Treatment in a specialised out-patient mood disorder clinic v. standard out-patient treatment in the early course of bipolar disorder: randomised clinical trial.

BACKGROUND: Little is known about whether treatment in a specialised out-patient mood disorder clinic improves long-term prognosis for patients discharged from initial psychiatric hospital admissions for bipolar disorder. AIMS: To assess the effect of treatment in a specialised out-patient mood disorder clinic v. standard decentralised psychiatric treatment among patients discharged from one of their first three psychiatric hospital admissions for bipolar disorder. METHOD: Patients discharged from their first, second or third hospital admission with a single manic episode or bipolar disorder were randomised to treatment in a specialised out-patient mood disorder clinic or standard care (ClinicalTrials.gov: NCT00253071). The primary outcome measure was readmission to hospital, which was obtained from the Danish Psychiatric Central Register. RESULTS: A total of 158 patients with mania/bipolar disorder were included. The rate of readmission to hospital was significantly decreased for patients treated in the mood disorder clinic compared with standard treatment (unadjusted hazard ratio 0.60, 95% CI 0.37-0.97, P = 0.034). Patients treated in the mood disorder clinic more often used a mood stabiliser or an antipsychotic and satisfaction with treatment was more prevalent than among patients who received standard care. CONCLUSIONS: Treatment in a specialised mood disorder clinic early in the course of bipolar disorder substantially reduces readmission to a psychiatric hospital and increases satisfaction with care.

Does participation in clinical trials influence the costs of future management of patients?

BACKGROUND: An earlier study showed that from a societal perspective it was less expensive to encourage patients to self-regulate their medication for GERD (gastro-esophageal reflux disease) by treating patients on-demand. OBJECTIVE: The objective was to investigate whether physician involvement in a clinical trial financed by the pharmaceutical industry subsequently results in higher health care costs. STUDY DESIGN: An open, observational, multicenter study compared direct medical costs and total costs for three groups of patients with different exposure to the clinical trial; (1) Dual exposed, where both the patients and the GP participated in the former clinical trial, (2) GP exposed, where only the GP participated in the former clinical trial and (3) nonexposed, where neither the patients nor the GP participated in the former clinical trial. RESULTS: We did not find any statistically significant differences in neither direct medical nor total costs. However, we did observe a numerical difference in direct medical costs of 24% higher in the dual exposed group compared to the nonexposed group mainly due to a higher consumption of prescribed medication. The higher direct medical cost in the dual exposed group was however counterbalanced by lower observed direct nonmedical and indirect costs. CONCLUSION: Although we did not find any statistical significant differences in health care costs, we did observe a higher consumption of prescribed medication and lower costs of work hours lost if both patient and GPs participated in a former clinical trial. The results may be limited due to a lower number of patients included than expected.

Exploring the relationship between costs and quality: does the joint evaluation of costs and quality alter the ranking of Danish hospital departments?

OBJECTIVE: The purpose is to evaluate the relationship between costs and quality and to assess whether the joint evaluation of costs and quality affects the ranking of hospital departments relative to comparison based on costs alone. METHODS: Using patient level data for 3,754 patients in six vascular departments, we estimate fixed effect models for costs (linear) and quality (logistic). We consider two quality measures; mortality and wound complications. To assess whether the joint evaluation of costs and quality affects the ranking of departments, we construct joint confidence regions for each pair of departmental effects for costs and quality using a bootstrap method and rank departments according to their cost-effectiveness ratio. The findings are used to evaluate a theory of a U-shaped cost/quality relationship. RESULTS: The association between cost and quality differs depending on how quality is measured. Lower costs are associated with higher mortality, implying a cost/quality trade-off. In contrast, there is no clear association between costs and wound complications among vascular departments. CONCLUSIONS: Compared to benchmarking of departments based solely on their costs, we show that the ranking of departments may be altered considerably when quality is taken into account. Consequently, it is important to have a well-rounded view of departmental objectives when undertaking performance evaluation. The results for mortality may lend some support to the theory of a U-shaped cost/quality relationship. However, the results for wound complications do not support the theory of a U-shaped cost/quality relationship.

Comparing hospital costs: what is gained by accounting for more than a case-mix index?

We explore what effect controlling for various patient characteristics beyond a case-mix index (DRG) has on inferences drawn about the relative cost performance of hospital departments. We estimate fixed effect cost models in which 3754 patients are clustered within six Danish vascular departments. We compare a basic model including a DRG index only with models also including age and gender, health related characteristics, such as smoking status, diabetes, and American Society of Anesthesiogists score (ASA-score), and socioeconomic characteristics such as income, employment and whether the patient lives alone. We find that the DRG index is a robust and important explanatory factor and adding other routinely collected characteristics such as age and gender and other health related or socioeconomic characteristics do not seem to alter the results significantly. The results are more sensitive to choice of functional form, i.e. in particular to whether costs are log transformed. Our results suggest that the routinely collected characteristics such as DRG index, age and gender are sufficient when drawing inferences about relative cost performance. Adding health related or socioeconomic patient characteristics only slightly improves our model in terms of explanatory power but not when drawing inferences about relative performance. The results are, however, sensitive to whether costs are log transformed.

Expectations and effectiveness of medical treatment and classical homeopathic treatment for patients with hypersensitivity illnesses--one year prospective study.

OBJECTIVE: To describe and compare characteristics of adult patients who received treatment for hypersensitivity illnesses by general practitioners (GPs) and classical homeopaths (CHs) over a period of 1 year and examine the statistical predictors of self-reported treatment outcomes. MATERIAL AND METHODS: We conducted a survey on 151 Danish adult patients with hypersensitivity illnesses, who chose treatment from one of 13 GPs or one of 10 CHs who participated in the project. The treatments were given as individual packages in the naturalistic clinical setting. Patients completed questionnaires at start of treatment, after 6 months and a year after start of treatment. Response rates for the first, second and third questionnaire were respectively 68%, 98%, 95% for the GP patients and 82%, 98%, 94% for the CH patients. RESULTS: Patients seeking CH treatment in this study are significantly different in gender and education from patients seeking GP treatment. We did not find significant differences in terms of occupational training, occupation, sickness absence due to hypersensitivity illnesses, diseases other than hypersensitivity illnesses, symptoms severity due to hypersensitivity illnesses before treatment and expectation of the ability of the treatment to alleviate symptoms. Eighty-eight percent of GP and 21% of CH patients were continuing treatment after 1 year. Regression analysis showed that the only significant independent variables to explain the probability of obtaining very positive effect or cure for GPs and CHs were that the patients were in 'maintenance treatment', and had high expectation before treatment of the ability of the treatment to relieve their symptoms. CONCLUSION: In this study self-reported very positive effect of GP treatment and very positive effect and cure of CH treatment are associated with the patients' high expectation of the treatment and continuation of maintenance treatment.

Preventive health screenings and health consultations in primary care increase life expectancy without increasing costs.

AIMS: The intention was to investigate whether preventive health checks and health discussions are cost effective. METHODS: In a randomized trial the authors compared two intervention groups (A and B) and one control group. In 1991 2,000 30- to 49-year-old persons were invited and those who accepted were randomized. Both intervention groups were offered a broad (multiphasic) screening including cardiovascular risk and a personal letter including screening results and advice on healthy living. Individuals in group A could contact their family physician for a normal consultation whereas group B were given fixed appointments for health consultations. The follow-up period was six years. Analysis was carried out on the "intention to treat" principle. Outcome parameters were life years gained, and direct and total health costs (including productivity costs), discounted by 3% annually. Costs were based on register data. Univariate sensitivity analysis was carried out. RESULTS: Both intervention groups have significantly better life expectancy than the control group (no intervention). Group B and (A) significantly gain 0.14 (0.08) life years more than the control group. There were no differences in average direct (3,255 euro (3,703 euro) versus 4,186 euro) and total costs (10,409 euro (9,399 euro) versus 10,667 euro). The effect in group B is, however, better than in group A with no significant differences in costs. The results are insensitive to a range of assumptions regarding costs, effects, and discount rates. CONCLUSIONS: Preventive health screening and consultation in primary care in 30- to 49-year-olds produce significantly better life expectancy without extra direct and total costs over a six-year follow-up period.

[Preventive out-patient treatment of affective disorders]. / Forebyggende ambulant behandling ved affektiv lidelse (depression og mani).

The present article is based on a Health Technology Assessment Report (HTA, available with an English summary at www.cemtv.dk) on preventive out-patient treatment of affective disorders. The article briefly reviews the course of depressive disorder and bipolar affective disorder and reviews the best available treatment modalities including shared care models, prophylactic pharmacotherapy and prophylactic combination therapy involving pharmacotherapy and psychological treatment.