Heavy users of acute psychiatric beds: randomized controlled trial of enhanced community management in an outer London borough.

BACKGROUND: Heavy users of psychiatric services, often defined as the population that uses the most beds, consume a large part of the resources used by the whole service, despite being relatively small in number. Any intervention that reduces heavy use is therefore likely to lead to significant savings, and enhancement of standard care using a form of intensive case management akin to assertive community treatment was thought to be a pragmatic strategy for testing in this group. METHODS: The effectiveness of enhanced community management (ECM) was compared with standard care alone in heavy users, who represented the 10% of patients with the highest number of hospital admissions and occupied bed days over the previous 6.5 years in an outer London borough. One hundred and ninety-three patients were randomly assigned to ECM or standard care and their use of services was determined after 1 and 2 years, with assessments of costs, clinical symptoms, needs, and social function made before entry into the study and after 1 and 2 years. RESULTS: Despite a 24 fold increase in community contacts in the study group, there were no significant differences between the two groups in any of the main outcome measures. Small savings on in-patient and day-hospital service costs were counterbalanced by the increased costs of outpatient and community care for the subjects assigned to ECM. Clinical outcome data derived from interviews in two-thirds of the subjects were similar in both groups. CONCLUSIONS: Providing additional intensive community focused care to a group of heavy users of psychiatric in-patient services in an outer London borough does not lead to any important clinical gains or reduced costs of psychiatric care.

Alzheimer's disease in the UK: comparative evidence on cost of illness and volume of health services research funding.

OBJECTIVE: To review the economic cost of Alzheimer's disease, to determine the level of research expenditure directed at this illness and to make comparisons with cancer, stroke and heart disease. METHOD: A literature search of cost-of-illness studies was conducted and major funders of research were contacted. Cost-of-illness estimates were updated and adjusted to enable comparability across the four disease areas. RESULTS: The direct costs of Alzheimer's disease were estimated to be between 7.06 billion pounds sterling and 14.93 billion pounds sterling , which was substantially greater than stroke (3.2 billion pounds sterling), heart disease (4.05 billion pounds sterling ) and cancer (1.6 billion pounds sterling excluding informal care costs). Research expenditure on Alzheimer's disease was 57% of that on stroke, 10% of that on heart disease and 3% of that on cancer. DISCUSSION: Alzheimer's disease imposes a high economic burden. However, spending on research is disproportionately low compared with spending on other major illnesses. In the light of these two findings we recommend further discussion of the distribution of public funding for research into this disease.

Costs and characteristics of heavy inpatient service users in outer London.

"Heavy users" is a new term often used to describe those who occupy a disproportionate number of psychiatric beds. In this study we identified the heaviest 10% (193) inpatient service users in one London borough over a 6 year period and compared these with a control group of 400 ordinary inpatient users. A weighting index was used to combine frequency of admission with duration. Heavy users were diagnostically and demographically similar to ordinary inpatient service users and only differed by their extensive use of services, about 3 times more than ordinary users in terms of health care costs, during the measured year. Their heavy use mainly depended on occupying hospital beds, and their use of outpatient, day patient and community services was relatively light.

Nicotine receptor inactivation decreases sensitivity to cocaine.

The reinforcing properties of nicotine and psychomotor stimulants are thought to be mediated through the mesolimbic dopamine (DA) system. This study investigates the role of high affinity nicotinic acetylcholine receptors (nAChRs) in cocaine place preference and examines some neurochemical changes in the mesolimbic DA system that might account for the interaction between nicotine and cocaine. 5 mg/kg is the lowest dose of cocaine able to condition a place preference in C57Bl/6 mice. Co-treatment with the nicotinic antagonist mecamylamine (1.0 mg/kg) disrupted place preference to 5 mg/kg cocaine. In addition, mice lacking the high affinity nAChR containing the beta2 subunit showed decreased place preference to 5 mg/kg cocaine, although higher doses of cocaine could condition a place preference in these knock out animals. In contrast, co-administration of a low dose of nicotine (0.2 mg/kg) potentiated place preference to a subthreshold dose of cocaine (3 mg/kg). DA turnover was monitored in several brain regions using tissue levels of DA and its primary metabolite DOPAC as an indication of DA release. Wild type mice showed decreased DA turnover following treatment with 5 mg/kg cocaine; whereas, this response was not seen in mice lacking the beta2 subunit of the nAChR. Induction of chronic fos-related antigens by cocaine was also reduced in mutant mice as compared to their wild type siblings, implying that downstream actions of cocaine were also affected by inactivation of the high affinity nAChR. These data indicate that activation of the high affinity nAChR may contribute to cocaine reinforcement.

Cost effectiveness analysis of school based Mantoux screening for TB infection.

OBJECTIVE: To assess the cost-effectiveness of adding school based Mantoux screening programs to the New South Wales current TB prevention strategy. METHOD: A decision analysis model compared the costs and consequences of screening strategies against the current no-screen strategy. Costs associated with screening and with treating future cases of TB were considered. Consequences considered were deaths and adult cases of TB prevented. The study was based on data from prevalence surveys conducted in 1992 and 1994 in Central and South Western Sydney, New South Wales. Screening strategies considered were screening all or only overseas born (OSB) 6 year olds and all or only OSB 14 year olds in school settings. RESULTS: Screening 14 year olds prevented more deaths and adult cases of TB than screening 6 year olds for a similar cost. For both age groups targeted screening of OSB children was more cost-effective than screening all children. Targeted screening of 14 year olds--the most cost effective option--cost $17,956 (costs and benefits discounted at 5%) per adult case prevented, equivalent to approximately $130,000 per life year saved. The cost-effectiveness ratios decline substantially if lower discount rates and less conservative assumptions are applied. CONCLUSION: Targeted screening was more cost effective than screening all children, however, there are ethical implications of targeting a group based on their origin of birth. IMPLICATIONS: As prevention and control of TB continues to be a high priority for NSW, the implications of a school based screening program should be seriously considered.

The cost-effectiveness of varicella vaccine programs for Australia.

OBJECTIVE: to examine the cost-effectiveness of three different varicella vaccination programs compared with no vaccination program. DESIGN: cost-effectiveness study. Simulations of the costs and consequences of chickenpox and the vaccination programs over a 30-year period. Direct (health-care) costs only were used in the simulations. SETTING: Australia.Participants/subjects: annual birth cohorts of infants (12-months old) and adolescents (12 years old). INTERVENTIONS: strategy I (no vaccination) was compared with three different varicella vaccination programs: strategy II - all infants; strategy III - adolescents without a history of varicella; and strategy IV ('catch-up')- all infants plus, for the first 11 years, adolescents without a history. OUTCOME MEASURES: fatalities and hospitalisations for varicella and its complications (encephalitis, pneumonitis, long-term disability). RESULTS: the average cost per case of chickenpox averted was $64, $530 and $418 in the infant, adolescent and catch-up programs, respectively. The infant program was the most cost-effective of the three. This program could avert 4. 4 million cases, 13,500 hospitalisations and 30 fatalities for chickenpox over a 30-year period. RESULTS were sensitive to the price of the vaccine and the discount rate, but relatively insensitive to changes in vaccine efficacy, coverage rates or vaccine complication rates. Improved accuracy of a negative varicella history in adolescents would substantially reduce the costs of the adolescent and catch-up programs making these programs feasible. CONCLUSIONS: the infant vaccine program is the preferred program, but the direct costs of any of the vaccination programs considered here are greater than the direct costs of no vaccination program.

Prescription of transdermal nicotine patches for smoking cessation in general practice: evaluation of cost-effectiveness.

BACKGROUND: The 1998 UK government White Paper Smoking Kills emphasises that normal practice should be for general practitioners (GPs), practice nurses, and others to offer advice and support to smokers in their efforts to stop. However, GPs are not allowed to write NHS prescriptions for nicotine-replacement therapy, even though this is the only effective pharmaceutical treatment available in the UK. We estimated the cost-effectiveness, for the NHS, of allowing GPs to prescribe transdermal nicotine patches for up to 12 weeks. METHODS: We used data from a randomised, placebo-controlled efficacy trial of nicotine patches and a survey of associated resource use in 30 GP surgeries in 15 English counties. We calculated the health benefit of nicotine-patch treatment in number of life years that would be saved by stopping smoking at various ages, and used an abstinence-contingent treatment model to calculate the incremental cost per life year saved by GP counselling with nicotine-patch treatment over GP counselling alone. Cost effectiveness was assessed on the basis that GPs would provide repeat NHS prescriptions for up to 12 weeks if the treatment was proving successful. FINDINGS: If GPs were allowed to prescribe transdermal nicotine patches on the NHS, for up to 12 weeks, the incremental cost per life year saved would be: Pound Sterling 398 per person younger than 35 years; Pound Sterling 345 for those aged 35-44 years; Pound Sterling 432 for those aged 45-54 years; and Pound Sterling 785 for those aged 55-65 years. INTERPRETATION: The low cost per life year saved would make GP intervention against smoking a cost-effective life-saving treatment. The priniciples of the government White Paper could be cost-effectively extended into general practice to reduce smoking and smoking-related illnesses.

A survey of nurse associate training programs.

A survey of nurse associate training programs in the United States and its territories was made in 1972. Data were obtained by questionnaires mailed to program directors, with mail and telephone followup, for 60 operating programs and 9 programs being planned. The response rate was 79 percent of an estimated 87 programs in existence. The survey data indicated that the "typical" nurse associate training program lasts 4 to 6 months, began instruction in 1971, and is sponsored solely by a university or a 4-year college. The most frequently mentioned sources of financial support are the sponsoring institutions or the National Institutes of Health, or both. The typical program receives about 24 trainee applications a year and can accommodate 16 new students annually; 12 students graduate each year at a cost of about $3,536 per graduate. Most students in nurse associate training are white women who have either a diploma or bachelor's nursing degree. In addition to a substantial amount of nursing experience, they are likely to have a guarantee of employment on graduation. Nurse associates are expected to exercise a significant amount of independent judgment in tasks performed, and they are likely to work with primary care physicians in a wide range of settings, including rural and remote areas. They are likely to perform a variety of tasks and activities, including giving physical examinations, ordering tests and medications (under standing order), instructing, counseling, and monitoring patients, and management of disease.

A report of a 1972 survey of physician's assistant training programs.

This article presents select results of a 1972 survey of all physician's assistant training programs in the United States and its territories. The survey gathered a broad range of information useful to federal health manpower policymakers, physician assistant training program administrators, guidance counselors, and prospective students. Responses were received from 75 operational programs and 13 programs still in planning for an estimated response rate of 81 per cent from the estimated 108 programs in existence.