How should cost data in pragmatic randomised trials be analysed?

Loss of quality of life and increased societal costs in patients with hypertrophic cardiomyopathy: the AFFECT-HCM study

INTRODUCTION

Hypertrophic cardiomyopathy (HCM) is the most prevalent inherited cardiac disease. The impact of HCM on quality of life (QoL) and societal costs remains poorly understood. This prospective multi-centre burden of disease study estimated QoL and societal costs of genotyped HCM patients and genotype-positive phenotype-negative (G+/P-) subjects.

METHODS AND RESULTS

Participants were categorized into three groups based on genotype and phenotype: (i) G+/P- [left ventricular (LV) wall thickness <13 mm], (ii) non-obstructive HCM [nHCM, LV outflow tract (LVOT) gradient <30 mmHg], and (iii) obstructive HCM (oHCM, LVOT gradient ≥30 mmHg). We assessed QoL with EQ-5D-5L and Kansas City Cardiomyopathy Questionnaires (KCCQ). Societal costs were measured using medical consumption (Medical Consumption Questionnaire) and productivity cost (iMTA Productivity Cost Questionnaire) questionnaires. We performed subanalyses within three age groups: <40, 40-59, and ≥60 years. From three Dutch hospitals, 506 subjects were enrolled (84 G+/P-, 313 nHCM, 109 oHCM; median age 59 years, 39% female). HCM (both nHCM and oHCM) patients reported reduced QoL vs. G+/P- subjects (KCCQ: 88 vs. 98, EQ-5D-5L: 0.88 vs. 0.96; both P < 0.001). oHCM patients reported lower KCCQ scores than nHCM patients (83 vs. 89, P = 0.036). Societal costs were significantly higher in HCM patients (€19,035/year vs. €7385/year) compared with G+/P- controls, mainly explained by higher healthcare costs and productivity losses. Being symptomatic and of younger age (<60 years) particularly led to decreased QoL and increased costs.

CONCLUSION

HCM is associated with decreased QoL and increased societal costs, especially in younger and symptomatic patients. oHCM patients were more frequently symptomatic than nHCM patients. This study highlights the substantial disease burden of HCM and can aid in assessing new therapy cost-effectiveness for HCM in the future.

Real-world healthcare utilization and costs of peripheral nerve stimulation with a micro-IPG system

AIM

To characterize real-world healthcare resource utilization (HCRU) and costs in adults with chronic pain of peripheral nerve origin treated with peripheral nerve stimulation (PNS) using the micro-implantable pulse generator (IPG).

MATERIALS & METHODS

This retrospective observational study (9/1/19-1/31/23) linked patients from the Nalu medical database to the OM1 Real-World Data Cloud (RWDC). Eligible patients received the micro-IPG implant for PNS, were identifiable in both databases, and had ≥ 12 months of RWDC pre/post-implantation claims data. Primary outcomes were all-cause HRCU and medical costs (12 months pre- and post-implantation); secondary outcomes were all-cause pharmacy costs, including opioids, over the same time.

RESULTS

Patients (N = 122) had a higher mean (standard deviation; SD) number of outpatient visits pre-implantation (5.7 [5.4]) than post-implantation (4.9 [5.7]). Mean (SD) total medical costs were 50% lower, from $27,493 ($44,756) to $13,717 ($23,278). Median (first-third quartile [Q1-Q3]) medical costs were 57% lower, from $11,809 ($4,075-$31,788) to $5,094 ($1,815-$13,820). Mean (SD) pharmacy costs (n = 77) were higher post-implantation ($22,470 [$77,203]) than pre-implantation ($20,092 [$64,132]), while median (Q1-Q3) costs were lower (from $2,708 [$222 -11,882] to $2,122 [$50-9,370]). Post-implantation, the proportion of patients using opioids was 31.4% lower.

CONCLUSION

Patients with PNS using the micro-IPG had reduced HCRU, costs, and opioid use.

The cost of maternity and neonatal care in Aotearoa New Zealand: A cost analysis by plurality and gestation using a population-based cohort

BACKGROUND

Maternity services in New Zealand are largely delivered by autonomously practising community midwives. This model of care is unique and may result in differences in the distribution of maternity healthcare utilisation and costs compared to other countries. New Zealand-specific cost data are needed to inform economic analyses, local policy and healthcare resource planning.

AIMS

To provide estimates of the average total cost of maternity and neonatal healthcare for New Zealand women and infants, including cost impacts of multiple and preterm births.

MATERIALS AND METHODS

A whole-of-population linked dataset, including 262 687 pregnancies resulting in a live birth (from 1 January 2016 to 30 June 2020), was created by combining several sources of healthcare data to calculate an average per-pregnancy cost of healthcare, taking a public health system perspective, during antenatal, intrapartum, and postnatal periods to one year after birth.

RESULTS

The mean cost of public healthcare was NZ$19 795 for both maternal and infant care to one year post-birth. The bulk of this cost was incurred during pregnancy and birth. Mean total cost to one year was NZ$69 895 for twin and NZ$201 448 for higher order multiple compared to singleton pregnancies at NZ$19 098. Mean total healthcare cost decreased as gestation increased.

CONCLUSIONS

Most of the costs associated with pregnancy and childbirth were incurred during the birth and in the early neonatal period. Costs were disproportionately higher for multiple and preterm births. These cost data can usefully inform policy and assist healthcare decision-making around reproductive and neonatal technologies.

Evaluating Outcomes for Women with Metastatic Breast Cancer: Palliative Care Consultations, Hospital Charges, and Length of Stay

Introduction: Women with late-stage metastatic breast cancer are at an increased risk of pain and distress from symptoms and often struggle with associated emotional and financial burden of their disease. Palliative care is known to alleviate symptom burden in patients with end-stage, terminal diseases but is often underutilized in both inpatient and outpatient settings. The current study aims to investigate the prevalence of palliative care consultation on inpatients with metastatic breast cancer and examine the association between palliative care consultation and length of hospital stay and total hospital charges. Methods: Patients diagnosed with metastatic breast cancer between 1998-2017 were abstracted from the Healthcare Cost and Utilization Project (HCUP) Nationwide Inpatient Database (NIS). The primary outcome was the presence of a palliative care consultation (PCC) during the inpatient stay. Secondary outcomes were hospital length of stay and total hospital charges. Multivariable logistic regression was used to examine factors associated with the presence of a PCC. The relationship between PCC and hospital length of stay and total hospital charges were investigated using linear regression. Results: 513,509 cases of metastatic breast cancer were identified, 5.7% had a documented in-hospital palliative care encounter. Of those who received PCC, total hospital charges were about USD 5452 less than those who did not receive consultation. Women who received PCC had higher odds of a longer hospital stay. Predictors of PCC were older age, non-White race, and residing in a lower-income ZIP code. Conclusions: Palliative care remains to be an underutilized resource among patients with end-stage metastatic breast cancer.

Tele-collaborative outreach to rural patients with chronic pain: pragmatic effectiveness trial protocol for the CORPs study

BACKGROUND

Despite the increased availability of evidence-based treatments for chronic pain, many patients in rural areas experience poor access to services. Patients receiving care through the VA may also need to navigate multiple systems of care.

OBJECTIVE

To examine the effectiveness of a remotely delivered collaborative care intervention for improving pain interference among veterans with high-impact chronic pain living in rural areas.

DESIGN

We will conduct a four-site pragmatic effectiveness trial of remotely delivered collaborative care for high-impact chronic pain. Participants (n = 608) will be randomized to the Tele-Collaborative Outreach to Rural Patients (CORPs) intervention or to minimally enhanced usual care (MEUC). Participants randomized to CORPs will complete a biopsychosocial assessment and five follow-up sessions with a nurse care manager (NCM), who will collaborate with a consulting clinician to provide personalized recommendations and care management. CORP participants will also be invited to a virtual 6-session pain education group class. Participants randomized to MEUC will receive a one-time education session with the NCM to review available pain services. All participants will complete quarterly research assessments for one year. The primary study outcome is pain interference. This trial will oversample veterans of female birth sex and minoritized race or ethnicity to test heterogeneity of treatment effects across these patient characteristics. We will conduct an implementation process evaluation and incremental cost-effectiveness analysis.

DISCUSSION

This pragmatic trial will test the real-world effectiveness of a remotely delivered collaborative care intervention for chronic pain. Study findings will inform future implementation efforts to support potential uptake of the intervention.

Healthcare costs attributable to diabetes in pregnancy: A cost of illness study in Tasmania, Australia

AIMS

To estimate the direct costs during the prenatal, delivery and postpartum periods in mothers with diabetes in pregnancy, compared to those without.

METHODS

This study used a population-based dataset from 2004 to 2017, including 57,090 people with diabetes and 114,179 people without diabetes in Tasmania, Australia. Based on diagnostic codes, delivery episodes with gestational diabetes mellitus (GDM) were identified and matched with delivery episodes without diabetes in pregnancy. A group of delivery episodes with pre-existing diabetes was identified for comparison. Hospitalisation, emergency department and pathology costs of these groups were calculated and adjusted to 2020-2021 Australian dollars.

RESULTS

There were 2774 delivery episodes with GDM, 2774 delivery episodes without diabetes and 237 delivery episodes with pre-existing diabetes identified. Across the 24-month period, the pre-existing diabetes group required the highest costs, totalling $23,536/person. This was followed by the GDM ($13,210/person), and the no diabetes group ($11,167/person). The incremental costs of GDM over the no diabetes group were $890 (95% CI 635; 1160) in the year preceding delivery; $812 (616; 1031) within the delivery period and $341 (110; 582) in the year following delivery (p < 0.05). Within the year preceding delivery, the incremental costs in the prenatal period were $803 (579; 1058) (p < 0.05). Within the year following delivery, the incremental costs in the postpartum period were $137 (55; 238) (p < 0.05).

CONCLUSIONS

Our results emphasised the importance of proper management of diabetes in pregnancy in the prenatal and postpartum periods and highlighted the significance of screening and preventative strategies for diabetes in pregnancy.

Evaluation of Cost-Effectiveness of a Virtual Multidisciplinary Stroke Care Clinic for Community-Dwelling Survivors of Stroke

BACKGROUND

A technologically integrated, multidisciplinary approach to stroke rehabilitation service was delivered and embedded into conventional health care practice. This article reports an evaluation of cost-effectiveness analysis of a new Virtual Multidisciplinary Stroke Care Clinic (VMSCC) service for community-dwelling survivors of stroke.

METHODS AND RESULTS

A randomized controlled trial was conducted. Adults with a first/recurrent ischemic/hemorrhagic stroke were recruited from 10 hospitals. Eligible participants were randomly assigned to receive the VMSCC service (individual virtual consultations with a registered nurse, home blood pressure telemonitoring, and unlimited access to an online resource platform) plus usual care or usual care alone. Cost-effectiveness analyses were performed based on incremental cost-effectiveness ratios expressed as incremental cost per emergency admission reduced, and day of hospitalization reduced over the study period. A total of 256 participants (intervention group n=141 versus control group n=115) with complete cost and health care use data were included in the cost-effectiveness analyses. The VMSCC service, on average, resulted in a greater reduction in the number of emergency admission (-0.06 [95% bootstrapped CI, -0.14 to 0.01]) and fewer days of hospitalization (-0.08, [95% bootstrapped CI -0.40 to 0.24]) but incurred a higher total cost of HK$375 (95% bootstrapped CI, -2103 to 2743) compared with the usual care. The incremental cost-effectiveness ratios of the VMSCC service compared with the usual care were HK$6070 and HK$4826 per an emergency admission and a day of hospital stay reduced respectively.

CONCLUSIONS

The study provides preliminary but not confirmative evidence that the VMSCC service could be more effective but more costly than usual care in reducing health service use.

REGISTRATION

URL: https://www.chictr.org.cn. Unique identifier: ChiCTR1800016101.

Direct and indirect costs of paediatric asthma in the UK: a cost analysis

OBJECTIVE

To estimate the cost of paediatric asthma from a UK National Health Service (NHS) and societal perspective and explore determinants of these costs.

DESIGN

Cost analysis based on data from a large clinical trial between 2017 and 2019. Case report forms recorded healthcare resource use and productivity losses attributable to asthma over a 12-month period. These were combined with national unit cost data to generate estimates of health service and indirect costs.

SETTING

Asthma clinics in primary and secondary care in England and Scotland.

MAIN OUTCOME MEASURES

Cost per asthma attack stratified by highest level of care received. Total annual health service and indirect costs. Modelled effect of sex, age, severity, number of attacks and adherence on total annual costs.

RESULTS

Of 506 children included in the analysis, 252 experienced at least one attack. The mean (SD) cost per attack was £297 (806) (median £46, IQR 40-138) and the mean total annual cost to the NHS was £1086 (2504) (median £462, IQR 296-731). On average, children missed 6 days of school and their carers missed 13 hours of paid work, contributing to a mean annual indirect cost of £412 (879) (median £30, IQR 0-477). Health service costs increased significantly with number of attacks and participant age (>11 years). Indirect costs increased with asthma severity and number of attacks but were found to be lower in older children.

CONCLUSIONS

Paediatric asthma imparts a significant economic burden on the health service, families and society. Efforts to improve asthma control may generate significant cost savings.

TRIAL REGISTRATION NUMBER

ISRCTN 67875351.

Economic burden of generalized myasthenia gravis (MG) in the United States and the impact of common comorbidities and acute MG-events

BACKGROUND

This study assessed the incremental healthcare costs and resource utilization (HRU) associated with generalized myasthenia gravis (gMG), as well as variability in these outcomes among patients with gMG and common comorbidities and acute MG-related events.

METHODS

Adults with gMG and without MG were identified from a large US database (2017-2021). The index date was the first MG diagnosis (gMG cohort) or random date (non-MG cohort). Cohorts were propensity score matched 1:1. The gMG cohort included subgroups of patients with a 12-month pre-index (baseline) cardiometabolic or psychiatric comorbidity, or a post-index MG exacerbation/crisis. Monthly healthcare costs (2021 USD) and HRU were compared post-index between gMG and non-MG cohorts.

RESULTS

The gMG and matched non-MG cohorts each contained 2,739 patients. Mean incremental healthcare costs associated with MG were $4,155 (gMG: $5,567; non-MG: $1,411), with differences driven by incremental inpatient costs of $2,166 (gMG: $2,617; non-MG: $452); all p < 0.001. The gMG versus non-MG cohort had 4.36 times more inpatient admissions and 2.26 times more outpatient visits; all p < 0.001. Among patients with gMG in cardiometabolic (n = 1,859), psychiatric (n = 1,308), and exacerbation/crisis (n = 419) subgroups, mean monthly healthcare costs were $6,660, $7,443, and $17,330, respectively.

CONCLUSIONS

gMG is associated with substantial incremental costs and HRU, with inpatient costs driving the total incremental costs. Costs increased by 20% and 34% among patients with cardiometabolic and psychiatric conditions, respectively, and over three times among those with acute MG-related events. gMG is a complex disease requiring management of comorbidities and treatment options that can prevent acute symptomatic events.

Economic Burden of Induced Laryngeal Obstruction in Adolescents and Children

PURPOSE

Diagnosing pediatric induced laryngeal obstruction (ILO) requires equipment typically available in specialist settings, and patients often see multiple providers before a diagnosis is determined. This study examined the financial burden associated with the diagnosis and treatment of ILO in pediatric patients with reference to socioeconomic disadvantage.

METHODS

Adolescents and children (<18 years of age) diagnosed with ILO were identified through the University of Madison Voice and Swallow Outcomes Database. Procedures, office visits, and prescribed medications were collected from the electronic medical record. Expenditures were calculated for two time periods (1) pre-diagnosis (first dyspnea-related visit to diagnosis), and (2) the first year following diagnosis. The Area Deprivation Index (ADI) was used to estimate patient socioeconomic status to determine if costs differed with neighborhood-level disadvantage.

RESULTS

A total of 113 patients met inclusion criteria (13.9 years, 79% female). Total pre-diagnosis costs of ILO averaged $6486.93 (SD = $6604.14, median = $3845.66) and post-diagnosis costs averaged $2067.69 (SD = $2322.78; median = $1384.12). Patients underwent a mean of 3.01 (SD = 1.9; median = 2) procedures and 5.8 (SD = 4.7; median = 5) office visits prior to diagnosis. Pharmaceutical, procedure/office visit, and indirect costs significantly decreased following diagnosis. Patients living in neighborhoods with greater socioeconomic disadvantage underwent fewer procedures and were prescribed more medication than those from more affluent areas. However, total expenditures did not differ based on ADI.

CONCLUSIONS

Pediatric ILO is associated with considerable financial costs. The source of these costs, however, differed according to socioeconomic advantage. Future work should determine how ILO diagnosis and management can be more efficient and equitable across all patients. Laryngoscope, 134:3384-3390, 2024.

Does size matter? Hospital volume and resource use in paediatric diabetes care

AIMS

Paediatric diabetes care has become increasingly specialised due to the multidisciplinary approach and technological developments. Guidelines recommend sufficient experience of treatment teams. This study evaluates associations between hospital volume and resource use and hospital expenditure in Dutch children with diabetes.

METHODS

Retrospective cohort study using hospital claims data of 5082 children treated across 44 Dutch hospitals (2019-2020). Hospitals were categorised into three categories; small (≥20-100 patients), medium (≥100-200 patients) and large (≥200 patients). All-cause hospitalisations, consultations, technology and hospital expenditure were analysed and adjusted for age, sex, socio-economic status (SES) and hospital of treatment.

RESULTS

Fewer hospitalisations were observed in large hospitals compared to small hospitals (OR 0.48; [95% CI 0.32-0.72]; p < 0.001). Median number of yearly paediatrician visits was 7 in large and 6 in small hospitals, the significance of which was attenuated in multilevel analysis (OR ≥7 consultations: 1.89; [95%CI 0.74-4.83]; p = 0.18). Technology use varies between individual hospitals, whereas pump usage and real-time continuous glucose monitoring showed no significant differences between hospital volumes. Mean overall expenditure was highest in medium-sized centres with €6434 per patient (IQR €2555-7955); the difference in diabetes care costs was not significant between hospital patient volumes.

CONCLUSIONS

Care provision patterns vary by hospital patient volume. Large hospitals had the lowest hospitalisation rates. The use of diabetes technology was not different between hospital patient volumes. Medium-sized hospitals showed the highest overall expenditure, but diabetes care costs were similar across hospital volumes.

Creating an interactive map visualising the geographic variations of the burden of diabetes to inform policymaking: An example from a cohort study in Tasmania, Australia

OBJECTIVES

To visualise the geographic variations of diabetes burden and identify areas where targeted interventions are needed.

METHODS

Using diagnostic criteria supported by hospital codes, 51,324 people with diabetes were identified from a population-based dataset during 2004-2017 in Tasmania, Australia. An interactive map visualising geographic distribution of diabetes prevalence, mortality rates, and healthcare costs in people with diabetes was generated. The cluster and outlier analysis was performed based on statistical area level 2 (SA2) to identify areas with high (hot spot) and low (cold spot) diabetes burden.

RESULTS

There were geographic variations in diabetes burden across Tasmania, with highest age-adjusted prevalence (6.1%), excess cost ($2627), and annual costs per person ($5982) in the West and Northwest. Among 98 SA2 areas, 16 hot spots and 25 cold spots for annual costs, and 10 hot spots and 10 cold spots for diabetes prevalence were identified (p<0.05). 15/16 (94%) and 6/10 (60%) hot spots identified were in the West and Northwest.

CONCLUSIONS

We have developed a method to graphically display important diabetes outcomes for different geographical areas.

IMPLICATIONS FOR PUBLIC HEALTH

The method presented in our study could be applied to any other diseases, regions, and countries where appropriate data are available to identify areas where interventions are needed to improve diabetes outcomes.

An exploration of service use pattern changes and cost analysis following implementation of community perinatal mental health teams in pregnant women with a history of specialist mental healthcare in England: a national population-based cohort study

BACKGROUND

The National Health Service in England pledged >£365 million to improve access to mental healthcare services via Community Perinatal Mental Health Teams (CPMHTs) and reduce the rate of perinatal relapse in women with severe mental illness. This study aimed to explore changes in service use patterns following the implementation of CPMHTs in pregnant women with a history of specialist mental healthcare in England, and conduct a cost-analysis on these changes.

METHODS

This study used a longitudinal cohort design based on existing routine administrative data. The study population was all women residing in England with an onset of pregnancy on or after 1st April 2016 and who gave birth on or before 31st March 2018 with pre-existing mental illness (N = 70,323). Resource use and costs were compared before and after the implementation of CPMHTs. The economic perspective was limited to secondary mental health services, and the time horizon was the perinatal period (from the start of pregnancy to 1-year post-birth, ~ 21 months).

RESULTS

The percentage of women using community mental healthcare services over the perinatal period was higher for areas with CPMHTs (30.96%, n=9,653) compared to areas without CPMHTs (24.72%, n=9,615). The overall percentage of women using acute care services (inpatient and crisis resolution teams) over the perinatal period was lower for areas with CPMHTs (4.94%, n=1,540 vs. 5.58%, n=2,171), comprising reduced crisis resolution team contacts (4.41%, n=1,375 vs. 5.23%, n=2,035) but increased psychiatric admissions (1.43%, n=445 vs. 1.13%, n=441). Total mental healthcare costs over the perinatal period were significantly higher for areas with CPMHTs (fully adjusted incremental cost £111, 95% CI £29 to £192, p-value 0.008).

CONCLUSIONS

Following implementation of CPMHTs, the percentage of women using acute care decreased while the percentage of women using community care increased. However, the greater use of inpatient admissions alongside greater use of community care resulted in a significantly higher mean cost of secondary mental health service use for women in the CPMHT group compared with no CPMHT. Increased costs must be considered with caution as no data was available on relevant outcomes such as quality of life or satisfaction with services.

Societal and economic burden of migraine in Spain: results from the 2020 National Health and Wellness Survey

BACKGROUND

The burden of migraine goes beyond the pain and associated symptoms. We aimed to describe the impact of migraine in healthcare resource utilization (HCRU), work productivity, and mood disorders, as well as its economic cost.

METHODS

Case-control study nested in a cross-sectional analysis of patient-reported data collected between 30/12/2019 and 20/04/2020 as part of the National Health and Wellness Survey, from respondents located in Spain. Adults (≥ 18 years old) who reported a physician diagnosis of migraine and ≥ 1 monthly headache days (MHD) in the previous 30 days were included. HCRU, health-related quality-of-life, depression scores, work and activity impairment, and the associated direct and indirect costs were assessed for four cohorts of migraine patients, according to the frequency of headache (MHD: 1-3, 4-7, 8-14, ≥ 15) and compared to a no-migraine control, matched to migraine cases by a propensity score based on demographic and clinical variables.

RESULTS

The survey was completed by 595 people with active migraine, of whom 461 (77.4%) experienced < 8 MHDs and 134 (22.6%) ≥ 8 MHDs, and 1,190 non-migraine matched controls. Migraine patients presented worse mental and physical health functioning (SF-12 MCS: 41.9 vs. 44.7, p < 0.001; SF-12 PCS: 48.6 vs. 51.5, p < 0.001), worse self-reported health (EQ-5D VAS: 65.8 vs. 73.5, p < 0.001), more severe depression (PHQ-9: 8.9 vs. 6.1, p < 0.001), and higher overall work impairment (WPAI: 41.4 vs. 25.5, p < 0.001). People with migraine had higher HCRU, twice higher hospitalization rates (17.0% vs. 8.3%, p < 0.001) and 1.6 higher emergency room (ER) visit rates (51.4% vs. 31.2%, p < 0.001). Having migraine translated into higher annual costs with HCRU (€894 vs. €530) and productivity losses (€8,000 vs. €4,780) per person. Respondents with more MHDs presented worse outcomes and higher costs but suffering from 1-3 MHD also increased costs by 51.3%.

CONCLUSIONS

Having migraine not only causes a massive impact on patients' quality of life and ability to work, but it also generates considerable economic costs for society. In Spain, having migraine was associated to 1.7 higher costs per patient. The clinical and economic burden increases with the frequency of headaches but is higher than controls even in patients suffering from 1-3 MHD.

Economic and clinical burden of chronic corticosteroid use in patients with Crohn[apos]s disease initiated on biologic or conventional therapies in the US: A retrospective claims study

BACKGROUND

Chronic corticosteroid (CS) use is associated with complications, but estimates of the economic and clinical burden in patients with Crohn's disease (CD) are lacking.

OBJECTIVE

To estimate the burden of chronic CS use in CD in the United States in terms of health care resource utilization (HRU), health care costs, and CS-related complications.

METHODS

This was a retrospective study of adults with CD initiated on biologics or conventional therapies (index date). Patients from a deidentified insurance claims database (2004-2021) were classified as chronic CS users (>90 days of CS use) or nonchronic CS users based on a 12-month landmark period starting on the index date. Patient baseline characteristics were balanced, and outcomes (HRU, costs [2021 US dollars], and CS-related complications) 12 months after the landmark period were compared between CS groups using regressions with nonparametric bootstrap resampling to estimate confidence intervals and P values.

RESULTS

Biologic initiators (mean age: 44 years, 55% female) included 3366 chronic and 3401 nonchronic CS users; conventional therapy initiators (mean age: 51 years, 59% female) included 3657 chronic and 3727 nonchronic CS users. Compared with nonchronic users, chronic users had significantly more inpatient days and outpatient visits (biologic initiators: 37% and 24% more, respectively; conventional therapy initiators: 36% and 17%, respectively; all P<0.05). Chronic users also had significantly higher mean all-cause total costs per-patient-per year (biologic: $72,967 vs. $63,100, mean cost difference [MCD] = $9867; conventional therapy: $40,144 vs. $26,426, MCD = $13,718; all P<0.001), as well as higher odds of infection (biologic: 14% higher; conventional therapy: 20% higher) and bone loss (63% and 41%, respectively) (all P<0.05).

CONCLUSION

Chronic CS use in patients with CD is associated with a significant economic and clinical burden including higher HRU, health care costs, and prevalence of complications, suggesting unmet needs in the clinical management of this population.

Quantifying the Cost of Shigella Diarrhea in the Enterics for Global Health (EFGH) Shigella Surveillance Study

Background

Comparative costs of public health interventions provide valuable data for decision making. However, the availability of comprehensive and context-specific costs is often limited. The Enterics for Global Health (EFGH) Shigella surveillance study-a facility-based diarrhea surveillance study across 7 countries-aims to generate evidence on health system and household costs associated with medically attended Shigella diarrhea in children.

Methods

EFGH working groups comprising representatives from each country (Bangladesh, Kenya, Malawi, Mali, Pakistan, Peru, and The Gambia) developed the study methods. Over a 24-month surveillance period, facility-based surveys will collect data on resource use for the medical treatment of an estimated 9800 children aged 6-35 months with diarrhea. Through these surveys, we will describe and quantify medical resources used in the treatment of diarrhea (eg, medication, supplies, and provider salaries), nonmedical resources (eg, travel costs to the facility), and the amount of caregiver time lost from work to care for their sick child. To assign costs to each identified resource, we will use a combination of caregiver interviews, national medical price lists, and databases from the World Health Organization and the International Labor Organization. Our primary outcome will be the estimated cost per inpatient and outpatient episode of medically attended Shigella diarrhea treatment across countries, levels of care, and illness severity. We will conduct sensitivity and scenario analysis to determine how unit costs vary across scenarios.

Conclusions

Results from this study will contribute to the existing body of literature on diarrhea costing and inform future policy decisions related to investments in preventive strategies for Shigella.

Evaluation of intensive community care services for young people with psychiatric emergencies: study protocol for a multi-centre parallel-group, single-blinded randomized controlled trial with an internal pilot phase

BACKGROUND

Over 3000 young people under the age of 18 are admitted to Tier 4 Child and Adolescent Mental Health Services (CAMHS) inpatient units across the UK each year. The average length of hospital stay for young people across all psychiatric units in the UK is 120 days. Research is needed to identify the most effective and efficient ways to care for young people (YP) with psychiatric emergencies. This study aims to evaluate the clinical effectiveness and cost-effectiveness of intensive community care service (ICCS) compared to treatment as usual (TAU) for young people with psychiatric emergencies.

METHODS

This is a multicentre two-arm randomized controlled trial (RCT) with an internal pilot phase. Young people aged 12 to < 18 considered for admission at participating NHS organizations across the UK will be randomized 1:1 to either TAU or ICCS. The primary outcome is the time to return to or start education, employment, or training (EET) at 6 months post-randomization. Secondary outcomes will include evaluations of mental health and overall well-being and patient satisfaction. Service use and costs and cost-effectiveness will also be explored. Intention-to-treat analysis will be adopted. The trial is expected to be completed within 42 months, with an internal pilot phase in the first 12 months to assess the recruitment feasibility. A process evaluation using visual semi-structured interviews will be conducted with 42 young people and 42 healthcare workers.

DISCUSSION

This trial is the first well-powered randomized controlled trial evaluating the clinical and cost-effectiveness of ICCS compared to TAU for young people with psychiatric emergencies in Great Britain.

TRIAL REGISTRATION

ISRCTN ISRCTN42999542, Registration on April 29, 2020.

Cost saving in implementing ERAS protocol in emergency abdominal surgery

INTRODUCTION

ERAS (Enhanced Recovery After Surgery) protocol is now proposed as the standard of care in elective major abdominal surgery. Implementation of the ERAS protocol in emergency setting has been proposed but his economic impact has not been investigated. Aim of this study was to evaluate the cost saving of implementing ERAS in abdominal emergency surgery in a single institution.

METHODS

A group of 80 consecutive patients treated by ERAS protocol for gastrointestinal emergency surgery in 2021 was compared with an analogue group of 75 consecutive patients treated by the same surgery the year before implementation of ERAS protocol. Adhesion to postoperative items, length of stay, morbidity and mortality were recorded. Cost saving analysis was performed.

RESULTS

50% Adhesion to postoperative items was reached on day 2 in the ERAS group in mean. Laparoscopic approach was 40 vs 12% in ERAS and control group respectively (p ,002). Length of stay was shorter in ERAS group by 3 days (9 vs 12 days p ,002). Morbidity and mortality rate were similar in both groups. The ERAS group had a mean cost saving of 1022,78 € per patient.

CONCLUSIONS

ERAS protocol implementation in the abdominal emergency setting is cost effective resulting in a significant shorter length of stay and cost saving per patient.

A novel scale for triage assessment of frailty in the emergency department (ED-FraS): a prospective videotaped study

BACKGROUND

Rapid recognition of frailty in older patients in the ED is an important first step toward better geriatric care in the ED. We aimed to develop and validate a novel frailty assessment scale at ED triage, the Emergency Department Frailty Scale (ED-FraS).

METHODS

We conducted a prospective cohort study enrolling adult patients aged 65 years or older who visited the ED at an academic medical center. The entire triage process was recorded, and triage data were collected, including the Taiwan Triage and Acuity Scale (TTAS). Five physician raters provided ED-FraS levels after reviewing videos. A modified TTAS (mTTAS) incorporating ED-FraS was also created. The primary outcome was hospital admission following the ED visit, and secondary outcomes included the ED length of stay (EDLOS) and total ED visit charges.

RESULTS

A total of 256 patients were included. Twenty-seven percent of the patients were frail according to the ED-FraS. The majority of ED-FraS was level 2 (57%), while the majority of TTAS was level 3 (81%). There was a weak agreement between the ED-FraS and TTAS (kappa coefficient of 0.02). The hospital admission rate and charge were highest at ED-FraS level 5 (severely frail), whereas the EDLOS was longest at level 4 (moderately frail). The area under the Receiver Operating Characteristic curve (AUROC) in predicting hospital admission for the TTAS, ED-FraS, and mTTAS were 0.57, 0.62, and 0.63, respectively. The ED-FraS explained more variation in EDLOS (R2 = 0.096) compared with the other two methods.

CONCLUSIONS

The ED-Fras tool is a simple and valid screening tool for identifying frail older adults in the ED. It also can complement and enhance ED triage systems. Further research is needed to test its real-time use at ED triage internationally.

A Trial-Based Cost-Utility Analysis of a Medication Optimization Intervention Versus Standard Care in Older Adults

BACKGROUND

Older adults are at greater risk of medication-related harm than younger adults. The Integrated Medication Management model is an interdisciplinary method aiming to optimize medication therapy and improve patient outcomes.

OBJECTIVE

We aimed to investigate the cost effectiveness of a medication optimization intervention compared to standard care in acutely hospitalized older adults.

METHODS

A cost-utility analysis including 285 adults aged ≥ 70 years was carried out alongside the IMMENSE study. Quality-adjusted life years (QALYs) were derived using the EuroQol 5-Dimension 3-Level Health State Questionnaire (EQ-5D-3L). Patient-level data for healthcare use and costs were obtained from administrative registers, taking a healthcare perspective. The incremental cost-effectiveness ratio was estimated for a 12-month follow-up and compared to a societal willingness-to-pay range of €/QALY 27,067-81,200 (NOK 275,000-825,000). Because of a capacity issue in a primary care resulting in extended hospital stays, a subgroup analysis was carried out for non-long and long stayers with hospitalizations < 14 days or ≥ 14 days.

RESULTS

Mean QALYs were 0.023 [95% confidence interval [CI] 0.022-0.025] higher and mean healthcare costs were €4429 [95% CI - 1101 to 11,926] higher for the intervention group in a full population analysis. This produced an incremental cost-effectiveness ratio of €192,565/QALY. For the subgroup analysis, mean QALYs were 0.067 [95% CI 0.066-0.070, n = 222] and - 0.101 [95% CI - 0.035 to 0.048, n = 63] for the intervention group in the non-long stayers and long stayers, respectively. Corresponding mean costs were €- 824 [95% CI - 3869 to 2066] and €1992 [95% CI - 17,964 to 18,811], respectively. The intervention dominated standard care for the non-long stayers with a probability of cost effectiveness of 93.1-99.2% for the whole willingness-to-pay range and 67.8% at a zero willingness to pay. Hospitalizations were the main cost driver, and readmissions contributed the most to the cost difference between the groups.

CONCLUSIONS

According to societal willingness-to-pay thresholds, the medication optimization intervention was not cost effective compared to standard care for the full population. The intervention dominated standard care for the non-long stayers, with a high probability of cost effectiveness.

CLINICAL TRIAL REGISTRATION

The IMMENSE trial was registered in ClinicalTrials.gov on 28 June, 2016 before enrolment started (NCT02816086).

Cost-effectiveness of peer-delivered physical activity promotion and maintenance programs for initially sedentary breast cancer survivors

The evidence for the survival and health benefits of physical activity (PA) among cancer survivors is well documented. However, it has been challenging to maintain PA among cancer survivors. To evaluate the cost-effectiveness of peer support to encourage maintenance of moderate-to-vigorous physical activity (MVPA) among breast cancer survivors. Participants were randomized into Reach Plus Message (weekly text/email messages), Reach Plus Phone (monthly phone calls) or Reach Plus (a self-monitoring intervention) over 6 months after an initial adoption phase. We calculated the incremental cost-effectiveness ratios (ICER) in terms of quality-adjusted years life years (QALYs) and self-reported MVPA, from the payer's budgetary and societal perspectives over 1 year. Intervention costs were collected via time logs from the trainers and peer coaches, and participant costs from the participants via surveys. For our sensitivity analyses, we bootstrapped costs and effects to construct cost-effectiveness planes and acceptability curves. The intervention that provides weekly messages from peer coaches has an ICER of $14,446 per QALY gained and $0.95 per extra minute of MVPA per day over Reach Plus. Reach Plus Message has a 49.8% and 78.5% probability of cost-effectiveness respectively when decision makers are willing to pay approximately $25,000 per QALY and $10 per additional minute of MVPA. Reach Plus Phone, which requires tailored monthly telephone calls, costs more than Reach Plus Message but yields less QALY and self-reported MVPA at 1 year. Reach Plus Message may be a viable and cost-effective intervention strategy to maintain MVPA among breast cancer survivors.

Study protocol for ELders AT Ease (ELATE): a cluster randomised controlled trial of cognitive behaviour therapy to reduce depressive symptoms in aged care residents

BACKGROUND

This protocol describes a study of the effectiveness of cognitive behaviour therapy (CBT) for reducing depressive symptoms in older adults living in residential aged care (RAC) facilities in Australia. Depressive symptoms are highly prevalent in this population, yet the benefits of CBT for reducing such symptoms in RAC facilities have not been widely investigated. Elders at Ease (ELATE) is a 16-session CBT intervention designed for implementation in RAC facilities. The intervention includes cognitive, behavioural and reminiscence strategies and is delivered by mental health trainees (MHTs) in collaboration with RAC facility staff and residents' family.

METHODS AND ANALYSIS

ELATE will be evaluated using a cluster randomised trial comparing outcomes for residents who participate in the intervention with those living in usual care control facilities. The participants are RAC residents aged 65 years or above, with depressive symptoms (Patient Health Questionnaire-2 ≥ 3) and normal cognition or mild cognitive impairment (Standardised Mini Mental Status Examination ≥ 21). They are assessed at four time points: baseline prior to randomisation (T1), mid-treatment (T2; 2.5 months post randomisation), post-treatment (T3; 5 months post-randomisation) and 3-month follow-up (T4; 8 months post randomisation). The primary outcome is change in depressive symptoms between T1 and T3. Secondary outcomes are depressive symptoms at T4, anxiety, suicide ideation, sleep problems, quality of life, staff and family knowledge of late-life depression, stress levels and efficacy in caring for residents, and MHT levels of geropsychology competencies. Residents receiving the intervention are hypothesised to report a greater decrease in depressive symptoms between T1 and T3 compared to residents receiving usual care. The primary analysis is a regression, clustered over site to account for correlated readings, and independent variables are condition and depressive symptoms at T1. A cost-utility analysis is also undertaken.

DISCUSSION

ELATE is a comprehensive CBT intervention for reducing depressive symptoms in RAC residents. It is designed to be implemented in collaboration with facility staff and residents' families, individually tailored to residents with normal cognition to mild cognitive impairment and delivered by trainee therapists. ELATE offers a model that may be widely applicable across the RAC sector.

TRIAL REGISTRATION

Trial registered with the Australian and New Zealand Clinical Trial Registry (ANZCTR) Number ACTRN12619001037190, prospectively registered on 22 July 2019.

Study protocol of an economic evaluation embedded in the Midwives and Obstetricians Helping Mothers to Quit Smoking (MOHMQuit) trial

BACKGROUND

Tobacco smoking during pregnancy is the most important preventable risk factor for pregnancy complications and adverse birth outcomes and can have lifelong consequences for infants. Smoking during pregnancy is associated with higher healthcare costs related to birth complications and during childhood. Psychosocial interventions to support pregnant women to quit are effective, yet provision of smoking cessation support has been inconsistent. The Midwives and Obstetricians Helping Mothers to Quit Smoking (MOHMQuit) intervention provides systems change, and leadership and clinician elements, to support clinicians to help women stop smoking in pregnancy. There have been few long-term analyses conducted of the cost-effectiveness of smoking cessation interventions for pregnant women that target healthcare providers. This protocol describes the economic evaluation of the MOHMQuit trial, a pragmatic stepped-wedge cluster-randomised controlled implementation trial in nine public maternity services in New South Wales (NSW), Australia, to ascertain whether MOHMQuit is cost-effective in supporting clinicians to help women quit smoking in pregnancy compared to usual care.

METHODS

Two primary analyses will be carried out comparing MOHMQuit with usual care from an Australian health care system perspective: i) a within-trial cost-effectiveness analysis with results presented as the incremental cost per additional quitter; and ii) a lifetime cost-utility analysis using a published probabilistic decision analytic Markov model with results presented as incremental cost per quality-adjusted life-year (QALY) gained for mother and child. Patient-level data on resource use and outcomes will be used in the within-trial analysis and extrapolated and supplemented with national population statistics and published data from the literature for the lifetime analysis.

DISCUSSION

There is increasing demand for information on the cost-effectiveness of implementing healthcare interventions to provide policy makers with critical information for the best value for money within finite budgets. Economic evaluation of the MOHMQuit trial will provide essential, policy-relevant information for decision makers on the value of evidence-based implementation of support for healthcare providers delivering services for pregnant women.

TRIAL REGISTRATIONS

ACTRN12622000167763, registered 2 February 2022.

Cost and health-related quality of life for children hospitalized with respiratory syncytial virus in Central China

BACKGROUND

The economic burden of respiratory syncytial virus (RSV) infection and its impact on health-related quality of life (HRQoL) are not well-understood in China. This study assessed total cost and HRQoL for children hospitalized with RSV in Central China.

METHODS

Based on a prospective case series study in Henan Province in 2020-2021, inpatients aged 0-59 months with RSV-related acute respiratory infections (ARIs) were included into analysis. Total cost included direct medical cost (sum of medical cost before and during hospitalization), direct non-medical cost, and indirect cost. Direct medical cost during hospitalization data were extracted from the hospital information system. Other costs and HRQoL status were obtained from a telephone survey conducted in the caregivers of the enrolled patients.

RESULTS

Among 261 RSV-infected inpatients, caregivers of 170 non-severe cases (65.1%, 170/261) were successfully interviewed. Direct medical cost per episode was 1055.3 US dollars (US$) (95% CI: 998.2-1112.5 US$). Direct non-medical cost and indirect cost per episode were 83.6 US$ (95% CI: 77.5-89.7 US$) and 162.4 US$ (95% CI: 127.9-197.0 US$), respectively. Quality adjusted life years (QALY) loss for non-severe RSV hospitalization was 8.9 × 10-3 (95% CI: 7.9 × 10-3 -9.9 × 10-3 ). The majority of inpatients were <1 year of age comprising significantly higher cost and more QALY loss than older children.

CONCLUSIONS

RSV-associated hospitalization poses high economic and health burden in Central China particularly for children <1 year old. Our findings are crucial for determining the priority of interventions and allocation of health resources.

Individual and population level costs and health-related quality of life outcomes of third-generation cephalosporin resistant bloodstream infection in Blantyre, Malawi

Data which accurately enumerate the economic costs of antimicrobial resistance (AMR) in low- and middle- income countries are essential. This study aimed to quantify the impact of third-generation cephalosporin resistant (3GC-R) bloodstream infection (BSI) on economic and health related quality of life outcomes for adult patients in Blantyre, Malawi. Participants were recruited from a prospective, longitudinal cohort study of hospitalised patients with bloodstream infection caused by Enterobacterales at Queen Elizabeth Central Hospital (QECH). Primary costing studies were used to estimate the direct medical costs associated with the inpatient stay. Recruited participants were asked about direct non-medical and indirect costs associated with their admission and their health-related quality of life was measured using the EuroQol EQ-5D questionnaire. Multiple imputation was undertaken to account for missing data. Costs were adjusted to 2019 US Dollars. Cost and microbiology surveillance data from QECH, Blantyre was used to model the annual cost of, and quality-adjusted life years lost to, 3GC-R and 3GC-Susceptible BSI from 1998 to 2030 in Malawi. The mean health provider cost per participant with 3GC-R BSI was US$110.27 (95%CR; 22.60-197.95), higher than for those with 3GC-S infection. Patients with resistant BSI incurred an additional indirect cost of US$155.48 (95%CR; -67.80, 378.78) and an additional direct non-medical cost of US$20.98 (95%CR; -36.47, 78.42). Health related quality of life outcomes were poor for all participants, but participants with resistant infections had an EQ-5D utility score that was 0.167 (95% CR: -0.035, 0.300) lower than those with sensitive infections. Population level burden estimates suggest that in 2016, 3GC-R accounted for 84% of annual societal costs from admission with bloodstream infection and 82% of QALYs lost. 3GC-R bloodstream infection was associated with higher health provider and patient level costs than 3GC-S infection, as well as poorer HRQoL outcomes. We demonstrate a substantial current and future economic burden to society as a result of 3GC-R E. coli and Klebsiella spp. BSI, data urgently needed by policy makers to provide impetus for implementing strategies to reduce AMR.

The impact of the time to last seizure before admission to the epilepsy monitoring unit (EMU) on epilepsy classifications

INTRODUCTION AND BACKGROUND

The impact of the timing of the last seizure (TTLS) prior to admission to the epilepsy monitoring unit (EMU) on epilepsy classification is unclear for which we conducted this study.

METHODS

We reviewed patients with epilepsy admitted to EMU between January 2021 and April 2022 and identified TTLS before EMU admission. We considered EMU yield as whether; it confirmed epilepsy classification, added new knowledge to the classification, or failed to classify epilepsy.

RESULTS

We studied 156 patients. There were 72 (46%) men, with a mean age of 30. TTLS was divided according to a one- or three-month cutoff. We confirmed the pre-EMU epilepsy classification in 52 (33%) patients, learned new findings on epilepsy classification in 80 (51%) patients, and failed to classify epilepsy in 24 (15%) patients. Patients with "confirmed epilepsy classifications" reported seizures sooner to EMU admission than other groups (0.7 vs. 2.3 months, p-value = 0.02, 95% CI; -1.8, -1.3). Also, the odds of confirming epilepsy classification were more than two times in patients with TTLS within a month compared to those with TTLS of more than a month (OR = 2.4, p-value = 0.04, 95% CI; 1.1, 5.9). The odds were also higher when the 3-month TTLS cutoff was considered (OR = 6.2, p-value = 0.002, 95% CI; 1.6, 40.2). Confirming epilepsy classification was also associated with earlier seizures recorded at one- or three-month cutoff (OR = 2.1 and OR = 2.3, respectively, p-value = 0.05). We did not observe similar findings when we modified the classification or failed to reach a classification.

CONCLUSIONS

The timing of the last seizure before EMU admission appeared to influence the yield of EMU and enhanced the confirmation of epilepsy classifications. Such findings can improve the utilization of EMU in the presurgical evaluation of patients with epilepsy.

Use of hospital care among Dutch diabetes patients

AIM

To provide insight into healthcare resource utilization and hospital expenditure of patients treated for diabetes in Dutch hospitals.

MATERIALS AND METHODS

We conducted an observational cohort study of 193 840 patients aged ≥18 years and treated for diabetes mellitus in 65 Dutch hospitals in 2019 to 2020, using real-world reimbursement data. Consultations, hospitalizations, technology use, total hospital and diabetes care costs (encompassing all care for diabetes itself) were assessed during 1-year follow-up. In addition, expenditure was compared with that in the general Dutch population.

RESULTS

Total hospital costs for all patients with diabetes were €1 352 690 257 (1.35 billion) per year, and 15.9% (€214 963 703) was associated with treatment of diabetes. Mean yearly costs per patient were €6978, with diabetes care costs of €1109. Mean hospital costs of patients exceeded that of the Dutch population three- to sixfold. Total hospital costs increased with age, whereas diabetes expenditure decreased with age (18-40 years, €1575; >70 years, €932). Of all patients with diabetes, 51.3% (n = 99 457) received care related to cardiovascular complications. Micro- and macrovascular complications, or a combination, increased hospital costs (1.4-5.3 times higher).

CONCLUSIONS

The hospital resource use of Dutch diabetes patients is high, with a large burden of cardiovascular complications. Resource use is rooted mainly in hospital care of diabetes-related complications, not in the treatment of diabetes. Early treatment and prevention of complications remain imperative to taper future healthcare expenditure on patients with diabetes.

Healthcare expenditure and technology use in pediatric diabetes care

BACKGROUND

Diabetes mellitus is one of the most common chronic diseases in childhood. With more advanced care options including ever-evolving technology, allocation of resources becomes increasingly important to guarantee equal care for all. Therefore, we investigated healthcare resource utilization, hospital costs, and its determinants in Dutch children with diabetes.

METHODS

We conducted a retrospective, observational analysis with hospital claims data of 5,474 children with diabetes mellitus treated in 64 hospitals across the Netherlands between 2019-2020.

RESULTS

Total hospital costs were €33,002,652 per year, and most of these costs were diabetes-associated (€28,151,381; 85.3%). Mean annual diabetes costs were €5,143 per child, and treatment-related costs determined 61.8%. Diabetes technology significantly increased yearly diabetes costs compared to no technology: insulin pumps € 4,759 (28.7% of children), Real-Time Continuous Glucose Monitoring € 7,259 (2.1% of children), and the combination of these treatment modalities € 9,579 (27.3% of children). Technology use increased treatment costs significantly (5.9 - 15.3 times), but lower all-cause hospitalisation rates were observed. In all age groups, diabetes technology use influenced healthcare consumption, yet in adolescence usage decreased and consumption patterns changed.

CONCLUSIONS

These findings suggest that contemporary hospital costs of children with diabetes of all ages are driven primarily by the treatment of diabetes, with technology use as an important additive factor. The expected rise in technology use in the near future underlines the importance of insight into resource use and cost-effectiveness studies to evaluate if improved outcomes balance out these short-term costs of modern technology.

Economic and health impacts of the Change4Life Food Scanner app: Findings from a randomized pilot and feasibility study

Introduction

The UK Government developed the Change4Life Food Scanner app to provide families with engaging feedback on the nutritional content of packaged foods. There is a lack of research exploring the cost-effectiveness of dietary health promotion apps.

Methods

Through stakeholder engagement, a conceptual model was developed, outlining the pathway by which the Food Scanner app leads to proximal and distal outcomes. The conceptual model informed the development of a pilot randomized controlled trial which investigated the feasibility and acceptability of evaluating clinical outcomes in children and economic effectiveness of the Food Scanner app through a cost-consequence analysis. Parents of 4–11 years-olds (n = 126) were randomized into an app exposure condition (n = 62), or no intervention control (n = 64). Parent-reported Child Health Utility 9 Dimension (CHU9D) outcomes were collected alongside child healthcare resource use and associated costs, school absenteeism and parent productivity losses at baseline and 3 months follow up. Results for the CHU9D were converted into utility scores based on UK adult preference weights. Sensitivity analysis accounted for outliers and multiple imputation methods were adopted for the handling of missing data.

Results

64 participants (51%) completed the study (intervention: n = 29; control: n = 35). There was a mean reduction in quality adjusted life years between groups over the trial period of –0.004 (SD = 0.024, 95% CI: –0.005; 0.012). There was a mean reduction in healthcare costs of –£30.77 (SD = 230.97; 95% CI: –£113.80; £52.26) and a mean reduction in workplace productivity losses of –£64.24 (SD = 241.66, 95% CI: –£147.54; £19.07) within the intervention arm, compared to the control arm, over the data collection period. Similar findings were apparent after multiple imputation.

Discussion

Modest mean differences between study arms may have been due to the exploration of distal outcomes over a short follow-up period. The study was also disrupted due to the coronavirus pandemic, which may have confounded healthcare resource data. Although measures adopted were deemed feasible, the study highlighted difficulties in obtaining data on app development and maintenance costs, as well as the importance of economic modeling to predict long-term outcomes that may not be reliably captured over the short-term.

Clinical trial registration

https://osf.io/, identifier 62hzt.

Nonoperative versus operative management of frail institutionalized older patients with a proximal femoral fracture: a cost-utility analysis alongside a multicenter prospective cohort study

Hip fractures are associated with significant healthcare costs. In frail institutionalized patients, the costs of nonoperative management are less than operative management with comparable short-term quality of life. Nonoperative management of hip fractures in patients at the end of life should be openly discussed with SDM.

PURPOSE

The aim was to describe healthcare use with associated costs and to determine cost-utility of nonoperative management (NOM) versus operative management (OM) of frail institutionalized older patients with a proximal femoral fracture.

METHODS

This study included institutionalized patients with a limited life expectancy aged ≥ 70 years who sustained a proximal femoral fracture in the Netherlands. Costs of hospital- and nursing home care were calculated. Quality adjusted life years (QALY) were calculated based on EuroQol-5D-5L utility scores at day 7, 14, and 30 and at 3 and 6 months. The incremental cost-effectiveness ratio (ICER) was calculated from a societal perspective.

RESULTS

Of the 172 enrolled patients, 88 (51%) patients opted for NOM and 84 (49%) for OM. NOM was associated with lower healthcare costs at 6 months (NOM; €2425 (SD 1.030), OM; €9325 (SD 4242), p < 0.001). The main cost driver was hospital stay (NOM; €738 (SD 841) and OM; €3140 (SD 2636)). The ICER per QALY gained in the OM versus NOM was €76,912 and exceeded the threshold of €20,000 per QALY. The gained QALY were minimal in the OM group in patients who died within 14- and 30-day post-injury, but OM resulted in more than triple the costs.

CONCLUSION

OM results in significant higher healthcare costs, mainly due to the length of hospital stay. For frail patients at the end of life, NOM of proximal femoral fractures should be openly discussed in SDM conversations due to the limited gain in QoL.

TRIAL REGISTRATION

Netherlands Trial Register (NTR7245; date 10-06-2018).

A multicomponent psychosocial intervention to reduce substance use by adolescents involved in the criminal justice system: the RISKIT-CJS RCT

Background

Substance use and offending are related in the context of other disinhibitory behaviours. Adolescents involved in the criminal justice system constitute a particularly vulnerable group, with a propensity to engage in risky behaviour that has long-term impact on their future health and well-being. Previous research of the RISKIT programme provided evidence of a potential effect in reducing substance use and risky behaviour in adolescents.

Objectives

To evaluate the clinical effectiveness and cost-effectiveness of a multicomponent psychosocial intervention compared with treatment as usual in reducing substance use for substance-using adolescents involved in the criminal justice system.

Design

A mixed-methods, prospective, pragmatic, two-arm, randomised controlled trial with follow-up at 6 and 12 months post randomisation.

Setting

The study was conducted across youth offending teams, pupil referral units and substance misuse teams across four areas of England (i.e. South East, London, North West, North East).

Participants

Adolescents aged between 13 and 17 years (inclusive), recruited between September 2017 and June 2020.

Interventions

Participants were randomised to treatment as usual or to treatment as usual in addition to the RISKIT-Criminal Justice System (RISKIT-CJS) programme. The RISKIT-CJS programme was a multicomponent intervention and consisted of two individual motivational interviews with a trained youth worker (lasting 45 minutes each) and two group sessions delivered over half a day on consecutive weeks.

Main outcome measures

At 12 months, we assessed per cent days abstinent from substance use over the previous 28 days. Secondary outcome measures included well-being, motivational state, situational confidence, quality of life, resource use and fidelity of interventions delivered.

Results

A total of 693 adolescents were assessed for eligibility, of whom 505 (73%) consented. Of these, 246 (49%) were allocated to the RISKIT-CJS intervention and 259 (51%) were allocated to treatment as usual only. At month 12, the overall follow-up rate was 57%: 55% in the RISKIT-CJS arm and 59% in the treatment-as-usual arm. At month 12, we observed an increase in per cent days abstinent from substances in both arms of the study, from 61% to 85%, but there was no evidence that the RISKIT-CJS intervention was superior to treatment as usual. A similar pattern was observed for secondary outcomes. The RISKIT-CJS intervention was not found to be any more cost-effective than treatment as usual. The qualitative research indicated that young people were positive about learning new skills and acquiring new knowledge. Although stakeholders considered the intervention worthwhile, they expressed concern that it came too late for the target population.

Limitations

Our original aim to collect data on offences was thwarted by the onset of the COVID-19 pandemic, and this affected both the statistical and economic analyses. Although 214 (87%) of the 246 participants allocated to the RISKIT-CJS intervention attended at least one individual face-to-face session, 98 (40%) attended a group session and only 47 (19%) attended all elements of the intervention.

Conclusions

The RISKIT-CJS intervention was no more clinically effective or cost-effective than treatment as usual in reducing substance use among adolescents involved in the criminal justice system.

Future research

The RISKIT-CJS intervention was considered more acceptable, and adherence was higher, in pupil referral units and substance misuse teams than in youth offending teams. Stakeholders in youth offending teams thought that the intervention was too late in the trajectory for their population.

Trial registration

This trial is registered as ISRCTN77037777.

Funding

This project was funded by the National Institute for Health and Care Research (NIHR) Public Health Research programme and will be published in full in Public Health Research; Vol. 11, No. 3. See the NIHR Journals Library website for further project information.

Pegbovigrastim treatment resulted in an economic benefit in a large randomized clinical trial in grazing dairy cows

This randomized controlled trial on 4 commercial grazing dairy farms investigated whether pegbovigrastim (PEG) treatment affected partial net return as calculated from milk revenues and costs for feed, medical treatments [clinical mastitis, uterine disease, and other diseases (i.e., any medical treatment that was not intended for clinical mastitis or uterine disease)], inseminations, and culling during a full lactation in grazing dairy cows. We also explored the effect of potential interactions of PEG treatment with parity, prepartum body condition score, and prepartum nonesterified fatty acids concentration on partial net return, milk revenues, and the costs mentioned above. Holstein cows were randomly assigned to 1 of the 2 following trial arms: a first PEG dose 9.4 ± 0.3 (mean ± standard error) days before the calving date and a second dose within 24 hours after calving (PEG: primiparous = 342; multiparous = 697) compared with untreated controls (control: primiparous = 391; multiparous = 723). The effect of PEG treatment on the outcomes of interest expressed per year was tested using general linear mixed models. Results are presented as least squares means ± standard error. Overall, PEG treatment increased the partial net return, resulting in an economic benefit per cow per year of $210 ± 100. The cost of treatment of clinical mastitis was lower for PEG treated cows compared with control cows ($9 ± 3). The largest nonsignificant difference was seen for the cost of culling; additionally, PEG treatment numerically reduced the cost of culling by $145 ± 77.

Apathy in patients with Alzheimer's disease is a cost-driving factor

BACKGROUND

Apathy is the most frequent neuropsychiatric symptom in patients with dementia of the Alzheimer's type (DAT). We analyzed the influence of apathy on the resource use of DAT patients and their caregivers.

METHODS

Included were baseline data of 107 DAT patients from a randomized clinical trial on apathy treatment. The Resource Utilization in Dementia (RUD) instrument assessed costs over a 1-month period prior to baseline. Cost predictors were determined via a least absolute shrinkage and selection operator (LASSO).

RESULTS

On average, total monthly costs were €3070, of which €2711 accounted for caregivers' and €359 for patients' costs. An increase of one point in the Apathy Evaluation Scale resulted in a 4.1% increase in total costs.

DISCUSSION

Apathy is a significant cost driving factor for total costs in mild to moderate DAT. Effective treatment of apathy might be associated with reduced overall costs in DAT.

Task-sharing with lay counsellors to deliver a stepped care intervention to improve depression, antiretroviral therapy adherence and viral suppression in people living with HIV: a study protocol for the TENDAI randomised controlled trial

INTRODUCTION

Non-adherence to antiretroviral therapy (ART) is the main cause of viral non-suppression and its risk is increased by depression. In countries with high burden of HIV, there is a lack of trained professionals to deliver depression treatments. This paper describes the protocol for a 2-arm parallel group superiority 1:1 randomised controlled trial, to test the effectiveness and cost effectiveness of the TENDAI stepped care task-shifted intervention for depression, ART non-adherence and HIV viral suppression delivered by lay interventionists.

METHODS AND ANALYSIS

Two hundred and ninety people living with HIV aged ≥18 years with probable depression (Patient Health Questionnaire=>10) and viral non-suppression (≥ 1000 HIV copies/mL) are being recruited from HIV clinics in towns in Zimbabwe. The intervention group will receive a culturally adapted 6-session psychological treatment, Problem-Solving Therapy for Adherence and Depression (PST-AD), including problem-solving therapy, positive activity scheduling, skills to cope with stress and poor sleep and content to target barriers to non-adherence to ART. Participants whose score on the Patient Health Questionnaire-9 remains ≥10, and/or falls by less than 5 points, step up to a nurse evaluation for possible antidepressant medication. The control group receives usual care for viral non-suppression, consisting of three sessions of adherence counselling from existing clinic staff, and enhanced usual care for depression in line with the WHO Mental Health Gap intervention guide. The primary outcome is viral suppression (<1000 HIV copies/mL) at 12 months post-randomisation.

ETHICS AND DISSEMINATION

The study and its tools were approved by MRCZ/A/2390 in Zimbabwe and RESCM-18/19-5580 in the UK. Study findings will be shared through the community advisory group, conferences and open access publications.

TRIAL REGISTRATION NUMBER

NCT04018391.

Stepped care for suicide prevention in teens and young adults: Design and methods of a randomized controlled trial

BACKGROUND

Suicide is the second‑leading cause of death among adolescents and young adults in the United States, with rates rising over much of the last decade. The design, testing, and implementation of interventions to prevent suicide in this population is a public health priority. This manuscript outlines the design and methods for a research study that compares two interventions aimed at reducing suicide and suicide attempts in youth.

METHODS

We will enroll 300 youth aged 12-24 at high risk for suicide in this randomized controlled parallel group superiority trial. Participants will be randomly assigned to one of two study arms: (1) Zero Suicide Quality Improvement (ZSQI) implemented within the Kaiser Permanente Northwest (KPNW) health system, or (2) ZSQI plus a stepped care intervention for suicide prevention (SC-SP), where the services offered (including care management and dialectical behavior therapy [DBT]) increase based on risk level. Outcomes will be assessed at baseline, as well as 3-, 6-, and 12-months post randomization. The study was conceptualized and designed collaboratively by investigators at UCLA and KPNW.

RESULTS

To be reported in future manuscripts.

CONCLUSION

The main objective of the study is to determine whether the SC-SP intervention is superior to ZSQI with regard to lowering rates of fatal and nonfatal suicide attempts. Interventions that incorporate the latest research need to be designed and tested under controlled conditions to make progress toward the goal of achieving zero suicide. The results from this trial will directly inform those efforts.

TRIAL REGISTRATION

CLINICALTRIALS

gov, NCT03092271, https://clinicaltrials.gov/ct2/show/NCT03092271https://clinicaltrials.gov/ct2/show/NCT01379027.

Costs of major complications in people with and without diabetes in Tasmania, Australia

Objective We set out to estimate healthcare costs of diabetes complications in the year of first occurrence and the second year, and to quantify the incremental costs of diabetes versus non-diabetes related to each complication. Methods In this cohort study, people with diabetes (n  = 45 378) and their age/sex propensity score matched controls (n  = 90 756) were identified from a linked dataset in Tasmania, Australia between 2004 and 2017. Direct costs (including hospital, emergency room visits and pathology costs) were calculated from the healthcare system perspective and expressed in 2020 Australian dollars. The average-per-patient costs and the incremental costs in people with diabetes were calculated for each complication. Results First-year costs when the complications occurred were: dialysis $78 152 (95% CI 71 095, 85 858), lower extremity amputations $63 575 (58 290, 68 688), kidney transplant $48 487 (33 862, 68 283), non-fatal myocardial infarction $30 827 (29 558, 32 197), foot ulcer/gangrene $29 803 (27 183, 32 675), ischaemic heart disease $29 160 (26 962, 31 457), non-fatal stroke $27 782 (26 285, 29 354), heart failure $27 379 (25 968, 28 966), kidney failure $24 904 (19 799, 32 557), angina pectoris $18 430 (17 147, 19 791), neuropathy $15 637 (14 265, 17 108), nephropathy $15 133 (12 285, 18 595), retinopathy $14 775 (11 798, 19 199), transient ischaemic attack $13 905 (12 529, 15 536), vitreous hemorrhage $13 405 (10 241, 17 321), and blindness/low vision $12 941 (8164, 19 080). The second-year costs ranged from 16% (ischaemic heart disease) to 74% (dialysis) of first-year costs. Complication costs were 109-275% higher than in people without diabetes. Conclusions Diabetes complications are costly, and the costs are higher in people with diabetes than without diabetes. Our results can be used to populate diabetes simulation models and will support policy analyses to reduce the burden of diabetes.

A scoping review of statistical methods for trial-based economic evaluations: The current state of play

The statistical quality of trial-based economic evaluations is often suboptimal, while a comprehensive overview of available statistical methods is lacking. Therefore, this review summarized and critically appraised available statistical methods for trial-based economic evaluations. A literature search was performed to identify studies on statistical methods for dealing with baseline imbalances, skewed costs and/or effects, correlated costs and effects, clustered data, longitudinal data, missing data and censoring in trial-based economic evaluations. Data was extracted on the statistical methods described, their advantages, disadvantages, relative performance and recommendations of the study. Sixty-eight studies were included. Of them, 27 (40%) assessed methods for baseline imbalances, 39 (57%) assessed methods for skewed costs and/or effects, 27 (40%) assessed methods for correlated costs and effects, 18 (26%) assessed methods for clustered data, 7 (10%) assessed methods for longitudinal data, 26 (38%) assessed methods for missing data and 10 (15%) assessed methods for censoring. All identified methods were narratively described. This review provides a comprehensive overview of available statistical methods for dealing with the most common statistical complexities in trial-based economic evaluations. Herewith, it can provide valuable input for researchers when deciding which statistical methods to use in a trial-based economic evaluation.

Burden and severity of children's hospitalizations by respiratory syncytial virus in Portugal, 2015-2018

BACKGROUND

Respiratory syncytial virus (RSV) is a leading cause of acute lower respiratory infection (ALRI) in young children and is of considerable burden on healthcare systems. Our study aimed to evaluate ALRI hospitalizations related to RSV in children in Portugal.

METHODS

We reviewed hospitalizations potentially related to RSV in children aged <5 years from 2015 to 2018, using anonymized administrative data covering all public hospital discharges in mainland Portugal. Three case definitions were considered: (a) RSV-specific, (b) (a) plus unspecified acute bronchiolitis (RSV-specific & Bronchiolitis), and (c) (b) plus unspecified ALRI (RSV-specific & ALRI).

RESULTS

A total of 9697 RSV-specific hospitalizations were identified from 2015 to 2018-increasing to 26 062 for RSV-specific & ALRI hospitalizations-of which 74.7% were during seasons 2015/2016-2017/2018 (November-March). Mean hospitalization rates per season were, for RSV-specific, RSV-specific & Bronchiolitis, and RSV-specific & ALRI, respectively, 5.6, 9.4, and 11.8 per 1000 children aged <5 years and 13.4, 22.5, and 25.9 in children aged <2 years. Most RSV-specific hospitalizations occurred in healthy children (94.9%) and in children aged <2 years (96.3%). Annual direct costs of €2.4 million were estimated for RSV-specific hospitalizations-rising to €5.1 million for RSV-specific & ALRI-mostly driven by healthy children (87.6%).

CONCLUSION

RSV is accountable for a substantial number of hospitalizations in children, especially during their first year of life. Hospitalizations are mainly driven by healthy children. The variability of the potential RSV burden across case definitions highlights the need for a universal RSV surveillance system to guide prevention strategies.

MSmonitor-plus program and video calling care (MPVC) for multidisciplinary care and self-management in multiple sclerosis: study protocol of a single-center randomized, parallel-group, open label, non-inferiority trial

BACKGROUND

We designed a new multi-modal version of the MSmonitor, called the MSmonitor-Plus and Video calling Care (MPVC), a self-management and education program with e-health interventions that combines frequent use of specific questionnaires with video calling in treating multiple sclerosis (MS) patients.

OBJECTIVE

To assess the effectiveness, cost-effectiveness and feasibility of MPVC compared to care as usual (CAU), with the goal of achieving equal or better quality of life for MS patients and their partners/informal caregivers. Our hypothesis is that by using MPVC, monitoring will become more efficient, that patients' self-efficacy, quality of life, and adherence to treatment will improve, and that they will be able to live their lives more autonomously.

METHODS

A randomized, parallel-group, open label, non-inferiority trial will be conducted to compare MPVC with CAU in MS patients and their partners/informal caregivers. A total of 208 patients will be included with follow-up measurements for 2 years (at baseline and every 3 months). One hundred four patients will be randomized to MPVC and 104 patients to CAU. Partners/informal caregivers of both groups will be asked to participate. The study will consist of three parts: 1) a clinical effectiveness study, 2) an economic evaluation, and 3) a process evaluation. The primary outcome relates to equal or improved disease-specific physical and mental quality of life of the MS patients. Secondary outcomes relate to self-efficacy, efficiency, cost-effectiveness, autonomy, satisfaction with the care provided, and quality of life of partners/informal caregivers.

DISCUSSION

The idea behind using MPVC is that MS patients will gain more insight into the individual course of the disease and get a better grip on their symptoms. This knowledge should increase their autonomy, give patients more control of their condition and enable them to better and proactively interact with health care professionals. As the consulting process becomes more efficient with the use of MPVC, MS-related problems could be detected earlier, enabling earlier multidisciplinary care, treatment or modification of the treatment. This could have a positive effect on the quality of life for both the MS patient and his/her partner/informal caregiver, reducing health and social costs.

TRIAL REGISTRATION

NCT05242731 Clinical Trials.gov. Date of registration: 16 February 2022 retrospectively registered.

Healthcare resource utilization in patients with myeloproliferative neoplasms: A Danish nationwide matched cohort study

Few studies have assessed healthcare resource utilization (HRU) in patients with Philadelphia-negative myeloproliferative neoplasms (MPN) using a matched cohort design. Further, no detailed assessment of HRU in the years preceding an MPN diagnosis exists. We conducted a registry-based nationwide Danish cohort study, including patients with essential thrombocythemia, polycythemia vera, myelofibrosis, and unclassifiable MPN diagnosed between January 2010 and December 2016. HRU data were summarized annually from 2 years before MPN diagnosis until emigration, death, or end of study (December 2017). We included 3342 MPN patients and 32 737 comparisons without an MPN diagnosis, matched on sex, age, region of residence, and level of education. During the study period, the difference in HRU (rate ratio) between patients and matched comparisons ranged from 1.0 to 1.5 for general practitioner contacts, 0.9 to 2.2 for hospitalizations, 0.9 to 3.8 for inpatient days, 1.0 to 4.0 for outpatient visits, 1.3 to 2.1 for emergency department visits, and 1.0 to 4.1 for treatments/examinations. In conclusion, MPN patients had overall higher HRU than the matched comparisons throughout the follow-up period (maximum 8 years). Further, MPN patients had substantially increased HRU in both the primary and secondary healthcare sector in the 2 years preceding the diagnosis.

Quality of life, out-of-pocket expenditures, and indirect costs among patients with the central nervous system tumors in Thailand

Objectives

The aim of this study was to investigate out-of-pocket (OOP) expenditures, indirect costs, and health-related quality of life (HRQoL) associated with the central nervous system (CNS) tumors in Thailand.

Materials and Methods

A prospective study of CNS tumor patients who underwent first tumor resection at a tertiary care institution in Thailand was conducted. Patients were interviewed during hospitalization for undergoing first surgery. Within 6 months, they were interviewed once more if the disease continued to progress. Costs collected from a patient perspective and converted to 2019 US dollars. For dealing with these skewed data, a generalized linear model was used to investigate the effects of disease severity (malignancy, progressive disease, Karnofsky performance status score, and histology) and other factors on costs (OOP, informal care, productivity loss, and total costs). P < 0.05 was considered statistical significant for all analysis.

Results

Among a total of 123 intracranial CNS tumor patients, there were 83 and 40 patients classified into benign and malignant, respectively. In the first brain surgery, there was no statistical difference in HRQoL between patients with benign and malignant tumors (P = 0.072). However, patients with progressive disease had lower HRQoL mean scores at pre-operative and progressive disease periods were 0.711 (95% confidence interval [CI]: 0.662-0.760) and 0.261 (95% CI: 0.144-0.378), respectively. Indirect expenditures were the primary cost driver, accounting for 73.81% of annual total costs. The total annual costs accounted for 59.81% of the reported patient's income in malignant tumor patients. The progressive disease was the only factor that was significantly increases in all sorts of costs, including the OOP (P = 0.001), the indirect costs (P = 0.013), and the total annual costs (P = 0.001).

Conclusion

Although there was no statistical difference in HRQoL and costs between patients with benign and malignant tumor, the total costs accounted for more than half of the reported income in malignant tumor patients. The primary cause of significant increases in all costs categories was disease progression.

Healthcare costs of adverse drug reactions and potentially inappropriate prescribing in older adults: a population-based study

OBJECTIVES

To describe the distribution of costs based on potentially inappropriate prescribing (PIP) and adverse drug reaction (ADR) status in terms of total direct costs and costs caused by ADRs, among older adults.

DESIGN

A retrospective cohort study was conducted among older adults, identified from a random sample of the general Swedish population. PIP was identified based on the Screening Tool of Older Persons' Prescriptions (STOPP) criteria and ADRs were identified using the Howard criteria. Causality between PIP and ADRs was evaluated using Hallas' criteria. Prevalence-based direct healthcare costs were calculated for the 3-month study period, including the total cost for healthcare and drugs, and the cost caused by ADRs.

SETTING

All care levels, including primary care, other outpatient care and inpatient care.

PARTICIPANTS

813 adults ≥65 years.

PRIMARY OUTCOME MEASURES

The prevalence and cost of PIP and ADRs.

RESULTS

Total direct cost for persons with PIP was approximately twice the total cost of those without PIP (€1958 (€1428-€2616) vs €881 (€817-€1167), p=0.0020). The costs caused by ADRs was 10 times higher among persons with PIP, compared with those without PIP (€270 (€86-€545) vs €27 (€10-€61), p=0.047). For persons with ADRs caused by PIP, total direct costs were €4646 (€2617-€7931). This group represented 8% of the study population and used 25% of the costs. The main cost driver in all studied patient groups was healthcare contacts.

CONCLUSIONS

Older persons with PIP and ADRs had high healthcare costs, particularly when ADRs were caused by PIP. Since these costs appear to be substantial, the potential savings by preventing their occurrence may, to a certain degree, cover the added cost of such activities. Further studies should be undertaken to provide further evidence on the costs of PIP, ADRs and ADRs caused by PIP.

Physician gestalt for emergency department triage: A prospective videotaped study

OBJECTIVE

Appropriate triage in patients presenting to the emergency department (ED) is often challenging. Little is known about the role of physician gestalt in ED triage. We aimed to compare the accuracy of emergency physician gestalt against the currently used computerized triage process.

METHODS

We conducted a prospective observational study in the ED at an academic medical center. Adult patients aged ≥20 years were included and underwent a standard triage protocol. The patients underwent system-based triage using the computerized software the Taiwan Triage and Acuity Scale. The entire triage process was recorded, and triage data were collected. Five physician raters provided triage levels (physician-based) according to their perceived urgency after reviewing videos. The primary outcome was hospital admission. The secondary outcomes were ED length of stay (EDLOS) and charges.

RESULTS

In total, 656 patients were recruited (mean age 52 years, 50% male). The median system-based triage level was 3. By contrast, the median physician-based triage level was 4. The physician raters tended to provide lower triage levels than the system, with an average difference of 1. There was modest concordance between the two triage methods (correlation coefficient 0.30), with a weighted kappa coefficient of 0.18. The area under the receiver operating curve for the system- and physician-based triage in predicting hospital admission were similar (0.635 vs. 0.631, p = 0.896). Attending physicians appeared to have better performance than residents in predicting admission. The variation explained (R² ) in EDLOS and charges were similar between the two triage methods (R²  = 3% for EDLOS, 7%-9% for charges).

CONCLUSIONS

Emergency physician gestalt for triage showed similar performance to a computerized system; however, physicians redistributed patients to lower triage levels. Physician gestalt has advantages for identifying low-risk patients. This approach may avoid undue time pressure for health care providers and promote rapid discharge.

Treating common mental disorder including psychotic experiences in the primary care improving access to psychological therapies programme (the TYPPEX study): protocol for a stepped wedge cluster randomised controlled trial with nested economic and process evaluation of a training package for therapists

INTRODUCTION

At least one in four people treated by the primary care improving access to psychological therapies (IAPT) programme in England experiences distressing psychotic experiences (PE) in addition to common mental disorder (CMD). These individuals are less likely to achieve recovery. IAPT services do not routinely screen for nor offer specific treatments for CMD including PE. The Tailoring evidence-based psychological therapY for People with common mental disorder including Psychotic EXperiences study will evaluate the clinical and cost-effectiveness of an enhanced training for cognitive behavioural therapists that aims to address this clinical gap.

METHODS AND ANALYSIS

This is a multisite, stepped-wedge cluster randomised controlled trial. The setting will be IAPT services within three mental health trusts. The participants will be (1) 56-80 qualified IAPT cognitive behavioural therapists and (2) 600 service users who are triaged as appropriate for cognitive behavioural therapy in an IAPT service and have PE according to the Community Assessment of Psychic Experiences-Positive 15-items Scale. IAPT therapists will be grouped into eight study clusters subsequently randomised to the control-intervention sequence. We will obtain pseudonymous clinical outcome data from IAPT clinical records for eligible service users. We will invite service users to complete health economic measures at baseline, 3, 6, 9 and 12-month follow-up. The primary outcome will be the proportion of patients with common mental disorder psychotic experiences who have recovered by the end of treatment as measured by the official IAPT measure for recovery.

ETHICS AND DISSEMINATION

The study received the following approvals: South Central-Berkshire Research Ethics Committee on 28 April 2020 (REC reference 20/SC/0135) and Health Research Authority (HRA) on 23 June 2020. An amendment was approved by the Ethics Committee on 01 October 2020 and HRA on 27 October 2020. Results will be made available to patients and the public, the funders, stakeholders in the IAPT services and other researchers.

TRIAL REGISTRATION NUMBER

ISRCTN93895792.

Retrospective Cohort Study of the 12-Month Epidemiology, Treatment Patterns, Outcomes, and Healthcare Costs Among Adult Patients with Complicated Urinary Tract Infections

Background

Limited data are available in the United States on the 12-month epidemiology, outpatient (OP) antibiotic treatment patterns, outcomes, and costs associated with complicated urinary tract infections (cUTIs) in adult patients.

Methods

A retrospective observational cohort study of adult patients with incident cUTIs in IBM MarketScan Databases between 2017 and 2019 was performed. Patients were categorized as OP or inpatient (IP) based on initial setting of care for index cUTI and were stratified by age (<65 years vs ≥65 years). OP antibiotic treatment patterns, outcomes, and costs associated with cUTIs among adult patients over a 12-month follow-up period were examined.

Results

During the study period, 95 322 patients met inclusion criteria. Most patients were OPs (84%) and age <65 years (87%). Treatment failure (receipt of new unique OP antibiotic or cUTI-related ED visit/IP admission) occurred in 23% and 34% of OPs aged <65 years and ≥65 years, respectively. Treatment failure was observed in >38% of IPs, irrespective of age. Across both cohorts and age strata, >78% received ≥2 unique OP antibiotics, >34% received ≥4 unique OP antibiotics, >16% received repeat OP antibiotics, and >33% received ≥1 intravenous (IV) OP antibiotics. The mean 12-month cUTI-related total health care costs were $4697 for OPs age <65 years, $8924 for OPs age >65 years, $15 401 for IPs age <65 years, and $17 431 for IPs age ≥65 years.

Conclusions

These findings highlight the substantial 12-month health care burden associated with cUTIs and underscore the need for new outpatient treatment approaches that reduce the persistent or recurrent nature of many cUTIs.

Incremental healthcare expenditure attributable to diabetes mellitus: A cost of illness study in Tasmania, Australia

AIMS

To quantify the incremental direct medical costs in people with diabetes from the healthcare system perspective; and to identify trends in the incremental costs.

METHODS

This was a matched retrospective cohort study based on a linked data set developed for investigating chronic kidney disease in Tasmania, Australia. Using propensity score matching, 51,324 people with diabetes were matched on age, sex and residential area with 102,648 people without diabetes. Direct medical costs (Australian dollars 2020-2021) due to hospitalisation, Emergency Department visits and pathology tests were included. The incremental costs and cost ratios between mean annual costs of people with diabetes and their controls were calculated.

RESULTS

On average, people with diabetes had healthcare costs that were almost double their controls ($2427 [95% CI 2322-2543]; ratio 1.87 [95% CI 1.85-1.91]; pooled from 2007-2017). While in the first year of follow-up, the costs of a person with diabetes were $1643 (95% CI 1489-1806); ratio 1.83 (95% CI 1.76-1.92) more than their control, this increased to $2480 (95% CI 2265-2680); ratio 1.69 (95% CI 1.62-1.77) in the final year. Although the incremental costs were higher in older age groups (e.g., ≥70: $2498 [95% CI 2265-2754]; 40-49: $2117 [95% CI 1887-2384]), the cost ratios were higher in younger age groups (≥70: 1.52 [95% CI 1.48-1.56]; 40-49: 2.37 [95% CI 2.25-2.61]).

CONCLUSIONS

Given the increasing burden that diabetes imposes, our findings will support policymakers in future planning for diabetes and enable targeting sub-groups with higher long-term costs for possible cost savings for the Tasmanian healthcare system.

Perinatal mental health services in pregnancy and the year after birth: the ESMI research programme including RCT

Background

It is unclear how best to identify and treat women with mental disorders in pregnancy and the year after birth (i.e. the perinatal period).

Objectives

(1) To investigate how best to identify depression at antenatal booking [work package (WP) 1]. (2) To estimate the prevalence of mental disorders in early pregnancy (WP1). (3) To develop and examine the efficacy of a guided self-help intervention for mild to moderate antenatal depression delivered by psychological well-being practitioners (WP1). (4) To examine the psychometric properties of the perinatal VOICE (Views On Inpatient CarE) measure of service satisfaction (WP3). (5) To examine the clinical effectiveness and cost-effectiveness of services for women with acute severe postnatal mental disorders (WPs 1–3). (6) To investigate women’s and partners’/significant others’ experiences of different types of care (WP2).

Design

Objectives 1 and 2 – a cross-sectional survey stratified by response to Whooley depression screening questions. Objective 3 – an exploratory randomised controlled trial. Objective 4 – an exploratory factor analysis, including test–retest reliability and validity assessed by association with the Client Satisfaction Questionnaire contemporaneous satisfaction scores. Objective 5 – an observational cohort study using propensity scores for the main analysis and instrumental variable analysis using geographical distance to mother and baby unit. Objective 6 – a qualitative study.

Setting

English maternity services and generic and specialist mental health services for pregnant and postnatal women.

Participants

Staff and users of mental health and maternity services.

Interventions

Guided self-help, mother and baby units and generic care.

Main outcome measures

The following measures were evaluated in WP1(i) – specificity, sensitivity, positive predictive value, likelihood ratio, acceptability and population prevalence estimates. The following measures were evaluated in WP1(ii) – participant recruitment rate, attrition and adverse events. The following measure was evaluated in WP2 – experiences of care. The following measures were evaluated in WP3 – psychometric indices for perinatal VOICE and the proportion of participants readmitted to acute care in the year after discharge.

Results

WP1(i) – the population prevalence estimate was 11% (95% confidence interval 8% to 14%) for depression and 27% (95% confidence interval 22% to 32%) for any mental disorder in early pregnancy. The diagnostic accuracy of two depression screening questions was as follows: a weighted sensitivity of 0.41, a specificity of 0.95, a positive predictive value of 0.45, a negative predictive value of 0.93 and a likelihood ratio (positive) of 8.2. For the Edinburgh Postnatal Depression Scale, the diagnostic accuracy was as follows: a weighted sensitivity of 0.59, a specificity of 0.94, a positive predictive value of 0.52, a negative predictive value of 0.95 and a likelihood ratio (positive) of 9.8. Most women reported that asking about depression at the antenatal booking appointment was acceptable, although this was reported as being less acceptable for women with mental disorders and/or experiences of abuse. Cost-effectiveness analysis suggested that both the Whooley depression screening questions and the Edinburgh Postnatal Depression Scale were more cost-effective than with the Whooley depression screening questions followed by the Edinburgh Postnatal Depression Scale or no-screen option. WP1(ii) – 53 women with depression in pregnancy were randomised. Twenty-six women received modified guided self-help [with 18 (69%) women attending four or more sessions] and 27 women received usual care. Three women were lost to follow-up (follow-up for primary outcome: 92%). At 14 weeks post randomisation, women receiving guided self-help reported fewer depressive symptoms than women receiving usual care (adjusted effect size −0.64, 95% confidence interval −1.30 to 0.06). Costs and quality-adjusted life-years were similar, resulting in a 50% probability of guided self-help being cost-effective compared with usual care at National Institute for Health and Care Excellence cost per quality-adjusted life-year thresholds. The slow recruitment rate means that a future definitive larger trial is not feasible. WP2 – qualitative findings indicate that women valued clinicians with specialist perinatal expertise across all services, but for some women generic services were able to provide better continuity of care. Involvement of family members and care post discharge from acute services were perceived as poor across services, but there was also ambivalence among some women about increasing family involvement because of a complex range of factors. WP3(i) – for the perinatal VOICE, measures from exploratory factor analysis suggested that two factors gave an adequate fit (comparative fit index = 0.97). Items loading on these two dimensions were (1) those concerning aspects of the service relating to the care of the mother and (2) those relating to care of the baby. The factors were positively correlated (0.49; p < 0.0001). Total scores were strongly associated with service (with higher satisfaction for mother and baby units, 2 degrees of freedom; p < 0.0001) and with the ‘gold standard’ Client Service Questionnaire total score (test–retest intraclass correlation coefficient 0.784, 95% confidence interval 0.643 to 0.924; p < 0.0001). WP3(ii) – 263 of 279 women could be included in the primary analysis, which shows that the odds of being readmitted to acute care was 0.95 times higher for women who were admitted to a mother and baby unit than for those not admitted to a mother and baby unit (0.95, 95% confidence interval 0.86 to 1.04; p = 0.29). Sensitivity analysis using an instrumental variable found a markedly more significant effect of admission to mother and baby units (p < 0.001) than the primary analysis. Mother and baby units were not found to be cost-effective at 1 month post discharge because of the costs of care in a mother and baby unit. Cost-effectiveness advantages may exist if the cost of mother and baby units is offset by savings from reduced readmissions in the longer term.

Limitations

Policy and service changes had an impact on recruitment. In observational studies, residual confounding is likely.

Conclusions

Services adapted for the perinatal period are highly valued by women and may be more effective than generic services. Mother and baby units have a low probability of being cost-effective in the short term, although this may vary in the longer term.

Future work

Future work should include examination of how to reduce relapses, including in after-care following discharge, and how better to involve family members.

Trial registration

This trial is registered as ISRCTN83768230 and as study registration UKCRN ID 16403.

Funding

This project was funded by the National Institute for Health and Care Research (NIHR) Programme Grants for Applied Research programme and will be published in full in Programme Grants for Applied Research; Vol. 10, No. 5. See the NIHR Journals Library website for further project information.

Multisite randomised controlled trial of trauma-focused cognitive behaviour therapy for psychosis to reduce post-traumatic stress symptoms in people with co-morbid post-traumatic stress disorder and psychosis, compared to treatment as usual: study protocol for the STAR (Study of Trauma And Recovery) trial

Background

People with psychosis have high rates of trauma, with a post-traumatic stress disorder (PTSD) prevalence rate of approximately 15%, which exacerbates psychotic symptoms such as delusions and hallucinations. Pilot studies have shown that trauma-focused (TF) psychological therapies can be safe and effective in such individuals. This trial, the largest to date, will evaluate the clinical effectiveness of a TF therapy integrated with cognitive behaviour therapy for psychosis (TF-CBTp) on post-traumatic stress symptoms in people with psychosis. The secondary aims are to compare groups on cost-effectiveness; ascertain whether TF-CBTp impacts on a range of other meaningful outcomes; determine whether therapy effects endure; and determine acceptability of the therapy in participants and therapists.

Methods

Rater-blind, parallel arm, pragmatic randomised controlled trial comparing TF-CBTp + treatment as usual (TAU) to TAU only. Adults (N = 300) with distressing post-traumatic stress and psychosis symptoms from five mental health Trusts (60 per site) will be randomised to the two groups. Therapy will be manualised, lasting 9 months (m) with trained therapists. We will assess PTSD symptom severity (primary outcome); percentage who show loss of PTSD diagnosis and clinically significant change; psychosis symptoms; emotional well-being; substance use; suicidal ideation; psychological recovery; social functioning; health-related quality of life; service use, a total of four times: before randomisation; 4 m (mid-therapy); 9 m (end of therapy; primary end point); 24 m (15 m after end of therapy) post-randomisation. Four 3-monthly phone calls will be made between 9 m and 24 m assessment points, to collect service use over the previous 3 months. Therapy acceptability will be assessed through qualitative interviews with participants (N = 35) and therapists (N = 5–10). An internal pilot will ensure integrity of trial recruitment and outcome data, as well as therapy protocol safety and adherence. Data will be analysed following intention-to-treat principles using generalised linear mixed models and reported according to Consolidated Standards of Reporting Trials-Social and Psychological Interventions Statement.

Discussion

The proposed intervention has the potential to provide significant patient benefit in terms of reductions in distressing symptoms of post-traumatic stress, psychosis, and emotional problems; enable clinicians to implement trauma-focused therapy confidently in this population; and be cost-effective compared to TAU through reduced service use.

Trial registration

ISRCTN93382525 (03/08/20)

Supplementary Information

The online version contains supplementary material available at 10.1186/s13063-022-06215-x.

Prevalence and Cost of Care for Parkinson's Disease in Luxembourg: An Analysis of National Healthcare Insurance Data

BACKGROUND

Parkinson's disease (PD) is the second most common neurodegenerative disorder, with an increasing prevalence worldwide. Estimates of the economic burden associated with PD vary widely across existing studies due to differences in setting and study design. The prevalence and cost of care for PD in Luxembourg are currently unknown.

OBJECTIVE

The aims of this study were to estimate (1) the prevalence of PD in Luxembourg and (2) the cost of care for PD to the national healthcare insurance based on routinely collected healthcare data.

METHODS

This analysis was based on individual patient-level data collected by the national healthcare insurance in Luxembourg during 2007-2017, which covers over 95% of the resident population. People with PD were identified based on drug reimbursement profiles. Cost of care was estimated according to a comparative analysis of the healthcare resources consumed by people with PD compared with an age- and sex-matched control group.

RESULTS

We determined a PD prevalence of 928 per 100,000 individuals aged 50 years and older in 2016, higher in men (1032 per 100,000) than in women (831 per 100,000). The total mean cost of care for PD was estimated at €22,673 per patient per year in 2016, with the highest costs being associated with long-term care (69%).

CONCLUSION

This was the first attempt to estimate the prevalence and cost of care of PD in Luxembourg. The work demonstrated the usefulness of routinely collected data in Luxembourg for such analyses. Our study confirms the significant burden of PD to the healthcare system, especially on long-term care.