Improving the management of behaviour that challenges associated with dementia in care homes:protocol for pharmacy-health psychology intervention feasibility study

INTRODUCTION: The inappropriate use of antipsychotics in people with dementia for behaviour that challenges is associated with an estimated 1800 deaths annually. However, solely focusing on antipsychotics may transfer prescribing to other equally dangerous psychotropics. Little is known about the role of pharmacists in the management of psychotropics used to treat behaviours that challenge. This research aims to determine whether it is feasible to implement and measure the effectiveness of a combined pharmacy-health psychology intervention incorporating a medication review and staff training package to limit the prescription of psychotropics to manage behaviour that challenges in care home residents with dementia. METHODS/ANALYSIS: 6 care homes within the West Midlands will be recruited. People with dementia receiving medication for behaviour that challenges, or their personal consultee, will be approached regarding participation. Medication used to treat behaviour that challenges will be reviewed by the pharmacist, in collaboration with the general practitioner (GP), person with dementia and carer. The behavioural intervention consists of a training package for care home staff and GPs promoting person-centred care and treating behaviours that challenge as an expression of unmet need. The primary outcome measure is the Neuropsychiatric Inventory-Nursing Home version (NPI-NH). Other outcomes include quality of life (EQ-5D and DEMQoL), cognition (sMMSE), health economic (CSRI) and prescribed medication including whether recommendations were implemented. Outcome data will be collected at 6 weeks, and 3 and 6 months. Pretraining and post-training interviews will explore stakeholders' expectations and experiences of the intervention. Data will be used to estimate the sample size for a definitive study. ETHICS/DISSEMINATION: The project has received a favourable opinion from the East Midlands REC (15/EM/3014). If potential participants lack capacity, a personal consultee will be consulted regarding participation in line with the Mental Capacity Act. Results will be published in peer-reviewed journals and presented at conferences.

Evaluation of low vision services on the quality of life of individuals with age-related macular degeneration

Background: Age-related macular degeneration (ARMD) is a major cause of irreversible visual loss in the elderly and a significant threat to their quality of life. Although low vision services often improve the functional outcomes of individuals with macular disease, it remains unclear whether or not they have any impact on quality of life. The principal aim of this study was to determine the effect of a hospital-based low vision clinic on the quality of life of individuals with ARMD. Methods: Forty patients with ARMD attended the low vision clinic at Milton Keynes University Hospital. Quality of life was measured with the vision-specific Low Vision Quality of Life (LVQOL) questionnaire and the general health EuroQol (EQ-5D-5L) questionnaire. Measures were completed at baseline (time zero, T0), and at three- (T3) and six-month (T6) follow-up visits. Results: The near visual acuity of individuals attending the low vision clinic for the first time improved significantly between visits T0 and T3 (p=0.005), reflecting the practiced use of their newly-dispensed low vision aids. As expected, there was no significant change in near acuity over this time period for existing patients. For both new and existing patients, a significant increase in LVQOL score was evident between visits T0 and T3, with a further significant improvement between T3 and T6. Similarly, there was a significant decrease in EQ-5D-5L questionnaire scores between visits T0 and T6. Conclusions: The higher LVQOL scores obtained at the end of the study period (T6) provide evidence that low vision services at Milton Keynes University Hospital served to improve patient quality of life. The reduction in EQ-5D-5L scores over the same time period suggests that low vision services also provide for an improvement in general health-related quality of life. Impact: The findings support the cause of low vision services to improve not only the vision and functional outcomes of individuals with macular disease but also their quality of life. Moreover, the findings suggest that a more efficient allocation of resources at low vision clinics may be possible through the standardisation of patient follow-up frequency.

Parkinson-kóros betegek betegségteher felmérése Magyarországon

Szerte Európában az öregedő társadalom problémájával nézünk szembe. Ezzel függ össze a növekvő Parkinson-esetszám (Magyarországon megközelítőleg 20 000 beteg él ezzel a betegséggel), és az egyre nagyobb igény az idősödéssel összefüggő egészségügyi kiadásokra. Egyre fontosabb szerephez jut a költségtudatos egészségügyi gondoskodás. A betegségteher felmérések ezt igyekszenek alátámasztani. Keresztmetszeti kérdőíves vizsgálatot végeztünk a SE Neurológiai Klinika Parkinson-kórral élő betegein, életminőséget (EQ-5D és PDQ-39 kérdőívekkel) és a betegség költségeit (indirekt és direkt) vizsgálva. Az eredmények szerint a betegséggel összefüggő költségek jelentősek, 3 509 310 Ft/beteg/év, és a betegség jelentős életminőség csökkenést okoz. Tanulmányunkban a 2008 őszén elkezdett kutatást szeretnénk bemutatni, ismertetni a módszertant és az eredményeket, összevetve nemzetközi adatokkal.

Epilepszia betegségteher felmérés Magyarországon

Tanulmányomban a 2008 októberében kezdődött Epilepszia Betegségteher Felmérés Magyarországon módszertanát és eredményeit szeretném bemutatni és összehasonlítani a nemzetközi adatokkal. Az epilepszia a felnőtteknél a neurológiai betegségek közül a második leggyakoribb megbetegedés (Magyarországon kb.50-60.000 fő). A keresztmetszeti, kérdőíves felmérés az Egészség-gazdaságtani és Egészségügyi Technológiaelemzési Kutatóközpont és három budapesti Epilepszia Centrum együttműködésében zajlott, több mint 100 beteg bevonásával. A kérdőív egy általános epilepszia kérdőívből és két generikus életminőség kérdőívből (EQ-5D és SF-36) állt. Az eredmények alátámasztották, hogy a terápia-rezisztens betegek éves társadalmi költsége az átlagnál jóval magasabb, főleg a rokkant nyugdíj költsége miatt, és jelentős életminőség romlás is megfigyelhető, elsősorban a rohamtól való félelem miatt.

A study protocol of a randomised controlled trial to measure the effects of an augmented prescribed exercise programme (APEP) for frail older medical patients in the acute setting

Background: Older adults experience functional decline in hospital leading to increased healthcare burden and morbidity. The benefits of augmented exercise in hospital remain uncertain. The aim of this trial is to measure the short and longer-term effects of augmented exercise for older medical in-patients on their physical performance, quality of life and health care utilisation. Design and Methods: Two hundred and twenty older medical patients will be blindly randomly allocated to the intervention or sham groups. Both groups will receive usual care (including routine physiotherapy care) augmented by two daily exercise sessions. The sham group will receive stretching and relaxation exercises while the intervention group will receive tailored strengthening and balance exercises. Differences between groups will be measured at baseline, discharge, and three months. The primary outcome measure will be length of stay. The secondary outcome measures will be healthcare utilisation, activity (accelerometry), physical performance (Short Physical Performance Battery), falls history in hospital and quality of life (EQ-5D-5 L). Discussion: This simple intervention has the potential to transform the outcomes of the older patient in the acute setting.

Cost-effectiveness of zoledronic acid and strontium-89 as bone protecting treatments in addition to chemotherapy in patients with metastatic castrate-refractory prostate cancer: results from the TRAPEZE trial (ISRCTN 12808747)

OBJECTIVE: To evaluate the cost-effectiveness of adding zoledronic acid or strontium-89 to standard docetaxel chemotherapy for patients with castrate-refractory prostate cancer (CRPC).

PATIENTS AND METHODS: Data on resource use and quality of life for 707 patients collected prospectively in the TRAPEZE 2 × 2 factorial randomised trial (ISRCTN 12808747) were used to assess the cost-effectiveness of i) zoledronic acid versus no zoledronic acid (ZA vs. no ZA), and ii) strontium-89 versus no strontium-89 (Sr89 vs. no Sr89). Costs were estimated from the perspective of the National Health Service in the UK and included expenditures for trial treatments, concomitant medications, and use of related hospital and primary care services. Quality-adjusted life-years (QALYs) were calculated according to patients' responses to the generic EuroQol EQ-5D-3L instrument, which evaluates health status. Results are expressed as incremental cost-effectiveness ratios (ICERs) and cost-effectiveness acceptability curves.

RESULTS: The per-patient cost for ZA was £12 667, £251 higher than the equivalent cost in the no ZA group. Patients in the ZA group had on average 0.03 QALYs more than their counterparts in no ZA group. The ICER for this comparison was £8 005. Sr89 was associated with a cost of £13 230, £1365 higher than no Sr89, and a gain of 0.08 QALYs compared to no Sr89. The ICER for Sr89 was £16 884. The probabilities of ZA and Sr89 being cost-effective were 0.64 and 0.60, respectively.

CONCLUSIONS: The addition of bone-targeting treatments to standard chemotherapy led to a small improvement in QALYs for a modest increase in cost (or cost-savings). ZA and Sr89 resulted in ICERs below conventional willingness-to-pay per QALY thresholds, suggesting that their addition to chemotherapy may represent a cost-effective use of resources.

Patient-reported quality-of-life analysis of radium-223 dichloride from the phase III ALSYMPCA study

BACKGROUND: Radium-223 dichloride (radium-223), a first-in-class α-emitting radiopharmaceutical, is recommended in both pre- and post-docetaxel settings in patients with castration-resistant prostate cancer (CRPC) and symptomatic bone metastases based on overall survival benefit demonstrated in the phase III ALSYMPCA study. ALSYMPCA included prospective measurements of health-related quality of life (QOL) using two validated instruments: the general EuroQoL 5D (EQ-5D) and the disease-specific Functional Assessment of Cancer Therapy-Prostate (FACT-P).

PATIENTS AND METHODS: Analyses were conducted to determine treatment effects of radium-223 plus standard of care (SOC) versus placebo plus SOC on QOL using FACT-P and EQ-5D. Outcomes assessed were percentage of patients experiencing improvement, percentage of patients experiencing worsening, and mean QOL scores during the study.

RESULTS: Analyses were carried out on the intent-to-treat population of patients randomized to receive radium-223 (n = 614) or placebo (n = 307). The mean baseline EQ-5D utility and FACT-P total scores were similar between treatment groups. A significantly higher percentage of patients receiving radium-223 experienced meaningful improvement in EQ-5D utility score on treatment versus placebo {29.2% versus 18.5%, respectively; P = 0.004; odds ratio (OR) = 1.82 [95% confidence interval (CI) 1.21-2.74]}. Findings were similar for FACT-P total score [24.6% versus 16.1%, respectively; P = 0.020; OR = 1.70 (95% CI 1.08-2.65)]. A lower percentage of patients receiving radium-223 experienced meaningful worsening versus placebo measured by EQ-5D utility score and FACT-P total score. Prior docetaxel use and current bisphosphonate use did not affect these findings. Treatment was a significant predictor of EQ-5D utility score, with radium-223 associated with higher scores versus placebo (0.56 versus 0.50, respectively; P = 0.002). Findings were similar for FACT-P total score (99.08 versus 95.22, respectively; P = 0.004).

CONCLUSIONS: QOL data from ALSYMPCA demonstrated that improved survival with radium-223 is accompanied by significant QOL benefits, including a higher percentage of patients with meaningful QOL improvement and a slower decline in QOL over time in patients with CRPC.

Supporting self-management: development and evaluation of a digital resource for adults with asthma

The problem: Around 300 million people worldwide have asthma and prevalence is increasing. Support for optimal self-management can be effective in improving a range of outcomes and is cost effective, but is underutilised as a treatment strategy. Supporting optimum self-management using digital technology shows promise, but how best to do this is not clear. Aim: The purpose of this project was to explore the potential role of a digital intervention in promoting optimum self-management in adults with asthma. Methods: Following the MRC Guidance on the Development and Evaluation of Complex Interventions which advocates using theory, evidence, user testing and appropriate modelling and piloting, this project had 3 phases. Phase 1: Examination of the literature to inform phases 2 and 3, using systematic review methods and focussed literature searching. Phase 2: Developing the Living Well with Asthma website. A prototype (paper-based) version of the website was developed iteratively with input from a multidisciplinary expert panel, empirical evidence from the literature (from phase 1), and potential end users via focus groups (adults with asthma and practice nurses). Implementation and behaviour change theories informed this process. The paper-based designs were converted to the website through an iterative user centred process (think aloud studies with adults with asthma). Participants considered contents, layout, and navigation. Development was agile using feedback from the think aloud sessions immediately to inform design and subsequent think aloud sessions. Phase 3: A pilot randomised controlled trial over 12 weeks to evaluate the feasibility of a Phase 3 trial of Living Well with Asthma to support self-management. Primary outcomes were 1) recruitment & retention; 2) website use; 3) Asthma Control Questionnaire (ACQ) score change from baseline; 4) Mini Asthma Quality of Life (AQLQ) score change from baseline. Secondary outcomes were patient activation, adherence, lung function, fractional exhaled nitric oxide (FeNO), generic quality of life measure (EQ-5D), medication use, prescribing and health services contacts. Results: Phase1: Demonstrated that while digital interventions show promise, with some evidence of effectiveness in certain outcomes, participants were poorly characterised, telling us little about the reach of these interventions. The interventions themselves were poorly described making drawing definitive conclusions about what worked and what did not impossible. Phase 2: The literature indicated that important aspects to cover in any self-management intervention (digital or not) included: asthma action plans, regular health professional review, trigger avoidance, psychological functioning, self-monitoring, inhaler technique, and goal setting. The website asked users to aim to be symptom free. Key behaviours targeted to achieve this include: optimising medication use (including inhaler technique); attending primary care asthma reviews; using asthma action plans; increasing physical activity levels; and stopping smoking. The website had 11 sections, plus email reminders, which promoted these behaviours. Feedback during think aloud studies was mainly positive with most changes focussing on clarification of language, order of pages and usability issues mainly relating to navigation difficulties. Phase 3: To achieve our recruitment target 5383 potential participants were invited, leading to 51 participants randomised (25 to intervention group). Age range 16-78 years; 75% female; 28% from most deprived quintile. Nineteen (76%) of the intervention group used the website for an average of 23 minutes. Non-significant improvements in favour of the intervention group observed in the ACQ score (-0.36; 95% confidence interval: -0.96, 0.23; p=0.225), and mini-AQLQ scores (0.38; -0.13, 0.89; p=0.136). A significant improvement was observed in the activity limitation domain of the mini-AQLQ (0.60; 0.05 to 1.15; p = 0.034). Secondary outcomes showed increased patient activation and reduced reliance on reliever medication. There was no significant difference in the remaining secondary outcomes. There were no adverse events. Conclusion: Living Well with Asthma has been shown to be acceptable to potential end users, and has potential for effectiveness. This intervention merits further development, and subsequent evaluation in a Phase III full scale RCT.

El dolor en la enfermedad de Parkinson. Implicaciones autonómicas y afectivas

Introducción y objetivo: La enfermedad de Parkinson (EP) es una enfermedad neurodegenerativa, la segunda con mayor prevalencia, después de la enfermedad de Alzheimer (EA). La enfermedad presenta tanto síntomas motores como “no motores”, entre los que se encuentra disfunción autonómica, dolor, deterioro cognitivo, ansiedad, depresión, entre otros. El dolor en la EP, a pesar de su frecuencia, sigue siendo un síntoma infravalorado, infradiagnosticado e infratratado. Nuestro objetivo principal es evaluar la frecuencia y configuración del dolor en la EP y sus implicaciones afectivas y autonómicas. Pacientes, material y métodos: Estudio multicéntrico, transversal, de carácter retrospectivo y prospectivo. Se incluyeron 407 pacientes con enfermedad de Parkinson (EP) de los que un 70% estaban en una situación leve-moderada (estadios 2 o 3 de Hoehn y Yahr), con edad media de 65,01 años y 7,07 años de duración de la EP. Se administraron las escalas SCOPA-Motor, SCOPA-Autonómica, SCOPA-Cog, Parkinson’s Psychosis Rating Scale modificada, Hoehn & Yarh, las Escala Hospitalaria de Ansiedad y Depresión, Dolor (EVA frecuencia), EQ-5D y estudios neurofisiológicos específicos de Sistema Nervioso Autónomo (SNA). El análisis estadístico se ha realizado con el programa de cálculo estadístico SPSS versión 22. Resultados: En nuestro estudio encontramos una prevalencia del dolor elevada (72%) y los pacientes afirman mayoritariamente (79,2%) que su dolor tiene relación con la EP. La duración de la enfermedad se correlaciona con la intensidad y frecuencia del dolor (dolor intensidad: r: 0,138; p< 0,01; dolor frecuencia: r: 0,168; p< 0,01 ). A mayor evolución de la EP mayor es la percepción del dolor. El 60% de los pacientes de EP manifiestan sentir dolor cuando aparecen episodios de rigidez y tirantez en alguno de los miembros superiores o inferiores frente a un 40% que no. Curiosamente un número mayor (el 76% de los pacientes) siente dolor durante los episodios de discinesias frente a un 24% que no lo percibe. Sin embargo, en la EP el dolor se relaciona más con la situación afectiva que con la motora, como hemos podido demostrar la relación entre el Dolor Total y la HADS (Depresión) Total y la Escala Hoehn & Yahr. El coeficiente de contingencia es mayor en la depresión (C: 0,894; N=403) que en la situación motora (C: 0,637; N=401). El dolor evoluciona y se percibe de forma paralela a otros síntomas no motores (ánimo, nicturia, alteración del control vesical, estreñimiento, etc.) pero con lo que se relaciona más es con la situación afectiva del paciente parkinsoniano (ansiedad (r: 0,40; p < 0,01), depresión (r: 0.28; p < 0,01). La mayor asociación se encuentra entre la ansiedad y el dolor, seguida de la depresión y en menor grado nicturia y sialorrea. Existe una correlación positiva entre las dos subescalas de la HADS (depresión y ansiedad). Existe una alta prevalencia de alteración de la memoria inmediata como síntoma “no motor” (SNM) en nuestra serie (96,5%). En base a nuestros resultados el sexo femenino se asocia al dolor en la EP. Con respecto a la fenomenología el dolor en la EP es muy variable. Se percibe con mayor frecuencia como una corriente eléctrica (64%), calor (60%), frialdad (60%), punzante (52%), difuso (52%), interno (40%), acorchamiento u hormigueo (40%), La frecuencia de la cantidad de tipos de dolor es la siguiente: un tipo de dolor (12%), dos tipos de dolores (16%) y tres tipos de dolores (72%). La media de tipos de dolor en nuestro estudio es superior a 2 tipos (x ̅: 2,60 ± 0,63; rango: 1-3). En los casos que toman levodopa les sigue unas tres cuartas partes que lo perciben como palpitante, tirante, punzante. En los casos que toman agonista dopaminérgico lo perciben en un 75% como adormecimiento, interno, descarga eléctrica, frialdad y calor. El dolor en la EP respecto a su configuración es multimodal. Los parámetros neurofisiológicos están relacionados con los umbrales de dolor. La actividad simpática y la sensibilidad nociceptiva están disminuidas en la EP. Los enfermos con EP tienen un umbral menor para el frío según los datos del estudio del Cold-Ice. En lo referente a la terapéutica el tratamiento dopaminérgico es eficaz para el control del dolor en el 48% de los pacientes mientras que el tratamiento analgésico estándar prescrito mejora el dolor en un 78,8%. Por último, casi la mitad de la población de nuestro estudio (47,52%) evaluada con la EQ-5D tiene problemas en alguna de las dimensiones de la calidad de vida. Hay una relación positiva entre la escala analógica visual del dolor (EVA) y la EQ-5D que evalúa la CVRS y entre la intensidad de dolor y la CVRS (r:-0,298; p < 0,01). Es decir, una mayor vivencia de dolor empeora la CVRS del paciente con EP. Conclusiones: En la enfermedad de Parkinson el dolor es un síntoma no motor de elevada prevalencia, íntimamente relacionado con la afectación de los sistemas afectivos y autonómicos medido con test neuro-vegetativos específicos. El presente estudio confirma su relación con el lado más afecto de la enfermedad, las fluctuaciones motoras, el tiempo de evolución, con la situación anímica (depresión y ansiedad) y con el sexo femenino, así como su carácter multimodal y gran variedad de expresión sintomática. Es muy llamativa su asociación con el déficit mnésico. Por último esta vivencia repercute en forma llamativa en la calidad de vida relacionada con la salud por lo que sería importante conocer y manejar mejor estos aspectos de la enfermedad de Parkinson.

Social/economic costs and health-related quality of life in patients with epidermolysis bullosa in Europe

BACKGROUND: The aim of this study was to determine the social/economic costs and health-related quality of life (HRQOL) of patients with epidermolysis bullosa (EB) in eight EU member states. METHODS: We conducted a cross-sectional study of patients with EB from Bulgaria, France, Germany, Hungary, Italy, Spain, Sweden and the United Kingdom. Data on demographic characteristics, health resource utilisation, informal care, labour productivity losses, and HRQOL were collected from the questionnaires completed by patients or their caregivers. HRQOL was measured with the EuroQol 5-domain (EQ-5D) questionnaire. RESULTS: A total of 204 patients completed the questionnaire. Average annual costs varied from country to country, and ranged from euro9509 to euro49,233 (reference year 2012). Estimated direct healthcare costs ranged from euro419 to euro10,688; direct non-healthcare costs ranged from euro7449 to euro37,451 and labour productivity losses ranged from euro0 to euro7259. The average annual cost per patient across all countries was estimated at euro31,390, out of which euro5646 accounted for direct health costs (18.0 %), euro23,483 accounted for direct non-healthcare costs (74.8 %), and euro2261 accounted for indirect costs (7.2 %). Costs were shown to vary across patients with different disability but also between children and adults. The mean EQ-5D score for adult EB patients was estimated at between 0.49 and 0.71 and the mean EQ-5D visual analogue scale score was estimated at between 62 and 77. CONCLUSION: In addition to its negative impact on patient HRQOL, our study indicates the substantial social/economic burden of EB in Europe, attributable mostly to high direct non-healthcare costs.

Non-institutionalized nonagenarians health-related quality of life and nutritional status: is there a link between them?

Introduction: Nonagenarian population, clearly increasing, shows different characteristics from the rest of elderly people. Health-related quality of life is a way to study population health in physical, psychological and social dimensions. Objectives: To examine the relationship between nutritional status and health-related quality of life in a group of free-living nonagenarians. Differences with octogenarians were also studied. Methods: Within Villanueva Older Health Study, 20 non-institutionalised people (92.5±3.5 years; 80% women) make the nonagenarian subsample. Nutritional risk was assessed by Mininutritional Assessment questionnaire, dietary intake by a 24-hour dietary recall and health-related quality of life by EuroQoL-5D questionnaire. SPSS was used for statistical analysis. Results: 40% nonagenarians were at risk of malnutrition. Dietary assessment showed magnesium, zinc, potassium, folic acid, vitamin D and vitamin E deficiencies. Problems in mobility were more frequently reported (80%). EQ-5Dindex was associated with MNA (p<0.05). Self-care dimension was associated with calcium and niacin (p<0.05), retinol and cholesterol (p<0.01) intake. Usual activities dimension was associated with niacin (p<0.01) and cholesterol(p<0.05) intake. Pain/discomfort dimension was associated with protein (p<0.01), energy, selenium and niacin (p<0.05) intake. Anxiety/depression was associated with protein(p<0.01) and selenium (p<0.05) intake. Conclusions: Risk of malnutrition is a factor associated to health-related quality of life. Results suggest that energy and some nutrient intakes could be possibly associated to health-related quality of life but further research on this influence is required.

Effectiveness of diapers among people with chronic incontinence in Thailand

Objectives:
The aim of this study was to assess effect of adult diapers on health-related quality of life (HRQOL) and the independent level of performing activities of daily living (ADLs) in people with urinary or fecal incontinence. Psychological consequences of patients’ caregivers were also measured.
Methods:
This quasi-experimental study was conducted at two rehabilitation centers in Thailand. People aged 15 years or greater with chronic urinary or fecal incontinence were
eligible. Study participants received adult diapers for 10 weeks after recruitment. Thai EuroQol Five Dimensions (EQ-5D) and the Barthel Index were measured at baseline and weeks
2, 6, and 10 to evaluate HRQOL and the independent level of performing ADLs, respectively. The Braden Scale was used to assess the risk of having pressure ulcers. Mean
differences in the Thai EQ-5D, the Barthel Index, and the Braden Scale, before and after receiving adult diapers, were estimated using a multilevel linear regression model.
Results:
There were ninety patients and forty-eight caregivers who took part in this study. HRQOL and independent level of performing ADLs had improved significantly by week 10
after receiving adult diapers with mean differences of 0.102 (95% confidence interval [CI], 0.046–0.158) and 4.40 (95% CI, 1.74–7.07), respectively. The risk of having
pressure ulcers had significantly decreased by 67 percent (95% CI, 16 percent–78 percent) by week 10 after receiving adult diapers.
Conclusions:
The results indicate a significant improvement of HRQOL and the independent level of performing ADLs among incontinent patients after receiving adult diapers. These results were used to inform the development of the health benefits package under the Universal Health Coverage Scheme in Thailand.

Burden of epilepsy: a prevalence-based cost of illness study of direct, indirect and intangible costs for epilepsy

OBJECTIVES: We aimed to gauge the burden of epilepsy in China from a societal perspective by estimating the direct, indirect and intangible costs. METHODS: Patients with epilepsy and controls were enrolled from two tertiary hospitals in China. Patients were asked to complete a Cost-of-Illness (COI), Willingness-to-Pay (WTP) questionnaires, two utility elicitation instruments and Mini Mental State Examination (MMSE). Healthy controls only completed WTP questionnaire, and utility instruments. Univariate analyses were performed to investigate the differences in cost on the basis of different variables, while multivariate analysis was undertaken to explore the predictors of cost/cost component. RESULTS: In total, 141 epilepsy patients and 323 healthy controls were recruited. The median total cost, direct cost and indirect cost due to epilepsy were US$949.29, 501.34 and 276.72, respectively. Particularly, cost of anti-epileptic drugs (AEDs) (US$394.53) followed by cost of investigations (US$59.34), cost of inpatient and outpatient care (US$9.62) accounted for the majority of the direct medical costs. While patients' (US$103.77) and caregivers' productivity costs (US$103.77) constituted the major component of indirect cost. The intangible costs in terms of WTP value (US$266.07 vs. 88.22) and utility (EQ-5D, 0.828 vs. 0.923; QWB-SA, 0.657 vs. 0.802) were both substantially higher compared to the healthy subjects. CONCLUSIONS: Epilepsy is a cost intensive disease in China. According to the prognostic groups, drug-resistant epilepsy generated the highest total cost whereas patients in seizure remission had the lowest cost. AED is the most costly component of direct medical cost probably due to 83% of patients being treated by new generation of AEDs.

Twelve-month outcomes following surgical repair of the achilles tendon

IntroductionIncidence of Achilles tendon rupture (ATR) has increased over recent years, and debate regarding optimal management has been widely documented. Most papers have focused on surgical success, complications and short term region-specific outcomes. Inconsistent use of standardised outcome measures following surgical ATR repair has made it difficult to evaluate the impact of ATR on a patient’s health status post-surgery, and to compare this to other injury types. This study aimed to report the frequency of surgical repairs of the Achilles tendon over a five-year period within an orthopaedic trauma registry, and to investigate return to work (RTW) status, health status and functional outcomes at 12 months post-surgical repair of the Achilles tendon.MethodsTwo hundred and four adults registered by the Victorian Orthopaedic Trauma Outcomes Registry (VOTOR) who underwent surgical repair of the Achilles tendon between July 2009 and June 2014 were included in this prospective cohort study. The Extended Glasgow Outcome Scale (GOS-E), 3-level European Quality of Life 5 Dimension measure (EQ-5D-3L), and RTW status 12 months following surgical ATR repair were collected through structured telephone interviews conducted by trained interviewers.ResultsAt 12 months, 92% of patients were successfully followed up. Of those working prior to injury, 95% had returned to work. 42% of patients reported a full recovery on the GOS-E scale. The prevalence of problems on the EQ-5D–3 L at 12 months was 0.5% for self-care, 11% for anxiety, 13% for mobility, 16% for activity, and 22% for pain. 16% of patients reported problems with more than one domain. The number of surgical repairs of the Achilles tendon within the VOTOR registry decreased by 68% over the five-year study period.ConclusionsOverall, patients recover well following surgical repair of the Achilles tendon. However, in this study, deficits in function persisted for over half of patients at 12 months post-injury. The decreased incidence of surgical Achilles tendon repair may reflect a change in practice at VOTOR hospitals whereby surgery may be becoming less favoured for initial ATR management.

Effect of investigation intensity and treatment differences on prostate cancer survivor's physical symptoms, psychological well-being and health-related quality of life: a two country cross-sectional study.

Aim: To investigate effects on men's health and well-being of higher prostate cancer (PCa) investigation and treatment levels in similar populations. Participants: PCa survivors in Ireland where the Republic of Ireland (RoI) has a 50% higher PCa incidence than Northern Ireland (NI). Method: A cross-sectional postal questionnaire was sent to PCa survivors 2–18 years post-treatment, seeking information about current physical effects of treatment, health-related quality of life (HRQoL; EORTC QLQ-C30; EQ-5D-5L) and psychological well-being (21 question version of the Depression, Anxiety and Stress Scale, DASS-21). Outcomes in RoI and NI survivors were compared, stratifying into ‘late disease’ (stage III/IV and any Gleason grade (GG) at diagnosis) and ‘early disease’ (stage I/II and GG 2–7). Responses were weighted by age, jurisdiction and time since diagnosis. Between-country differences were investigated using multivariate logistic and linear regression. Results: 3348 men responded (RoI n=2567; NI n=781; reflecting population sizes, response rate 54%). RoI responders were younger; less often had comorbidities (45% vs 38%); were more likely to present asymptomatically (66%; 41%) or with early disease (56%; 35%); and less often currently used androgen deprivation therapy (ADT; 2%; 28%). Current prevalence of incontinence (16%) and impotence (56% early disease, 67% late disease) did not differ between RoI and NI. In early disease, only current bowel problems (RoI 12%; NI 21%) differed significantly in multivariate analysis. In late disease, NI men reported significantly higher levels of gynaecomastia (23% vs 9%) and hot flashes(41% vs 19%), but when ADT users were analysed separately, differences disappeared. For HRQoL, in multivariate analysis, only pain (early disease: RoI 11.1, NI 19.4) and financial difficulties (late disease: RoI 10.4, NI 7.9) differed significantly between countries. There were no significant between-country differences in DASS-21 or index ED-5D-5L score. Conclusions: Treatment side effects were commonly reported and increased PCa detection in RoI has left more men with these side effects. We recommended that men be offered a PSA test only after informed discussion.