Costs and benefits of non-invasive fetal RhD determination.

OBJECTIVE: Non-invasive fetal Rhesus (Rh) D genotyping, using cell-free fetal DNA (cffDNA) in the maternal blood, allows targeted antenatal anti-RhD prophylaxis in unsensitized RhD-negative pregnant women. The purpose of this study was to determine the cost and benefit of this approach as compared to routine antenatal anti-RhD prophylaxis for all unsensitized RhD-negative pregnant women, as is the current policy in the province of Alberta, Canada. METHODS: This study was a decision analysis based on a theoretical population representing the total number of pregnancies in Alberta over a 1-year period (n = 69 286). A decision tree was created that outlined targeted prophylaxis for unsensitized RhD-negative pregnant women screened for cffDNA (targeted group) vs routine prophylaxis for all unsensitized RhD-negative pregnant women (routine group). Probabilities at each decision point and costs associated with each resource were calculated from local clinical and administrative data. Outcomes measured were cost, number of women sensitized and doses of Rh immunoglobulin (RhIG) administered. RESULTS: The estimated cost per pregnancy for the routine group was 71.43 compared with 67.20 Canadian dollars in the targeted group. The sensitization rates per RhD-negative pregnancy were equal, at 0.0012, for the current and targeted programs. Implementing targeted antenatal anti-RhD prophylaxis would save 4072 doses (20.1%) of RhIG over a 1-year period in Alberta when compared to the current program. CONCLUSIONS: These data support the feasibility of a targeted antenatal anti-RhD prophylaxis program, at a lower cost than that of the existing routine prophylaxis program, with no increased risk of sensitization.

Temporal stability of alcohol screening measures in a psychiatric setting.

The authors evaluated the test-retest reliability of two common screening instruments administered in a psychiatric setting. The Michigan Alcoholism Screening Test (MAST; M. L. Selzer, 1971) and the CAGE (D. Mayfield, G. McLeod, & P. Hall, 1974) were administered twice, separated by a 1-week interval, to 71 people receiving outpatient psychiatric services and 64 people in the community with no reported history of psychiatric care. The MAST (r = .95) and the CAGE (r = .80) demonstrated adequate test-retest reliability and showed little evidence of variation with respect to degree or direction when administered in a psychiatric setting. Compared to a nonclinical sample, reliability estimates obtained in a psychiatric setting were only slightly lower and more variable. In the psychiatric sample, younger men who had a history of alcohol use disorder were found to be the least reliable. Overall, data suggest that people with severe and persistent mental disorders can offer reliable information about their alcohol-related problems.

The validity of the MAST in psychiatric settings: a meta-analytic integration. Michigan Alcoholism Screening Test.

OBJECTIVE: Assessment of alcohol-related problems is essential in psychiatric settings. The Michigan Alcoholism Screening Test (MAST) has been the most commonly evaluated self-report alcohol assessment tool in psychiatric settings. However, due to a large variation in reports of findings and conclusions, a clear understanding of the utility of the MAST in psychiatric settings continues to be elusive. Therefore, the major goals of this investigation were (1) to integrate the available information pertaining to the validity of the MAST when used in psychiatric settings, and (2) to investigate factors that may moderate the performance of the MAST. METHOD: Using clinically determined alcohol-related diagnosis as a criterion, a meta-analytic integration of nine published studies investigating the criterion validity of the MAST in psychiatric settings is presented. RESULTS: Findings revealed that the MAST is significantly valid when used in psychiatric settings. However, sensitivity estimates were found to be of greater magnitude than specificity estimates. Further, validity estimates of the MAST were found to be higher in psychiatric samples that had a greater proportion of women and in samples that exhibited higher base rates of alcohol-use disorder. CONCLUSIONS: Results of this integration support the continued use of the MAST in psychiatric settings as a screening instrument and suggest that those who administer the MAST must be attentive to particular characteristics of respondents.

Cognitive and behavioural impairment among elderly people in institutions providing different levels of care.

OBJECTIVE: To compare the prevalence and degree of cognitive and behavioural impairment in elderly patients in institutions providing different levels of care. DESIGN: Prevalence study. SETTING: A nursing home, a home for the aged and psychogeriatric wards in a provincial psychiatric hospital. PATIENTS: Only subjects 65 years of age or older were eligible for inclusion. A random sample was selected comprising 25% of the residents in the nursing home and the home for the aged; of the 119 asked to participate 95 agreed (44 in the nursing home and 51 in the home for the aged). All 50 on the psychogeriatric wards agreed to participate. MAIN OUTCOME MEASURES: The Mini-Mental State Examination (MMSE) and the Kingston Dementia Rating Scale (KDRS). RESULTS: An MMSE score of less than 24 (cognitive impairment) was given to 37 (84%) of the residents in the nursing home, 43 (84%) of those in the home for the aged and 48 (96%) of the patients in the psychiatric hospital; the corresponding numbers for a KDRS score of more than 0 (cognitive impairment) were 41 (93%), 48 (94%) and 50 (100%). The seven patients receiving the highest level of care at the home for the aged (special care) had more behavioural problems than those in the psychiatric hospital did (p less than 0.001). CONCLUSIONS: Cognitive and behavioural impairment was widespread in the three institutions regardless of the level of care. When planning services and allocating resources government funding agencies should consider the degree and prevalence of such impairment among elderly people in institutions.

Psychogeriatric consultation services: effect and effectiveness.

OBJECTIVES: To determine the nature of referrals to a psychogeriatric consultation/outreach service, the types of interventions provided, and the effects and effectiveness of the service. METHOD: The study used a prospective approach in which 67 consecutive patients referred for psychogeriatric assessment were followed up 6 to 8 weeks after the initial assessment and then again 6 months after initial contact. Patients were rated at the time of referral and at follow-up on presence of psychiatric diagnosis, need for institutional care, and placement outcome. RESULTS: Of the 67 patients initially seen, 51 (76%) experienced memory problems and 46 (69%) had depressed mood. Consistent with this finding, 36 (54%) were diagnosed by consultants as having a dementia, and 15 (22%) received a diagnosis of depression. The most frequent recommendations included medication changes in 34 cases (50%) and further assessments in 37 cases (55%). Although information at 6-week follow-up was available for only 58% (n = 38) of the sample, 18 (46%) patients were generally improved. Interestingly, only 12 (31%) of referring physicians indicated that they had followed the advice of the consultants. Cognitive impairment and depressive symptoms were major concerns among referring physicians. The most common recommendation made involved pharmacotherapy. While compliance of family doctors to recommendations made was poor, patients improved over time. Patients requiring inpatient assessment were very old, living alone, experiencing behavioural problems, and not depressed. CONCLUSIONS: Psychogeriatric consultations appear most useful in cases where patients are more severely affected and/or are suffering from a greater range of symptoms.