Background: School-based treatments for anxiety disorders are needed to address barriers to accessing community-based services. A key question for school administers are the costs related to these treatments.
Aims of the study: This study examined the cost-effectiveness of a school-based modular cognitive behavioral therapy (M-CBT) for pediatric anxiety disorders compared to school-based treatment as usual (TAU).
Methods: Sixty-two school-based clinicians in Maryland and Connecticut were randomized (37 in CBT; 25 in TAU), trained, and enrolled at least one anxious student (148 students in CBT; 68 in TAU). Students (N = 216) were ages 6-18 (mean age 10.9); 63.9% were non-Hispanic White race-ethnicity; and 48.6% were female. Independent evaluators (IEs) assessed outcomes at post treatment and at a one-year follow up. Anxiety related costs included mental health care expenses and the opportunity costs of added caregiver time and missed school days.
Results: The overall M-CBT ICER value of $6917/QALY reflected both lower costs for days absent from school (mean difference: $--117 per youth; p = 0.045) but also lower QALY ratings (mean difference: -0.024; p = 0.900) compared with usual school counseling. Among youth with more severe anxiety at baseline, M-CBT had a more favorable ICER ($-22,846/QALY). Other mental health care costs were similar between groups (mean difference: $-90 per youth; p = 0.328).
Discussion: Although training school clinicians in M-CBT resulted in lower costs for school absences, evidence for the cost effectiveness of a modular CBT relative to existing school treatment for pediatric anxiety disorders was not robustly supported. Findings suggest school-based M-CBT is most cost effective for youth with the highest levels of anxiety severity and that M-CBT could help reduce the costs of missed school. Interpretations are limited due to use of retrospective recall, lack of data on medication use, and small sample size.
Implications for health care provision and use: Schools may benefit from providing specialized school-based services such as M-CBT for students with the highest levels of anxiety.
Implications for health policies: Investment decisions by schools should take into account lower costs (related to school absences), the costs of training clinicians, and student access to CBT in the community.
Implications for further research: Replication with a larger sample, service use diaries, and objective school and medical records over a longer period of time is warranted.
Background: Certificate of need (CON) laws require would-be healthcare providers to obtain the permission of a state board before opening or expanding. 35 US states operate some type of CON program, though they vary widely in the specific services or equipment they target, with 25 states requiring CON for psychiatric services.
Aims of the study: We provide the first empirical estimates on how CON affects the provision of psychiatric services.
Methods: We use Ordinary Least Squares regression to analyze 2010-2016 data on psychiatric CON from the American Health Planning Association together with data on psychiatric facilities and services from the National Mental Health Services Survey.
Results: We find that CON laws targeting psychiatric services are associated with a statistically significant 0.527 fewer psychiatric hospitals per million residents (20% fewer) and 2.19 fewer inpatient psychiatric clients per ten thousand residents (56% fewer). Psychiatric CON is also associated with psychiatric hospitals being 5.35 percentage points less likely to accept Medicare. Our estimates for CON's effect on the number of inpatient psychiatric beds per ten thousand residents and the likelihood of psychiatric hospitals accepting Medicaid, private insurance, or charity care (no charge) are negative but not statistically significant.
Discussion: CON laws may substantially reduce access to psychiatric care. A limitation of our study is that there is almost no variation in which states have psychiatric-related CON laws during the time period of our data (New Hampshire is the only state to change its psychiatric services CON requirement in this period, repealing its CON program entirely in 2016). This precludes the use of preferred econometric techniques such as difference-in-difference.
Implications for health policies: Our results indicate that CON laws may reduce access to inpatient psychiatric care. State policymakers should consider whether CON repeal could be a simple way of enhancing access to psychiatric care.
Implications for further research: While hundreds of articles have examined the effects of CON laws, we believe ours is the first to provide empirical estimates of their effects on mental health care specifically. We hope it is not the last.
Background: Decades of research that predate the COVID-19 pandemic demonstrate that most people with mental health needs are not receiving adequate care. The inequities between those who need care and those who receive adequate care are larger for racial and ethnic minority groups and people living in underserved communities. The pandemic is associated with an exacerbation of these inequities, resulting in increased morbidity and mortality for the most vulnerable populations.
Aims: This Perspective summarizes longstanding and evolving challenges to the provision of high quality care for people with mental illness, describes the National Institute of Mental Health's (NIMH) commitment to addressing those challenges, and embeds salient research priorities most germane to the health policy readership of this journal.
Methods: Example funding announcements and extant funding priorities are highlighted to demonstrate NIMH's commitment to health services research during the pandemic. The collaborative care model is presented as an evidence-supported service delivery model that could be delivered via telehealth. Recent studies that compare the utilization of routine telehealth services during the pandemic, when compared to in-person services pre-pandemic, are summarized.
Results: In FY2020, NIMH invested $171,194,275 in health services research. Over the past two years, NIMH led or participated on dozens of funding announcements that call for mental health services research to help improve the provision of care for people with mental illness. Service delivery models like collaborative care can offer effective intervention via telehealth. The practice community can deliver routine services via telehealth at volumes similar to pre-pandemic in-person levels. However, wide variation in telehealth utilization exists, with inequities associated with racial and ethnic groups and underserved rural locations. A limitation is that clinical outcomes are not routinely available from administrative datasets.
Discussion: There continues to be an urgent need for health policy research and collaboration with the health policy community as part of the research enterprise.
Implications for health care provision and use: NIMH encourages and often requires strong research practice partnerships to help ensure findings will be of value to end users and make their way into the practice setting. There is a need to study pandemic related changes in financing, delivery, receipt, and outcomes of mental health care.
Implications for health policies: Despite robust evidence, clinical practice guideline recommendations, and established financing mechanisms, uptake of service delivery models that can be delivered in part or in full via telehealth (e.g., the collaborative care model) is poor.
Implications for further
Background: Burden of opioid use disorder (OUD) is expressed in economic values or health metrics like Disability Adjusted Life Years (DALYs). Disability Weight (DW), a component of DALYs is estimated using economic methods or psychometric tools. Estimating DW at patient level using psychometric tools is an alternative to non-population specific DW overestimated by economic methods. Providing Medication Assisted Treatment (MAT) using buprenorphine/naloxone film (BUP/NX-F) for OUD is limited by financial constraints.
Aim: To estimate the burden of OUD at patient level and explore the cost-benefit of two buprenorphine treatment interventions.
Methods: The present study was conducted alongside a randomized controlled trial of 141 adults with OUD stabilized on BUP/NX-F and randomized to BUP/NX-F with Incentivized Abstinence and Adherence Monitoring (experimental, n=70) and BUP/NX-F in usual care (control, n=71). The cost of illness was estimated applying a societal perspective. The Impairment Weight (IW) was estimated over a '0' to '1' scale, where '0' represents no impairment and '1' full impairment using the Work and Social Adjustment Scale (WSAS).
Results: Median (interquartile range) annual cost of OUD per participant was AED 498,171.1 (413,499.0 -635,725.3) and AED 538,694.4 (4,211,398.0 - 659,949.0) in the experimental and control groups, respectively (p=0.33). Illicit drug purchase represented 60 % of the annual cost of illness. At baseline, the mean Impairment Weight (IW) was 0.55 (SD 0.26) and 0.62 (SD 0.24) in the experimental and control groups, respectively. At end of the study, the IW was 0.26 (SD 0.28) representing 51% reduction in the experimental group compared to 0.42 (SD 0.33) in the control group representing a 27% reduction. Excluding imprisonment, the cost-benefit of treatment was not realized. In contrast, accounting for imprisonment, cost benefit expressed as a return-on-investment was established at 1.55 and 1.29 in the experimental and control groups, respectively.
Implications for mental health policy: Cost benefit analysis can serve as a simple and practical tool to evaluate the cost benefit of treatment interventions. Demonstrating the cost benefit of buprenorphine treatment has the potential to facilitate public funding and accessibility to opioid assisted treatment.
Background: Interest in and use of mental health apps have grown over the past decade, and now further with the COVID-19 pandemic. Digital mental health offers potential to increase access to care, but tangible risks around safety and poor efficacy remain common.
Methods: We conduct a select analysis of U.S. and international published evidence, government websites, grey literature, and media outlets. We present the marked discordance around digital mental health policy, as these frameworks grapple with the challenges of regulating in this sphere.
Results: Across the world, there is no consensus around evaluation with countries piloting or proposing different models. Common barriers include the defining the scope and risk of health apps, creating processes able to update evaluation with software updates, lacking better data to inform evaluation, and educating users to the risks and benefits.
Discussion: We propose four next steps for guiding any future policy: (i) clear clarification of the categorical status of mental health apps; (ii) objective methodology for assessing apps on a premarket basis which does not solely rely on self-reporting; (iii) well-designed, detailed procedures for iterative post-market app review; (iv) clinician and patient education which empowers users to make smart mental health app choices.
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