Cost-effectiveness analysis of a placebo-controlled randomized trial evaluating the effectiveness of arthroscopic subacromial decompression in patients with subacromial shoulder pain.

AIMS: The aims of this study were to compare the use of resources, costs, and quality of life outcomes associated with subacromial decompression, arthroscopy only (placebo surgery), and no treatment for subacromial pain in the United Kingdom National Health Service (NHS), and to estimate their cost-effectiveness. PATIENTS AND METHODS: The use of resources, costs, and quality-adjusted life-years (QALYs) were assessed in the trial at six months and one year. Results were extrapolated to two years after randomization. Differences between treatment arms, based on the intention-to-treat principle, were adjusted for covariates and missing data were handled using multiple imputation. Incremental cost-effectiveness ratios were calculated, with uncertainty around the values estimated using bootstrapping. RESULTS: Cumulative mean QALYs/mean costs of health care service use and surgery per patient from baseline to 12 months were estimated as 0.640 (standard error (se) 0.024)/£3147 (se 166) in the decompression arm, 0.656 (se 0.020)/£2830 (se 183) in the arthroscopy only arm and 0.522 (se 0.029)/£1451 (se 151) in the no treatment arm. Statistically significant differences in cumulative QALYs and costs were found at six and 12 months for the decompression versus no treatment comparison only. The probabilities of decompression being cost-effective compared with no treatment at a willingness-to-pay threshold of £20 000 per QALY were close to 0% at six months and approximately 50% at one year, with this probability potentially increasing for the extrapolation to two years. DISCUSSION: The evidence for cost-effectiveness at 12 months was inconclusive. Decompression could be cost-effective in the longer-term, but results of this analysis are sensitive to the assumptions made about how costs and QALYs are extrapolated beyond the follow-up of the trial.

Monitoring ocular hypertension, how much and how often? A cost-effectiveness perspective.

OBJECTIVE: To assess the efficiency of alternative monitoring services for people with ocular hypertension (OHT), a glaucoma risk factor. DESIGN: Discrete event simulation model comparing five alternative care pathways: treatment at OHT diagnosis with minimal monitoring; biennial monitoring (primary and secondary care) with treatment if baseline predicted 5-year glaucoma risk is ≥6%; monitoring and treatment aligned to National Institute for Health and Care Excellence (NICE) glaucoma guidance (conservative and intensive). SETTING: UK health services perspective. PARTICIPANTS: Simulated cohort of 10 000 adults with OHT (mean intraocular pressure (IOP) 24.9 mm Hg (SD 2.4). MAIN OUTCOME MEASURES: Costs, glaucoma detected, quality-adjusted life years (QALYs). RESULTS: Treating at diagnosis was the least costly and least effective in avoiding glaucoma and progression. Intensive monitoring following NICE guidance was the most costly and effective. However, considering a wider cost-utility perspective, biennial monitoring was less costly and provided more QALYs than NICE pathways, but was unlikely to be cost-effective compared with treating at diagnosis (£86 717 per additional QALY gained). The findings were robust to risk thresholds for initiating monitoring but were sensitive to treatment threshold, National Health Service costs and treatment adherence. CONCLUSIONS: For confirmed OHT, glaucoma monitoring more frequently than every 2 years is unlikely to be efficient. Primary treatment and minimal monitoring (assessing treatment responsiveness (IOP)) could be considered; however, further data to refine glaucoma risk prediction models and value patient preferences for treatment are needed. Consideration to innovative and affordable service redesign focused on treatment responsiveness rather than more glaucoma testing is recommended.

64-Slice computed tomography angiography in the diagnosis and assessment of coronary artery disease: systematic review and meta-analysis.

CONTEXT: Coronary artery disease (CAD) is a major cause of mortality and ill health. OBJECTIVE: To assess whether 64-slice CT angiography might replace some coronary angiography (CA) for diagnosis and assessment of CAD. DATA SOURCES: Electronic databases, conference proceedings and reference lists of included studies. STUDY SELECTION: Eligible studies compared 64-slice CT with a reference standard of CA in adults with suspected/known CAD, reporting sensitivity and specificity or true and false positives and negatives. DATA EXTRACTION: Two reviewers independently extracted data from included studies. RESULTS: Forty studies were included; 28 provided sufficient data for inclusion in the meta-analyses, all using a cut off point of >/=50% stenosis to define significant CAD. In patient-based detection (n = 1286) 64-slice CT pooled sensitivity was 99% (95% credible interval (CrI) 97% to 99%), specificity 89% (95% CrI 83% to 94%), median positive predictive value (PPV) across studies 93% (range 64-100%) and negative predictive value (NPV) 100% (range 86-100%). In segment-based detection (n = 14 199) 64-slice CT pooled sensitivity was 90% (95% CrI 85% to 94%), specificity 97% (95% CrI 95% to 98%), median PPV across studies 76% (range 44-93%) and NPV 99% (range 95-100%). CONCLUSIONS: 64-Slice CT is highly sensitive for patient-based detection of CAD and has high NPV. An ability to rule out significant CAD means that it may have a role in the assessment of chest pain, particularly when the diagnosis remains uncertain despite clinical evaluation and simple non-invasive testing.

Dissatisfaction with medical care among women with HIV: dimensions and associated factors.

Studies have shown that women with HIV/AIDS in the USA are less likely than men to have access to appropriate health care and to utilize services, including the latest antiretroviral drug therapies. One explanation for this underutilization is patient dissatisfaction with medical care. Dissatisfaction with care has been shown to be associated not only with treatment underutilization, but also with discontinuity of care and poor clinical outcomes. Using Patient Satisfaction Questionnaire data from a national cohort of women with HIV, this study examines levels of dissatisfaction across seven established dimensions of care, and uses multivariate analysis to identify patient characteristics associated with these dimensions (N = 1,303). Women were most dissatisfied with access to care and the technical quality of care, and least dissatisfied with financial aspects of care and their providers' interpersonal manner. Women who reported poor health, who had depressive symptomatology, who were not receiving antiretroviral therapy (ART), who had no consistent care providers or who were Hispanic/Latina were more likely to be dissatisfied across most dimensions of care. Implications for enhancing clinical care for women with HIV/AIDS and overcoming barriers to utilization of care and treatment are discussed.

Managed-care research, Part 2: Researching the domain.

A review of research pertaining to managed care suggests that little information is known about the impact of the components of managed care on care delivery outcomes. Characteristics of managed-care systems rarely are considered, resulting in uncertainty and confusion about which of the domain components of managed care have contributed to the outcomes seen. In part 1 (JONA November 1999) of this two-part series, we described how the shift to managed care has affected healthcare organizations and healthcare providers. We also identified several research questions relevant to the five domain components of managed care. In this article, we review the research literature concerning managed care and identify where research deficiencies exist within the domain.

Managed-care research, Part 1: Defining the domain.

New research opportunities are arising in response to the changes associated with care delivery provided in managed-care environments. A review of the managed-care literature suggests five characteristics that are associated with the care delivery models currently in place. Each of these components needs investigation to determine which of them contribute to cost reductions and care delivery outcomes seen.

The effect of patient-focused redesign on midlevel nurse managers' role responsibilities and work environment.

OBJECTIVE: The authors determine the effect of patient-focused redesign on midlevel nurse managers' role responsibilities and perceptions of work environment. BACKGROUND: Patient-focused redesign models have been initiated in a number of hospitals over the past 10 years. Few studies of the impact of these models on nurse leaders' roles and work responsibilities have been conducted. METHODS: Nine midlevel nurse managers were interviewed about their redesigned leadership roles and the challenges they experienced in implementing patient-focused redesign. RESULTS: Several themes emerged from the data. These themes focused on role change, ambiguity, position power, and environmental uncertainty and turbulence. Each of the nurse managers described feelings of frustration, disconnectedness, and inadequacy and spoke of how difficult it was to be the central figure in the eye of the storm. They noted that previously successful administrative strategies were not producing the same effect as in the past. CONCLUSION: This study provides beginning information about the magnitude of the impact of organizational redesign on midlevel nurse managers. Midlevel managers in this study struggled to keep up with the demands of the change and their own recognition of the importance of remaining committed to the uncertain goals of the institution. They were frustrated by their perceived inability to fix the situation and to meet the multiple needs of the staff. Nonetheless, they supported senior executives and attempted reasonable solutions to the problem.

Professional-led versus family-led support groups: exploring the differences.

Support groups often help families cope more effectively with relatives' mental illnesses. This study examines the differences between support groups led by professionals and those led by family members, focusing specifically on group participation benefits and group content. Results indicate that participants of both professional and family-led groups reported that the groups provided them with needed information about mental illness and its treatment and that the groups improved their relationships with their ill relatives. Professional-led groups placed a greater emphasis on the relatives' problems and coping with emotions, and family-led groups placed a greater emphasis on advocacy. Suggestions are provided regarding increased collaboration between professional and family-led support groups.

Benefits of support groups for families of adults with severe mental illness.

Predictors of benefits derived from participating in support groups for families of persons with mental illness were examined. A survey of 131 families indicated that social support resources outside the group, as well as support received from and provided by the group, were associated with information acquired by the participant. Improved relationships with family and the ill relative were predicted by the participant's health and provision of support in the group.

Positive parent/adult child relationships: impact of severe mental illness and caregiving burden.

Comparison of 222 parents of an adult child who had a psychiatric disability and 434 parents with a nondisabled adult child revealed that parents' positive appraisals of their relationship with the target child was significantly predicted by their perceived caregiving burden, but not by their child's psychiatric status. Implications for interventions that enhance parent/adult child relationships are discussed.

Service delivery using consumer staff in a mobile crisis assessment program.

Interest has developed in the use of mental health consumers as staff members in community programs for persons with serious mental illness. The present study investigates consumer service delivery in a mobile assessment program designed to assist homeless people with severe psychiatric disorders. Consumer and non-consumer staff were generally comparable. Results suggest that consumer staff engaged in more street outreach and were less often dispatched for emergencies. There was a trend for consumer staff to be more likely to certify their clients for psychiatric hospitalization. In sum, consumer staff appear to provide a valuable contribution to this form of service delivery.

A randomized evaluation of consumer versus nonconsumer training of state mental health service providers.

Preliminary evidence suggests that mental health consumers can successfully serve as peer companions, case management aides, case managers, job coaches, and drop-in center staff. However, few empirical investigations have addressed the use of consumers to train mental health professionals. This project employed a randomized design to test the effects of using consumers as trainers for mental health service providers. Fifty-seven state mental health professionals participated in a two-day training designed to acquaint trainees with the attitudes and knowledge necessary for delivering assertive case management services. Participants were randomly assigned to one of two conditions: one in which they received the second day of training from a consumer and the other involving training by a nonconsumer. Analyses revealed that post-training attitudes were significantly more positive for those participants trained by the consumer. Subjective evaluations also reflected positive reactions to the use of consumers as trainers. Implications for further use of mental health consumers as trainers are explored.

Age and family burden among parents of offspring with severe mental illness.

Family burden reported by parents of offspring with severe mental illness was examined to determine whether burden increases with age. Older parents were troubled by cognitive dimensions of burden, while younger parents were distressed by their offspring's behavior, suggesting that interventions should vary according to parents' age as well as developmental stage of their child's illness.

Schistosoma mansoni control in Cul de Sac Valley, Saint Lucia. II. Chemotherapy as a supplement to a focal mollusciciding programme.

After an intensive area-wide mollusciciding campaign, over four and a half years, transmission of Schistosoma mansoni was reduced. A cheaper scheme suitable for the follow-up or consolidation stage of control was evaluated and two selective population chemotherapy campaigns using hycanthone (2 mg/kg b.w.) and oxamniquine (15 mg/kg b.w.) were mounted. Prevalence dropped to 6% and 3% in areas with previously high and low levels of transmission respectively. Calculations suggested that these figures were falsely low and that perhaps 20% of the population were still excreting S. mansoni ova in small numbers. The unco-operative groups in the population are probably more important in maintaining a reservoir of infection in the community than persons with light infections undetected by the sedimentation concentration stool examination technique used. The benefit of more sensitive but more costly examination techniques is not clear since the importance of very light infections in transmission is uncertain. Case detection absorbs an increasing proportion of the total cost of chemotherapy programmes with fewer cases being found amongst the same number screened. Using hycanthone (649 treated) the cost per person protected was $0.74 and using oxamniquine (264 treated) $0.94. The need to develop low cost consolidation or follow-up procedures for preventing a resurgence of transmission after successful control, when the infection is no longer of public health importance, is stressed.

Control of Schistosoma mansoni transmission by chemotherapy in St. Lucia. I. Results in man.

Control of Schistosoma mansoni transmission solely by treatment of all infected persons was attempted in Marquis Valley (population about 3,100), St. Lucia. Two-year results are reported. Excluding 26 pregnant patients, 709 to 729 persons who were found to be infected received treatment the first year. Most of these, 677, were given a single injection of hycanthone (2.5 mg/kg of body weight), and the same treatment was administered to 159 patients the second year. Side effects were not severe; the major side effect, vomiting, occurred in about 22% on both occasions. In villages with initially high transmission rates, the incidence of new infections in children 0 to 14 years fell from 20.8% before chemotherapy to 7.4% after 1 year and to 3.7% after 2 years. This pattern was significantly different from that in the comparison area where no control scheme exists. Chemotherapy alone appears to be a rapid, effective, and comparatively inexpensive method of controlling S. mansoni transmission in St. Lucia.