The safety and effectiveness of different methods of ear wax removal: a systematic review and economic evaluation

Build-up of earwax is a common reason for attendance in primary care. Current practice for earwax removal generally involves the use of a softening agent, followed by irrigation of the ear if required. However, the safety and benefits of the different methods of removal are not known for certain.

Cost effectiveness of childhood obesity interventions: Evidence and methods for CHOICES

INTRODUCTION: The childhood obesity epidemic continues in the U.S., and fiscal crises are leading policymakers to ask not only whether an intervention works but also whether it offers value for money. However, cost-effectiveness analyses have been limited. This paper discusses methods and outcomes of four childhood obesity interventions: (1) sugar-sweetened beverage excise tax (SSB); (2) eliminating tax subsidy of TV advertising to children (TV AD); (3) early care and education policy change (ECE); and (4) active physical education (Active PE). METHODS: Cost-effectiveness models of nationwide implementation of interventions were estimated for a simulated cohort representative of the 2015 U.S. population over 10 years (2015-2025). A societal perspective was used; future outcomes were discounted at 3%. Data were analyzed in 2014. Effectiveness, implementation, and equity issues were reviewed. RESULTS: Population reach varied widely, and cost per BMI change ranged from $1.16 (TV AD) to $401 (Active PE). At 10 years, assuming maintenance of the intervention effect, three interventions would save net costs, with SSB and TV AD saving $55 and $38 for every dollar spent. The SSB intervention would avert disability-adjusted life years, and both SSB and TV AD would increase quality-adjusted life years. Both SSB ($12.5 billion) and TV AD ($80 million) would produce yearly tax revenue. CONCLUSIONS: The cost effectiveness of these preventive interventions is greater than that seen for published clinical interventions to treat obesity. Cost-effectiveness evaluations of childhood obesity interventions can provide decision makers with information demonstrating best value for the money.

Cost-effectiveness of recruitment methods in a population-based epidemiological study: the Melbourne Visual Impairment Project

The cost-effectiveness of five recruitment methods was evaluated to determine the best method of encouraging eligible persons to participate in the Melbourne Visual Impairment Project (a population-based epidemiological study). The evaluation was divided into two phases. Phase 1 included one of two types of initial contact, by direct personal contact or by telephone. Phase 2 involved recruiting residents after an attempt had been made by either the telephone or the doorstep approach, and included a second attempt by a field interviewer, subsequent attempts by senior field staff, and finally, financial incentives. The cost-effectiveness of each method was determined by dividing the approach's cost by the effectiveness ratio. We identified 269 eligible households with 356 eligible residents. An 89 per cent response rate was achieved at the examination centre, comprising 61 per cent from Phase 1 and 28 per cent from Phase 2. Although both recruitment methods in Phase 1 were equally cost-effective, there was a significant difference in the effectiveness of each method in actually recruiting residents. The doorstep method was more costly per attender but was far more effective at 76 per cent recruitment than the telephone method at 47 per cent (P < 0.001). We have demonstrated a practical two-stage approach (the doorstep method in Phase 1 and follow-up strategies in Phase 2) to population-based recruitment involving the middle to elderly age group that should be relevant to many epidemiological studies.

Weaning of Australian shortfin glass eels (Anguilla Australis): a comparison on the effectiveness of four types of fish roe

Eel culture is solely dependent on wild seed stock, caught in estuaries during the freshwater migratory phase as glass eels. The methods used for weaning glass eels are very variable, and range from the use of live zooplankton to fish roe to fines of commercial fish feeds. The present experiments were conducted on glass eels of the Australian shortfin eel, when the effectiveness of four types of readily available fish roe (European carp, mirror dory, orange roughy and warehou) were evaluated over a 42-day period, in the laboratory.

After 28 days the eels did not show an interest in orange roughy and mirror dory roe, and these two treatments were discontinued to avoid mortality. In all treatments there was a decrease in mean weight during this period, but the survival was over 99%. In the 28th to 42nd day period the mean weight and specific growth rate of glass eels reared on European carp and warehou roe increased, but the differences between these two treatments were not significant.

The physical features of the roe and the oocytes thereof, the proximate composition, amino acid and fatty acid composition indicated major differences amongst the roe types, particularly with regard to the amount of n−6 polyunsaturated fatty acids (PUFA) and the ratio of n−3 to n−6. European carp and warehou roe (and oocytes) had a significantly higher arachidonic acid (AA-20:4n−6; over 60% of PUFA) content and a considerably lower n−3 to n−6 ratio (n−3 to n−6 ratio being 1.32, 5.92, 3.77 and 2.67 for roe types, and 1.25, 4.83, 2.91 and 2.42 for oocytes, of European carp, mirror dory, orange roughy and warehou, respectively), than in the other two roe types. The fatty acid profiles of European carp and warehou roe were similar to that of metamorphosing glass eels.

Effectiveness of treatment programmes for depression among adults with mild/moderate intellectual disability

Background The current study describes the development and evaluation of group treatment programme for people with mild/moderate intellectual disability (ID).
Methods A total of 34 participants (16 males, 18 females) completed the treatment programme and 15 participants (six males, nine females) comprised a control group.
Results Compared to the control group, the intervention group showed an improvement in levels of depression, positive feelings about the self, and lower levels of automatic negative thoughts after the intervention. These changes were maintained at 3-month follow-up.
Conclusions These results demonstrate that intervention programmes are effective for the treatment of depression among people with ID.

Randomised controlled trial evaluating the effectiveness of behavioural interventions to modify cardiovascular risk factors in men and women with imparied glucose tolerance: outcomes at 6 months

Aims: To evaluate the efficacy of interventions to promote a healthy diet and physical activity in people with impaired glucose tolerance (IGT). Methods: A randomised controlled trial in Newcastle upon Tyne, UK, 1995–98. Participants included 67 adults (38 men; 29 women) aged 24–75 years with IGT. The intervention consisted of regular diet and physical activity counselling based on the stages of change model. Main outcome measures were changes between baseline and 6 months in nutrient intake; physical activity; anthropometric and physiological measurements including serum lipids; glucose tolerance; insulin sensitivity. Results: The difference in change in total fat consumption was significant between intervention and control groups (difference −21.8 (95% confidence interval (CI) −37.8 to −5.8) g/day, P=0.008). A significantly larger proportion of intervention participants reported taking up vigorous activity than controls (difference 30.1, (95% CI 4.3–52.7)%, P=0.021). The change in body mass index was significantly different between groups (difference −0.95 (95% CI −1.5 to −0.4) kg/m2, P=0.001). There was no significant difference in change in mean 2-h plasma glucose between groups (difference −0.19 (95% CI −1.1 to 0.71) mmol/l, NS) or in serum cholesterol (difference 0.02 (95% CI −0.26 to 0.31) mmol/l, NS). The difference in change in fasting serum insulin between groups was significant (difference −3.4 (95% CI −5.8 to −1.1) mU/l, P=0.005). Conclusions: After 6 months of intensive lifestyle intervention in participants with IGT, there were changes in diet and physical activity, some cardiovascular risk factors and insulin sensitivity, but not glucose tolerance. Further follow-up is in progress to investigate whether these changes are sustained or augmented over 2 years.

The effectiveness of callback counselling for smoking cessation: a randomized trial

Aims. The development of acceptable, widely available and effective smoking cessation methods is central to public health strategy for tobacco control. We examined the effectiveness of a telephone callback counselling intervention, compared to the provision of self-help resources alone.

Methods. Participants were 998 smokers calling a state-wide "Quitline" service randomly allocated to either callback counselling or ordinary care. The callback condition consisted of a series of brief counselling calls at strategic times in addition to ordinary care. The number of calls varied according to caller needs, and most occurred generally just before the person's quit day and in the week or two after it. The service was delivered by trained telephone counsellors.

Results. At the 3-month follow-up, significantly more participants in the callback group (24%) reported that they were quit, compared to those in the usual care comparison group (13%). The difference in point prevalence of smoking declined to 6% by the 12-month follow-up. Using sustained abstinence there was a significant benefit of callback counselling at 12-month follow-up. Treating dropouts as smokers reduced the overall magnitude of the effects somewhat. The benefit of callbacks was to marginally increase quit attempts and to significantly reduce relapse.

Conclusion. Our findings are consistent with those of other studies demonstrating benefits of callback telephone counselling to facilitate cessation. Such counselling provides a flexible, relatively inexpensive and widely available form of cessation service. It appears to encourage a greater proportion of quit attempts and to reduce the rate of relapse among those quitting. Further research is required to determine ways to enhance effectiveness, particularly studies of how to reduce relapse.

Cost-effectiveness of cognitive-behavioural therapy and drug interventions for major depression

Objective: Antidepressant drugs and cognitive–behavioural therapy (CBT) are effective treatment options for depression and are recommended by clinical practice guidelines. As part of the Assessing Cost-effectiveness – Mental Health project we evaluate the available evidence on costs and benefits of CBT and drugs in the episodic and maintenance treatment of major depression.

Method: The cost-effectiveness is modelled from a health-care perspective as the cost per disability-adjusted life year. Interventions are targeted at people with major depression who currently seek care but receive non-evidence based treatment. Uncertainty in model inputs is tested using Monte Carlo simulation methods.

Results: All interventions for major depression examined have a favourable incremental cost-effectiveness ratio under Australian health service conditions. Bibliotherapy, group CBT, individual CBT by a psychologist on a public salary and tricyclic antidepressants (TCAs) are very cost-effective treatment options falling below $A10 000 per disability-adjusted life year (DALY) even when taking the upper limit of the uncertainty interval into account. Maintenance treatment with selective serotonin re-uptake inhibitors (SSRIs) is the most expensive option (ranging from $A17 000 to $A20 000 per DALY) but still well below $A50 000, which is considered the affordable threshold.

Conclusions: A range of cost-effective interventions for episodes of major depression exists and is currently underutilized. Maintenance treatment strategies are required to significantly reduce the burden of depression, but the cost of long-term drug treatment for the large number of depressed people is high if SSRIs are the drug of choice. Key policy issues with regard to expanded provision of CBT concern the availability of suitably trained providers and the funding mechanisms for therapy in primary care.

Enhancing the effectiveness of clustering with spectra analysis

For many clustering algorithms, such as K-Means, EM, and CLOPE, there is usually a requirement to set some parameters. Often, these parameters directly or indirectly control the number of clusters, that is, k, to return. In the presence of different data characteristics and analysis contexts, it is often difficult for the user to estimate the number of clusters in the data set. This is especially true in text collections such as Web documents, images, or biological data. In an effort to improve the effectiveness of clustering, we seek the answer to a fundamental question: How can we effectively estimate the number of clusters in a given data set? We propose an efficient method based on spectra analysis of eigenvalues (not eigenvectors) of the data set as the solution to the above. We first present the relationship between a data set and its underlying spectra with theoretical and experimental results. We then show how our method is capable of suggesting a range of k that is well suited to different analysis contexts. Finally, we conclude with further  empirical results to show how the answer to this fundamental question enhances the clustering process for large text collections.

The effectiveness of the levonorgestrel-releasing intrauterine system in menorrhagia: a systematic review

Objective: To determine whether the levonorgestrel-releasing intrauterine device (LNG-IUS), licensed at present for contraceptive use, may reduce menstrual blood loss with few side effects. If effective, surgery could be avoided with consequent resource savings. Methods: A systematic review addressing the effectiveness and cost effectiveness of the LNG-IUS for menorrhagia was undertaken. Results: Five controlled trials and five case series were found which measured menstrual blood loss. Nine studies recorded statistically significant average menstrual blood loss reductions with LNG-IUS (range 74%–97%). Another showed reduction in menstrual disturbance score. The LNG-IUS was more effective than tranexamic acid, but slightly less effective than endometrial resection at reducing menstrual blood loss. In one study, 64% of women cancelled surgery at six months, compared with 14% of control group women. In another, 82% were taken off surgical waiting lists at one year. No cost effectiveness studies were found. Discussion: Small studies of moderate quality indicate the LNG-IUS is an effective treatment for menorrhagia. Costs may be less than for tranexamic acid in primary and secondary care. Although its use may reduce surgical waiting lists, cost effectiveness assessment requires longer follow up. Conclusion: Effectiveness and cost effectiveness relative to other treatments and the effect on surgical waiting lists can only be established in larger trials measuring patient-centred outcomes in women with menorrhagia.

Cost-effectiveness of a family-based GP-mediated intervention targeting overweight and moderately obese children

Objective
 To assess from a societal perspective the incremental cost-effectiveness of a family-based GP-mediated intervention targeting overweight and moderately obese children. The intervention was modelled on the LEAP (live, eat and play) trial, a randomised controlled trial conducted by the Centre for Community Child Health, Melbourne, Australia in 2002–2003. This study was undertaken as part of the assessing cost-effectiveness (ACE) in obesity project which evaluated, using consistent methods, 13 interventions targeting unhealthy weight gain in children and adolescents.
Method
A logic pathway was used to model the effects of the intervention compared to no intervention on body mass index (BMI) and health outcomes (disability-adjusted life years—DALYs). Disease costs and health benefits were tracked until the cohort of eligible children reached the age of 100 years or death. Simulation-modelling techniques were used to present a 95% uncertainty interval around the cost-effectiveness ratio. The intervention was also assessed against a series of filters (‘equity’, ‘strength of evidence’, ‘acceptability’, ‘feasibility’, sustainability’ and ‘side-effects’) to incorporate additional factors that impact on resource allocation decisions.
Results
The intervention, as modelled, reached 9685 children aged 5–9 years with a BMI z-score of ≥3.0, and cost $AUD6.3M (or $AUD4.8M excluding time costs). It resulted in an incremental saving of 2300 BMI units which translated to 511 DALYs. The cost-offsets stemming from the intervention totalled $AUD3.6M, resulting in a net cost per DALY saved of $AUD4670 (dominated; $0.1M) (dominated means intervention costs more for less effect).
Conclusion
Compared to a ‘no intervention’ control group, the intervention was cost-effective under current assumptions, although the uncertainty intervals were wide. A key question related to the long-term sustainability of the small incremental weight loss reported, based on the 9-month follow-up results for LEAP.

The effectiveness of nutrition interventions on dietary outcomes by relative social disadvantage : a systematic review

Objective: To determine whether nutrition interventions widen dietary inequalities across socioeconomic status groups.

Design: Systematic review of interventions that aim to promote healthy eating.

Data sources: CINAHL and MEDLINE were searched between 1990 and 2007.

Review methods: Studies were included if they were randomised controlled trials or concurrent controlled trials of interventions to promote healthy eating delivered at a group level to low socioeconomic status groups or studies where it was possible to disaggregate data by socioeconomic status.

Results: Six studies met the inclusion criteria. Four were set in educational setting (three elementary schools, one vocational training). The first found greater increases in fruit and vegetable consumption in children from high-income families after 1 year (mean difference 2.4 portions per day, p<0.0001) than in children in low-income families (mean difference 1.3 portions per day, p<0.0003). The second did not report effect sizes but reported the nutrition intervention to be less effective in disadvantaged areas (p<0.01). The third found that 24-h fruit juice and vegetable consumption increased more in children born outside the Netherlands ("non-native") after a nutrition intervention (beta coefficient = 1.30, p<0.01) than in "native" children (beta coefficient = 0.24, p<0.05). The vocational training study found that the group with better educated participants achieved 34% of dietary goals compared with the group who had more non-US born and non-English speakers, which achieved 60% of dietary goals. Two studies were conducted in primary care settings. The first found that, as a result of the intervention, the difference in consumption of added fat between the intervention and the control group was –8.9 g/day for blacks and –12.0 g/day for whites (p<0.05). In the second study, there was greater attrition among the ethnic minority participants than among the white participants (p<0.04).

Conclusions: Nutrition interventions have differential effects by socioeconomic status, although in this review we found only limited evidence that nutrition interventions widen dietary inequalities. Due to small numbers of included studies, the possibility that nutrition interventions widen inequalities cannot be excluded. This needs to be considered when formulating public health policy.

Cost-effectiveness of surgically induced weight loss for the management of type 2 diabetes : modeled lifetime analysis

OBJECTIVE--To estimate the cost-effectiveness of surgically induced weight loss relative to conventional therapy for the management of recently diagnosed type 2 diabetes in class VII obese patients.

RESEARCH DESIGN AND METHODS--This study builds on a within-trial cost-efficacy analysis. The analysis compares the lifetime costs and quality-adjusted life-years (QALYs) between the two intervention groups. Intervention costs were extrapolated based on observed resource utilization during the trial. The proportion of patients in each intervention group with remission of diabetes at 2 years was the same as that observed in the trial. Health care costs for patients with type 2 diabetes and outcome variables required to derive estimates of QALYs were sourced from published literature. A health care system perspective was adopted. Costs and outcomes were discounted annually at 3%. Costs are presented in 2006 Australian dollars (AUD) (currency exchange: 1 AUD = 0.74 USD).

RESULTS--The mean number of years in diabetes remission over a lifetime was 11.4 for surgical therapy patients and 2.1 for conventional therapy patients. Over the remainder of their lifetime, surgical and conventional therapy patients lived 15.7 and 14.5 discounted QALYs, respectively. The mean discounted lifetime costs were 98,900 AUD per surgical therapy patient and 101,400 AUD per conventional therapy patient. Relative to conventional therapy, surgically induced weight loss was associated with a mean health care saving of 2,400 AUD and 1.2 additional QALYs per patient.

CONCLUSIONS--Surgically induced weight loss is a dominant intervention (it both saves health care costs and generates health benefits) for managing recently diagnosed type 2 diabetes in class IBI obese patients in Australia.

Cost-effectiveness of active transport for primary school children - Walking School Bus Program

Background : To assess from a societal perspective the incremental cost-effectiveness of the Walking School Bus (WSB) program for Australian primary school children as an obesity prevention measure. The intervention was modelled as part of the ACE-Obesity study, which evaluated, using consistent methods, thirteen interventions targeting unhealthy weight gain in Australian children and adolescents.

Methods : A logic pathway was used to model the effects on body mass index [BMI] and disability-adjusted life years [DALYs] of the Victorian WSB program if applied throughout Australia. Cost offsets and DALY benefits were modelled until the eligible cohort reached 100 years of age or death. The reference year was 2001. Second stage filter criteria ('equity', 'strength of evidence', 'acceptability', feasibility', sustainability' and 'side-effects') were assessed to incorporate additional factors that impact on resource allocation decisions.

Results : The modelled intervention reached 7,840 children aged 5 to 7 years and cost $AUD22.8M ($16.6M;$30.9M). This resulted in an incremental saving of 30 DALYs (7:104) and a net cost per DALY saved of $AUD0.76M ($0.23M; $3.32M). The evidence base was judged as 'weak' as there are no data available documenting the increase in the number of children walking due to the intervention. The high costs of the current approach may limit sustainability.

Conclusions : Under current modelling assumptions, the WSB program is not an effective or cost-effective measure to reduce childhood obesity. The attribution of some costs to non-obesity objectives (reduced traffic congestion and air pollution etc.) is justified to emphasise the other possible benefits. The program's cost-effectiveness would be improved by more comprehensive implementation within current infrastructure arrangements. The importance of active transport to school suggests that improvements in WSB or its variants need to be developed and fully evaluated.