Cost-effectiveness of depression case management in small practices.

BACKGROUND: Case management undertaken by healthcare assistants in small primary care practices is effective in improving depression symptoms and adherence in patients with major depression. AIMS: To evaluate the cost-effectiveness of depression case management by healthcare assistants in small primary care practices. METHOD: Cost-effectiveness analysis on the basis of a pragmatic randomised controlled trial (2005-2008): practice-based healthcare assistants in 74 practices provided case management to 562 patients with major depression over 1 year. Our primary outcome was the incremental cost-effectiveness ratio (ICER) calculated as the ratio of differences in mean costs and mean number of quality-adjusted life-years (QALYs). Our secondary outcome was the mean depression-free days (DFDs) between the intervention and control group at 24-month follow-up. The study was registered at the International Standard Randomised Controlled Trial Number Registry: ISRCTN66386086. RESULTS: Intervention v. control group: no significant difference in QALYs; significantly more DFDs (mean: 373 v. 311, P<0.01); no significant difference in mean direct healthcare costs (€4495 v. €3506, P = 0.16); considerably lower mean indirect costs (€5228 v. €7539, P = 0.06), resulting in lower total costs (€9723 v. €11 045, P = 0.41). The point estimate for the cost-utility ratio was €38 429 per QALY gained if only direct costs were considered, and 'dominance' of the intervention if total costs were considered. Yet, regardless of decision makers' willingness to pay per QALY, the probability of the intervention being cost-effective was never above 90%. CONCLUSIONS: In small primary care practices, 1 year of case management did not increase the number of QALYs but it did increase the number of DFDs. The intervention was likely to be cost-effective.

Patient-reported outcome measures (PROMs) in patients undergoing patellofemoral arthroplasty and total knee replacement: A comparative study.

BACKGROUND: Incongruity in the evaluation of outcomes between patients and surgeons has led to an increasing utilization of patient-reported outcome measures (PROMs) as an evaluation method of outcome. OBJECTIVE: The aim of this study was to compare Oxford Knee Score (OKS), KOOS-PS and Kujala Score results in patients who received either PFA or TKA with and without patella resurfacing in the tretament of knee osteoarthritis. METHODS: A total of 50 patients (PFA = 19 patients; TKA with patelloplasty = 15 patients; TKA with patellar resurfacing = 16 patients) undergone surgery between 2011 and 2014 and were included for final analysis. RESULTS: No statistical significance was found for OKS, KOOS-PS and Kujala scores between the three groups. However, although patients with PFA experienced higher levels of pain. CONCLUSIONS: According to our results, it is essential to discuss the treatment options and quality of life expectations with the patient prior joint replacement surgery in order to reduce patient dissatisfaction. LEVEL OF EVIDENCE: Level III, retrospective comparative study.

Improved systolic and diastolic myocardial function with intracoronary pyruvate in patients with congestive heart failure.

BACKGROUND: Pyruvate increases myocardial performance in isolated myocardium and improves hemodynamics in patients with congestive heart failure. AIMS: To investigate the influence of pyruvate on detailed parameters of systolic and diastolic left ventricular (LV) function. METHODS AND RESULTS: In patients with heart failure due to dilated cardiomyopathy (LVEF 30+/-4%, n=9) pyruvate was infused intracoronarily. LV function was analysed before, during and after application of different pyruvate concentrations using a LV-micromanometer catheter. LV volumes were determined using cine ventriculography. Pyruvate increased maximum rate of LV isovolumic pressure rise (Peak +dP/dt) from 802+/-106 to 1125+/-103 mmHg/s (P<0.05). Left ventricular end-diastolic pressure declined in parallel from 17+/-2 to 12+/-2 mmHg (P<0.05) and heart rate decreased from 79+/-4 to 72+/-5 min(-1) (P<0.05). Stroke volume index increased from 34+/-4 to 43+/-6 ml/m(2) (P<0.05), end-diastolic LV volume remained unchanged, thus left ventricular ejection fraction increased with pyruvate from 30+/-4 to 39+/-4% (P<0.05). Maximum rate of LV isovolumic pressure decline (Peak -dP/dt) was significantly increased with pyruvate (from 794+/-94 to 980+/-108 mmHg/s; P<0.05) and mean arterial pressure increased from 80+/-5 to 88+/-4 mmHg (P<0.05). Discontinuation of pyruvate resulted in immediate reversibility of its effects. CONCLUSION: Intracoronary pyruvate improves systolic and diastolic myocardial function and increases ejection fraction without increasing heart rate. Pyruvate thus exhibits the profile of a favourable inotropic agent, however, further investigation for the treatment of patients with acute heart failure is mandatory.

[Cost structure of a telephone-based case management in primary care depression therapy]. / Kostenstruktur eines case-management-programms in der hausärztlichen depressionstherapie.

OBJECTIVES: Case management by health care assistants in small primary care practices has proven effective in improving depression symptoms in depressive patients. Resource consumption and costs of this intervention have not been evaluated yet. METHODS: Health care assistants and general practitioners of 15 participating practices were interviewed for intervention-related time expenditures. Intervention costs were based on individual labour costs. RESULTS: The annual time spent was 6.3 h per patient for health care assistants and 3.6 h for general practitioners (mean 8.9 patients per practice). The case management caused costs of € 277 per patient and year. CONCLUSIONS: A telephone-based case management as add-on therapy improves quality of primary care depression therapy while causing only moderate costs for health care providers.