Cost-effectiveness of family psychoeducation to prevent relapse in major depression: results from a randomized controlled trial.

BACKGROUND: Family psychoeducation is a relatively simple and straightforward intervention whose prophylactic effectiveness and cost-effectiveness is well-established for schizophrenia. We have recently demonstrated its effectiveness for unipolar depression, but its cost-effectiveness has never been examined. We hereby report a cost-effectiveness analysis alongside a randomized controlled trial in order to assess its cost-effectiveness for preventing relapse/recurrence in depression. METHODS: Fifty-seven patients diagnosed with major depression and undergoing its maintenance treatment, and their primary family members were randomized to treatment as usual (TAU) only or to TAU plus family psychoeducation, which consisted of four 2-hour multiple-family sessions consisting of didactic lectures about depression (30 minutes) and group discussion and problem solving (60-90 minutes). The economic analyses were undertaken from the perspective of the National Health Insurance (NHI), assuming the most reasonable price of US$50 per psychoeducation session per patient. The main outcome measures included relapse-free days and direct costs to the NHI. RESULTS: The intervention group enjoyed 272 (SD: 7.1) relapse-free days, while the control group spent 214 (SD: 90.8) relapse-free days (Cox proportional hazard ratio=0.17, 95%CI: 0.04 to 0.75, p=0.002). Cost-effectiveness acceptability curves suggested that the family psychoeducation has 90% or more chances of being cost-effective if the decision-maker is prepared to pay US$20 for one additional relapse-free day. This cost-effectiveness finding was robust when the price for family psychoeducation ranged between 50% to 150% of the baseline scenario in sensitivity analyses. If a relapse-free day is considered to be worth $30 or more, all the pricing scenarios have a close to 100% probability of being cost-effective. CONCLUSION: Family psychoeducation is effective in the relapse prevention of depression and is highly likely to be cost-effective if a relapse-free day is valued as US$20 or more. TRIAL REGISTRATION: UMIN-CTR (UMIN000005555).

Residential program for long-term hospitalized persons with mental illness in Japan: Randomized controlled trial.

Research on the merits of long-term group residences is inconclusive. The purpose of the present paper was to investigate the effects of supported group residence on the symptoms, social function, quality of life, general health quality, and the medical/psychiatric cost in Japan of a large number of psychiatric beds and long average length of stay. Patients were assessed every 6 months for 2 years using Positive and Negative Syndrome Scale, Katz Adjustment Scale, World Health Organization Quality of Life (WHO-QOL) and General Health Questionnaire 12-item version. Patients discharged to the supported group residence (SGR) significantly improved with regard to positive symptoms, the level of socially expected activities and free-time activities. The QOL physical domain of the inpatients was significantly more deteriorated compared to the SGR group. The total psychiatric/medical cost of the SGR group was approximately one-third that of the inpatient group, while the cost of the SGR to treat physical comorbidity was much higher. The present findings indicate that SGR has advantages for mental and social function but not for physical health. A major limitation of the present study was the high mean age (>60 years) of the subjects who had been hospitalized for a long period (mean, 24 years).

Medical cost analysis of family psychoeducation for schizophrenia.

Family psychoeducation has been shown to prevent the relapse of schizophrenia. However, whether medical costs are reduced by this approach remains uncertain. The subjects were patients with schizophrenia who lived with high-expressed emotion (EE) families and were at high risk of relapse. A total of 30 patients whose families underwent psychoeducation and intensive family sessions or psychoeducation and subsequent support were regarded as the psychoeducation group. A high-EE group without family psychoeducation made up of 24 patients was used as a control group. The mean outpatient medical cost, duration of hospitalization, inpatient medical cost, and total medical cost during the follow-up period were compared between the psychoeducation group and the control group. The mean inpatient medical cost was 270,000 yen in the psychoeducation group and 470,000 yen in the control group. The mean total medical costs were 500,000 yen in the psychoeducation group and 710,000 yen in the control group. The cost in the psychoeducation group was significantly lower than the control group by Mann-Whitney U-test. The proportion of patients with a total medical cost greater than the median value was 23% in the psychoeducation group and 54% in the control group with a significant difference. The medical cost can be reduced in the psychoeducation group compared with the control group due to the prevention of re-hospitalization by family psychoeducation.

A cross-cultural study on expressed emotion in carers of people with dementia and schizophrenia: Japan and England.

Expressed emotion (EE) research has been productive in investigating the influence of the interpersonal environment on a range of disorders. The majority of EE research on the influence of carers has been carried out in the west. This is the first EE study of the carers of people with dementia in Japan. The aim of this study was to investigate the relationships between EE status and aspect of burden through cross-cultural comparison of the two countries, Japan and England, with large cultural and linguistic differences. Comparisons were made between samples of EE of carers of dementia and schizophrenic patients. In total, data on 80 carer/relative-patient dyads were collected and examined: (1) 20 Japanese carers of people with dementia (JD), (2) 20 English carers of patients with Alzheimer's disease (ED), (3) 20 Japanese relatives of patients with schizophrenia (JS), and (4) 20 English relatives of patients with schizophrenia (ES). The Camberwell Family Interview was administered in each country to ascertain levels of EE. Large differences between Japan and England were found in the frequency of critical comments, in which ES>ED>JS>JD. EE correlated significantly with burden in the JD sample alone. With an operational cut-off of 2CC (CC, critical comments), EE correlated significantly with cognitive impairment as well as with clinical severity in the JD sample. There was a tendency for lower expression of both positive and negative emotional reactions towards family members in the Japanese sample. The results of this study indicate that EE is an appropriate measure for use with carers of sufferers of dementia and can be utilized across different cultures. However, flexibility with the cut-offs may be required in Eastern cultures. This needs to be tested on larger samples with sensitivity to illness and cross-cultural differences.

Does seropositivity for Helicobacter pylori antibodies increase outpatient costs for gastric and duodenal ulcer or inflammation?

BACKGROUND: Helicobacter pylori is regarded as an important cause of both peptic ulcer and chronic gastritis. In particular, seropositivity is highest in patients with duodenal ulcer. No studies have determined whether there are differences in the direct medical costs associated with gastric/duodenal ulcer or inflammation, between seropositive and seronegative patients. OBJECTIVE: To examine the relationship between seropositivity for H. pylori and outpatient visits and direct medical costs for gastric/duodenal ulcer or inflammation in Japan from the perspective of the payor and patients. METHODS: Participants were males (n = 653) who worked for an agricultural co-operative in Fukuoka Prefecture, attended an annual health examination (including a written lifestyle and medical survey), belonged to the same health insurance society consistently for 4 years from April 1996 to March 2000, and provided a blood sample. The survey asked about lifestyle, including smoking and drinking, and past medical history. We retrospectively analysed the annual number of outpatient visits per person and outpatient medical cost (Yen, 2000 values) per person for visits relating to gastric or duodenal ulcer or inflammation using International Classification of Diseases (9th edition) -- Clinical Modification codes. We assessed for potential confounding factors using analysis of covariance and the chi-square test. RESULTS: The annual outpatient incidence of disease, the number of visits to physicians, and the medical costs for gastric or duodenal ulcer or inflammation were about 2-fold greater in individuals with antibodies to H. pylori compared with those without antibodies. CONCLUSION: Population-based studies and/or randomised controlled clinical trials that target high-risk groups and account for the unique way in which data are collected in Japan are needed to determine whether medical costs for gastric and duodenal ulcer might be reduced by treating asymptomatic patients who have antibodies to H. pylori.

[Clinical study using activity-based costing to assess cost-effectiveness of a wound management system utilizing modern dressings in comparison with traditional wound care].

In recent years, the concept of cost-effectiveness, including medical delivery and health service fee systems, has become widespread in Japanese health care. In the field of pressure ulcer management, the recent introduction of penalty subtraction in the care fee system emphasizes the need for prevention and cost-effective care of pressure ulcer. Previous cost-effectiveness research on pressure ulcer management tended to focus only on "hardware" costs such as those for pharmaceuticals and medical supplies, while neglecting other cost aspects, particularly those involving the cost of labor. Thus, cost-effectiveness in pressure ulcer care has not yet been fully established. To provide true cost effectiveness data, a comparative prospective study was initiated in patients with stage II and III pressure ulcers. Considering the potential impact of the pressure reduction mattress on clinical outcome, in particular, the same type of pressure reduction mattresses are utilized in all the cases in the study. The cost analysis method used was Activity-Based Costing, which measures material and labor cost aspects on a daily basis. A reduction in the Pressure Sore Status Tool (PSST) score was used to measure clinical effectiveness. Patients were divided into three groups based on the treatment method and on the use of a consistent algorithm of wound care: 1. MC/A group, modern dressings with a treatment algorithm (control cohort). 2. TC/A group, traditional care (ointment and gauze) with a treatment algorithm. 3. TC/NA group, traditional care (ointment and gauze) without a treatment algorithm. The results revealed that MC/A is more cost-effective than both TC/A and TC/NA. This suggests that appropriate utilization of modern dressing materials and a pressure ulcer care algorithm would contribute to reducing health care costs, improved clinical results, and, ultimately, greater cost-effectiveness.

A study on a reduction in visits to physicians after introduction of 30% co-payments in the employee health insurance in Japan.

The purpose of the study is to evaluate influences of the introduction of 30% co-payments on potential visit behavior using a questionnaire in order to determine whether "employment state of the spouse" and "number of dependent children", as indicators of economic backgrounds, affect visits to physicians in a health insurance society. The subjects were 1,674 insured consisting of 1,165 males and 509 females, who underwent a regular health examination in July 2002, in a health insurance society. In the survey, they were asked whether the subject "will reduce" or "will not reduce" visits to physicians due to the increase in co-payments in the health insurance system scheduled in 2003. Multivariate analyses showed that "employment state of the spouse" was significantly related to the reduction in visits for myocardial infarction or stroke, cancer or heart disease, and hypertension and diabetes mellitus. Concerning "number of dependent children", it was related to the risk of reducing visits to physicians for myocardial infarction or stroke, trauma or fracture, cancer or heart disease, and low back pain or knee pain. Finally, upper limit expenditures of co-payments of physicians to visits due to hypertension and diabetes mellitus were related to "number of dependent children". The study results suggest that "employment state of the spouse" and "number of dependent children" are significant factors to affect potential visits to physicians after the introduction of 30% co-payments.

Effects of an increase in patient copayments on medical service demands of the insured in Japan.

OBJECTIVES: To examine quantitatively the effects of an increase in patient copayments from 10% to 20% on the demand for medical services in Japan. METHODS: The subjects of the study were the employees insured by the 1,797 health insurance societies, belonging to the National Federation of Health Insurance Societies, in 1996 and 1998. Indicators of medical service demands analyzed include the inpatient, outpatient, and dental case rates, the number of serviced days per case, the medical cost per day and the medical cost per insured. RESULTS: When the effects of an increase in patient copayments from 10% to 20% were evaluated, taking into account the average age, the average monthly salary, the total number, the gender (male-to-female) ratio and the dependent ratio of the insured, the estimated change in the case rate was -6.96% for inpatient, -4.79% for outpatient, and -5.77% for dental care. The estimated change in the number of serviced day per case was -4.66% for inpatient, -5.67% for outpatient, and -1.82% for dental care. The estimated change in the medical cost per day was -3.15% for inpatient, -13.00% for outpatient, and -11.48% for dental care. The estimated change in the medical cost per insured was -14.08% for inpatient, -21.54% for outpatient, and -18.11% for dental care. CONCLUSIONS: The increase in patient copayments from 10% to 20% enabled insurers to substantially reduce medical costs by cost shifting from the insurer to the insured, with resultant changes in the case rate and the number of service days per case.

Institutionalisation and schizophrenia in Japan: social environments and negative symptoms: Nationwide survey of in-patients.

BACKGROUND: The number of psychiatric beds per capita in Japan is the highest in the world, and a replication of earlier British research is needed to identify possible means of improving the mental health system. Aims To describe the current situation of psychiatric hospitals in Japan and to examine the relationship between negative symptoms of schizophrenia and social environments. METHOD: In-patients with schizophrenia were randomly selected from 139 hospitals. Data were obtained for 2758 participants using several scales, including the Manchester Scale and social environment scales. RESULTS: Negative symptom scales showed a significant correlation with understimulating social environments in hospitals. CONCLUSIONS: This study confirms the results from the UK and provides evidence for the importance of community-based care and for providing more-stimulating rehabilitation environments.