Cost-Effectiveness of an Online Intervention for Caregivers of People Living With Dementia

ObjectivesLittle evidence exists on costs or cost-effectiveness of online interventions for caregivers of people living with dementia. We aimed to assess cost-effectiveness of online cognitive behavioral therapy (CBT) for dementia caregivers with mild-to-moderate depression/anxiety, with or without telephone support, relative to a psychoeducational control treatment.DesignCost-effectiveness study of data from 3-armed randomized controlled trial comparing computerized CBT (cCBT) or telephone-supported cCBT (cCBT+Telephone) to modular online educational program on dementia (Psychoeducation).Setting and ParticipantsUK-resident adult dementia caregivers with mild-to-moderate anxiety/depression.Cost-effectiveness analysisWe calculated health and social care costs, from participant-reported data collected at baseline, 12, 26 weeks, costs of intervention delivery. We examined 3 outcomes: cost of one-point reduction in General Health Questionnaire–12 (GHQ-12) rating at 26-weeks, cost of prevented “caseness” on GHQ-12 at 26 weeks, and cost per quality-adjusted life year (QALY) based on Short Form–6 Dimensions (SF-6D) over 26 weeks.ResultsData from 176 participants (44 cCBT, 91 cCBT+Telephone, 41 Psychoeducation) were analyzed. Costs did not differ between cCBT and Psychoeducation; costs were £125 higher in cCBT+Telephone. Control and intervention groups did not differ on GHQ-12. Caseness was lower in cCBT+Telephone than Psychoeducation; cost of preventing a case was £610, and probability of cost-effectiveness on this outcome reached 98.5% at willingness to pay (WTP) of £12,900. Mean QALY did not differ between cCBT+Telephone and Psychoeducation. QALY gain in cCBT was 0.01 (95% CI 0.001, 0.021). Cost per QALY was £8130. Although base case probability of cost-effectiveness of cCBT was 93% at WTP-per-QALY of £27,600, sensitivity analyses suggested cCBT+Telephone was the more cost-effective.Conclusions and ImplicationsWe report preliminary evidence for adopting telephone-supported online CBT. This may be cost-effective in preventing a case of mental health disorder if, absent a societally accepted WTP threshold for this outcome, payers are willing to pay £12,900. Future research should investigate whether supported/unsupported online CBT improves health-related quality of life.     

Local Factors Affecting the Tendency to Bypass Local Hospitals for Inpatient Mental Health Care: An Exploratory Analysis

Using the records of 2,171 rural residents of Illinois who received inpatient treatment for mental illness or substance abuse, this paper examines factors that influence the tendency to seek service from a distant rather than a local hospital. Results indicate that the age and insurance coverage of the individual, the per capita income of the community area, surrogates for the service orientation of the local hospital and the proximity of the patient's residence to an urban center are significant influences. With the exceptions of drug abuse requiring detoxification or other symptomatic treatment, drug abuse accompanied by comorbidity and psychosocial disorders, psychosis, and childhood disorders, the primary diagnosis of the individual failed to have a significant effect on the propensity to bypass local sources of inpatient treatment.     

Evaluation of an Organisational Intervention to Promote Integrated Working between Health Services and Care Homes in the Delivery of End-of-Life Care for People with Dementia: Understanding the Change Process Using a Social Identity Approach

In the United Kingdom, approximately a third of people with dementia live in long-term care facilities for adults, the majority of whom are in the last years of life. Working arrangements between health services and care homes in England are largely ad hoc and often inequitable, yet quality end-of-life care for people with dementia in these settings requires a partnership approach to care that builds on existing practice.This paper reports on the qualitative component of a mixed method study aimed at evaluating an organisational intervention shaped by Appreciative Inquiry to promote integrated working between visiting health care practitioners (i.e. General Practitioners and District Nurses) and care home staff. The evaluation uses a social identity approach to elucidate the mechanisms of action that underlie the intervention, and understand how organisational change can be achieved.We uncovered evidence of both (i) identity mobilisation and (ii) context change, defined in theory as mechanisms to overcome divisions in healthcare. Specifically, the intervention supported integrated working across health and social care settings by (i) the development of a common group identity built on shared views and goals, but also recognition of knowledge and expertise specific to each service group which served common goals in the delivery of end-of-life care, and (ii) development of context specific practice innovations and the introduction of existing end-of-life care tools and frameworks, which could consequently be implemented as part of a meaningful bottom-up rather than top-down process.Interventions structured around a Social Identity Approach can be used to gauge the congruence of values and goals between service groups without which efforts to achieve greater integration between different health services may prove ineffectual. The strength of the approach is its ability to accommodate the diversity of service groups involved in a given area of care, by valuing their respective contributions and building on existing ways of working within which practice changes can be meaningfully integrated.     

An Exploratory Study of Canadian Aboriginal Online Health Care Forums

Internet-based discussion forums provide access to health information and social support, and serve as a resource for others. This investigation analyzed health-oriented Aboriginal Internet discussion forum (Forum A; Forum B) conversations. The findings were framed with Nutbeam's model of health literacy. Discussions within Forum B were centralized around issues of political activism and advocacy regarding Aboriginal health care. Activity in Forum A encouraged the development of “virtual” social capital, with health care discussions providing a “just-in-time” model for health education. Members of Forum A functioned as a smoking cessation self-help group and as health educators. The Internet provided a venue for the dissemination of health information and also served as a virtual voice for lifestyle coaching, political action, community building, and advocacy.     

Utility-Based Instruments for People with Dementia: A Systematic Review and Meta-Regression Analysis

Background

Several utility-based instruments have been applied in cost-utility analysis to assess health state values for people with dementia. Nevertheless, concerns and uncertainty regarding their performance for people with dementia have been raised.

Cost-Effectiveness of a Proactive Primary Care Program for Frail Older People: A Cluster-Randomized Controlled Trial

Background

A proactive integrated approach has shown to preserve daily functioning among older people in the community. The aim is to determine the cost-effectiveness of a proactive integrated primary care program.

Health Care Coverage and Costs in Small Business: An Exploratory Study

Health coverage and health care costs continue to frustrate employers, employees, and public policy makers. Controlling escalating health costs, improving coverage for the uninsured, and providing retiree health care are all important to the small employer. This study was undertaken to investigate the availability and extent of health care coverage and to assess the effects of health care costs on small firms. The results revealed that the percentage of small firms offering health benefits totaled 58 percent. The availability of group health insurance increases as firm size increases. Small employers cited insufficient profits, high insurance costs, and unavailable group coverage as the primary reasons for not offering health benefits. The results also indicated that the vast majority of small firms opposed a mandated employer-provided health coverage and suggested that small businesses should pool together to form groups to reduce the cost of health care coverage for small firms.     

Health Years in Total: A New Health Objective Function for Cost-Effectiveness Analysis

ObjectivesTo find an alternative for quality-adjusted life-year (QALY) and equal value of life (EVL) measures. Despite the importance of QALY in cost-effectiveness analysis (CEA)—because it captures the effects of both life expectancy and health-related quality of life (QOL) and enables comparisons across interventions and disease areas—its potential to be discriminatory towards patients with lower QOL presents a critical challenge that has resulted in the exclusion of its use in some public decision making (eg, US Medicare) on healthcare in the United States. Alternatives to QALY, such as EVL, have not gained traction because EVL fails to recognize the QOL gains during added years of life.MethodsWe present a new metric for effectiveness for CEA, health years in total (HYT), which overcomes both the specific distributional issue raised by QALY and the efficiency challenges of EVL.ResultsThe HYT framework separates life expectancy changes and QOL changes on an additive scale. HYT have the same axiomatic foundations as QALY and perform better than both QALY, in terms of the discriminatory implications, and EVL, in terms of capturing QOL gains during added years of life. HYT are straightforward to calculate within a CEA model. We found that thresholds of $34 000/HYT and $89 000/HYT correspond to CEA thresholds of $50 000/QALY and $150 000/QALY, respectively.ConclusionsThe HYT framework may provide a viable alternative to both the QALY and the EVL; its application to diverse healthcare technologies and stakeholder assessments are important next steps in its development and evaluation.     

整体护理结合孕期保健对提高产科护理质量的影响分析

目的：研究整体护理对提高产科护理满意度的影响。方法：选取2013年4-9月在本院分娩的80例产妇,按照随机数字表法将其分为对照组和观察组各40例。对照组给予产科常规护理,观察组在常规护理的基础上定时授课进行孕期健康宣教,产期进行整体护理,观察并比较产妇妊娠期糖尿病（GDM）发生率、孕期保健知识掌握率、护理满意度、住院周期、SAS（Zung焦虑自评量表）评分和SDS（抑郁自评量表）评分。结果：观察组的妊娠合并症发生率为5.0%（2/40）,对照组的妊娠合并症发生率为15.0%（6/40）,比较差异无统计学意义（P〉0.05）;而观察组对孕期保健知识掌握率82.5%明显高于对照组的60.0%,且产妇对护理工作的满意率92.5%明显高于对照组的72.5%,差异均有统计学意义（P〈0.05）。观察组住院周期（4.15±0.95）d明显短于对照组的（4.72±1.30）d,且SAS和SDS评分分别为（45.35±1.66）分、（46.35±1.61）分,均明显低于对照组的（46.13±1.74）分和（47.18±1.97）分,差异均有统计学意义（P〈0.05）。结论：整体护理可以缩短住院周期,改善SAS评分及SDS评分,明显提高产妇保健知识掌握率及对产科护理的满意度,值得在临床上推广。     

Online Training and Support Programs Designed to Improve Mental Health and Reduce Burden Among Caregivers of People With Dementia: A Systematic Review

Introduction

Dementia poses a considerable socioeconomic burden to society. On a global scale, family and other unpaid care predominates. Supporting caregivers is crucial, but scalable interventions are currently lacking. Because a growing number of studies have suggested that online training and support programs hold considerable promise for scaling up, we reviewed existing literature.

Effects of a Brief Case Management Intervention Linking People With HIV to Oral Health Care: Project SMILE

Objectives. Although people with HIV experience significant oral health problems, many consistently identify oral health as an unmet health care need. We conducted a randomized controlled trial to evaluate the impact of a dental case management intervention on dental care use.Methods. We evaluated the intervention according to self-reported dental care use at 6-, 12-, and 18-month follow-ups. Multivariable logistic models with generalized estimating equations were used to assess the effects of the intervention over time.Results. The odds of having a dental care visit were about twice as high in the intervention group as in the standard care group at 6 months (adjusted odds ratio [OR] = 2.52; 95% confidence interval [CI] = 1.58, 4.08) and 12 months (adjusted OR = 1.98; 95% CI = 1.17, 3.35), but the odds were comparable in the 2 groups by 18 months (adjusted OR = 1.07; 95% CI = 0.62, 1.86). Factors significantly associated with having a dental care visit included frequent physician visits and dental care referrals.Conclusions. We demonstrated that a dental case management intervention targeting people with HIV was efficacious but not sustainable over time. Barriers not addressed in the intervention must be considered to sustain its use over time.In the era of antiretroviral therapy, people with HIV are living longer and the treatment of associated medical and oral manifestations of the disease has shifted to a chronic disease model.1 Previous studies have shown that a person living with HIV/AIDS is more likely than a person without the disease to experience oral health problems.2–5 Furthermore, the oral health problems of individuals with HIV can be more severe and difficult to treat than those of the general population and may also contribute to the onset of opportunistic infections.5The oral health complications associated with HIV are well documented,2–6 and oral manifestations are increasingly being recognized as markers for monitoring treatment efficacy and predicting treatment failure.7 Oral manifestations, including Kaposi’s sarcoma, necrotizing ulcerative periodontitis, oral hairy leukoplakia, and candidiasis, may be present in up to 50% of people with HIV and 80% of people diagnosed with AIDS,5,6 and may predict low CD4 counts.8 In addition, individuals living with HIV/AIDS may experience difficulty in maintaining adequate salivary flow, which affects chewing, swallowing, and the ability to take medication.4 Chronic use of highly active antiretroviral therapy can also contribute to diminished salivary flow as well as an increased risk of oral candidiasis and oral hairy leukoplakia.9Throughout the 1990s, a series of study findings highlighted the unmet needs for dental care among people with HIV infection.10–14 This gap in oral health care services was corroborated by findings from the oral health component of the HIV Cost and Services Utilization Study,15 which demonstrated that unmet dental needs were twice as common as unmet medical needs among HIV-positive adults16,17 and led to a national call to action to improve access to oral health care.18 That study also showed that approximately half of people living with HIV had dental insurance, and those without dental insurance had greater unmet needs for dental services.17,19,20Recently published findings suggest that an unmet need still persists. One example is an initiative, funded by the Health Resources and Services Administration, that included 2469 people living with HIV who had not received dental care during the preceding year. Nearly half of these individuals (48%) reported an unmet dental need since their HIV diagnosis, 52% had not seen a dentist in more than 2 years, and 63% rated the health of their teeth and gums as fair or poor.21,22 An earlier investigation involving baseline data from the study presented here showed that oral health problems and symptoms were very prevalent among our study population, with 63% of participants having experienced an oral health impact very often or fairly often in the preceding 4 weeks.23Barriers to dental care use among individuals living with HIV include fear of dental care, HIV-specific stigma, fear of disclosing their HIV status to health care providers, perceived cost barriers, and poor adherence to medical guidance.20,22,24–31 Compounding patient access barriers, dental care providers may be reluctant to treat patients with HIV owing to fears of HIV transmission and associated stigma.32–36Previous research conducted in Florida revealed that more than one third of people with HIV do not discuss oral health with their primary care providers.37 Although clinical guidelines recommend that HIV care providers examine the oral cavity during initial and interim physical examinations of people living with HIV, this still may not be a regular clinical practice.37 To address underuse of oral health care services among individuals with HIV, we evaluated the efficacy of an intervention that linked individuals to dental care. The sample comprised a population of HIV-positive individuals in south Florida who had received HIV primary care but had not received oral health services in the preceding 12 months.     

CDX2 Biomarker Testing and Adjuvant Therapy for Stage II Colon Cancer: An Exploratory Cost-Effectiveness Analysis

ObjectivesAdjuvant chemotherapy is not recommended for patients with average-risk stage II (T3N0) colon cancer. Nevertheless, a subgroup of these patients who are CDX2-negative might benefit from adjuvant chemotherapy. We evaluated the cost-effectiveness of testing for the absence of CDX2 expression followed by adjuvant chemotherapy (fluorouracil combined with oxaliplatin [FOLFOX]) for patients with stage II colon cancer.MethodsWe developed a decision model to simulate a hypothetical cohort of 65-year-old patients with average-risk stage II colon cancer with 7.2% of these patients being CDX2-negative under 2 different interventions: (1) test for the absence of CDX2 expression followed by adjuvant chemotherapy for CDX2-negative patients and (2) no CDX2 testing and no adjuvant chemotherapy for any patient. We derived disease progression parameters, adjuvant chemotherapy effectiveness and utilities from published analyses, and cancer care costs from the Surveillance, Epidemiology, and End Results (SEER)-Medicare data. Sensitivity analyses were conducted.ResultsTesting for CDX2 followed by FOLFOX for CDX2-negative patients had an incremental cost-effectiveness ratio of $5500/quality-adjusted life-years (QALYs) compared with no CDX2 testing and no FOLFOX (6.874 vs 6.838 discounted QALYs and $89 991 vs $89 797 discounted US dollar lifetime costs). In sensitivity analyses, considering a cost-effectiveness threshold of $100 000/QALY, testing for CDX2 followed by FOLFOX on CDX2-negative patients remains cost-effective for hazard ratios of <0.975 of the effectiveness of FOLFOX in CDX2-negative patients in reducing the rate of developing a metastatic recurrence.ConclusionsTesting tumors of patients with stage II colon cancer for CDX2 and administration of adjuvant treatment to the subgroup found CDX2-negative is a cost-effective and high-value management strategy across a broad range of plausible assumptions.