves were also generated. Sensitivity analyses were conducted to assess treatment differences on the quality-adjusted life-years and cost-effectiveness measures.

RESULTS

Cognitive-behavioral therapy was the most costly treatment component (mean $1,787 [in monotherapy] and $1,833 [in combination therapy], median $1,923 [for both]). Reflecting higher direct and indirect costs associated with psychiatric hospital use, the costs of services received outside Treatment of Adolescents with Depression Study in fluoxetine-treated patients (mean $5,382, median $2,341) were significantly higher than those in participants treated with cognitive-behavioral therapy (mean $3,102, median $1,373) or combination (mean $2,705, median $927). Accordingly, cost-effectiveness acceptability curves indicate that combination treatment is highly likely (>90%) to be more cost-effective than fluoxetine alone at 36 weeks. Cognitive-behavioral therapy is not likely to be more cost-effective than fluoxetine.

CONCLUSIONS

These findings support the use of combination treatment in adolescents with depression over monotherapy.

Measuring and valuing mental health for use in economic evaluation

This article presents research undertaken as part of a wider programme of work concerned with measuring and health and wellbeing for economic evaluation. The focus is on developing quality adjusted life years (QALYs) in mental health, but the issues are common across all areas of health care. The article begins by reviewing the issues of what should be valued (health or broader notions of wellbeing), how mental health and wellbeing should be described, how mental health states should be valued and who should do the valuing. The article presents four pieces of work. The first is a re-analysis of the ONS Psychiatric Morbidity 2000 Survey to provide evidence on the relevance of generic measures across different mental health disorders. It found that common mental health problems, such as anxiety and depression, had a significant impact on the generic preference-based measure of health in the SF-6D, but psychosis and personality disorders did not. The article then presents two studies using the ratings of people experiencing the states of health. Both studies found that people experiencing different health states gave mental health greater weight than physical health compared to members of the general public trying to imagine the health states. Finally, the article presents a study developing a condition-specific preference-based measure for calculating QALYs from an existing measure of mental health, the CORE-OM, using modern psychometric methods to construct health states amenable to valuation. It also considers a proposal to develop an entirely new QALY measure in mental health.

Utility assessment in patients with mental disorders: validity and discriminative ability of the time trade-off method

BACKGROUND

Preference-based health-state values, also referred to as utility scores, are considered an important measure of outcome in the evaluation of healthcare. A common approach to elicit utility scores is the use of the time trade-off (TTO) method; however, the data on TTO utility scores in patients with mental disorders are scarce.

OBJECTIVE

To analyse the TTO method in patients with mental disorders in terms of discriminative ability, validity and the refusal to trade life time (zero trade).

METHODS

In patients with affective (n = 172), schizophrenia spectrum (n = 166) and alcohol-related (n = 160) mental disorders, TTO utilities were administered through a standardized interview. Measures of quality of life (QOL) EQ-5D, WHOQOL-BREF, subjective (SCL-90R) and objective (CGI-S) psychopathology, and functioning (GAF, GARF, SOFAS, HoNOS) provided comparison. Discriminative ability was analysed by assessing frequency distributions of TTO utilities. Validity was analysed by assessing the correlation of TTO utilities with all other scores. The association of a patient's QOL, sociodemographic and disease-related variables with zero trade was analysed by logistic regression.

RESULTS

Of patients with affective/schizophrenic/alcohol-related mental disorders, 153/143/145 (89/86/91%), respectively, completed the TTO elicitation; 29/43/28% of the respondents were zero traders. The mean TTO utility was 0.66/0.75/0.61 and the median was 0.85/0.95/0.75. TTO utility scores discriminated well among more impaired mental health states, but discrimination was limited among less impaired health states. In patients with affective and alcohol-related mental disorders, TTO utility scores were significantly correlated (mostly moderate: 0.3 < r < 0.5) with all other scores. However, in schizophrenic patients, TTO utility scores were only a little correlated with other subjective measures and not correlated with objective measures. QOL was significantly associated with zero trade; the influence of the other variables on zero trade was negligible.

CONCLUSIONS

TTO utility scores in patients with affective or alcohol-related mental disorders were reasonably valid, but discriminative ability was compromised by a ceiling effect due to zero trade. In schizophrenic patients, validity of TTO utility scores was not demonstrated.