Background: Since June 2017, the Primary Health Care Integrated Geriatric Services Initiative (PHC IGSI) has been implemented in Alberta, Canada to, among other aims, reduce costs of unplanned health service utilization while maximizing the utilization of available community resources to support people living with dementia living in communities.
Aim of the study: We performed an economic evaluation of this initiative to inform policy regarding sustainability, scale up and spread.
Methods: We used a cohort design together with a difference-in-difference approach and a propensity score matching technique to calculate impacts of the intervention on patient's health service utilization, including inpatient, outpatient and physician services, as well as prescription drugs. We then used a decision tree to compare between benefits and costs of the intervention and reported net benefits (NB) and return on investment ratios (ROI). We used a health system perspective and a time horizon of 1 year. Both deterministic and probabilistic sensitivity analyses were performed for the uncertainty of parameters. We analyzed real-world data extracted from the Alberta Health Administrative Databases. All costs/savings were inflated to 2019 CAD (CAD 1 sim = USD 0.75) using the Canadian Consumer Price Index.
Results: The intervention reduced the use of hospital (inpatient, emergency, and outpatient) services by increasing the use of community services (physician and prescription drug). As hospital services are expensive, the PHC IGSI community intervention resulted in a NB from CAD 554 to 4,046 per patient-year for the health system, and a ROI from 1.3 to 3.1 meaning that every CAD invested in PHC IGSI would bring CAD 1.3 to 3.1 in return. The probability of PHC IGSI to be cost-saving was 56.4% to 69.3%.
Implications for health care provision and use: The PHC IGSI is cost-effective in Alberta.
Implications for health policy: The savings would be larger if the initiative is sustained, scaled up and spread because of not only a reduced cost of intervention in the sustainability phase, but also because of the increased number of patients that would be impacted.
Implications for further research: Future studies taking a societal perspective to also include costs for families and health and social sectors at the community level, would be desirable. Additionally, future works to determine how wellbeing is impacted by the PHC IGSI as vertical and horizontal integration interventions are implemented at the community level, are essential to undertake. Finally, in addition to people living with dementia, the PHC IGSI also supports people living in the community with frailty and other geriatric syndromes, therefore, the cost-savings estimated in this study are likely underestimated.
Background: Illegal drug use causes a variety of negative consequences for the society -- referred to as the social costs of illegal drug use -- and therefore they are estimated in many countries. The main purpose of social cost estimation is prevention or, at least, attenuation of the negative effects of illegal drug use.
Aims of study: The main aim of the study was the estimation of the basic social costs of illegal drug use in Poland in the year 2015 with the use of standardized methodology and the standardized presentation of results, which can ensure better comparison of the costs between countries. The other aim of the study was to present a method to fill the gaps in statistical data concerning the criminal justice system costs attributable to illegal drugs use.
Method: Cost-of-illness (COI), human capital, and prevalence-based approaches were applied to costs estimation. The author proposed a method combining survey results with official statistical data, which allows for rough estimation of some of the criminal justice costs. Furthermore, the method for and the results of the estimation of mortality rates for drug users and non-users and their life expectation were presented.
Results: The results indicate that the total direct costs of illegal drug use in Poland in the year 2015 expressed in monetary terms amounted to EUR 135.67m, which constituted about 0.03% of Poland's GDP in 2015. The highest costs were incurred by the criminal justice system (EUR 74.05m) and the health care system (EUR 44.42m). Estimated productivity costs attributable to premature mortality of illegal drug users and their absenteeism were equal to EUR 18.42m. The mortality rates of drug users were much higher than those of non-users. The users could lose, on average, over 12 years of their expected life (men), and over 8 years (women).
Discussion: The social cost estimation performed in the study covers only basic costs and could be expanded in many ways. For several reasons, the estimated costs represent only the lower limit of the social costs of illegal drug use in Poland in 2015. Whenever it was possible the data were obtained from official statistical sources, but some information came from surveys, burdened with their usual weaknesses. In spite of certain shortcomings of statistical data, the use of standardized methodology and the standardized presentation of the results could ensure better comparison of the costs and their distribution between countries, which is especially needed in the EU countries.
Implications for health policies: The knowledge of the levels and distribution of the social costs of illegal drug use may help to improve health policies in individual countries as well as in the EU, especially when the costs are estimated in a similar way. Additionally, the dissemination of the information on the differences
Background: The inclusion of indirect spillover costs and benefits that occur in non-healthcare sectors of society is necessary to make optimal societal decisions when assessing the cost effectiveness of healthcare interventions. Education costs and benefits are relevant in the disease area of mental and behavioral disorders, but their inclusion in economic evaluations is largely neglected due to lack of methodological knowledge.
Aim of the study: This study aims to explore, using a scoping review, the identification, measurement, and valuation methods used to assess the impact of mental and behavioural disorders on education costs and benefits.
Methods: A scoping review was conducted to identify articles that were set in the education sector and assessed education costs and benefits. An adapted 5-step approach was used: (i) initating a scoping review; (ii) identifying component studies; (iii) data extraction; (iv) reporting results; (v) discussion and interpretation of findings. Results were summarized in a narrative synthesis per identification, measurement, and valuation method.
Results: 177 component articles were identified in the scoping review that reported 61 mutually exclusive education costs and benefits. The nomenclature used to describe the costs and benefits was poorly defined, heterogeneous in nature and largely context dependent. This was also reflected in the diverse number of measurement and valuation methods found in the component articles.
Discussion: This is the first study, which offers a classification of education costs and benefits and costing methods reported by studies set in the education sector. In conclusion, mental and behavioral disorders have a notable impact on a variety of different education costs and benefits.
Implications for health policies: The classification provided in the current study gives an indication of the wide-spread impact of mental and behavioral disorders on the education sector. Hence, the inclusion of relevant education costs and benefits in economic evaluations for mental and behavioral disorders is necessary to make optimal societal decisions.
Implications for further research: By exploring a new area of research from a sector-specific perspective, the current study adds to the existing intersectoral cost and benefit literature base. Future research should focus on standardizing costing methods in pharmacoeconomic guidelines and assessing the relative importance of individual education costs and benefits in economic evaluations for specific interventions and diseases.
Background: Boarding of patients in hospital emergency departments (EDs) occurs routinely across the U.S. ED patients with behavioral health conditions are more likely to be boarded than other patients. However, the existing literature on ED boarding of psychiatric patients remains largely descriptive and has not empirically related mental health system capacity to psychiatric boarding. Nor does it show how the mental health system could better address the needs of populations at the highest risk of ED boarding.
Aims of the study: We examined extent and determinants of "boarding" of patients with severe mental illness (SMI) in hospital emergency departments (ED) and tested whether greater mental health system capacity may mitigate the degree of ED boarding.
Methods: We linked Oregon's ED Information Exchange, hospital discharge, and Medicaid data to analyze encounters in Oregon hospital EDs from October 2014 through September 2015 by 7,103 persons aged 15 to 64 with SMI (N = 34,207). We additionally utilized Medicaid claims for years 2010-2015 to identify Medicaid beneficiaries with SMI. Boarding was defined as an ED stay over six hours. We estimated a recursive simultaneous-equation model to test the pathway that mental health system capacity affects ED boarding via psychiatric visits.
Results: Psychiatric visits were more likely to be boarded than non-psychiatric visits (30.2% vs. 7.4%). Severe psychiatric visits were 1.4 times more likely to be boarded than non-severe psychiatric visits. Thirty-four percent of psychiatric visits by children were boarded compared to 29.6% for adults. Statistical analysis found that psychiatric visit, substance abuse, younger age, black race and urban residence corresponded with an elevated risk of boarding. Discharge destinations such as psychiatric facility and acute care hospitals also corresponded with a higher probability of ED boarding. Greater supply of mental health resources in a county, both inpatient and intensive community-based, corresponded with a reduced risk of ED boarding via fewer psychiatric ED visits.
Discussion: Psychiatric visit, severity of psychiatric diagnosis, substance abuse, and discharge destinations are among important predictors of psychiatric ED boarding by persons with SMI. A greater capacity of inpatient and intensive community mental health systems may lead to a reduction in psychiatric ED visits by persons with SMI and thereby decrease the extent of psychiatric ED boarding.
Implications for health policies: Continued investment in mental health system resources may reduce psychiatric ED visits and mitigate the psychiatric ED boarding problem.
Background: The approach to care for persons with an acute illness is different from that for a person with a chronic disease. Whilst the goal of treatment for an acute illness is to cure the disease, a chronic condition has no cure as such, and hence management requires a team approach that is aimed at achieving goals that are jointly set by service users and providers. Severe and persistent mental illness (SPMI) is a chronic disease. However, in many mental health services, the approach to care for persons with SPMI is similar to those who have an acute mental illness.
Aim: The aims of this paper are twofold: (i) to make an argument for recovery oriented services to focus on meeting clients' needs rather than on symptom reduction, (ii) to propose a model of service provision where clinical mental health services form a part rather than the mainstay of care for people with SPMI.
Results: Using examples from Australia's Partner's in Recovery initiative and other recovery literature, we start by describing how SPMI should be treated as a chronic disease that focuses on recovery. We then highlight how mental health services continue to monitor outcomes based on clinical rather than personal recovery. Next, we diagrammatically illustrate how needs can be aligned with the recovery process and illustrate how care coordination can be the hub of service delivery in a hub and spoke model. We conclude with comments on workforce requirements and costs of a needs-based recovery oriented service.
Discussion: In a needs based model, the role of the specialist mental health service will move from being at the centre of care to being one of the components of care and the role of the care coordinator will become central. Although, there are as yet no randomised controlled trials to show that meeting needs of persons with SPMI will significantly contribute to their recovery, preliminary studies show that it is possible.
Implications for healthcare provision and use: The role of the care coordinator becomes the hub of service provision collaborating with agencies such as family practices, specialist mental health services, legal, housing, employment, education, and community services.
Implications for health policies: A shift from the current model of care to a needs based approach requires a revolutionary change in the way we do business and will have to be the largest shake up of the mental health service system since deinstitutionalisation.
Implications for further research: It is a long journey from the status quo to a needs based approach. The first step would be to gather more evidence on the usefulness of addressing people's needs in achieving recovery.
Background: Research has documented a low rate of opioid use disorder (OUD) treatment utilization among individuals involved in the criminal justice system. However, racial disparities in sources of payment for OUD treatment have not been examined in the existing literature.
Aim of the study: Although substance use disorder (SUD) treatment is relatively rare for all criminal justice system involved racial-groups, previous research has indicated that, among individuals with SUD, members of racial minority groups receive treatment at lower rates than their non-Hispanic White counterparts. Given the alarming rise of OUD in the US and the association between source of payment and utilization of health care services, this study seeks to quantify racial disparities in sources of payment for OUD treatment among individuals with criminal justice involvement.
Method: Using data from the 2008-2016 National Survey of Drug Use and Health (NSDUH), this study analyzes data on non-incarcerated individuals with OUD who have had any criminal justice involvement in the previous 12 months. An extension of the Blinder-Oaxaca decomposition method for non-linear models is implemented to determine the extent that differences in OUD treatment utilization across non-Hispanic Blacks and non-Hispanic Whites are explained by observed and measurable characteristics and/or unobserved factors.
Results: Results indicate that non-Hispanic Whites are more likely to have their OUD treatment paid by a court (10%) relative to non-Hispanic Blacks (4.0%). Black-White differences in measurable factors explain 87% of the disparity, while the rest is attributed to unobserved factors. Non-Hispanic Blacks are more likely to have their OUD treatment paid by public insurance (77% vs 36%) than non-Hispanic Whites and only 72% of this disparity can be explained by observed characteristics.
Implications for health care provision and use: Our findings indicate racial disparities in sources of payment for OUD treatment among the criminal justice-involved population. Expansion of health insurance coverage and access to substance use disorder treatments would be beneficial for reducing health care disparities.
Implications for health policy: Equitable treatment options in the criminal justice system that incentivize OUD treatment availability may help address racial disparities in sources of payment among the criminal justice-involved population with OUD.
Implications for further research: Future research should focus on understanding the main factors driving the court's treatment decisions among the criminal justice system involved individuals.
Background: Schizophrenia is a chronic debilitating condition characterized by disorders in thought, affect and behavior. Considering the low effectiveness of antipsychotic drugs for schizophrenia and the potentially high cost of an inadequate choice, a systematic cost-effectiveness evaluation of the list of subsidized antipsychotic drugs is necessary in order to allow an adequate choice of pharmacotherapy for the patient and the financial reality of the Brazilian public health system (SUS).
Objective: The aims of this study are to conduct a cost-effectiveness analysis of the subsidized antipsychotic drugs for the first-line treatment of schizophrenia in Brazil and aripiprazole, and to discuss a reasonable incorporation price for aripiprazole.
Methods: A three-year Markov model with quarterly cycles was developed in TreeAge Pro® 2009 to assess the cost-effectiveness of six listed oral antipsychotic drugs for the first-line treatment of schizophrenia in the Brazilian public health system (haloperidol, chlorpromazine, risperidone, quetiapine, ziprasidone, and olanzapine) and oral aripiprazole. Outcomes were measured in quality-adjusted life years (QALYs). Reasonable prices for aripiprazole were calculated based on the placement of the drug in the efficiency frontier and the cost-effectiveness ratio of the most efficient comparator.
Results: Olanzapine was considered cost-effective adopting any threshold value. If me-too drugs are required to be least as efficient as the comparators, olanzapine would still be cost-effective under 0.031 USD/mg. Aripiprazole was absolutely dominated by risperidone. The sensitivity analysis showed important uncertainty, which was expected. There is, nevertheless, a prominent separation between ziprasidone, quetiapine and the efficiency frontier. Aripiprazole was not considered cost-effective even when its price was set at zero: CER = USD 4,102 vs. USD 3,945 (haloperidol), USD 3,616 (chlorpromazine), USD 3,646 (risperidone) and USD 3,752 (olanzapine) USD/QALY.
Conclusion: Olanzapine was considered the most cost-effective drug for the first-line treatment of schizophrenia in Brazil. Aripiprazole was dominated by risperidone and was not considered cost-effective against olanzapine.
Implications for health care provision and use: This work demonstrated, using a price adjustment process, that there is no viable price that would make aripiprazole cost-effective for incorporation in the Brazilian public health system in the first-line of treatment of schizophrenia. The drug can be useful in specific cases, since individual variability of response to antipsychotic drugs is important.
Background: The Organisation for Economic Cooperation and Development reports that one in every two people experiences a mental illness in their lifetime, and developed policy guidelines to address the impact of mental health-related issues on employment and health. The results of this policy initiative have been reported in many member countries but no survey findings are available yet for Japan. Previous studies in Japan focused on the social costs of mental illness, but little empirical evidence exists on burdens created by mental illness in individual households.
Aims: This study investigated the effects of mental illness and mental distress on family members' employment and sleep time. Employed men and women family members and unemployed women family members who wanted to work were included in the study.
Methods: Japanese survey data from the 2013 Comprehensive Survey of Living Conditions were analyzed to identify the above-mentioned effects. A propensity score matching method was used to create a valid comparison group for family members of patients with mental illness and distress.
Results: For depression, family member average weekly work hours decreased by a range of 1.06 (p%lt;0.01) to 1.18 (p<0.01) for men, and 0.53 (p<0.1) to 1.06 (p<0.05) for women. For dementia (termed "major neurocognitive disorder" in the DSM-5), there were no statistically significant effects on work hours in men, but the work hours of employed women increased, ranging from 1.15 (p<0.05) to 1.25 (p<0.01). Mental illness in a family member also significantly influenced future employment prospects of unemployed women. In family members of patients with dementia, sleep time decreased by a range of 3.6 minutes (p<0.05) to 4.8 minutes (p<0.01) per night for men and 12 minutes (p<0.01) per night for women.
Discussion and limitations: These findings can add to the existing evidence on the effects of mental illness and distress on family members' work hours and sleep time in Japan, which are consistent with research from other countries such as Germany, the UK, and the US. This study has two limitations. First, the magnitude of the effect of mental illness is limited with respect to the illness category in our study, since the severity of the condition and the impact on actual daily life may vary across categories or differ even within the same category. Second, measurement error might exist in the self-reported mental illness measures.
Policy implications: First, cooperation and mutual support between employers and the community are necessary to support working family caregivers by allowing them to adjust work schedules to accommodate caregiving responsibilities. Second, social institutional policies are needed that reduce the burden of informal caregiving for family members with mental illness and increase access to long-term care for t
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