Nathan Bray

High Prevalence of Untreated Depression in Patients Accessing Low-Vision Services

News about untreatable sight loss is devastating. Clinicians have an important role to play in determining when and how information is provided, gauging how effectively patients are likely to cope, and recognizing when someone needs to access treatment for their psychological distress. It is true that some resilient individuals are able to adjust, eventually, to their new situation, but many others find the myriad of practical problems associated with sight loss and worry about the future overwhelming, their psychological wellbeing suffers, and many sink into chronic depression. Depression is common in those with a visual impairment and particularly so in those seeking help at low vision rehabilitation clinics, but just how prevalent is it and are people getting the help they need? Large-scale epidemiologic studies indicate that about 13% of people with a visual impairment have significant depressive symptoms, about 3 times greater than in the general population. In those accessing low vision rehabilitation clinics the prevalence is known to be higher at about 30%. However, these estimates should be treated with caution. Small sample sizes and volunteers rather than consecutive attendees may underestimate the scale of the problem because people with depression are less likely to volunteer. The data in this report are from the Depression in Visual Impairment Trial (DEPVIT), a multicenter, randomized controlled trial that screened >1000 consecutive attendees at low vision rehabilitation clinics in Britain (ISRCTN46824140). Two important aims of the study were to estimate the prevalence of significant depressive symptoms in consecutive attendees at National Health Service (NHS) funded low vision rehabilitation services in Britain and to identify the proportion currently accessing treatments for depression. Participants were consecutive adult patients attending 1 of 16 low vision rehabilitation services in Britain between November 2011 and March 2014. Fourteen of the services were provided in a primary care setting in Wales and the others were hospital-based services in London. All of the clinics gave a routine preassessment survey to all patients before their clinic visit. The survey included the Geriatric Depression Scale (GDS-15) to quantify depressive symptoms, a short version of the National Eye Institute Visual Function Questionnaire (7-item NEI-VFQ) and a single question from the Short Form Health Survey to assess overall health. To ensure that data collection was standardized across centers, clinicians attended a 1-day training event to improve their understanding of depression and all study procedures. For those who consented, information on date of birth, gender, ethnicity, medical illness, time since vision loss first identified, primary ocular diagnosis, corrected Early Treatment Diabetic Retinopathy Study logarithm of the minimum angle of resolution acuity and threshold reading ability (Bailey-Lovie Word Reading Chart) was recorded at the clinic. In line with the large-scale Medical Research Council assessment of older adults study, we adopted the relatively conservative cutoff score of !6 on the GDS-15 to identify those with significant depressive symptoms. People who screened positive for depressive symptoms were also asked if they were receiving treatment for their low mood. Data were analyzed on STATA Ver 12. The prevalence of depressive symptoms together with 95% CIs was computed by the exact binomial method. Ethical approval was obtained from the NHS National Research Ethics Service (11/WA/0014). During the 30-month recruitment period, a total of 1323 consecutive adult patients attended the low vision rehabilitation clinics. Of these, consenting patients 1008 (76.2%) provided complete datasets. The mean (SD) age of consenting patients was 74.4 (16.1) years, 61.7% were women, and 52.8% had a diagnosis of age-related macular degeneration. Overall, the prevalence of significant depressive symptoms, as measured by a GDS-15 score of!6, was 43% (95% CI, 40%e46%). And, of those who screened positive for significant depressive symptoms, 74.8% (95% CI, 79.2%e70.7%) were not being treated for their depression. Table 1 (available at www.aaojournal.org) describes the prevalence of significant depressive symptoms according to study location and patient characteristics. Interestingly, a regression analysis indicated that the prevalence of significant depressive symptoms was not related to visual acuity or to the time since sight loss was first identified. Figure 1 describes the prevalence of significant depressive symptoms as a function of time since the onset of sight loss and it seems that depression does not resolve over time. However, because this was a cross-sectional study, we cannot rule out the possible effects of time. The prevalence of clinically significant depressive symptoms in 43% of those seeking help for sight loss in Britain is striking. To put the findings into perspective, 45% of those with a diagnosis of cancer who are about to undergo chemotherapy have clinically significant depressive features. Clearly, people seeking help for their visual problems are a high-risk group for depression, but the fact that three-quarters of those who screened positive were not receiving any form of treatment suggests that depression is being routinely overlooked in this vulnerable group. We are only aware of 2 low vision services in Britain that screen people regularly for depression. People are not getting the help they need. Addressing a patient’s needs should include more than improving their acuity or other aspect of visual function. Depression is a major cause of disability in its own right; it reduces the effectiveness of low vision rehabilitation interventions, quality of life, and even life expectancy. Depression is a medical condition, treatments can be effective, and screening is relatively straightforward. In Britain, the National Institute for Health and Clinical Excellence (NICE) recommend screening high risk groups by Ophthalmology Volume 123, Number 2, February 2016

Effectiveness of portable electronic and optical magnifiers for near vision activities in low vision: a randomised crossover trial

To compare the performance of near vision activities using additional portable electronic vision enhancement systems (p‐EVES), to using optical magnifiers alone, by individuals with visual impairment.

Depression in Visual Impairment Trial (DEPVIT): A Randomized Clinical Trial of Depression Treatments in People With Low Vision

PURPOSE The purpose of this study was to compare two interventions for depression, problem solving treatment (PST) and referral to the patients physician, with a waiting-list control group in people with sight loss and depressive symptoms. METHODS This was an assessor-masked, exploratory, multicenter, randomized clinical trial, with concurrent economic analysis. Of 1008 consecutive attendees at 14 low-vision rehabilitation centers in Britain, 43% (n = 430) screened positive for depressive symptoms on the Geriatric Depression Scale and 85 of these attendees participated in the trial. Eligible participants were randomized in the ratio 1:1:1 to PST, referral to their physician, or a waiting-list control arm. PST is a manualized talking intervention delivered by a trained therapist who teaches people over six to eight sessions to implement a seven-step method for solving their problems. Referral to the physician involved sending a referral letter to the persons physician, encouraging him or her to consider treatment according to the stepped care protocol recommended by the U.K.s National Institute of Health and Care Excellence. The primary outcome was change in depressive symptoms (6 months after baseline) as determined by the Beck Depression Inventory. RESULTS At 6 months, Beck Depression Inventory scores reduced by 1.05 (SD 8.85), 2.11 (SD 7.60), and 2.68 (SD 7.93) in the waiting-list control, referral, and PST arms, respectively. The cost per patient of the PST intervention was £1176 in Wales and £1296 in London. CONCLUSIONS Depressive symptoms improved most in the PST group and least in the control group. However, the change was small and the uncertainty of the measurements relatively large.

Portable electronic vision enhancement systems in comparison with optical magnifiers for near vision activities: an economic evaluation alongside a randomized crossover trial

To determine the incremental cost‐effectiveness of portable electronic vision enhancement system (p‐EVES) devices compared with optical low vision aids (LVAs), for improving near vision visual function, quality of life and well‐being of people with a visual impairment.

Allocation of biologics: health economics and clinical decision making in plaque psoriasis

Over the last decade biological treatments for plaque psoriasis have become increasingly popular due to their efficacy and safety. However, these treatments are also associated with substantially increased treatment costs. Due to the finite resources available to healthcare services, it is imperative that available funds are used in the most cost-effective and efficient manner possible. Evidence-based practice utilizes evidence of effectiveness and cost-effectiveness to guide service provision, and thus when implemented correctly can enable commissioners and clinicians to prioritize treatments based on potential patient benefits and health service expenditure. Health economics is becoming increasingly influential in dermatology commissioning and funding decisions. Health economists examine the relationship between the cost of health care and the associated patient benefits, using methods of economic evaluation to identify the incremental costs and benefits of competing interventions. In the U.K., the average annual cost for treating a patient with plaque psoriasis using a biological treatment is more than £10 000. Although biologics cost more than conventional therapeutics (such as methotrexate), overall they offer increased patient benefits and reduced side-effects, particularly when conventional therapeutics are unsuitable. Almost onethird of patients discontinue methotrexate treatment due to side-effects, therefore alternative treatments are essential. In practice, the treatment of psoriasis using biologics can be convoluted, as patients may need to try more than one biological agent before either finding a drug that works for them or resorting to nonbiological supportive care when biological treatment fails. The failure of one biologic does not predict the efficacy of another, thus clinicians must be prepared to change treatment promptly if clinical goals are not being met. Rates of diminishing response to treatment are relatively high for these drugs; between 10% and 25% of patients experience loss of efficacy of biologics. Each failed biological treatment causes substantial and potentially avoidable expenditure. National Institute for Health and Care Excellence guidance in the U.K. supports the prescribing of secondary biologics as an alternative to best supportive care, but there is less clear guidance on the order in which these drugs should be prescribed. It is therefore imperative to establish firstly when clinicians should change from conventional to biological therapy, and secondly the order in which different biologics should be prescribed. Such decisions must be based on good-quality evidence from a range of sources. For instance, head-to-head trial-based comparisons of cost-effectiveness and efficacy are important to guide practice, but these should also be supplemented with evaluations of real-world data, as demonstrated by Klijn et al. in the Dutch BioCAPTURE study. In the BioCAPTURE study the estimated cost and effect differences among six consecutive lines of biological treatments (with etanercept, adalimumab and ustekinumab) over a 10-year time horizon were marginal and remained without statistical significance in this analysis. Indeed, the maximum differences in costs (€141 962–148 442) and associated quality-adjusted life-years (QALYs) (7 79–8 03) were both < 5% (4 6% and 3 1%, respectively). Although a seemingly small maximum gain of 0 24 QALYs may constitute over 3 5 additional months of health for the average patient with psoriasis (as outlined by the authors of the analysis), this has to be seen in the context of a lifelong chronic disease with the burden of skin symptoms lasting over decades. Notably, the clinicians in the BioCAPTURE group may have chosen wisely and/or intuitively the treatment sequences that met health economic goals. Further research is needed to prioritize biological treatments definitively using a range of criteria, including cost-effectiveness, efficacy, tolerability, patient demographics and others. Diverse methods of analysis, including sensitivity analysis and statistical modelling, should be used to examine the probability of a given biological treatment being effective and costeffective in a specific clinical situation or patient group. In the future, personalized medicine using genetic markers including HLA-C*06 allele status and/or the presence of certain singlenucleotide polymorphisms of the IL17RA gene, or variants involved in nuclear factor-jB, tumour necrosis factor (TNF)-a and pattern recognition, may be able to predict a priori a differential clinical outcome to treatment with TNF antagonists vs. ustekinumab or other biologics. Recent data have shown that approximately one-third of patients with psoriasis do not respond to a specific treatment and require a change. The employment of predictive approaches may help to avoid the ‘trial and error’ policy that often takes place and results in periods of suboptimal treatment for the patient and increased treatment costs. Clinical outcomes are important (such as the Psoriasis Area and Severity Index); however, plaque psoriasis affects many aspects of patients’ health and well-being, thus adopting a focus solely on clinical outcomes and costs may underestimate the impact of these treatments. Treatment decisions ultimately

Defining health-related quality of life for young wheelchair users: A qualitative health economics study

Background Wheelchairs for children with impaired mobility provide health, developmental and psychosocial benefits, however there is limited understanding of how mobility aids affect the health-related quality of life of children with impaired mobility. Preference-based health-related quality of life outcome measures are used to calculate quality-adjusted life years; an important concept in health economics. The aim of this research was to understand how young wheelchair users and their parents define health-related quality of life in relation to mobility impairment and wheelchair use. Methods The sampling frame was children with impaired mobility (≤18 years) who use a wheelchair and their parents. Data were collected through semi-structured face-to-face interviews conducted in participants’ homes. Qualitative framework analysis was used to analyse the interview transcripts. An a priori thematic coding framework was developed. Emerging codes were grouped into categories, and refined into analytical themes. The data were used to build an understanding of how children with impaired mobility define health-related quality of life in relation to mobility impairment, and to assess the applicability of two standard measures of health-related quality of life. Results Eleven children with impaired mobility and 24 parents were interviewed across 27 interviews. Participants defined mobility-related quality of life through three distinct but interrelated concepts: 1) participation and positive experiences; 2) self-worth and feeling fulfilled; 3) health and functioning. A good degree of consensus was found between child and parent responses, although there was some evidence to suggest a shift in perception of mobility-related quality of life with child age. Conclusions Young wheelchair users define health-related quality of life in a distinct way as a result of their mobility impairment and adaptation use. Generic, preference-based measures of health-related quality of life lack sensitivity in this population. Development of a mobility-related quality of life outcome measure for children is recommended.

A conceptual framework to assess effectiveness in wheelchair provision

Background Currently, inadequate wheelchair provision has forced many people with disabilities to be trapped in a cycle of poverty and deprivation, limiting their ability to access education, work and social facilities. This issue is in part because of the lack of collaboration among various stakeholders who need to work together to design, manufacture and deliver such assistive mobility devices. This in turn has led to inadequate evidence about intervention effectiveness, disability prevalence and subsequent costeffectiveness that would help facilitate appropriate provision and support for people with disabilities. Objectives In this paper, we describe a novel conceptual framework that can be tested across the globe to study and evaluate the effectiveness of wheelchair provision. Method The Comparative Effectiveness Research Subcommittee (CER-SC), consisting of the authors of this article, housed within the Evidence-Based Practice Working Group (EBP-WG) of the International Society of Wheelchair Professionals (ISWP), conducted a scoping review of scientific literature and standard practices used during wheelchair service provision. The literature review was followed by a series of discussion groups. Results The three iterations of the conceptual framework are described in this manuscript. Conclusion We believe that adoption of this conceptual framework could have broad applications in wheelchair provision globally to develop evidence-based practices. Such a perspective will help in the comparison of different strategies employed in wheelchair provision and further improve clinical guidelines. Further work is being conducted to test the efficacy of this conceptual framework to evaluate effectiveness of wheelchair service provision in various settings across the globe.

Increased healthcare costs for filaggrin-related eczema and asthma: hope for targeted management and prevention

1 Odhiambo JA, Williams HC, Clayton TO et al.; ISAAC Phase Three Study Group. Global variations in prevalence of eczema symptoms in children from ISAAC Phase Three. J Allergy Clin Immunol 2009; 124:1251–8. 2 Hanghøj S, Boisen KA. Self-reported barriers to medication adherence among chronically ill adolescents: a systematic review. J Adolesc Health 2014; 54:121–38. 3 Lundin S, Wahlgren CF, Bergstr€om A et al. Use of emollients and topical glucocorticoids among adolescents with eczema: data from the population-based birth cohort BAMSE. Br J Dermatol 2018; 179:709–16. 4 Ballardini N, Kull I, S€ oderh€all C et al. Eczema severity in preadolescent children and its relation to sex, filaggrin mutations, asthma, rhinitis, aggravating factors and topical treatment: a report from the BAMSE birth cohort. Br J Dermatol 2013; 168:588–94. 5 Barbarot S, Auziere S, Gadkari A et al. Epidemiology of atopic dermatitis in adults: results from an international survey. Allergy 2018; 73:1284–93.

The Warm Homes for Health project: exploring the cost-effectiveness of improving population health through better housing

Abstract Housing has a major effect on the health and wellbeing of individuals. There are an estimated 40 000 more deaths in the UK during the coldest months of the year (December to March) than during the rest of the year. Two-thirds of these excess deaths are related to dangerously cold homes. An estimated 20% of the National Health Service clinical budget is spent on avoidable illness (such as cardiovascular and respiratory disease) caused or exacerbated by issues such as poor housing. Housing modifications to improve warmth and damp can help to improve population health. At present there are no data on the cost-effectiveness of improving the warmth of homes through housing modification. The Warm Homes for Health project is a collaboration between public health economists at Bangor University and UK housing providers Gentoo Green and Nottingham City Homes. The project will measure the effect of housing improvements on the health, quality of life, and wellbeing of residents in some of the most socioeconomically disadvantaged areas of the UK. Data will be collected from occupants of retrofitted homes. We will collect data at baseline before housing modification installation and then 6 and 12 months after installation. Outcome measures will include the EQ-5D (for health related quality of life) and the Short Warwick-Edinburgh Mental Well-being Scale. We will also collect individual health and social service use data. We will explore how a cost per quality-adjusted life year (QALY) for housing modification can be calculated for the purpose of comparing relative cost-effectiveness with medical interventions and the National Institute for Health and Care Excellence threshold of £20 000 to £30 000 per QALY. We will produce an incremental cost-effectiveness ratio to examine the incremental cost and quality of life effects of housing improvements. We will use independent t tests between individuals to test the hypothesis that different housing improvements have different effects on quality of life. If we require additional analysis of subgroups we will use one-way repeated measures and between-groups ANOVAs with ad-hoc comparisons. Sensitivity analyses will be used to test uncertainty. We aim to establish whether housing improvements are a cost-effective approach to improving population health. The project is currently ongoing, so there are no results to report. Funding The Warm Homes for Health project is jointly funded by Gentoo Green and Nottingham City Homes. The funders are also represented on the research team and have provided input into the design of the study, recruitment, data collection, and follow-up.