Economic evaluation of cystic fibrosis screening: A Review of the literature, CHERE Working Paper 2006/6

Objectives: To critically examine the economic evidence on Cystic Fibrosis (CF) screening and to understand issues relating to the transferability of findings to the Australian context for policy decisions. Methods: A systematic literature search identified 25 economic studies with empirical results on CF published between 1990 and 2005. These articles were then assessed against international benchmarks on conducting and reporting of economic evaluations, focusing on the transferability of the evidence to the local setting. Results: Six studies described only costs, 12 were cost-effectiveness studies, 6 were cost-benefit studies and one had a combined design (cost utility, cost benefit and cost effectiveness). Most of the cost-effectiveness studies compared screening versus ?no-screening? but the screening programs under consideration differed markedly. Four considered neonatal screening, three prenatal screening, three pre-conception and carrier screening, and one considered all types of screening programs. The outcome measures also varied considerably between studies. One study included a quality adjusted life year measure. Cost?benefit measures mostly included economic savings ? evaded lifetime medical costs of avoiding CF child birth. Conclusion: The variability in study design, model inputs and reporting of economic evaluations of CF carrier screening raises issues on the applicability and transferability of such evidence to the Australian context.Cystic fibrosis, economic evaluation

Comparative effectiveness of cognitive therapies delivered face-to-face or over the telephone: an observational study using propensity methods.

OBJECTIVES: To compare the clinical and cost-effectiveness of face-to-face (FTF) with over-the-telephone (OTT) delivery of low intensity cognitive behavioural therapy. DESIGN: Observational study following SROBE guidelines. Selection effects were controlled using propensity scores. Non-inferiority comparisons assessed effectiveness. SETTING: IAPT (improving access to psychological therapies) services in the East of England. PARTICIPANTS: 39,227 adults referred to IAPT services. Propensity score strata included 4,106 individuals; 147 pairs participated in 1:1 matching. INTERVENTION: Two or more sessions of computerised cognitive behavioural therapy (CBT). MAIN OUTCOME MEASURES: Patient-reported outcomes: Patient Health Questionnaire (PHQ-9) for depression; Generalised Anxiety Disorder questionnaire (GAD-7); Work and Social Adjustment Scale (WSAS). Differences between groups were summarised as standardised effect sizes (ES), adjusted mean differences and minimally important difference for PHQ-9. Cost per session for OTT was compared with FTF. RESULTS: Analysis of covariance controlling for number of assessments, provider site, and baseline PHQ-9, GAD-7 and WSAS indicated statistically significantly greater reductions in scores for OTT treatment with moderate (PHQ-9: ES: 0.14; GAD-7: ES: 0.10) or small (WSAS: ES: 0.03) effect sizes. Non-inferiority in favour of OTT treatment for symptom severity persisted as small to moderate effects for all but individuals with the highest symptom severity. In the most stringent comparison, the one-to-one propensity matching, adjusted mean differences in treatment outcomes indicated non-inferiority between OTT versus FTF treatments for PHQ-9 and GAD-7, whereas the evidence was moderate for WSAS. The per-session cost for OTT was 36.2% lower than FTF. CONCLUSIONS: The clinical effectiveness of low intensity CBT-based interventions delivered OTT was not inferior to those delivered FTF except for people with more severe illness where FTF was superior. This provides evidence for better targeting of therapy, efficiencies for patients, cost savings for services and greater access to psychological therapies for people with common mental disorders

A memory clinic v. traditional community mental health team service: comparison of costs and quality.

Aims and method To compare the cost and quality of a memory-clinic-based service (MCS) with a traditional community mental health team (CMHT) service. Using a retrospective case-note review, we studied two groups, each with 33 participants. Consecutive referrals for diagnostic 'memory' assessments over 4 months were evaluated. Participants were evaluated for up to 6 months. Results The MCS was less costly than the CMHT service but the difference was not statistically significant (mean cost for MCS was £742, mean cost for CMHT service was £807). The MCS offered more multidisciplinary and comprehensive care, including: pre- and post-diagnostic counselling, more systematic screening of blood for reversible causes of dementia, more use of structured assessment instruments in patients/carers, signposting to the third sector as well as more consistent copying of letters to patients/carers. Clinical implications An MCS service offered more comprehensive and multidisciplinary service at no extra cost to secondary care

Location of care for people with serious mental illness (LOCAPE) : implications for service use and costs using a mixed-methods approach

BackgroundThis study focuses on health care received by people with serious mental illness (SMI). The aim is to examine the economic implications of different locations of management of care and the views of service users and staff regarding services set up as alternatives to secondary care.ObjectivesSpecific objectives are to (1) identify people with SMI managed in primary or secondary care; (2) identify those who could be potentially transferred to primary care; (3) compare the characteristics of these groups; (4) compare service use and costs; (5) generate models to estimate cost changes following transfer between settings; (6) identify characteristics associated with time to transition to secondary care; (7) investigate experiences of patients receiving support from community-based interventions; and (8) assess the economic impact of interventions to facilitate transfer of care management.Methods(1) Quantitative component – using linked primary and secondary care data we examined differences between those discharged to primary care (n = 1410) and those still in secondary care (n = 1629). Service use and costs were compared and predictors of costs were identified using regression models. (2) Qualitative component – interviews following a topic guide were conducted at two time points with 31 people using and 10 people working in services set up as alternatives to secondary care. (3) Economic modelling – an analysis of the health-care costs of the above services compared with usual care was conducted using decision modelling. Data were obtained from local services where possible, and the time horizon was 12 months.Results(1) Quantitative component – characteristics of those discharged to primary care (n = 1410) were similar to those still in secondary care (n = 1629). Costs for those discharged to primary care were 48% lower than for those remaining in secondary care. Other variables strongly associated with costs were a history of violence and a diagnosis of schizophrenia or bipolar disorder. Few patients in secondary care had a high probability of primary care management and, therefore, excess costs were only around £150,000 across the sample. (2) Qualitative component – service users’ views about a community options team and a primary care support service were positive and compared favourably to services used previously. Views about peer support were slightly less consistent. Staff had concerns with regard to caseload sizes and staff turnover. (3) Economic modelling – services to help transition had costs that were 40% of those for standard care. The results of this showed that triaging patients into these services would save £1578 over a 1-year period and that the results were robust to changes in most parameters.LimitationsAnalysis was hindered by the extent to which data were available. Qualitative analyses were limited by the fact that most of the participants did not have a SMI as usually defined and that many had been out of contact with secondary services for a long period of time.ConclusionsCosts are substantially lower in primary care than secondary care, even after controlling for service-user patient differences. Generally, there is satisfaction with services to help facilitate primary care provision and these appear to be cost saving. Future work should continue the analysis of linked data and involve a more comprehensive evaluation of the specific services investigated here.FundingThe National Institute for Health Research Health Services and Delivery Research programme

Virtual Touch (TM) Quantification to Diagnose and Monitor Liver Fibrosis in Hepatitis B and Hepatitis C: A NICE Medical Technology Guidance

King’s Technology Evaluation Centre is funded by NICE to act as an External Assessment Centre for the Medical Technologies Evaluation Programme. The NHS has a financial interest in the guidance issued by NICE as a result of this work and two authors are NHS employees (Prof. Keevil and Dr. Lewis

Manual small incision cataract surgery in eyes with white cataracts

PURPOSE: To assess the safety and efficacy of Manual Small Incision Cataract Surgery (MSICS) in cases of white cataract with the use of trypan blue as an adjunct for performing continuous curvilinear capsulorthexis (CCC). MATERIALS AND METHODS: Prospective observational study on 100 consecutive eyes of 100 patients with white cataract who had undergone MSICS with trypan blue assisted CCC. The nucleus was prolapsed into anterior chamber by using a sinskey hook and extracted out of the eye using irrigating vectis. Intraoperative and postoperative findings (according to OCTET classification) as well as postoperative visual outcomes were used as main measures to report the safety and efficacy of the surgery. RESULTS: Of the 100 eyes, 16 had intumescent, 67 had mature and 17 had hypermature cataract. Intraoperatively CCC was incomplete in 4 eyes (4%) and had to be converted to canopener capsulotomy. None of the eyes had posterior capsular rupture or zonular dialysis and no eyes were converted to conventional Extra Capsular Cataract Extraction (ECCE). Postoperatively, 6 eyes (6%) developed corneal oedema with >10 Descemets folds and 7 eyes (7%) had corneal oedema with < 10 Descemets folds. Mild iritis was seen in 6 eyes (6%) and moderate iritis with fibrin membrane was seen in 3 eyes (3%). Iridodialysis was observed in 1 eye (1%). Of the 99 patients (99%) categorised under good visual outcomes category, 94 patients (94%) had a best-corrected visual acuity of 6/9 or better on the 40th post-operative day. CONCLUSION: In developing countries like India where phacoemulsification may not be affordable to a majority of those requiring cataract surgery, MSICS proves to be a safe and efficacious alternative for white cataracts especially with the adjunctive use of trypan blue dye

Economic and social factors that influence households not willing to undergo cataract surgery

Purpose: Literature investigating barriers to cataract surgery is mostly done from the patient's point of view. However, many medical decisions are jointly taken by household members, especially in developing countries such as India. We investigated from the household head's (or representative's) perspective, households' view on those not willing to undergo cataract surgery along with the economic and social factors associated with it. Materials and Methods: A cross-sectional survey of four randomly selected village clusters in rural areas of Theni district, Tamil Nadu, India, was conducted to elicit the willingness to pay for cataract surgery by presenting "scenarios" that included having or not having free surgery available. The presentation of scenarios allowed the identification of respondents who were unwilling to undergo surgery. Logistic regression was used to estimate relationships between economic and social factors and unwillingness to undergo cataract surgery. Results: Of the 1271 respondents, 49 (3.85%) were not willing to undergo surgery if they or their family members have cataract even if free surgery were available. In the regression results, those with good understanding of cataract and its treatment were less likely to be unwilling to undergo cataract surgery. Those not reporting household income were more likely to be unwilling to undergo cataract surgery. Conclusions: As a good understanding of cataract was an important predictor of willingness to undergo cataract surgery, health education on cataract and its intervention can improve uptake

Economics of cataract surgery in rural India

In India, cataract surgeries are provided by both the private and public sectors. Free cataract surgeries (with minimal amenities), funded through subsidies/reimbursements by government and non-governmental organizations, are provided for underprivileged and poor patients. However, no evidence exists as to whether these free surgeries are used by those who could afford to pay for cataract surgery. This thesis evaluates the current assistance programme (with free surgery availability) in comparison to a hypothetical programme(without free surgery availability) using a cost-benefit analysis approach. The thesis also suggests an alternative programme that is sustainable, without any external support such as subsidies for conducting free surgeries.Data from a cross-sectional survey of 1272 households from four randomly selected rural household clusters in the Theni district, Tamilnadu state, India were used. Respondents from households were presented with ‘scenarios’ (with and without free surgery availability) to elicit their preferences and willingness to pay (WTP) for cataract surgery. Of those willing to undergo surgery, 57 % were willing to undergo ‘Paid Surgery’, 12% were willing to undergo ‘Free Surgery’ and 31% were willing to undergo ‘Paid Surgery if Free Surgery was not available’. In a multinomial logit model, household wealth items, income variables and a family history of cataract surgery largely distinguished the preferences. Results from interval regression models indicate that households with resources to pay have a positive WTP for cataract surgery. Results also show that ‘free surgeries’ are utilized by a significant proportion of people who might be willing to pay a positive amount. Free surgeries may be ‘crowding out’ surgeries from which costs can be recovered. From the results of a cost-benefit analysis it is clear that the cost benefit of the hypothetical programmes is greater than that of the current programme.On the basis of the results, a theoretical self-selection model is recommended as an alternative mechanism through which cataract surgery providers can screen patients based on WTP. The self-selection model is based on the intuition that a provider can offer cataract surgery packages with different pricing and different service levels and amenities by distorting service quality. Evidence of the suggested self-selection model in practice is also given by a leading eye care provider in India