PubMed Health⌕ Search

Biomedical subjects

Sarah Byford

Publications and source records attributed to Sarah Byford.

16 recordsLinked to original sources

Comparison of alternative methods of collection of service use data for the economic evaluation of health care interventions.

Economic evaluation of health care interventions usually requires the collection of service use data to estimate the total cost of participants in an evaluation. There are a number of methods available to measure the quantity of services used but little is known about the relative accuracy of alternative methods. In a multicentre randomised controlled trial of interventions for the treatment of adults with recurrent episodes of deliberate self-harm (the POPMACT trial), health service data were collected by patient self-report after six and twelve months and also from GP records by independent investigators. Agreement for overall costs was relatively high. However, this hides substantial variation in agreement between the two sources of information for different services. The results suggest that GP records provide more accurate data on the use of general practice-based contacts than patient report, but less reliable information on contacts with other health services. Thus reliance on GP records for data on hospital services and other community health services based outside of general practice surgeries is not recommended. Future research should explore the level of agreement between patient report and other providing sector records, such as hospital records.

Adult↗

Methodology for the Randomised Injecting Opioid Treatment Trial (RIOTT): evaluating injectable methadone and injectable heroin treatment versus optimised oral methadone treatment in the UK.

Whilst unsupervised injectable methadone and diamorphine treatment has been part of the British treatment system for decades, the numbers receiving injectable opioid treatment (IOT) has been steadily diminishing in recent years. In contrast, there has been a recent expansion of supervised injectable diamorphine programs under trial conditions in a number of European and North American cities, although the evidence regarding the safety, efficacy and cost effectiveness of this treatment approach remains equivocal. Recent British clinical guidance indicates that IOT should be a second-line treatment for those patients in high-quality oral methadone treatment who continue to regularly inject heroin, and that treatment be initiated in newly-developed supervised injecting clinics. The Randomised Injectable Opioid Treatment Trial (RIOTT) is a multisite, prospective open-label randomised controlled trial (RCT) examining the role of treatment with injected opioids (methadone and heroin) for the management of heroin dependence in patients not responding to conventional substitution treatment. Specifically, the study examines whether efforts should be made to optimise methadone treatment for such patients (e.g. regular attendance, supervised dosing, high oral doses, access to psychosocial services), or whether such patients should be treated with injected methadone or heroin. Eligible patients (in oral substitution treatment and injecting illicit heroin on a regular basis) are randomised to one of three conditions: (1) optimized oral methadone treatment (Control group); (2) injected methadone treatment; or (3) injected heroin treatment (with access to oral methadone doses). Subjects are followed up for 6-months, with between-group comparisons on an intention-to-treat basis across a range of outcome measures. The primary outcome is the proportion of patients who discontinue regular illicit heroin use (operationalised as providing >50% urine drug screens negative for markers of illicit heroin in months 4 to 6). Secondary outcomes include measures of other drug use, injecting practices, health and psychosocial functioning, criminal activity, patient satisfaction and incremental cost effectiveness. The study aims to recruit 150 subjects, with 50 patients per group, and is to be conducted in supervised injecting clinics across England.

Journal Article↗

Joint crisis plans for people with psychosis: economic evaluation of a randomised controlled trial.

OBJECTIVE: To investigate the cost effectiveness of joint crisis plans, a form of advance agreement for people with severe mental illness. DESIGN: Single blind randomised controlled trial. SETTING: Eight community mental health teams in southern England. PARTICIPANTS: 160 people with a diagnosis of psychotic illness or non-psychotic bipolar disorder who had been admitted to hospital at least once within the previous two years. INTERVENTION: Joint crisis plan formulated by the patient, care coordinator, psychiatrist, and project worker containing contact information, details of illnesses, treatments, relapse indicators, and advance statements of preferences for care for future relapses. Control group was standardised service information. MAIN OUTCOME MEASURES: Admission to hospital; service use over 15 months. RESULTS: Use of a joint crisis plan was associated with less service use and lower costs on average than in the standardised service information group, but differences were not significant. Total costs during follow-up were 7264 pounds sterling (10,616 euros, 13,560 dollars) for each participant with a joint crisis plan and 8359 pounds sterling (12,217 euros, 15,609 dollars) for each participant with standardised service information (mean difference 1095 pounds sterling; 95% confidence interval -2814 to 5004). Cost effectiveness acceptability curves, used to explore uncertainty in estimates of costs and effects, suggest there is a greater than 78% probability that joint crisis plans are more cost effective than standardised service information in reducing the proportion of patients admitted to hospital. CONCLUSION: Joint crisis plans produced a non-significant decrease in admissions and total costs. Though the cost estimates had wide confidence intervals, the associated uncertainty suggests there is a relatively high probability of the plans being more cost effective than standardised service information for people with psychotic disorders.

Community Mental Health Services↗

Violence in women with psychosis in the community: prospective study.

BACKGROUND: Little is known about the determinants of violence in women with psychosis. AIMS: To identify predictors of violence in a community sample of women with chronic psychosis. METHOD: The 2-year prevalence of physical assault was estimated for a sample of 304 women with psychosis. Baseline socio-demographic and clinical factors were used to identify predictors of assault. RESULTS: The 2-year prevalence of assault in the sample was 17%. Assaultive behaviour was associated with previous violence (OR=5.87,95% CI 2.42-14.25), non-violent convictions (OR=2.63,95% CI 1.17-5.93), victimization (OR=2.46, 95% CI1.02-5.93), African-Caribbean ethnicity (OR=2.24,95% CI1.02-4.77), cluster B personality disorder (OR=2.66, 95% CI1.11-6.38) and high levels of unmet need (OR=1.17,95% CI1.01-1.35). An interaction between African-Caribbean ethnicity and cluster B personality disorder was identified in relation to violent outcome. Violent women were found to be more costly to services. CONCLUSIONS: Nearly a fifth of community-dwelling women with chronic psychosis committed assault over a period of 2 years. Six independent risk factors were found to predict violence.

Adult↗

Mental health provision for young offenders: service use and cost.

BACKGROUND: The full costs of accommodating and supporting young people in the criminal justice system are unknown. There is also concern about the level of mental health needs among young offenders and the provision of appropriate mental health services. AIMS: To estimate the full cost of supporting young people in the criminal justice system in England and Wales and to examine the relationship between needs, service use and cost. METHOD: Cross-sectional survey of 301 young offenders, 151 in custody and 150 in the community, conducted in six geographically representative areas of England and Wales. RESULTS: Mental health service use was low despite high levels of need, particularly in the community. Monthly costs were significantly higher among young people interviewed in secure facilities than in the community (pound 4645 v. pound 1863; P<0.001). Younger age and a depressed mood were associated with greater costs. CONCLUSIONS: Young people in the criminal justice system are a significant financial burden not only on that system but also on social services, health and education. The relationship between cost and depressed mood indicates a role for mental health services in supporting young offenders, particularly those in the community.

Adolescent↗

Cost-effectiveness of screening and referral to an alcohol health worker in alcohol misusing patients attending an accident and emergency department: a decision-making approach.

We present the cost and cost-effectiveness of referral to an alcohol health worker (AHW) and information only control in alcohol misusing patients. The study was a pragmatic randomised controlled trial conducted from April 2001 to March 2003 in an accident and emergency department (AED) in a general hospital in London, England. A total of 599 adults identified as drinking hazardously according to the Paddington Alcohol Test were randomised to referral to an alcohol health worker who delivered a brief intervention (n = 287) or to an information only control (n = 312). Total societal costs, including health and social services costs, criminal justice costs and productivity losses, and clinical measures of alcohol consumption were measured. Levels of drinking were observably lower in those referred to an AHW at 12 months follow-up and statistically significantly lower at 6 months follow-up. Total costs were not significantly different at either follow-up. Referral to AHWs in an AED produces favourable clinical outcomes and does not generate a significant increase in cost. A decision-making approach revealed that there is at least a 65% probability that referral to an AHW is more cost-effective than the information only control in reducing alcohol consumption among AED attendees with a hazardous level of drinking.

Adult↗

Service costs for severe personality disorder at a special hospital.

BACKGROUND: Much attention has been given to the reform of services for people with personality disorder in the UK, yet little is known of the cost of existing services, particularly in secure forensic settings. Existing cost estimates almost always rely on aggregate estimates of the cost of care rather than individual-level costing, but the latter is necessary for the economic evaluation of new services. METHOD: This paper uses a new instrument for recording service use in secure forensic settings to report the service use and care package costs of 16 patients being considered for the dangerous and severe personality disorder programme in the Personality Disorder Directorate at Rampton, a high secure hospital in Nottinghamshire, UK. RESULTS: The mean cost over a six-month period was 65,545 UK pounds (approximately 131,000 pounds per annum) but there was considerable variation within this figure, with a range of 59,119 to 82,709 UK pounds. CONCLUSIONS: Aggregate costs for individuals in secure hospital settings hide substantial variation between individuals. This paper demonstrates the feasibility of estimating the cost of individual care packages in a secure forensic setting.

Data Collection↗

Evidence of cost-effective treatments for depression: a systematic review.

BACKGROUND: High levels of public spending, rising costs of treatments and scarcity of mental health resources have intensified the need for information on the cost-effectiveness of interventions for depression. There have been few reviews that consider the cost-effectiveness of all treatments for depression together. METHODS: Systematic review of published economic evaluations of interventions for depression to identify where evidence of cost-effectiveness exists and where ambiguity remains. RESULTS: Fifty-eight papers met the criteria and were included in the review. The quality of the evaluations varied greatly. Evidence establishing the cost-effectiveness of interventions for depression is accumulating; selective serotonin reuptake inhibitors (SSRI) and the newer antidepressants venlafaxine, mirtazepine and nefazodone appear cost-effective compared with older drugs. Despite the availability of high quality economic evaluations of psychological therapies compared to usual care, there is limited evidence of their cost-effectiveness particularly when compared directly to pharmacotherapies. Changes to health systems have been found to be cost-effective in some patient groups, but there is no evidence that screening in primary care populations is a cost-effective strategy. LIMITATIONS: Vastly different interventions, outcome measures and cost perspectives meant a meta-analysis of costs and effects was not considered possible. CONCLUSIONS: On the basis of available evidence, it is not possible to identify the most cost-effective strategy for alleviating the symptoms of depression, although the SSRIs and newer antidepressants consistently appear more cost-effective than tricyclic antidepressants in many patient groups. Better quality economic evidence is needed.

Antidepressive Agents↗

Annotation: Economic evaluations of child and adolescent mental health interventions: a systematic review.

BACKGROUND: Recognition has grown over recent years of the need for economic information on the impacts of child and adolescent mental health problems and the cost-effectiveness of interventions. METHODS: A range of electronic databases were examined using a predefined search strategy to identify economic studies which focused on services, pharmacological interventions and other treatments for children and adolescents with a diagnosed mental health problem or identified as at risk of mental illness. Published studies were included in the review if they assessed both costs and outcomes, with cost-effectiveness being the primary interest. Studies meeting the criteria for inclusion were assessed for quality. RESULTS: There are still relatively few economic evaluations in this field. Behavioural disorders have been given relatively greater attention in economic evaluations of child and adolescent mental health. These studies tentatively suggest child behavioural gains and parent satisfaction from parent and child training programmes, although the cost-effectiveness of the location of delivery for behavioural therapies is less clear. In general, the quality of economic evaluations was limited by small sample sizes, constrained measurement of costs, narrow perspectives and over-simple statistical and econometric methods. CONCLUSION: Economic evaluations in the field of child and adolescent mental health interventions are few in number and generally poor in quality, although the number of studies being undertaken now appears to be rising.

Adolescent↗

A guide to cost-effectiveness acceptability curves.

Use of cost-effectiveness acceptability curves, as a method for summarising information on uncertainty in cost-effectiveness, has become widespread within applied studies. This includes several studies in the mental health field. This editorial uses examples from recent papers to illustrate how cost-effectiveness acceptability curves are constructed, what they represent and how they should be interpreted.

Cost-Benefit Analysis↗

Differential effects of manual assisted cognitive behavior therapy in the treatment of recurrent deliberate self-harm and personality disturbance: the POPMACT study.

A total of 480 patients were treated in a large, multicenter randomized trial of a brief form of cognitive therapy, manual-assisted cognitive behavior therapy (MACT) versus treatment as usual (TAU) for recurrent deliberate self-harm. Each patient was randomized after a self-harm episode assessed at an accident and emergency center and followed up over 1 year. The main hypothesis tested was that those allocated to MACT would have a lower proportion of self-harm episodes in the succeeding year. A total of 60% of those allocated to MACT had face-to-face treatment and 430 (90%) of all patients had self-harm data recorded after 1 year. Although the results showed no significant difference between those repeating self-harm in the MACT group (39%) compared with the TAU group (46%) (P = 0.20), the treatment was cost effective (10% cheaper than TAU) and the frequency of self-harm episodes was fewer (50%) in the MACT group. A total of nine of 10 patients had some personality disturbance (42% of these with disorder), and for those where information on parasuicide events was collected, the proportion having a repeat episode ranged from 33% to 63% for different personality disorders. Those with BPD were most likely to repeat episodes quickly (mean 89 days for 25% to repeat) with dissocial personality disorder (equivalent mean 384 days) the slowest to repeat. Total costs were significantly greater in those with personality disorder and were reduced in those allocated to MACT; this saving was reversed in those with borderline disorder. On average, MACT appeared to increase the cost of those patients with BPD (BPD) and reduce the cost of those with other personality disorders. It is concluded that MACT has value in preventing self-harm cost effectively but this appears to be confined mainly to those who do not have BPD.

Adult↗

Meta-analysis of data on costs from trials of counselling in primary care: using individual patient data to overcome sample size limitations in economic analyses.

OBJECTIVE: To assess the feasibility of overcoming sample size limitations in economic analyses of clinical trials through meta-analysis of data on individual patients from multiple trials. DESIGN: Meta-analysis of individual patient data from trials of counselling in primary care compared with usual care by a general practitioner. SETTING: Primary care. PATIENTS: People with mental health problems. MAIN OUTCOME MEASURES: Direct treatment costs, depressive symptoms, and cost effectiveness. RESULTS: Meta-analysis of individual patient data proved feasible. The results showed that the previous analyses of individual trials were underpowered to provide useful conclusions about the cost comparisons. The results are sensitive to assumptions made about the costs of sessions with a counsellor and the management of patients by a general practitioner. CONCLUSIONS: Meta-analysis of individual patient data may assist in overcoming sample size limitations in economic analyses. Although feasible, such analysis has shortcomings that may limit the validity of the results. The relative costs and benefits of this method, as opposed to further collection of primary data, are as yet unclear.

Clinical Trials as Topic↗

Exposure to case management: relationships to patient characteristics and outcome. Report from the UK700 trial.

BACKGROUND: Trials in community psychiatry must balance rigour with generalisability. The UK700 trial failed to find a significant effect on hospitalisation, but its sample population contained significant heterogeneity of exposure to case management in the two groups. AIMS: To test whether patients successfully exposed to a minimum of 12 months' intensive case management over the 2-year follow-up period achieved reduced hospitalisation. METHOD: Of 679 participants with hospitalisation data, 84 were identified as having < 12 months' exposure owing to prolonged hospitalisation, imprisonment or a combination of the two. These patients were excluded and outcomes tested for the remaining 595 patients. RESULTS: Overall reduced case-load size did not reduce hospitalisation or treatment costs over 2 years despite elimination of outliers. Age, previous hospitalisation and source of recruitment to the study all correlated with outcome. CONCLUSIONS: Case-load reduction is not in itself enough to reduce the need for hospital care in psychosis. Baseline patient characteristics (in particular length of previous hospitalisation and recruitment from in-patient care) have a significant influence and should be allowed for in power calculations. Identifying the optimal clinical profile for patients likely to benefit from intensive case management remains a pressing need for further studies.

Age Factors↗

Screening and referral for brief intervention of alcohol-misusing patients in an emergency department: a pragmatic randomised controlled trial.

BACKGROUND: Alcohol misuse is highly prevalent among people attending emergency departments, but the effect of intervention by staff working in these departments is unclear. We investigated the effect of screening and referral of patients found to be misusing alcohol while attending an emergency department. METHODS: We undertook a single-blind pragmatic randomised controlled trial. Patients received either an information leaflet or an information leaflet plus an appointment with an alcohol health worker. Outcome data were collected by patient interview and examination of hospital records at 6 and 12 months. FINDINGS: 599 patients were randomised over a 12-month period. At 6 months, those referred to an alcohol health worker were consuming a mean of 59.7 units of alcohol per week compared with 83.1 units in the control group (t -2.4, p=0.02). At 12 months those referred were drinking 57.2 units per week compared with 70.8 in controls (t -1.7, p=0.09). Those referred to the alcohol health worker had a mean of 0.5 fewer visits to the emergency department over the following 12 months (1.2 compared with 1.7, t -2.0, p=0.046). Differences in quality of life were not found. INTERPRETATION: Opportunistic identification and referral for alcohol misuse in an emergency department is feasible, associated with lower levels of alcohol consumption over the following 6 months, and reduces reattendance at the department. Short-term reductions in alcohol consumption associated with referral for brief intervention for alcohol misuse benefit patients and reduce demand for accident and emergency department services.

Adult↗