Eliciting a value set for the Swedish Capability-Adjusted Life Years instrument (CALY-SWE).

PURPOSE: Our aim was to elicit a value set for Capability-Adjusted Life Years Sweden (CALY-SWE); a capability-grounded quality of life instrument intended for use in economic evaluations of social interventions with broad consequences beyond health. METHODS: Building on methods commonly used in the quality-adjusted life years EQ-5D context, we collected time-trade off (TTO) and discrete choice experiment (DCE) data through an online survey from a general population sample of 1697 Swedish participants. We assessed data quality using a score based on the severity of inconsistencies. For generating the value set, we compared different model features, including hybrid modeling of DCE and TTO versus TTO data only, censoring of TTO answers, varying intercept, and accommodating for heteroskedasticity. We also assessed the models' DCE logit fidelity to measure agreement with potentially less-biased DCE data. To anchor the best capability state to 1 on the 0 to 1 scale, we included a multiplicative scaling factor. RESULTS: We excluded 20% of the TTO answers of participants with the largest inconsistencies to improve data quality. A hybrid model with an anchor scale and censoring was chosen to generate the value set; models with heteroskedasticity considerations or individually varying intercepts did not offer substantial improvement. The lowest capability weight was 0.114. Health, social relations, and finance and housing attributes contributed the largest capability gains, followed by occupation, security, and political and civil rights. CONCLUSION: We elicited a value set for CALY-SWE for use in economic evaluations of interventions with broad social consequences.

In situ breast cancer surgeries in Sweden: lumpectomy or mastectomy?-a cost-effectiveness analysis over a 30-Year period using Markov model.

BACKGROUND: Breast cancer represents the most prevalent cancer among Swedish women. Although considerable research has investigated the cost-effectiveness of emerging innovative medical treatments for breast cancer, studies addressing existing surgical procedures remain scant. Therefore, this study aimed to evaluate the cost-effectiveness of three surgical procedures for in situ breast cancer treatment in Sweden: mastectomy, lumpectomy without irradiation, and lumpectomy with irradiation. METHODS: A six-state Markov model with a 30-year time horizon was used to compare the cost-effectiveness of the three alternatives. Transition probabilities were based on a targeted literature review focusing on available evidence in Sweden and comparable contexts. Costs were estimated from both healthcare and societal perspectives, using patient data from the Swedish National Cancer Registry in 2020 (Cancerregistret). Health outcomes were quantified in terms of quality-adjusted life years (QALYs). Cost and health outcomes were then summarised into an incremental cost-effectiveness ratio (ICER) between competing strategies. A probabilistic sensitivity analysis (PSA) was conducted to address the uncertainties in the input parameters. RESULTS: The results showed that compared to lumpectomy without irradiation, lumpectomy with irradiation yielded a "moderate" ICER per QALY gained of 402,994 Swedish Krona (SEK) from a healthcare perspective and a "high" ICER of 575,833 SEK from a societal perspective. Mastectomy proved to be the costliest and least effective of the three alternatives over a 30-year period. The PSA results further substantiated these findings. CONCLUSIONS: Our study demonstrated that lumpectomy with irradiation is "moderately" cost-effective compared with lumpectomy without irradiation. Nevertheless, extending this study by conducting a comprehensive budget impact analysis to account for the prevalence of in situ breast cancer in Sweden is prudent. These results imply that a costlier and less effective mastectomy should only be considered when lumpectomy options are infeasible. Further studies are needed to obtain more reliable parameters relevant to Sweden and to increase the consistency of the findings.

Health-related quality of life and healthcare consultations among adult patients before and after diagnosis with rheumatic heart disease in Namibia.

BACKGROUND: Rheumatic Heart Disease (RHD) causes high morbidity and mortality rates among children and young adults, impacting negatively on their health-related quality of life (HRQoL). This study aimed to evaluate the HRQoL and healthcare consultations of adult patients with RHD in Namibia. METHODS: From June 2019 to March 2020, a questionnaire was administered to 83 RHD patients during routine follow-ups. The EQ-5D-5L instrument was used to assess the health-related quality of life before diagnosis and at the time of the survey. The Ethiopian value set for EQ-5D-5L was used to calculate Quality-Adjusted Life Years (QALY). RESULTS: Most respondents were women (77%), young adults below the age of 30 years (42%), and individuals who grew up in rural areas (87%). The mean QALY statistically significantly improved from 0.773 pre-diagnosis to 0.942 in the last 12 months (p < 0.001). Sixty-six patients who had surgery reported a better QALY. Healthcare visits statistically significantly increased from on average 1.6 pre-diagnosis to 2.7 days in the last 12 months (p < 0.001). The mean distance to the nearest facility was 55 km, mean cost of transport was N$65, and mean time spent at the clinic was 3.6 h. The median time from diagnosis to the survey was 7 years (quartiles 4 and 14 years). CONCLUSION: Treatment and surgery can improve HRQoL substantially among RHD patients. Being diagnosed with RHD affects patients living in socioeconomically disadvantaged rural areas through cost and time for healthcare visits. It would be valuable with further research to understand differences between disease severities.

Health, wealth, and medical expenditures among the elderly in rural Tanzania: experiences from Nzega and Igunga districts.

BACKGROUND: The per capita health expenditure (HE) and share of gross domestic product (GDP) spending on elderly healthcare are expected to increase. The gap between health needs and available resources for elderly healthcare is widening in many developing countries, like Tanzania, leaving the elderly in poor health. These conditions lead to catastrophic HEs for the elderly. This study aimed to analyse the association between measures of health, wealth, and medical expenditure in rural residents aged 60 years and above in Tanzania. METHODS: The data of this study were collected through a cross-sectional household survey to residents aged 60 years and above living in Nzega and Igunga districts using a standardised World Health Organization (WHO) Study on Global Ageing and Adult Health (SAGE) and European Quality of Life Five Dimension (EQ-5D) questionnaires. The quality of life (QoL) was estimated using EQ-5D weights. The wealth index was generated from principal component analysis (PCA). The linear regression analyses (outpatient/inpatient) were performed to analyse the association between measures of health, wealth, medical expenditure, and socio-demographic variables. RESULTS: This study found a negative and statistically significant association between QoL and HE, whereby HE increases with the decrease of QoL. We could not find any significant relationship between HE and social gradients. In addition, age influences HE such that as age increases, the HE for both outpatient and inpatient care also increases. CONCLUSION: The health system in these districts allocate resources mainly according to needs, and social position is not important. We thus conclude that the elderly of lower socio-economic status (SES) was subjected to similar health expenditure as those of higher socio-economic status. Health, not wealth, determines the use of medical expenditures.

A Randomized Clinical Trial of Attempted Suicide Short Intervention Program versus Crisis Counseling in Preventing Repeat Suicide Attempts: A Two-Year Follow-Up Study.

INTRODUCTION: The Attempted Suicide Short Intervention Program (ASSIP) is a brief psychotherapeutic intervention, and a pivotal study found it to be remarkably effective in reducing repeat suicide attempts. OBJECTIVE: To compare the effectiveness of ASSIP to crisis counseling (CC) in a randomized clinical trial (ISRCTN13464512). METHODS: Adult patients receiving treatment for a suicide attempt in a Helsinki City general hospital emergency room in 2016-2017 were eligible to participate. We excluded psychotic or likely non-adherent substance-abusing or substance-dependent patients. Eligible patients (n = 239) were randomly allocated to one of two interventions. (a) ASSIP comprised three visits, including a videotaped first visit, a case formulation, and an individualized safety plan, plus letters from the therapist every 3 months for 1 year, and then, every 6 months for the next year. (b) CC typically involved 2-5 (median 3) face-to-face individual sessions. In addition, all participants received their usual treatment. One and 2 years after baseline, information related to participants' suicidal thoughts and attempts, and psychiatric treatment received was collected via telephone and from medical and psychiatric records. RESULTS: Among randomized patients, two-thirds initiated either ASSIP (n = 89) or CC (n = 72), with 73 (82%) completing ASSIP and 58 (81%) CC. The proportion of patients who attempted suicide during the 2-year follow-up did not differ significantly between ASSIP and CC (29.2% [26/89] vs. 35.2% [25/71], OR 0.755 [95% Cl 0.379-1.504]). CONCLUSIONS: We found no difference in the effectiveness of the two brief interventions to prevent repeat suicide attempts.

Estimating a social value set for EQ-5D-5L in Sweden.

BACKGROUND: The study aims to elicit a value set based on the EQ-VT for the EQ-5D-5L that can be used to support decision-making in Sweden. METHODS: Participants were recruited from the general population based on age, sex and urban/rural area quota sampling from five regions across Sweden. In total, 785 interviews were conducted from February 2020 to April 2021 using the EQVT 2.1 protocol, and both composite time trade-off (c-TTO) and discrete choice experiments (DCE) were used to elicit health preferences. A variety of models have been tested for the c-TTO data (generalized least square, Tobit, heteroskedastic models) and DCE data (conditional logit model), as well as the combined c-TTO and DCE data (hybrid modelling). Model selection was based on theoretical considerations, logical consistency of the parameter estimates, and significance of the parameters (p = 0.05). Model goodness-of-fit was assessed by AIC and BIC, and prediction accuracy was assessed in terms of mean absolute error. The predictions for the EQ-5D-5L health states between models were compared using scatterplots. RESULTS: The preferred model for generating the value set was the heteroskedastic model based on the c-TTO data, with the health utilities ranging from -0.31 for the worst (55,555) to 1 for the best (11111) EQ-5D-5L states. CONCLUSION: This is the first c-TTO-based social value set for the EQ-5D-5L in Sweden. It can be used to support the health utility estimation in economic evaluations for reimbursement decision making in Sweden.

Reference data among general population and known-groups validity among hypertensive population of the EQ-5D-5L in Vietnam.

PURPOSE: This study aims to provide EQ-5D-5L population norms among the general population in Vietnam and to test EQ-5D-5L' construction validity among people living with hypertension there. METHODS: Descriptive statistics of the five dimensions and five levels, EQ-VAS and EQ-5D-5L indexes were categorised into gender and age groups for the EQ-5D-5L population norms. Known-groups testing was set for lower EQ-5D-5L outcomes among people who were aware of their hypertensive status, females, people with more comorbidities, less education, older ages, and higher body mass indexes. Level of confident interval was 95%. RESULTS: The mean EQ-VAS and EQ-5D-5L indexes were 81.10 (SD: 13.35) and 0.94 (SD: 0.09) among the general population. The EQ-5D-5L outcomes were better among younger people, males, people with more education, employees, and single people. Respondents reported fewer problems with self-care and usual activities and tend to have problems at higher levels across older ages. The known-group testing showed statistically significant results. The mean EQ-VAS and EQ-5D-5L indexes of people in the diagnosed hypertensive group (71.48 and 0.94, respectively) were statistically significantly smaller than they were in the non-hypertensive and undiagnosed hypertensive group (76.65 and 0.97; 76.95 and 0.96 accordingly). Statistically significant associations of lower EQ-5D-5L indexes and EQ-VAS were found among people diagnosed for hypertension, people suffering from an incremental comorbidity, and obese people. CONCLUSION: This study has provided EQ-5D-5L population norms for the general population and evidence for known-groups validity of the EQ-5D-5L instrument among hypertensive people in Vietnam.

Perceived changes in capability during the COVID-19 pandemic: A Swedish cross-sectional study from June 2020.

AIMS: Measures against COVID-19 potentially impact quality of life in different ways. The capability approach by Amartya Sen with a broad and consistent framework for measuring quality of life is suited to capture the various consequences. We aimed to examine (a) whether individuals experienced change in 10 capability dimensions during the first half of 2020, (b) which dimensions were affected most, and (c) whether changes were unequally distributed in terms of gender, education, income, geography, housing, living situation and place of birth. METHODS: We assessed self-reported capability change in Sweden in 10 capability dimensions in a cross-sectional online survey among 500 participants on a five-item Likert scale. We analysed the distribution of answers by comparing the balance of positive and negative perceived changes and used mixed effects logistic regression to examine associations with background characteristics of the participants. RESULTS: Reported perceived negative changes outweighed positive changes, and a higher proportion stated negative perceived changes if they also stated having low capability in the same dimension. In the capabilities of financial situation, political resources and health, the proportions of perceived negative change were highest. Odds for perceived negative change compared to no or positive change were higher for lower incomes, living in smaller municipalities compared to living in medium-sized municipalities, being born outside Europe, living in the south of Sweden, and renting instead of owning housing. CONCLUSIONS: Self-reported negative capability change, and associated inequalities related to socioeconomic position, place of birth and regional residence should be of concern for policymakers.

Association of education and feedback on hypertension management with risk for stroke and cardiovascular disease.

PURPOSE: Education and feedback on hypertension management has been associated with improved hypertension control. This study aimed to assess the effectiveness of such interventions to reduce the risk of stroke and cardiovascular events. MATERIALS AND METHODS: Individuals ≥18 years with a blood pressure (BP) recording in Västerbotten or Södermanland County during the study period 2001 to 2009 were included in 108 serial cohort studies, each with 24 months follow-up. The primary outcome was risk of first-ever stroke in Västerbotten County (intervention) compared with Södermanland County (control). Secondary outcomes were first-ever major adverse cardiovascular event (MACE), myocardial infarction, and heart failure, as well as all-cause and cardiovascular mortality. All outcomes were analysed using time-to-event data included in a Cox proportional hazards model adjusted for age, sex, hypertension, diabetes, coronary artery disease, atrial fibrillation, systolic BP at inclusion, marital status, and disposable income. RESULTS: A total of 121 365 individuals (mean [SD] age at inclusion 61.7 [16.3] years; 59.9% female; mean inclusion BP 142.3/82.6 mmHg) in the intervention county were compared to 131 924 individuals (63.6 [16.2] years; 61.2% female; 144.1/81.1 mmHg) in the control county. A first-ever stroke occurred in 2 823 (2.3%) individuals in the intervention county, and 3 584 (2.7%) individuals in the control county (adjusted hazard ratio 0.96, 95% CI 0.90 to 1.03). No differences were observed for MACE, myocardial infarction or heart failure, whereas all-cause mortality (HR 0.91, 95% CI 0.87 to 0.95) and cardiovascular mortality (HR 0.91, 95% CI 0.85 to 0.98) were lower in the intervention county. CONCLUSIONS: This study does not support an association between education and feedback on hypertension management to primary care physicians and the risk for stroke or cardiovascular outcomes. The observed differences for mortality outcomes should be interpreted with caution.

A randomized clinical trial of the ASSIP vs. crisis counselling in preventing suicide attempt repetition: a two-year follow-up study.

BACKGROUND: ASSIP (Attempted Suicide Short Intervention Program) is a brief psychotherapeutic intervention found remarkably effective in reducing rate of suicide attempt repetition in the pivotal study in Bern, Switzerland. We compared effectiveness of the ASSIP to usual crisis counselling (CC) in a randomized trial (ISRCTN13464512). METHODS: Adult patients receiving somatic treatment for a suicide attempt at the Helsinki City general hospital emergency rooms in 2016-2017 were requested to participate. Psychotic or likely nonadherent substance abusing or dependent patients were excluded. Consenting, eligible patients (N = 239) were randomly allocated to two interventions. (a) The ASSIP comprised three visits, including a videotaped first visit, a case formulation, individualized safety plan, plus letters from their therapist every 3 months for 1 year and then every 6 months for the next year. (b) The CC involved on average four face-to-face individual sessions. In addition, all participants received treatments as usual. One and two years after the baseline, the participants' suicidal thoughts and attempts and psychiatric treatments received during the follow-up were investigated by telephone and from psychiatric records. RESULTS: Of patients randomized, two thirds initiated either ASSIP (n = 89) or CC (n = 72), with 73 (82%) completing the ASSIP and 58 (81%) the CC. There was no significant difference between the ASSIP vs. the CC patients having at least one suicide attempt during the 2-year follow-up (29.2% (26/89) vs. 35.2% (25/71), χ21 = 0.654, p = 0.419). CONCLUSION: We found no evidence for a difference in effectiveness of the two active interventions in preventing the repetition of suicide attempts.

Community health workers to improve adherence to anti-seizure medication in rural South Africa: Is it cost-effective?

OBJECTIVE: Epilepsy is a common, chronic neurological disorder that disproportionately affects individuals living in low- and middle-income countries (LMICs), where the treatment gap remains high and adherence to medication remains low. Community health workers (CHWs) have been shown to be effective at improving adherence to chronic medications, yet no study assessing the costs of CHWs in epilepsy management has been reported. METHODS: Using a Markov model with age- and sex-varying transition probabilities, we determined whether deploying CHWs to improve epilepsy treatment adherence in rural South Africa would be cost-effective. Data were derived using published studies from rural South Africa. Official statistics and international disability weights provided cost and health state values, respectively, and health gains were measured using quality adjusted life years (QALYs). RESULTS: The intervention was estimated at International Dollars ($) 123 250 per annum per sub-district community and cost $1494 and $1857 per QALY gained for males and females, respectively. Assuming a costlier intervention and lower effectiveness, cost per QALY was still less than South Africa's Gross Domestic Product per capita of $13 215, the cost-effectiveness threshold applied. SIGNIFICANCE: CHWs would be cost-effective and the intervention dominated even when costs and effects of the intervention were unfavorably varied. Health system re-engineering currently underway in South Africa identifies CHWs as vital links in primary health care, thereby ensuring sustainability of the intervention. Further research on understanding local health state utility values and cost-effectiveness thresholds could further inform the current model, and undertaking the proposed intervention would provide better estimates of its efficacy on reducing the epilepsy treatment gap in rural South Africa.

Is mass screening for coeliac disease a wise use of resources? A health economic evaluation.

BACKGROUND: Living with undiagnosed symptomatic coeliac disease is connected with deteriorated health, and persons with coeliac disease often wait a long time for their diagnosis. A mass screening would lower the delay, but its cost-effectiveness is still unclear. Our aim was to determine the cost-effectiveness of a coeliac disease mass screening at 12 years of age, taking a life course perspective on future benefits and drawbacks. METHODS: The cost-effectiveness was derived as cost per quality-adjusted life-year (QALY) using a Markov model. As a basis for our assumptions, we mainly used information from the Exploring the Iceberg of Celiacs in Sweden (ETICS) study, a school-based screening conducted in 2005/2006 and 2009/2010, where 13,279 12-year-old children participated and 240 were diagnosed with coeliac disease, and a study involving members of the Swedish Coeliac Association with 1031 adult participants. RESULTS: The cost for coeliac disease screening was 40,105 Euro per gained QALY. Sensitivity analyses support screening based on high compliance to a gluten-free diet, rapid progression from symptom-free coeliac disease to coeliac disease with symptoms, long delay from celiac disease with symptoms to diagnosis, and a low QALY score for undiagnosed coeliac disease cases. CONCLUSIONS: A coeliac disease mass screening is cost-effective based on the commonly used threshold of 50,000 Euro per gained QALY. However, this is based on many assumptions, especially regarding the natural history of coeliac disease and the effects on long-term health for individuals with coeliac disease still eating gluten.

What is the time cost of exercise? Cost of time spent on exercise in a primary health care intervention to increase physical activity.

BACKGROUND: In health care interventions aimed at increased physical activity, the individual's time spent on exercise is a substantial input. Time costs should therefore be considered in cost-effectiveness analyses. The aim of this study was to estimate the cost of time spent on exercise among 333 primary health care patients with metabolic risk factors receiving physical activity on prescription. METHODS: Based on a theoretical framework, a yardstick was constructed with experience of work (representing claim of salary as compensation) as the lower anchor-point, and experience of leisure activity forgone due to extended exercise time (no claim) as the higher anchor-point. Using this yardstick experience of exercise can be valued. Another yardstick was constructed with experience of cleaning at home in combination with willingness to pay for cleaning as the lowest anchor-point. RESULTS: The estimated costs of exercise time were between 14 and 37% of net wages, with physical activity level being the most important factor in determining the cost. Among sedentary individuals, the time cost was 21-51% of net wages while among individuals performing regular exercise it was 2-10%. When estimating the cost of time spent on exercise in a cost-effectiveness analysis, experience of exercise, work, leisure activity forgone, and cleaning at home (or other household work that may be relevant to purchase) should be measured. The individual's willingness to pay for cleaning at home and their net salary should also be measured. CONCLUSIONS: When using a single valuation of cost of time spent on exercise in health care interventions, for employed participants 15-30% of net salary should be used. Among unemployed individuals, lower cost estimation should be applied. Better precision in cost estimations can be achieved if participants are stratified by physical activity levels.Trial registration The study was conducted as a survey of existing clinical physical activity on prescription work, and was approved by the Regional Ethical Review Board in Gothenburg, Sweden (ref: 678-14).

Can survey data facilitate local priority setting? Experience from the Igunga and Nzega districts in Tanzania.

PURPOSE: This study aimed to investigate whether a local survey applying EQ-5D and SAGE could provide data valuable in setting priorities. METHODOLOGY: A cross-sectional household survey was used to collect information from a total of 1,899 elderly individuals aged 60 years and over living in the Nzega and Igunga districts using the WHO-SAGE and EQ-5D questionnaires. QALY weights were generated using the average of an EQ-5D index. A multivariable regression model was performed to analyse the effect of socioeconomic factors and self-rated health status on the EQ-5D index, using a linear regression model. RESULTS: The confidence interval estimates indicate higher HRQoL among men, married, urban dwellers, and elderly rated with good health than in women, unmarried, rural dwellers, and elderly rated with bad/moderate health, and it decreases with age. Income and education level have a positive relationship with HRQoL. The regression analysis; Model 1 (not adjusted with SAGE variables): age in all groups (p = 0.01, 0.00 and 0.02) and marital status (p = 0.01) have an influence on HRQoL. Model 2 (adjusted with SAGE variables): self-rated health (p < 0.00), the age for the 80-89 group (p = 0.01), marital status (not married), and high income have an influence on HRQoL. Sex, education, and residence were not statistically significant (in either model) to affect the HRQoL of the elderly. CONCLUSION: Local surveys, applying a combination of EQ-5D and SAGE, generate relevant and valuable information for policy makers when setting priorities at the district level. Therefore, this paper provides an empirical analysis for decision makers to consider the importance of combining EQ-5D, SAGE, and socioeconomic factors when setting priorities to improve HRQoL among the elderly.

An EQ-5D-5L Value Set for Vietnam.

PURPOSE: The objective of this study was to develop an EQ-5D-5L value set based on the health preferences of the general adult population of Vietnam. METHODS: The EQ-VT protocol version 2.1 was applied. Multi-stage stratified cluster sampling was employed to recruit a nationally representative sample. Both composite time trade-off (C-TTO) and discrete choice experiment (DCE) methods were used. Several modelling approaches were considered including hybrid; tobit; panel and heteroscedastic models. First, models using C-TTO or DCE data were tested separately. Then possibility of combining the C-TTO and DCE data was examined. Hybrid models were tested if it was sensible to combine both types of data. The best-performing model was selected based on both the consistency of the results produced and the degree to which models used all the available data. RESULTS: Data from 1200 respondents representing the general Vietnamese adult population were included in the analyses. Only the DCE Logit model and the regular Hybrid model that uses all available data produced consistent results. As the priority was to use all available data if possible, the hybrid model was selected to generate the Vietnamese value set. Mobility had the largest effect on health state values, followed by pain/discomfort, usual activities, anxiety/depression and self-care. The Vietnam values ranged from - 0.5115 to 1. CONCLUSION: This is the first value set for EQ-5D-5L based on social preferences obtained from a nationally representative sample in Vietnam. The value set will likely play a key role in economic evaluations and health technology assessments in Vietnam.

The burden of high workload on the health-related quality of life among home care workers in Northern Sweden.

OBJECTIVE: Previous studies have shown that high workload affects health negatively. However, studies are lacking among home care workers. The aim of this study is to examine the burden of perceived workload on health-related quality of life (HRQoL) among home care workers and to determine whether psychosocial factors modify such a relationship. METHODS: A cross-sectional study was conducted in which 1162 (58% response rate) home care workers participated. The psychosocial factors were measured by QPSnordic. HRQoL was measured by EuroQol 5 dimensions, from which responses were translated into quality-adjusted life year scores (QALY). Propensity scores were used with absolute risk differences (RD). Stratified analysis was used to test the buffer hypothesis of the demand-control-support model. RESULTS: Personnel with a high workload had a statistically significant 0.035 lower QALY than personnel with a normal workload. This difference was also statistically significant for the Visual Analogue Scale (RD 5.0) and the mobility (RD 0.033) and anxiety/depression scales (RD 0.20) dimensions of EQ-5D. For QALY, the effect of a high workload compared to a normal workload was higher, with low (RD 0.045, significant) compared with high (RD 0.015, non-significant) social support; while it was similar, and non-significant results, for low and high control. CONCLUSIONS: Our study shows that lowered work burden would be beneficial for home care personnel. Furthermore, our results suggest that interventions aimed at increasing social support could reduce work-related illness.

Does unemployment contribute to poorer health-related quality of life among Swedish adults?

BACKGROUND: Previous studies have shown that unemployment has negative impacts on various aspects of health. However, little is known about the effect of unemployment on health-related quality of life. Our aim was to examine how unemployment impacts upon health-related quality of life among Swedish adults, and to investigate these effects on population subgroups defined by education level, marital status, previous health, and gender. METHODS: As part of a cross-sectional study, a questionnaire was sent to 2500 randomly selected individuals aged 20 to 64 years living in Sweden in 2016. The questionnaire included the EuroQol 5 dimensions (EQ-5D) instrument and was answered by 967 individuals (39%). Quality-adjusted life year (QALY) scores were derived from the EQ-5D responses. Of the respondents, 113 were unemployed and 724 were employed. We used inverse probability-weighted propensity scores in our analyses to estimate a risk difference. Gender, age, education level, marital status, and previous health were used as covariates in our analyses. RESULTS: There was a statistically significant lower QALY score by 0.096 points for the unemployed compared to the employed. There were also statistically significant more problems due to unemployment for usual activities (6.6% more), anxiety/depression (23.6% more), and EQ-5D's Visual Analogue Scale (7.5 point lower score). Grouped analyses indicated a larger negative health effect from becoming unemployed for men, those who are married, and young individuals. CONCLUSIONS: In our study, we show that the health deterioration from unemployment is likely to be large, as our estimated effect implies an almost 10% worse health (in absolute terms) from being unemployed compared to being employed. This further highlights that unemployment is a public health problem that needs more focus. Our study also raises further demands for determining for whom unemployment has the most negative effects and thus suggesting groups of individuals who are in greatest need for labor market measures.

Incremental cost and health gains of the 2016 WHO antenatal care recommendations for Rwanda: results from expert elicitation.

OBJECTIVES: High-quality evidence of effectiveness and cost-effectiveness is rarely available and relevant for health policy decisions in low-resource settings. In such situations, innovative approaches are needed to generate locally relevant evidence. This study aims to inform decision-making on antenatal care (ANC) recommendations in Rwanda by estimating the incremental cost-effectiveness of the recent (2016) WHO antenatal care recommendations compared to current practice in Rwanda. METHODS: Two health outcome scenarios (optimistic, pessimistic) in terms of expected maternal and perinatal mortality reduction were constructed using expert elicitation with gynaecologists/obstetricians currently practicing in Rwanda. Three costing scenarios were constructed from the societal perspective over a 1-year period. The two main inputs to the cost analyses were a Monte Carlo simulation of the distribution of ANC attendance for a hypothetical cohort of 373,679 women and unit cost estimation of the new recommendations using data from a recent primary costing study of current ANC practice in Rwanda. Results were reported in 2015 USD and compared with the 2015 Rwandan per-capita gross domestic product (US$ 697). RESULTS: Incremental health gains were estimated as 162,509 life-years saved (LYS) in the optimistic scenario and 65,366 LYS in the pessimistic scenario. Incremental cost ranged between $5.8 and $11 million (an increase of 42% and 79%, respectively, compared to current practice) across the costing scenarios. In the optimistic outcome scenario, incremental cost per LYS ranged between $36 (for low ANC attendance) and $67 (high ANC attendance), while in the pessimistic outcome scenario, it ranged between $90 (low ANC attendance) and $168 (high ANC attendance) per LYS. Incremental cost effectiveness was below the GDP-based thresholds in all six scenarios. DISCUSSION: Implementing the new WHO ANC recommendations in Rwanda would likely be very cost-effective; however, the additional resource requirements are substantial. This study demonstrates how expert elicitation combined with other data can provide an affordable source of locally relevant evidence for health policy decisions in low-resource settings.

What is important for the sustained implementation of evidence-based brief psychotherapy interventions in psychiatric care? A quantitative evaluation of a real-world programme.

PURPOSE: Behavioural activation and motivational interviewing, both evidence-based treatments (EBTs), were implemented in secondary psychiatric care. This longitudinal evaluation of a real-world programme focused on the penetration of EBT adoption and its associations with therapist-related and perceived intervention-related variables. The implementation plan was also compared to sub-processes of Normalization Process Theory. MATERIAL AND METHODS: Six participating units employed 72 therapists regularly and they comprise the target group. Due to staff turnover, a total of 84 therapists were trained stepwise. Three survey points (q1, q2, q3) were set for a four-year cycle beginning a year after the initial training and completed 4-5 months after closing patient recruitment. The implementation plan included two workshop days, one for each EBT, and subsequent case consultation groups and other more general strategies. RESULTS: Fifty-seven (68%) of programme-trained therapists responded to one or more of three questionnaires. The self-reported penetration covers about a third of the target group a few months after the completion of the programme. Therapists' favourable perceptions of the EBTs regarding relative advantage, compatibility and complexity were associated with their sustained adoption. Therapists' background factors (e.g. work experience) and positive adoption intention at q1 did not predict the actual adoption of the EBTs at q3. No specific sustainment strategies were included in the implementation plan. CONCLUSION: Brief but multi-faceted training with subsequent case consultations promoted the adoption of EBTs in a real-world setting. Adding specific sustainment strategies to the implementation plan is proposed to ensure the long-term survival of the implementation outcomes.

Behavioral activation versus treatment as usual in naturalistic sample of psychiatric patients with depressive symptoms: a benchmark controlled trial.

BACKGROUND: More systematic use of evidence-based brief therapies is needed in the treatment of depression within psychiatric care. The aim of this study was to explore the impact of behavioral activation therapy (BA) for patients with depressive symptoms in a routine clinical setting of secondary psychiatric care. METHODS: The BA-treated intervention group (n = 242) comprised patients with depressive symptoms (Beck Depression Inventory (BDI) score ≥ 17 at baseline). The control group (n = 205) patients received treatment as usual in the same catchment area. The groups were matched at baseline using BDI and Alcohol Use Disorders Identification Test scores and inpatient/outpatient status. The groups were compared at 6-, 12- and 24-month follow-up points on functional outcome (Global Assessment of Functioning scale), service use, dropout and deaths. The Montgomery-Åsberg Depression Rating Scale was used to assess depressive symptoms in the intervention group. RESULTS: The estimated difference in GAF score between intervention and control group patients was significant at 12- and 24-months follow-up points in favor of intervention group (GAF score difference 4.85 points, p = 0.006 and 5.71 points, p = 0.005, respectively; estimate for patient group 2.26, p = 0.036). The rates of dropout, mortality and service use were similar between the groups. Among the intervention group patients, the estimated improvement in MADRS score compared to baseline was statistically significant throughout the follow-up (p < 0.001 at all follow-up points). CONCLUSIONS: The systematic use of BA among secondary psychiatric care depressive patients provides encouraging results despite the patients had various comorbid non-psychotic disorders. TRIAL REGISTRATION: ClinicalTrials.gov , Identifier NCT02520271, Release Date: 06/27/2015, retrospectively registered.