Societal costs and quality of life analysis in patients undergoing resective epilepsy surgery: A one-year follow-up.

Although effectiveness of Resective Epilepsy Surgery (RES) for patients with drug-resistant epilepsy (DRE) is widely proven, research on the impact of societal costs (SC) is lacking. The aim of this study is to provide both clinical and economic outcomes of RES by offering an overview of treatment effectiveness as well as SC of RES in a cohort of 30 Dutch DRE patients. This project serves as a pilot project to offer an up-to-date model for larger cost-effectiveness studies. Medical consumption, productivity losses, disease-specific and generic health-related quality of life (QoL), and seizure frequency were assessed before and 3-, 6-, and 12-months post-surgery with validated questionnaires. Linear mixed models, ANOVAs, and logistic regressions were performed. SC for the first year after RES entailed €54,376 and decreased over time. Moreover, 50% of patients experienced a clinically important increase in disease-specific QoL and 53% of patients in generic health-related QoL. Lastly, 73% of patients reached seizure freedom 12 months postoperative. Seizure reduction was correlated with increase in disease-specific QoL. Within one year after surgery, RES leads to reduction in SC and improvements in QoL over time. Future research should encompass longer follow-up periods, larger sample size, and a cost-effectiveness analysis with a comparator.

The economic impact of mental healthcare consumption before and after stroke in a cohort of stroke patients in the Netherlands: a record linkage study.

BACKGROUND: Post-stroke healthcare consumption is strongly associated with a mental health diagnosis. This study aimed to identify stroke patients who utilised mental healthcare facilities, explored their mental healthcare consumption pre-stroke and post-stroke, and examined possible predictors of costs incurred by mental healthcare consumption post-stroke. METHODS: Three databases were integrated, namely the Maastricht University Medical Centre (MUMC) Medical Administration, the Stroke Registry from the Department of Neurology at MUMC, and the Psychiatric Case Registry South-Limburg. Patients from the MUMC who suffered their first-ever stroke between January 1 2000 and December 31 2004 were included and their records were analysed for mental healthcare consumption from 5 years preceding to 5 years following their stroke (1995-2009). Regression analysis was conducted to identify possible predictors of mental healthcare consumption costs. RESULTS: A total of 1385 patients were included and 357 (25.8%) received services from a mental healthcare facility during the 10-year reference period around their stroke. The costs of mental healthcare usage increased over time and peaked 1 year post-stroke (€7057; 22% of total mental healthcare costs). The number of hospitalisation days and mental healthcare consumption pre-stroke were significant predictors of mental healthcare costs. Explained variances of these models (costs during the 5 years post-stroke: R 2 = 15.5%, costs across a 10 year reference period: R 2 = 4.6%,) were low. CONCLUSION: Stroke patients have a significant level of mental healthcare comorbidity leading to relatively high mental healthcare costs. There is a relationship between stroke and mental healthcare consumption costs, but results concerning the underlying factors responsible for these costs are inconclusive.

An economic evaluation of an augmented cognitive behavioural intervention vs. computerized cognitive training for post-stroke depressive symptoms.

BACKGROUND: Stroke survivors encounter emotional problems in the chronic phase after stroke. Post-stroke depressive symptoms have major impact on health-related quality of life (HRQol) and lead to increased hospitalization and therefore substantial healthcare costs. We present a cost-effectiveness and cost-utility evaluation of a cognitive behavioural therapy augmented with occupational and movement therapy to support patients with a stroke with depressive symptoms in goal-setting and goal attainment (augmented CBT) in comparison with a computerized cognitive training program (CogniPlus) as a control intervention. METHODS: A trial-based economic evaluation was conducted from a societal perspective with a time horizon of 12 months. Stroke patients (aged 18+ years) with signs of depression (Hospital Anxiety and Depression Scale (HADS) - subscale depression > 7) were eligible to participate. Primary outcomes were the HADS and Quality Adjusted Life Years (QALYs) based on the three-level five-dimensional EuroQol (EQ-5D-3 L). Missing data were handled through mean imputation (costs) and multiple imputation (HADS and EuroQol), and costs were bootstrapped. Sensitivity analyses were performed to test robustness of baseline assumptions. RESULTS: Sixty-one patients were included. The average total societal costs were not significantly different between the control group (€9,998.3) and the augmented CBT group (€8,063.7), with a 95 % confidence interval (-5,284, 1,796). The augmented CBT intervention was less costly and less effective from a societal perspective on the HADS, and less costly and slightly more effective in QALYs, in comparison with the control treatment. The cost-effectiveness and cost-utility analyses provided greater effects and fewer costs for the augmented CBT group, and fewer effects and costs for the HADS. Based on a willingness to pay (WTP) level of €40,000 per QALY, the augmented CBT intervention had a 76 % chance of being cost-effective. Sensitivity analyses showed robustness of results. CONCLUSION: The stroke-specific augmented CBT intervention did not show convincing cost-effectiveness results. In addition to other literature, this study provided new insights into the potential cost-effectiveness of an adjusted cognitive behavioural therapy intervention. However, as our study showed a 76 % chance of being cost-effective for one outcome measure (QALY) and did not provide convincing cost-effectiveness results on the HADS we recommend further research in a larger population.

The burden of stroke in the Netherlands: estimating quality of life and costs for 1†year poststroke.

OBJECTIVES: To assess and explore over 1 year poststroke (1) the societal costs, (2) changes in costs and quality of life (QoL) and (3) the relation between costs and QoL. DESIGN: The current study is a burden of disease study focusing on the cost-of-illness (in Euros) and QoL (in utilities) after stroke. SETTING: Adult patients with stroke were recruited from stroke units in hospitals and followed for 1 year. PARTICIPANTS: Data were collected from 395 patients with stroke. MAIN OUTCOME MEASURES: Costs and QoL expressed in utilities. METHODS: Cost categories were identified through a bottom-up method. The Dutch 3-level 5-dimensional EuroQol (EQ-5D-3L) was used to calculate utilities. Non-parametric bootstrapping was applied to test for statistical differences in costs. Subgroup analyses were performed to identify predictors for costs and QoL. Robustness of results was tested via sensitivity analyses. RESULTS: The total societal costs for 1 year poststroke were €29 484 (n=352) of which 74% were in the first 6 months. QoL remained stable over time. The discharge location was a significant predictor for cost and QoL; men had a significantly higher QoL than women and younger patients (<65) had significantly more costs than older patients (>65). Ceiling effects appear on all dimension of the EQ-5D-3L. Costs and QoL show a weak correlation (r=-0.29). Sensitivity analyses showed robustness of results. CONCLUSIONS: We found lower patient costs and higher QoL than expected. This may be explained by the good state of health of our study population and by change in the Dutch healthcare system, which has led to considerable shorter hospitalisation poststroke. Future research must question the use of the EQ-5D-3L in a similar population due to ceiling effects. TRIAL REGISTRATION NUMBER: NTR3051.

A systematic review and cost-effectiveness analysis of specialist services and adrenaline auto-injectors in anaphylaxis.

BACKGROUND: Anaphylaxis is a severe, life-threatening generalised or systemic hypersensitivity reaction with high mortality. Specialist services (SSs) are believed to reduce anaphylaxis recurrence and improve use of adrenaline injectors (AIs), which can reduce mortality if used correctly and in time. OBJECTIVES: To review the evidence on which persons are at high risk of anaphylactic episodes, the effects of history-taking (including signs, symptoms and physical examination) for anaphylaxis, and when (suspected) patients should be referred. To assess the cost-effectiveness of SS compared with standard care (SC) with or without prescription of AIs. DATA SOURCES: In order to assess the clinical effectiveness, 10 databases [Cochrane Database of Systematic Reviews (CDSR), Cochrane Central Register of Controlled Trials (CENTRAL), Database of Abstracts of Reviews of Effects (DARE), Health Technology Assessment (HTA), NHS Economic Evaluation Database (NHS EED), Science Citation Index (SCI), Cumulative Index to Nursing and Allied Health Literature (CINAHL), EMBASE, MEDLINE, MEDLINE In-Process & Other Non-Indexed Citations, from inception up to March 2011] were searched without data restriction in order to identify relevant studies [randomised controlled trials (RCTs), controlled clinical trials, observational studies, prognostic studies using a multivariate model] written in English. REVIEW METHODS: Standard review methods were applied for the assessment of clinical effectiveness. A Markov model, validated by clinical experts, was constructed, which modelled anaphylaxis according to trigger: either food, drug, insect or idiopathic. Anaphylaxis mortality was modelled as a function of time to die and time for emergency response. Probabilistic sensitivity analysis on key parameters was performed. RESULTS: From the systematic review, 11,058 references were identified by the searches for studies assessing the clinical effectiveness. In total, 107 papers were obtained, and five prospective observational studies, including 1725 patients, were included. These studies estimated the risk of recurrence to be between 30% and 42.8%. In children (< 12 years), an overall recurrence of 27% was reported, with food being the most frequent allergen (71%). From the cost-effectiveness analysis (CEA), SC with injectors was dominated by SS with or without injectors. SS with no injectors would be cost-effective if the threshold for a quality-adjusted life-year (QALY) was greater than about £ 740 and with injectors would be cost-effective if the threshold was > £ 1800. These results were robust to all sensitivity analyses except at relatively extreme values of a small number of parameters. LIMITATIONS: Limitations of the study include the low yield from the systematic review; in particular there were no good-quality studies of either SSs or AI effectiveness. This implied a great reliance on expert opinion in the CEA. However, this was appropriately addressed using sensitivity analysis. CONCLUSIONS: Only five observational studies assessing clinical effectiveness were identified. Owing to the lack of good data to inform the effectiveness of anaphylaxis intervention, we recommend considerations of RCTs or at least well-designed observational studies of the components of care in SSs. The results of the CEA showed that SS with AIs was cost-effective at a threshold of £ 20,000 per QALY. More well-designed prospective studies on the effectiveness of SSs are needed to confirm these findings.

A prospective randomized multicenter comparison on health-related quality of life: the value of add-on arrhythmia surgery in patients with paroxysmal, permanent or persistent atrial fibrillation undergoing valvular and/or coronary bypass surgery.

INTRODUCTION: This is a multicenter, prospective, randomized controlled trial to determine the effect of add-on arrhythmia surgery on health-related quality of life during 1-year follow-up of cardiac surgery patients with atrial fibrillation. METHODS: 150 patients with documented atrial fibrillation were randomly assigned to undergo cardiac surgery with or without add-on surgery. Patients completed quality of life questionnaires, comprising the RAND 36-item Health Survey 1.0 (SF-36), Multidimensional Fatigue Inventory-20 (MFI-20) and EuroQoL (EQ-5D and VAS) at baseline and 3, 6, and 12 months following operation. RESULTS: 132 patients completed the questionnaires at a minimum of one time-point during follow-up. At baseline patient characteristics, operative data and health-related quality of life were comparable. At 12-month follow-up 62 patients were free of atrial fibrillation without significant differences between groups (P = 0.28). Conversion to SR occurred in 69.8% (37/53) of patients with paroxysmal AF, in 28.2% (11/39) of patients with permanent AF and in 44.4% (12/27) of patients in persistent AF. Cardiac surgery in general resulted in an overall improvement of the RAND SF-36 and the MFI-20. However, the EQ-5D showed a significant deterioration in the subscale Pain/Discomfort for both groups (P < 0.001), with a significant worse outcome for the control group (P = 0.006). CONCLUSIONS: Health-related quality of life in patients with paroxysmal, permanent and persistent atrial fibrillation improves after cardiac surgery regardless of giving add-on surgery or not, but this improvement is presumably more affected by treating the underlying heart disease than by restoring sinus rhythm.