Cost Effectiveness in Health and Medicine.

Patient-Centered Medicine: Transforming the Clinical Method

OBJECTIVE To synthesize the cost-effectiveness (CE) of interventions to prevent and control diabetes, its complications, and comorbidities. RESEARCH DESIGN AND METHODS We conducted a systematic review of literature on the CE of diabetes interventions recommended by the American Diabetes Association (ADA) and published between January 1985 and May 2008. We categorized the strength of evidence about the CE of an intervention as strong, supportive, or uncertain. CEs were classified as cost saving (more health benefit at a lower cost), very cost-effective (≤$25,000 per life year gained [LYG] or quality-adjusted life year [QALY]), cost-effective ($25,001 to $50,000 per LYG or QALY), marginally cost-effective ($50,001 to $100,000 per LYG or QALY), or not cost-effective (>$100,000 per LYG or QALY). The CE classification of an intervention was reported separately by country setting (U.S. or other developed countries) if CE varied by where the intervention was implemented. Costs were measured in 2007 U.S. dollars. RESULTS Fifty-six studies from 20 countries met the inclusion criteria. A large majority of the ADA recommended interventions are cost-effective. We found strong evidence to classify the following interventions as cost saving or very cost-effective: (I) Cost saving— 1 ) ACE inhibitor (ACEI) therapy for intensive hypertension control compared with standard hypertension control; 2 ) ACEI or angiotensin receptor blocker (ARB) therapy to prevent end-stage renal disease (ESRD) compared with no ACEI or ARB treatment; 3 ) early irbesartan therapy (at the microalbuminuria stage) to prevent ESRD compared with later treatment (at the macroalbuminuria stage); 4 ) comprehensive foot care to prevent ulcers compared with usual care; 5 ) multi-component interventions for diabetic risk factor control and early detection of complications compared with conventional insulin therapy for persons with type 1 diabetes; and 6 ) multi-component interventions for diabetic risk factor control and early detection of complications compared with standard glycemic control for persons with type 2 diabetes. (II) Very cost-effective— 1 ) intensive lifestyle interventions to prevent type 2 diabetes among persons with impaired glucose tolerance compared with standard lifestyle recommendations; 2 ) universal opportunistic screening for undiagnosed type 2 diabetes in African Americans between 45 and 54 years old; 3 ) intensive glycemic control as implemented in the UK Prospective Diabetes Study in persons with newly diagnosed type 2 diabetes compared with conventional glycemic control; 4 ) statin therapy for secondary prevention of cardiovascular disease compared with no statin therapy; 5 ) counseling and treatment for smoking cessation compared with no counseling and treatment; 6 ) annual screening for diabetic retinopathy and ensuing treatment in persons with type 1 diabetes compared with no screening; 7 ) annual screening for diabetic retinopathy and ensuing treatment in persons with type 2 diabetes compared with no screening; and 8 ) immediate vitrectomy to treat diabetic retinopathy compared with deferred vitrectomy. CONCLUSIONS Many interventions intended to prevent/control diabetes are cost saving or very cost-effective and supported by strong evidence. Policy makers should consider giving these interventions a higher priority.

https://care.diabetesjournals.org/content/diacare/33/8/1872.full.pdf

Cost-effectiveness of interventions to prevent and control diabetes mellitus: a systematic review.

Background
Research shows that stroke patients and their families are dissatisfied with the information provided and have a poor understanding of stroke and associated issues.

Objectives
To assess the effectiveness of information provision strategies in improving the outcome for stroke patients or their identified caregivers, or both.

Search methods
For this update we searched the Cochrane Stroke Group Trials Register (June 2012), the Cochrane Central Register of Controlled trials (CENTRAL), the Cochrane Database of Systematic Reviews (CDSR), the Database of Abstracts of Reviews of Effects (DARE), the NHS Economic Evaluation Database (EED), and the Health Technology Assessment (HTA) Database (The Cochrane Library June, 2012), MEDLINE (1966 to June 2012), EMBASE (1980 to June 2012), CINAHL (1982 to June 2012) and PsycINFO (1974 to June 2012). We also searched ongoing trials registers, scanned bibliographies of relevant articles and books and contacted researchers.

Selection criteria
Randomised trials involving patients or carers of patients with a clinical diagnosis of stroke or transient ischaemic attack (TIA) where an information intervention was compared with standard care, or where information and another therapy were compared with the other therapy alone.

Data collection and analysis
Two review authors independently assessed trial eligibility and methodological quality and extracted data. Primary outcomes were knowledge about stroke and stroke services, and impact on mood.

Main results
We have added four new trials to this update. This review now includes 21 trials involving 2289 patient and 1290 carer participants. Nine trials evaluated a passive and 12 trials an active information intervention. Meta-analyses showed a significant effect in favour of the intervention on patient knowledge (standardised mean difference (SMD) 0.29, 95% confidence interval (CI) 0.12 to 0.46, P 0.05) on number of cases of anxiety or depression in patients, carer mood or satisfaction, or death. Qualitative analyses found no strong evidence of an effect on other outcomes. Post-hoc subgroup analyses showed that active information had a significantly greater effect than passive information on patient mood but not on other outcomes.

Authors' conclusions
There is evidence that information improves patient and carer knowledge of stroke, aspects of patient satisfaction, and reduces patient depression scores. However, the reduction in depression scores was small and may not be clinically significant. Although the best way to provide information is still unclear there is some evidence that strategies that actively involve patients and carers and include planned follow-up for clarification and reinforcement have a greater effect on patient mood.

Information provision for stroke patients and their caregivers

This paper provides a review of the quantitative literature on HIV-related stigma and medication adherence, including: (1) synthesis of the empirical evidence linking stigma to adherence, (2) examination of proposed causal mechanisms of the stigma and adherence relationship, and (3) methodological critique and guidance for future research. We reviewed 38 studies reporting either cross-sectional or prospective analyses of the association of HIV-related stigma to medication adherence since the introduction of antiretroviral therapies (ART). Although there is substantial empirical evidence linking stigma to adherence difficulties, few studies provided data on psychosocial mechanisms that may account for this relationship. Proposed mechanisms include: (a) enhanced vulnerability to mental health difficulties, (b) reduction in self-efficacy, and (c) concerns about inadvertent disclosure of HIV status. Future research should strive to assess the multiple domains of stigma, use standardized measures of adherence, and include prospective analyses to test mediating variables.

The Association of HIV-Related Stigma to HIV Medication Adherence: A Systematic Review and Synthesis of the Literature

BackgroundA self-reporting questionnaire is the most convenient and cheapest way to assess medication adherence. A new 8-item self-reported Morisky Medication Adherence Scale (MMAS) has been developed and has shown better psychometric properties than the original 4-item Morisky scale.ObjectiveTo examine the validity, including convergent known-groups and construct validity, and reliability, including internal consistency and test–retest reliability, of the MMAS in Thai patients with type 2 diabetes.MethodsThe data were derived from a cross-sectional study. In a convenience sample, 303 type 2 diabetic outpatients were interviewed at the General Police Hospital in Bangkok, Thailand, between January and June 2007. Face-to-face interviews included MMAS, medication adherence visual analog scale (MA-VAS), and sociodemographic data. Medical records were reviewed for clinical data such as hemoglobin A1c (A1C) levels.ResultsInternal consistency reliability was moderate (Cronbach's α = 0.61), whereas the test–retes...

Psychometric Properties of the Thai Version of the 8-item Morisky Medication Adherence Scale in Patients with Type 2 Diabetes

Background
Data are scarce on the comparison of EQ-5D index scores using the UK, US, and Japan preference weights in other populations. This study was aimed to examine the differences and agreements between these three weights, psychometric properties including test-retest reliability, convergent and known-groups validity, and the impact of differences in the EQ-5D scores on the outcome of cost-utility analysis in Thai people.

https://link.springer.com/content/pdf/10.1186%2F1477-7525-6-71.pdf

A comparison of EQ-5D index scores using the UK, US, and Japan preference weights in a Thai sample with type 2 diabetes

Due to the problem of high ceiling effects of the EQ-5D-3L, the EQ-5D-5L was developed. However, little was known about the full psychometric properties of the EQ-5D-5L. Thus, this study aimed to evaluate its practicality, reliability, validity, and responsiveness in Thai patients with chronic diseases. One thousand one hundred and fifty-six adults taking a medicine at least 3 months were identified from three university hospitals in Bangkok, Thailand, between July 2014 and March 2015. Practicality was evaluated by administration times and ceiling effects. Test–retest reliability was assessed using weighted kappa and intraclass correlation coefficients (ICCs). Validity was tested with correlations between the EQ-5D-5L and WHOQoL-BREF and SF-12v2, and known-groups validity. Responsiveness was measured with standardized effect sizes (SES). The mean administration time was approximately 2 min, and the ceiling effect of the EQ-5D-5L index was 13.6 %. The weighted kappa values and ICC of the EQ-5D-5L were 0.48–0.61 and 0.82, respectively. Similar dimensions of the EQ-5D-5L had higher correlations with those of WHOQoL-BREF and SF-12v2. As expected, elderly, female, low-educated, unemployed, higher number of comorbidities and medicines, patients’ perception of poor disease control, and having an adverse drug reaction tended to have poorer EQ-5D-5L scores. The SES of EQ-5D-5L index and EQ-VAS were considered small (0.33–0.42) for the improved group. For the worsened group, the SES of the EQ-5D-5L index were considered small (−0.29) but that of the EQ-VAS considered large (−0.82). The EQ-5D-5L was practical, reliable, valid, and responsive in Thai patients with chronic diseases.

Psychometric properties of the EQ-5D-5L in Thai patients with chronic diseases

Objective: To assess reliability and validity of the Thai abbreviated version of World Health Organization quality of life (WHOQOL-BREF-THAI) in HIV/AIDS patients. Material and Method: The present study is descriptive research. Data were purposively collected from 120 HIV/AIDS outpatients at Bamrasnaradura Infectious Disease Institute, Thailand, during September-December, 2004. Results: Cronbach’s alpha ranged from 0.61 to 0.81 across domains. Exploratory factor analysis identified four major domains: physical, psychological, social and environmental domains, corresponding to the four WHOQOL-BREF domains. The four domain scores correlated positively with general health satisfaction and overall quality of life questions (all p < 0.01 except general health & social domain p < 0.05), and correlated negatively with the frequency and severity of HIV symptoms (all p < 0.01). The four domain scores discriminated between patients with higher and lower frequency and severity of HIV symptoms (all p < 0.01). Conclusion: The present study shows that WHOQOL-BREF THAI can be a good generic health-related quality of life instrument in HIV/AIDS patients.

Psychometric properties of WHOQOL-BREF-THAI in patients with HIV/AIDS.

The utility approach to assessing health-related quality of life is the most widely used technique for assessing preferences for health outcomes in the economic evaluation of health care. The scale for utility scores assigns a value of 1.0 to perfect health and 0.0 to death. The utility scores are employed to weigh time spent in each health state to estimate quality-adjusted life years (QALYs) gained, which is used as the denominator in cost-utility analysis and cost-effectiveness analysis. Utility scores are obtained through direct assessments using techniques such as standard gamble (SG), time-trade off (TTO), and visual analog scale (VAS), or by using multi-attribute systems such as the Health Utilities Index (HUI) or EuroQol (EQ-5D). According to international HE guidelines, the most preferred utility methods are SG and TTO, followed by EQ-5D, VAS and HUI, respectively In Thailand, the EQ-5D is the most recommended utility method because it has acceptable feasibility and validity.

Phantipa Sakthong

Papers

Psychometric Properties of the Thai Version of the 8-item Morisky Medication Adherence Scale in Patients with Type 2 Diabetes

A comparison of EQ-5D index scores using the UK, US, and Japan preference weights in a Thai sample with type 2 diabetes

Psychometric properties of the EQ-5D-5L in Thai patients with chronic diseases

Psychometric properties of WHOQOL-BREF-THAI in patients with HIV/AIDS.

Measurement of clinical-effect: utility.