The search for relevant outcome measures for cost-utility analysis of systemic family interventions in adolescents with substance use disorder and delinquent behavior: a systematic literature review.

PURPOSE: Systemic family interventions have shown to be effective in adolescents with substance use disorder and delinquent behavior. The interventions target interactions between the adolescent and involved systems (i.e. youth, family, peers, neighbors, school, work, and society). Next to effectiveness considerations, economic aspects have gained attention. However, conventional generic quality of life measures used in health economic evaluations may not be able to capture the broad effects of systemic interventions. This study aims to identify existing outcome measures, which capture the broad effects of systemic family interventions, and allow use in a health economic framework. METHODS: We based our systematic review on clinical studies in the field. Our goal was to identify effectiveness studies of psychosocial interventions for adolescents with substance use disorder and delinquent behavior and to distill the instruments used in these studies to measure effects. Searched databases were PubMed, Education Resource Information Center (ERIC), Cochrane and Psychnet (PsycBOOKSc, PsycCRITIQUES, print). Identified instruments were ranked according to the number of systems covered (comprehensiveness). In addition, their use for health economic analyses was evaluated according to suitability characteristics such as brevity, accessibility, psychometric properties, etc. RESULTS: One thousand three hundred seventy-eight articles were found and screened for eligibility. Eighty articles were selected, 8 instruments were identified covering 5 or more systems. CONCLUSIONS: The systematic review identified instruments from the clinical field suitable to evaluate systemic family interventions in a health economic framework. None of them had preference-weights available. Hence, a next step could be to attach preference-weights to one of the identified instruments to allow health economic evaluations of systemic family interventions.

Cost-effectiveness of multidimensional family therapy compared to cognitive behavioral therapy for adolescents with a cannabis use disorder: Data from a randomized controlled trial.

OBJECTIVE: To evaluate the cost-effectiveness of Multidimensional Family Therapy (MDFT) for adolescents with a cannabis use disorder, compared to Cognitive Behavioural Therapy (CBT). METHODS: A parallel-group randomized controlled trial was performed. 109 adolescents with a DSM-IV cannabis use disorder (CBT n=54; MDFT n=55) were included. Assessments were conducted at baseline, and 3, 6, 9 and 12 months post-baseline, and included measures on cannabis and other substance use, delinquency, health care utilization, and general health related quality of life. RESULTS: Excluding those with missing cost-data, 96 participants (MDFT n=49; CBT n=47) were included. From a health care perspective, the average annual direct medical costs in the CBT group were €2015 (95%C.I. 1397-2714), compared to €5446 (95%C.I. 4159-7092) in the MDFT group. The average quality-adjusted life years (QALY's) gained were 0.06 QALY higher for the MDFT group, which led to an incremental cost-effectiveness ratio (ICER) of 54,308 Euro/QALY or €43,405 per recovered patient. Taking the costs of delinquency into account, the costs increased to €21,330 (95%C.I. 12,389-32,894) for the CBT group and to €21,915 (95%C.I. 16,273-28,181) for the MDFT group, which lead to an ICER of 9266 Euro/QALY or a cost per recovered patient of €7491. CONCLUSIONS: This is the first comprehensive CEA of MDFT compared to CBT and it demonstrated that when costs of delinquency were included, the ICERS were modest. The results underline the importance of adopting a broader perspective regarding cost effectiveness analyses in mental health care.

[Multidimensional family therapy and cognitive behavioral therapy in adolescents with a cannabis use disorder: a randomised controlled study]. / Multidimensionele gezinstherapie en cognitieve gedragstherapie bij adolescenten met een stoornis in het gebruik van cannabis; een gerandomiseerd onderzoek.

BACKGROUND: More and more adolescents with cannabis problems are seeking treatment at addiction clinics. There is an urgent need for new types of treatment in this field. AIM: To evaluate the effectiveness of multidimensional family therapy (MDFT) and cognitive behavioral therapy (CBT) in adolescents with a cannabis use disorder. METHOD: One hundred and nine adolescents were randomly assigned to outpatient MDFT or CBT. Both types of therapy groups had a planned treatment course lasting 5 to 6 months. After 12 months the two groups were compared in terms of changes in cannabis use and in terms of secondary outcome measures, including delinquency. RESULTS: Adolescents in both treatment groups showed significant and relevant reductions in cannabis use and delinquency over 12 months. Although the MDFT treatment lasted longer and was more intensive than the CBT treatment, there was no difference in the key outcome measures of the treatments. Secondary analyses indicated that older adolescents and those without comorbid psychiatric problems derived considerably more benefit from CBT, whereas younger adolescents and those with comorbid psychiatric problems benefited much more from MDFT. CONCLUSION: MDFT and CBT are equally effective in reducing cannabis use and delinquent behavior in adolescents with a cannabis use disorder. Age and comorbid psychiatric problems turned out to be important moderators of the treatment results of MDFT and CBT and could therefore be used as a starting point for matching adolescent substance abusers to the most appropriate type of treatment.

[Availability and services of dentists under pressure?]. / Beschikbaarheid en dienstverlening van tandartsen onder druk?

Signals in society point to a shortage of dentists in the Netherlands. Aim of this study is to explore how patients, against the background of supposed shortage, judge the availability and services of dentists. For this research the 'Consumerspanel Health Care', in which 1.395 persons participate, was asked to complete a postal questionnaire. Response rate was 73.8%. Results show that there are presently no serious problems for patients with the services of dentist due to the presumed lack of dentists. The patients were very satisfied with the accessibility and the services delivered by the dentists in the Netherlands. With the availability there seem to be some possible problems.

Myo-electrical and motor activity of the stomach in the first days after abdominal surgery: evaluation by electrogastrography and impedance gastrography.

The electrical and motor activities of the stomach were studied in the early postoperative phase after abdominal surgery by means of surface recording techniques: electrogastrography (EGG) and impedance gastrography (IGG). EGG and IGG recordings were made pre-operatively and on the first and second postoperative days. Physical signs and symptoms related to gastrointestinal motility were assessed. Two patient groups were studied; a group of patients undergoing cholecystectomy (n = 9) was compared with a group with major colonic surgery (n = 14). After colonic surgery, resumption of a normal oral diet was later and nausea and vomiting were seen more frequently than after cholecystectomy. Other physical signs concerning intestinal motility did not differ between the groups. Gastric myo-electrical activity (0.04-0.06 Hz), recorded electrogastrographically, tended to decrease in the postoperative phase in both groups, and return to pre-operative values later in the colonic surgery group. However, none of the differences reached statistical significance. Abnormal gastric activity (tachyarrhythmia) was observed in one pre-operative patient but in 6 patients (2 cholecystectomy, 4 colonic surgery) after operation. IGG variables were not significantly affected by the operation and were not significantly different between the groups. No correlation between the symptoms nausea and vomiting in the postoperative phase and the incidence of tachyarrhythmias could be demonstrated in this study. It is concluded that antral myo-electrical and motor activity, measured with non-invasive techniques (EGG and IGG), are not grossly abnormal on the first and second postoperative day after abdominal surgery. It is further concluded that abnormal gastric frequencies do not appear to play a major role in the genesis of postoperative nausea and vomiting.

Effects of highly selective vagotomy on gastric myoelectrical activity. An electrogastrographic study.

Changes in gastric myoelectrical activity following highly selective vagotomy were studied in 12 patients by means of electrogastrography (EGG) using cutaneous electrodes. Measurements were made before, 10 days after, and six months after operation. Eight patients undergoing cholecystectomy served as controls. Preoperatively all controls and patients had normal recordings. In the cholecystectomized patients no significant changes were found postoperatively. Ten days after highly selective vagotomy the normal initial postprandial dip in gastric ECA frequency and the subsequent increase in frequency and power were not seen. Tachygastrias were observed in three patients. Six months after operation the normal frequency and power responses to a test meal had returned, but both the fasting and postprandial ECA frequencies were raised significantly. It is concluded that highly selective vagotomy is associated with abnormalities in myoelectrical activity, in particular in the postprandial state, most of which are reversible with time.

Evaluation of patterns of human antral and pyloric motility with an antral wall motion detector.

We have examined the hypothesis that isolated pyloric pressure waves occur in the absence of even low-amplitude antral contractions. Antropyloroduodenal motility was recorded in seven healthy adult volunteers. A sleeve/side-hole manometric assembly was positioned across the pylorus with the aid of measurements of transmucosal potential difference. A new sensor consisting of an elliptical wire transducer 2.5 cm long and 1.5 cm in transverse diameter was incorporated into the assembly above the sleeve. This sensor was designed to detect nonlumen-occluding antral contractions. Motility was studied for 45 min under each of three conditions: 1) fasting, 2) after ingestion of a 100-g beef burger, and 3) during and after a 15-min intraduodenal infusion of 25% dextrose at a rate of 4 ml/min. Overall, only 51% of antral transducer deflections were associated with a change in antral side-hole pressures. Eighty-nine percent of antral side-hole pressure waves were associated with an indication of antral wall motion. Of the pressure waves recorded by the sleeve classified as isolated pyloric pressure waves, none was associated with antral transducer deflection during fasting, 1.1% after intraduodenal dextrose, and 18% after the solid meal. Antral contractions were detected by the wall motion detector with greater sensitivity than antral side holes, possibly reflecting the occurrence of nonlumen-occluding antral contractions. With some exceptions during solid gastric emptying, manometrically defined isolated pyloric pressure waves appear to represent truly localized contraction.

Electrogastrographic study of gastric myoelectrical activity in patients with unexplained nausea and vomiting.

Using cutaneous electrodes an electrogastrographic study was made of gastric myoelectrical activity in both the fasting and postprandial states in 48 patients with unexplained nausea and vomiting and in 52 control subjects. A gastric emptying study, using a radio-labelled solid phase meal, was carried out in 30 of these 48 patients. A follow up study was done after one year. In 48% of the patients abnormal myoelectrical activity was found which was characterised by: instability of the gastric pacemaker frequency; tachygastrias in both the fasting and postprandial states; the absence of the normal amplitude increase in the postprandial electrogastrogram. This last characteristic was correlated with a delayed gastric emptying of solids. The present study shows that with electrogastrography in a heterogeneous group of patients with unexplained nausea and vomiting a subgroup can be discerned with abnormal myoelectrical activity. Our findings suggests that this abnormal myoelectrical activity is related to these symptoms.

Electrogastrographic characteristics of interdigestive migrating complex in humans.

Interdigestive myoelectric activity and mechanical activity were studied simultaneously by means of cutaneous electrodes (electrogastrography) and intraluminal pressure recording, respectively, in 10 healthy male volunteers. The aims of the present study were 1) to describe the characteristics of the electrogastrogram during the different phases of the interdigestive migrating complex (IMC) in healthy subjects and 2) to determine to what extent these characteristics can be used to identify the different phases of the IMC. The electrogastrograms were analyzed visually and by running-spectrum analysis. It was concluded that in humans the gastric frequency present in the electrogastrogram appears to be less stable during motor activity than during motor quiescence, in particular during phase III, but far more stable than its canine counterpart. A small but consistent drop in gastric frequency was observed in the changeover from motor quiescence to phase II motor activity. The power of the gastric frequency increased with increasing motor activity, except during phase III. A characteristic frequency and power behavior during phase III could only be recognized in a minority of the IMCs. In general, electrogastrography cannot, given the present state of the art, be used to precisely identify the different phases of the IMC.

Recording of gastrointestinal electrical activity from surface electrodes.

The surface recording of electrical activities generated by the gastrointestinal tract is reviewed, with particular reference to surface recording of gastric electrical activity (electrogastrography or EGG). The available data on interdigestive and postprandial characteristics of the EGG signal in health and disease, including techniques of recording and signal analysis, are summarised.

Contraction-related, low-frequency components in canine electrogastrographic signals.

Interdigestive gastric contraction-related phenomena were studied in four healthy conscious dogs by running-spectrum analysis of signals derived from the abdominal surface. When groups of contractions occur irregularly spaced in time, low frequencies (in the range below 0.085 Hz) show up in the power spectra of the electrogastrograms. It has been hypothesized that prolonged electrical control activity (ECA) intervals shown to coincide with irregular contractions are related in some way to these low frequencies. This hypothesis was investigated in detail. Whereas a certain degree of correlation was demonstrated between ECA interval variations, contractile activity, and the presence of low frequencies in the spectra obtained from electrogastrograms recorded during interdigestive migrating complexes, a more pronounced correlation between these phenomena was found during "minute rhythms." It was concluded that the presence of lower frequencies ranging from the normal gastric one to about 0.01 Hz in the running-spectrum representation of electrogastrograms recorded in fasting dogs is indicative of strong antral contractions and that the mechanism through which this is brought about involves prolongation of ECA intervals associated with these contractions.

What is measured in electrogastrography?

The object of this study was to elucidate what is actually measured in electrogastrography. Comparison of gastric signals simultaneously recorded from serosal and cutaneous electrodes in the conscious dog led to the following findings: 1. In the absence of phasic contractile activity and electrical response activity (ERA), the cutaneous recordings contained a frequency corresponding to the fundamental frequency of the electrical control activity (ECA) of the stomach (about 0.08 Hz). 2. Tachygastrias gave rise to cutaneous signals containing the tachygastric frequency (about 0.25 Hz). 3. The amplitude of the electrogastrogram increased when ERA occurred. It is concluded that both ECA and ERA are reflected in the electrogastrogram. A model is proposed that describes the electrogastrogram as the result of field potentials generated by depolarization and repolarization dipoles.

Gastric pacemaker rhythm in conscious dog.

The pacemaker rhythm in the stomach of six healthy conscious dogs was studied by means of the measurement of sequential electrical control activity (ECA) intervals. Only the rhythm originating in the normal pacemake area was studied. An electrical response activity (ERA) score was used to assess contractile activity. Whereas substantial shortening of nonectopic ECA intervals did not occur, contraction-related interval lengthening was a characteristic phenomenon. The temporal relations between ERA scores and interval durations were found to be dependent on the gastric level at which the signals were derived. The activity front of the interdigestive myoelectric complex (IDMEC) appeared to be correlated with the periodic occurrence of considerably prolonged intervals; this sign could be used for recognition of the IDMEC. The motor quiescence phase of the IDMEC was correlated with small interval-to-interval variation, as was the early postprandial phase.