Cost-effectiveness of counselling, graded-exercise and usual care for chronic fatigue: evidence from a randomised trial in primary care

ABSTRACT: BACKGROUND: Fatigue is common and has been shown to result in high economic costs to society. The aim of this study is to compare the cost-effectiveness of two active therapies, graded-exercise (GET) and counselling (COUN) with usual care plus a self-help booklet (BUC) for people presenting with chronic fatigue. METHODS: A randomised controlled trial was conducted with participants consulting for fatigue of over three months' duration recruited from 31 general practices in South East England and allocated to one of three arms. Outcomes and use of services were assessed at 6-month follow-up. The main outcome measure used in the economic evaluation was clinically significant improvements in fatigue, measured using the Chalder fatigue scale. Cost-effectiveness was assessed using the net-benefit approach and cost-effectiveness acceptability curves. RESULTS: Full economic and outcome data at six months were available for 163 participants; GET = 51, COUN = 58 and BUC = 54. Those receiving the active therapies (GET and COUN) had more contacts with care professionals and therefore higher costs, these differences being statistically significant. COUN was more expensive and less effective than the other two therapies. The incremental cost-effectiveness ratio of GET compared to BUC was equal to [POUND SIGN]987 per unit of clinically significant improvement. However, there was much uncertainty around this result. CONCLUSION: This study does not provide a clear recommendation about which therapeutic option to adopt, based on efficiency, for patients with chronic fatigue. It suggests that COUN is not cost-effective, but it is unclear whether GET represents value for money compared to BUC. Clinical Trial Registration number at ISRCTN register: 72136156.     

Determinants of demand for total hip and knee arthroplasty: a systematic literature review

ABSTRACT: BACKGROUND: Documented age, gender, race and socio-economic disparities in total joint arthroplasty (TJA), suggest that those who need the surgery may not receive it and present a challenge to explain the causes of unmet need. It is not clear whether doctors limit treatment opportunities to patients, nor is it known the effect that patient beliefs and expectations about the operation, including their paid work status and retirement plans, have on the decision to undergo TJA. Identifying socio-economic and other determinants of demand would inform the design of effective and efficient health policy. This review was conducted to identify the factors that lead patients in need to undergo TJA. METHODS: An electronic search of the Embase and Medline (Ovid) bibliographic databases conducted in September 2011 identified studies in the English language that reported on factors driving patients in need of hip or knee replacement to undergo surgery. The review included reports of elective surgery rates in eligible patients or, controlling for disease severity, in general subjects, and stated clinical experts' and patients' opinions on suitability for or willingness to undergo TJA. Quantitative and qualitative studies were reviewed, but quantitative studies involving fewer than 20 subjects were excluded. The quality of individual studies was assessed on the basis of study design (i.e., prospective versus retrospective), reporting of attrition, adjustment for and report of confounding effects, and reported measures of need (self-reported versus doctor-assessed). Reported estimates of effect on the probability of surgery from analyses adjusting for confounders were summarised in narrative form and synthesised in odds ratio (OR) forest plots for individual determinants. RESULTS: The review included 26 quantitative studies 23 on individuals' decisions or views on having the operation and three about health professionals' opinions- and 10 qualitative studies. Ethnic and racial disparities in TJA use are associated with socio-economic access factors and expectations about the process and outcomes of surgery. In the United States, health insurance coverage affects demand, including that from the Medicare population, for whom having supplemental Medicaid coverage increases the likelihood of undergoing TJA. Patients with post-secondary education are more likely to demand hip or knee surgery than those without it (range of OR 0.87-2.38). Women are as willing to undergo surgery as men, but they are less likely to be offered surgery by specialists than men with the same need. There is considerable variation in patient demand with age, with distinct patterns for hip and knee. Paid employment appears to increase the chances of undergoing surgery, but no study was found that investigated the relationship between retirement plans and demand for TJA. There is evidence of substantial geographical variation in access to joint replacement within the territory covered by a public national health system, which is unlikely to be explained by differences in preference or unmeasured need alone. The literature tends to focus on associations, rather than testing of causal relationships, and is insufficient to assess the relative importance of determinants. CONCLUSIONS: Patients' use of hip and knee replacement is a function of their socio-economic circumstances, which reinforce disparities by gender and race originating in the doctorpatient interaction. Willingness to undergo surgery declines steeply after the age of retirement, at the time some eligible patients may lower their expectations of health status achievement. There is some evidence that paid employment independently increases the likelihood of operation. The relative contribution of variations in surgical decision making to differential access across regions within countries deserves further research that controls for clinical need and patient lifestyle preferences, including retirement decisions. Evidence on this question will become increasingly relevant for service planning and policy design in societies with ageing populations.     

Health utility after emergency medical admission: a cross-sectional survey

Objectives  

Health utility combines health related quality of life and mortality to produce a generic outcome measure reflecting both morbidity and mortality. It has not been widely used as an outcome measure in evaluations of emergency care and little is known about the feasibility of measurement, typical values obtained or baseline factors that predict health utility. We aimed to measure health utility after emergency medical admission, to compare health utility to age, gender and regional population norms, and identify independent predictors of health utility.     

Oral health in a convenience sample of Chinese older adults living in Melbourne,Australia

Objectives  

To present data on the dental and periodontal status of a convenience sample of 101 ambulant China-born older adults who now live in Melbourne. These older adults participated in a study to assess the prevalence of specific oral diseases.     

Obesity Prevention in Young Schoolchildren: Results of a Pilot Study

BACKGROUND: Overweight and obesity occur in 17% of children in the United States. Complications of excess weight in Americans cause 216,000 to 300,000 deaths yearly and cost $147 billion. METHODS: A convenience sample of 14 intervention and 15 control schools in the Catholic Diocese of Pittsburgh was used. A program to improve lifestyle (Values Initiative Teaching About Lifestyle [VITAL®]), was implemented in young children to encourage healthy eating and appropriate physical activity. Students had annual evaluations of height and weight over a 2‐year period, and teachers participating in VITAL completed questionnaires regarding the program. Changes in age‐ and sex‐adjusted body mass index (BMI) percentiles in control and intervention groups were compared using linear mixed models regression. RESULTS: VITAL was highly rated by teachers and was popular with children. Over the 2‐year period, adjusted mean BMI percentiles declined from 66.1 to 65.0 in control children and from 62.8 to 58.9 in intervention children. The rates of change in the 2 groups were significantly different (p = .015). CONCLUSION: VITAL improves lifestyle of young schoolchildren, is inexpensive, easy to implement, and should be expanded to improve health and reduce healthcare's financial burden.     

Home mechanical ventilation in the Netherlands

Over the last 20 years the number of Dutch patients on home mechanical ventilation has increased from 200 to 2000. Home mechanical ventilation is a cost-effective treatment which significantly improves the quality of life of patients. In 2011 83% of patients on home mechanical ventilation in the Netherlands is living at home. In the future further growth can be expected in the number of patients with obesity hypoventilation syndrome and a potential new group of patients with COPD. Strict conditions are necessary to ensure safety in the complex care that home mechanical ventilation entails.     

The Development and Psychometric Properties of the Humanitarian Emergency Settings Perceived Needs (HESPER) Scale

Objectives. We developed the Humanitarian Emergency Settings Perceived Needs (HESPER) Scale, a valid and reliable scale to rapidly assess perceived needs of populations in humanitarian settings in low- and middle-income countries.Methods. We generated items through a literature review; reduced the number of items on the basis of a survey with humanitarian experts; pilot-tested the scale in Gaza, Jordan, Sudan, and the United Kingdom; and field-tested it in Haiti, Jordan, and Nepal.Results. During field-testing, intraclass correlation coefficients (absolute agreement) for the total number of unmet needs were 0.998 in Jordan, 0.986 in Haiti, and 0.995 in Nepal (interrater reliability), and 0.961 in Jordan and 0.773 in Nepal (test–retest reliability). Cohen’s κ for the 26 individual HESPER items ranged between 0.66 and 1.0 (interrater reliability) and between 0.07 and 1.0 (test–retest reliability) across sites. Most HESPER items correlated as predicted with related questions of the World Health Organization Quality of Life-100 (WHOQOL-100), and participants found items comprehensive and relevant, suggesting criterion (concurrent) validity and content validity.Conclusions. The HESPER Scale rapidly provides valid and reliable population-based data on perceived needs in humanitarian settings.Needs assessments in humanitarian settings (i.e., places in which a large part of the population is at risk of dying or experiencing immense suffering) are vital in enabling effective and efficient emergency relief. However, current needs assessments are often far from ideal; indeed, in 2009, heads of 26 large humanitarian donor agencies signed a letter to the United Nations asking for an improvement in the area of needs assessment (J. Isbister, G. Weinberger, J.-P. Loir, et al., unpublished letter, 2009).There have also been repeated recommendations for increased participation of affected populations in humanitarian assessment.1–6 People’s participation in assessment is seen as a right and as essential for optimizing resource allocation, program design, and population empowerment.6 It increases the likelihood that interventions are based on needs as expressed by the affected population. The international humanitarian community’s focus on participation is exemplified by the fact that the recently revised, influential Sphere Handbook (5,6) on standards for humanitarian aid emphasizes the involvement of affected people.Participation is recommended throughout the assessment, design, monitoring, and evaluation program cycle.1,3–5 Additionally, in a recent ranking exercise for research priorities in the area of mental health and psychosocial support, 3 of the 10 most highly prioritized research questions in humanitarian settings included the participation of affected populations; the identification of affected populations’ stressors was ranked as top priority.7 Related to this is the notion of accountability within the international humanitarian response, including that humanitarian action should be accountable to affected populations.4Within this framework of increased participation and accountability, it has been recommended that the assessment of perceived needs be used to inform project design, monitoring, and evaluation,1–5,8,9 and perceived needs are considered a key determinant of psychosocial well-being.1,8,10 Perceived needs are defined here as needs expressed by members of the affected population themselves. They are thus problem areas for which people would likely want help. In the humanitarian field, perceived needs are still assessed mostly through rapid participatory assessments in the early phase of a crisis; these assessments tend to involve gaining qualitative data from selected stakeholders through focus groups or key respondent interviews.11 Although certainly valuable, such assessments cannot provide a population-level picture. Most population-based quantitative assessments are of “objective” indicators, such as mortality rates, malnutrition rates, or livelihood data.12–14 These indicators are often defined by outsiders (i.e., nonmembers of the affected population) and do not quantify the prevalence and distribution of needs as perceived by members of the population themselves.With a few exceptions,15–17 assessment tools in the humanitarian field tend to have unknown psychometric properties (i.e., indices of validity and reliability). Without published psychometric properties, it is unknown to what extent assessment tools are fit for purpose.To address these gaps, we developed a method and instrument to rapidly and quantitatively assess perceived needs in emergency-affected populations—the Humanitarian Emergency Settings Perceived Needs (HESPER) Scale.18 We describe the development and psychometric properties of the scale.