Development of an interprofessional person-centred care concept for persons with care needs living in their own homes (interprof HOME): study protocol for a mixed-methods study.

INTRODUCTION: People receiving home care usually have complex healthcare needs requiring the involvement of informal caregivers and various health professionals. In this context, successful collaboration is an important element of person-centred care, which is often insufficiently implemented. Consequences might be found in avoidable hospitalisations. The aim of the study is to develop a care concept to improve person-centred interprofessional collaboration for people receiving home care considering the perspectives of all person groups involved. METHODS AND ANALYSIS: This study uses a mixed-methods design consisting of a literature review, several qualitative inquiries, a cross-sectional quantitative study and a final structured workshop. After a literature review (work package (WP) 1), we will explore the perspectives of people receiving home care (n=20), their relatives (n=20) and representatives of statutory health insurances (n=5) in semistructured interviews (WP2). Moreover, 100 individuals of each group (people receiving home care, relatives, registered nurses, general practitioners and therapists) involved in home care will answer a survey on collaboration that will be analysed descriptively (WP3). Additionally, monoprofessional focus groups (n=9) of registered nurses, general practitioners and therapists, respectively, will discuss current practices. Data will be analysed by qualitative content analysis. Best practice cases (n=8) will be analysed by a case-based qualitative content analysis based on data of observations of home visits and interviews (WP4). The findings of WP2 will be discussed in mixed focus groups (n=4) with 10 participants each (WP5). Considering the results of joint displays of WP3, WP4 and WP5, the interprofessional care concept and its implementation will be elaborated in an expert workshop (WP6). ETHICS AND DISSEMINATION: Ethical approval was obtained from all ethics committees of the project partners. Study results will be disseminated through publications, conference presentations, student education and advanced training of health professionals. TRIAL REGISTRATION NUMBER: NCT05149937.

International comparability of reference unit costs of education services: when harmonizing methodology is not enough (PECUNIA project).

BACKGROUND: Health problems can lead to costs in the education sector. However, these costs are rarely incorporated in health economic evaluations due to the lack of reference unit costs (RUCs), cost per unit of service, of education services and of validated methods to obtain them. In this study, a standardized unit cost calculation tool developed in the PECUNIA project, the PECUNIA RUC Template for services, was applied to calculate the RUCs of selected education services in five European countries. METHODS: The RUCs of special education services and of educational therapy were calculated using the information collected via an exploratory gray literature search and contact with service providers. RESULTS: The RUCs of special education services ranged from €55 to €189 per school day. The RUCs of educational therapy ranged from €6 to €25 per contact and from €5 to €35 per day. Variation was observed in the type of input data and measurement unit, among other. DISCUSSION: The tool helped reduce variability in the RUCs related to costing methodology and gain insights into other aspects that contribute to the variability (e.g. data availability). Further research and efforts to generate high quality input data are required to reduce the variability of the RUCs.

Magnitude of terminological bias in international health services research: a disambiguation analysis in mental health.

AIMS: Health services research (HSR) is affected by a widespread problem related to service terminology including non-commensurability (using different units of analysis for comparisons) and terminological unclarity due to ambiguity and vagueness of terms. The aim of this study was to identify the magnitude of the terminological bias in health and social services research and health economics by applying an international classification system. METHODS: This study, that was part of the PECUNIA project, followed an ontoterminology approach (disambiguation of technical and scientific terms using a taxonomy and a glossary of terms). A listing of 56 types of health and social services relevant for mental health was compiled from a systematic review of the literature and feedback provided by 29 experts in six European countries. The disambiguation of terms was performed using an ontology-based classification of services (Description and Evaluation of Services and DirectoriEs - DESDE), and its glossary of terms. The analysis focused on the commensurability and the clarity of definitions according to the reference classification system. Interrater reliability was analysed using κ. RESULTS: The disambiguation revealed that only 13 terms (23%) of the 56 services selected were accurate. Six terms (11%) were confusing as they did not correspond to services as defined in the reference classification system (non-commensurability bias), 27 (48%) did not include a clear definition of the target population for which the service was intended, and the definition of types of services was unclear in 59% of the terms: 15 were ambiguous and 11 vague. The κ analyses were significant for agreements in unit of analysis and assignment of DESDE codes and very high in definition of target population. CONCLUSIONS: Service terminology is a source of systematic bias in health service research, and certainly in mental healthcare. The magnitude of the problem is substantial. This finding has major implications for the international comparability of resource use in health economics, quality and equality research. The approach presented in this paper contributes to minimise differentiation between services by taking into account key features such as target population, care setting, main activities and type and number of professionals among others. This approach also contributes to support financial incentives for effective health promotion and disease prevention. A detailed analysis of services in terms of cost measurement for economic evaluations reveals the necessity and usefulness of defining services using a coding system and taxonomical criteria rather than by 'text-based descriptions'.

The excess costs of depression: a systematic review and meta-analysis.

AIMS: Major depressive disorders are highly prevalent in the world population, contribute substantially to the global disease burden and cause high health care expenditures. Information on the economic impact of depression, as provided by cost-of-illness (COI) studies, can support policymakers in the decision-making regarding resource allocation. Although the literature on COI studies of depression has already been reviewed, there is no quantitative estimation of depression excess costs across studies yet. Our aims were to systematically review COI studies of depression with comparison group worldwide and to assess the excess costs of depression in adolescents, adults, elderly, and depression as a comorbidity of a primary somatic disease quantitatively in a meta-analysis. METHODS: We followed the PRISMA reporting guidelines. PubMed, PsycINFO, NHS EED, and EconLit were searched without limitations until 27/04/2018. English or German full-text peer-reviewed articles that compared mean costs of depressed and non-depressed study participants from a bottom-up approach were included. We only included studies reporting costs for major depressive disorders. Data were pooled using a random-effects model and heterogeneity was assessed with I2 statistic. The primary outcome was ratio of means (RoM) of costs of depressed v. non-depressed study participants, interpretable as the percentage change in mean costs between the groups. RESULTS: We screened 12 760 articles by title/abstract, assessed 393 articles in full-text and included 48 articles. The included studies encompassed in total 55 898 depressed and 674 414 non-depressed study participants. Meta-analysis showed that depression was associated with higher direct costs in adolescents (RoM = 2.79 [1.69-4.59], p < 0.0001, I2 = 87%), in adults (RoM = 2.58 [2.01-3.31], p < 0.0001, I2 = 99%), in elderly (RoM = 1.73 [1.47-2.03], p < 0.0001, I2 = 73%) and in participants with comorbid depression (RoM = 1.39 [1.24-1.55], p < 0.0001, I2 = 42%). In addition, we conducted meta-analyses for inpatient, outpatient, medication and emergency costs and a cost category including all other direct cost categories. Meta-analysis of indirect costs showed that depression was associated with higher costs in adults (RoM = 2.28 [1.75-2.98], p < 0.0001, I2 = 74%). CONCLUSIONS: This work is the first to provide a meta-analysis in a global systematic review of COI studies for depression. Depression was associated with higher costs in all age groups and as comorbidity. Pooled RoM was highest in adolescence and decreased with age. In the subgroup with depression as a comorbidity of a primary somatic disease, pooled RoM was lower as compared to the age subgroups. More evidence in COI studies for depression in adolescence and for indirect costs would be desirable.

Cost-effectiveness of focal psychodynamic therapy and enhanced cognitive-behavioural therapy in out-patients with anorexia nervosa.

BACKGROUND: Anorexia nervosa (AN) is a serious illness leading to substantial morbidity and mortality. The treatment of AN very often is protracted; repeated hospitalizations and lost productivity generate substantial economic costs in the health care system. Therefore, this study aimed to determine the differential cost-effectiveness of out-patient focal psychodynamic psychotherapy (FPT), enhanced cognitive-behavioural therapy (CBT-E), and optimized treatment as usual (TAU-O) in the treatment of adult women with AN. METHOD: The analysis was conducted alongside the randomized controlled Anorexia Nervosa Treatment of OutPatients (ANTOP) study. Cost-effectiveness was determined using direct costs per recovery at 22 months post-randomization (n = 156). Unadjusted incremental cost-effectiveness ratios (ICERs) were calculated. To derive cost-effectiveness acceptability curves (CEACs) adjusted net-benefit regressions were applied assuming different values for the maximum willingness to pay (WTP) per additional recovery. Cost-utility and assumptions underlying the base case were investigated in exploratory analyses. RESULTS: Costs of in-patient treatment and the percentage of patients who required in-patient treatment were considerably lower in both intervention groups. The unadjusted ICERs indicated FPT and CBT-E to be dominant compared with TAU-O. Moreover, FPT was dominant compared with CBT-E. CEACs showed that the probability for cost-effectiveness of FTP compared with TAU-O and CBT-E was ⩾95% if the WTP per recovery was ⩾€9825 and ⩾€24 550, respectively. Comparing CBT-E with TAU-O, the probability of being cost-effective remained <90% for all WTPs. The exploratory analyses showed similar but less pronounced trends. CONCLUSIONS: Depending on the WTP, FPT proved cost-effective in the treatment of adult AN.

Estimating the lifetime cost of childhood obesity in Germany: Results of a Markov Model.

BACKGROUND: Child obesity is a growing public health concern. Excess weight in childhood is known to be associated with a high risk of obesity and obesity-related comorbidities in adulthood. OBJECTIVES: This study quantifies lifetime excess costs of overweight and obese adults in Germany taking the history of obesity in childhood into account. METHODS: A two-stage Markov cohort state transition model was developed. At stage 1, the distribution of body mass index (BMI) categories was tracked from childhood (ages 3-17) to adulthood (age 17 and up). Based on these results, it was distinguished whether adults had been normal in weight or overweight/obese as child. At stage 2, age-specific and lifetime costs from age 18 onwards were simulated in two further Markov cohort models, one for each of the two BMI groups. Model parameter values were obtained from the German Interview and Examination Survey for Children and Adolescents (KiGGS), the German Microcensus 2009 and published literature. RESULTS: When compared with normal weight adults, lifetime excess costs are higher among adults who had been overweight or obese at any point during childhood. For 18-year-old women (men), who have been overweight/obese during their childhood (ages 3-17), undiscounted lifetime excess costs are estimated at €19,479 (€14,524), with 60% (67%) occurring beyond age 60. Discounted (3%) lifetime excess costs are considerably lower, amounting to €4262 for men and €7028 for women. CONCLUSIONS: Because childhood obesity determines healthcare costs occurring in adulthood, interventions preventing the persistence of child obesity and obesity-related comorbidities during adulthood could have a substantial impact on reducing the burden of the obesity epidemic.

[Mental health of children, adolescents and young adults--part 1: prevalence, illness persistence, adversities, service use, treatment delay and consequences]. / Die psychische Gesundheit von Kindern, Jugendlichen und jungen Erwachsenen--Teil 1: Häufigkeit, Störungspersistenz, Belastungsfaktoren, Service-Inanspruchnahme und Behandlungsverzögerung mit Konsequenzen.

Numerous birth-control studies, epidemiological studies, and observational studies have investigated mental health and health care in childhood, adolescence and early adulthood, including prevalence, age at onset, adversities, illness persistence, service use, treatment delay and course of illness. Moreover, the impact of the burden of illness, of deficits of present health care systems, and the efficacy and effectiveness of early intervention services on mental health were evaluated. According to these data, most mental disorders start during childhood, adolescence and early adulthood. Many children, adolescents and young adults are exposed to single or multiple adversities, which increase the risk for (early) manifestations of mental diseases as well as for their chronicity. Early-onset mental disorders often persist into adulthood. Service use by children, adolescents and young adults is low, even lower than for adult patients. Moreover, there is often a long delay between onset of illness and first adequate treatment with a variety of linked consequences for a poorer psychosocial prognosis. This leads to a large burden of illness with respect to disability and costs. As a consequence several countries have implemented so-called "early intervention services" at the interface of child and adolescent and adult psychiatry. Emerging studies show that these health-care structures are effective and efficient. Part 1 of the present review summarises the current state of mental health in childhood, adolescence and early adulthood, including prevalence, age at onset, adversities, illness persistence, service use, and treatment delay with consequences.

[Mental health of children, adolescents and young adults--part 2: burden of illness, deficits of the German health care system and efficacy and effectiveness of early intervention services]. / Die psychische Gesundheit von Kindern, Jugendlichen und jungen Erwachsenen--Teil 2: Krankheitslast, Defizite des deutschen Versorgungssystems, Effektivität und Effizienz von "Early Intervention Services"

Numerous birth-control studies, epidemiological studies, and observational studies investigated mental health and health care in childhood, adolescence and early adulthood, including prevalence, age at onset, adversities, illness persistence, service use, treatment delay and course of illness. Moreover, the impact of the burden of illness, of deficits of present health care systems, and the efficacy and effectiveness of early intervention services on mental health were evaluated. According to these data, most mental disorders start during childhood, adolescence and early adulthood. Many children, adolescents and young adults are exposed to single or multiple adversities, which increase the risk for (early) manifestations of mental diseases as well as for their chronicity. Early-onset mental disorders often persist into adulthood. Service use of children, adolescents and young adults is low, even lower than in adult patients. Moreover, there is often a long delay between onset of illness and first adequate treatment with a variety of linked consequences for poorer psychosocial prognosis. This leads to a large burden of illness with respect to disability and costs. As a consequence several countries have implemented so-called "early intervention services" at the border of child and adolescent and adult psychiatry. Emerging studies show that these health care structures are effective and efficient. Part 2 of the present review focuses on illness burden including disability and costs, deficits of the present health care system in Germany, and efficacy and efficiency of early intervention services.

Co-morbid mental health conditions in cancer patients at working age--prevalence, risk profiles, and care uptake.

OBJECTIVE: This study examined the prevalence of mental health conditions in cancer patients, the role of socioeconomic position in relation to that, and the use of professional mental health care. METHODS: Prospective cohort with measurements at the beginning of inpatient treatment (baseline) and 3, 9, and 15 months after baseline using structured clinical interviews based on DSM-IV, questionnaires, and medical records. RESULTS: At baseline, 149 out of 502 cancer patients (30%) were diagnosed with a mental health condition. Prevalence was associated with unemployment (odds ratio [OR] 2.0), fatigue (OR 1.9), and pain (OR 1.7). Of those with mental health conditions, 9% saw a psychotherapist within 3 months of the diagnosis, 19% after 9 months, and 11% after 15 months. Mental health care use was higher in patients with children ≤18 years (OR 3.3) and somatic co-morbidity (OR 2.6). There was no evidence for an effect of sex on the use of mental health care. CONCLUSION: Few cancer patients with psychiatric disorders receive professional mental health care early enough. If patients are unemployed or if they suffer from fatigue or pain, special attention should be paid because the risk of having a mental health condition is increased in these patients.

The health burden and costs of incident fractures attributable to osteoporosis from 2010 to 2050 in Germany--a demographic simulation model.

UNLABELLED: To predict the burden of incident osteoporosis attributable fractures (OAF) in Germany, an economic simulation model was built. The burden of OAF will sharply increase until 2050. Future demand for hospital and long-term care can be expected to substantially rise and should be considered in future healthcare planning. INTRODUCTION: The aim of this study was to develop an innovative simulation model to predict the burden of incident OAF occurring in the German population, aged >50, in the time period of 2010 to 2050. METHODS: A Markov state transition model based on five fracture states was developed to estimate costs and loss of quality adjusted life years (QALYs). Demographic change was modelled using individual generation life tables. Direct (inpatient, outpatient, long-term care) and indirect fracture costs attributable to osteoporosis were estimated by comparing Markov cohorts with and without osteoporosis. RESULTS: The number of OAF will rise from 115,248 in 2010 to 273,794 in 2050, cumulating to approximately 8.1 million fractures (78 % women, 22 % men) during the period between 2010 and 2050. Total undiscounted incident OAF costs will increase from around 1.0 billion Euros in 2010 to 6.1 billion Euros in 2050. Discounted (3 %) cumulated costs from 2010 to 2050 will amount to 88.5 billion Euros (168.5 undiscounted), with 76 % being direct and 24 % indirect costs. The discounted (undiscounted) cumulated loss of QALYs will amount to 2.5 (4.9) million. CONCLUSIONS: We found that incident OAF costs will sharply increase until the year 2050. As a consequence, a growing demand for long-term care as well as hospital care can be expected and should be considered in future healthcare planning. To support decision makers in managing the future burden of OAF, our model allows to economically evaluate population- and risk group-based interventions for fracture prevention in Germany.

[Costs of diseases with long-term survival]. / Kostenmessung bei Krankheiten mit Langzeitüberleben.

In the past decades medical progress in the treatment of fatal diseases has led to substantial improvement of survival. This long-term survival has financial consequences for health care and society. In this article methodological challenges of measuring the costs of long-term survival are presented. In this regard the costs of long-term treatment, indirect costs, unrelated future health care costs and discounting of costs are highlighted and illustrated by examples. A methodological challenge related to the economic evaluation of therapies leading to long-term survival is the consideration of unrelated future health care costs occurring in life years gained. In the literature the issue of unrelated future health care costs is discussed comprehensively on a methodological-theoretical basis. In economic evaluations published in the literature, these costs have rarely been considered so far, which may cause biased results. Concerning the comparability of study results, a standardization of the methods of measuring costs is desirable.

The long-term cost-effectiveness of obesity prevention interventions: systematic literature review.

Obesity prevention provides a major opportunity to improve population health. As health improvements usually require additional and scarce resources, novel health technologies (interventions) should be economically evaluated. In the prevention of obesity, health benefits may slowly accumulate over time and it can take many years before an intervention has reached full effectiveness. Decision-analytic simulation models (DAMs), which combine evidence from diverse sources, can be utilized to evaluate the long-term cost-effectiveness of such interventions. This literature review summarizes long-term economic findings (defined as ≥ 40 years) for 41 obesity prevention interventions, which had been evaluated in 18 cost-utility analyses, using nine different DAMs. Interventions were grouped according to their method of delivery, setting and risk factors targeted into behavioural (n=21), community (n=12) and environmental interventions (n=8). The majority of interventions offered good value for money, while seven were cost-saving. Ten interventions were not cost-effective (defined as >50,000 US dollar), however. Interventions that modified a target population's environment, i.e. fiscal and regulatory measures, reported the most favourable cost-effectiveness. Economic findings were accompanied by a large uncertainty though, which complicates judgments about the comparative cost-effectiveness of interventions.

Age- and gender-specific prevalence of depression in latest-life--systematic review and meta-analysis.

OBJECTIVE: The objective of the study is to systematically analyze the prevalence of depression in latest life (75+), particularly focusing on age- and gender-specific rates across the latest-life age groups. DESIGN: Relevant articles were identified by systematically searching the databases MEDLINE, Web of Science, Cochrane Library and Psycinfo and relevant literature from 1999 onwards was reviewed. Studies based on the community-based elderly population aged 75 years and older were included. Quality of studies was assessed. Meta-analysis was performed using random effects model. RESULTS: 24 studies reporting age- and gender-specific prevalence of depression were found. 13 studies had a high to moderate methodical quality. The prevalence of major depression ranged from 4.6% to 9.3%, and that of depressive disorders from 4.5% to 37.4%. Pooled prevalence was 7.2% (95% CI 4.4-10.6%) for major depression and 17.1% (95% CI 9.7-26.1%) for depressive disorders. Potential sources of high heterogeneity of prevalence were study design, sampling strategy, study quality and applied diagnostics of latest life depression. CONCLUSIONS: Despite the wide variation in estimates, it is evident that latest life depression is common. To reduce variability of study results, particularly sampling strategies (inclusion of nursing home residents and severe cognitively impaired individuals) for the old age study populations should be addressed more thoroughly in future research.

[Economic aspects of prevention and treatment of overweight and obesity in children and adolescents]. / Prävention und Therapie von Übergewicht und Adipositas im Kindes- und Jugendalter aus gesundheitsökonomischer Sicht.

This article provides an overview of the costs associated with overweight and obesity in children and adolescents, and of the cost effectiveness of preventive and therapeutic interventions. First, the results of cost-of-illness studies from the international literature are presented. These studies show ambiguous results, but indicate moderate excess costs due to obesity for this age group. Subsequently, this paper describes the methods that can be used to analyze the cost effectiveness of preventive and therapeutic interventions. Problems arise from the necessity to estimate long-term effects on costs and health consequences of multiple, associated diseases. A number of economic evaluations of preventive and therapeutic interventions published in the scientific literature have reported favorable cost effectiveness. In order to increase the efficiency of health care, more cost-effective services for overweight and obesity should be developed and used.

[Health economic aspects of physical-mental comorbidity]. / Gesundheitsökonomische Aspekte psychischer Komorbidität bei somatischen Krankheiten.

Physical-mental comorbidity is often associated with worse clinical and psychosocial outcomes, reduced health-related quality of life, and increased healthcare utilization. The following article is dedicated to the health economic aspects of physical-mental comorbidity. It presents basic theoretical and methodological aspects of cost-of-illness studies and economic evaluations related to physical-mental comorbidity, which are explained and discussed for the practical example of comorbid depression in diabetes mellitus. The results show that mental comorbidity in diabetes is associated with increased healthcare costs, which can in part be attributed to an increased somatic health service use. Appropriate interventions can lower these excess costs. Economic evaluations assessing the effectiveness of interventions for depressive diabetics have shown that overall health can be improved and costs saved. However, especially in health economics, mental comorbidity in somatic diseases has not been comprehensively investigated and further research is warranted.

Health burden and costs of obesity and overweight in Germany.

This study aimed to estimate the health burden and the direct as well as indirect costs of morbidity and mortality attributable to obesity and overweight in Germany for the year 2002. We used the concept of attributable fractions based on German prevalence data and relative risks from US studies as well as routine statistics. We estimated obesity- and overweight-attributable deaths, years of potential life lost (YPLL) and quality-adjusted life years lost (QALY) for various diseases associated with obesity and overweight. Direct costs were estimated for inpatient and outpatient treatment, rehabilitation and non-medical costs. Indirect costs were estimated for sickness absence, early retirement and mortality using the human capital approach. We estimated 36,653 obesity- and overweight-attributable deaths with 428,093 consecutive YPLL and 367,772 QALYs lost. Obesity caused 4,854 million EUR in direct costs corresponding to 2.1% of the overall German health expenditures in 2002 and 5,019 million EUR in indirect costs. Forty-three percent of direct costs resulted from endocrinological diseases like diabetes and obesity itself, followed by cardiovascular diseases (38%), neoplasms (14%) and digestive diseases (6%). Sixty percent of indirect costs resulted from unpaid work, and 67% of overall indirect costs were due to mortality. Obesity and overweight are connected to considerable morbidity and mortality as well as societal costs. Improvement and further development of effective strategies for preventing and dealing with obesity and overweight are necessary.

The health and economic consequences of osteopenia- and osteoporosis-attributable hip fractures in Germany: estimation for 2002 and projection until 2050.

SUMMARY: The health and economic burden of osteopenia- and osteoporosis-attributable hip fractures (OHF) in Germany was estimated for 2002 and projected until 2050. We found 108,341 OHF resulting in 2,998 million Euros cost, which will more than double by the year 2050, calling for improvement and development of prevention strategies for OHF. INTRODUCTION: This study aimed to estimate the health impact and the societal costs of OHF in Germany in the year 2002 and to extrapolate these estimates to the years 2020 and 2050. METHODS: We estimated OHF-attributable deaths, years of potential life lost (YPLL) and quality-adjusted life years lost (QALYs) using attributable fractions. Direct costs for acute treatment, rehabilitation, nursing care, non-medical costs and indirect costs for sickness absence, early retirement and mortality were estimated. All estimates were extrapolated to 2020 and 2050 using an estimation of future population composition and life expectancy. RESULTS: We found 108,341 OHF resulting in 3,485 deaths, 22,724 YPLL, 114,058 QALYs, 2,736 millions of Euros direct cost and 262 millions of Euros indirect costs. Projection to 2020 showed corresponding increases of 44%, 62%, 56%, 49%, 47% and 33%, whereas the projection to 2050 resulted in changes of 128%, 215%, 196%, 152%, 138% and 90%, respectively. CONCLUSIONS: OHF have considerable impact on health and direct costs in the elderly. Both may strongly increase in future decades due to demographic changes, calling for improvement and development of effective strategies for preventing and dealing with OHF.

Cost effectiveness of the determination of autoantibodies against cyclic citrullinated peptide in the early diagnosis of rheumatoid arthritis.

OBJECTIVE: To estimate the incremental cost-effectiveness ratio (ICER) of antibodies against cyclic citrullinated peptides (aCCP) in the early diagnosis of rheumatoid arthritis (RA). METHODS: A Markov model was used to model 10-year progression of RA in patients first diagnosed with undifferentiated arthritis (UA) and to estimate the incremental costs and quality-adjusted life years (QALYs) of using aCCP additionally to American College of Rheumatology (ACR) criteria. The impact of later diagnosis and treatment due to non-use of aCCP was modelled as increased Health Assessment Questionnaire (HAQ) progression. Utilities were assigned to HAQ states for calculating QALYs. Uncertainty was analysed using univariate and probabilistic sensitivity analyses (Monte Carlo simulation). RESULTS: Baseline ICER was euro 930/QALY. Univariate sensitivity analyses identified the impact of later diagnosis on HAQ progression as a major source of uncertainty, resulting in an ICER range from "dominance" to euro 153 092/QALY, compared with a maximum ICER of euro4870/QALY for other variables. Monte Carlo simulation resulted in a 95% uncertainty interval from euro 3537/QALY (dominance) to euro 5429/QALY; when indirect costs were considered, Monte Carlo simulation resulted in a 95% uncertainty interval from euro 78 115/QALY (dominance) to -euro 23 444/QALY (dominance). CONCLUSIONS: Using aCCP in the diagnosis of RA in patients with UA is likely to be cost effective compared with using ACR criteria alone. When indirect costs are incorporated, aCCP seems to save costs. Clearly, more research is needed relating the effects of diagnosis and treatment on the long-term course and the resulting functional impairment of RA as measured by the HAQ.