Issues in evaluating the costs and cost-effectiveness of Cognitive Behavioural Therapy for overweight/obese adolescents, CHERE Working Paper 2009/1

Economic evaluation is the systematic assessment of the costs and consequences of alternative courses of action. In health and healthcare, the results can be used to inform clinicians and policy makers about the relative cost-effectiveness of options under consideration [1]. Many economic evaluations are undertaken alongside randomised controlled trials (RCTs); the advantages of this approach are that i) prospective, accurate data can be collected on costs and effects and ii) appropriate outcome measures for use in economic evaluation can be chosen. The outcome of an economic evaluation is usually described as a ratio of the costs and effects ? often called the incremental cost-effectiveness ratio (ICER). The ICER is determined by calculating the differences in the costs and effects of both intervention and control groups and dividing the former by the latter. In designing an economic evaluation, the important questions to resolve are: which costs should be included and which outcome measures are most appropriate for estimating the cost-effectiveness ratio? In 2005, the Australian Technology Network of Universities funded the Centre for Metabolic Fitness (CMF) through a competitive, peer-reviewed process. The aims of the centre are to develop and evaluate diet and exercise interventions to counteract metabolic syndrome and assess their acceptability by target community groups. Metabolic syndrome is a cluster of metabolically determined risk factors associated with obesity (e.g. hypertension, impaired blood glucose etc). A number of collaborative projects have been developed within the centre, one of which is the CHOOSE HEALTH project. As part of this project, the effectiveness of cognitive behavioural therapy (CBT) as an intervention for overweight or obese adolescents has been trialled at the University of RMIT by Leah Brennan and the University of South Australia by Margarita Tsiros, as part of their post-graduate studies1. Subsequently, it has been decided to add an economic component to this work. Trials of the effectiveness and cost-effectiveness of different means of delivering cognitive behaviourally based weight management programs are planned2. This paper reports the results of investigations into the two questions which need to be addressed prior to undertaking a formal economic evaluation of the CHOOSE HEALTH program: i) what costs should be included and ii) which measures of outcome are suitable for estimating an ICER in this context. The paper is organised in four sections. Following the introduction (section 1) and brief descriptions of the background to and context in which the program was planned (section 2), details of the RMIT trial design and results are provided in section 3. In the final section (section 4), a cost model is presented and the implications of the outcomes used in the initial trials of the effectiveness are discussed in relation to designing a prospective economic evaluation of the CHOOSE HEALTH program.costs, economic evaluation, cognitive behavioural therapy (CBT), adolescent obesity, Australia

Gap anisotropy in the angle-resolved photoemission spectroscopy of Bi_2Sr_2CaCu_2O_{8+\delta}

The gap anisotropy in Bi$_2$Sr$_2$CaCu$_2$O$_{8+\delta}$ is revisited in the framework of a d-wave scenario in view of the recent angle-resolved photoemission experiment. Based on a tight-binding fit to the normal state dispersion, a detail analysis on the effects of the inclusion of the next harmonic in the d-wave has been presented. Significant effect has been observed in the superconducting T$_c$. The density of states is linear at the nodes with enhanced weight, caused by a marked increase in the low energy excitaions which affect the thermodynamics considerably. The slope of the $\rho_s - T$ curve in the low temperature regime increases and the specific heat reflects the enhanced entropy at low temperatures. The leading edge of the ARPES energy distribution curves have been calculated and found to shift towards higher energy. The effect of scattering by non-magnetic impurities in this context is also outlined.Comment: 8 pages, 7 figures (akw.eps and edc.eps in one panel

A model for best practice HTA

The aims of this paper are: to review and describe different approaches to HTA used in Australia and in other countries and to identify the features of best practice in HTA, particularly those likely to be most relevant to HTA at a local (ie state/regional) level. There are a number of well-developed models of HTA at the national and local levels. Most information about the operation of these models, particularly about the type and number of evaluations conducted, the recommendations/decisions made and the reasons for these is available for national processes, but there is much less readily available documentation about local level HTA. Most HTA processes that operate nationally and internationally can be categorised in one of three ways: guidance (provides structured information about appropriate technologies), mandatory (provides mandatory information about technologies to be implemented) and funding and implementation (provides structured evidence-based advice about which technologies should be implemented, the level of funding required to implement them and the source of these funds). The main factors which distinguish a high quality HTA process are that i) it is efficient in terms of setting priorities, the scope of the technologies to be assessed, avoidance of duplication and overall cost of the process, ii) the overall impact on utilisation and health budget is calculated as part of the HTA and iii) procedural justice occurs and is seen to occur; iv) it includes a comprehensive assessment of the impact on issues such as workforce, credentialing of providers and the ethical dimension of the technology; v) it influences decision making by being communicated appropriately and using trusted methods; vi) it influences adoption and diffusion of technology by ensuring that there is no diffusion prior to HTA, the results are incorporated into guidelines or recommendations, funding is linked to the decision, and remuneration arrangements and other characteristics of the HS facilitate the appropriate adoption and diffusion and vii) it influences health outcomes/efficiency/equity by ensuring that the methods and/or results are available and able to be used at a local level. Firm recommendations for an ideal system for HTA at the local level are not possible as much of the necessary information and evidence is not available about the strengths and weaknesses of HTA practices and processes currently in use. However, it is likely that the operation of a successful model of HTA at a local level would require the development of a central organizational unit, a process for implementing the results of HTA and, crucially, the building of capacity to support both types of activities. Additional expertise and skills will be required for both providers of HTA evaluations and for the commissioners and users of HTA.health technology assessment, Australia, review

Dementia Care Mapping and Patient-Centred Care in Australian residential homes: An economic evaluation of the CARE Study, CHERE Working Paper 2008/4

Background: As the population ages, the incidence of dementia and its burden on society will increase. The economic costs of dementia are high, particularly for persons in the mid and late stages of the disease, when formal care arrangements such as nursing home placement are required. The need for care is often precipitated by the development of behavioural and psychological symptoms of dementia (BPSD) which also severely affect the quality of life of affected persons and their carers The Caring for Aged-Care REsident Study (CARES), the first randomised controlled trial to evaluate Dementia Care Mapping (DCM) and Person Centred Care (PCC), demonstrated that either of the two interventions improved outcomes compared to Usual Care (UC) on the primary outcome measure, the Cohen-Mansfield Agitation Inventory (CMAI). This study reports the results of an economic evaluation which was undertaken in conjunction with the trial. This information will provide additional information to assist policy makers in making choices between competing options. Methods: Fifteen nursing homes were randomised to one of three conditions: DCM, PCC or Usual Care (UC). The sample consisted of 360 residents with dementia. Data were collected at baseline, three months, and eight months by assessors blind to group assignment. In addition to the CMAI, data were collected about the use and costs of health care resources and pharmacological interventions. Total costs associated with each of the interventions were estimated, which were contrasted with the outcomes using standard health economics methodology. Results: Over one year, the cost per residential setting of implementing DCM and PCC relative to UC was $10,034 and$2,250 respectively. The additional cost per resident-level unit improvement in CMAI post-intervention (at follow-up) relative to UC was $48.95 ($46.89) for DCM and $8.01 ($6.43) for PCC. Compared to DCM, PCC produced a greater reduction in anxiety and agitation at a lower cost. Therefore, DCM was dominated by PCC and removed from the economic evaluation. Sensitivity analysis suggests this result is robust to changing model parameters. Conclusions: PCC provides a greater decrease in agitation and related behavioural and psychological symptoms of dementia, compared with DCM, at a lower cost and is the preferred option for cost-effectiveness. While there is no existing standard for a reasonable cost for a point improvement in CMAI, the cost per unit under PCC seems acceptable.Dementia, patient centred care

DIALOGIC: A Core Natural-Language Processing System

The DIALOGIC system translates English sentences into representations of their literal meaning in the context of an utterance. These representations, or "logical forms," are intended to be a purely formal language that is as close as possible to the structure of natural language, while providing the semantic compositionality necessary for meaning-dependent computational processing. The design of DIALOGIC (and of its constituent modules) was influenced by the goal of using it as the core language-processing component in a variety of systems, some of which are transportable to new domains of application.Engineering and Applied Science

Caring for Aged Dementia Care Resident Study (CADRES) of person-centred care, dementia-care mapping, and usual care in dementia: a cluster-randomised trial

Background: Evidence for improved outcomes for people with dementia through provision of person-centred care and dementia-care mapping is largely observational. We aimed to do a large, randomised comparison of person-centred care, dementia-care mapping, and usual care. Methods: In a cluster randomised controlled trial, urban residential sites were randomly assigned to person-centred care, dementia-care mapping, or usual care. Carers received training and support in either intervention or continued usual care. Treatment allocation was masked to assessors. The primary outcome was agitation measured with the Cohen-Mansfield agitation inventory (CMAI). Secondary outcomes included psychiatric symptoms including hallucinations, neuropsychological status, quality of life, falls, and cost of treatment. Outcome measures were assessed before and directly after 4 months of intervention, and at 4 months of follow-up. Hierarchical linear models were used to test treatment and time effects. Analysis was by intention to treat. This trial is registered with the Australia and New Zealand Clinical Trials Registry, number ACTRN12608000084381. Findings: 15 care sites with 289 residents were randomly assigned. Pairwise contrasts revealed that at follow-up, and relative to usual care, CMAI score was lower in sites providing mapping (mean difference 10·9, 95% CI 0·7-21·1; p=0·04) and person-centred care (13·6, 3·3-23·9; p=0·01). Compared with usual care, fewer falls were recorded in sites that used mapping (0·24, 0·08-0·40; p=0·02) but there were more falls with person-centred care (0·15, 0·02-0·28; p=0·03). There were no other significant effects. Interpretation: Person-centred care and dementia-care mapping both seem to reduce agitation in people with dementia in residential care. Funding: Australian Health Ministers' Advisory Council

Quasiparticle spectrum of a type-II superconductor in a high magnetic field with randomly pinned vortices

We show that gapless superconductivity of a strongly type-II superconductor in a high magnetic field prevails in the presence of disorder, suggesting a topological nature. We calculate the density of states of the Bogoliubov-de Gennes quasiparticles for a two-dimensional inhomogeneous system in both cases of weak and strong disorder. In the limit of very weak disorder, the effect is very small and the density of states is not appreciably changed. As the disorder increases, the density of states at low energies increases and the ratio of the low-energy density of states to its maximum increases significantly

Narrow-line AGN in the ISO-2MASS Survey

Context: A long-standing challenge of observational AGN research is to find type 2 quasars, the luminous analogues of Seyfert-2 galaxies. Aims: We search for luminous narrow-line type 2 AGN, characterise their properties, and compare them with broad-line type 1 AGN. Methods: Combining the ISOCAM parallel survey at 6.7 mu with 2MASS, we have selected AGN via near-mid-infrared colours caused by the hot nuclear dust emission. We performed spectroscopy in the optical and, for a subset of the sample, also in the mid-infrared with Spitzer. Results: We find nine type 2 AGN at redshift 0.1<z<0.5, three of them have even quasar-like [OIII] luminosities. At the given redshift and luminosity range the number of type 2 AGN is at least as high as that of type 1s. At z>0.5 we did not find type 2 AGN, probably because the hottest dust emission, still covered by the NIR filters, is obscured. The optical spectra of the type 2 host galaxies show young and old stellar populations. Only one object is an ultraluminous infrared galaxy with starburst. The 5-38 mu spectra of the two type 2 sources observed show a strong continuum with PAH emission in one case and silicate absorption in the other case. Conclusions: The near-mid-infrared selection is a successful strategy to find luminous type 2 AGN at low z. The objects exhibit a large range of properties so that it is difficult to infer details by means of popular SED fitting with simple average templates.Comment: Accepted for publication in A&

Low energy collective modes, Ginzburg-Landau theory, and pseudogap behavior in superconductors with long-range pairing interactions

We study the superconducting instability in systems with long but finite ranged, attractive, pairing interactions. We show that such long-ranged superconductors exhibit a new class of fluctuations in which the internal structure of the Cooper pair wave function is soft, and thus lead to "pseudogap" behavior in which the actual transition temperature is greatly depressed from its mean field value. These fluctuations are {\it not} phase fluctuations of the standard superconducting order parameter, and lead to a highly unusual Ginzburg-Landau description. We suggest that the crossover between the BCS limit of a short-ranged attraction and our problem is of interest in the context of superconductivity in the underdoped cuprates.Comment: 20 pages with one embedded ps figure. Minor revisions to the text and references. Final version to appear in PRB on Nov. 1st, 200