Design and testing of a health economic Markov model for treatment of anorexia nervosa.

OBJECTIVES: Anorexia Nervosa (AN) is a severe psychiatric disorder and knowledge about the cost-effectiveness of potential interventions is limited. The aim of this paper is to introduce the Trimbos Institute health economic cost-effectiveness model for Anorexia Nervosa (AnoMod-TI), a flexible modeling tool for assessing the long-term cost-effectiveness of interventions for AN in late adolescent and adult patients, which could support clinical decision making. METHODS: AnoMod-TI is a state-transition cohort simulation (Markov) model developed from a Dutch societal perspective, which consists of four health states - namely full remission (FR), partial remission (PR), AN and death. Results are expressed as total healthcare costs, QALYs and incremental cost-effectiveness ratio. RESULTS: For the purpose of demonstrating AnoMod-TI and how it could be used to estimate cost-effectiveness over a 20-year time horizon, it was applied to a hypothetical treatment scenario. Results illustrate how a relatively costly intervention with only modest effects can still be cost-effective in the long term. CONCLUSIONS: AnoMod-TI can be used to examine long-term cost-effectiveness of various interventions aimed at either treating AN or preventing relapse from a state of partial or full remission. AnoMod-TI is freely available upon request to the authors.

ZMILE, a multicomponent self-management intervention for adults with epilepsy: Rationale and description of the intervention.

OBJECTIVE: In this paper, we aim to provide a comprehensive description of the multicomponent self-management intervention for adults with epilepsy, ZMILE. RATIONALE OR THEORY: Acquiring self-management skills has been shown to play a vital role in enabling patients with epilepsy overcoming (health-related) struggles in daily life and coping with limitations their condition poses on them. ZMILE is a course consisting of education (to increase concordance to treatment), goal-setting (proactive coping), and self-monitoring. RESOURCES NEEDED: The course is guided by two nurse practitioners and each patient is allowed to bring one family member or friend. Self-monitoring plays an important role and can be done through e-Health tools or written diaries. PROCESSES INVOLVED: During and after the course, patients are required to work toward a personally defined goal using a five-step approach by means of pro-active coping. Moreover, patients are expected to use self-monitoring tools to reflect on their own behavior and identify ways to optimize medication intake when required. QUANTIFICATION: ZMILE is provided in an outpatient setting over five weekly group sessions and one booster session. From the start, patients are encouraged to set individual goals. Each group session will have a different theme but part of every session is reflecting on personal goals and to learn from eachother. CONCLUSIONS: The ZMILE-intervention has been evaluated and may be a promising intervention in terms of effectiveness and feasibility for adults with epilepsy, relatives, and professionals. We present the adapted version which can be implemented in clinical practice.

Sensitivity of magnetoencephalography as a diagnostic tool for epilepsy: a prospective study.

The diagnostic process for epilepsy can be lengthy and stressful, which may delay the start of treatment. The objective of this study was to determine the benefit of routine magnetoencephalography (MEG) with regard to diagnostic gain, compared to routine electroencephalography (EEG), EEG following sleep deprivation (EEGsd), and 24-hour EEG. In this prospective study, patients were included from two centres (Academic Centre for Epileptology Kempenhaeghe, Heeze and Elisabeth-Twee Steden Hospital, Tilburg) and MEG recording took place at a single centre (Amsterdam University Medical Centre, Vrije Universiteit Amsterdam) in The Netherlands. Consecutively referred patients from peripheral hospitals were included between August 2013 and March 2016. Patients were offered routine MEG in addition to EEG examination and MRI for the diagnosis of epilepsy. The final clinical diagnosis was based on all available clinical data and test results at the end of the diagnostic process. Sensitivity, specificity, and positive and negative predictive values were calculated for routine EEG, routine EEG plus additional EEG and MEG. In addition, diagnostic gain associated with MEG, relative to the other modalities, was calculated. Secondary outcome was congruence of localization of epileptiform discharges between MEG and MRI or final clinical diagnosis. Based on a cohort of 138 patients, sensitivity and specificity was shown to be 31.6% and 78.4% for routine MEG, 31.6% and 100% for routine EEG, and 52.6% and 97.3% for routine EEG plus additional EEG, respectively. Routine MEG demonstrated a diagnostic gain of 16.8% compared to routine EEG and 9.5% compared to routine EEG plus additional EEG. In 35.7% of patients with a lesion on MRI that was consistent with the final clinical diagnosis, MEG showed epileptiform discharges in the same area. Routine MEG may provide additional value during the initial diagnosis of epilepsy.

Complaint-Directed Mini-Interventions for Depressive Symptoms: A Health Economic Evaluation of Unguided Web-Based Self-Help Interventions Based on a Randomized Controlled Trial.

BACKGROUND: Depression prevention and early intervention have become a top priority in the Netherlands, but with considerable room for improvement. To address this, Web-based complaint-directed mini-interventions (CDMIs) were developed. These brief and low-threshold interventions focus on psychological stress, sleep problems, and worry, because these complaints are highly prevalent, are demonstrably associated with depression, and have substantial economic impact. OBJECTIVE: The objective of this economic evaluation was to examine the added value of Web-based, unguided, self-help CDMIs compared with a wait-listed control group with unrestricted access to usual care from both a societal and a health care perspective. METHODS: This health economic evaluation was embedded in a randomized controlled trial. The study entailed 2 arms, in which 3 Web-based CDMIs were compared with a no-intervention waiting-list control group (which received the intervention after 3 months). We conducted measurements at baseline, and at 3 and 6 months. The primary outcome was the rate of responders to treatment on depressive symptoms as measured by the Inventory of Depressive Symptomatology Self-Report (IDS-SR). We estimated change in quality of life by calculating effect sizes (Cohen d) for individual pre- and posttreatment IDS-SR scores using a conversion factor to map a change in standardized effect size onto a corresponding change in utility. We calculated incremental cost-effectiveness ratios using bootstraps (5000 times) of seemingly unrelated regression equations and constructed cost-effectiveness acceptability curves for the costs per quality-adjusted life-year (QALY) gained. RESULTS: Of 329 study participants, we randomly assigned 165 to the CDMI group. At 3 months, the rate of responders to treatment was 13.9% (23/165) in the CDMI group and 7.3% (12/164) in the control group. At 3 months, participants in the CDMI group gained 0.15 QALYs compared with baseline, whereas participants in the control group gained 0.03 QALYs. Average total costs per patient at 3 months were €2094 for the CDMI group and €2230 for the control group (excluding baseline costs). Bootstrapped seemingly unrelated regression equations models resulted in a dominant incremental cost-effectiveness ratio (ie, lower costs and a higher rate of responders to treatment) for the CDMI group compared with the control group at 3 months, with the same result for the costs per QALY gained. Various sensitivity analyses attested to the robustness of the findings of the main analysis. CONCLUSIONS: Brief and low-threshold Web-based, unguided, self-help CDMIs have the potential to be a cost-effective addition to usual care for adults with mild to moderate depressive symptoms. The CDMIs improved health status, while reducing participant health care costs, and hence dominated the care-as-usual control condition. As intervention costs were relatively low, and the internet is readily available in the Western world, we believe CDMIs can be easily implemented on a large scale. TRIAL REGISTRATION: Netherlands Trial Register NTR4612; http://www.trialregister.nl/trialreg/admin/rctview.asp?TC=4612 (Archived by WebCite at http://www.webcitation.org/6n4PVYddM).

Discrete-choice experiments versus rating scale exercises to evaluate the importance of attributes.

AIM: To examine the difference between discrete-choice experiments (DCE) and rating scale exercises (RSE) in determining the most important attributes using a case study. METHODS: Undergraduate health sciences students were asked to complete a DCE and a RSE. Six potentially important attributes were identified in focus groups. Fourteen unlabelled choice tasks were constructed using a statistically efficient design. Mixed multinomial logistic regression analysis was used for DCE data analysis. RESULTS: In total, 254 undergraduate students filled out the questionnaire. In the DCE, only four attributes were statistically significant, whereas in the RSE, all attributes except one were rated four or higher. CONCLUSION: Attribute importance differs between DCE and RSE. The DCE had a differentiating effect on the relative importance of the attributes; however, determining relative importance using DCE should be done with caution as a lack of statistically significant difference between levels does not necessarily imply that the attribute is not important.

(Cost)-effectiveness of a multi-component intervention for adults with epilepsy: study protocol of a Dutch randomized controlled trial (ZMILE study).

BACKGROUND: In patients with epilepsy, poor adherence to anti-epileptic drugs has been shown to be the most important cause of poorly controlled epilepsy. Furthermore, it has been noted that the quality of life among patients with epilepsy can be improved by counseling and treatments aimed at increasing their self-efficacy and concordance, thus stimulating self-management skills. However, there is a need for evidence on the effectiveness of such programs, especially within epilepsy care. Therefore, we have developed a multi-component intervention (MCI) which combines a self-management/education program with e-Health interventions. Accordingly, the overall objective of this study is to assess the (cost)-effectiveness and feasibility of the MCI, aiming to improve self-efficacy and concordance in patients with epilepsy. METHODS: A RCT in two parallel groups will be conducted to compare the MCI with a control condition in epilepsy patients. One hundred eligible epilepsy patients will be recruited and allocated to either the intervention or control group. The intervention group will receive the MCI consisting of a self-management/education program of six meetings, including e-Health interventions, and will be followed for 12 months. The control group will receive care as usual and will be followed for 6 months, after which patients will be offered the possibility of participating in the MCI. The study will consist of three parts: 1) a clinical effectiveness study, 2) a cost-effectiveness study, and 3) process evaluation. The primary outcome will be self-efficacy. Secondary outcomes include adherence, side effects, change in seizure severity & frequency, improved quality of life, proactive coping, and societal costs. Outcome assessments will be done using questionnaires at baseline and after 3, 6, 9, and 12 months (last two applicable only for intervention group). DISCUSSION: In times of budget constraints, MCI could be a valuable addition to the current healthcare provision for epilepsy, as it is expected that higher concordance and self-efficacy will result in reduced use of healthcare resources and an increased QOL. Accordingly, this study is aimed helping patients to be their own provider of health care, shifting epilepsy management from professionals to self-care by patients equipped with appropriate skills and tools. TRIAL REGISTRATION NUMBER: NTR4484 .