Editor's Choice - Short Term Cost Effectiveness of Radiofrequency Ablation and High Ligation and Stripping for Great Saphenous Vein Incompetence.

OBJECTIVE: Superficial venous incompetence (SVI) is a common disease that causes significant quality of life (QoL) impairment. There is a need for more health economic evaluations of SVI treatment. The aim of this study was to perform a cost effectiveness analysis in patients with great saphenous vein (GSV) incompetence comparing radiofrequency ablation (RFA), high ligation and stripping (HL/S), and no treatment or conservative treatment with one year follow up. METHODS: Randomised controlled trial economic analysis from an ongoing trial; 143 patients (156 limbs) with GSV incompetence (CEAP clinical class 2 - 6) were included. Treatment was performed with RFA or HL/S. Follow up was performed up to one year using duplex ultrasound, revised venous clinical severity score (r-VCSS), Aberdeen Varicose Vein Questionnaire (AVVQ), and EuroQol-5D-3L (EQ-5D-3L). RESULTS: Seventy-eight limbs were treated with RFA and HL/S respectively. No treatment or conservative treatment was assumed to have zero in treatment cost and no treatment benefit. In the RFA group, one limb had reflux in the GSV after one month and three limbs after one year. In HL/S, two limbs had remaining reflux in the treated area at one month and one year. Both disease severity (r-VCSS, p = .004) and QoL (AVVQ, p = .021 and EQ-5D-3L, p = .028) were significantly improved over time. The QALY gain was 0.21 for RFA and 0.17 for HL/S. The cost per patient was calculated as €1 292 for RFA and €2 303 for HL/S. The cost per QALY (compared with no treatment or conservative treatment) was €6 155 for RFA and €13 549 for HL/S. With added cost for days absent from work the cost per QALY was €7 358 for RFA and €24 197 for HL/S. The cost per QALY for both methods was well below the threshold suggested by Swedish National Board of Health. CONCLUSION: RFA is more cost effective than HL/S and no treatment or conservative treatment at one year follow up.

The budget impact of implementing atrial fibrillation-screening in European countries.

A budget impact analysis estimates the short-term difference between the cost of the current treatment strategy and a new treatment strategy, in this case to implement population screening for atrial fibrillation (AF). The aim of this study is to estimate the financial impact of implementing population-based AF-screening of 75-year-olds compared with the current setting of no screening from a healthcare payer perspective in eight European countries. The net budget impact of AF-screening was estimated in country-specific settings for Denmark, Germany, Ireland, Italy, Netherlands, Serbia, Spain, and Sweden. Country-specific parameters were used to allow for variations in healthcare systems and to reflect the healthcare sector in the country of interest. Similar results can be seen in all countries AF-screening incurs savings of stroke-related costs since AF treatment reduces the number of strokes. However, the increased number of detected AF and higher drug acquisition will increase the drug costs as well as the costs of physician- and control visits. The net budget impact per invited varied from €10 in Ireland to €122 in the Netherlands. The results showed the increased costs of implementing AF-screening were mainly driven by increased drug costs and screening costs. In conclusion, across Europe, though the initial cost of screening and more frequent use of oral anti-coagulants will increase the healthcare payers' costs, introducing population screening for AF will result in savings of stroke-related costs.

Cost-effectiveness of population screening for atrial fibrillation: the STROKESTOP study.

AIMS: Previous studies on the cost-effectiveness of screening for atrial fibrillation (AF) are based on assumptions of long-term clinical effects. The STROKESTOP study, which randomised 27 975 persons aged 75/76 years into a screening invitation group and a control group, has a median follow-up time of 6.9 years. The aim of this study was to estimate the cost-effectiveness of population-based screening for AF using clinical outcomes. METHODS AND RESULTS: The analysis is based on a Markov cohort model. The prevalence of AF, the use of oral anticoagulation, clinical event data, and all-cause mortality were taken from the STROKESTOP study. The cost for clinical events, age-specific utilities, utility decrement due to stroke, and stroke death was taken from the literature. Uncertainty in the model was considered in a probabilistic sensitivity analysis. Per 1000 individuals invited to the screening, there were 77 gained life years and 65 gained quality-adjusted life years. The incremental cost was €1.77 million lower in the screening invitation group. Gained quality-adjusted life years to a lower cost means that the screening strategy was dominant. The result from 10 000 Monte Carlo simulations showed that the AF screening strategy was cost-effective in 99.2% and cost-saving in 92.7% of the simulations. In the base-case scenario, screening of 1000 individuals resulted in 10.6 [95% confidence interval (CI): -22.5 to 1.4] fewer strokes (8.4 ischaemic and 2.2 haemorrhagic strokes), 1.0 (95% CI: -1.9 to 4.1) more cases of systemic embolism, and 2.9 (95% CI: -18.2 to 13.1) fewer bleedings associated with hospitalization. CONCLUSION: Based on the STROKESTOP study, this analysis shows that a broad AF screening strategy in an elderly population is cost-effective. Efforts should be made to increase screening participation.

Cost analysis comparison between peripherally inserted central catheters and implanted chest ports in patients with cancer-A health economic evaluation of the PICCPORT trial.

BACKGROUND: A reliable central venous access device is a cornerstone in the treatment of cancer. Both peripherally inserted central catheters (PICC) and totally implanted chest ports (PORT) are commonly used for the delivery of chemotherapy. Both types of catheter can cause adverse events such as catheter-related deep venous thrombosis (CR-DVT), infection and mechanical complications. METHOD: We conducted a randomized controlled trial including 399 patients with cancer and performed a health economic evaluation investigating the cost related to PICCs and PORTs using several clinically relevant dimensions from a healthcare perspective. The cost was determined using process and cost estimate models. RESULT: PICCs are associated with a higher total cost when compared with PORTs. Combining the costs of all categories, the prize per inserted device was 824.58 EUR for PICC and 662.34 EUR for PORT. When adjusting for total catheter dwell time the price was 6.58 EUR/day for PICC and 3.01 EUR/day for PORT. The difference in CR-DVT was the main contributor to the difference in cost. The daily cost of PICC is approximately twice to that of PORT. CONCLUSION: We have demonstrated that the cost from a healthcare perspective is higher in cancer patients receiving a PICC than to those with a PORT. The difference is driven mainly by the cost related to the management of adverse events. Our findings are relevant to anaesthetists, oncologists and vascular access clinicians and should be considered when choosing vascular access device prior to chemotherapy.

Patient-controlled sedation with propofol for endoscopic procedures-A cost analysis.

BACKGROUND: Patient-controlled sedation (PCS) with propofol accompanied by a bedside nurse anaesthetist is an alternative sedation method for endoscopic procedures compared with midazolam administered by a nurse or endoscopist. Increasing costs in health care demands an economic perspective when introducing alternative methods. We applied a hospital perspective on a cost analysis comparing different methods of sedation and the resource use that were expected to affect cost differences related to the sedation. METHODS: Based on two randomised previous studies, the direct costs were determined for different sedation methods during two advanced endoscopic procedures: endoscopic retrograde cholangiopancreatography (ERCP) and flexible bronchoscopy including endobronchial ultrasound. ERCP comparisons were made between midazolam sedation by the endoscopic team, PCS with a bedside nurse anaesthetist and propofol sedation administered by a nurse anaesthetist. Bronchoscopy comparisons were made between midazolam sedation by the endoscopic team and PCS with a bedside nurse anaesthetist, categorised by premedication morphine-scopolamine or glycopyrronium. RESULTS: Propofol PCS with a bedside nurse anaesthetist resulted in lower costs per patient for sedation for both ERCP (233 USD) and bronchoscopy (premedication morphine-scopolamine 267 USD, premedication glycopyrronium 269 USD) compared with midazolam (ERCP 425 USD, bronchoscopy 337 USD). Aborted procedures that needed to be repeated and prolonged hospital stays significantly increased the cost for the midazolam groups. CONCLUSION: Propofol PCS with a bedside nurse anaesthetist reduces the direct sedation costs for ERCP and bronchoscopy procedures compared with midazolam sedation.

Direct Costs of Very Old Persons with Subsyndromal Depression: A 5-Year Prospective Study.

OBJECTIVES: This study aimed to compare, over a 5-year period, the prospective direct healthcare costs and service utilization of persons with subsyndromal depression (SSD) and non-depressive persons (ND), in a population of very old persons. A second aim was to develop a model that predicts direct healthcare costs in very old persons with SSD. DESIGN AND SETTING: A prospective population-based study was undertaken on 85-year-old persons in Sweden. MEASUREMENTS: Depressiveness was screened with the Geriatric Depression Scale at baseline and at 1-year follow-up, and the results were classified into ND, SSD, and syndromal depression. Data on individual healthcare costs and service use from a 5-year period were derived from national database registers. Direct costs were compared between categories using Mann-Whitney U tests, and a prediction model was identified with linear regression. RESULTS: For persons with SSD, the direct healthcare costs per month of survival exceeded those of persons with ND by a ratio 1.45 (€634 versus €436), a difference that was significant even after controlling for somatic multimorbidity. The final regression model consisted of five independent variables predicting direct healthcare costs: male sex, activities of daily living functions, loneliness, presence of SSD, and somatic multimorbidity. CONCLUSIONS: SSD among very old persons is associated with increased direct healthcare costs independently of somatic multimorbidity. The associations between SSD, somatic multimorbidity, and healthcare costs in the very old need to be analyzed further in order to better guide allocation of resources in health policy.

People in states worse than dead according to the EQ-5D UK value set: would they rather be dead?

PURPOSE: Quality-adjusted life years (QALYs) measure health by combining length and quality of life. QALYs constitute the effect side of incremental cost-effectiveness ratios, describing the results of health economic evaluations. The objectives of this study were to (1) investigate the prevalence of states worse than dead (SWD) when using the EuroQol-5D UK value set, and (2) to study to what extent SWDs are reasonable with a starting point in experience-based valuations of health states. METHODS: Data from a Swedish cross-sectional population survey were used. The survey was directed to 10,000 persons 65 years and older and its primary aim was to investigate the prevalence and consequences of chronic pain. The survey included questions reflecting life situation and well-being. Some of these were used in order to characterise people in SWD. RESULTS: SWD were found in 1.8% of the 6611 respondents. The prevalence of SWD increased with advancing age and was more common among women than men. The control questions used indicated that most of the persons being in SWD according to the EQ-5D UK value set most probably would not judge themselves to be in a SWD. CONCLUSIONS: Though negative QALY-weights are not very common, they constitute a non-negligible part of health states in a Swedish population 65 years and older. Prevalence of SWD is higher among women than men and increases with age. From responses to other questions on well-being and life situation, there is reason to doubt the reasonableness of experience-based negative QALY-weights in many cases.

Is excess weight a burden for older adults who suffer chronic pain?

BACKGROUND: Obesity and chronic pain are common comorbidities and adversely influence each other. Advanced age is associated with more comorbidities and multi-morbidities. In this study, we investigated the burden of overweight/obesity and its comorbidities and their associations with chronic pain in a random population sample of Swedish older adults. METHODS: The cross-sectional analysis involved a random sample of a population ≥ 65 years in south-eastern Sweden (N = 6243). Data were collected from a postal questionnaire that addressed pain aspects, body mass index (BMI), and health experiences. Chronic pain was defined as pain during the previous three months. According to the 0-10 Numeric Rating Scale, pain scored ≥7 corresponds to severe pain. Binary logistic regression was used to determine the variables associated to pain aspects. RESULTS: A total of 2633 (42%) reported chronic pain. More obese older adults (BMI ≥30 kg/m2) experienced chronic pain (58%) than those who were low-normal weight (BMI < 25 kg/m2, 39%) or overweight (25 ≤ BMI < 30 kg/m2, 41%). Obese elderly more frequently had pain in extremities and lower back than their peers. In the multivariate model, obesity (Odds Ratio (OR) 1.59, 95% Confidence Interval (CI) 1.33-1.91) but not overweight (OR 1.08, 95% CI 0.95-1.22) was associated with chronic pain. Obesity (OR 1.53, 95% CI 1.16-2.01) was also significantly related to severe pain. We also found other comorbidities - i.e., traumatic history (OR 2.52, 95% CI 1.99-3.19), rheumatic diseases (OR 5.21, 95% CI 4.54-5.97), age ≥ 85 years (OR 1.66, 95% CI 1.22-2.25), and depression or anxiety diagnosis (OR 1.83, 95% CI 1.32-2.53) - showed stronger associations with pain aspects than weight status. CONCLUSION: In older adults, excess weight (BMI 30 or above) is a potentially modifiable factor but not the only risk factor that is associated with chronic pain and severe pain. Future studies should investigate the effectiveness of interventions that treat comorbid pain and obesity in older adults.

Severe fear of childbirth indicates high perinatal costs for Swedish women giving birth to their first child.

INTRODUCTION: The objective of this study was to calculate costs associated with severe fear of childbirth (FOC) during pregnancy and peripartum by comparing two groups of women expecting their first child and attending an ordinary antenatal program; one with low FOC and one with severe FOC. MATERIAL AND METHODS: In a prospective case-control cohort study one group with low FOC [Wijma Delivery Expectancy/Experience Questionnaire (W-DEQ) sum score ≤60, n = 107] and one with severe FOC (W-DEQ ≥85, n = 43) were followed up till 3 months postpartum and included in the analysis. Medical records were assessed and medical parameters were mapped. Mean costs for healthcare consumption and sick leave during pregnancy were calculated and compared. RESULTS: When means were compared between the groups, the group with severe FOC had more visits for psychosocial reasons (p = 0.001) and more hours on sick leave (p = 0.03) during pregnancy, and stayed longer at the maternity ward (p = 0.04). They also more seldom had normal spontaneous deliveries (p = 0.03), and more often had an elective cesarean section on maternal request (p = 0.02). Postpartum, they more often than the group with low FOC paid visits to the maternity clinic because of complications (p = 0.001) and to the antenatal unit because of adverse childbirth experiences (p = 0.001). The costs for handling women with severe FOC was 38% higher than those for women with low FOC. CONCLUSION: Women with severe FOC generate considerably higher perinatal costs than women with low FOC when handled in care as usual.

Distinctive subgroups derived by cluster analysis based on pain and psychological symptoms in Swedish older adults with chronic pain - a population study (PainS65+).

BACKGROUND: Improved knowledge based on clinical features of chronic pain in older adults would be valuable in terms of patient-orientated approaches and would provide support for health care systems in optimizing health care resources. This study identifies subgroups based on pain and psychological symptoms among Swedish older adults in the general population and compares derived subgroups with respect to socio-demographics, health aspects, and health care costs. METHODS: This cross-sectional study uses data collected from four registers and one survey. The total sample comprised 2415 individuals ≥65 years old. A two-step cluster analysis was performed. Data on pain intensity, number of pain sites, anxiety, depression, and pain catastrophizing were used as classification variables. Differences in socio-demographics, quality of life, general health, insomnia, and health care costs among the clusters were investigated. Association of the clusters with the above parameters was further evaluated using multinomial logistic regression. RESULTS: Four major clusters were identified: Subgroup 1 (n = 325; 15%) - moderate pain and high psychological symptoms; Subgroup 2 (n = 516; 22%) - high pain and moderate psychological symptoms; Subgroup 3 (n = 686; 30%) - low pain and moderate psychological symptoms; and Subgroup 4 (n = 767; 33%) - low pain and low psychological symptoms. Significant differences were found between the four clusters with regard to age, sex, educational level, family status, quality of life, general health, insomnia, and health care costs. The multinomial logistic regression analysis revealed that Subgroups 1 and 2, compared to Subgroup 4, were significantly associated with decreased quality of life, decreased general health, and increased insomnia. Subgroup 3, compared to Subgroup 4, was associated with decreased general health and increased insomnia. In addition, compared to Subgroup 4, Subgroups 1 and 2 were significantly associated with higher health care costs. CONCLUSIONS: Two high risk clusters of older adults suffering from chronic pain; one mainly based on psychological symptoms and one mainly on pain intensity and pain spread, associated with decreased quality of life and health and increased health care costs were identified. Our findings indicate that subgroup-specific treatment will improve pain management and reduce health care costs.

Insomnia severity and its relationship with demographics, pain features, anxiety, and depression in older adults with and without pain: cross-sectional population-based results from the PainS65+ cohort.

BACKGROUND: Insomnia is a major cause of concern in the elderly with and without pain. This study set out to examine the insomnia and its correlates in a large sample of community adults aged ≥65 years. METHODS: A cross-sectional postal survey was completed by 6205 older individuals (53.8% women; mean age = 76.2 years; SD = 7.5). The participants also completed the Insomnia Severity Index (ISI) and questionnaires assessing pain intensity, pain spreading, anxiety, depression, and basic demographic information. The sample was divided into three groups based on the presence and duration of pain: chronic pain (CP; n = 2790), subacute pain (SP; n = 510), and no pain (NP; n = 2905). RESULTS: A proportion of each of the groups had an ISI score of 15 or greater (i.e., clinical insomnia): CP = 24.6%; SP = 21.3%; and NP = 13.0%. The average scores of ISI differed significantly among CP, SP, and NP groups (p < 0.001). Stratified regression analyses showed that pain intensity, pain spreading, anxiety, and depression were independently related to insomnia in the CP group. Anxiety and depression were independently related to insomnia in the SP group, but only anxiety was significantly associated with insomnia in the NP group. Age and sex were not associated with insomnia. CONCLUSIONS: This study confirms that insomnia is not associated with chronological aging per se within the elderly population. Although the possible associations of insomnia with pain are complex, ensuing from pain intensity, pain spreading, anxiety, and depression, our results highlighted that anxiety was more strongly associated with insomnia in all groups than the depression and pain characteristics. Therapeutic plans should consider these relations during the course of pain, and a comprehensive assessment including both pain and psychological features is essential when older people are seeking primary health care for insomnia complaints.

Early and Late Return to Work After Sick Leave: Predictors in a Cohort of Sick-Listed Individuals with Common Mental Disorders.

OBJECTIVES: The study aims to identify individual and workplace factors associated with early return to work (RTW)-defined as within 3 months-and factors associated with later RTW-between 3 and 12 months after being sick-listed-in a cohort of newly sick-listed individuals with common mental disorders. METHODS: In a prospective cohort study, a cross-sectional analysis was performed on baseline measures of patients granted sick leave due to common mental disorders. A total of 533 newly sick-listed individuals fulfilled the inclusion criteria and agreed to participate. A baseline questionnaire was sent by post within 3 weeks of their first day of certified medical sickness; 354 (66%) responded. Those who were unemployed were excluded, resulting in a study population of 319 individuals. Sick leave was recorded for each individual from the Social Insurance Office during 1 year. Analyses were made with multiple Cox regression analyses. RESULTS: Early RTW was associated with lower education, better work ability at baseline, positive expectations of treatment and low perceived interactional justice with the supervisor. RTW after 3 months was associated with a need to reduce demands at work, and turnover intentions. CONCLUSIONS: Early RTW among sick-listed individuals with common mental disorders seems to be associated with the individual's need to secure her/his employment situation, whereas later RTW is associated with variables reflecting dissatisfaction with work conditions. No health measures were associated with RTW. The study highlights the importance of considering not only health and functioning, but also workplace conditions and relations at the workplace in implementing RTW interventions.

Costs of rheumatoid arthritis during the period 1990-2010: a register-based cost-of-illness study in Sweden.

OBJECTIVES: The objectives of this study were to analyse the total socio-economic impact of RA in Sweden during the period 1990-2010 and to analyse possible changes in costs during this period. The period was deliberately chosen to cover 10 years before and 10 years after the introduction of biologic drugs. METHODS: A prevalence-based cost-of-illness study was conducted based on data from national and regional registries. RESULTS: There was a decrease in the utilization of RA-related inpatient care as well as sick leave and disability pension during 1990-2010 in Sweden. Total costs for RA are presented in current prices as well as inflation-adjusted with the consumer price index (CPI) and a healthcare price index. The total fixed cost of RA was €454 million in 1990, adjusted to the price level of 2010 with the CPI. This cost increased to €600 million in 2010 and the increase was mainly due to the substantially increasing costs for pharmaceuticals. Of the total costs, drug costs increased from 3% to 33% between 1990 and 2010. Consequently the portion of total costs accounting for indirect costs for RA is lowered from 75% in 1990 to 58% in 2010. CONCLUSION: By inflation adjusting with the CPI, which is reasonable from a societal perspective, there was a 32% increase in the total fixed cost of RA between 1990 and 2010. This suggests that decreased hospitalization and indirect costs have not fallen enough to offset the increasing cost of drug treatment.

A case of community-based fall prevention: Survey of organization and content of minor home help services in Swedish municipalities.

BACKGROUND: The aim of this study was to survey minor home help services provided by Swedish municipalities with the main purpose to prevent fall injuries. METHODS: If minor home help services were presented on the homepage of a municipality, an initial telephone contact was taken. Thereafter a questionnaire was administered, including questions about target groups, aim with the services, tasks included, costs and restrictions for users, budget, and experienced gains with the services. Municipalities not providing minor home help services were asked about the reason therefore and if the municipality had previously provided the services Results: The questionnaire response rate was 92%. In 191 of Sweden's 290 municipalities services were provided by, or in cooperation with, the municipality. Reasons for not providing the services were mainly financial and lack of demand. Services were more often provided in larger cities and in municipalities located in populous regions. In some municipalities services were performed by persons with functional disabilities or unemployed persons. CONCLUSIONS: Both providers and users expressed satisfaction with the services aspects expressed were that services lead to greater sense of safety and social gains the effect of the services in terms of fall prevention is yet to be proved with only a small fall-preventive effect services are probably cost-effective improved quality of life, sense of safety, and being able to offer meaningful work to otherwise unemployed persons are important aspects that might in themselves motivate the provision of minor home help services.

Outcome of physiotherapy after surgery for cervical disc disease: a prospective randomised multi-centre trial.

BACKGROUND: Many patients with cervical disc disease require leave from work, due to long-lasting, complex symptoms, including chronic pain and reduced levels of physical and psychological function. Surgery on a few segmental levels might be expected to resolve disc-specific pain and reduce neurological deficits, but not the non-specific neck pain and the frequent illness. No study has investigated whether post-surgery physiotherapy might improve the outcome of surgery. The main purpose of this study was to evaluate whether a well-structured rehabilitation programme might add benefit to the customary post-surgical treatment for cervical disc disease, with respect to function, disability, work capability, and cost effectiveness. METHODS/DESIGN: This study was designed as a prospective, randomised, controlled, multi-centre study. An independent, blinded investigator will compare two alternatives of rehabilitation. We will include 200 patients of working age, with cervical disc disease confirmed by clinical findings and symptoms of cervical nerve root compression. After providing informed consent, study participants will be randomised to one of two alternative physiotherapy regimes; (A) customary treatment (information and advice on a specialist clinic); or (B) customary treatment plus active physiotherapy. Physiotherapy will follow a standardised, structured programme of neck-specific exercises combined with a behavioural approach. All patients will be evaluated both clinically and subjectively (with questionnaires) before surgery and at 6 weeks, 3 months, 6 months, 12 months, and 24 months after surgery. The main outcome variable will be neck-specific disability. Cost-effectiveness will also be calculated. DISCUSSION: We anticipate that the results of this study will provide evidence to support physiotherapeutic rehabilitation applied after surgery for cervical radiculopathy due to cervical disc disease. TRIAL REGISTRATION: ClinicalTrials.gov identifier: NCT01547611.

Health-related quality of life of ticagrelor versus clopidogrel in patients with acute coronary syndromes-results from the PLATO trial.

OBJECTIVES: The purpose of this study was to compare the effects of ticagrelor versus clopidogrel on health-related quality of life in the PLATelet inhibition and patient Outcomes (PLATO) trial. BACKGROUND: The PLATO trial showed that ticagrelor was superior to clopidogrel for the prevention of cardiovascular death, myocardial infarction, or stroke in a broad population of patients with acute coronary syndromes. METHODS: HRQOL in the PLATO study was measured at hospital discharge, 6-month visit, and end of treatment (anticipated at 12 months) by using the EuroQol five-dimensional (EQ-5D) questionnaire. All patients who had an EQ-5D questionnaire assessment at discharge from the index hospitalization (n = 15,212) were included in the study. Patients who died prior to the end-of-treatment visit were assigned an EQ-5D questionnaire value of 0. RESULTS: The EQ-5D questionnaire value at discharge among 7631 patients assigned to ticagrelor was 0.847 and among 7581 patients assigned to clopidogrel was 0.846 (P = 0.71). At 12 months, the mean EQ-5D questionnaire value was 0.840 for ticagrelor and 0.832 for clopidogrel (P = 0.046). Excluding patients who died resulted in mean EQ-5D questionnaire values of 0.864 among ticagrelor patients and 0.863 among clopidogrel patients (P = 0.69). CONCLUSIONS: In patients hospitalized with acute coronary syndromes with or without ST-segment elevation, treatment with ticagrelor was associated with a lower mortality but otherwise no difference in quality of life relative to treatment with clopidogrel. The improved survival and reduction in cardiovascular events with ticagrelor are therefore obtained with no loss in quality of life.

Effects of neck-specific exercise with or without a behavioural approach in addition to prescribed physical activity for individuals with chronic whiplash-associated disorders: a prospective randomised study.

BACKGROUND: Up to 50% of chronic whiplash associated disorders (WAD) patients experience considerable pain and disability and remain on sick-leave. No evidence supports the use of physiotherapy treatment of chronic WAD, although exercise is recommended. Previous randomised controlled studies did not evaluate the value of adding a behavioural therapy intervention to neck-specific exercises, nor did they compare these treatments to prescription of general physical activity. Few exercise studies focus on patients with chronic WAD, and few have looked at patients' ability to return to work and the cost-effectiveness of treatments. Thus, there is a great need to develop successful evidence-based rehabilitation models. The study aim is to investigate whether neck-specific exercise with or without a behavioural approach (facilitated by a single caregiver per patient) improves functioning compared to prescription of general physical activity for individuals with chronic WAD. METHODS/DESIGN: The study is a prospective, randomised, controlled, multi-centre study with a 2-year follow-up that includes 216 patients with chronic WAD (> 6 months and < 3 years). The patients (aged 18 to 63) must be classified as WAD grade 2 or 3. Eligibility will be determined with a questionnaire, telephone interview and clinical examination. The participants will be randomised into one of three treatments: (A) neck-specific exercise followed by prescription of physical activity; (B) neck-specific exercise with a behavioural approach followed by prescription of physical activity; or (C) prescription of physical activity alone without neck-specific exercises. Treatments will be performed for 3 months. We will examine physical and psychological function, pain intensity, health care consumption, the ability to resume work and economic health benefits. An independent, blinded investigator will perform the measurements at baseline and 3, 6, 12 and 24 months after inclusion. The main study outcome will be improvement in neck-specific disability as measured with the Neck Disability Index. All treatments will be recorded in treatment diaries and medical records. DISCUSSION: The study findings will help improve the treatment of patients with chronic WAD. TRIALS REGISTRATION: ClinicalTrials.gov identifier: NCT01528579.

Evaluation of self-reported work ability and usefulness of interventions among sick-listed patients.

AIM: To describe the types of intervention offered, to investigate the relationship between the type of intervention given, patient-reported usefulness of interventions and the effect on self-reported work ability in a cohort of sick-listed patients with musculoskeletal disorders (MSD) or mental disorders (MD). METHODS: A prospective cohort study was performed including 810 newly sick-listed patients (MSD 62 % and MD 38 %). The baseline questionnaire included sociodemographic characteristics and measures of work ability. The 3-month follow-up questionnaire included measures of work ability, type of intervention received, and judgment of usefulness. RESULTS: Twenty-five percent received medical intervention modalities (MI) only, 45 % received a combination of medical and rehabilitative intervention modalities (CRI) and 31 % received work-related interventions combined with medical or rehabilitative intervention modalities (WI). Behavioural treatments were more common for patients with MD compared with MSD and exercise therapy were more common for patients with MSD. The most prevalent workplace interventions were adjustment of work tasks or the work environment. Among patients with MD, WI was found to be useful and improved work ability significantly more compared with only MI or CRI. For patients with MSD, no significant differences in improved work ability were found between interventions. CONCLUSIONS: Patients with MD who received a combination of work-related and clinical interventions reported best usefulness and best improvement in work ability. There was no difference in improvements in work ability between rehabilitation methods in the MSD group. There seems to be a gap between scientific evidence and praxis behaviour in the rehabilitation process. Unimodal rehabilitation was widely applied in the early rehabilitation process, a multimodal treatment approach was rare and only one-third received work-related interventions. It remains a challenge to understand who needs what type of intervention.

Individualized metal implants for focal cartilage lesions in the knee can be cost-effective: A simulation on 47-year-old in a Swedish setting.

OBJECTIVES: In the aging population, the knee is the joint most commonly causing impaired function and incapacity. While definite treatment by prosthetic replacement is often performed late, symptomatic knee cartilage lesions cause much suffering also in younger ages. Early intervention could, therefore, be instituted at an early stage to the benefit of both patients and society. Small, metal surface, resurfacing implants have been tested with promising results. A system that features patient-specific implants and surgical instruments shows good clinical results and favorable survival rates. This study aims to assess the cost utility of this metal device compared with microfracture (MFX), being the standard procedure in Sweden. METHODS: We constructed a simulation model in Excel. In the model, a cohort of 47-year-old patients (which is the mean age of patients treated with the metal implant) with symptomatic knee cartilage lesions received either MFX or metal implantation. Outcomes for the cohort were simulated over 40 years, such as in a previously published model based on MFX, and sensitivity analyses (deterministic and probabilistic) of the results were undertaken. Data on transition probabilities, costs, and quality of life were taken from clinical data, published literature, and official price lists. Only direct medical costs were included. RESULTS: Results from the analysis showed that the metal device is a cost-effective treatment strategy compared with MFX. The incremental cost-effectiveness ratio (ICER) reached acceptable levels at ∼5 years postoperatively. Over the full-time horizon of 40 years, the metal device was cost saving with concomitant gains in quality-adjusted life years (QALYs), translating to a dominant treatment strategy. Results were robust according to sensitivity analysis with the initial success rate of up to three years for both metal and MFX having the largest impact. CONCLUSIONS: A metal implant may be a cost-effective treatment alternative for patients in their 40's when compared to MFX in a Swedish setting. LEVEL OF EVIDENCE: 5 [1].