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1.
JAMA Netw Open ; 4(4): e213927, 2021 04 01.
Artigo em Inglês | MEDLINE | ID: mdl-33792730

RESUMO

Importance: Parental smoking adversely affects parents' and children's health. There are effective interventions delivered in pediatric settings to help parents quit smoking. The cost-effectiveness of this type of intervention is not known. Objective: To evaluate the cost-effectiveness of a parental smoking cessation intervention, the Clinical Effort Against Secondhand Smoke Exposure (CEASE) program, delivered in pediatric primary care, compared with usual care from a health care organization's perspective. Design, Setting, and Participants: This economic evaluation used data on intervention costs and parental smoking cessation collected prospectively as part of the CEASE randomized clinical trial. Data were collected at pediatric offices in 5 US states from April 2015 to October 2017. Participants included parents of children attending 10 pediatric primary care practices (5 control, 5 intervention). Data analysis was performed from October 2019 to August 2020. Exposures: The trial compared CEASE (practice training and support to address family tobacco use) vs usual care. Main Outcomes and Measures: The overall cost and incremental cost per quit of the CEASE intervention were calculated using microcosting methods. CEASE effectiveness was estimated using 2 trial outcomes measures assessed in repeated cross-sections: (1) change in smoking prevalence assessed by parental report for intervention vs usual care practices at 2 weeks after program initiation (baseline) and at 2-year follow-up and (2) changes in the proportion of smokers who achieved cotinine-confirmed smoking cessation in the previous 2 years at baseline vs follow-up. Monte Carlo analyses were used to provide 95% CIs. Results: The study included a total of 3054 participants (1523 at baseline and 1531 at follow-up); 2163 (70.8%) were aged 25 to 44 years old, and 2481 (81.2%) were women. Over 2 years, the total cost of implementing and sustaining CEASE across 5 intervention practices was $115 778. The incremental cost per quit for CEASE compared with usual care was $1132 (95% CI, $653-$3603), according to the change in parent-reported smoking prevalence, and $762 (95% CI, $418-$2883), according to cotinine-confirmed cessation. CEASE was cost-effective at a willingness-to-pay threshold of $2000 per quit in 88.0% of simulations based on the parent-reported smoking prevalence and 94.6% of simulations based on cotinine-confirmed smoking cessation measures. Conclusions and Relevance: These findings suggest that the CEASE intervention was associated with an incremental cost per quit that compared favorably with those of other clinical smoking cessation interventions. CEASE is inexpensive to initiate and maintain in the clinical pediatric setting, suggesting that it has the potential for a high impact on population health.


Assuntos
Terapia Comportamental/economia , Relações Pais-Filho , Atenção Primária à Saúde/economia , Abandono do Hábito de Fumar/economia , Adulto , Terapia Comportamental/métodos , Criança , Análise Custo-Benefício , Feminino , Seguimentos , Comportamentos Relacionados com a Saúde , Humanos , Pais , Pediatria/economia , Atenção Primária à Saúde/métodos , Abandono do Hábito de Fumar/métodos
2.
JAMA Netw Open ; 4(3): e211778, 2021 03 01.
Artigo em Inglês | MEDLINE | ID: mdl-33720373

RESUMO

Importance: Youth anxiety and depression are common and undertreated. Pediatric transdiagnostic interventions for anxiety and/or depression may be associated with improved access to treatment among youths. Objective: To evaluate the cost-effectiveness of a pediatric transdiagnostic brief behavioral therapy (BBT) program for anxiety and/or depression compared with assisted referral to community outpatient mental health care (ARC). Design, Setting, and Participants: In this economic evaluation, an incremental cost-effectiveness analysis was performed from the societal perspective using data from a randomized clinical trial of youths with full or probable diagnoses of anxiety or depression who were recruited from pediatric clinics in San Diego, California, and Pittsburgh, Pennsylvania. The trial was conducted from October 6, 2010, through December 5, 2014, and this analysis was performed from January 1, 2019, through October 20, 2020. Interventions: In the randomized clinical trial, youths were randomized to BBT (n = 95) or ARC (n = 90). The BBT program consisted of 8 to 12 weekly 45-minute sessions of behavioral therapy delivered in pediatric clinics by master's-level therapists. Families randomized to ARC received personalized referrals to mental health care and telephone calls to support access to care. Main Outcomes and Measures: Anxiety-free days, depression-free days, quality-adjusted life-years (QALYs), and costs based on incremental cost-effectiveness ratios from intake through 32-week follow-up. A cost-effectiveness acceptability curve for QALYs was used to assess the probability that BBT was cost-effective compared with ARC over a range of amounts that a decision-maker might be willing to pay for an additional outcome. Results: Enrolled patients included 185 youths (mean [SD] age, 11.3 [2.6] years; 107 [57.8%] female; 144 [77.8%] White; and 38 [20.7%] Hispanic). Youths who received BBT experienced significantly more anxiety-free days (difference, 28.63 days; 95% CI, 5.86-50.71 days; P = .01) and QALYs (difference, 0.026; 95% CI, 0.009-0.046; P = .007) compared with youths who received ARC. Youths who received BBT experienced more depression-free days than did youths who received ARC (difference, 10.52 days; 95% CI, -4.50 to 25.76 days; P = .18), but the difference was not statistically significant. The mean incremental cost-effectiveness ratio was -$41 414 per QALY (95% CI, -$220 601 to $11 468). The cost-effectiveness acceptability curve analysis indicated that, at a recommended willingness-to-pay threshold of $50 000 per QALY, the probability that BBT would be cost-effective compared with ARC at 32 weeks was 95.6%. Conclusions and Relevance: In this economic evaluation, BBT in primary care was significantly associated with better outcomes and a greater probability of cost-effectiveness at 32 weeks compared with ARC. The findings suggest that transdiagnostic BBT may be associated with improved youth anxiety and functioning at a reasonable cost.


Assuntos
Ansiedade/terapia , Terapia Comportamental/economia , Análise Custo-Benefício , Depressão/terapia , Atenção Primária à Saúde/economia , Adolescente , Criança , Feminino , Humanos , Masculino
3.
Postgrad Med ; 133(4): 421-427, 2021 May.
Artigo em Inglês | MEDLINE | ID: mdl-33593201

RESUMO

Background: The opioid epidemic continues to generate a significant mental and physical health burden on patients, and claims the life of almost 150 Americans daily. Making matters worse, an increase in relapses and/or opioid-related deaths has been reported in more than 40 U.S. states since the start of the COVID-19 pandemic. Opioid use disorder (OUD) is one of the single most expensive disorders in the United States, generating average medical costs of $60B from just 2 million Americans diagnosed with the disorder. In commercial use since 2019, reSET-O is a non-drug, prescription digital therapeutic (PDT) that delivers evidence-based neurobehavioral treatment for OUD and helps overcome the barriers associated with access to care, stigma, and social distancing. Although shown to be cost effective and efficacious in clinical trials and real-world evidence studies, respectively, information on its value for money from a health utilities and cost per quality-adjusted life-year is needed to inform policy discussions.Objectives: To evaluate the impact of reSET-O on health utilities and assess its overall cost per quality-adjusted life year (QALY) gained vs. treatment-as-usual (TAU).Methods: Decision analytic model comparing reSET-O plus TAU to TAU alone (i.e. buprenorphine, face-to-face counseling, and contingency management) over 12 weeks. Clinical effectiveness data (abstinence and health utility) were obtained from a clinical trial, and resource utilization and cost data were adapted from a recent claims data analysis to reflect less frequent face-to-face counseling with the therapeutic.Results: The addition of reSET-O to TAU decreases total health care costs by -$131 and resulted in post-treatment utility values within population norms, with a corresponding gain of 0.003 QALYs. reSET-O when used adjunctively to TAU was economically dominant (less costly, more effective) vs. TAU alone.Conclusion: reSET-O is an economically-dominant adjunctive treatment for OUD and is associated with an overall reduction in total incremental cost vs TAU.


Assuntos
Terapia Comportamental/organização & administração , Acesso aos Serviços de Saúde/organização & administração , Transtornos Relacionados ao Uso de Opioides/terapia , Terapia Comportamental/economia , COVID-19/epidemiologia , Análise Custo-Benefício , Acesso aos Serviços de Saúde/economia , Humanos , Modelos Econométricos , Epidemia de Opioides , Transtornos Relacionados ao Uso de Opioides/epidemiologia , Pandemias , Distanciamento Físico , Anos de Vida Ajustados por Qualidade de Vida , SARS-CoV-2 , Estigma Social
4.
Nicotine Tob Res ; 23(1): 99-106, 2021 01 07.
Artigo em Inglês | MEDLINE | ID: mdl-31993637

RESUMO

INTRODUCTION: Financial incentives effectively increase smoking cessation rates, but it is unclear via which psychological mechanisms incentives influence quit behavior. The current study examines how receiving financial incentives for smoking cessation leads to quitting smoking and investigates several mediators and moderators of that relationship. AIMS AND METHODS: The study sample consisted of 604 tobacco-smoking employees from 61 companies in the Netherlands who completed a baseline and follow-up questionnaire. The current study is a secondary analysis from a cluster randomized trial where employees received smoking cessation group counseling at the workplace. Participants in the intervention group additionally received financial incentives of €350 in total for 12-month continuous smoking abstinence. We used a two-level path analysis to test a model that assesses the effects of financial incentives through smoking cessation program evaluation, medication use, nicotine replacement use, attitudes, self-efficacy, and social influences on quit success. We additionally tested whether an individual's reward responsiveness moderated the influence of incentives on quit success. RESULTS: The effect of financial incentives on quit success was mediated by a higher self-efficacy. Financial incentives were also associated with a higher use of cessation medication. A more positive program evaluation was related to higher self-efficacy, more social influence to quit, and more positive attitudes about quitting. The results did not differ significantly by individual reward responsiveness. CONCLUSIONS: The results of the current study suggest that financial incentives may be used to increase medication use and self-efficacy for quitting smoking, which offers an indirect way to increase successful smoking cessation. IMPLICATIONS: (1) This is the first study investigating via which psychological pathways financial incentives for quitting smoking can lead to long-term quit success. (2) The results showed a path between financial incentives and a higher likelihood of medication use. Incentives may encourage smokers to use medication in order to increase their chance of quitting smoking and receive the reward. (3) There was a path from financial incentives to quit success via a higher self-efficacy. (4) The effects of financial incentives did not depend on individual reward responsiveness.


Assuntos
Terapia Comportamental/economia , Motivação , Fumantes/psicologia , Abandono do Hábito de Fumar/economia , Fumar/terapia , Dispositivos para o Abandono do Uso de Tabaco/estatística & dados numéricos , Terapia Comportamental/métodos , Feminino , Promoção da Saúde , Humanos , Masculino , Pessoa de Meia-Idade , Países Baixos/epidemiologia , Fumar/epidemiologia , Fumar/psicologia , Abandono do Hábito de Fumar/métodos , Abandono do Hábito de Fumar/psicologia , Local de Trabalho
5.
J Autism Dev Disord ; 51(2): 715-724, 2021 Feb.
Artigo em Inglês | MEDLINE | ID: mdl-32617794

RESUMO

Services for children with autism spectrum disorder (ASD) and their families have evolved with the advent of the Medicaid waiver, leading to more family-based coordination of care. Evaluating family involvement, the current investigation compared 230 families of children with ASD receiving Medicaid waiver services to a propensity-score matched group of 230 families who were waiting for such services (i.e., registry families). Compared to the registry, waiver families reported more involvement in service planning tasks, but not activities related to future-planning, managing crisis situations, or searching for and securing funding. Additional analyses characterize waiver families as engaging in high levels of coordinating and delivering behavioral interventions for their child. Implications for family burden and future programming for waiver programs are discussed.


Assuntos
Transtorno do Espectro Autista/economia , Terapia Comportamental/economia , Cuidadores/economia , Família , Serviços de Assistência Domiciliar/economia , Medicaid/economia , Adolescente , Transtorno do Espectro Autista/epidemiologia , Transtorno do Espectro Autista/terapia , Terapia Comportamental/tendências , Cuidadores/tendências , Criança , Estudos Transversais , Feminino , Serviços de Assistência Domiciliar/tendências , Humanos , Masculino , Medicaid/tendências , Estados Unidos/epidemiologia
6.
Med Care ; 58(10): 919-926, 2020 10.
Artigo em Inglês | MEDLINE | ID: mdl-32842044

RESUMO

BACKGROUND: Relative costs of care among treatment options for opioid use disorder (OUD) are unknown. METHODS: We identified a cohort of 40,885 individuals with a new diagnosis of OUD in a large national de-identified claims database covering commercially insured and Medicare Advantage enrollees. We assigned individuals to 1 of 6 mutually exclusive initial treatment pathways: (1) Inpatient Detox/Rehabilitation Treatment Center; (2) Behavioral Health Intensive, intensive outpatient or Partial Hospitalization Services; (3) Methadone or Buprenorphine; (4) Naltrexone; (5) Behavioral Health Outpatient Services, or; (6) No Treatment. We assessed total costs of care in the initial 90 day treatment period for each strategy using a differences in differences approach controlling for baseline costs. RESULTS: Within 90 days of diagnosis, 94.8% of individuals received treatment, with the initial treatments being: 15.8% for Inpatient Detox/Rehabilitation Treatment Center, 4.8% for Behavioral Health Intensive, Intensive Outpatient or Partial Hospitalization Services, 12.5% for buprenorphine/methadone, 2.4% for naltrexone, and 59.3% for Behavioral Health Outpatient Services. Average unadjusted costs increased from $3250 per member per month (SD $7846) at baseline to $5047 per member per month (SD $11,856) in the 90 day follow-up period. Compared with no treatment, initial 90 day costs were lower for buprenorphine/methadone [Adjusted Difference in Differences Cost Ratio (ADIDCR) 0.65; 95% confidence interval (CI), 0.52-0.80], naltrexone (ADIDCR 0.53; 95% CI, 0.42-0.67), and behavioral health outpatient (ADIDCR 0.54; 95% CI, 0.44-0.66). Costs were higher for inpatient detox (ADIDCR 2.30; 95% CI, 1.88-2.83). CONCLUSION: Improving health system capacity and insurance coverage and incentives for outpatient management of OUD may reduce health care costs.


Assuntos
Tratamento de Substituição de Opiáceos/economia , Transtornos Relacionados ao Uso de Opioides/tratamento farmacológico , Transtornos Relacionados ao Uso de Opioides/economia , Transtornos Relacionados ao Uso de Opioides/reabilitação , Adolescente , Adulto , Idoso , Assistência Ambulatorial/economia , Terapia Comportamental/economia , Buprenorfina/uso terapêutico , Estudos de Coortes , Feminino , Custos de Cuidados de Saúde , Hospitalização/economia , Humanos , Masculino , Medicare , Metadona/uso terapêutico , Pessoa de Meia-Idade , Naltrexona/uso terapêutico , Antagonistas de Entorpecentes/uso terapêutico , Estudos Retrospectivos , Estados Unidos
7.
Nutrients ; 12(8)2020 Jul 31.
Artigo em Inglês | MEDLINE | ID: mdl-32752114

RESUMO

Eating disorders (ED) are among the top three most common debilitating illnesses in adolescent females, while high Body Mass Index (BMI) is one of the five leading modifiable risk factors for preventable disease burden. The high prevalence of eating and weight-related problems in adolescence is of great concern, particularly since this is a period of rapid growth and development. Here, we comment on the current evidence for the prevention of EDs and high BMI and the importance of assessing the cost-effectiveness of interventions that integrate the prevention of EDs and high BMI in this population. There is evidence that there are effective interventions targeted at children, adolescents and young adults that can reduce the prevalence of risk factors associated with the development of EDs and high BMI concurrently. However, optimal decision-making for the health of younger generations involves considering the value for money of these effective interventions. Further research investigating the cost-effectiveness of potent and sustainable integrated preventive interventions for EDs and high BMI will provide decision makers with the necessary information to inform investment choices.


Assuntos
Índice de Massa Corporal , Transtornos da Alimentação e da Ingestão de Alimentos/prevenção & controle , Obesidade Pediátrica/prevenção & controle , Serviços Preventivos de Saúde/economia , Adolescente , Terapia Comportamental/economia , Criança , Pré-Escolar , Análise Custo-Benefício , Transtornos da Alimentação e da Ingestão de Alimentos/economia , Feminino , Humanos , Masculino , Obesidade Pediátrica/economia , Adulto Jovem
8.
Trials ; 21(1): 562, 2020 Jun 23.
Artigo em Inglês | MEDLINE | ID: mdl-32576275

RESUMO

BACKGROUND: In Germany, evidence-based outpatient smoking cessation therapies are widely available. Long-term abstinence rates, however, are limited. Studies suggest that short-term residential therapy enables a higher level of environmental control, more intense contact and greater support among patients and from therapists, which could result in higher abstinence rates. The aim of the current START-study is to investigate the long-term efficacy of a short-term residential therapy exclusively for smoking cessation, conducted by a mobile team of expert therapists. METHODS: A randomized controlled trial (RCT) is conducted to examine the efficacy of residential behavior therapeutic smoking cessation therapy compared to standard outpatient behavior therapeutic smoking cessation group therapy. Adult smokers consuming 10 or more cigarettes per day, who are willing to stop smoking, are randomized in a ratio of 1:1 between therapy groups. The primary endpoint is sustained abstinence for 6-month and 12-month periods. Secondary endpoints include smoking status after therapy, 7-day point abstinence after the 6-month and 12-month follow-ups, level of physical dependence, cost-effectiveness, use of nicotine replacement products, health-related quality of life, self-efficacy expectation for tobacco abstinence, motivational and volitional determinants of behavior change, self-reported depressive symptom severity, adverse events and possible side effects. Assessments will take place at baseline, post-therapy, and at 6-month and 12-month intervals after smoking cessation. DISCUSSION: There is a high demand for long-term effective smoking cessation therapies. This study represents the first prospective RCT to examine the long-term efficacy of a residential smoking cessation therapy program compared to standard outpatient group therapy as an active control condition. The residential therapeutic concept may serve as a new model to substantially enhance future cessation therapies and improve the understanding of therapeutic impact factors on tobacco abstinence. Utilizing a mobile team, the model could be applied efficiently to medical centers that do not have permanent and trained personnel for smoking cessation at their disposal. TRIAL REGISTRATION: German Register for Clinical Trials (Deutsches Register für Klinische Studien), DRKS00013466. Retrospectively registered on 1 April 2019. https://www.drks.de/drks_web/navigate.do?navigationId=start.


Assuntos
Assistência Ambulatorial/métodos , Terapia Comportamental/métodos , Fumar Cigarros/terapia , Psicoterapia Breve/métodos , Psicoterapia de Grupo/métodos , Tratamento Domiciliar/métodos , Abandono do Hábito de Fumar/métodos , Adulto , Idoso , Idoso de 80 Anos ou mais , Assistência Ambulatorial/economia , Terapia Comportamental/economia , Fumar Cigarros/epidemiologia , Análise Custo-Benefício , Depressão , Seguimentos , Alemanha/epidemiologia , Humanos , Pessoa de Meia-Idade , Motivação , Estudos Prospectivos , Psicoterapia Breve/economia , Psicoterapia de Grupo/economia , Qualidade de Vida , Ensaios Clínicos Controlados Aleatórios como Assunto , Tratamento Domiciliar/economia , Abandono do Hábito de Fumar/economia , Dispositivos para o Abandono do Uso de Tabaco , Resultado do Tratamento , Adulto Jovem
9.
J Stud Alcohol Drugs ; 81(2): 152-163, 2020 03.
Artigo em Inglês | MEDLINE | ID: mdl-32359044

RESUMO

OBJECTIVE: The purpose of this study was to evaluate the costs and cost-effectiveness of two treatments for 101 alcohol use disorder patients and their intimate partners--group behavioral couples' therapy plus individual-based treatment (G-BCT), or standard behavioral couples' therapy plus individual-based treatment (S-BCT). METHOD: We estimated the per-patient cost of each intervention using a microcosting approach that allowed us to estimate costs of specific components in each intervention as well as the overall total costs. Using simple means analysis and multiple regression models, we estimated the incremental effectiveness of G-BCT relative to S-BCT. Immediately after treatment and 12 months after treatment, we computed incremental cost-effectiveness ratios (ICER) and cost-effectiveness acceptability curves for percentage days abstinent, adverse consequences of alcohol and drugs, and overall relationship functioning. RESULTS: The average per-patient cost of delivering G-BCT was $674, significantly less than the cost of S-BCT ($831). However, 12 months after treatment, S-BCT participants performed better on all outcomes compared with those in G-BCT, and the calculated ICER moving from G-BCT to S-BCT ranged from $10 to $12 across these outcomes. The current findings indicated that, except at very low willingness-to-pay values, S-BCT is a cost-effective option relative to G-BCT when considering 12-month posttreatment outcomes. CONCLUSIONS: As expected, G-BCT was delivered at a lower cost per patient than S-BCT; however, S-BCT performed better over time on the clinical outcomes studied. These economic findings indicate that alcohol use disorder treatment providers should seriously consider S-BCT over G-BCT when deciding what format to use in behavioral couples' therapy.


Assuntos
Alcoolismo/economia , Alcoolismo/terapia , Terapia Comportamental/economia , Análise Custo-Benefício , Terapia de Casal/economia , Parceiros Sexuais , Adulto , Alcoolismo/psicologia , Terapia Comportamental/métodos , Análise Custo-Benefício/métodos , Terapia de Casal/métodos , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Psicoterapia de Grupo/economia , Psicoterapia de Grupo/métodos , Parceiros Sexuais/psicologia
11.
Nicotine Tob Res ; 22(9): 1632-1635, 2020 08 24.
Artigo em Inglês | MEDLINE | ID: mdl-32304211

RESUMO

INTRODUCTION: Incentive-based smoking cessation interventions increase quit rates. The optimal incentive, however, is unknown. We used a willingness-to-accept (WTA) auction where smokers submitted bids indicating the incentive they would need to receive for 1 week of smoking cessation. AIMS AND METHODS: Smokers ready to quit (n = 35) participated in a WTA auction, naming the amount they needed to be paid to quit for 1 week. Auction winners received an incentive if they successfully quit. All smokers received nicotine replacement therapy and self-help cessation materials. Carbon monoxide concentrations were monitored remotely three times during the week and in person at the final session. RESULTS: Participants who smoked their first cigarette within 5 min of waking demanded a significantly larger incentive in exchange for quitting than those who waited (p < .05). About 45% of auction winners quit smoking compared to 20% of nonwinners (p < .05). The cost per quit was $466 among auction winners compared to $894 among nonwinners. CONCLUSIONS: WTA auctions may be an effective way to determine the amount smokers need to be paid to quit, which would allow researchers to estimate the most cost-effective payment to offer as part of incentive-based smoking cessation programs. Replication evaluating longer-term cessation outcomes with larger samples is warranted. IMPLICATIONS: Incentive-based smoking cessation interventions increase quit rates. However, the optimal incentive is unknown. We found that a WTA auction is a feasible technique for estimating the amount smokers need to be paid to quit. Incentives are a surprisingly cost-effective way to facilitate smoking cessation because they are only paid to those who successfully quit. WTA auctions are a promising tool for determining the incentive that strikes the optimal balance between being large enough to motivate cessation, but small enough that it can be offered to the largest possible population of smokers for a given program budget.


Assuntos
Terapia Comportamental/métodos , Promoção da Saúde/economia , Motivação , Fumantes/psicologia , Abandono do Hábito de Fumar/métodos , Fumar/terapia , Dispositivos para o Abandono do Uso de Tabaco/estatística & dados numéricos , Adulto , Terapia Comportamental/economia , Feminino , Comportamentos Relacionados com a Saúde , Humanos , Masculino , Fumar/economia , Fumar/psicologia , Abandono do Hábito de Fumar/economia , Abandono do Hábito de Fumar/psicologia , Adulto Jovem
12.
J Acad Nutr Diet ; 120(7): 1163-1171, 2020 07.
Artigo em Inglês | MEDLINE | ID: mdl-31899170

RESUMO

BACKGROUND: Rural Americans have higher prevalence of obesity and type 2 diabetes (T2D) than urban populations and more limited access to behavioral programs to promote healthy lifestyle habits. Descriptive evidence from the Rural Lifestyle Intervention Treatment Effectiveness trial delivered through local cooperative extension service offices in rural areas previously identified that behavioral modification with both nutrition education and coaching resulted in a lower program delivery cost per kilogram of weight loss maintained at 2-years compared with an education-only comparator intervention. OBJECTIVE: This analysis extended earlier Rural Lifestyle Intervention Treatment Effectiveness trial research regarding weight loss outcomes to assess whether nutrition education with behavioral coaching delivered through cooperative extension service offices is cost-effective relative to nutrition education only in reducing T2D cases in rural areas. DESIGN: A cost-utility analysis was conducted. PARTICIPANTS/SETTING: Trial participants (n=317) from June 2008 through June 2014 were adults residing in rural Florida counties with a baseline body mass index between 30 and 45, but otherwise identified as healthy. INTERVENTION: Trial participants were randomly assigned to low, moderate, or high doses of behavioral coaching with nutrition education (ie, 16, 32, or 48 sessions over 24 months) or a comparator intervention that included 16 sessions of nutrition education without coaching. Participant glycated hemoglobin level was measured at baseline and the end of the trial to assess T2D status. MAIN OUTCOME MEASURES: T2D categories by treatment arm were used to estimate participants' expected annual health care expenditures and expected health-related utility measured as quality adjusted life years (ie, QALYs) over a 5-year time horizon. Discounted incremental costs and QALYs were used to calculate incremental cost-effectiveness ratios for each behavioral coaching intervention dose relative to the education-only comparator. STATISTICAL ANALYSES PERFORMED: Using a third-party payer perspective, Markov transition matrices were used to model participant transitions between T2D states. Replications of the individual participant behavior were conducted using Monte Carlo simulation. RESULTS: All three doses of the behavioral coaching intervention had lower expected total costs and higher estimated QALYs than the education-only comparator. The moderate dose behavioral coaching intervention was associated with higher estimated QALYs but was costlier than the low dose; the moderate dose was favored over the low dose with willingness to pay thresholds over $107,895/QALY. The low dose behavioral coaching intervention was otherwise favored. CONCLUSIONS: Because most rural Americans live in counties with cooperative extension service offices, nutrition education with behavioral coaching programs similar to those delivered through this trial may be effective and efficient in preventing or delaying T2D-associated consequences of obesity for rural adults.


Assuntos
Terapia Comportamental/economia , Análise Custo-Benefício/estatística & dados numéricos , Diabetes Mellitus Tipo 2/prevenção & controle , População Rural/estatística & dados numéricos , Adulto , Idoso , Terapia Comportamental/métodos , Índice de Massa Corporal , Diabetes Mellitus Tipo 2/sangue , Diabetes Mellitus Tipo 2/economia , Feminino , Florida , Hemoglobina A Glicada/análise , Educação em Saúde , Gastos em Saúde/estatística & dados numéricos , Humanos , Estilo de Vida , Masculino , Pessoa de Meia-Idade , Ciências da Nutrição/educação , Resultado do Tratamento
13.
Am J Drug Alcohol Abuse ; 46(1): 109-119, 2020.
Artigo em Inglês | MEDLINE | ID: mdl-31290698

RESUMO

Background: Contingency management (CM) is an empirically supported behavioral treatment for tobacco use, but its efficacy with university student smokers in a developing country is unknown. Objectives: We evaluate a randomized controlled trial of a CM smoking cessation program conducted on a sample of treatment-seeking student smokers at the University of Cape Town.Methods: The study included a recruitment period, a 6-week intervention period, and a 6-month follow-up period. Subjects in the control group (information and monitoring; n = 47, 76% male) were given information to help them quit smoking and had their quit attempt monitored, receiving R50 ($8) at each assessment. Subjects in the treatment group (information and monitoring, plus CM; n = 40, 80% male) could additionally earn R150 ($24) in abstinence-contingent incentives at each assessment. Outcome variables: 7-day point-prevalence abstinence at 6 months and at the end of the intervention period, and a repeated measure of smoking intensity of non-abstinent subjects.Results: CM had no long-term effect on abstinence at 6 months but had a marked and statistically significant effect on the likelihood of abstinence by the end of the intervention period (p < .001). In addition, while CM did not affect smoking intensity, participation in the program decreased the average number of cigarettes smoked per day by non-abstainers (p < .001).Conclusions: The CM program was efficacious in promoting abstinence amongst treatment-seeking university students in a developing country but only while incentives were in place. Future research should focus on promoting continuous abstinence with this target sample.


Assuntos
Motivação , Abandono do Hábito de Fumar , Terapia Comportamental/economia , Terapia Comportamental/métodos , Fumar Cigarros/terapia , Países em Desenvolvimento , Feminino , Humanos , Masculino , África do Sul/epidemiologia , Estudantes , Universidades , Adulto Jovem
14.
Drug Alcohol Depend ; 206: 107687, 2020 01 01.
Artigo em Inglês | MEDLINE | ID: mdl-31753735

RESUMO

BACKGROUND: There is a need for new research addressing the cost prohibitive nature of maintaining contingency management (CM) in community settings. While researchers propose managed care as an option to support costs, there is no research on self-pay models. To inform such research, it is important first to understand client willingness to pay for CM services. We examine acceptability and willingness to pay for CM services among parents with and without young adult children with problematic opioid use. METHODS: A web-based survey was administered to a sample of parents of adult children ages 18-35 with (target sample) and without (comparison sample) a history of problematic opiate use. RESULTS: One hundred thirty parents participated (ntarget = 30; ncomparison = 100) and were predominately white, college educated, and of higher income. Findings showed a high proportion of participants had positive opinions of using incentives for substance use treatment and would consider incentive-based treatments for their child. Most participants reported they would be willing to pay for CM at levels consistent with amounts used in efficacious programs but expressed worry that incentives would be used to buy drugs. Most participants reported this worry would be eased if incentives were delivered via reloadable gift cards and if incentives were only delivered during periods of abstinence. CONCLUSIONS: This is the first study to examine parent perceptions of incentives and acceptability and willingness to pay for CM services. Results suggest self-pay models for disseminating CM to young adults with problematic opioid use may be an option.


Assuntos
Terapia Comportamental/economia , Custos de Cuidados de Saúde , Transtornos Relacionados ao Uso de Opioides/economia , Aceitação pelo Paciente de Cuidados de Saúde/estatística & dados numéricos , Adolescente , Adulto , Atitude , Estudos de Casos e Controles , Criança , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Motivação , Inquéritos e Questionários , Adulto Jovem
15.
BMC Public Health ; 19(1): 1700, 2019 Dec 18.
Artigo em Inglês | MEDLINE | ID: mdl-31852536

RESUMO

BACKGROUND: The rate of tobacco use among people with mental illness is nearly twice that of the general population. Psychotropic medications for tobacco cessation are relatively expensive for most Kenyans. Behavioral counseling and group therapy are effective lower cost strategies to promote tobacco cessation, yet have not been studied in Kenya among individuals with concomitant mental illness. METHODS/DESIGN: One hundred tobacco users with mental illness who were part of an outpatient mental health program in Nairobi, Kenya were recruited and allocated into intervention and control groups of the study (50 users in intervention group and 50 users in control group). Participants allocated to the intervention group were invited to participate in 1 of 5 tobacco cessation groups. The intervention group received the 5As (Ask, Advise, Assess, Assist and Arrange) and tobacco cessation group behavioral intervention, which included strategies to manage cravings and withdrawal, stress and anxiety, and coping with depression due to withdrawal; assertiveness training and anger management; reasons to quit, benefits of quitting and different ways of quitting. Individuals allocated to the control group received usual care. The primary outcome was tobacco cessation at 24 weeks, measured through cotinine strips. Secondary outcomes included number of quit attempts and health-related quality of life. DISCUSSION: This study will provide evidence to evaluate the efficacy and safety of a tobacco cessation group behavioral intervention among individuals with mental illness in Kenya, and to inform national and regional practice and policy. TRIAL REGISTRATION: Trial registration number: NCT04013724. Name of registry: ClinicalTrials.gov. URL of registry: https://register.clinicaltrials.gov Date of registration: 9 July 2019 (retrospectively registered). Date of enrolment of the first participant to the trial: 5th September 2017. Protocol version: 2.0.


Assuntos
Terapia Comportamental/métodos , Análise Custo-Benefício/estatística & dados numéricos , Aconselhamento/métodos , Qualidade de Vida/psicologia , Abandono do Hábito de Fumar/métodos , Abandono do Uso de Tabaco/psicologia , Tabagismo/terapia , Adulto , Idoso , Idoso de 80 Anos ou mais , Terapia Comportamental/economia , Aconselhamento/economia , Feminino , Humanos , Quênia , Masculino , Pessoa de Meia-Idade , Estudos Retrospectivos , Abandono do Hábito de Fumar/economia , Abandono do Uso de Tabaco/estatística & dados numéricos
16.
BMC Psychiatry ; 19(1): 264, 2019 09 02.
Artigo em Inglês | MEDLINE | ID: mdl-31477086

RESUMO

BACKGROUND: The terms affective dysregulation (AD) and irritability describe transdiagnostic dimensions and are characterized by an excessive reactivity to negative emotional stimuli with an affective (anger) and a behavioral component (aggression). Due to early onset, high prevalence and persistence, as well as developmental comorbidity, AD in childhood is one of the most psychosocially impairing and cost-intensive mental health conditions. AD is especially prevalent in children in the youth welfare service. Despite continuous research, there remains a substantial need for diagnostic approaches and optimization of individualized treatment strategies in order to improve outcomes and reduce the subjective and economic burden. METHODS: The ADOPT (Affective Dysregulation - Optimizing Prevention and Treatment) Consortium integrates internationally established, highly experienced and interdisciplinary research groups. The work program encompasses (a) epidemiology, including prevalence of symptoms and disorders, (b) development and evaluation of screening and assessment tools, (c) stepped care approaches for clinically useful personalized medicine, (d) evaluation of an easily accessible and cost-effective online intervention as indicated prevention (treatment effects, moderation/mediation analysis), and (e) evaluation of an intensive personalized modular outpatient treatment in a cohort of children with AD who live with their parents and in a cohort of children with AD who live in out-of-home care (treatment effects, moderation/mediation analysis). DISCUSSION: The results will lead to significant recommendations for improving treatment within routine clinical care in two cohorts of children with AD and coexisting conditions, especially oppositional-defiant disorder, conduct disorder and disruptive mood dysregulation disorder. TRIAL REGISTRATION: Trial registration ADOPT Online: German Clinical Trials Register (DRKS) DRKS00014963 . Registered 27 June 2018. Trial registration ADOPT Treatment: German Clinical Trials Register (DRKS) DRKS00013317 . Registered 27 September 2018. Trial registration ADOPT Institution: German Clinical Trials Register (DRKS) DRKS00014581 . Registered 04 July 2018.


Assuntos
Terapia Comportamental/métodos , Transtornos do Humor/prevenção & controle , Transtornos do Humor/terapia , Adolescente , Agressão , Transtornos de Deficit da Atenção e do Comportamento Disruptivo/epidemiologia , Transtornos de Deficit da Atenção e do Comportamento Disruptivo/prevenção & controle , Transtornos de Deficit da Atenção e do Comportamento Disruptivo/terapia , Terapia Comportamental/economia , Criança , Comorbidade , Transtorno da Conduta/epidemiologia , Transtorno da Conduta/prevenção & controle , Transtorno da Conduta/terapia , Análise Custo-Benefício , Emoções , Feminino , Humanos , Masculino , Transtornos do Humor/epidemiologia , Pais/psicologia , Prevalência , Ensaios Clínicos Controlados Aleatórios como Assunto , Resultado do Tratamento
17.
Health Technol Assess ; 23(45): 1-108, 2019 08.
Artigo em Inglês | MEDLINE | ID: mdl-31460865

RESUMO

BACKGROUND: Cannabis is the most prevalent illicit substance among people with psychosis, and its use is associated with poorer clinical and social outcomes. However, so far, there has been limited evidence that any treatment is effective for reducing use. Contingency management (CM) is an incentive-based intervention for substance misuse that has a substantial evidence base across a range of substances and cohorts. However, to date there have been no randomised controlled trials (RCTs) of CM as a treatment for cannabis use specifically in psychosis. OBJECTIVE: To conduct a RCT investigating the clinical effectiveness and cost-effectiveness of CM in reducing cannabis use among Early Intervention in Psychosis (EIP) service users. DESIGN: The CIRCLE (Contingency Intervention for Reduction of Cannabis in Early Psychosis) trial was a rater-blinded, multicentre RCT with two arms. Participants were randomised 1 : 1 to either an CM arm, in which participants received CM for cannabis use alongside an optimised treatment-as-usual programme including structured psychoeducation, or a control arm in which participants received the treatment as usual only. SETTING: EIP services across the Midlands and the south-east of England. PARTICIPANTS: The main eligibility criteria were EIP service users with a history of psychosis, aged 18-36 years, and having used cannabis at least once per week during 12 of the previous 24 weeks. INTERVENTION: The CM intervention offered financial incentives (i.e. shopping vouchers) for cannabis abstinence over 12 once-weekly sessions, confirmed using urinalysis. The maximum value in vouchers that participants could receive was £240. MAIN OUTCOME MEASURES: The main outcome was time to relapse, operationalised as admission to an acute mental health service or hospital. The primary outcome was assessed at 18 months post inclusion using electronic patient records. Secondary outcomes assessed the clinical effectiveness and cost-effectiveness of the intervention, for which data were collected at 3 and 18 months. RESULTS: A total of 278 participants were randomised to the CM arm and 273 were randomised to the control arm. In total, 530 (96%) participants were followed up for the primary outcome. There was no significant difference in time to admission between trial arms by 18 months following consent (hazard ratio 1.03, 95% confidence interval 0.76 to 1.40). There were no statistically significant differences in most secondary outcomes, including cannabis use, at either follow-up assessment. There were 58 serious adverse events, comprising 52 inpatient episodes, five deaths and one arrest. LIMITATIONS: Participant retention was low at 18 months, limiting the assessment of secondary outcomes. A different CM intervention design or reward level may have been effective. CONCLUSIONS: The CM intervention did not appear to be effective in reducing cannabis use and acute relapse among people with early psychosis and problematic cannabis use. FUTURE WORK: Cannabis use is still a significant clinical concern in this population. A pressing need remains to identify suitable treatments. A wider perspective on the social circumstances of young people with psychosis may be needed for a successful intervention to be found. TRIAL REGISTRATION: Current Controlled Trials ISRCTN33576045. FUNDING: This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 23, No. 45. See the NIHR Journals Library website for further project information.


Assuntos
Terapia Comportamental/economia , Cannabis/efeitos adversos , Transtornos Psicóticos/terapia , Recidiva , Adolescente , Adulto , Análise Custo-Benefício/economia , Inglaterra , Feminino , Humanos , Masculino , Motivação , Transtornos Relacionados ao Uso de Substâncias/terapia , Resultado do Tratamento , Adulto Jovem
18.
Health Psychol ; 38(8): 669-671, 2019 Aug.
Artigo em Inglês | MEDLINE | ID: mdl-31368750

RESUMO

Behavioral interventions can be offered within a wide range of contexts, including public health, medicine, surgery, physical rehabilitation, nutrition, and other health services. These differing services compete for the same resources and it is difficult to compare their value. Systematic standardized methodologies for valuing outcomes are available and are being applied by economists and health services researchers, but are not widely used in our field. With support from the Society for Health Psychology, the National Cancer Institute (NCI), and the Office for Behavioral and Social Sciences Research (OBSSR) at the National Institutes of Health, two working group meetings were held to consider the use of well-established cost-effectiveness methodologies for the evaluation of behavioral and public health interventions. In this special section, we acknowledge a wide range of variability in terms of behavioral interventions typically delivered in nonclinical versus more traditional clinical settings. Three articles address (1) standardizing methods for conducting cost-effectiveness and cost-utility analyses, (2) providing examples to illustrate progress in applying these methods to evaluate interventions delivered in whole or in part in clinical settings, and (3) providing nonclinical intervention examples selected to highlight the challenges and opportunities for evaluating the cost-effectiveness of interventions in more diverse settings. The ability of our field to communicate cost-effectiveness data to policy makers, employers, and insurers that incorporates implementation costs is central to the likelihood of our interventions being adopted by practitioners and reimbursed by payers. (PsycINFO Database Record (c) 2019 APA, all rights reserved).


Assuntos
Terapia Comportamental/economia , Terapia Comportamental/métodos , Medicina do Comportamento/economia , Medicina do Comportamento/métodos , Análise Custo-Benefício/métodos , Humanos
19.
Health Psychol ; 38(8): 672-679, 2019 Aug.
Artigo em Inglês | MEDLINE | ID: mdl-31368751

RESUMO

Health care remains the most expensive sector in the U.S. economy, now accounting for nearly 1 in every 5 dollars spent. The purpose of health care is to improve the health of populations. However, formal medical care is one of many alternatives for improving health. In order to make better use of scarce resources, cost-effectiveness methodologies have been developed to evaluate how to produce the most health within the constraints of available resources. Standardized cost-effectiveness methodologies are now commonly used in the evaluation of medical therapies and new technologies. However, these methods have rarely been employed for the evaluation of behavioral interventions. Behavioral interventions often use measures that are not generally applied in other areas of health outcomes research. A consequence of neglecting to employ standardized cost-effectiveness analysis is that behavioral, psychological, and environmental interventions may be left out of resource allocation discussions. The purpose of this paper is to review standardized approaches to cost-effectiveness analysis and to encourage their use for the evaluation of behavioral intervention programs. Application of standardized methods of cost-effectiveness analysis will allow direct comparisons between investing in behavioral interventions programs in comparison to a wide range of other alternatives. The methods are general and can be used to estimate the cost-effectiveness of social and environmental interventions in addition to traditional medical and surgical treatments. (PsycINFO Database Record (c) 2019 APA, all rights reserved).


Assuntos
Terapia Comportamental/economia , Análise Custo-Benefício/métodos , Humanos , Avaliação de Resultados em Cuidados de Saúde
20.
Health Psychol ; 38(8): 689-700, 2019 Aug.
Artigo em Inglês | MEDLINE | ID: mdl-31368753

RESUMO

This paper examines three distinct examples of interventions in nonclinical settings selected to highlight the challenges and opportunities for evaluating cost-effectiveness in the field of health psychology and behavioral medicine. Nonclinical settings are defined as those involving systems outside of traditional medical/clinical settings, and include interventions tested in clinical settings that can also be implemented in nonclinical settings. The examples in this paper reflect the use of a varying degree of existing cost-effectiveness data and previous health economic analyses. First, the Chronic Disease Self-Management Program model reflects an intervention protocol designed to increase patients' confidence and mastery in their ability to manage their conditions that has been shown to be cost effective for a variety of chronic disease conditions. Second, the cost and cost-effectiveness of tobacco quitlines (e.g., National Tobacco Quit Line) has been the subject of several preliminary cost-effectiveness examinations and has proven to have significant reach and impact on tobacco-related behaviors. Finally, environmental interventions for promoting walking and physical activity in community-based contexts (e.g., PATH trial) are presented and have been shown to be highly relevant for demonstrating cost-effectiveness. Overall, the disciplines of health psychology and behavioral medicine are in a unique position to develop, implement, and evaluate a broader range of interventions in more diverse environments than cost-effectiveness applications in more traditional, clinical settings. (PsycINFO Database Record (c) 2019 APA, all rights reserved).


Assuntos
Terapia Comportamental/economia , Análise Custo-Benefício/métodos , Avaliação de Resultados em Cuidados de Saúde/métodos , Humanos
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