J.E. Bosmans

Effect of integrated care for sick listed patients with chronic low back pain: economic evaluation alongside a randomised controlled trial

Objective To evaluate the cost effectiveness, cost utility, and cost-benefit of an integrated care programme compared with usual care for sick listed patients with chronic low back pain. Design Economic evaluation alongside a randomised controlled trial with 12 months’ follow-up. Setting Primary care (10 physiotherapy practices, one occupational health service, one occupational therapy practice) and secondary care (five hospitals) in the Netherlands, 2005-9. Participants 134 adults aged 18-65 sick listed because of chronic low back pain: 66 were randomised to integrated care and 68 to usual care. Interventions Integrated care consisted of a workplace intervention based on participatory ergonomics, with involvement of a supervisor, and a graded activity programme based on cognitive behavioural principles. Usual care was provided by general practitioners and occupational physicians according to Dutch guidelines. Main outcome measures The primary outcome was duration until sustainable return to work. The secondary outcome was quality adjusted life years (QALYs), measured using EuroQol. Results Total costs in the integrated care group (£13u2009165, SD £13u2009600) were significantly lower than in the usual care group (£18u2009475, SD £13u2009616). Cost effectiveness planes and acceptability curves showed that integrated care was cost effective compared with usual care for return to work and QALYs gained. The cost-benefit analyses showed that every £1 invested in integrated care would return an estimated £26. The net societal benefit of integrated care compared with usual care was £5744. Conclusions Implementation of an integrated care programme for patients sick listed with chronic low back pain has a large potential to significantly reduce societal costs, increase effectiveness of care, improve quality of life, and improve function on a broad scale. Integrated care therefore has large gains for patients and society as well as for employers.

Cost effectiveness of a pharmacy-based coaching programme to improve adherence to antidepressants.

IntroductionThe efficacy of antidepressants in the treatment of depression has been convincingly demonstrated in randomised trials. However, non-adherence to antidepressant treatment is common.ObjectiveTo evaluate, from a societal perspective, the cost effectiveness of a pharmacy-based intervention to improve adherence to antidepressant therapy in adult patients receiving treatment in primary care.MethodsAn economic evaluation was performed alongside a 6-month randomised controlled trial in The Netherlands.Patients who came to 19 pharmacies with a new prescription for a non-tricyclic antidepressant, i.e. those who had not received any prescription for an antidepressant in the past 6 months, were invited to participate. They were then randomly allocated to education and coaching by the pharmacist or to usual care. The coaching programme consisted of three contacts with the pharmacist, with a mean duration of between 13 and 20 minutes, and a take-home video reviewing important facts on depression and antidepressant treatment.The clinical outcome measures were adherence to antidepressant treatment measured using an electronic pill container (eDEM) and improvement in depressive symptoms measured using the Hopkins Symptom Checklist (SCL). Resource use was measured by means of questionnaires. The uncertainty around differences in costs and cost effectiveness between the treatment groups was evaluated using bootstrapping.ResultsSeventy patients were randomised to the intervention group and 81 to the usual care group; of these, 40 in the intervention group and 48 in the control group completed all of the follow-up questionnaires.There were no significant differences in adherence, improvements in the SCL depression mean item score and costs over 6 months between the two treatment groups. Mean total costs (2002 values) were €3275 in the intervention group and €2961 in the control group (mean difference €315; 95% CI —1922, 2416). The incremental cost-effectiveness ratio associated with the pharmacist intervention was €149 per 1% improvement in adherence and €2550 per point improvement in the SCL depression mean item score. Cost-effectiveness planes and acceptability curves indicated that the pharmacist intervention was not likely to be cost effective compared with usual care.ConclusionIn patients starting treatment with antidepressants, there were no significant differences in adherence, severity of depression, costs and cost effectiveness between patients receiving coaching by a pharmacist and patients receiving usual care after 6 months. Considering the resources needed to implement an intervention like this in clinical practice, based on these results, the continuation of usual care is recommended.

Cost-effectiveness of a disease management program for major depression in elderly primary care patients.

AbstractBACKGROUND: Major depression is common in older adults and is associated with increased health care costs. Depression often remains unrecognized in older adults, especially in primary care.n OBJECTIVE: To evaluate the cost-effectiveness of a disease management program for major depression in elderly primary care patients compared with usual care.n DESIGN: Economic evaluation alongside a cluster randomized-controlled trial.n PARTICIPANTS: Consecutive patients of 55 years and older were screened for depression using the Geriatric Depression Scale and the PRIME-MD was used for diagnosis.n INTERVENTIONS: General practitioners in the intervention group received training on how to implement the disease management program consisting of screening, patient education, drug therapy with paroxetine, and supportive contacts. General practitioners in the usual care group were blind to the screening results. Treatment in this group was not restricted in any way.n MEASUREMENTS: Severity of depression, recovery from depression, and quality of life. Resource use measured over a 12-month period using interviews and valued using standard costs.n RESULTS: Differences in clinical outcomes between the intervention and usual care group were small and statistically insignificant. Total costs were

Clinical effectiveness of usual care with or without antidepressant medication for primary care patients with minor or mild-major depression: a randomized equivalence trial

2,123 in the intervention and

(Cost)-effectiveness of family meetings on indicated prevention of anxiety and depressive symptoms and disorders of primary family caregivers of patients with dementia: design of a randomized controlled trial

2,259 in the usual care group (mean difference −

Trial-Based Economic Evaluations in Occupational Health: Principles, Methods, and Recommendations

136, 95% confidence interval: −

Cost-effectiveness of interpersonal psychotherapy for elderly primary care patients with major depression

1,194;

The cost-effectiveness of a lifestyle physical activity intervention in addition to a work style intervention on recovery from neck and upper limb symptoms and pain reduction in computer workers

1,110). Cost-effectiveness planes indicated that there were no statistically significant differences in cost-effectiveness between the 2 groups.n CONCLUSIONS: This disease management program for major depression in elderly primary care patients had no statistically significant relationship with clinical outcomes, costs, and cost-effectiveness. Therefore, based on these results, continuing usual care is recommended.

Is Behavioral Graded Activity Cost-Effective in Comparison With Manual Therapy for Patients With Subacute Neck Pain? An Economic Evaluation Alongside a Randomized Clinical Trial

BackgroundMinor and mild-major depression are highly prevalent in primary care. There is insufficient evidence for the effectiveness of antidepressants in the treatment of minor and mild-major depression. We compared the effectiveness of usual primary care treatment, with or without antidepressants, in minor and mild-major depression.MethodsA pragmatic patient-randomized equivalence trial with 52 weeks follow-up was conducted in The Netherlands. In total, 59 primary care physicians (PCPs) recruited and treated 181 adult patients with minor or mild-major depression. Patients were randomized to four consultations within 3 months of usual care plus antidepressants (UCandAD) or usual care alone (UCnoAD). The Montgomery Åsberg Depression Rating Scale (MADRS) was used to assess changes in severity of depressive symptoms. The predefined equivalence margin was set at five points. Multilevel analysis was used to analyze the data. Secondary outcome measures were the Short-Form 36 (SF-36), and the Client Satisfaction Questionnaire (CSQ-8).ResultsPatients received on average 3.0 (SD 1.4) 15-min consultations within 3 months with (n = 85) or without paroxetine (n = 96). Equivalence of UCandAD and UCnoAD was demonstrated in the intention-to-treat analyses as well as the per-protocol analysis after 6 weeks, but not at 13, 26 and 52 weeks follow-up. No statistical differences in effectiveness between treatment groups were found in the intention-to-treat analysis. No differences in the physical and mental functioning (SF-36) were found between the treatment groups. Patients allocated to UCandAD were slightly more satisfied with their treatment at 13 weeks follow-up (but not at 52 weeks follow-up) than patients allocated to UCnoAD. Preliminary analyses suggested that subgroups such as patients with mild-major (instead of a minor) depression might benefit from antidepressant treatment. Patients who were assigned to their preferred treatment (in particular to UCnoAD) were more often compliant and had better clinical outcomes.ConclusionUCandAD was as effective as UCnoAD over the first 6 weeks, but not at 13, 26, and 52 weeks. However, superiority of either treatment could not be demonstrated either. The question whether antidepressants add any clinical effect to usual care remains unresolved. We recommend future studies to look for subgroups of patients who may benefit from antidepressants.Trial registrationDutch Trial Registry ISRCN03007807.

Economic Evaluation of a Web-Based Guided Self-Help Intervention for Employees With Depressive Symptoms: Results of a Randomized Controlled Trial.

BackgroundDementia is a major public health problem with enormous costs to society and major consequences for both patients and their relatives. Family members of persons with dementia provide much of the care for older adults with dementia in the community. Caring for a demented relative is not easy and fraught with emotional strain, distress, and physical exhaustion. Family caregivers of dementia patients have an extremely high risk developing affective disorders such as major depression and anxiety disorder. Family meetings appear to be among the most powerful psychosocial interventions to reduce depression in caregivers.An American landmark study reported substantial beneficial effects of a multifaceted intervention where family meetings had a central place on depression in family caregivers as well as on delay of institutionalization of patients. These effects were not replicated in other countries yet. We perform the first trial comparing only structured family meetings with significant others versus usual care among primary family caregivers of community dwelling demented patients and measure the effectiveness on both depression and anxiety in the primary caregiver, both on disorder and symptom levels.Methods/designIn this randomized controlled trial effectiveness as well as cost-effectiveness of family meetings is evaluated. The intervention group receives four family meetings with family and close friends of the primary family caregiver of a community dwelling patient with a clinical diagnosis of dementia. Dyads of patients and their primary caregiver are followed up to one year after baseline assessment. The main outcome measures are the incidence of anxiety and depressive disorders assessed with the Mini-International Neuropsychiatric Interview (MINI) and the severity of anxiety and depressive symptoms in caregivers is measured by validated self report instruments: the Centre for Epidemiologic Studies Depression Scale (CES-D) for depression and the anxiety scales of the Hospital Anxiety and Depression scales (HADS) for anxiety. The economic evaluation is performed from a societal perspective.DiscussionBy evaluating the effectiveness of only structured family meetings organized in the Netherlands, this study will contribute to the existing literature about the value of psychosocial interventions for dementia caregivers.Trial registrationDutch Trial Registry ISRCTN90163486