Cost-Effectiveness analysis of the surgical management of fractures in Malawi: An economic evaluation of a high and low-income country surgical collaboration.

INTRODUCTION: Cost-effectiveness is an essential tool for identifying high-value interventions in resource-limited settings. This study aims to evaluate the cost-effectiveness of the surgical management of fractures by surgical residents at Kamuzu Central Hospital (KCH). Currently, the 5-year surgical training program is supported by the Malawi Ministry of Health, and two universities in the United States and Norway. METHODS: We performed a modeled cost-effectiveness analysis (CEA) from a public health sector perspective. Cost data were collected from the current residency program and effectiveness data estimated from clinical data derived from operative interventions for fractures between 2013 and 2017 at KCH. Three patient groups were used as the base case; (1) patients of all ages, (2) patients age ≥18 years, and (3) patients who were <18 years. A Monte Carlo simulation of 10,000 trials was conducted for the probabilistic sensitivity analysis. RESULTS: The estimated average lifetime cost of training and compensating residency-trained surgeons over a 35-year career was $448,600 (SD $31,167). The incremental cost-effectiveness ratio (ICER) for providing surgical care to patients of all ages was $215 (SD $3,666) per disability-adjusted life-year (DALY), which is below the willingness-to pay-threshold (WTP) of $1,170 per DALY and highly cost-effective at a WTP threshold of $390. Each surgeon is estimated to avert approximately 5,570 DALYs during their career when performing operations to treat fractures. CONCLUSION: The KCH surgical training program is highly cost-effective at reducing disability at an incremental cost of $215 per averted DALY. This CEA demonstrates that the current surgical training program is cost-effective in reducing morbidity among individuals with fractures.

PTSD Care Among Veterans With and Without Co-Occurring Substance Use Disorders.

OBJECTIVE: This study examined whether a co-occurring substance use disorder contributed to disparities in receipt of Veterans Health Administration (VHA) posttraumatic stress disorder (PTSD) specialty care or psychotherapy. METHODS: Logistic regression, controlling for sociodemographic characteristics, was used to examine predictors of PTSD care among 424,211 veterans with confirmed PTSD (two or more PTSD diagnosis encounters) who accessed care in a VHA facility between fiscal years 2009 and 2010. RESULTS: Overall, 16% of veterans had PTSD and a co-occurring substance use disorder diagnosis. In adjusted analyses, veterans with a co-occurring substance use disorder were more likely than veterans with PTSD alone to receive any outpatient PTSD specialty care and complete eight or more sessions of outpatient psychotherapy within 14 weeks, but they were less likely to be treated in inpatient PTSD specialty units. CONCLUSIONS: Co-occurring substance use disorders did not appear to hinder receipt of outpatient specialty PTSD treatment or of sufficient psychotherapy among VHA-enrolled veterans.

Posttraumatic stress disorder and incident heart failure among a community-based sample of US veterans.

OBJECTIVES: We investigated the association between posttraumatic stress disorder (PTSD) and incident heart failure in a community-based sample of veterans. METHODS: We examined Veterans Affairs Pacific Islands Health Care System outpatient medical records for 8248 veterans between 2005 and 2012. We used multivariable Cox regression to estimate hazard ratios and 95% confidence intervals for the development of heart failure by PTSD status. RESULTS: Over a mean follow-up of 7.2 years, veterans with PTSD were at increased risk for developing heart failure (hazard ratio [HR] = 1.47; 95% confidence interval [CI] = 1.13, 1.92) compared with veterans without PTSD after adjustment for age, gender, diabetes, hyperlipidemia, hypertension, body mass index, combat service, and military service period. Additional predictors for heart failure included age (HR = 1.05; 95% CI = 1.03, 1.07), diabetes (HR = 2.54; 95% CI = 2.02, 3.20), hypertension (HR = 1.87; 95% CI = 1.42, 2.46), overweight (HR = 1.72; 95% CI = 1.25, 2.36), obesity (HR = 3.43; 95% CI = 2.50, 4.70), and combat service (HR = 4.99; 95% CI = 1.29, 19.38). CONCLUSIONS: Ours is the first large-scale longitudinal study to report an association between PTSD and incident heart failure in an outpatient sample of US veterans. Prevention and treatment efforts for heart failure and its associated risk factors should be expanded among US veterans with PTSD.

Identifying priorities for patient-centered outcomes research for serious mental illness.

OBJECTIVE: The purpose of this project was to engage a diverse group of stakeholders (N=38) to help establish priorities to guide patient-centered outcomes research (PCOR) in serious mental illness. METHODS: Three meetings, two Web-based and one on site, were held to generate and prioritize an initial list of topics. Topics were then sorted and organized into common themes. RESULTS: About 140 topics were identified and sorted into 21 main themes, ranked by priority. Three of the top four themes focused on how research was conducted, particularly the need to develop consensus measurement and outcomes definitions; improving infrastructure for research, longitudinal studies, and new data sets and investigators; and developing PCOR methodology. Stakeholders also identified a need to focus on service delivery, treatment settings, and structure of the delivery of care. CONCLUSIONS: Engagement by a broad group of stakeholders in a transparent process resulted in the identification of priority areas for PCOR. Stakeholders clearly indicated a need to fundamentally change how research on serious mental illness is conducted and a critical need for the development of methodology and infrastructure. Most current PCOR has been focused on relatively short-term outcomes, but real world, long-term studies providing guidance for treatment over the lifetime of a serious mental illness are needed.

Clinical heterogeneity in systematic reviews and health technology assessments: synthesis of guidance documents and the literature.

OBJECTIVES: The aim of this study was to synthesize best practices for addressing clinical heterogeneity in systematic reviews and health technology assessments (HTAs). METHODS: We abstracted information from guidance documents and methods manuals made available by international organizations that develop systematic reviews and HTAs. We searched PubMed® to identify studies on clinical heterogeneity and subgroup analysis. Two authors independently abstracted and assessed relevant information. RESULTS: Methods manuals offer various definitions of clinical heterogeneity. In essence, clinical heterogeneity is considered variability in study population characteristics, interventions, and outcomes across studies. It can lead to effect-measure modification or statistical heterogeneity, which is defined as variability in estimated treatment effects beyond what would be expected by random error alone. Clinical and statistical heterogeneity are closely intertwined but they do not have a one-to-one relationship. The presence of statistical heterogeneity does not necessarily indicate that clinical heterogeneity is the causal factor. Methodological heterogeneity, biases, and random error can also cause statistical heterogeneity, alone or in combination with clinical heterogeneity. CONCLUSIONS: Identifying potential modifiers of treatment effects (i.e., effect-measure modifiers) is important for researchers conducting systematic reviews and HTAs. Recognizing clinical heterogeneity and clarifying its implications helps decision makers to identify patients and patient populations who benefit the most, who benefit the least, and who are at greatest risk of experiencing adverse outcomes from a particular intervention.

Deployment and mental health diagnoses among children of US Army personnel.

OBJECTIVE: To characterize the risk of mental health diagnoses among children of US military personnel associated with parental deployment in support of Operation Iraqi Freedom (OIF) and Operation Enduring Freedom (OEF). DESIGN: Nonrandomized, retrospective cohort study (2003-2006). SETTING: Electronic medical record data for outpatient care. PARTICIPANTS: Children (N = 307 520) aged 5 to 17 years with at least 1 active-duty US Army parent. MAIN EXPOSURE: Number of months of parental deployment for OIF and OEF. MAIN OUTCOME MEASURES: A mental health diagnosis was defined as having at least 1 mental health-related International Classification of Diseases, Ninth Revision, code out of 4 possible codes for a given outpatient medical visit. Diagnoses were further classified into 1 of 17 disorder categories. RESULTS: Overall, children with parental deployment represented an excess of 6579 mental health diagnoses during the 4-year period compared with children whose parents did not deploy. After the children's age, sex, and mental health history were adjusted for, excess mental health diagnoses associated with parental deployment were greatest for acute stress reaction/adjustment, depressive, and pediatric behavioral disorders and increased with total months of parental deployment. Boys and girls showed similar patterns within these same categories, with more diagnoses observed in older children within sex groups and in boys relative to girls within age groups. CONCLUSIONS: A dose-response pattern between deployment of a parent for OIF and OEF and increased mental health diagnoses was observed in military children of all ages. Findings may be used to inform policy, prevention, and treatment efforts for military families facing substantial troop deployments.

Suicidal or self-harming ideation in military personnel transitioning to civilian life.

Suicides have markedly increased among military personnel in recent years. We used path analysis to examine factors associated with suicidal/self-harming ideation among male Navy and Marine Corps personnel transitioning to civilian life. Roughly 7% of men (Sailors = 5.3%, Marines = 9.0%) reported ideation during the previous 30 days. Results suggest that combat exposure, substance abuse, and resilience are associated with suicidal ideation/self-harming thoughts through the mediation of posttraumatic stress disorder symptoms and/or depression symptoms. Substance abuse plays a moderating role. Resilience had a direct effect only among the Marines. Implications for improving the transition to civilian life are discussed.

Measurement invariance of posttraumatic stress disorder symptoms among U.S. military personnel.

Studies have not examined the factor structure or measurement invariance of posttraumatic stress disorder (PTSD) symptomatology using population-based data. Confirmatory factor analysis of the PTSD Checklist-Civilian Version (PCL-C) was conducted in a representative sample of U.S. active duty military personnel (N = 15,593). Consistent with prior research, a 4-factor model consisting of reexperiencing, avoidance, emotional numbing, and arousal factors was superior to four alternative models. Measurement invariance was found for factor loadings, but not observed item intercepts when comparing personnel with and without a recent deployment (

Deployment and the use of mental health services among U.S. Army wives.

BACKGROUND: Military operations in Iraq and Afghanistan have involved the frequent and extended deployment of military personnel, many of whom are married. The effect of deployment on mental health in military spouses is largely unstudied. METHODS: We examined electronic medical-record data for outpatient care received between 2003 and 2006 by 250,626 wives of active-duty U.S. Army soldiers. After adjustment for the sociodemographic characteristics and the mental health history of the wives, as well as the number of deployments of the personnel, we compared mental health diagnoses according to the number of months of deployment in Operation Iraqi Freedom in the Iraq-Kuwait region and Operation Enduring Freedom in Afghanistan during the same period. RESULTS: The deployment of spouses and the length of deployment were associated with mental health diagnoses. In adjusted analyses, as compared with wives of personnel who were not deployed, women whose husbands were deployed for 1 to 11 months received more diagnoses of depressive disorders (27.4 excess cases per 1000 women; 95% confidence interval [CI], 22.4 to 32.3), sleep disorders (11.6 excess cases per 1000; 95% CI, 8.3 to 14.8), anxiety (15.7 excess cases per 1000; 95% CI, 11.8 to 19.6), and acute stress reaction and adjustment disorders (12.0 excess cases per 1000; 95% CI, 8.6 to 15.4). Deployment for more than 11 months was associated with 39.3 excess cases of depressive disorders (95% CI, 33.2 to 45.4), 23.5 excess cases of sleep disorders (95% CI, 19.4 to 27.6), 18.7 excess cases of anxiety (95% CI, 13.9 to 23.5), and 16.4 excess cases of acute stress reaction and adjustment disorders (95% CI, 12.2 to 20.6). CONCLUSIONS: Prolonged deployment was associated with more mental health diagnoses among U.S. Army wives, and these findings may have relevance for prevention and treatment efforts.