Jennifer Beecham

Cost effectiveness of telehealth for patients with long term conditions (Whole Systems Demonstrator telehealth questionnaire study): nested economic evaluation in a pragmatic, cluster randomised controlled trial.

Objective To examine the costs and cost effectiveness of telehealth in addition to standard support and treatment, compared with standard support and treatment. Design Economic evaluation nested in a pragmatic, cluster randomised controlled trial. Setting Community based telehealth intervention in three local authority areas in England. Participants 3230 people with a long term condition (heart failure, chronic obstructive pulmonary disease, or diabetes) were recruited into the Whole Systems Demonstrator telehealth trial between May 2008 and December 2009. Of participants taking part in the Whole Systems Demonstrator telehealth questionnaire study examining acceptability, effectiveness, and cost effectiveness, 845 were randomised to telehealth and 728 to usual care. Interventions Intervention participants received a package of telehealth equipment and monitoring services for 12 months, in addition to the standard health and social care services available in their area. Controls received usual health and social care. Main outcome measure Primary outcome for the cost effectiveness analysis was incremental cost per quality adjusted life year (QALY) gained. Results We undertook net benefit analyses of costs and outcomes for 965 patients (534 receiving telehealth; 431 usual care). The adjusted mean difference in QALY gain between groups at 12 months was 0.012. Total health and social care costs (including direct costs of the intervention) for the three months before 12 month interview were £1390 (€1610;

Economic cost of autism in the UK

2150) and £1596 for the usual care and telehealth groups, respectively. Cost effectiveness acceptability curves were generated to examine decision uncertainty in the analysis surrounding the value of the cost effectiveness threshold. The incremental cost per QALY of telehealth when added to usual care was £92 000. With this amount, the probability of cost effectiveness was low (11% at willingness to pay threshold of £30 000; >50% only if the threshold exceeded about £90 000). In sensitivity analyses, telehealth costs remained slightly (non-significantly) higher than usual care costs, even after assuming that equipment prices fell by 80% or telehealth services operated at maximum capacity. However, the most optimistic scenario (combining reduced equipment prices with maximum operating capacity) eliminated this group difference (cost effectiveness ratio £12 000 per QALY). Conclusions The QALY gain by patients using telehealth in addition to usual care was similar to that by patients receiving usual care only, and total costs associated with the telehealth intervention were higher. Telehealth does not seem to be a cost effective addition to standard support and treatment. Trial registration ISRCTN43002091.

The economic impact of chronic pain in adolescence: methodological considerations and a preliminary costs-of-illness study.

Autism has lifetime consequences, with potentially a range of impacts on the health, wellbeing, social integration and quality of life of individuals and families. Many of those impacts are economic. This study estimated the costs of autism spectrum disorders (ASDs) in the UK. Data on prevalence, level of intellectual disability and place of residence were combined with average annual costs of services and support, together with the opportunity costs of lost productivity. The costs of supporting children with ASDs were estimated to be £2.7 billion each year. For adults, these costs amount to £25 billion each year. The lifetime cost, after discounting, for someone with ASD and intellectual disability is estimated at approximately £1.23 million, and for someone with ASD without intellectual disability is approximately £0.80 million.

Costs and longer-term savings of parenting programmes for the prevention of persistent conduct disorder: a modelling study.

&NA; Chronic pain in adulthood is one of the most costly conditions in modern western society. However, very little is known about the costs of chronic pain in adolescence. This preliminary study explored methods for collecting economic‐related data for this population and estimated the cost‐of‐illness of adolescent chronic pain in the United Kingdom. The client service receipt inventory was specifically adapted for use with parents of adolescent chronic pain patients to collect economic‐related data (CSRI‐Pain). This method was compared and discussed in relation to other widely used methods. The CSRI‐Pain was sent to 52 families of adolescents with chronic pain to complete as a self‐report retrospective questionnaire. These data were linked with unit costs to estimate the total care cost package for each family. The economic impact of adolescent chronic pain was found to be high. The mean cost per adolescent experiencing chronic pain was approximately £8000 per year, including direct and indirect costs. The adolescents attending a specialised pain management unit, who had predominantly non‐inflammatory pain, accrued significantly higher costs, than those attending rheumatology outpatient clinics, who had mostly inflammatory diagnoses. Extrapolating the mean total cost to estimated UK prevalence data of adolescent chronic pain demonstrates a cost‐of‐illness to UK society of approximately £3840 million in one year. The implications of the study are discussed.

Do adolescents with eating disorder not otherwise specified or full-syndrome bulimia nervosa differ in clinical severity, comorbidity, risk factors, treatment outcome or cost?

BackgroundConduct disorders are the most common psychiatric disorders in children and may persist into adulthood in about 50% of cases. The costs to society are high and impact many public sector agencies. Parenting programmes have been shown to positively affect child behaviour, but little is known about their potential long-term cost-effectiveness. We therefore estimate the costs of and longer-term savings from evidence-based parenting programmes for the prevention of persistent conduct disorder.MethodsA decision-analytic Markov model compares two scenarios: 1) a 5-year old with clinical conduct disorder receives an evidence-based parenting programme; 2) the same 5-year old does not receive the programme. Cost-savings analysis is performed by comparing the probability that conduct disorder persists over time in each scenario, adopting both a public sector and a societal perspective. If the intervention is successful in reducing persistent conduct disorder, cost savings may arise from reduced use of health services, education support, social care, voluntary agencies and from crimes averted.ResultsResults strongly suggest that parenting programmes reduce the chance that conduct disorder persists into adulthood and are cost-saving to the public sector within 5-8 years under base case conditions. Total savings to society over 25 years are estimated at £16,435 per family, which compares with an intervention cost in the range of £952-£2,078 (2008/09 prices).ConclusionsEffective implementation of evidence-based parenting programmes is likely to yield cost savings to the public sector and society. More research is needed to address evidence gaps regarding the current level of provision, longer-term effectiveness and questions of implementation, engagement and equity.

Exploring the relationships between costs and quality of services for adults with severe intellectual disabilities and the most severe challenging behaviours in Wales: A multivariate regression analysis

OBJECTIVE We wanted to know whether adolescents with eating disorder not otherwise specified (EDNOS) differ from those with bulimia nervosa (BN) in clinical features, comorbidity, risk factors, treatment outcome or cost. METHOD Adolescents with EDNOS (n = 24) or BN (n = 61) took part in a trial of family therapy versus guided self-care. At baseline, eating disorder symptoms, risk factors, and costs were assessed by interview. Patients were reinterviewed at 6 and 12 months. RESULTS Compared with EDNOS, BN patients binged, vomited and purged significantly more, and were more preoccupied with food. Those with EDNOS had more depression and had more current and childhood obsessive-compulsive disorder. 66.6% of EDNOS versus 27.8% of BN patients were abstinent from bingeing and vomiting at 1 year. Diagnosis did not moderate treatment outcome. Costs did not differ between groups. CONCLUSION EDNOS in adolescents is not trivial. It has milder eating disorder symptoms but more comorbidity than BN.

The Maudsley Outpatient Study of Treatments for Anorexia Nervosa and Related Conditions (MOSAIC): Comparison of the Maudsley Model of Anorexia Nervosa Treatment for Adults (MANTRA) With Specialist Supportive Clinical Management (SSCM) in Outpatients With Broadly Defined Anorexia Nervosa: A Randomized Controlled Trial

A survey in Wales of people with severe intellectual disabilities and the most severe challenging behaviour identified 17 adults living in new specialist community housing and 19 in traditional services. With the omission of two people from the latter group, this study explored the relationships between resident characteristics, service characteristics, service processes, quality of life outcome and costs in a series of mutivariate regression analyses. Higher accommodation costs were associated with lower resident ability and community services. Costs were inversely associated with setting size when the variable representing service model was omitted, but setting size did not otherwise add to explanation. Resident autonomy was associated with higher resident ability, community services or smaller setting size, and lower staff:resident ratios. Participation in domestic life was associated with higher resident ability and community services or smaller scale. More frequent community involvement was associated with higher resident ability and smaller setting size, with lower levels of challenging behaviour and greater individual orientation as subsidiary influences. Higher resident engagement in activity was associated with higher resident ability and the extent of interaction between staff and residents which, in turn, was primarily associated with service model. Variation in the various quality of life indicators measured did not contribute to the explanation of accommodation costs. Variation in accommodation costs did not contribute to the explanation of the level of staff:resident interaction or quality of life, neither did staff:resident ratios, after control for service model.

Annual Research Review: Child and adolescent mental health interventions: a review of progress in economic studies across different disorders

OBJECTIVE Anorexia nervosa (AN) in adults has poor outcomes, and treatment evidence is limited. This study evaluated the efficacy and acceptability of a novel, targeted psychological therapy for AN (Maudsley Model of Anorexia Nervosa Treatment for Adults; MANTRA) compared with Specialist Supportive Clinical Management (SSCM). METHOD One hundred forty-two outpatients with broadly defined AN (body mass index [BMI] ≤ 18.5 kg/m²) were randomly allocated to receive 20 to 30 weekly sessions (depending on clinical severity) plus add-ons (4 follow-up sessions, optional sessions with dietician and with carers) of MANTRA (n = 72) or SSCM (n = 70). Assessments were administered blind to treatment condition at baseline, 6 months, and 12 months after randomization. The primary outcome was BMI at 12 months. Secondary outcomes included eating disorders symptomatology, other psychopathology, neuro-cognitive and social cognition, and acceptability. Additional service utilization was also assessed. Outcomes were analyzed using linear mixed models. RESULTS Both treatments resulted in significant improvements in BMI and reductions in eating disorders symptomatology, distress levels, and clinical impairment over time, with no statistically significant difference between groups at either 6 or 12 months. Improvements in neuro-cognitive and social-cognitive measures over time were less consistent. One SSCM patient died. Compared with SSCM, MANTRA patients rated their treatment as significantly more acceptable and credible at 12 months. There was no significant difference between groups in additional service consumption. CONCLUSIONS Both treatments appear to have value as first-line outpatient interventions for patients with broadly defined AN. Longer term outcomes remain to be evaluated.

Caregiving and coping in carers of people with anorexia nervosa admitted for intensive hospital care

Background Resources for supporting children and adolescents with psychiatric disorders continue to be scarce. Economics research can identify current patterns of expenditure, and help inform allocation of treatment and support resources between competing needs or uses. Scope and methods The aim was to identify the costs of supporting children and adolescents, the economic impacts of childhood psychiatric disorders in adulthood and any new evidence on the cost-effectiveness of interventions. An electronic search of databases (including PubMed, Medline and Psychinfo) identified peer-reviewed journal articles published between 2005 and 2012. Findings Sixty-seven papers provided data on support and treatment costs now or in the future, or cost-effectiveness analyses of services. Half the articles came from the United States. Most articles focussed on autism spectrum disorder (ASD; 23 articles), attention deficit hyperactivity disorder (ADHD; n = 15), conduct disorder (CD; n = 7), and anxiety or depression (n = 8). Conclusion Only 14 studies used a cost perspective wider than health care; most included education costs (n = 11), but only five included costs to the justice system. The number of studies estimating costs to the family has increased, particularly for children with autism spectrum disorder (ASD). In the United Kingdom, support costs for children and adolescents with conduct disorder (CD) appear to be lower than for those with attention deficit hyperactivity disorder (ADHD), although for the United States, the opposite may be true. Support costs for children and adolescents with ASD may be higher than both CD and ADHD. However, there were many differences between the samples and the methods employed making comparisons between studies difficult. Outcomes in adulthood include negative impacts on (mental) health, quality of life, public sector services, employment status and income. The evidence base is improving for child and adolescent psychiatric disorders, although only one full cost-effectiveness analysis was identified since the previous review published in 2012. However, we still do not know enough about the economic implications of support and treatment for specific disorders.

Elderly people with advanced cognitive impairment in England - resource use and costs

OBJECTIVE The aim of the study was to examine how carers cope practically and emotionally with caring for individuals with anorexia nervosa who require intensive hospital care. METHOD This study explores objective burden (time spent with caregiving and number of tasks), subjective burden (psychological distress), and social support in a sample of parents (n = 224) and partners (n = 28) from a consecutive series of patients (n = 178) admitted to inpatient units within the United Kingdom. RESULTS Most time was spent providing emotional support and less with practical tasks. Time spent with caregiving was associated with carer distress and was fully mediated by carer burden. This was ameliorated by social support. Partners received minimal support from others, and we found similar levels of burden and distress for mothers and partners. DISCUSSION The data indicate that professional and social support alleviates carer distress and may be of particular value for partners who are more isolated than parents. The data also suggest that time spent with practical support may be of more value than emotional support.