Cost-effectiveness analysis of paediatric mental health interventions: a systematic review of model-based economic evaluations

Mental health disorders among children and youth are causing significant burden on health care systems. Hence, identifying cost-effective interventions is important for effective mental health care allocation. Although model-based economic evaluations are an essential component of assessing cost-effectiveness, evidence are limited in the context of child and youth mental health care. The objective was to systematically review the model-based economic evaluations of mental health interventions for children and youth. Methods: Four databases (MEDLINE, EMBASE, PsycINFO and Web of Science) were searched using appropriate search terms to retrieve model-based economic evaluations of mental health interventions for children and youth. The reporting quality of the included studies were appraised using the Consolidated health economic evaluation reporting standards (CHEERS) checklist. Results: The database search yielded 1921 records. Of the 12 selected for review, 66% were published after year 2015. Most of the studies were related to anxiety and post-traumatic stress disorder. There were eight cost-utility studies, three cost-effectiveness studies, and one study using both forms of analysis. Six studies used Markov models, three used decision trees, and three studies used both types of models. However, the model structure, health states, time horizon, and economic perspective showed wide variation. The reporting quality of the included studies varied from 91% to 96%. Conclusion: Model based mental health economic evaluations among children and youth are increasingly being reported in recent research. The included studies used Markov models and decision trees, either alone or in combination, and the majority of the articles were of good reporting quality

A systematic review of the validity and reliability of patient-reported experience measures

Objectives: To identify patient-reported experience measures (PREMs), assess their validity and reliability, and assess any bias in the study design of PREM validity and reliability testing. Data Sources/Study Setting: Articles reporting on PREM development and testing sourced from MEDLINE, CINAHL and Scopus databases up to March 13, 2018. Study Design: Systematic review. Data Collection/Extraction Methods: Critical appraisal of PREM study design was undertaken using the Appraisal tool for Cross-Sectional Studies (AXIS). Critical appraisal of PREM validity and reliability was undertaken using a revised version of the COSMIN checklist. Principal Findings: Eighty-eight PREMs were identified, spanning across four main health care contexts. PREM validity and reliability was supported by appropriate study designs. Internal consistency (n = 58, 65.2 percent), structural validity (n = 49, 55.1 percent), and content validity (n = 34, 38.2 percent) were the most frequently reported validity and reliability tests. Conclusions: Careful consideration should be given when selecting PREMs, particularly as seven of the 10 validity and reliability criteria were not undertaken in ≥50 percent of the PREMs. Testing PREM responsiveness should be prioritized for the application of PREMs where the end user is measuring change over time. Assessing measurement error/agreement of PREMs is important to understand the clinical relevancy of PREM scores used in a health care evaluation capacity.</p

Reliability and validity of patient-reported experiences measures: A systematic review

Patient-reported experience measures (PREMs) are instruments used to examine patients’ experiences of healthcare services. Typically measured are care processes, such as the timeliness of service delivery. PREMs are used as an indicator of healthcare quality and internationally are used in hospital reimbursement and pay-for-performance schemes

Comparison of topical tacrolimus and clobetasol in the management of symptomatic oral lichen planus: A double-blinded, randomized clinical trial in Sri Lanka

AimOral lichen planus (OLP) is a common, chronic inflammatory disease of the oral mucosa. Although several studies have shown the efficacy of different treatment modalities, a definitive cure has not yet been established. The present trial compares the effectiveness of topically-applied clobetasol and tacrolimus in the symptomatic management of OLP.MethodsA randomized, comparative, double-blind study with 68 patients (43 females, 25 males; mean age: 46.76 years) was undertaken. Patients were randomly divided into two groups of 34 patients each to receive topical tacrolimus 0.1% cream or clobetasol propionate 0.05% cream for 3 weeks.ResultsAfter 3 weeks of treatment, the mean pain score dropped by 1.59 (right) and 1.53 (left) in the tacrolimus group, while in clobetasol group these values were 0.94 and 0.85, respectively. The mean scores for clinical appearance reduced by 1.18 (right) and 1.0 (left) in the tacrolimus group compared with a reduction of 0.5 and 0.26, respectively, in the clobetasol group. These reductions were statistically significant (P ConclusionThe results suggest that tacrolimus 0.1% cream is an effective alternative to topical steroid and can be considered a first-line therapy in OLP. However, further studies are needed to confirm the effectiveness of this treatment before it is recommended for use in clinical practice.<br/

Reducing Emergency Department demand through expanded primary healthcare practice: Full report of the research and findings.Vol. 1.

BackgroundDemand for public hospital emergency departments’ services and care is increasing, placing considerable restraint on their performance and threatens patient safety. Many factors influence such demand including individual characteristics (e.g. perceptions, knowledge, values and norms), healthcare availability, affordability and accessibility, population aging, and internal health system factors (e.g patient flow, discharge process). To alleviate demand, many initiatives have been trialled or suggested, including early identification of at-risk patients, better management of chronic disease to reduce avoidable ED presentation, expanded capacity of front-line clinician to manage sub-acute and non-urgent care, improved hospital flow to reduce access block, and diversion to alternate site for care. However, none have had any major or sustained impact on the growth in ED demand.A major focus of the public discourse on ED demand has been the use and integration of primary healthcare and ED, based on the assumption that between 10%–25% of ED presentations are potentially avoidable if patients’ access to appropriate primary healthcare (PHC) services were enhanced. However, this requires not only improved access but also appropriateness in terms of the patients’ preference and PHC providers’ capacity to address the needs. What is not known at the moment is the extent of the potential for diversion of non-urgent ED patients to PHC and the cost-benefits of such policy and funding changes required, particularly in the Australian context. There is a need to better understand ED patients’ needs and capacity constraint so as to effect delivery of accessible, affordable, efficient and responsive services.Aim and objectivesThe main aim of this study was to investigate, from a whole-of-system perspective, the suitability, features and viability of primary healthcare (PHC) as an alternative to emergency department (ED) care for non-urgent acute illness.The objectives of this project were to:1. Identify the features required of PHC as a suitable ED alternative for acute care from patients’ perspectives;2. Identify the factors that affect patients’ preference and choice between ED care and PHC;3. Validate and quantify the suitability and features required of PHC as an ED alternative, and measure the relative impact of factors that affect patients’ preferences and choice between ED care and PHC;4. Quantify the number and type of ED patients that may be suitable for receiving PHC;5. Identify through stakeholders' engagement viable PHC models, and evaluate the economic, policy and system changes required to manage the provision of acute care in non-ED settings safely, effectively and efficiently.Research methodWe conducted a multistage mixed methods study within the Brisbane Metro North area. The study involved:1) Cross-sectional survey of 514 patients attending the four major public hospital EDs in the area (Caboolture, Redcliffe, The Prince Charles, Royal Brisbane &amp; Women’s);2) Secondary analysis of over 822,000 presentations data related to patients attending the above named EDs during the three year period of 2014-15 to 2016-17;3) In-depth interviews with 11 health providers and/or policy experts and decision-makers from medical, nursing and pharmaceutical backgrounds whose views could inform the study objectives.FindingsSurvey of ED patients identified their main reasons for presenting to ED, their contact with GP beforehand, and their decision-making. For 85% of the respondents, attending the ED was because they perceived they required immediate (urgent) care. When asked how they rated the urgency of their condition prior to attending the ED, the mean score was 7 out of 10. Around 43% reported they had contacted their GP, but in many instances, either the GP or the receptionist referred them on to the ED due to various reasons, e.g not having an appointment, requiring extra care or services not available at the GP. Nearly 30% also reported having contacted the ambulance, 13Health or a pharmacist in relation to their illness prior to presenting to the ED. Forty percent were confident a GP would be able to treat their illness, however, mostly agreed that right settings and arrangements were required for GPs to be able to become involved in acute care, including special equipment and facilities, prioritising system for urgent cases, availability and bulk-billing.We also assessed if the patients would hypothetically accept the ED triage nurse’s advice if the nurse advises them that their condition could be treated by a GP. Over 80% reported they would accept the advice. However, further analyses showed that this potential acceptance was contingent upon perceived seriousness, availability of alternative/primary care, and affordability. This finding has significant implications for patient navigation and care coordination. It should be emphasised that we only assessed the patient’s acceptance hypothetically and no advice was actually offered. We did not investigate practicalities of providing such advice, long-term sustainability and effectiveness of such initiatives in practice, for instance patients’ compliance, and whether it reduces ED demand.Our analysis of the EDIS data (number of patient presentations to the four EDs during 2014-15 to 2016-17) showed that between 6% to 26.7% of the presentations were potentially of GP-type, according to three different methods. However, two methods returned close estimates (6% and 7.5%) while the AIHW method returned 26.7%. All three methods showed that the proportion of GP-type presentations decreased over time. The costs of treating GP-type patients in EDs were estimated at around $400 while for non-GP-type patients it varied between$500 and $700 for children and adults and different methods. We did not have a comparable data for similar patients who are treated in a GP setting. The key issues emerged from this analysis included:- Defining and identifying the so-called GP-type patients in ED is contested and challenging;- The considerable number of GP-type patients who are admitted plus their long length of stay in ED indicate that these patients may not be simply suitable for GP care with a standard consultation time of about 15 minutes;- The cost of treating GP-type patients in an ED setting, inclusive of all ancillary costs, is far less than non-GP-type patients. However, in the absence of comparable GP data, we cannot rule out that the ED may still be the most cost-effective place for managing these patients.Our interviews with healthcare providers and decision-makers identified the following major issues:1) Barriers to provision of acute care in PHC, including: inadequate renumeration, high costs of specialised equipment, staff availability, litigation and Medicare audits, EDs’ legal duty not to divert patients, and GPs’ varied skills and interests;2) Barriers to patient use of PHC instead of ED, including: timely access, convenience, confidence, and out of pocket expenses;3) Suggestions for a new healthcare model, including: dedicated centres for less acute or low urgency cases staffed by primary care providers, and optimising or repurposing existing GP facilities for afterhours use;4) Suggestions for improving the current ED model, including: reducing bed block, enhancing workforce model and efficiency (e.g. recruiting salaried GPs in EDs), and improving communication between EDs and PHC sector;5) Enablers for GPs to provide acute care, including: financial incentives, training and professional development, and enhancing hospital-ED-GP collaborative care.The way forwardProviding patient-centred care requires a deep understanding of the social-psychological determinants of health seeking behaviour, which are embedded in and impacted by the societal and political environments within which health systems and actors operate. Our research findings provide evidence about these interrelationships within the context of ED demand and PHC’s role in acute care. To reduce demand for EDs, multiple approaches and alternatives are required in order to ensure patients’ needs for healthcare are met in a safe and suitable way. GPs and PHC sector in general are one of the alternatives that have the potential to, at least partly, alleviate such demand. This requires effective care coordination and patient navigation systems, patient education; legal, financial, clinical and technical support; communication and collaboration among various stakeholders (e.g. PHC, pre-hospital and hospital-based acute care providers); and responsiveness to changing population needs and challenges as they arise (e.g. pandemics and disasters, aging, migration). Furthermore, all new initiatives and alternatives require monitoring their impacts and rigorous economic evaluation to ensure their cost-effectiveness and sustainability

Pediatric quality of life instruments in oral health research: A systematic review

Objective: To identify the generic or disease-specific pediatric quality of life (QoL) instruments used in oral health research among children and adolescents and to provide an overview of these QoL instruments. Methods: A systematic literature search was performed with multiple databases to identify the pediatric QoL instruments used in oral health research. Results: The literature search yielded 872 records; from these, 16 pediatric QoL instruments were identified that had been used among children and adolescents in oral health research. Of these, 11 were oral health–specific QoL instruments and five were generic instruments. Of the 11 oral health–specific QoL instruments, none were multiattribute utility instruments (MAUI), whereas of the five generic instruments, two (Child Health Utility 9D index and EuroQoL-5D youth) were classified as an MAUI. Except for one, all pediatric QoL instruments were published after the year 2000 and the majority originated from the USA (n = 8). Of the 11 oral health–specific QoL instruments, five instruments are designed for the respondent to be a child (i.e., self-report), one uses proxy responses from a parent or guardian, and five instruments have both self and proxy versions. Of the five generic QoL instruments, one uses proxy responses and the other four instruments have both self and proxy versions. Conclusions: This review identified a wide variety of pediatric oral health–specific and generic QoL instruments used in oral health research among children and adolescents. The availability of these QoL instruments provides researchers with the opportunity to select the instrument most suited to address their research question.</p

Economic case for intraoperative interventions to prevent surgical-site infection

Surgical-site infection (SSI) occurs in 1-10 per cent of all patients undergoing surgery; rates can be higher depending on the type of surgery. The aim of this review was to establish whether (or not) surgical hand asepsis, intraoperative skin antisepsis and selected surgical dressings are cost-effective in SSI prevention, and to examine the quality of reporting. Methods The authors searched MEDLINE via Ovid, CINAHL via EBSCO, Cochrane Central and Scopus databases systematically from 1990 to 2016. Included were RCTs and quasi-experimental studies published in English, evaluating the economic impact of interventions to prevent SSI relative to surgical hand and skin antisepsis, and wound dressings. Characteristics and results of included studies were extracted using a standard data collection tool. Study and reporting quality were assessed using SIGN and CHEERS checklists. Results Across the three areas of SSI prevention, the combined searches identified 1214 articles. Of these, five health economic studies evaluating the cost-effectiveness of selected surgical dressings were eligible. Study authors concluded that the interventions being assessed were cost-effective, or were potentially cost-saving. Still, there is high uncertainty around the decision to adopt these dressings/devices in practice. The studies' reporting quality was reasonable; three reported at least 15 of the 24 CHEERS items appropriately. Assessment of methodological quality found that two studies were considered to be of high quality. Conclusion With few economic studies undertaken in this area, the cost-effectiveness of these strategies is unclear. Incorporating economic evaluations alongside RCTs will help towards evidence-informed decisions

Valuation study for a preference-based quality of life measure for dental caries (Dental Caries Utility Index - DCUI) among Australian adolescents - study protocol

Introduction A new health state classification system has been developed for dental caries - Dental Caries Utility Index (DCUI) to facilitate the assessment of oral health interventions in the cost-utility analysis (CUA). This paper reports the protocol for a valuation study, which aims to generate a preference-based algorithm for the classification system for the DCUI. Methods and analysis Discrete choice experiments (DCEs) will be conducted to value health states generated by the DCUI classification system and preferences for these health states will be modelled to develop a utility algorithm. DCEs produce utility values on a latent scale and these values will be anchored into the full health-dead scale to calculate the quality-adjusted life years in CUA. There is no previous evidence for the most suitable anchoring method for dental caries health state valuation. Hence, we will first conduct pilot studies with two anchoring approaches; DCE including duration attribute and DCE anchoring to worst heath state in Visual Analogue Scale. Based on the pilot studies, the most suitable anchoring method among two approaches will be used in the main valuation survey, which will be conducted as an online survey among a representative sample of 2000 adults from the Australian general population. Participants will be asked to complete a set of DCE choice tasks along with anchoring tasks, basic social-demographic questions, DCUI, a generic preference-based measure and oral health quality of life instrument. Ethics and dissemination Ethical approval for this study was obtained from the Human Research Ethics Committee, Griffith University (reference number HREC/2019/550). The generated algorithm will facilitate the use of the new dental caries preference-based measure in economic evaluations of oral health interventions. The results will be disseminated through journal articles and professional conferences.</p

A scoping review of cost‐effectiveness analyses of school‐based interventions for caries

Objectives The aims of this study were to: identify the evidence on cost‐effectiveness of school‐based interventions for caries prevention globally up to 2019; summarize key characteristics of interventions applied within this setting; summarize the reporting quality of previous studies; and to identify and analyse knowledge gaps.Methods A scoping review of published literature on the cost‐effectiveness of school‐based interventions to prevent child tooth decay was conducted. A search in Medline, Cinahl and Embase was performed with no date restriction. Reporting quality of the included studies was assessed against Consolidated Health Economic Evaluation Reporting Standards (CHEERS) checklist.Results Of the 738 records identified in the initial search, 15 studies met the pre‐specified inclusion criteria. The majority were published after 2011 (n = 9,) and applied to high‐income countries (n = 12). Nearly 80% of the studies assessed the cost‐effectiveness of the interventions based on topical fluoride therapies and fissure sealants at school premises. Although, the outcome measures differed across the studies, almost all the caries preventive interventions were cost‐saving or cost‐effective when compared with usual care. Compliance with the CHEERS checklist differed.Conclusions There is evidence to suggest that school‐based caries preventive interventions are cost‐effective, and in some cases cost‐saving. Further evidence is required from low‐ to middle‐income countries to confirm the generalizability of these findings. Future studies should consider adopting Quality Adjusted Life Years as a generic outcome measure that would enable the cost‐effectiveness findings to be compared across different types of interventions and diseases. Improved standardization and quality of reporting are also required

An analysis of rate and factors affecting malignant transformation of oral submucous fibrosis in patients attending the Oral Medicine Clinic, Dental Hospital Peradeniya, Sri Lanka - A retrospective study

Background: Oral submucous fibrosis (OSF) is a chronic, progressive, scarring and potentially malignant disease of the oral mucosa seen primarily in the Indian subcontinent and in South East Asia. OSF is a premalignant condition with a malignant transformation rate varying from 7-12%. Even though OSF and oral cancer are common in Sri Lanka, malignant transformation potential and rate have not been studied in our population. Objectives: To identify the relationship of malignant transformation with age, gender, habits, amount of mouth opening, duration of follow up, presence of other oral potentially malignant disorders and dysplasia in a group of patients with OSF attending the Oral Medicine clinic, University Dental Hospital Peradeniya. Methods: All the clinical files of patients with OSF attending the Oral Medicine clinic, University Dental Hospital Peradeniya were selected. Cases with OSF where histopathological diagnosis was not available, patients who had developed oral cancer before the diagnosis of OSF and patients who were diagnosed with OSF and received prior surgical therapy were excluded. Data were analysed to identify any relationship of malignant transformation with other variables. Results: There were 135 patients with a follow up period ranging from 6 months to 23 years and average follow up period was 5.26 years. 75.6% of them were males. 42.2% of them presented with burning sensation as the main complaint. 96.3% of them chewed betel with all ingredients whereas the rest chewed only arecanut. Eight patients developed malignancy during the follow up period giving a malignant transformation rate of 5.9% after a mean follow up period of 6.5 years. Conclusions: Malignant transformation in patients with OSF is significantly associated with presence of dysplasia on the initial biopsy, presence of any other potentially malignant disorder and the duration of betel chewing