Pre-eclampsia Diagnosis and Treatment Options:A Review of Published Economic Assessments

Pre-eclampsia is a pregnancy complication affecting both mother and fetus. Although there is no proven effective method to prevent pre-eclampsia, early identification of women at risk of pre-eclampsia could enhance appropriate application of antenatal care, management and treatment. Very little is known about the cost effectiveness of these and other tests for pre-eclampsia, mainly because there is no clear treatment path. The aim of this study was to provide a comprehensive overview of the existing evidence on the health economics of screening, diagnosis and treatment options in pre-eclampsia.We searched three electronic databases (PubMed, EMBASE and the Cochrane Library) for studies on screening, diagnosis, treatment or prevention of pre-eclampsia, published between 1994 and 2014. Only full papers written in English containing complete economic assessments in pre-eclampsia were included.From an initial total of 138 references, six papers fulfilled the inclusion criteria. Three studies were on the cost effectiveness of treatment of pre-eclampsia, two of which evaluated magnesium sulphate for prevention of seizures and the third evaluated the cost effectiveness of induction of labour versus expectant monitoring. The other three studies were aimed at screening and diagnosis, in combination with subsequent preventive measures. The two studies on magnesium sulphate were equivocal on the cost effectiveness in non-severe cases, and the other study suggested that induction of labour in term pre-eclampsia was more cost effective than expectant monitoring. The screening studies were quite diverse in their objectives as well as in their conclusions. One study concluded that screening is probably not worthwhile, while two other studies stated that in certain scenarios it may be cost effective to screen all pregnant women and prophylactically treat those who are found to be at high risk of developing pre-eclampsia.This study is the first to provide a comprehensive overview on the economic aspects of pre-eclampsia in its broadest sense, ranging from screening to treatment options. The main limitation of the present study lies in the variety of topics in combination with the limited number of papers that could be included; this restricted the comparisons that could be made. In conclusion, novel biomarkers in screening for and diagnosing pre-eclampsia show promise, but their accuracy is a major driver of cost effectiveness, as is prevalence. Universal screening for pre-eclampsia, using a biomarker, will be feasible only when accuracy is significantly increased.</p

Economic Analyses of Respiratory Tract Infection Diagnostics:A Systematic Review

BACKGROUND: Diagnostic testing for respiratory tract infections is a tool to manage the current COVID-19 pandemic, as well as the rising incidence of antimicrobial resistance. At the same time, new European regulations for market entry of in vitro diagnostics, in the form of the in vitro diagnostic regulation, may lead to more clinical evidence supporting health-economic analyses. OBJECTIVE: The objective of this systematic review was to review the methods used in economic evaluations of applied diagnostic techniques, for all patients seeking care for infectious diseases of the respiratory tract (such as pneumonia, pulmonary tuberculosis, influenza, sinusitis, pharyngitis, sore throats and general respiratory tract infections). METHODS: Following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines, articles from three large databases of scientific literature were included (Scopus, Web of Science and PubMed) for the period January 2000 to May 2020. RESULTS: A total of 70 economic analyses are included, most of which use decision tree modelling for diagnostic testing for respiratory tract infections in the community-care setting. Many studies do not incorporate a generally comparable clinical outcome in their cost-effectiveness analysis: fewer than half the studies (33/70) used generalisable outcomes such as quality-adjusted life-years. Other papers consider outcomes related to the accuracy of the test or outcomes related to the prescribed treatment. The time horizons of the studies generally are limited. CONCLUSIONS: The methods to economically assess diagnostic tests for respiratory tract infections vary and would benefit from clear recommendations from policy makers on the assessed time horizon and outcomes used. SUPPLEMENTARY INFORMATION: The online version contains supplementary material available at 10.1007/s40273-021-01054-1

Economic Evaluation of Family Planning Interventions in Low and Middle Income Countries:A Systematic Review

Background A significant number of women in low and middle income countries (L-MICs) who need any family planning, experience a lack in access to modern effective methods. This study was conducted to review potential cost effectiveness of scaling up family planning interventions in these regions from the published literatures and assess their implication for policy and future research. Study design A systematic review was performed in several electronic databases i.e Medline (Pubmed), Embase, Popline, The National Bureau of Economic Research (NBER), EBSCOHost, and The Cochrane Library. Articles reporting full economic evaluations of strategies to improve family planning interventions in one or more L-MICs, published between 1995 until 2015 were eligible for inclusion. Data was synthesized and analyzed using a narrative approach and the reporting quality of the included studies was assessed using the Consolidated Health Economic Evaluation Reporting Standards (CHEERS) statement. Results From 920 references screened, 9 studies were eligible for inclusion. Six references assessed cost effectiveness of improving family planning interventions in one or more LMICs, while the rest assessed costs and consequences of integrating family planning and HIV services, concerning sub-Saharan Africa. Assembled evidence suggested that improving family planning interventions is cost effective in a variety of L-MICs as measured against accepted international cost effectiveness benchmarks. In areas with high HIV prevalence, integrating family planning and HIV services can be efficient and cost effective; however the evidence is only supported by a very limited number of studies. The major drivers of cost effectiveness were cost of increasing coverage, effectiveness of the interventions and country-specific factors. Conclusion Improving family planning interventions in low and middle income countries appears to be cost-effective. Additional economic evaluation studies with improved reporting quality are necessary to generate further evidence on costs, cost-effectiveness, and affordability, and to support increased funding and investments in family planning programs

A two-step procedure to generate utilities for the Infant health-related Quality of life Instrument (IQI)

BACKGROUND:Because of a lack of preference-based health-related quality of life (HRQoL) instruments suitable for infants aged 0-12 months, we previously developed the Infant QoL Instrument (IQI). The present study aimed to generate an algorithm to estimate utilities for the IQI. METHODS:Via an online survey, respondents from the general population and primary caregivers from China-Hong Kong, the UK, and the USA were presented 10 discrete choice scenarios based on the IQI classification system. An additional sample of respondents from the general population were also asked if they considered the examined health states to be worse than death. Coefficients for the IQI item levels were obtained with a conditional logit model based on the responses of the primary caregivers for IQI states only. These coefficients were then normalized using the rank-ordered logit model based on the responses from the general population who assessed "death" as a choice option. In this way, the values were rescaled from full health (1.0) to death (0.0), and consequently, they became suitable for the computation of quality-adjusted life years. RESULTS:The total sample consisted of 1409 members of the general population and 1229 primary caregivers. Results indicated that, out of the 7 IQI items ("sleeping," "feeding," "breathing," "stooling/poo," "mood," "skin," and "interaction"), "breathing" had the highest impact on the HRQoL of infants. Moreover, except for "stooling," all item levels were statistically significant. The general population sample considered none of the health states as worse than death. The utility value for the worst health state was 0.015 (State 4444444). CONCLUSIONS:The IQI is the first generic instrument to assess overall HRQoL in 0-1-year-old infants by providing values and utilities. Using discrete choice experiments, we demonstrated that it is possible to derive utilities of infant health states. The next step will be to collect IQI values in a clinical population of infants and to compare these values with those of other instruments

Health-Economic Analyses of Diagnostics:Guidance on Design and Reporting

Cost-effectiveness analyses (CEAs) can be used to assess the value of diagnostics in clinical practice. Due to the introduction of the European in vitro diagnostic and medical devices regulations, more clinical data on new diagnostics may become available, which may improve the interest and feasibility of performing CEAs. We present eight recommendations on the reporting and design of CEAs of diagnostics. The symptoms patients experience, the clinical setting, locations of test sampling and analysis, and diagnostic algorithms should be clearly reported. The used time horizon should reflect the time horizon used to model the treatment after the diagnostic pathway. Quality-adjusted life-years (QALYs) or disability-adjusted life-years (DALYs) should be used as the clinical outcomes but may be combined with other relevant outcomes, such as real options value. If the number of tests using the same equipment can vary, the economy of scale should be considered. An understandable graphical representation of the various diagnostic algorithms should be provided to understand the results, such as an efficiency frontier. Finally, the budget impact and affordability should be considered. These recommendations can be used in addition to other, more general, recommendations, such as the Consolidated Health Economic Evaluation Reporting Standards (CHEERS) or the reference case for economic evaluation by the international decision support initiative

Diabetes distress in Indonesian patients with type 2 diabetes:a comparison between primary and tertiary care

BACKGROUND: The number of people living with diabetes mellitus (DM) in Indonesia has continued to increase over the last 6 years. Four previous studies in U.S have found that higher DD scores were associated with worse psychological outcomes, lower health-related quality of life (HRQoL) and increased risk of T2DM complications. In this study, we aimed to firstly compare DD scores in Indonesian T2DM outpatients treated in primary care versus those in tertiary care. Subsequently, we investigated whether socio-demographic characteristics and clinical conditions explain potential differences in DD score across healthcare settings. METHODS: A cross-sectional study was conducted on Java island in three primary care (n = 108) and four tertiary care (n = 524) facilities. The participants completed the Bahasa Indonesia version of the Diabetes Distress Scale questionnaire (DDS17 Bahasa Indonesia). Ordinal regression analysis was conducted with the quartile of the summation of the DD score as the dependent variable to investigate how the association between the level of healthcare facilities and DD altered when adding different variables in the model. RESULTS: The final adjusted model showed that the level of healthcare facilities was strongly associated with DD (p < .001), with participants in primary care having a 3.68 times (95% CI 2.46-5.55) higher likelihood of being more distressed than the participants in tertiary care. This association was detected after including the socio-demographic characteristics and clinical conditions as model confounders. CONCLUSIONS: This is the first study in Indonesia to compare DD scores within different healthcare facilities. We recommend a regular DD assessment, possibly closely aligned with health-literacy partner programs, especially for T2DM patients in primary care settings

Impact of personality functioning and pathological traits on mental wellbeing of older patients with personality disorders

BACKGROUND: Although personality disorders are common and consequential, they are largely ignored in geriatric mental healthcare. We examined the relative contributions of different aspects of personality disorders and comorbid mental disorders to the impairment of mental wellbeing in older adults. METHODS: Baseline data were used of 138 patients who participated in a randomized controlled trial on schema therapy for geriatric mental health outpatients with a full or subthreshold cluster B or C personality disorder. Personality was assessed according to both the categorical and dimensional model of DSM-5. Aspects of mental wellbeing assessed were; psychological distress, positive mental health, subjective health, and life satisfaction. The current study uses baseline data of the RCT to examine the associations between different aspects of personality pathology and mental wellbeing by multivariate regression analysis, controlling for age, sex, level of education, and number of chronic somatic illnesses. RESULTS: The vast majority of patients (79.0%) had one or more mental disorders in addition to personality disorder. Personality pathology was responsible for the core of the mental health burden experienced by patients, and negated the influence of co-occurring mental disorders when entered subsequently in multivariate analysis. Personality dimensions proved to be highly predictive of mental wellbeing, and this contrasted with absence of influence of personality disorder diagnosis. Although the personality functioning dimensions – and in particular Identity integration (large effect size with partial eta-squared = 0.36) – were the primary predictors of mental wellbeing, personality trait dimensions added significant predictive value to that (Disinhibition 0.25 and Negative affect 0.24). CONCLUSIONS: Personality disorders seriously affect the mental wellbeing of patients, and this overshadows the impact of comorbid mental disorders. In particular personality functioning and pathological traits of the Alternative Model of Personality Disorders (AMPD) of DSM-5 contribute to this impact on mental wellbeing. Alertness for and treatment of personality disorders in geriatric mental healthcare seems warranted. SUPPLEMENTARY INFORMATION: The online version contains supplementary material available at 10.1186/s12888-022-03857-8

Oral esketamine for treatment-resistant depression:rationale and design of a randomized controlled trial

BACKGROUND: There is an urgent need to develop additional treatment strategies for patients with treatment-resistant depression (TRD). The rapid but short-lived antidepressant effects of intravenous (IV) ketamine as a racemic mixture have been shown repeatedly in this population, but there is still a paucity of data on the efficacy and safety of (a) different routes of administration, and (b) ketamine's enantiomers esketamine and arketamine. Given practical advantages of oral over IV administration and pharmacodynamic arguments for better antidepressant efficacy of esketamine over arketamine, we designed a study to investigate repeated administration of oral esketamine in patients with TRD. METHODS: This study features a triple-blind randomized placebo-controlled trial (RCT) comparing daily oral esketamine versus placebo as add-on to regular antidepressant medications for a period of 6 weeks, succeeded by a follow-up of 4 weeks. The methods support examination of the efficacy, safety, tolerability, mechanisms of action, and economic impact of oral esketamine in patients with TRD. DISCUSSION: This is the first RCT investigating repeated oral esketamine administration in patients with TRD. If shown to be effective and tolerated, oral esketamine administration poses important advantages over IV administration. TRIAL REGISTRATION: Dutch Trial Register, NTR6161. Registered 21 October 2016

Correction to:Oral esketamine for treatment-resistant depression: rationale and design of a randomized controlled trial

After publication of our article [1] we were notified that Figure 1 was wrongly presented

The Opportunity of Point-of-Care Diagnostics in General Practice:Modelling the Effects on Antimicrobial Resistance

OBJECTIVES: Antimicrobial resistance (AMR) is a public health threat associated with antibiotic consumption. Community-acquired acute respiratory tract infections (CA-ARTIs) are a major driver of antibiotic consumption in primary care. We aimed to quantify the investments required for a large-scale rollout of point-of care (POC) diagnostic testing in Dutch primary care, and the impact on AMR due to reduced use of antibiotics. METHODS: We developed an individual-based model that simulates consultations for CA-ARTI at GP practices in the Netherlands and compared a scenario where GPs test all CA-ARTI patients with a hypothetical diagnostic strategy to continuing the current standard-of-care for the years 2020-2030. We estimated differences in costs and future AMR rates caused by testing all patients consulting for CA-ARTI with a hypothetical diagnostic strategy, compared to the current standard-of-care in GP practices. RESULTS: Compared to the current standard-of-care, the diagnostic algorithm increases the total costs of GP consultations for CA-ARTI by 9% and 19%, when priced at €5 and €10, respectively. The forecast increase in Streptococcus pneumoniae resistance against penicillins can be partly restrained by the hypothetical diagnostic strategy from 3.8 to 3.5% in 2030, albeit with considerable uncertainty. CONCLUSIONS: Our results show that implementing a hypothetical diagnostic strategy for all CA-ARTI patients in primary care raises the costs of consultations, while lowering antibiotic consumption and AMR. Novel health-economic methods to assess and communicate the potential benefits related to AMR may be required for interventions with limited gains for individual patients, but considerable potential related to antibiotic consumption and AMR