Cost effectiveness

About: Cost effectiveness is a research topic. Over the lifetime, 69775 publications have been published within this topic receiving 1531477 citations.

Why we should be wary of single-center trials.

Abstract: Objective: To highlight the limitations of single-center trials in critical care, using prominent examples from the recent literature; to explore possible reasons for discrepancies between these studies and subsequent multicenter effectiveness trials; and to suggest how the evidence from single-center trials might be used more appropriately in clinical practice. STUDY SELECTION: Topical and illustrative examples of the concepts discussed including trials of patient positioning, the use of steroids for acute respiratory distress syndrome, the dose of hemofiltration, the control of glycemia, and the targets of resuscitation in sepsis. DATA SYNOPSIS: Many positive single-center trials have been contradicted when tested in other settings and, in one case, the subsequent definitive multicentered trial has found a previously recommended intervention associated with active harm. Problems inherent in the nature of single-center studies make recommendations based on their results ill advised. Single-center studies frequently either lack the scientific rigor or external validity required to support widespread changes in practice, and their premature incorporation into guidelines may make the conduct of definitive studies more difficult. Conclusions: We recommend that practice guidelines should rarely, if ever, be based on evidence from single-center trials. Physicians should apply the findings of single-center trials only after careful evaluation of their methodology, and in particular after comparing the context of the trial with their own situation.

Community occupational therapy for older patients with dementia and their care givers: cost effectiveness study

Abstract: OBJECTIVE: To assess the cost effectiveness of community based occupational therapy compared with usual care in older patients with dementia and their care givers from a societal viewpoint. DESIGN: Cost effectiveness study alongside a single blind randomised controlled trial. SETTING: Memory clinic, day clinic of a geriatrics department, and participants' homes. Patients 135 patients aged > or =65 with mild to moderate dementia living in the community and their primary care givers. INTERVENTION: 10 sessions of occupational therapy over five weeks, including cognitive and behavioural interventions, to train patients in the use of aids to compensate for cognitive decline and care givers in coping behaviours and supervision. MAIN OUTCOME MEASURES: Incremental cost effectiveness ratio expressed as the difference in mean total care costs per successful treatment (that is, a combined patient and care giver outcome measure of clinically relevant improvement on process, performance, and competence scales) at three months after randomisation. Bootstrap methods used to determine confidence intervals for these measures. RESULTS: The intervention cost 1183 euros (848 pounds sterling, $1738) (95% confidence interval 1128 euros (808 pounds sterling, $1657) to 1239 euros (888 pounds sterling, $1820)) per patient and primary care giver unit at three months. Visits to general practitioners and hospital doctors cost the same in both groups but total mean costs were 1748 euros (1279 pounds sterling, $2621) lower in the intervention group, with the main cost savings in informal care. There was a significant difference in proportions of successful treatments of 36% at three months. The number needed to treat for successful treatment at three months was 2.8 (2.7 to 2.9). CONCLUSIONS: Community occupational therapy intervention for patients with dementia and their care givers is successful and cost effective, especially in terms of informal care giving.

The clinical effectiveness and cost-effectiveness of long-term weight management schemes for adults: a systematic review.

Abstract: Objective To assess the long-term clinical effectiveness and cost-effectiveness of multicomponent weight management schemes for adults in terms of weight loss and maintenance of weight loss. Data sources Bibliographic databases were searched from inception to December 2009, including the Cochrane Library, MEDLINE (Ovid), EMBASE (Ovid), and MEDLINE In-Process & Other Non-Indexed Citations. Bibliographies of related papers were screened, key conferences and symposia were searched and experts were contacted to identify additional published and unpublished references. Review methods For the clinical effectiveness review, two reviewers independently screened titles and abstracts for eligibility. Inclusion criteria were applied to the full text of retrieved papers by one reviewer and checked by a second reviewer using a pre-piloted inclusion flow chart. The studies were long-term randomised controlled trials (RCTs) of adult participants who were classified by body mass index as overweight or obese. Interventions were multicomponent weight management programmes (including diet, physical activity and behaviour change strategies) that assessed weight measures. Programmes that involved the use of over-the-counter medicines licensed in the UK were also eligible. For the cost-effectiveness review two reviewers independently screened studies for inclusion. Cost-effectiveness, cost-utility, cost-benefit or cost-consequence analyses were eligible. Data were extracted using a standardised and pre-piloted data extraction form. The quality of included studies was assessed using standard criteria. Studies were synthesised through a narrative review with full tabulation of results. Results A total of 3358 references were identified, of which 12 were included in the clinical effectiveness review. Five RCTs compared multicomponent interventions with non-active comparator groups. In general, weight loss appeared to be greater in the intervention groups than in the comparator groups. Two RCTs compared multicomponent interventions that focused on the diet component. In these studies there were no statistically significant differences in weight loss between interventions. Four RCTs compared multicomponent interventions that focused on the physical activity component. There was little consistency in the pattern of results seen, in part owing to the differences in the interventions. In one RCT the intervention focused on the goal-setting interval and it appeared that weight loss was greatest in those given daily goals compared with weekly goals. Overall, where measured, it appeared that most groups began to regain weight at further follow-up. Of the 419 studies identified in the cost-effectiveness searches, none met the full inclusion criteria. Two economic evaluations are described in our review; however, caution is required in their interpretation, as they did not meet all inclusion criteria. Lifetime chronic disease models were used in these studies and the models included the costs and benefits of avoiding chronic illness. Both studies found the interventions to be cost-effective, with estimates varying between -£473 and £7200 (US$12,640) per quality-adjusted life-year gained; methodological omissions from these studies were apparent and caution is therefore required in the interpretation of these results. Conclusions Long-term multicomponent weight management interventions were generally shown to promote weight loss in overweight or obese adults. Weight changes were small however and weight regain was common. There were few similarities between the included studies; consequently an overall interpretation of the results was difficult to make. There is some evidence that weight management interventions are likely to be cost-effective, although caution is required as there were some limitations in the two cost-evaluation studies described. Funding The National Institute for Health Research Health Technology Assessment programme.

Inclusive education ten years after Salamanca: Setting the agenda

Abstract: The articles in this special edition focus on what is, arguably, the biggest challenge facing school systems throughout the world, that of educational inclusion. In economically poorer countries this is mainly about the millions of children who are not able to attend formal education of any kind (Bellamy, 1999). Meanwhile, in wealthier countries many young people leave school with no worthwhile qualifications, whilst others are placed in various forms of special provision away from mainstream educational experiences, and some simply choose to drop out since the lessons seem irrelevant to their lives (Ainscow, 2005; Cesar & Oliveira, 2005). Faced with these challenges, there is evidence of an increased interest in the idea of inclusive education. However, the field remains confused as to what actions need to be taken in order to move policy and practice forward. In some countries, inclusive education is thought of as an approach to serving children with disabilities within general education settings. Internationally, however, it is increasingly seen more broadly as a reform that supports and welcomes diversity amongst all learners (UNESCO, 2001). It presumes that the aim of inclusive education is to eliminate social exclusion that is a consequence of attitudes and responses to diversity in race, social class, ethnicity, religion, gender and ability (Vitello & Mithaug, 1998). As such, it starts from the belief that education is a basic human right and the foundation for a more just society. Just over ten years ago the Salamanca World Conference on Special Needs Education endorsed the idea of inclusive education (UNESCO, 1994). Arguably the most significant international document that has ever appeared in the field of special education, the Salamanca Statement argues that regular schools with an inclusive orientation are "the most effective means of combating discriminatory attitudes, building an inclusive society and achieving education for all" (p. iv). Furthermore, it suggests that such schools can "provide an effective education for the majority of children and improve the efficiency and ultimately the cost effectiveness of the entire education system" (UNESCO, 1994, p. iv). During the subsequent years, there have been considerable efforts in many countries to move educational policy and practice in a more inclusive direction (Freire & Cesar, 2002; Mittler, 2000). In the articles in this special edition, authors from a range of countries present

Clinical and cost-effectiveness of continuous subcutaneous insulin infusion for diabetes

Abstract: Objectives: To assess the clinical and cost-effectiveness of continuous subcutaneous insulin infusion (CSII) compared with multiple daily injections (MDI) in the delivery of intensive insulin therapy for the treatment of diabetes mellitus. Data sources: Electronic databases, references of retrieved articles and manufacturer submissions. Experts in the field were consulted. Review methods: For the systematic review of clinical and cost-effectiveness, studies were assessed for inclusion according to predefined criteria by two reviewers. Data extraction and quality assessment were undertaken by one reviewer and checked by a second reviewer. Data on clinical effectiveness were synthesised through a narrative review with full tabulation of all eligible studies, with meta-analysis performed where appropriate. Results: Twenty studies comparing CSII with MDI were identified. Quality was generally poor. In adults with Type 1 diabetes, glycated haemoglobin improved by 0.61% (95% CI –1.29 to 0.07) in longer term studies, although this improvement was smaller when a study using bovine ultralente was excluded. A reduction in insulin dose with CSII of about 12 units per day (–11.90, 95% CI –18.16 to 5.63) was found in shortterm studies, with smaller differences in longer term studies. Body weight and cholesterol levels were similar between treatments. Hypoglycaemic events did not differ significantly between CSII and MDI in most trials, but some found fewer events with CSII and one found more hypoglycaemia and hypoglycaemic coma with CSII. There was no consistency between the studies in patient preference, but progress has been made both with insulin pumps and injector pens since the publication of many of the older studies. No difference in glycated haemoglobin between CSII and MDI was found in pregnancy; one study found less insulin was required by patients with CSII, but two other studies found no significant difference. One study of adolescents found lower glycated haemoglobin and insulin dose with CSII whereas a second study found no significant difference. In CSII analogue insulin was associated with lower glycated haemoglobin levels than soluble insulin. No economic evaluations comparing CSII with MDI were identified. The estimated additional cost of CSII compared to MDI varies from £1091 per annum to £1680 per annum, according to the make of the insulin pump and the estimated life of the device. These estimates include the costs for the insulin pump, the consumables associated with delivery of CSII, and an allowance for the initial education required when patients switch from MDI to CSII. The largest component of the annual cost for CSII is the cost of consumable items (e.g. infusion sets). Conclusions: When compared with optimised MDI, CSII results in a modest but worthwhile improvement in glycated haemoglobin in adults with Type 1 diabetes. It has not been possible to establish the longer term benefits of such a difference in glycated haemoglobin, although there is an expectation that it would be reflected in a reduction in long-term complications. More immediate primary benefits from CSII may be associated with an impact on the incidence of hypoglycaemic events and the dawn phenomenon, and greater flexibility of lifestyle. However, there is limited evidence on this, and information presented to offer context on quality-of-life is based on testimonies from those patients who have had a positive experience of CSII. The estimated cost to the NHS per year for CSII would be around £3.5 million in England and Wales if 1% of people with Type 1 diabetes used CSII, £10.5 million for 3%, and £17.5 million for 5%. Further research should focus on wider benefits of CSII, such as flexibility of lifestyle and quality of life, and on the psychological impact of wearing a device for 24 hours every day. Research into the use of CSII in children of different ages is also needed.