Cost-benefit & cost-effectiveness analysis of the rapid onset of selective serotonin reuptake inhibitors by augmentation

The cytoskeleton of the parabasalid protozoan Holomastigotoides was investigated by epifluorescence, scanning confocal, and transmission electron microscopy using antibodies to centrin, tubulin, and MPM-2 epitopes. Previous microscopic analysis of Holomastigotoides spp. has shown that up to 10,000 flagella are arranged in 2-8 spiral bands encircling the cell. Spindle poles are associated with two flagellar bands. Sheets of cytoplasmic microtubules (MTs) called axostyles originate in the cell apex and extend to the cell base. Antibodies to centrin, a member of the EF-hand family of calcium-binding proteins, labeled a number of structures in Holomastigotoides, namely axostyles, the mitotic spindle, and portions of flagellar bands. The identity of these structures was confirmed by transmission electron microscopy and by immunofluorescence microscopy using antibodies to tubulin and MPM-2 epitopes. Antibodies to tubulin labeled MTs in basal bodies, flagella, axostyles, and the mitotic spindle. MPM-2 antibodies labeled spindle poles and short segments of flagellar bands to which the spindle poles are attached. Centrin is known to show calcium-sensitive contractile behavior. The pattern of flagellar band staining by antibodies to centrin was affected by [Ca2+]. In detergent-extracted cell fragments, the centrin staining pattern could be changed by changing [Ca2+]. This Ca2+ effect was modulated by a monoclonal antibody to centrin (20H5), indicating that centrin plays a role in altering flagellar band structure. These results show that centrin is located in key positions for maintaining cell polarity and directing cell movement through interactions with other cytoskeletal elements. Calcium may regulate the morphology of centrin-containing structures.     

In search of power and significance: issues in the design and analysis of stochastic cost-effectiveness studies in health care

Application of techniques such as cost-effectiveness analysis (CEA) is growing rapidly in health care. There are two general approaches to analysis: deterministic models based upon assumptions and secondary analysis of retrospective data, and prospective stochastic analyses in which the design of a clinical experiment such as randomised controlled trial is adapted to collect patient-specific data on costs and effects. An important methodological difference between these two approaches is in the quantification and analysis of uncertainty. Whereas the traditional CEA model utilizes sensitivity analysis, the mean-variance data on costs and effects from a prospective trial presents the opportunity to analyze cost-effectiveness using conventional inferential statistical methods. In this study we explored some of the implications of moving economic appraisal away from deterministic models and toward the experimental paradigm. Our specific focus was on the feasibility and desirability of constructing statistical tests of economic hypotheses and estimation of cost-effectiveness ratios with associated 95% confidence intervals. We show how relevant variances can be estimated for this task and discuss the implications for the design and analysis of prospective economic studies.     

Costing methods in the Canadian literature on the economic evaluation of health care. A survey and assessment

Administration of interleukin 2 (IL-2) has been associated with potent in vitro antitumor effects. However, systemic in vivo toxicity has been problematic. Because local delivery and liposomal formulations of IL-2 may improve the therapeutic index, we used dogs to evaluate and compare immunological activation of inhaled free IL-2 and IL-2 liposomes. Twelve normal dogs were treated with nebulized IL-2 formulations and controls for 2 to 7 weeks. Cellular immune activation of peripheral blood mononuclear cells and bronchoalveolar lavage (BAL) effector leukocytes against tumor cell lines, changes in effector leukocyte populations, and toxicity were monitored. No toxicity was seen with either aerosolized free IL-2 or IL-2 liposomes. Free IL-2 given at 0.5 x 10(6) Biologic Response Modifier Program (BRMP) units twice daily to dogs resulted in increased peripheral blood mononuclear cell activation compared with saline control-treated dogs. IL-2 liposomes given at 0.5 x 10(6) BRMP units twice daily to dogs resulted in significantly increased BAL effector activation compared with IL-2 liposomes given at 1.0 x 10(6) BRMP units once daily (P = 0.018) and empty liposome controls (P = 0.016). The BAL leukocyte cell count was increased significantly after inhalation of IL-2 liposomes versus inhalation of free IL-2 (P = 0.011). BAL effector populations included a greater proportion and total number of lymphocytes and eosinophils after treatment with IL-2 liposomes. Nontoxic activation of pulmonary immune effectors for the treatment of cancer in the lung may be possible using nebulized IL-2 liposomes.     

Statistical power considerations in the use of cost-effectiveness analysis.

Due to ever-increasing economic constraints, evaluators and administrators of human service delivery systems will find it necessary to eliminate programs from the system. In doing so they must consider the cost as well as the effectiveness of programs. Failure to take into account the statistical and methodological factors that affect the statistical power and Type II error rate of cost-effectiveness studies may lead to invalid inferences and erroneous programmatic decisions. Using a hypothetical evaluation design, the author examines factors relevant to statistical power analysis in cost-effectiveness evaluations. (15 ref) (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Cost-benefit and cost-effectiveness analyses of behavioral marital therapy as an addition to outpatient alcoholism treatment

Thirty-six newly abstinent married male alcoholics, who had recently begun outpatient individual alcoholism counseling, were randomly assigned to a no-marital-therapy control group or to 10 weekly sessions of a behavioral marital therapy (BMT) or an interactional couples group. The cost-benefit analysis of BMT plus individual alcoholism counseling showed (a) decreases in health care and legal costs in the 2 years after as compared to the year before treatment, (b) a positive cost offset, and (c) a benefit-to-cost ratio greater than 1 indicating that health and legal system cost savings (i.e., benefits) exceeded the cost of delivering the BMT treatment. None of the positive cost-benefit results observed for BMT were true for participants given interactional couples therapy plus individual alcoholism counseling for which posttreatment utilization costs increased. Thus, adding BMT to individual alcoholism counseling produced a positive cost benefit, whereas the addition of interactional couples therapy did not. Individual counseling both alone and with BMT added showed substantial and significant cost savings from reduced utilization that substantially and significantly exceeded the cost of delivering the treatment; and the two treatments did not differ significantly on these cost savings and cost offsets. Individual counseling alone did have a significantly more positive benefit-to-cost ratio than BMT plus individual counseling due to the lower cost of delivering the individual counseling which was about half the cost of delivering BMT plus individual counseling. Cost-effectiveness analyses indicated that BMT plus individual counseling was less cost effective than individual counseling alone and modestly more cost effective than interactional therapy in producing abstinence from drinking. When marital adjustment outcomes were considered, the three treatments were equally cost effective except during the active treatment phase when BMT was more cost effective than interactional couples therapy. Study limitations are discussed.     

Promoting adolescent mental health in primary care: a review of the literature

High levels of psychological disturbance amongst adolescents have been linked to behaviours which can damage physical health, and with mental health problems in adulthood. The aim of this review was to see if published literature supports the hypothesis that primary care is a suitable setting in which mental health problems in adolescents can be prevented by early detection and treatment. Medline, BIDS, SIGLE and Psychlit databases (January 1990-February 1997) were systematically searched for English language studies on adolescent health promotion and mental health in primary care; reference sections were checked for earlier work. When offered, adolescent health checks and clinics have been well received with attendance rates of 73% and 83% reported, respectively. Primary care offers a setting for the prevention and detection of mental health problems in adolescents. Further research is needed to determine cost effective ways of using these opportunities.     

Mental health care in the USSR.

The author received a scientist exchange grant from the National Institutes of Health and visited the USSR as a health-science representative in 1976. He reports that mental health services in the USSR are provided primarily by the medical profession through state mental hospitals and psychiatric sections in general hospitals and clinics. Drug therapy is the main treatment method, but psychotherapy is beginning to make some inroads. Family therapy settings are the newest additions to preventive mental health care. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Psychology and health care.

Recent advances in health care psychology are noted, especially those involving the conceptualization and treatment of lifestyle and chronic health problems. The contributions to health care psychology of community psychology, brief psychological treatments, behavioral medicine, and health psychology are outlined. The central task of both organized psychology and individual psychologists is to create an underlying structure of clear boundaries and standards for clinical practice and training in health care psychology. Initially, this task should involve an inventory of Canadian psychologists currently providing health care services and the nature and amount of those services. Subsequently, a need exists for the profession to examine and create guidelines in psychological service delivery, professional role models, training, and scientific methods pertaining to general health care. (French abstract) (27 ref) (PsycINFO Database Record (c) 2011 APA, all rights reserved)     

Using literature in health care: reflections on "the yellow wallpaper"

OBJECTIVE: To discuss how literature can be used to educate healthcare practitioners and students about the patient's physical and emotional response to treatment. DATA SOURCES: A MEDLINE search (January 1975-November 1997) of English-language literature pertinent to using literature in health care was performed. Additional literature was obtained from a search of the New York University Web site on medicine and humanities, biographies of Charlotte Perkins Gilman, and a search of the MLA and INFOTRAC database. SELECTION AND DATA EXTRACTION: All articles and literature were considered for possible inclusion in this article. Pertinent information, as judged by the author, was selected for discussion. SUMMARY: Literature can pose a wealth of information to the healthcare professional. The short story "The Yellow Wallpaper" is analyzed in this article as one example of how literature portrays the patient's emotional response to disease. This short story describes a 19th-century woman's "descent into madness" and the ineffective treatment attempted by her well-meaning physician husband. The author, Charlotte Perkins Gilman, loosely based the story on her own experience with the respected physician, S Weir Mitchell and his famous rest cure. Some biographical information about Mitchell and Perkins is included, as well as a commentary on the treatment of depression in the 19th century. CONCLUSIONS: Short stories such as "The Yellow Wallpaper," novels, and other short stories can help to remind the healthcare professional of the subjective nature of even our most proven therapies. As we strive to teach and deliver pharmaceutical care, we can use literature to help us understand the emotional impact of our drug therapies.     

Evidence-based medicine and cost-effectiveness analysis

Health care has become increasingly expensive and clinicians have come under increased scrutiny to critically appraise the economic impact of medical programs and interventions. To ensure an equitable allocation of scarce resources and the attainment of maximal clinical benefit, it is vital to adhere to certain basic tenets of economic analysis and to understand the basic approach to cost-effectiveness analysis. These principles are applied to critical care medicine and analogies are made to the methodological rigor of evidence-based medicine.     

Cost-benefit analysis of six alternative payment incentives for child therapists.

The outcomes and costs of 6 different methods of motivating therapists to meet service delivery goals at a community mental health center for children and adolescents were evaluated over a 5-yr period. The costs and cost-savings benefits of each motivational method were compared with each other and with 2 baselines. Four incentive interventions generated more cost savings than they required in monetary outlays. Most cost-beneficial were bonuses paid to therapists for each hour of service they delivered over their monthly goals and bonus plans that rewarded therapists for exceeding their goals while also rewarding staff if total department goals were exceeded. The most cost-beneficial system saved $25,542 over 6 mo that would have been paid to compensate for therapy hours not delivered, for an incentive investment of $9,726 over the 6 mo. This yielded a net benefit of $15,816, or $31,632 annually. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Delivery of mental health services in the changing health care system.

Comments on the anonymous article, "Hidden benefits of managed care" (see record 1995-33982-001), in which the author expresses concern that managed care organizations are making decisions on the basis of economics and not the well-being of the patient. B. Miller and L. Farber empathize with the author's concerns, but contend that, if structured properly, HMOs can become the vehicle for the reengineering of mental health services that will produce the best patient outcomes. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Intensive care unit prognostic scoring systems to predict death: a cost-effectiveness analysis

OBJECTIVE: To evaluate the cost-effectiveness, using the technique of decision analysis, of withdrawing care from patients in the intensive care unit (ICU) who are predicted to have a high probability of death (>90%) after 48 hrs using a mortality risk estimate based on daily Acute Physiology and Chronic Health Evaluation (APACHE) III scores. MATERIALS AND METHODS: A decision tree model was constructed to compare the cost-effectiveness of two clinical strategies. In the first strategy, patients receive ICU care until they were discharged, died, or had care withdrawn based on subjective clinical criteria. In the second strategy, patients remained in the ICU until they were either discharged, died, or had life-sustaining care withdrawn based on subjective criteria or if they were predicted to have a >90% risk of mortality after 48 hrs by a prognostic scoring system. Transition probabilities were based on a retrospective data analysis of 4,106 noncardiac ICU patients admitted to a tertiary surgical ICU over a 9-yr period. Cost estimates were based on daily Therapeutic Intervention Scoring System (TISS) scores from our database and using published data on the estimated production cost for a TISS point. The sensitivity (16.6%) and specificity (99.6%) of the mortality risk estimate at 48 hrs (using the >90% decision point) based on daily APACHE III scores were derived from published data. RESULTS: In the base case analysis, we assumed that the sensitivity and specificity of the prognostic risk estimate are unchanged when exported to a new environment. Not using a prognostic scoring system as the basis for withdrawing care resulted in a slightly higher survival rate (87.2% vs. 86.85%) at a cost-per-death prevented (CPDP) of $263,700. Since prognostic scoring systems have not been shown to retain the same predictive power when exported to new databases, we chose to explore the effect of varying the specificity of the scoring system on CPDP. Decreasing the specificity from .996 (baseline) to .98 causes the CPDP to drop to $53,300. Changing the specificity to .95 results in a CPDP prevented of $21,700. Using one-way sensitivity analysis, the CPDP is shown to be relatively insensitive to delaying the decision point from ICU day 3 to day 7. Sensitivity analysis also indicates that CPDP increases rapidly with hospital death rate. For a death rate of 30%, the CPDP increases to $768,600 (in the base case, the death rate is 12.8%); when the specificity is decreased to .95, the CPDP drops to $62,100. CONCLUSION: Unless daily mortality risk estimates based on APACHE III can be shown to retain the same level of predictive power in ICUs outside the development database, it is unlikely that the incremental cost-effectiveness gained by using them as the basis to withdraw care is sufficient to justify their use in this manner.     

Psychology and national health care.

Presents the position of the American Psychological Association concerning the national movement toward a "comprehensive and coordinated system of health services which will be of high quality and equally accessible to all persons." Provisions for recognition and management of emotional and mental disorders and for the optimum use of all qualified health care professionals are urged. Guidelines for the development of a health care program are enumerated and include concern for accessibility of services, patient rights, adequate funding, consumer roles, grievance provisions, program evaluation, and research into the system itself. Criteria for evaluating the adequacy of proposed legislation for a health care system in terms of the mental health provisions and the utilization of psychological services are also presented. It is concluded that "psychologists, by training and experience, have the qualifications to provide independent mental health services and should be permitted to do so." (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

'Public health status and perspectives' 1997. VII. Health care needs and health care consumption

In the 'Public health status and forecasts' 1997 attention is given to the relationship between health status and health care. The theme report 'Health care need and health care consumption' integrates information about both phenomena and about waiting lists in the different sectors of health care. It is difficult to quantify the need for health care, because statements about need always imply a judgment by parties involved. In the literature need for health care is often operationalized by historical data on health care consumption or by health status indicators. At the national level only limited quantitative information is available to support policy on waiting lists and waiting times. The data are seldom disease-specific. Changes in size and distribution (by age and sex) of the population will increase health care cost over the period 1994-2015 in the Netherlands by 0.9-1.0% per year. More detailed demographic projections, however, indicate that there are large disease-specific differences.