Quality of the Forensic Case Formulation in Mental Health

Objetivos: Con la meta de contribuir al desarrollo del servicio pericial, se pone a prueba la confiabilidad de la “Guía para Comprender y Valorar la Calidad de la Formulación en Salud Mental Forense – TECF”. Método: Doce profesionales de la salud mental de diversas tradiciones latinoamericanas valoraron la calidad de diez informes periciales internacionales, psicológicos y psiquiátricos, utilizando la TECF. La guía cuenta con manual que describe dimensiones, criterios e indicadores para apreciar la calidad de la formulación forense. Resultados: Los indicadores de congruencia interna tuvieron rango 0,34-0,81 para las dimensiones y valor de 0,85 para el total de la TECF. El coeficiente de correlación intraclase de acuerdo absoluto entre evaluadores con similar tradición alcanzó valores de 0,72; 0,52; 0,76 y 0,77 para las dimensiones, y de 0,84 para el total. El acuerdo entre evaluadores con tradiciones disímiles fue menor. Conclusiones: La TECF resulta un instrumento promisorio para guiar la apreciación de la calidad y estimular el perfeccionamiento de las formulaciones periciales. Desde la métrica tradicional se recomienda cautela por el efecto de tradiciones prácticas diversas.Facultad de Ciencias Médica

Quality of the Forensic Case Formulation in Mental Health

Objetivos: Con la meta de contribuir al desarrollo del servicio pericial, se pone a prueba la confiabilidad de la “Guía para Comprender y Valorar la Calidad de la Formulación en Salud Mental Forense – TECF”. Método: Doce profesionales de la salud mental de diversas tradiciones latinoamericanas valoraron la calidad de diez informes periciales internacionales, psicológicos y psiquiátricos, utilizando la TECF. La guía cuenta con manual que describe dimensiones, criterios e indicadores para apreciar la calidad de la formulación forense. Resultados: Los indicadores de congruencia interna tuvieron rango 0,34-0,81 para las dimensiones y valor de 0,85 para el total de la TECF. El coeficiente de correlación intraclase de acuerdo absoluto entre evaluadores con similar tradición alcanzó valores de 0,72; 0,52; 0,76 y 0,77 para las dimensiones, y de 0,84 para el total. El acuerdo entre evaluadores con tradiciones disímiles fue menor. Conclusiones: La TECF resulta un instrumento promisorio para guiar la apreciación de la calidad y estimular el perfeccionamiento de las formulaciones periciales. Desde la métrica tradicional se recomienda cautela por el efecto de tradiciones prácticas diversas.Facultad de Ciencias Médica

Costa Rica - Results of sensitivity analysis on average cost-effectiveness ratio (ACER).

a<p>Alternative stage distribution: 9.4% stage I, 14.2% stage II, 58.0% stage III, 18.4% stage IV <a href="http://www.plosone.org/article/info:doi/10.1371/journal.pone.0095836#pone.0095836-Groot1" target="_blank">[7]</a>.</p>b<p>Alternative Case Fatality rates; 0,0174 stage I, 0,0284 stage II, 0,0832 stage III, 0,2855 stage IV <a href="http://www.plosone.org/article/info:doi/10.1371/journal.pone.0095836#pone.0095836-Ortiz1" target="_blank">[24]</a>.</p>c<p>Mechanical equipment (e.g. mammography machines, CT, X-ray).</p>d<p>Alternative assumptions on effectiveness of awareness interventions (−25%), sensitivity of CBE, and stage shifts of CBE screening.</p

Graphical representation of the model showing the relationships between the different health states through the incidence rates of breast cancer (Ix1–Ix4), the different stage specific case fatality rates (Fx1–4), and the background mortality (M) [7].

<p>Stage specific relapse rates to stage IV were used to correct health state valuations only (Rx1–Rx3).</p

Definition and classification of individual interventions (coverage) (based on [22]).

a<p>Endocrine therapy consists of 20 mg tamoxifen per day for 5 years.</p>b<p>Down-staging interventions cause a shift in stage distribution and are only modeled in combination with treatment of all stages (I–IV).</p>c<p>BAR was excluded as a standalone intervention in Costa Rica and Mexico.</p>d<p>Palliative care interventions are only applied to stage IV patients, and substitutes stage IV treatment.</p>e<p>The (neo)adjuvant chemotherapy combination regimen consists of 7 cycles of Epirubicin, Fluorouracil and cyclophosphamide (FEC regimen) Given on an outpatient basis.</p>f<p>Radiotherapy includes a standard dose of 50 Gy given in 25 fractions of 2 Gy on an outpatient basis.</p>g<p>Trastuzumab is given for 8 months.</p

Costa Rica - Average costs (US$), effects and cost-effectiveness of breast cancer control scenarios per year.

a<p>All costs in this table are in 2009 US$(1CRC = 0,001784 US$).</p>b<p>DALYs, disability-adjusted life-years (age weighted, discounted).</p>c<p>ACER: Average cost-effectiveness ratio compared to the do nothing-scenario (US$per DALY averted).</p>d<p>ICER: Incremental cost effectiveness ratio, ratio of additional cost per additional life-year saved when next intervention is added to a mix on the intervention path (additional US$ per additional DALY saved).</p

Mexico- Results of sensitivity analysis on average cost-effectiveness ratio (ACER).

a<p>Unidad de Análisis Económico - 8.4% stage I, 38.5% stage II, 42.5% stage III, 10.6% stage IV <a href="http://www.plosone.org/article/info:doi/10.1371/journal.pone.0095836#pone.0095836-Comisin1" target="_blank">[42]</a>.</p>b<p>9.7% stage I, 52.7% stage II, 34.8% stage III, 2.8% stage IV <a href="http://www.plosone.org/article/info:doi/10.1371/journal.pone.0095836#pone.0095836-FloresLuna1" target="_blank">[41]</a>.</p>c<p>9.4% stage I, 14.2% stage II, 58.0% stage III, 18.4% stage IV <a href="http://www.plosone.org/article/info:doi/10.1371/journal.pone.0095836#pone.0095836-Groot1" target="_blank">[7]</a>.</p>d<p>Alternative Case Fatality rates: 0,013 stage I, 0,042 stage II, 0,102 stage III, 0,266 stage IV <a href="http://www.plosone.org/article/info:doi/10.1371/journal.pone.0095836#pone.0095836-Salomon1" target="_blank">[35]</a>.</p>e<p>Mechanical equipment (e.g. mammography machines, CT, X-ray).</p>f<p>Alternative assumptions on effectiveness of awareness interventions (−25%), sensitivity of CBE, and stage shifts of CBE screening.</p

Average utilization of diagnosis and treatment ingredients and unit costs per patient.

a<p>Based on estimates by Costa Rican CCSS.</p>b<p>Unit costs WHO-CHOICE database in 2000 US. Corrected for inflation: 2000–2009 (2.81 in CR & 1.66 in MX). 2009 exchange rates were used (560.45 CRC/US & 13.06 MXN/US$).</p>c<p>Based on values of IMSS.</p>d<p>Based on communication with Unidad de Análisis Económico of MoH.</p>e<p>Based on Norum et al. <a href="http://www.plosone.org/article/info:doi/10.1371/journal.pone.0095836#pone.0095836-Norum1" target="_blank">[61]</a>.</p>f<p>Based on Knaul et al. <a href="http://www.plosone.org/article/info:doi/10.1371/journal.pone.0095836#pone.0095836-Knaul1" target="_blank">[11]</a>.</p>g<p>palliative care (substitutes stage IV treatment).</p>h<p>50 Gy given in 25 fractions of 2 Gy.</p>i<p>daily dose of 20 mg. Tamoxifen for 5 years.</p>j<p>7 cycles of Epirubicin, Fluorouracil and cyclophosphamide (FEC regimen).</p>k<p>1 fraction of 10 Gy.</p>l<p>40 ml/54 s days.</p>m<p>35 mg/54 days.</p>n<p>8 mg/day.</p>o<p>751mg/day.</p>p<p>5 mg/day.</p

Analyzed interventions and the estimates used for the stage were interventions are applied to.

a<p>Case Fatality - Estimates for stages III and IV are from Groot et al. <a href="http://www.plosone.org/article/info:doi/10.1371/journal.pone.0095836#pone.0095836-Groot1" target="_blank">[7]</a> and for stages I and II from Zelle et al. <a href="http://www.plosone.org/article/info:doi/10.1371/journal.pone.0095836#pone.0095836-Zelle1" target="_blank">[22]</a>. The CFs for the untreated patients are from Groot et al. <a href="http://www.plosone.org/article/info:doi/10.1371/journal.pone.0095836#pone.0095836-Groot1" target="_blank">[7]</a> and were corrected based on Bloom et al <a href="http://www.plosone.org/article/info:doi/10.1371/journal.pone.0095836#pone.0095836-Bloom1" target="_blank">[57]</a>.</p>b<p>Disability Weights - Estimates from Zelle et al.<a href="http://www.plosone.org/article/info:doi/10.1371/journal.pone.0095836#pone.0095836-Zelle1" target="_blank">[22]</a>.</p>c<p>Current stage distribution CR is based on Ortiz <a href="http://www.plosone.org/article/info:doi/10.1371/journal.pone.0095836#pone.0095836-Ortiz1" target="_blank">[24]</a>; MX onKnaul et al. <a href="http://www.plosone.org/article/info:doi/10.1371/journal.pone.0095836#pone.0095836-Knaul2" target="_blank">[17]</a>; Effects of MAR derived from Devi <a href="http://www.plosone.org/article/info:doi/10.1371/journal.pone.0095836#pone.0095836-Devi1" target="_blank">[50]</a>; Effects of screening interventions were based on stage shifts from baseline Groot et al.<a href="http://www.plosone.org/article/info:doi/10.1371/journal.pone.0095836#pone.0095836-Groot1" target="_blank">[7]</a> to the stage distribution USA in Bland et al. <a href="http://www.plosone.org/article/info:doi/10.1371/journal.pone.0095836#pone.0095836-Bland1" target="_blank">[58]</a>. Stage shifts were adapted by calculating relative differences in detection rates between the USA and CR/MX from Duffy & Gabe <a href="http://www.plosone.org/article/info:doi/10.1371/journal.pone.0095836#pone.0095836-Duffy1" target="_blank">[59]</a>. Calculations included age-specific incidence (MoH CR & Unidad Analysis Económica MX), prevalence (WHO 2008), sojourn time Duffy & Gabe <a href="http://www.plosone.org/article/info:doi/10.1371/journal.pone.0095836#pone.0095836-Duffy1" target="_blank">[59]</a>, sensitivity Bobo et al. <a href="http://www.plosone.org/article/info:doi/10.1371/journal.pone.0095836#pone.0095836-Bobo1" target="_blank">[60]</a> and attendance rates (75% in the USA vs. 80% in Costa Rica and Mexico).</p>d<p>We assumed in Mexico implementing MAR could not lead to a higher proportion of stage IV patients and increase stage III with the difference of 0.6%.</p