Paul McNamee

Uptake and Costs of Care for Epilepsy: Findings from a U.K. Regional Study

Summary: Purpose: Epilepsy is a common neurological condition, with significant resource implications for the health services, but few studies to date have examined the uptake and costs of care for this condition. As part of a large prevalence study of epilepsy conducted in one U.K. Health Region, we investigated both direct and indirect costs of epilepsy care and measured and valued the direct costs.

Treatment of multiple sclerosis with interferon β: an appraisal of cost-effectiveness and quality of life

OBJECTIVE To evaluate the cost-effectiveness of interferon beta-1b (IFβ-1b) for relapsing-remitting multiple sclerosis (RRMS). METHODS Construction of a cost-effectiveness model using published data on IFβ-1b effectiveness and the natural history of RRMS, and new data on costs and quality of life (QoL) from a sample of 102 patients with RRMS and resident in northern England. RESULTS Poorer QoL was found for patients with multiple sclerosis compared with the general population; those who had had a relapse; those with worse states identified by a clinical measure (expanded disability status scale (EDSS)). Relapses have effects over several months. Health state valuations were higher than in the general population. Costs were higher in relapse than remission and for worse EDSS states. IFβ-1b costs were larger than cost savings. The best cost-effectiveness estimate was £28 700 per relapse avoided, which is £809 900 per QALY gained; or £328 300 per QALY gained allowing for effects of progression over 5 years. Estimates were robust to changes in assumptions. CONCLUSIONS The impact of multiple sclerosis on QoL is substantial. Future trials should base outcomes measurement on QoL and be better linked to natural history and cost data. IFβ-1b produces important occasional short term QoL gains, but small gains in QALYs overall and large additional costs.

Does an early increased-intensity interdisciplinary upper limb therapy programme following acute stroke improve outcome?

Objective: To determine whether an early increased-intensity upper limb therapy programme following acute stroke improves outcome. Design: A randomized controlled trial. Setting: A stroke unit which provides acute care and rehabilitation for all stroke admissions. Subjects: One hundred and twenty-three patients who had had a stroke causing upper limb impairment within the previous 10 days. Intervention: The intervention group received stroke unit care plus enhanced upper limb rehabilitation provided jointly by a physiotherapist and occupational therapist, commencing within 10 days of stroke, and available up to 30 minutes/day, five days/week for six weeks. The control group received stroke unit care. Main outcome measures: The primary outcome measure was the Action Research Arm Test (ARAT) three months after stroke. Secondary outcome measures: Motricity Index; Frenchay Arm Test; upper limb pain; Barthel ADL Index; Nottingham E-ADL Scale; and costs to health and social services at three and six months after stroke. Results: There were no differences in outcomes between the intervention and control groups three and six months after stroke. During the intervention period the intervention group received a median of 29 minutes of enhanced upper limb therapy per working day as inpatients. The total amount of inpatient physiotherapy and occupational therapy received by the intervention group was a median of 52 minutes per working day during the intervention period and 38 minutes per working day for the control group (p = 0.001). There were no differences in service costs. Conclusions: An early increased-intensity interdisciplinary upper limb therapy programme jointly provided by a physiotherapist and occupational therapist did not improve outcome after stroke. The actual difference in the amount of therapy received by intervention and control groups was less than planned due to a competitive therapy bias.

Promoting brief alcohol intervention by nurses in primary care: a cluster randomised controlled trial

This trial evaluated the clinical impact and cost-effectiveness of strategies promoting screening and brief alcohol intervention (SBI) by nurses in primary care. Randomisation was at the level of the practice and the interventions were: written guidelines (controls, n=76); outreach training (n=68); and training plus telephone-based support (n=68). After 3 months, just 39% of controls implemented the SBI programme compared to 74% of nurses in trained practices and 71% in trained and supported practices. Controls also screened fewer patients and delivered fewer brief interventions to risk drinkers than other colleagues. However, there was a trade-off between the extent and the appropriateness of brief intervention delivery with controls displaying the least errors in overall patient management. Thus cost-effectiveness ratios (cost per patient appropriately treated) were similar between the three strategies. Given the potential for anxiety due to misdirected advice about alcohol-related risk, the balance of evidence favoured the use of written guidelines to promote SBI by nurses in primary care.

Costs of formal care for frail older people in England:: the resource implications study of the MRC cognitive function and ageing study (RIS MRC CFAS)

The aim of this paper is to quantify service use and costs of supporting frail older people at home in the community, using data collected in a longitudinal multicentre stratified randomised study for 1055 mentally frail, physically frail, and mentally and physically frail subjects. Average costs per person per week were found to total 64.45 Pounds Sterling, with a small number of services accounting for a large proportion of the total costs. The level of services offered by the nonstatutory voluntary and private sectors was found to be small. To highlight issues for policy makers, the extent of cost variations between a number of different subgroups were calculated. These bivariate analyses revealed substantial variation in costs, especially according to household structure, type of frailty, whether admission to continuing care accommodation occurred and survival. Multiple regression analysis demonstrated that 26% of the variation in log average weekly costs could be explained by a number of socio-demographic and health status variables. A particularly close relationship was observed between costs and whether admission to continuing care accommodation occurred, highlighting a need for policy-makers to examine the nature and scale of provision of alternative community based care packages. The results demonstrate that descriptive cost data such as those presented can provide information useful to the planning process, enabling more informed choices to be made over the provision of services for particular groups of people.

Psychological distress among informal supporters of frail older people at home and in institutions

Objective. Investigate presence of psychiatric morbidity in informal carers using 30‐item General Health Questionnaire (GHQ) and examine which factors best predict psychiatric morbidity.

Benefits and Costs of Recombinant Human Erythropoietin for End-Stage Renal Failure: A Review: Benefits and Costs of Erythropoietin

Recombinant human erythropoietin is an efficacious therapy in treatment of the anemia of end-stage renal failure. However, the scale of impact on quality of life and medical care resources remains uncertain. By reviewing the literature we evaluate cost-effectiveness of recombinant human erythropoietin and show how previous studies may have implicitly overestimated cost-effectiveness.