Incorporating economic analysis in evidence-based guidelines for mental health: the profile approach

BACKGROUND: Many western health systems are currently developing the role of clinical guidelines to promote effective and efficient health care. However, introducing economic data into guideline methodology designed to assess the effectiveness of interventions raises some methodological issues. These include providing valid and generalizable cost estimates, the weight placed upon cost "evidence" and presenting cost-effectiveness information in a way that is helpful to clinicians. AIM OF THE STUDY: To explore a framework for including economic concepts in the development of a series of primary care guidelines, two of which address mental health conditions. METHODS: A profile approach, setting out best available evidence about the attributes of treatment choices (effectiveness, tolerability, safety, health service delivery, quality of life, resource use and cost), was used to help clinicians to derive treatment recommendations in a manner consistent with both the clinical decision-making process and social objectives. RESULTS: Clinicians involved in guideline development responded well to the process. Although there was often considerable debate about the meaning and importance of different aspects of evidence about treatment, in none of the guideline groups was there failure to agree treatment recommendations. DISCUSSION: The profile approach may be particularly useful in the field of mental health where disease processes may often feature very disparate effects, over long periods of time and impacting upon a broad circle of relatives, carers and agencies in addition to the patients themselves. CONCLUSION: A method has been applied in a series of primary care guidelines, which appears to enable clinicians to consider the issue of resource use alongside the various clinical attributes associated with treatment decisions. The basis of this work is the belief that guidance presenting physical measures describing effectiveness, adverse events, safety, compliance and quality of life, alongside resource consequences, is most likely to appropriately inform doctor-patient interactions. IMPLICATIONS FOR HEALTH CARE PROVISON AND USE: This research may provide a useful platform for other groups considering how to introduce cost-effectiveness concepts into guideline development groups. Whether guidelines change clinical behaviour remains a research question, and the subject of forthcoming trials. IMPLICATIONS FOR HEALTH POLICY FORMULATION: It is important that government agencies realize that guideline development is a health policy tool with prescribed methods to produce valid guidelines. Attempts to tamper with the methodology for cost-containment purposes or other political reasons are likely to discredit a useful mechanism for improving the scientific basis of health care provision. IMPLICATIONS FOR FURTHER RESEARCH: There are a number of limitations to completed work: for example it has a primary care focus and addresses fairly narrowly defined conditions. Work is ongoing to extend the scope to broader disease areas and to secondary care.     

Aggregation of childhood leukemia in geographic areas of Greece)

A total of 872 children aged up to 14 years, who were diagnosed withleukemia in Greece during the decade 1980-89, were allocated by place ofresidence to the 601 administrative districts of the country. Evaluation ofspatial clustering was done using the Potthoff-Whittinghill method, whichvalidly assesses heterogeneity of leukemia risk among districts with variableexpected numbers of cases. There was highly significant evidence for spatialclustering occurring particularly among children living in urban and, to alesser extent, semi-urban areas. The evidence was stronger for childrenyounger than 10 years old, applied also to children in different five-yearage groups, and persisted when cases of acute lymphoblastic leukemia wereanalyzed separately. These findings provide support to the hypothesis thatlocalized environmental exposures could contribute to the etiology ofchildhood leukemia, but they cannot distinguish between exposures of physicalor chemical nature, nor can they exclude socially conditioned patterns ofexposure to infectious agents.     

Common polymorphisms in ERCC2 (Xeroderma pigmentosum D) are not associated with breast cancer risk.

A substantial proportion of the familial risk of breast cancer may be due to genetic variants, each contributing a small effect. The protein encoded by ERCC2 is a key enzyme involved in nucleotide excision repair, in which gene defects could lead to cancer prone syndromes such as Xeroderma pigmentosum D. We have examined the association between single nucleotide polymorphisms in the ERCC2 gene and the incidence of invasive breast cancer in three case-control series, with a maximum of 3,634 patients and of 3,340 controls. None of the three single nucleotide polymorphisms were significantly associated with the incidence of breast cancer.