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Relating the new COPD GOLD strategy to quality-of-life and costs in a primary care population

Are disease management programs for COPD cost-effective?

Is integrated COPD care cost-effective?

Comparing short-term risk of repeat self-harm after psychosocial assessment of patients who self-harm by psychiatrists or psychiatric nurses in a general hospital: Cohort study

Copyright © 2020 Elsevier B.V. All rights reserved. BACKGROUND: There is mixed evidence for whether psychosocial assessment following hospital presentation for self-harm reduces self-harm repetition. A possible reason is the differences in professional background of assessors (primarily psychiatrists and psychiatric nurses) due to variability in training and therapist style. METHODS: Using data from the Oxford Monitoring System for Self-harm, we analysed data on patients making their first emergency department (ED) presentation for self-harm between 2000 and 2014, followed-up until 2015. Using logistic regression, we estimated the probability of repeat self-harm within 12 months, comparing: (i) patients receiving psychosocial assessment versus none, adjusting for age, gender, self-harm method, past self-harm presentation, and general hospital admission; and (ii) patients assessed by a psychiatric nurse versus those assessed by a psychiatrist, adjusting for age, self-harm method, time and year of presentation. RESULTS: The 12,652 patients who had an index ED presentation for self-harm during the study period accounted for 24,450 presentations, in 17,303 (71%) of which a psychosocial assessment was conducted; in 9318 (54%) by a psychiatric nurse and in 7692 (45%) by a psychiatrist. We found a reduced probability of repeat self-harm presentation among patients receiving psychosocial assessment versus none (adjusted odds ratio [AOR] = 0.70; 95% CI = 0.65-0.75; p 

Methodological quality of economic evaluations in integrated care: Evidence from a systematic review

© 2019, Ubiquity Press. All rights reserved. Introduction: The aim of this review is to systematically assess the methodological quality of economic evaluations in integrated care and to identify challenges with conducting such studies. Theory and methods: Searches of grey-literature and scientific papers were performed, from January 2000 to December 2018. A checklist was developed to assess the quality of economic evaluations. Authors’ statements of challenges encountered during their evaluations were qualitatively coded. Results: Forty-four articles were eligible for inclusion. The review found that study design, measurement of cost and outcomes, statistical analysis and presentation of data were the areas with most quality variation. Authors identified challenges mostly related to time horizon of the evaluation, inadequate or lack of comparator group, contamination bias, and a post-hoc evaluation culture. Discussion: Our review found significant differences in quality, with some studies showing poor methodological rigor; challenging conclusions on the cost-effectiveness of integrated care. Conclusion: It is essential for evaluators to use best-practice standards when planning and conducting economic evaluations, in order to build a reliable evidence base for decision-making in integrated care.

Broader economic evaluation of disease management programs using mutlti-criteria decision analysis

Objectives: The aim of this paper is to develop a methodological framework to facilitate the application of Multi-Criteria Decision Analysis (MCDA) for a comprehensive economic evaluation of disease management programs (DMPs). Methods: We studied previously developed frameworks for the evaluation of DMPs and different methods of MCDA and we used practical field experience in the economic evaluation of DMPs and personal discussions with stakeholders in chronic care. Results: The framework includes different objectives and criteria that are relevant for the evaluation of DMPs, indicators that can be used to measure how DMPs perform on these criteria, and distinguishes between the development and implementation phase of DMPs. The objectives of DMPs are categorised into a) changes in the process of care delivery, b) changes in patient lifestyle and self-management behaviour, c) changes in biomedical, physiological and clinical health outcomes, d) changes in health-related quality of life, and e) changes in final health outcomes. All relevant costs of DMPs are also included in the framework. Based on this framework we conducted a MCDA of a hypothetical DMP versus usual care. Conclusions: We call for a comprehensive economic evaluation of DMPs that is not just based on a single criterion but takes into account multiple relevant criteria simultaneously. The framework we presented here is a step towards standardising such an evaluation. © 2013 Cambridge University Press.

Towards integrated care for chronic conditions: Dutch policy developments to overcome the (financial) barriers

Chronic non-communicable diseases are a major threat to population health and have a major economic impact on health care systems. Worldwide, integrated chronic care delivery systems have been developed to tackle this challenge. In the Netherlands, the recently introduced integrated payment system - the chain-DTC - is seen as the cornerstone of a policy stimulating the development of a well-functioning integrated chronic care system. The purpose of this paper is to describe the recent attempts in the Netherlands to stimulate the delivery of integrated chronic care, focusing specifically on the new integrated payment scheme and the barriers to introducing this scheme. We also highlight possible threats and identify necessary conditions to the success of the system. This paper is based on a combination of methods and sources including literature, government documents, personal communications and site visits to disease management programs (DMPs). The most important conditions for the success of the new payment system are: complete care protocols describing both general (e.g. smoking cessation, physical activity) and disease-specific chronic care modules, coverage of all components of a DMP by basic health care insurance, adequate information systems that facilitate communication between caregivers, explicit links between the quality and the price of a DMP, expansion of the amount of specialized care included in the chain-DTC, inclusion of a multi-morbidity factor in the risk equalization formula of insurers, and thorough economic evaluation of DMPs. © 2010 Elsevier Ireland Ltd.

Cost-effectiveness of strategies to increase cervical screening uptake at first invitation (Strategic)

Objective: To assess the cost-effectiveness of strategies to increase cervical cancer screening uptake at first invitation (STRATEGIC trial). Methods: We performed an economic analysis alongside the STRATEGIC trial, comparing each of seven novel interventions for improving cervical screening uptake with control general practices in Greater Manchester and Grampian (United Kingdom). A template was developed to measure the intervention costs. Trial estimates of screening uptake were combined with data from the literature to estimate healthcare costs of each intervention. The added lifetime costs and quality adjusted life years (QALYs) of attending cervical screening were estimated by a systematic literature review, with relevant results pooled and weighted by study quality. Trial results and estimated lifetime costs and benefits of screening were then combined in a decision analytic model, giving an incremental cost per QALY gained for each intervention. Uncertainty was addressed in probabilistic and univariate sensitivity analyses. Results: Intervention costs per screening round per woman attending varied from about £1.20 (2014 UK) for the nurse navigator intervention to £62 for the unrequested HPV self-sampler kit. The meta-analysis revealed a lifetime discounted benefit from screening of 0.043 QALYs per woman attending, at an additional lifetime discounted cost of £234. The incremental cost per QALY gained in all interventions was below £13,000. Probabilistic sensitivity analyses suggested that only unrequested selfsampling and timed appointments have a high probability of being cost-effective. Conclusions: Unrequested self-sampling and timed appointments are likely to be cost-effective interventions. Further research is required on the duration of effects and on implementing combinations of interventions.

Finding the royal way to stimulate and evaluate integrated care in Europe

Integrated care is the most promising concept to tackle the increasing threat of chronic diseases by redesigning care and changing patient lifestyle and care provider behaviour. However, the evidence about integrated care in the literature is inconclusive. This might be largely explained by flaws in the development, delivery, evaluation and implementation of integrated care thus far. Therefore, the research agenda for integrated care should focus on the adequate development, comprehensive evaluation and successful implementation of integrated care in order to support the collaboration of health authorities, payers, care providers and patient organisations towards integrating care. These issues are not explicitly addressed in the current HORIZON 2020 work programme. This letter provides a short list of topics for future research in integrated care to provide evidence about the (cost-)effectiveness of integrated care.

Real-world performance and accuracy of stress echocardiography: the EVAREST observational multi-centre study

Aims: Stress echocardiography is widely used to identify obstructive coronary artery disease (CAD). High accuracy is reported in expert hands but is dependent on operator training and image quality. The EVAREST study provides UK-wide data to evaluate real-world performance and accuracy of stress echocardiography. Methods and results: Participants undergoing stress echocardiography for CAD were recruited from 31 hospitals. Participants were followed up through health records which underwent expert adjudication. Cardiac outcome was defined as anatomically or functionally significant stenosis on angiography, revascularization, medical management of ischaemia, acute coronary syndrome, or cardiac-related death within 6 months. A total of 5131 patients (55% male) participated with a median age of 65 years (interquartile range 57-74). 72.9% of studies used dobutamine and 68.5% were contrast studies. Inducible ischaemia was present in 19.3% of scans. Sensitivity and specificity for prediction of a cardiac outcome were 95.4% and 96.0%, respectively, with an accuracy of 95.9%. Sub-group analysis revealed high levels of predictive accuracy across a wide range of patient and protocol sub-groups, with the presence of a resting regional wall motion abnormalitiy significantly reducing the performance of both dobutamine (P < 0.01) and exercise (P < 0.05) stress echocardiography. Overall accuracy remained consistently high across all participating hospitals. Conclusion: Stress echocardiography has high accuracy across UK-based hospitals and thus indicates stress echocardiography is being delivered effectively in real-world practice, reinforcing its role as a first-line investigation in the assessment of patients with stable chest pain.

Should i stay or should i go? A retrospective propensity score-matched analysis using administrative data of hospital-at-home for older people in Scotland

Objectives To compare the characteristics of populations admitted to hospital-at-home services with the population admitted to hospital and assess the association of these services with healthcare costs and mortality. Design In a retrospective observational cohort study of linked patient level data, we used propensity score matching in combination with regression analysis. Participants Patients aged 65 years and older admitted to hospital-at-home or hospital. Interventions Three geriatrician-led admission avoidance hospital-at-home services in Scotland. Outcome measures Healthcare costs and mortality. Results Patients in hospital-at-home were older and more socioeconomically disadvantaged, had higher rates of previous hospitalisation and there was a greater proportion of women and people with several chronic conditions compared with the population admitted to hospital. The cost of providing hospital-at-home varied between the three sites from £628 to £2928 per admission. Hospital-at-home was associated with 18% lower costs during the follow-up period in site 1 (ratio of means 0.82; 95% CI: 0.76 to 0.89). Limiting the analysis to costs during the 6 months following index discharge, patients in the hospital-at-home cohorts had 27% higher costs (ratio of means 1.27; 95% CI: 1.14 to 1.41) in site 1, 9% (ratio of means 1.09; 95% CI: 0.95 to 1.24) in site 2 and 70% in site 3 (ratio of means 1.70; 95% CI: 1.40 to 2.07) compared with patients in the control cohorts. Admission to hospital-at-home was associated with an increased risk of death during the follow-up period in all three sites (1.09, 95% CI: 1.00 to 1.19 site 1; 1.29, 95% CI: 1.15 to 1.44 site 2; 1.27, 95% CI: 1.06 to 1.54 site 3). Conclusions Our findings indicate that in these three cohorts, the populations admitted to hospital-at-home and hospital differ. We cannot rule out the risk of residual confounding, as our analysis relied on an administrative data set and we lacked data on disease severity and type of hospitalised care received in the control cohorts.

Cost-effectiveness of cognitive-behavioural therapy for sleep disorder added to usual care in patients with schizophrenia: The BEST study

Copyright © The Royal College of Psychiatrists 2018. Sleep problems are pervasive in people with schizophrenia, but there are no clinical guidelines for their treatment. The Better Sleep Trial (BEST) concluded that suitably adapted cognitive-behavioural therapy (CBT) is likely to be highly effective, although its cost-effectiveness is unknown.Aims To assess the potential cost-effectiveness of CBT for sleep disorders in patients with schizophrenia.Method An economic evaluation of the BEST study with a 6-month time horizon was used to establish the cost-effectiveness of CBT plus usual care in terms of costs per quality-adjusted life year (QALY) gained. Uncertainty was displayed on cost-effectiveness planes and acceptability curves. Value of information analysis was performed to estimate the benefits of obtaining further evidence.Results On average, the treatment led to a 0.035 QALY gain (95% CI -0.016 to 0.084), and £1524 (95% CI -10 529 to 4736) and £1227 (95% CI -10 395 to 5361) lower costs from National Health Service and societal perspectives, respectively. The estimated value of collecting more information about the effects of the CBT on costs and QALYs was approximately £87 million.Conclusions CBT for insomnia in people with schizophrenia is effective and potentially cost-effective. A larger trial is needed to provide clear evidence about its cost-effectiveness.Relevance Patients with schizophrenia have multiple complex health needs, as well as very high rates of depression, suicidal ideation and poor physical health. The results of this study showed that treating pervasive sleep problems in this patient group with cognitive-behavioural therapy (CBT) is very likely to improve patient quality of life in the short term. Clinicians most commonly use hypnotic medication to treat sleeping disorders. This study indicates that CBT may be an effective and cost-effective intervention in this patient group. This alternative would also be aligned with patient preferences for psychological and behavioural-type therapy.Declaration of interest None.

Impact of financial agreements in European chronic care on health care expenditure growth

Various types of financial agreements have been implemented in Europe to reduce health care expenditure by stimulating integrated chronic care. This study used difference-in-differences (DID) models to estimate differences in health care expenditure trends before and after the introduction of a financial agreement between 9 intervention countries and 16 control countries. Intervention countries included countries with pay-for-coordination (PFC), pay-for-performance (PFP), and/or all inclusive agreements (bundled and global payment) for integrated chronic care. OECD and WHO data from 1996 to 2013 was used. The results from the main DID models showed that the annual growth of outpatient expenditure was decreased in countries with PFC (by 21.28 US$ per capita) and in countries with all-inclusive agreements (by 216.60 US$ per capita). The growth of hospital and administrative expenditure was decreased in countries with PFP by 64.50 US$ per capita and 5.74 US$ per capita, respectively. When modelling impact as a non-linear function of time during the total 4-year period after implementation, PFP decreased the growth of hospital and administrative expenditure and all-inclusive agreements reduced the growth of outpatient expenditure. Financial agreements are potentially powerful tools to stimulate integrated care and influence health care expenditure growth. A blended payment scheme that combines elements of PFC, PFP, and all-inclusive payments is likely to provide the strongest financial incentives to control health care expenditure growth.

Exploring the variability of patient costs in disease management programs: A hierarchical modelling approach

Disease management programs include a wide variation of patients with different chronic diseases and different health care utilization. The aim of this article was to identify factors on patient-level and organizational-level that explain the variability in costs of patients with different chronic diseases enrolled in a DMP by employing a rigorous analytical model. A generalized linear mixed model (GLMM) was specified to perform a multi-level analysis of cross-sectional hierarchical data from 16 DMPs in the Netherlands. Multiple imputation, sub-group analysis per disease and analysis from both the health care and the societal perspectives were also performed. Our model showed that age, the presence of cardiovascular disease, multi-morbidity and payments on top of the payment for the usual care had positive relation with costs, while better quality of life was associated with lower health care costs. In the COPD sample, physical activity and employment were associated with health care costs. Our study showed that there is great variability in health care costs among patients included in DMPs and identified patient and organizational explanatory factors. The findings are relevant to the design of future DMPs and their payment schemes. © 2013 © 2013 Taylor & Francis.

The welfare effects of innovative pharmaceuticals: An international perspective from the Dutch experience

Policy discussions on new medicines are often focused on cost containment rather than on the benefits they produce, such as health gains and cost savings in other sectors. In this study, we identify systematic differences in policies towards pharmaceuticals between countries and calculate the welfare gains of 39 innovative pharmaceuticals introduced in the Dutch market after 1997. Welfare gains are defined as the difference between the value of a QALY gained by innovative pharmaceuticals and their costs. The review shows that there are systematic differences among pharmaceutical policies and regulations between countries. It is further found that the welfare gains of pharmaceuticals are substantial and amount to €77 per capita per year in the Netherlands. The welfare gains could be higher if institutional barriers for an efficient utilization of innovative pharmaceuticals are removed. © 2013 Copyright Taylor and Francis Group, LLC.

The economic impact of violence perpetration in severe mental illness: a retrospective, prevalence-based analysis in England and Wales

© 2020 The Author(s). Published by Elsevier Ltd. This is an Open Access article under the CC BY 4.0 license Background: Calls for increased funding for mental health services require many lines of evidence in support, including estimates of economic impact. One understudied source of cost is violence perpetrated by individuals with severe mental illness. Estimating this economic impact can inform budget planning across several government sectors and emphasise the importance of violence prevention. Therefore, we aimed to provide a comprehensive estimate of the economic costs of violence perpetrated by people with severe mental illness. Methods: For this retrospective analysis, we used a prevalence-based modelling approach to estimate the annual economic cost of violent incidents committed by people with severe mental illness in England and Wales during 2015–16. The model was based on secondary data, including the association between violence and severe mental illness, illness prevalence, recidivism, absolute numbers of violent incidents in 2015–16, and costs to society per violent crime, by area of spending. Uncertainty was addressed with probabilistic and deterministic sensitivity analyses that tested the effect of underreporting of domestic violence and distributions of crime types in individuals with severe mental illness. Outcomes: The estimated annual economic impact of violence perpetrated by people with severe mental illness was £2·5 (95% CI 1·4–4·5) billion in England and Wales in 2015–16, or 5·3% of the total estimated societal cost of violence. The largest contributors to the cost of violent crime perpetrated by individuals with severe mental illness were the cost of physical and emotional harm to victims (£1·4 [95% CI 0·8–2·5] billion), followed by lost productivity of victims (£348.0 [190·0–628·8] million), while the combined cost to the police and criminal justice system was £561·3 (305·9–1009·2) million and the cost to health services was £136·7 [74·3–246·3] million. The additional cost to secure forensic care was estimated to be £487·7 (302·0–709·1) million. Interpretation: The economic impact of violence perpetrated by individuals with severe mental illness is potentially important. Preventing violence, especially through services for individuals with comorbid substance misuse, and reducing recidivism might lead to cost savings at a governmental and individual level, in addition to the clinical and societal benefits. Funding: Wellcome Trust, National Institute for Health Research (NIHR) Oxford Biomedical Research Centre, and NIHR Applied Research Collaboration Oxford and Thames Valley.

Cost-effectiveness of psychosocial assessment for individuals who present to hospital following self-harm in England: a model-based retrospective analysis Short title: Cost-effectiveness of psychosocial assessment

Background Guidance in England recommends psychosocial assessment when presenting to hospital following self-harm but adherence is variable. There is some evidence suggesting that psychosocial assessment is associated with lower risk of subsequent presentation to hospital for self-harm, but the potential cost-effectiveness of psychosocial assessment for hospital-presenting self-harm is unknown. Methods. A three-state four-cycle Markov model was used to assess cost-effectiveness of psychosocial assessment after self-harm compared with no assessment over two years. Data on risk of subsequent self-harm and hospital costs of treating self-harm were drawn from the Multicentre Study of Self-Harm in England, while estimates of effectiveness of psychosocial assessment on risk of self-harm, quality of life and other costs were drawn from literature. Incremental cost-effectiveness ratios (ICERs) for cost per Quality Adjusted Life Year (QALY) gained were estimated. Parameter uncertainty was addressed in univariate and probabilistic sensitivity analyses. Results. Cost per QALY gained from psychosocial assessment was £10, 962 (95% uncertainty interval (UI) £15, 538 - £9, 219) from the NHS perspective, and £9, 980 (95% UI £14, 538 - £6, 938) from the societal perspective. Results were generally robust to changes in model assumptions. The probability of the ICER being below £20, 000 per QALY gained was 78%, rising to 91% with a £30, 000 threshold. Conclusions Psychosocial assessment as implemented in the English NHS is likely to be cost51 effective. This evidence could support adherence to NICE guidelines. However, further evidence is needed about the precise impacts of psychosocial assessment on self-harm repetition and costs to individuals and their families beyond immediate hospital stay.

Financing and Reimbursement Models for Personalised Medicine: A Systematic Review to Identify Current Models and Future Options

Background: The number of healthcare interventions described as ‘personalised medicine’ (PM) is increasing rapidly. As healthcare systems struggle to decide whether to fund PM innovations, it is unclear what models for financing and reimbursement are appropriate to apply in this context. Objective: To review financing and reimbursement models for PM, summarise their key characteristics, and describe whether they can influence the development and uptake of PM. Methods: A literature review was conducted in Medline, Embase, Web of Science, and Econlit to identify studies published in English between 2009 and 2021, and reviews published before 2009. Grey literature was identified through Google Scholar, Google and subject-specific webpages. Articles that described financing and reimbursement of PM, and financing of non-PM were included. Data were extracted and synthesised narratively to report on the models, as well as facilitators, incentives, barriers and disincentives that could influence PM development and uptake. Results: One hundred and fifty-three papers were included. Research and development of PM was financed through both public and private sources and reimbursed largely through traditional models such as single fees, Diagnosis-Related Groups, and bundled payments. Financial-based reimbursement, including rebates and price-volume agreements, was mainly applied to targeted therapies. Performance-based reimbursement was identified mainly for gene and targeted therapies, and some companion diagnostics. Gene therapy manufacturers offered outcome-based rebates for treatment failure for interventions including Luxturna®, Kymriah®, Yescarta®, Zynteglo®, Zolgensma® and Strimvelis®, and coverage with evidence development for Kymriah® and Yescarta®. Targeted testing with OncotypeDX® was granted value-based reimbursement through initial coverage with evidence development. The main barriers and disincentives to PM financing and reimbursement were the lack of strong links between stakeholders and the lack of demonstrable benefit and value of PM. Conclusions: Public-private financing agreements and performance-based reimbursement models could help facilitate the development and uptake of PM interventions with proven clinical benefit.

The Net Benefit of Personalized Medicine: A Systematic Literature Review and Regression Analysis

Objectives: Amidst conflicting expectations about the benefits of personalized medicine (PM) and the potentially high implementation costs, we reviewed the available evidence on the cost-effectiveness of PM relative to non-PM. Methods: We conducted a systematic literature review of economic evaluations of PM and extracted data, including incremental quality-adjusted life-years (ΔQALYs) and incremental costs (Δcosts). ΔQALYs and Δcosts were combined with estimates of national cost-effectiveness thresholds to calculate incremental net monetary benefit (ΔNMB). Regression analyses were performed with these variables as dependent variables and PM intervention characteristics as independent variables. Random intercepts were used to cluster studies according to country. Results: Of 4774 studies reviewed, 128 were selected, providing cost-effectiveness data for 279 PM interventions. Most studies were set in the United States (48%) and the United Kingdom (16%) and adopted a healthcare perspective (82%). Cancer treatments (60%) and pharmaceutical interventions (72%) occurred frequently. Prognostic tests (19%) and tests to identify (non)responders (37%) were least and most common, respectively. Industry sponsorship occurred in 32%. Median ΔQALYs, Δcosts, and ΔNMB per individual were 0.03, Int$575, and Int$18, respectively. We found large heterogeneity in cost-effectiveness. Regression analysis showed that gene therapies were associated with higher ΔQALYs than other interventions. PM interventions for neoplasms brought higher ΔNMB than PM interventions for other conditions. Nonetheless, average ΔNMB in the ‘neoplasm' group was found to be negative. Conclusions: PM brings improvements in health but often at a high cost, resulting in 0 to negative ΔNMB on average. Pricing policies may be needed to reduce the costs of interventions with negative ΔNMB.

The early impact of the COVID-19 pandemic on patients with severe mental illness: An interrupted time series study in South-East England

Background: Deterioration in general population mental health since the start of the COVID-19 pandemic has been reported, but the impact of the pandemic on people with severe mental illness (SMI) has received less attention. Aims: Understand the impact of the early stages of the pandemic on the patients with SMI, in terms of provision of mental health care and patient outcomes. Method: We examined records of 34,446 patients with SMI in Oxford Health Foundation Trust between March 2016 and July 2020. We used interrupted time series analysis to estimate the immediate and subsequent changes in weekly rates of the use of community mental health services, hospitalisation, and patient outcomes (as measured by Health of the Nation Outcome Scales, or HoNOS, scores) during the weeks of lockdown between 23rd March and 3rd July, 2020. Results: Mean total HoNOS scores for all patients deteriorated in the weeks subsequent to lockdown (0.060 per week; 95%CI: 0.033, 0.087). Scores for patients with a history of psychosis deteriorated immediately (0.63; 95% CI: 0.26, 1.0). There was an immediate decrease in weekly referrals to community and outpatient services (-196; 95%CI: -300, -91) and no immediate change in weekly inpatient admissions (-4.2; 95%CI: -9.9, 1.5) or weekly total contacts (-26; 95%CI: -475, 423). Conclusions: Patients with SMI were negatively impacted during the early stages of the COVID-19 pandemic. Patients with a history of psychosis experienced distinct and immediate impacts. During the same period, referrals to community and outpatient services fell with no consequent impact on inpatient admissions.