Impact of different interventions on preventing suicide and suicide attempt among children and adolescents in the United States: a microsimulation model study

IntroductionDespite considerable investment in suicide prevention since 2001, there is limited evidence for the effect of suicide prevention interventions among children and adolescents. This study aimed to estimate the potential population impact of different interventions in preventing suicide-related behaviors in children and adolescents.MethodsA microsimulation model study used data from national surveys and clinical trials to emulate the dynamic processes of developing depression and care-seeking behaviors among a US sample of children and adolescents. The simulation model examined the effect of four hypothetical suicide prevention interventions on preventing suicide and suicide attempt in children and adolescents as follows: (1) reduce untreated depression by 20, 50, and 80% through depression screening; (2) increase the proportion of acute-phase treatment completion to 90% (i.e., reduce treatment attrition); (3) suicide screening and treatment among the depressed individuals; and (4) suicide screening and treatment to 20, 50, and 80% of individuals in medical care settings. The model without any intervention simulated was the baseline. We estimated the difference in the suicide rate and risk of suicide attempts in children and adolescents between baseline and different interventions.ResultsNo significant reduction in the suicide rate was observed for any of the interventions. A significant decrease in the risk of suicide attempt was observed for reducing untreated depression by 80%, and for suicide screening to individuals in medical settings as follows: 20% screened: −0.68% (95% credible interval (CI): −1.05%, −0.56%), 50% screened: −1.47% (95% CI: −2.00%, −1.34%), and 80% screened: −2.14% (95% CI: −2.48%, −2.08%). Combined with 90% completion of acute-phase treatment, the risk of suicide attempt changed by −0.33% (95% CI: −0.92%, 0.04%), −0.56% (95% CI: −1.06%, −0.17%), and −0.78% (95% CI: −1.29%, −0.40%) for reducing untreated depression by 20, 50, and 80%, respectively. Combined with suicide screening and treatment among the depressed, the risk of suicide attempt changed by −0.27% (95% CI: −0.dd%, −0.16%), −0.66% (95% CI: −0.90%, −0.46%), and −0.90% (95% CI: −1.10%, −0.69%) for reducing untreated depression by 20, 50, and 80%, respectively.ConclusionReducing undertreatment (the untreated and dropout) of depression and suicide screening and treatment in medical care settings may be effective in preventing suicide-related behaviors in children and adolescents

Cost-effectiveness of statin therapy for vascular event prevention in adults with elevated C-reactive protein: Implications of JUPITER

Objectives: High-sensitivity C-reactive protein (hs-CRP) has been explored for use in predicting cardiovascular risk. The recent Justification for the Use of Statins in Primary Prevention: An Intervention Trial Evaluating Rosuvastatin (JUPITER) study found that statin therapy reduced cardiovascular events in those with low-density lipoprotein (LDL) cholesterol levels below current treatment thresholds (130mg/dL, 3.4mmol/L), but with elevated hs-CRP levels (\u3e2.0mg/L). This study examines the cost-effectiveness of statin treatment for individuals with elevated hs-CRP but normal LDL cholesterol. Methods: A Markov decision-analytic model was conducted from the U.S. societal perspective. Data from JUPITER were used to estimate rates of myocardial infarction, angina and stroke. Statin costs were based on generic simvastatin 80mg, equipotent to the rosuvastatin 20mg dose used in JUPITER. Primary prevention was the focus and secondary prevention was not modeled explicitly. Quality-adjusted life-years (QALYs) were calculated using nationally representative preference-based utility weights. One-way sensitivity analyses and multivariate probabilistic sensitivity analysis were used to explore uncertainty in model parameters as well as estimate the likelihood of cost-effectiveness when all event rates, costs and utilities were drawn randomly from distributions reflecting uncertainty. Results: Statin therapy cost $10,889/QALY for vascular event prevention in this population. Results were sensitive to the cost of statin treatment. Based on 10,000 simulations, statin therapy was cost-effective in 99.5 of simulations, using a willingness-to-pay threshold of$20,000/QALY, and 100 of simulations using a threshold of $50,000/QALY. Conclusions: Treatment with statins in patients with elevated hs-CRP but normal cholesterol appears to be cost-effective. Limitations of this study include the assumption that an equipotent dose of simvastatin resulted in the same risk reduction as rosuvastatin. Further, post-event states simulated the average experience of a patient. Continued statin use, subsequent events and/or heart failure were not explicitly modeled. © 2010 Informa UK Ltd

Catalogue of EQ-5D scores for the United Kingdom

Background. The National Institute for Health and Clinical Excellence (NICE) has issued guidance on cost-effectiveness analyses, suggesting that preference-based health-related quality of life (HRQL) weights or utilities be based on UK community preferences, preferably using the EQ-5D; ideally all analyses would use the same system for deriving HRQL weights, to encourage consistency and comparability across analyses. Development of a catalogue of EQ-5D scores for a range of health conditions based on UK preferences would help achieve many of these goals. Objective. To provide a UK-based catalogue of EQ-5D index scores. Methods. Methods were consistent with the previously published catalogue of EQ-5D scores for the US. Community-based UK preferences were applied to EQ-5D descriptive questionnaire responses in the US-based Medical Expenditure Panel Survey (MEPS). Ordinary least squares (OLS), Tobit, and censored least absolute deviations (CLAD) regression methods were used to estimate the \u27marginal disutility\u27 of each condition controlling for covariates. Results. Pooled MEPS files (2000-2003) resulted in 79,522 individuals with complete EQ-5D scores. Marginal disutilities for 135 chronic ICD-9 and 100 CCC codes are provided. Unadjusted descriptive statistics including mean, median, 25th and 75th percentiles are also reported. Conclusion. This research provides community-based EQ-5D index scores for a wide variety of chronic conditions that can be used to estimate QALYs in cost-effectiveness analyses in the UK. Although using EQ-5D questionnaire responses from the US-based MEPS is less than ideal, the estimates approximate HRQL guidelines by NICE and provide an easily accessible off-the-shelf resource for cost-effectiveness and publichealth applications

Treatment Charges for Traumatic Brain Injury Among Older Adults at a Trauma Center

Objective—To provide charge estimates of treatment for traumatic brain injury (TBI), including both hospital and physician charges, among adults aged 65 and older treated at a trauma center. Methods—We identified older adults treated for TBI during 2008–2012 (n=1,843) at Maryland’s Primary Adult Resource Center and obtained hospital and physician charges separately. Analyses were stratified by sex and all charges were inflated to 2012 dollars. Total TBI charges were modeled as a function of covariates using a generalized linear model. Results—Women comprised 48% of the sample. The mean unadjusted total TBI hospitalization charges for adults aged 65 and older was $36,075 (standard deviation (SD)$63,073). Physician charges comprised 15% of total charges. Adjusted mean charges were lower in women than in men (adjusted difference −$894; 95$277, −$1,512). Length of hospital and ICU stay were associated with the highest charges. Conclusions—This study provides the first estimates of hospital and physician charges associated with hospitalization for TBI among older adults at a trauma center that will aid in resource allocation, triage decisions, and healthcare policy

Impact on postoperative bleeding and cost of recombinant activated factor VII in patients undergoing heart transplantation

Background: Cardiac transplantation can be complicated by refractory hemorrhage particularly in cases where explantation of a ventricular assist device is necessary. Recombinant activated factor VII (rFVIIa) has been used to treat refractory bleeding in cardiac surgery patients, but little information is available on its efficacy or cost in heart transplant patients. Methods: Patients who had orthotopic heart transplantation between January 2009 and December 2014 at a single center were reviewed. Postoperative bleeding and the total costs of hemostatic therapies were compared between patients who received rFVIIa and those who did not. Propensity scores were created and used to control for the likelihood of receiving rFVIIa in order to reduce bias in our risk estimates. Results: Seventy-six patients underwent heart transplantation during the study period. Twenty-one patients (27.6%) received rFVIIa for refractory intraoperative bleeding. There was no difference in postoperative red blood cell transfusion, chest tube output, or surgical re-exploration between patients who received rFVIIa and those who did not, even after adjusting with the propensity score (P = 0.94, P = 0.60, and P = 0.10, respectively). The total cost for hemostatic therapies was significantly higher in the rFVIIa group (median $10,819 vs.$1,985; P \u3c 0.0001). Subgroup analysis of patients who underwent redo-sternotomy with left ventricular assist device explantation did not show any benefit for rFVIIa either. Conclusions: In this relatively small cohort, rFVIIa use was not associated with decreased postoperative bleeding in patients undergoing heart transplantation; however, it led to significantly higher cost

Mortality and Associated Morbidities Following Traumatic Brain Injury in Older Medicare Statin Users

Objective: To assess the relationship between posttraumatic brain injury statin use and (1) mortality and (2) the incidence of associated morbidities, including stroke, depression, and Alzheimer’s disease and related dementias following injury. Setting and Participants: Nested cohort of all Medicare beneficiaries 65 years of age and older who survived a traumatic brain injury (TBI) hospitalization during 2006 through 2010. The final sample comprised 100 515 beneficiaries. Design: Retrospective cohort study of older Medicare beneficiaries. Relative risks (RR) and 95% confidence interval (CI) were obtained using discrete time analysis and generalized estimating equations. Measures: The exposure of interest included monthly atorvastatin, fluvastatin, lovastatin, pravastatin, rosuvastatin, and simvastatin use. Outcomes of interest included mortality, stroke, depression, and Alzheimer’s disease and related dementias. Results: Statin use of any kind was associated with decreased mortality following TBI hospitalization discharge. Any statin use was also associated with a decrease in any stroke (RR, 0.86; 95% confidence intervals (CI), 0.81-0.91), depression (RR, 0.85; 95% CI, 0.79-0.90), and Alzheimer’s disease and related dementias (RR, 0.77; 95% CI, 0.73-0.81). Conclusion: These findings provide valuable information for clinicians treating older adults with TBI as clinicians can consider, when appropriate, atorvastatin and simvastatin to older adults with TBI in order to decrease mortality and associated morbidities. Key words: Medicare, mortality, older adults, statins, TBI sequelae, traumatic brain injur