Immunoglobulin Replacement Therapy in Chronic Lymphocytic Leukaemia patients with hypogammaglobulinaemia and infection; analysis of total national utilisation data in Australia 2008-2013

Objectives To analyse total national utilisation of immunoglobulin (Ig) replacement therapy (IgRT) for Chronic Lymphocytic Leukaemia patients with acquired hypogammaglobulinaemia and severe and/or recurrent bacterial infections. Methods In 2007, the National Blood Authority first published Criteria for the clinical use of intravenous immunoglobulin in Australia. The Australian Red Cross Lifeblood assessed, approved, and recorded all supply with patient demographics, distribution data, intravenous Ig (IVIg) volumes and treatment episodes. IVIg was the sole product used in Australia from 2008-2013 inclusive. Results From 2008-2013 across Australia, 2,734 individual CLL patients received 48,870 treatment episodes using a total 1,324,926 grams of IVIg therapy. Six IVIg products were available, with domestically manufactured Intragam P accounting for 89.7% of supply. The average age for first dose was 74 years. Males received 60.6% of the total treatment episodes representing 20% more than females. The average pre-treatment IgG level was 4.03g/L +/- 2.03g/L (range 0.30-10.50g/L). A sustained average annual increased IVIg utilisation of 5.5% was observed. There was significant regional variation consistent with differences in prescriber preferences across states and territories. Conclusion This study provides a globally unique insight into IgRT supply and demand in CLL patients by analysis of total national use in Australia over a six year period.

Innovation in Service Delivery: the Expansion of General Practice Services for People with Serious and Ongoing Mental Illness

<p>Over the past 50 years there have been many innovations in New Zealand's mental health services. Using case study methodology this research examined two innovations involving general practice - the Newtown Union Health Service (NUHS) mental health programme and the Hawke's Bay (HB) shared care pilot - targeted at people with serious and ongoing mental illness (SOMI). The intent of the research was to inform service delivery arrangements and to provide new knowledge concerning the development of innovative services. Four sources of data - programme documentation, evaluation reports, utilisation data and stakeholders' experiences acquired through questionnaires and interviews - were used in developing the case studies. While the history of these innovations was traced to specific actions, these innovations emerged because of the national and clinical context. The NUHS programme was a bottom-up development the innovation occurring because NUHS needed to find a way of meeting the needs of the people with SOMI who were registered there. NUHS practitioners in consultation with the community made decisions concerning the programme's development The HB pilot was a top-down development that was purchased because new money became available. Primary and secondary service practitioners, managers, researchers and the purchaser made decisions concerning the pilot's initial development. The factors that shaped the innovations included: funding, staffing, clinical and financial risk management and time. Similarities in the innovations included the range of arrangements for mental health care for individual people (from GPs being the sole providers through to GPs providing only physical health care, with the mental health service providing the mental health care), issues of trust and poor communication between the primary and specialist services and the frequency and length of consultations. Differences included the payment arrangements, access issues, the formalisation of co-ordination arrangements and the role of the nurse. The research found that to be adopted for routine use these innovations needed to develop effective service delivery arrangements. The NUHS programme was more successful than the HB pilot at delivering accessible, acceptable, co-ordinated, comprehensive, efficient and effective services. The findings regarding targeting, funding mechanisms, practitioner roles and the time it takes for trust to develop so that innovative services can become established have implications for Primary Health Organisation development. Research is needed on other innovative services to establish whether evaluating the effectiveness of the service delivery arrangements provides a useful framework to monitor and guide the implementation of an innovation in service delivery.</p>

Innovation in Service Delivery: the Expansion of General Practice Services for People with Serious and Ongoing Mental Illness

<p>Over the past 50 years there have been many innovations in New Zealand's mental health services. Using case study methodology this research examined two innovations involving general practice - the Newtown Union Health Service (NUHS) mental health programme and the Hawke's Bay (HB) shared care pilot - targeted at people with serious and ongoing mental illness (SOMI). The intent of the research was to inform service delivery arrangements and to provide new knowledge concerning the development of innovative services. Four sources of data - programme documentation, evaluation reports, utilisation data and stakeholders' experiences acquired through questionnaires and interviews - were used in developing the case studies. While the history of these innovations was traced to specific actions, these innovations emerged because of the national and clinical context. The NUHS programme was a bottom-up development the innovation occurring because NUHS needed to find a way of meeting the needs of the people with SOMI who were registered there. NUHS practitioners in consultation with the community made decisions concerning the programme's development The HB pilot was a top-down development that was purchased because new money became available. Primary and secondary service practitioners, managers, researchers and the purchaser made decisions concerning the pilot's initial development. The factors that shaped the innovations included: funding, staffing, clinical and financial risk management and time. Similarities in the innovations included the range of arrangements for mental health care for individual people (from GPs being the sole providers through to GPs providing only physical health care, with the mental health service providing the mental health care), issues of trust and poor communication between the primary and specialist services and the frequency and length of consultations. Differences included the payment arrangements, access issues, the formalisation of co-ordination arrangements and the role of the nurse. The research found that to be adopted for routine use these innovations needed to develop effective service delivery arrangements. The NUHS programme was more successful than the HB pilot at delivering accessible, acceptable, co-ordinated, comprehensive, efficient and effective services. The findings regarding targeting, funding mechanisms, practitioner roles and the time it takes for trust to develop so that innovative services can become established have implications for Primary Health Organisation development. Research is needed on other innovative services to establish whether evaluating the effectiveness of the service delivery arrangements provides a useful framework to monitor and guide the implementation of an innovation in service delivery.</p>

Beating Adolescent Self-Harm (BASH): a randomised controlled trial comparing usual care versus usual care plus a smartphone self-harm prevention app (BlueIce) in young adolescents aged 12–17 who self-harm: study protocol

IntroductionA mobile app, BlueIce, was codesigned with young people with a history of self-harm to provide them with more accessible and available evidence-based support at times of distress. A preliminary evaluation found that BlueIce was acceptable, safe and used by young people and helped to reduce self-harm. The present study is designed to assess the effectiveness and cost-effectiveness of adding BlueIce to usual Child and Adolescent Mental Health Service (CAMHS).Methods and analysisThis study is a single-blind, randomised controlled trial comparing usual CAMHS care with usual care plus BlueIce. A total of 138 adolescents aged 12–17 with current or a history of self-harm will be recruited through the Oxford Health National Health Service (NHS) Foundation Trust via their CAMHS clinician. The primary outcome is self-harm at 12 weeks assessed using the Risk Taking and Self-Harm Inventory for Adolescents. Secondary outcomes include mood, anxiety, hopelessness, general behaviour, sleep and impact on everyday life at 12 weeks and 6 months. Health-related quality of life and healthcare resource utilisation data will be collected at baseline, 12 weeks and 6 months. Postuse interviews at 12 weeks will determine the acceptability, safety and usability of BlueIce.Ethics and disseminationThe study was approved by the NHS South Central—Oxford B NHS Research Ethics Committee (19/SC/0212) and by the Health Research Authority (HRA) and Health and Care Research Wales. Findings will be disseminated in peer review open-access journals and at academic conferences.Trial registration numberISRCTN10541045.

The cost of illness for childhood clinical pneumonia and invasive pneumococcal disease in Nigeria

Background: Pneumococcal disease contributes significantly to childhood morbidity and mortality and treatment is costly. Nigeria recently introduced the Pneumococcal Conjugate Vaccine (PCV) to prevent pneumococcal disease. The aim of this study is to estimate health provider and household costs for the treatment of pneumococcal disease in children aged <5 years (U5s), and to assess the impact of these costs on household income. Methods: We recruited U5s with clinical pneumonia, pneumococcal meningitis or pneumococcal septicaemia from a tertiary and a secondary level hospital in Kano, Nigeria. We obtained resource utilisation data from medical records to estimate costs of treatment to provider, and household expenses and income loss data from caregiver interviews to estimate costs of treatment to households. We defined catastrophic health expenditure (CHE) as household costs exceeding 25% of monthly household income and estimated the proportion of households that experienced it. We compared CHE across tertiles of household income (from the poorest to least poor). Results: Of 480 participants recruited, 244 had outpatient pneumonia, and 236 were hospitalised with pneumonia (117), septicaemia (66) and meningitis (53). Median (IQR) provider costs were US$17 (US$14-22) for outpatients and US$272 (US$271-360) for inpatients. Median household cost was US$51 (US$40-69). Overall, 33% of households experienced CHE, while 53% and 4% of the poorest and least poor households, experienced CHE respectively. The odds of CHE increased with admission at the secondary hospital, a diagnosis of meningitis or septicaemia, higher provider costs, and caregiver having a non-salaried job. Conclusion: Provider costs are substantial, and households incur treatment expenses that considerably impact on their income and this is particularly so for the poorest households. Sustaining the PCV programme and ensuring high and equitable coverage to lower disease burden will reduce the economic burden of pneumococcal disease to the healthcare provider and households.

Representation of homeless persons and coding of homelessness in general practices: descriptive evaluation using healthcare utilisation data

BackgroundEpidemiological studies focused on primary healthcare needs of persons experiencing homelessness (PEH) are often based on data from specialist homeless healthcare services.AimThe aim of this study is to explore the presentation of PEH, coding of homelessness and associated health conditions in mainstream primary care general practices in England.Design & settingEMIS electronic database search of medical records was conducted across 48 general practices in a Clinical Commissioning Group (CCG), representing one of the most socioeconomically deprived regions in England, which also lacks a specialist primary healthcare service for PEH.MethodKey terms and codes were used to identify PEH, their respective diagnoses across 22 health conditions and prescribed medications over the past 4 years.ResultsFrom a population of approximately 321,000, 43 (0.013%) persons were coded as PEH compared to a homelessness prevalence of 0.5% in the English general population. Mental health conditions were the most prevalent diagnoses amongst the PEH registrants (62.3%); the recorded prevalence of other common long-term conditions in PEH was lower than the levels observed in PEH registered with specialist homelessness health services.ConclusionIn a population with approximately four times higher rate of statutory homelessness, PEH representation in mainstream general practices was underrepresented by several folds. As homelessness overlaps with mental health, substance misuse and long term health conditions, consistent coding of homelessness in medical records is imperative to offer tailored support and prevention actions when patients present for services.

Characterizing mental health/addictions and assault visits in the year prior to death: a population-based linked cohort study of homicide victims

IntroductionHomicide is an important cause of death for older youth and adult Canadians; however, little is known about health care use prior to death among this population. ObjectivesTo characterise health care use for mental health and addictions (MHA) and serious assault (herein referred to assault) one year prior to death among individuals who died by homicide in Ontario, Canada using linked mortality and health care utilisation data. MethodsWe report rates of health care use for MHA and assault in the year prior to death among all individuals 16 years and older in Ontario, Canada, who died by homicide from April 2003 to December 2012 (N=1,541). Health care use for MHA included inpatient stays, emergency department (ED) visits and outpatient visits, whereas health care use for assault included only hospital-based care (ED visits and inpatient stays). Sociodemographic characteristics and health care utilisation were examined across homicide deaths, stratified by sex. ResultsOverall, 28.5% and 5.9% of homicide victims sought MHA and assault care in the year prior to death, respectively. A greater proportion of females accessed care for MHA, whereas a greater proportion of males accessed assault-related health care. Males were more likely to be hospitalised following an ED visit for a MHA or assault related reason, in comparison to females. The most common reason for a MHA hospital visit was for substance-related disorders. We found an increase over time for hospital-based visits for assault prior to death, a trend that was not observed for MHA-related visits. ConclusionsA large proportion of homicide victims interacted with the health care system for MHA or assault in the year prior to death. An increase in hospital-based visits for assault-related reasons prior to death was observed. These trends may offer insight into avenues for support and prevention for victims of homicide.

Cost-of-illness studies in rare diseases: a scoping review

Objective The aim of this scoping review was to overview the cost-of-illness studies conducted in rare diseases. Methods We searched papers published in English in PubMed from January 2007 to December 2018. We selected cost-of-illness studies on rare diseases defined as those with prevalence lower than 5 per 10,000 cases. Studies were selected by one researcher and verified by a second researcher. Methodological characteristics were extracted to develop a narrative synthesis. Results We included 63 cost-of-illness studies on 42 rare diseases conducted in 25 countries, and 9 systematic reviews. Most studies (94%) adopted a prevalence-based estimation, where the predominant design was cross-sectional with a bottom-up approach. Only four studies adopted an incidence-based estimation. Most studies used questionnaires to patients or caregivers to collect resource utilisation data (67%) although an important number of studies used databases or registries as a source of data (48%). Costs of lost productivity, non-medical costs and informal care costs were included in 68%, 60% and 43% of studies, respectively. Conclusion This review found a paucity of cost-of-illness studies in rare diseases. However, the analysis shows that the cost-of-illness studies of rare diseases are feasible, although the main issue is the lack of primary and/or aggregated data that often prevents a reliable estimation of the economic burden.

EXPRESS: Cost-effectiveness of an enhanced Paramedic Acute Stroke Treatment Assessment (PASTA) during emergency stroke care: economic results from a pragmatic cluster randomised trial

Background: The Paramedic Acute Stroke Treatment Assessment (PASTA) trial evaluated an enhanced emergency care pathway which aimed to facilitate thrombolysis in hospital. A pre-planned health economic evaluation was included. The main results showed no statistical evidence of a difference in either thrombolysis volume (primary outcome) or 90-day dependency. However, counter-intuitive findings were observed with the intervention group showing fewer thrombolysis treatments but less dependency. Aims: Cost-effectiveness of the PASTA intervention was examined relative to Standard Care (SC). Methods: A within trial cost-utility analysis estimated mean costs and quality adjusted life years (QALYs) over 90 days’ time horizon. Cost were derived from resource utilisation data for individual trial participants. QALYs were calculated by mapping modified Rankin scale scores to EQ-5D-3L utility tariffs. A post-hoc subgroup analysis examined cost-effectiveness when trial hospitals were divided into compliant and non-compliant with recommendations for a stroke specialist thrombolysis rota. Results: The trial enrolled 1214 patients: 500 PASTA and 714 SC. There was no evidence of a QALY difference between groups [0·007 (95%CI -0·003 to 0·018) favouring PASTA] but costs were lower in the PASTA group [-£1473 (95%CI: -£2736 to -£219)]. There was over 97.5% chance that the PASTA pathway would be considered cost-effective. There was no evidence of a difference in costs at seven thrombolysis rota compliant hospitals but costs at eight non-complaint hospitals costs were lower in PASTA with more dominant cost-effectiveness. Conclusions: Analyses indicate that the PASTA pathway may be considered cost-effective, particularly if deployed in areas where stroke specialist availability is limited. Trial Registration: ISRCTN12418919 www.isrctn.com/ISRCTN12418919

Global estimates of service coverage for severe mental disorders: findings from the WHO Mental Health Atlas 2017

Background The study estimated service coverage for severe mental disorders (psychosis, bipolar disorder and moderate-severe depression), globally and regionally, using data collected from the Mental Health Atlas 2017. Methods Service coverage was defined as the proportion of people with a disorder contacting a mental health service among those estimated to have the disorder during a 12-month period. We drew upon 12-month service utilisation data from the Mental Health Atlas 2017. Expected prevalent cases of individual disorders were estimated using the disorder-specific prevalence rate estimates of the Global Burden of Disease Study 2016 and total population sizes. Methods for assessing the validity of country-reported service utilisation data were developed and applied. Outcomes From 177 countries, 50 countries provided reliable service coverage estimates for psychosis, along with 56 countries for bipolar disorder, and 65 countries for depression. The mean service coverage for psychosis was lowest in low- [10.9% (95% confidence interval (CI) 3.3–30.4)] and lower middle-income countries [21.5% (95% CI 11.9–35.7)] and highest in high-income countries [59.5% (95% CI 42.9–74.1)]. Service coverage for bipolar disorder ranged between 3.1% (95% CI 0.8–11.5) and 10.4% (95% CI 6.7–15.8). Mean service coverage for moderate-severe depression ranged between 2.9% (95% CI 1.3–6.3) for low-income countries and 31.1% (95% CI 18.3–47.6) for high-income countries. Interpretation The reporting method utilised by the Mental Health Atlas appears to be reliable for psychosis but not for depression. This method of estimating service coverage provides progress in tracking an important indicator for mental health; however, it highlights that considerable work is needed to further develop global mental health information systems.